Complications of Pregnancy 2 Flashcards
Define chronic hypertension in terms of pregnancy
Hypertension existing pre-pregnancy or at booking (= 20 weeks gestation)
Define mild, moderate and severe hypertension
- Mild, 140-149/90-99
- Moderate, 150-159/100-109
- Severe, 160 or > / 110 or greater
2 hypertensive disorders in pregnancy
- Gestational hypertension (AKA pregnancy induced hypertension PIH),
- Pre-eclampsia
Define gestational hypertension and pre-eclampsia
- Gestational hypertension, Hypertension that develops after 20 weeks of pregnancy (categorised as mild, moderate or severe)
- Pre-eclampsia, Hypertension that develops after 20 weeks + significant proteinuria
3 ways of confirming significant proteinuria
- Dipstick test: Urine protein estimation >1+
- Spot urinary protein: Creatinine ratio >30 mg/mmol
- 24hrs urine protein collection >300 mg/day
A risk factor for chronic hypertension in pregnancy
Older mothers
Aim of BP in patients with chronic hypertension in pregnancy
<150/100
Treatment for chronic hypertension in pregnancy
- Beta-blockers (Labetalol)
- Calcium channel blocker (Nifedipine)
- Centrally acting antihypertensive drugs (Methyldopa)
What should be monitored during the a pregnancy with chronic hypertension
Foetal growth
What does chronic hypertension increase the risk of
Placental abruption
Criteria to diagnose pre-eclampsia
-Proteinuria (>300mg/24hrs or creatinine ratio >30mg/mmol or dipstick protein estimation >1+
-Mild HT on 2 occasions more than 4hrs apart
or Moderate to severe HT
Pathophysiology of pre-eclampsia
- Secondary invasion of maternal spiral arterioles by trophoblast impaired, leading to reduced placental perfusion
- Imbalance between vasodilators/vasoconstrictors in pregnancy
Immunological and a genetic disposition
Risk factors for pre-eclampsia
- First pregnancy
- Extremes of maternal age
- Ore-eclampsia in previous pregnancy
- BMI >35
- Multiple pregnancy
- FHx of pre-eclampsia
- Chronic hypertension
- Renal disease
- Pre-existing diabetes
- Autoimmune disorders (SLE, antiphospholipid antibodies)
6 maternal complications of pre-eclampsia
- Eclampsia (seizures)
- Stroke
- HELLP (haemolysis, Elevated liver enzymes, low platelets)
- DIC (disseminated intravascular coagulation)
- Pulmonary oedema
- Cardiac + renal failure
5 foetal complications of pre-eclampsia
Impaired placental perfusion leading to;
- IUGR (Intrauterine Growth Restriction)
- Foetal distress
- Prematurity
- Increased PN (?perinatal?) mortality
Symptoms of pre-eclampsia
- Headache + blurred vision
- Vomiting + epigastric pain and tenderness
- Sudden swelling in face + hands
- Severe hypertension + papillodema
- Reducing urine output + >3+ proteinuria
- Clonus/brisk reflexes + seizures (eclampsia)
- Tenderness over liver
Biochemical abnormalities of pre-eclampsia
- Raised liver enzymes
- Raised urea and creatinine
- Raised urate
Haematological abnormalities of pre-eclampsia
- Low platelets
- Low haemoglobin, signs of haemolysis
- Features of DIC
Management of pre-eclampsia
- Frequent BP checks + urine protein
- Check symptomatology: headaches, epigastric pain, visual disturbances
- Check for hyper-reflexia + tenderness over liver
- Blood investigations
- Foetal investigations
What investigations would be carried in pre-eclampsia
- Blood investigations: FBC (for haemolysis), LFT’s, Renal function tests (serum urea, creatinine, urate), coagulation test if indicated
- Foetal investigation: Scan for growth + Cardiotocography (CTG)
What would be considered if maternal or foetal condition deteriorates during pre-eclampsia and why
Induction of labour, regardless of gestation, as the only cure for pre-eclampsia is delivery
When would steroids be given to mature foetal lungs for pre-term delivery
<36 weeks gestation
Treatment of eclamptic seizures
Magnesium sulphate bolus + IV infusion
Prophylaxis for pre-eclampsia in subsequent pregnancies
Low dose aspirin, from 12 weeks till delivery
2 types of diabetes in pregnancy
- Pre-existing diabetes (type 1 & less often type 2)
- Gestational diabetes
3 characteristics of gestational diabetes
- Carbohydrate intolerance with onset in pregnancy
- Abnormal glucose tolerance that reverts to normal after delivery
- More at risk of developing type 2 later in life
Why does the insulin requirements of the mother increase in a healthy pregnancy
- Human chorionic gonadotropin
- Cortisol
- Progesterone
- Human placental lactogen
All have anti-insulin action
What causes foetal hyperinsulinaemia and what’s the effect of it
- Maternal glucose crosses the placenta, inducing increased insulin production in the foetus
- The foetal hyperinsulinaemia cause Macrosomia (large baby)
- Post delivery more risk of neonatal hypoglycaemia
Having diabetes during pregnancy increases the risk of what
- Miscarriage, stillbirth, perinatal mortality
- Pre-eclampsia
- Foetal macrosomia and polyhydramnios
- Congenital abnormalities
- Worsening of nephropathy, retinopathy, hypoglycaemia and reduced awareness of hypoglycaemia
- Neonatal: impaired lung function, neonatal hypoglycaemia, jaundice
What values for blood glucose and HbA1c are aimed for with diabetes during pregnancy
-Blood glucose: <5.3 mmol/L fasting
<7.8 mmol/L 1hr postprandial
<6.4 mmol/L 2hr postprandial
6mmol/L before bedtime
Treatment for diabetes during pregnancy
Can continue with oral metformin but may need to change to insulin for tighter glucose control
How does labour differ if diabetes is present during the pregnancy
- Usually induced 38-40 weeks (earlier if foetal or maternal concerns)
- Consider CS if significant macrosomia
- Continuous CTG foetal monitoring during labour
- Early feeding of baby to reduce neonatal hypoglycaemia
Risk factors for gestational diabetes mellitus (GDM)
- BMI >30
- Previous macrosomic baby (>4.5 kg)
- Previous GDM
- FHx of diabetes
- Polyhydramnios
What is GDM associated with
-Some increase in maternal complications (chronic hypertension) and foetal complications (macrosomia)
What is associated with a higher risk of maternal and foetal complications, GDM or type 1/2 diabetes
Type 1 or 2
How to screen for GDM
If risk factors are present
- Offer HbA1c at booking (first antenatal scan)
- If HbA1c >43 mmol/L do OGTT
- If OGTT normal repeat it at 24-28 weeks
-Can also offer a OGTT at 16 and repeat at 28 weeks is significant risk factor present (e.g. previous GDM)
Management of GDM
Control blood sugars with;
- Diet
- Metformin/insulin if sugars remain high
- 6-8 weeks post delivery check OGTT
- Yearly check of HbA1c (due to higher risk of developing overt diabetes)
