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Reproductive > Complications of pregnancy 2 > Flashcards

Complications of pregnancy 2 Flashcards

1
Q

What is the definition of chronic hypertension in pregnancy?

A
  • Hypertension either pre-pregnancy or <20 wks

Mild HT – Diastolic BP 90-99, Systolic BP 140-49

Moderate HT - Diastolic BP 100-109, Systolic BP 150-159

Severe HT - Diastolic BP ≥110, Systolic BP ≥ 160

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2
Q

What is gestational hypertension?

A

Hypertension that in induced due to the pregnancy.

Develops after 20 wks.

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3
Q

What is pre-eclampsia? What is it’s definition?

A

New hypertension > 20 weeks in association with significant proteinuria.

  • Mild Hypertension on two occasions more than 4 hrs apart
  • Moderate to severe HT
    • proteinurea of more than 300mgms/24hrs
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4
Q

What is the pathophysiology of pre-eclampsia?

A

No one really knows….

Could be immunological or a genetic predisposition.

Imbalance between vasodilators and vasoconstrictors, vasoconstrictors take over and there is a reduced placental perfusion. Baby grows less and mother gets HT

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5
Q

What is classed as significant proteinurea?

A

Automated reagent strip urine protein estimation > 1+

Spot Urinary Protein: Creatinine Ratio > 30 mg/mmol

24 hours urine protein collection > 300mg/ day

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6
Q

Who is most likely to have chronic hypertension and what should there management steps be?

A
  • More commom in older mothers
  • Ideally the patients should have pre-pregnancy care such as changing anti-hypertensive medication if indicated
  • Aim to keep BP <150/100
  • Monitor for superimposed pre-eclampsia
  • Monitor fetal growth
  • May have a higher incidence of placental abruption
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7
Q

Who is at risk of Pre-eclampsia?

A
  • First pregnancy
  • Extremes of maternal: age: young or old
  • Pre-eclampsia in a previous pregnancy
  • Pregnancy interval of >10 years
  • BMI > 35
  • History of PET
  • Multiple pregnancy
  • Underlying medical disorders: chronic hypertension, pre-existing renal disease, pre-existing diabetes
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8
Q

What organs can pre-eclampsia effect?

A

renal, liver, vascular, cerebral, pulmonary

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9
Q

What are the complications of pre-eclamsia?

A

Maternal

  • eclamptic seizures
  • severe hypertension: cerebral haemorrhage, stroke
  • renal failure
  • pulmonary oedema, cardiac failure
  • DIC (disseminated intravascular coagulation)
  • HELLP (hemolysis, elevated liver enzymes, low platelets)

Fetal

  • Impaired placenta perfusion
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10
Q

Sign/symptoms of Pre-eclampsia?

A
  • Headache, blurring of vision, epigastric pain, pain below ribs, vomiting, sudden swelling of hands face legs
  • Severe Hypertension; > 3+ of urine proteinuria
  • Clonus / brisk reflexes ; papillodema, epigastric tenderness
  • Reducing urine output
  • Convulsions (Eclampsia)
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11
Q

What are biochem abnormalities of pre-eclampsia?

A
  • raised liver enzymes, bilirubin if HELLP present
  • raised urea and creatinine, raised urate
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12
Q

What are the haematological abnormalities in PET?

A
  • low platelets
  • low haemoglobin, signs of haemolysis
  • features of DIC
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13
Q

What is the management of PET?

A
  • frequent BP checks, Urine protein
  • Check symptomatology – headaches, epigastric pain, visual disturbances
  • Check for hyper-reflexia (clonus), tenderness over the liver
  • Consider induction of labour / CS if maternal or fetal condition deteriorates, irrespective of gestation
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14
Q

What is the cure for PET?

A

Delivery of the baby

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15
Q

Investigations for PET?

A

Blood investigations:

  • Full Blood Count (for hemolysis, platelets)
  • Liver Function Tests
  • Renal Function Tests – serum urea, creatinine, urate
  • Coagulation tests if indicated

Fetal investigations

  • scan for growth
  • cardiotocography (CTG)
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16
Q

What is the conservative management for PET?

A
  • Close observation of clinical signs & investigations
  • Anti-hypertensives (labetolol, methyldopa, nifedipine)
  • Steroids for fetal lung maturity if gestation < 36wks
17
Q

What is the epidemiology of PET?

A
  • 5-8% of pregnant women have PET
  • 0.5% women have severe PET & 0.05% have eclamptic seizures
  • 38% of seizures occur antepartum, 18% intrapartum, 44% postpartum
18
Q

How do we treat PET seizures?

A
  • Magnesium sulphate bolus + IV infusion
  • Control of blood pressure – IV labetolol, hydrallazine (if > 160/110)
  • Avoid fluid overload – aim for 80mls/hour fluid intake
19
Q

What is our prophylactic treatment for PET in subsequent pregnancy?

A
  • Low dose Aspirin from 12 weeks till delivery
  • Women with PET at a higher risk to develop hypertension in later life
20
Q

What is gestational diabetes?

A
  • carbohydrate intolerance with onset (or first recognised) in pregnancy
  • Abnormal glucose tolerance that reverts to normal after delivery
  • However, more at risk of developing type II diabetes later in life
21
Q

Does gestational diabetes resolved post partum?

A

Yes

22
Q

What happens to insulin requirements in pregnant women?

A

They increase due hormones from the placenta [human placental lactogen, progesterone, human chorionic gonadotrophin and cortisol] have anti-insulin properties.

23
Q

What occurs to the fetus in terms of diabetes in pregnancy?

A

Maternal glucose crosses the placenta and induces increased insulin production in the fetus. The fetal hyperinsulinemia causes macrosomia.

Post delivery – more risk of neonatal hypoglycaemia and increased risk of respiratory distress

24
Q

What are the effects on the mother, fetus and neonate of diabetes?

A

Increased risk of:

  • Fetal congenital abnormalities eg cardiac abnormalities
  • Miscarriage
  • Fetal macrosomia, polyhydramnios
  • Shoulder dystocia
  • Stillbirth
  • Increased risk of pre-eclampsia
  • Worsening: maternal nephropathy, retinopathy, hypoglycaemia, reduced awareness of hypoglycaemia
  • Infections
25
Q

What is the management pre-conception for diabetic mothers?

A
  • Improve the glycemic control, ideally blood sugars should be around 4 – 7 mmol/l pre-conception and HbA1c < 6.5% ( < 48 mmol/mol)
  • Folic acid 5mg
  • Dietary advice
  • Retinal and renal assessment
26
Q

What is the management during pregnancy for diabetic mothers/gestational diabetes?

A
  • Optimise glucose control
    • < 5.3 mmol/l - Fasting
    • < 7.8 mmol/l - 1 hour postprandial
    • < 6.4 mmol/l - 2 hours postprandial
    • < 6 mmol/l – before bedtime
  • Could continue on metformin but may need to change to insulin for tighter contol
  • Be aware of risk of hypo. [provide glucagon injections]
  • Be aware of ketonuria
  • Repeat retinal assessments 28/34 wks
  • Observe for PET
  • Labour is usually induced 38-40 wks
  • Consider elective C section if macrosomia
  • Maintain blood sugar levels in labour with insulin
  • Continuous CTG fetal monitoring in labour
27
Q

What are the RF for gestational diabetes?

A
  • increased BMI >30
  • Previous macrosomic baby > 4.5kg
  • Previous GDM
  • Family history of diabetes
  • Women from high risk groups for developing diabetes – eg. Asian origin
  • Polyhydramnios or big baby in current pregnancy
  • Recurrent glycosuria in current pregnancy
28
Q

How do we screen for GDM?

A

If risk factor present, offer HbA1C estimation at booking, if > 6% (43 mmol/mol), 75gms OGTT to be done. If OGTT normal, repeat OGTT at 24 -28 weeks [OGTT - oral glucose tolerance test]

Can also offer OGTT at around 16 weeks and repeat at 28 weeks if significant risk factors (eg. Previous GDM) present

29
Q

What is the general management of GDM?

A
  • Control blood sugars: diet, metformin and insulin
  • Post delivery: check OGTT 6 t0 8 weeks post pregnancy
  • Yearly check of the HbA1C/ blood sugars as at a higher risk of developing overt diabetes
30
Q

What makes up virchows triad?

A
  • Stasis
  • Vessel wall injury
  • Hypercoagulability

All leading to thrombosis

31
Q

What are the risks of VTE in pregnancy?

A
  • Pregnancy is a hypercoagulable state to protect mother from post partum bleeding
    • increased fibrinogen, factor VIII, platelets
    • decrease in natural anticoagulents
    • increase in fibrolysis
  • Increased stasis: progesterone, effects enlarging uterus
  • May be vascular damage on delivery
32
Q

What things will increase the risks of VTE in pregnancy?

A
  • Older mothers
  • Increased BMI
  • Smoker
  • IV drug user
  • PET
  • Dehydration
  • Decreased mobility
  • Infections
33
Q

What are our prophylactic treatments for VTE?

A
  • TED stockings
  • Advice increased mobility and increased hydration
  • Prophylactic anticoagulation with 3 or more risk factors
34
Q

What are the signs/symptoms of VTE?

A

Pain in calf, increased girth of affected leg, calf muscle tenderness, breathlessness, pain on breathing, cough, tachycardia, hypoxic, pleural rub

Reproductive (34 decks)

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