Complications of pregnancy 2 Flashcards
What is the definition of chronic hypertension in pregnancy?
- 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
What is gestational hypertension?
Hypertension that in induced due to the pregnancy.
Develops after 20 wks.
What is pre-eclampsia? What is it’s definition?
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
What is the pathophysiology of pre-eclampsia?
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
What is classed as significant proteinurea?
Automated reagent strip urine protein estimation > 1+
Spot Urinary Protein: Creatinine Ratio > 30 mg/mmol
24 hours urine protein collection > 300mg/ day
Who is most likely to have chronic hypertension and what should there management steps be?
- 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
Who is at risk of Pre-eclampsia?
- 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
What organs can pre-eclampsia effect?
renal, liver, vascular, cerebral, pulmonary
What are the complications of pre-eclamsia?
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
Sign/symptoms of Pre-eclampsia?
- 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)
What are biochem abnormalities of pre-eclampsia?
- raised liver enzymes, bilirubin if HELLP present
- raised urea and creatinine, raised urate
What are the haematological abnormalities in PET?
- low platelets
- low haemoglobin, signs of haemolysis
- features of DIC
What is the management of PET?
- 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
What is the cure for PET?
Delivery of the baby
Investigations for PET?
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)
What is the conservative management for PET?
- Close observation of clinical signs & investigations
- Anti-hypertensives (labetolol, methyldopa, nifedipine)
- Steroids for fetal lung maturity if gestation < 36wks
What is the epidemiology of PET?
- 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
How do we treat PET seizures?
- Magnesium sulphate bolus + IV infusion
- Control of blood pressure – IV labetolol, hydrallazine (if > 160/110)
- Avoid fluid overload – aim for 80mls/hour fluid intake
What is our prophylactic treatment for PET in subsequent pregnancy?
- Low dose Aspirin from 12 weeks till delivery
- Women with PET at a higher risk to develop hypertension in later life
What is gestational diabetes?
- 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
Does gestational diabetes resolved post partum?
Yes
What happens to insulin requirements in pregnant women?
They increase due hormones from the placenta [human placental lactogen, progesterone, human chorionic gonadotrophin and cortisol] have anti-insulin properties.
What occurs to the fetus in terms of diabetes in pregnancy?
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
What are the effects on the mother, fetus and neonate of diabetes?
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
What is the management pre-conception for diabetic mothers?
- 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
What is the management during pregnancy for diabetic mothers/gestational diabetes?
- 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
What are the RF for gestational diabetes?
- 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
How do we screen for GDM?
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
What is the general management of GDM?
- 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
What makes up virchows triad?
- Stasis
- Vessel wall injury
- Hypercoagulability
All leading to thrombosis
What are the risks of VTE in pregnancy?
- 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
What things will increase the risks of VTE in pregnancy?
- Older mothers
- Increased BMI
- Smoker
- IV drug user
- PET
- Dehydration
- Decreased mobility
- Infections
What are our prophylactic treatments for VTE?
- TED stockings
- Advice increased mobility and increased hydration
- Prophylactic anticoagulation with 3 or more risk factors
What are the signs/symptoms of VTE?
Pain in calf, increased girth of affected leg, calf muscle tenderness, breathlessness, pain on breathing, cough, tachycardia, hypoxic, pleural rub
