Complications of pregnancy 2

Question 1

What is meant by chronic hypertension?

Answer 1

Hypertension pre-pregnancy or before 20 weeks gestation

Question 2

Mild, moderate and severe chronic hypertension

Answer 2

mild - 140-49/90-99
moderate - 150-59/100-109
severe - >160/>110

Question 3

What is meant by gestational diabetes?

Answer 3

new hypertension after 20 weeks

Question 4

How to determine significant proteinuria - 3 ways

Answer 4

automated reagent strip >1
spot urinary protein:creatinine >30mg/mmol
24 hours urine protein collection >300mg/day

Question 5

Important things to remember with chronic hypertension in pregnancy

Answer 5

more common in older women 
may need to change anti-hypertensives
bp <150/100
super imposed PET
fetal growth 
placental abruption

Question 6

Define PET

Answer 6

mild HT on 2 occasions 4 hours apart or moderate - sevre HT

PLUS proteinuria >300mgsms/24 hours

Question 7

Pathophysiology of PET

Answer 7

genetic
- secondary invasion of maternal spiral arterioles by trophoblasts is impaired - decrease placental perfusion
- imbalance between vasodilators and vasoconstrictors
immunological

Question 8

Risk factors for PET

Answer 8

BMI>35
PET in previous pregnancy 
pregnancy interval >10 years 
family history of PET 
extremes of maternal age
chronic HT/renal disease/DM
first pregnancy 
multiple pregnancy

Question 9

How is PET a multi-systemic multi-organ disorder?

Answer 9

renal, liver, vascular, cerebral, pulmonary

Question 10

Maternal complications of PET

Answer 10

eclampsia - seizures 
severe HT - cerebral haemorrhage and stroke
HELLP 
DIC 
renal failure 
pulmonary oedema and cardiac failure

Question 11

HELLP

Answer 11

haemolysis, elevated liver enzymes, low platelets

Question 12

Fetal complications of PET

Answer 12

impaired placental perfusion - IUGR, fetal distress, premature, mortality

Question 13

List some symptoms/signs of PET

Answer 13

headache, blurred vision, epigastric pain, pain below ribs, vomiting, sudden swelling of face/legs/hands
severe HT >3+ proteinuria 
clonus/brisk reflexes, papilloedema 
decreased urine output 
convulsions

Question 14

Biochemical abnormalities in severe PET

Answer 14

raised liver enzymes, bilirubin if HELLP

raised urea, creatinine and urate

Question 15

Haemotological abnormalities in severe PET

Answer 15

low platelets and hb

DIC

Question 16

Only cure of PET

Answer 16

delivery

Question 17

Managing PET

Answer 17

frequent bp and urine checks
check symptoms and signs eg clonus
bloods - FBC, LFT, renal, coagulation
fetal investigations - growth and CTG

Question 18

Conservative management of PET

Answer 18

Aim for fetal maturity
anti-hypertensives 
observe signs and investigations 
steroids for lung maturity <36 weeks 
IOL, CS

Question 19

What % of women have PET?

Answer 19

5-8

Question 20

What % of PET is severe?

Answer 20

0.5

Question 21

What % of PET goes on to have eclamptic seizures?

Answer 21

0.05

Question 22

% of eclamptic seizures for ante, intra and post partum

Answer 22

ante - 38
intra - 18
post - 44

Question 23

3 treatments for seizures

Answer 23

IV magnesium sulphate infusion and bolus
avoid fluid overload - 80ml/hour
control bp - IV labetolol, hydralazine if >160/110

Question 24

Prophylaxis for PET

Answer 24

low dose aspirin from 12 weeks –> delivery

Question 25

Do women with PET have a higher risk of developing HT in later life?

Answer 25

yes

Question 26

2 signs of gestational diabetes

Answer 26

CHO intolerance with onset or first recognised in pregnancy | abnormal glucose that reverts to normal after pregnancy

Question 27

What are women with GDM more at risk of developing later in life?

Answer 27

Type 2 DM

Question 28

Why do women require more insulin in pregnancy?

Answer 28

human placental lactogen, hCG, cortisol and progesterone are anti-insulin

Question 29

Why does fetal hyperinsulinaemia occur in GDM and the consequence of this?

Answer 29

maternal glucose crosses placenta and induces more insulin production in baby - macrosomia

Question 30

In GDM what is there more risk of post-delivery?

Answer 30

neonatal hypoglycaemia | respiratory distress

Question 31

RISKs of diabetes on mother, fetus and neonate

Answer 31

infections - stillbirth - operative delivery/shoulder dystocia - macrosomia - neonatal hypos - fetal congenital abnormalities - miscarriage - PET - neonate jaundice and impaired lung maturity - worse nephropathy and retinopathy

Question 32

Preconception management of diabetes

Answer 32

better glycaemic control (4-7mmol/l and HbA1c <48mmol/mol) folic acid high dose 5mg and diet retinal and renal assessment

Question 33

During pregnancy management of diabetes

Answer 33

optimise glucose control - could continue metformin but may need to change to insulin risk of hypos - glucagon injections/concentrated glucose solutions watch for ketonuria and infections repeat retinal assessment at 28 and 34 weeks watch fetal growth

Question 34

Management of diabetes - labour and after

Answer 34

observe for PET IOL early (38-40 weeks) or elective CS if macrosomia dextrose insulin infusion in labour CTG, fetal feeding early resume pre pregnancy insulin regimen after delivery

Question 35

Risk factors for GDM

Answer 35

``` high BMI previous baby >4.5kg previous GDM FH of diabetes risk for diabetes eg Asian polyhydramnios recurrent glycosuria ```

Question 36

Screening for GDM

Answer 36

if risk factor - offer HbA1c, >6% do OGTT | if OGTT negative repeat at 24-28 weeks

Question 37

Management of GDM

Answer 37

control blood sugars - metformin/insulin, diet check OGTT 6-8 weeks PN yearly HbA1c

Question 38

Virchow's triad

Answer 38

stasis vessel wall injury hypercoaguability

Question 39

Why is pregnancy hypercoaguable and pathophysiology of this

Answer 39

to prevent bleeding post delivery increased fibrinogen, clotting factors, platelets decrease in natural anticoagulants - antithrombin 3 increase in fibrinolysis

Question 40

Why is there increased stasis in pregnancy ?

Answer 40

progesterone and enlarging uterus

Question 41

When may there be vascular damage in pregnancy?

Answer 41

delivery/CS

Question 42

Risks for VTE in pregnancy

Answer 42

``` older, parity, BMI sickle cell disease, haemophilia smokers, IVDU PET dehydration/hyperemesis previous VTE, decreased mobility, operative delivery infection, haemorrhage ```

Question 43

VTE prophylaxis in pregnancy

Answer 43

TED stockings increase mobility and hydration anti-coagulation

Question 44

signs/symptoms of VTE

Answer 44

sore, swollen, red leg cough, SOB, hypoxia, pleural rub, chest pain on breathing calf muscle tenderness tachycardia

Question 45

Investigations of VTE

Answer 45

V/Q scan, ECG, doppler, blood gases | CTPA