Complications of pregnancy 2 Flashcards
What is meant by chronic hypertension?
Hypertension pre-pregnancy or before 20 weeks gestation
Mild, moderate and severe chronic hypertension
mild - 140-49/90-99
moderate - 150-59/100-109
severe - >160/>110
What is meant by gestational diabetes?
new hypertension after 20 weeks
How to determine significant proteinuria - 3 ways
automated reagent strip >1
spot urinary protein:creatinine >30mg/mmol
24 hours urine protein collection >300mg/day
Important things to remember with chronic hypertension in pregnancy
more common in older women may need to change anti-hypertensives bp <150/100 super imposed PET fetal growth placental abruption
Define PET
mild HT on 2 occasions 4 hours apart or moderate - sevre HT
PLUS proteinuria >300mgsms/24 hours
Pathophysiology of PET
genetic
- secondary invasion of maternal spiral arterioles by trophoblasts is impaired - decrease placental perfusion
- imbalance between vasodilators and vasoconstrictors
immunological
Risk factors for PET
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
How is PET a multi-systemic multi-organ disorder?
renal, liver, vascular, cerebral, pulmonary
Maternal complications of PET
eclampsia - seizures severe HT - cerebral haemorrhage and stroke HELLP DIC renal failure pulmonary oedema and cardiac failure
HELLP
haemolysis, elevated liver enzymes, low platelets
Fetal complications of PET
impaired placental perfusion - IUGR, fetal distress, premature, mortality
List some symptoms/signs of PET
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
Biochemical abnormalities in severe PET
raised liver enzymes, bilirubin if HELLP
raised urea, creatinine and urate
Haemotological abnormalities in severe PET
low platelets and hb
DIC
Only cure of PET
delivery
Managing PET
frequent bp and urine checks
check symptoms and signs eg clonus
bloods - FBC, LFT, renal, coagulation
fetal investigations - growth and CTG
Conservative management of PET
Aim for fetal maturity anti-hypertensives observe signs and investigations steroids for lung maturity <36 weeks IOL, CS
What % of women have PET?
5-8
What % of PET is severe?
0.5
What % of PET goes on to have eclamptic seizures?
0.05
% of eclamptic seizures for ante, intra and post partum
ante - 38
intra - 18
post - 44
3 treatments for seizures
IV magnesium sulphate infusion and bolus
avoid fluid overload - 80ml/hour
control bp - IV labetolol, hydralazine if >160/110
Prophylaxis for PET
low dose aspirin from 12 weeks –> delivery
Do women with PET have a higher risk of developing HT in later life?
yes
2 signs of gestational diabetes
CHO intolerance with onset or first recognised in pregnancy
abnormal glucose that reverts to normal after pregnancy
What are women with GDM more at risk of developing later in life?
Type 2 DM
Why do women require more insulin in pregnancy?
human placental lactogen, hCG, cortisol and progesterone are anti-insulin
Why does fetal hyperinsulinaemia occur in GDM and the consequence of this?
maternal glucose crosses placenta and induces more insulin production in baby - macrosomia
In GDM what is there more risk of post-delivery?
neonatal hypoglycaemia
respiratory distress
RISKs of diabetes on mother, fetus and neonate
infections - stillbirth - operative delivery/shoulder dystocia - macrosomia - neonatal hypos - fetal congenital abnormalities - miscarriage - PET - neonate jaundice and impaired lung maturity - worse nephropathy and retinopathy
Preconception management of diabetes
better glycaemic control (4-7mmol/l and HbA1c <48mmol/mol)
folic acid high dose 5mg and diet
retinal and renal assessment
During pregnancy management of diabetes
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
Management of diabetes - labour and after
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
Risk factors for GDM
high BMI previous baby >4.5kg previous GDM FH of diabetes risk for diabetes eg Asian polyhydramnios recurrent glycosuria
Screening for GDM
if risk factor - offer HbA1c, >6% do OGTT
if OGTT negative repeat at 24-28 weeks
Management of GDM
control blood sugars - metformin/insulin, diet
check OGTT 6-8 weeks PN
yearly HbA1c
Virchow’s triad
stasis
vessel wall injury
hypercoaguability
Why is pregnancy hypercoaguable and pathophysiology of this
to prevent bleeding post delivery
increased fibrinogen, clotting factors, platelets
decrease in natural anticoagulants - antithrombin 3
increase in fibrinolysis
Why is there increased stasis in pregnancy ?
progesterone and enlarging uterus
When may there be vascular damage in pregnancy?
delivery/CS
Risks for VTE in pregnancy
older, parity, BMI sickle cell disease, haemophilia smokers, IVDU PET dehydration/hyperemesis previous VTE, decreased mobility, operative delivery infection, haemorrhage
VTE prophylaxis in pregnancy
TED stockings
increase mobility and hydration
anti-coagulation
signs/symptoms of VTE
sore, swollen, red leg
cough, SOB, hypoxia, pleural rub, chest pain on breathing
calf muscle tenderness
tachycardia
Investigations of VTE
V/Q scan, ECG, doppler, blood gases
CTPA
