Complications of Pregnancy 2 Flashcards
what is chronic/essential hypertension in pregnancy?
This is HT that exists either pre-pregnancy or at booking (≤20 weeks gestation).
hypertension in pregnancy: mild
diastolic 90-99
systolic 140-49
hypertension in pregnancy: moderate
diastolic 100-9
s 150-9
hypertension in pregnancy: severe
d >=110
s >= 160
what antihypertensive drugs can cause birth defects and impaired growth?
ramipril
enalopril
ARBs - lostartan, candestartan
diuretics
what anti-hypertensive drugs are suitable during pregnancy?
labetolol
nifedipine
methyldopa
what is gestational hypertension?
Aka pregnancy induced hypertension (PIH). This is the classified in the same way as chronic but develops after 20 weeks
what is pre-eclampsia
New hypertension > 20 weeks in associate with significant proteinuria.
Definition:
Mild HT on two occasions more than 4 hours apart
or
Moderate to severe HT
+
Proteinuria of more than 300 mgms/24 hours
define significant proteinuria
- Automated reagent strip urine protein estimation >1+
- Spot urinary protein creatinine ratio >30mg/mmol
- 24 hours urine protein collection >300mg/day
pathophysiology of pre-eclampsia
It can be immunological or a genetic predisposition. Some theories include secondary invasion of maternal spiral arterioles by trophoblasts impaired resulting in reduced placental perfusion or an imbalance between vasodilators/vasoconstrictors in pregnancy. Prostacyclin/thromboxane.
risk factors for developing pre-eclampsia
• First pregnancy • Extremes of maternal age • Previous pre-eclampsia (esp. severe PET, delivery <34 weeks, IUGR baby, IUD, abruption) • Pregnancy interval > 10 years • BMI > 35 • Family history of PET • Multiple pregnancy • Underlying medical disorders o Chronic hypertension o Pre-existing renal disease o Pre-existing diabetes o Autoimmune disorders e.g. antiphospholipid antibodies, SLE
pre-eclampsia: what organs does it affect?
kidneys liver vascular cerebral pulmonary
pre-eclampsia: complications maternal
eclampsia severe HT HELLP DIC renal failure pulmonary oedema, cardiac failure
what is HELLP syndrome?
haemolysis
elevated liver enzymes
low platelets
pre-eclampsia: complications foetal
impaired placental perfusion:
severe pre-eclampsia: symptoms/signs
o Headache, blurring of vision, epigastric pain, pain below ribs, vomiting, sudden
swelling of hands, face and legs
o Severe hypertension > 3+ proteinuria
o Clonus/brisk reflexes, papilledema, epigastric tenderness
o Reducing urine output
o Convulsions (eclampsia)
severe pre-eclampsia: biochemical abnormalities
raised liver enzymes, bilirubin if HELLP present
raised urea and creatinine, raised urate
severe pre-eclampsia: haematological abnormalities
low platelets
low haemoglobin, signs of haemolysis
features of DIC
management of pre-eclampsia
• Frequent BP checks, urine protein
• Check symptomatology
o Headaches
o Epigastric pain
o Visual disturbances
• Check for hyper-reflexia (clonus), tenderness over the liber
• Blood investigations
o FBC (for haemolysis, platelets)
o LFTs
o U+Es
o Coagulation tests if indicated
• Foetal investigations
o Scan for growth
o CTG
• The only cure for PET is delivery of the baby and placenta
• Conservative (aim for foetal maturity)
o Close observation of clinical signs and investigations
o Anti-hypertensives (labetolol, methyldopa, nifedipine)
o Steroids for foetal lung maturity if gestation <36 weeks
• Consider induction of labour/CS if maternal or foetal condition deteriorates, irrespective of
gestation
treatment of eclampsia
• Seizures can happen at any time – during pregnancy, labour
• Treatment of seizures/impending seizures
o Magnesium sulphate bolus + IV infusion
o Control of BP – IV labetolol, hydralazine if >160/110
o Avoid fluid overload – aim for 80mls/hr fluid intake
prophylaxis for PET in subsequent pregnancy
low dose aspirin from 12 weeks till delivery
what is gestational diabetes
b. Abnormal glucose tolerance that reverts to normal after delivery
c. However, more at risk of developing type II diabetes later in life
discuss pre-existing diabetes and pregnancy
Insulin requirements of the mother increase as human placental lactogen, progesterone, human
chorionic gonadotrophin and cortisol from the placenta have anti-insulin actions. Foetal hyperinsulinemia
occurs as maternal glucose crosses the placenta and induces increased insulin production
in the foetus. The foetal hyperinsulinemia causes macrosomia. Post-delivery there is a greater risk of
neonatal hypoglycaemia.
effects of diabetes on mother, foetus and neonate
• Increased risk of:
o Foetal congenital abnormalities (especially if blood sugars high peri-conception)
o Miscarriage
o Pre-eclampsia
o Foetal macrosomia, polyhydramnios
o Operative delivery, shoulder dystocia
o Worsening of maternal nephropathy, retinopathy, hypoglycaemia, reduced
awareness of hypoglycaemia
• Infections
• Stillbirth, increased perinatal mortality
• Neonatal
o Impaired lung maturity, neonatal hypoglycaemia, jaundice
management of diabetes and pregnancy: preconception
o Better glycaemic control, ideally blood sugars should be around 4-7 mmol/l preconception o HbA1c < 6.5% (<48 mmol/mol) o Folic acid 5mg o Dietary advice o Retinal and renal assessment
management of diabetes and pregnancy: during pregnancy
o Optimise glucose control – insulin requirements will increase
§ <5.3 mmol/l fasting
§ <7.8 mmol/l 1 hour postprandial
§ <6.4 mmol/l 2 hours postprandial
§ <6 mmol/l before bedtime
o Could continue oral anti-diabetic agents (metformin) but may need to change to
insulin for tighter glucose control
o Should be aware of the risk of hypoglycaemia – provide glucagon injections/conc.
Glucose solution
o Watch for ketonuria/infections
o Repeat retinal assessments 28 and 34 weeks
o Watch foetal growth
management of diabetes and pregnancy: labour
- Observe for PET
- Labour usually induced 38-40 weeks, earlier if foetal or maternal concerns
- Consider elective C-section if significant foetal macrosomia
- Maintain blood sugar in labour with insulin – dextrose insulin infusion
- Continuous CTG foetal monitoring in labour
- Early feeding of baby to reduce neonatal hypoglycaemia
- Can go back to pregnancy regimen of insulin post delivery
risk factors for gestational diabetes
• Increased BMI >30
• Previous macrosomic baby > 4.5 kg
• Previous GDM
• Family history of diabetes
• Women from high risk groups for developing diabetes e.g. Asian origin
• Polyhydramnios or big baby in current pregnancy
• Recurrent glycosuria in current pregnancy
GDM associated with some increase in maternal complications (e.g. PET) and foetal complications (macrosomia) but much less than with type I or II diabetes.
screening for gestational diabetes
If risk factors 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. Can also offer OGTT at around 16 weeks and repeat at 28 weeks if significant risk factors (e.g. previous GDM present).
management of gestational diabetes
• Control of blood sugars
o Diet
o Metformin/insulin if sugars remain high
• Post-delivery check OGTT 608 weeks PN
• Yearly check on HbA1C/blood sugars as at a higher risk of developing overt diabetes
why are pregnant women more at risk of VTE?
Pregnancy is a hypercoagulable state to protect the mother against bleeding post-delivery. However, this puts women at a greater risk of VTE. There is an increase in fibrinogen, factor VIII, VW factor and platelets. Decrease in natural anticoagulants such as antithrombin III. Finally, there is an increase in fibrinolysis.
risk factors for VTE in pregnancy
- Older mothers, increasing parity
- Increased BMI, smokers
- IVDU
- PET
- Dehydration – hyperemesis
- Decreased mobility
- Infections
- Operative delivery, prolonged labour
- Haemorrhage, blood loss > 2l
- Previous VTE (not explained by other predisposing injuries e.g. fractures), those with thrombophilia (protein C, protein S, anti-thrombin III deficiencies etc), strong family Hx of VTE
- Sickle cell disease
VTE in pregnancy prophylaxis and treatment
• TED stockings
• Advise increased mobility
• Prophylactic anti-coagulation with 3 or more risk factors (may be indicated even with one risk
factor if significant risk), may need to continue 6 weeks postpartum
o Dalteparin
Appropriate treatment with anticoagulation if VTE confirmed
signs and symptoms of VTE in pregnancy
o Pain in calf o Breathlessness o Pain on breathing o Cough o Tachycardia o Hypoxic o Increased girth of affected leg o Calf muscle tenderness o Pleural rub
investigations of VTE in pregnancy
o ECG o BG o Doppler o V/Q lung scan o CTPA
