complications of pregnancy 2 Flashcards
what is classified as mild hypertension?
140/90mmHg
what is classified as moderate HT
150/100mmHg
what is classified as severe HT
160/110mmHg
define PRE-ECLAMPSIA (PET - pre-eclampsic toxaemia)
HYPERTENSION + PROTEINURIA + OEDEMA. Hypertension on two or more occasions more than 2 hours apart. New ht >20 weeks in association with significant proteinuria (more than 300mg/day)
classify significant proteinuria
urinary:creatinine ratio >30mg/mmol or 24hrs urine protein >300mg/day
what antihypertensive drugs/ drug class causes birth defects
ACE INHIBITORS! (ramipril) (also don’t use ARB’s)
Mx of chronic hypertension in pregnancy
anti diuretics and lower dietary sodium, methyl dopa, monitor fetal growth
outline the pathophysiology of pre-eclampsia
imbalance between vasodilators and vasoconstrictors, secondary invasion of maternal arterioles by throphoblasts causing reduced placental perfusion. It may also be immunological or due to genetic predisposition
Name the Risk factors for developing pre-eclampsia
Extremes of maternal age, First pregnancy (Primigravida), BMI, Family History of pre-eclampsia, Multiple prgnancy, pre-existing renal disease, pre-exisitng: DM, autoimmune disorders, hypertension.
What are the Maternal Complications of Pre-eclampsia?
seizures, severe hypertension (stroke, cerebral haemorrhage), DIC (disseminated intravascular coagulation), renal failure, pulmonary odema, cardiac failure,
HELLP syndrome = hemolysis, elevated liver enzymes, low platelets.
What are the Fetal Complications of Pre-eclampsia?
impaired placental perfusion, premature birth = death potentially.
Sx of severe PET (pre-eclamptic toxaemia)
headache, blurring of vision, epigastric pain, pain below the ribs, vomiting. Sudden swelling of the face and legs, clonus, pappilodema, epigastric tenderness, reduced urine output, convulsions
what Ix would you do for PET
FBC - thromboycytopenia/ Blood film - haemolysis/ renal function- raised urea and creatinine/ uric acid - elevated/ LFT’s - reduced albumin, deranged liver enzymes.
24hr Urinary protein - 0.5g in 24 hours/ USS - to detect interuterine growth rate and oligohydramnios/ Doppler - record placental blood flow - this will be reduced.
Renal function tests (serum urea, creatinine and urate), coagulation tests.
Fetal Ix - scan for growth, cardiotocography (CTG)
what biochemical abnormalities seen in PET
raised liver enzymes, bilirubin if HELLP is present, raised urea and creatinine, raised urate
what haematological abnormaliites are seen in PET
low platelets, low haemaglobin, signs of haemolysis, features of DIC
Mx of PET
delivery of baby and placenta (consider induction of labour), with mainly conservative management,
use antihypertensives = METHYL DOPA and LABETOLOL, frequent bp checks, urine proteinm, check symptoms severity, check for liver tenderness and clonus.
What are the antihypertensives used for a pregnant woman?
Labetolol and Methyl dopa!
how would you treat seizures during pre-eclampsia?
MgSO4 bolus and iv infusion, control dp with iv labetolol and avoid fluid overload (aim for 80mls/hr)
what is used for prophylaxis for PET in subsequent pregnancies?
Low Dose Asprin
DEFINE GESTATIONAL DIABETES
Carbohydrate intolerance with onset in pregnancy. Abnormal glucose tolerance which reverts to normal after delivery. However this makes mothers more at risk of developing t2dm later in life.
why does insulin requirements for the mother increase if she has pre-existing diabetes?
human placental lactogen, progesterone, human chorionic gonadotrophin, and cortisol from the placenta have anti-insulin action
how does fetal hyper insulinemia occour?
maternal glucose crosses the placenta and induces increased insulin production in the fetus.
what does fetal hyperinsulinemia cause?
Macrosomia (birth weight >8Lbs), increased risk of neonatal hypoglycaemia, increased risk of repiratory distress
what are the effects of DM on the mother, fetus and neonate?
fetal congenital abnormalities (cardiac, sacral agenesis), polycythaemia, miscarriage, macrosomia - obstructed labour, polyhydramnios, shoulder dystocia, stillbirth, hypoxia, increased perinatal mortality, pre-eclampsia, organomegaly.
maternal - nephropathy, retinopathy, hypoglycaemia, infections.
on the neonate - impaired lung maturity, neonatal jaundice, hypoglycaemia.
How would you manage the DM pre-conception?
gylcaemic ocntrol (keep blood sugar 4-7mmol/l, keep HbA1c < 48mmol/mol), folic acid supplements 5mg, dietary advice, retinal and renal assesment
How would you manage the DM during pregnancy?
increase insulin requirements, provide glucagon injections to control potential risk of hypoglycaemia, observe fpr PET, of macrosomia consider caesarean section,
give dextrose insulin infusion to maintain blood sugar in labour, CTG fetal monitoring, watch for ketonuria, retinal assesments every 28-34 weeks, watch fetal growth.
what are the rf for gestational DM?
age over 25, Asian, Hispanic, Maternal obesity - BMI >30, previous macrosomia baby or gdm, fhx of T2DM, asian origin, polyhydramnios, recurrent glycosuria.
Ix to confirm diagnosis of GDM?
OGTT (a fasted woman is given a 75g oral load of glucose, then has a venous plasma test done at 2 hours. GDM is defined as a 2 hr ogtt more than or equal to 7.8umol/L)
how would you screen for GDM?
look for rf’s, HbA1c >43mmol/mol, 75gms OGTT to be done, if this is normal then repeat OGTT at 24-28 weeks.
Mx for GDM
control diet, low sugar (use a dietician) and metformin/insulin, check OGTT post delivery, monitor blood glucose levels, encourage exercise. Monitor foetus using US, arrange elective caesarean section.
What constituates virchows triad?
Stasis, hypergoagulability and vessel wall injury - all leading to thrombosis
how does pregnancy effect virchows triad?
hypercoagulable state in order to protect the mother from bleeding post delivery so there is an increase in fibrinogen, factor 8, VW factor and platelets, decrease in natural anti-coagulants (antithrombin 3) and a Decrease in fibriniolysis (Plasminogen and antiplasmin concentrations rise during pregnancy but systemic fibrinolytic activity, as measured by the euglobulin lysis time, is markedly depressed during pregnancy). There is also increased stasis due to progesterone and the effects of a enlarging uterus. there may also be vascular damage at delivery.
what increases the risks of a thrombovenous embolism?
age, parity, bmi, smokers, pet, ivdu, dehydration, decreased mobility, infections, sickle cell disease.
Mx, prophylaxis for VTE in pregnancy
TED (Thrombo-Embolic-Deterrent) stockings, mobility, hydration.
Sx and Syx for VTE
calf pain, increase in girth, tenderness, breathlessness, cough, tachycardia, hypoxia, pleural rub
what are the Ix for VTE
doppler, blood gases, v/q lung scan, CT pulmonary angiogram
what is the most common cause of large-for-date pregnancy?
Multiple pregnancy
problems associated with multiple pregnancies?
Twin-twin transfusion, increased risk of structural abnormalities, malpresentaiton, polyhydramnios, PET, PPH, Preterm labour, Placenta previa, placental abruption, locked twins, conjoined twins, low birth weight, perinatal death, Intrauterine growth restriction. IUGR. Abortion, nausea and vomiting for the mother.
apart from multiple pregnancy give other indicaitons for a c section
foetal distress, malpresentation, failed delivery, macrosomia (GDM), severe pre-eclampsia, high gravida, failed induction of labour, placenta previa, obstructed labour, cervical dystocia, IUGR and placental failure, prolapsed cord, cephalo-pelvic disproportion (CPD), maternal choice.
complicaitons of a c section to the mother?
haemorrhage, infection, bladder or bowel injury, thromboembolic disease, risk of scar rupture, increased risk of future placenta previa.
what are the classificaitons of twin pregnancies?
Monochorionic diamniotic, Monochorionic monoamniotic, Dichorionic diamniotic. On US monochorinoic - T sign. Dichorionic - Lamda sign.
what does a Monochorionic pregnancy entail in terms of complication?
twin-twin transfusion.
explain twin-twin transfusion…
Occur in 20-25% of monochorionic twins
- One fetus donate blood to the other due to vascular anastomosis
- The recipient fetus will have heart failure, polyhydramnios, and hydrops
- The donor will have IUGR & oligohydramnios
Mx of twin-twin transfuison?
amnio-reduction of the receipient twin, intra-uterine blood transfusion for the donor twin, selective fetal reduction, fetoscopic laser ablation of placental anastomosis
Antenatal Mx of multiple pregnancy?
nutrition, prevent anaemia, more frequent antenatal visits, USS, assess chorionicity at 9-10 weeks, NT test. Assess for preterm labour risk: give steroids for fetal lung maturation, assess cervical length.
what is the incidence of monozygotic twins - this is constant
4/1000 pregnancies. Due to the cleavage of a single fertilised ova.
what does the incidence of dizygotic twins increase with?
Use of Assissted reproduction techniques (ART), Age, weight, height, parity
Dx of multiple pregnancy
USS - large for date, multiple fetal HR’s, HCG and meternal serum alpha-fetoprotein elevated for gestational age. Use of ART.
how do dichorionic diamniotic twins form?
Cleavage in the first 3 days after fertilization
Each fetus will be surrounded by amnion & chorion( each fetus has its own placenta)like dizygotic twins
Has the lowest mortality rate of monozygotic twins <10% of all monozygotic twins
how do monochorionic diamniotic twins form?
Cleavage between day 4 and 8 after fertilization
Share single placenta but separate amniotic sac
The mortality is 25%
how do monochorionic monoamniotic twins form?
< 1% of cases
Cleavage after the 8th day (day 9-12)
Share single placenta & single sac
Mortality is 50-60%, usually before 32 weeks
what day is the cleavage of conjoined twins?
after day 12. The fetuses may fuse in a number of ways, most commonly chestand/or abdomen.
what are the causes of perinatal mortality and morbidity?
prematurity, birth trauma, cerebral haemorrhage, birth asphyxia, congenital abnormalities, still birth.
what do dichorionic twins look like of USS - what sign is seen?
Lamda sign.
what do monochorionic twins look like of USS - what sign is seen?
T sign.
