Complications of pregnancy Flashcards
Define pre-eclampsia
New onset HTN in pregnancy with end-organ dysfunction, with proteinuria
When does pre-eclampsia typically occur?
20+ weeks gestation
What is the brief pathophysiology behind pre-eclampsia?
Spiral arteries of placenta form abnormally -> leads to high vascular resistance in these vessels.
Systemic BP increases
What are complications of pre-eclampsia?
Maternal organ damage FGR Seizures Preterm labour Death
What is the triad of pre-eclampsia?
Hypertension
Proteinuria
Oedema
Difference between pregnancy-induced HTN and pre-eclampsia?
Pregnancy-induced HTN does not result in proteinuria
Define eclampsia
Seizures resulting from pre-eclampsia
What are HIGH risk factors for pre-eclampsia?
Pre-existing HTN Previous HTN in pregnancy Exisiting autoimmune conditions (e.g. SLE) Diabetes CKD
What are MODERATE risk factors for pre-eclampsia?
40 yo+ BMI >35 10 years+ since previous pregnancy Multiple pregnancy First pregnancy Family history of pre-eclampsia
What is the criteria for giving prophylactic aspirin to women to protect against pre-eclampsia?
1 high risk factor
or
1+ moderate risk factor
At which gestational age onwards are women offered aspirin against pre-eclampsia?
12 weeks on wards
What drug is used prophylatically against pre-eclampsia?
Aspirin
Give symptoms of pre-eclampsia
Headache Visual disturbance/blurred Nausea/vomiting Upper abdo/epigastric pain Oedema Reduced urine output Brisk reflexes
NICE recommends using _____ between 20-35 weeks gestation to rule out pre-eclampsia
PIGF
Placental growth factor - stimulates development of new blood vessels
PIGF is low in pre-eclampsia
Give pre-eclampsia BP values (NICE guidelines)
140+ systolic
90+ diastrolic
Apart from BP, what other NICE criteria are used to diagnose pre-eclampsia?
Organ dysfunction (raised CK, raised liver enzymes, seizures, thrombocytopenia, haemolytic anaemia)
Proteinuria (1+ on urine dipstick)
Placental dysfunction (FGR, abnormal Doppler studies)
What two measurements can be used to quantify proteinuria?
Urine albumin:creatinine ratio (30+mg/mmol significant)
Urine protein:creatinine ratio (8+mg/mmol significant)
How is pre-eclampsia monitored at every antenatal appointment?
BP
Urine dip ?proteinuria
Symptom check
How is gestational hypertension (without proteinuria) managed?
List 6 ways
Aim lower than 135/85mmHg
Admit women with BP 160/100+ mmHg
Urine dip weekly
Blood tests weekly (FBC, liver enzymes, renal profile)
Serial growth scans to monitor fetal growth
PIGF testing (1x occasion)
How is pre-eclampsia managed differently to gestational hypertension?
List 4 differences
Same as gestational HTN but:
- scoring systems used to determine whether to admit woman fullPIERS or PREP-S
- BP monitored more frequently (48 hrs)
- Urine dip not necessary as diagnosis made
- USS monitoring of fetus, amniotic fluid and doppler performed 2 weekly
What scoring systems are used with pre-eclampsia to decide whether to admit the woman?
fullPIERS
or
PREP-S
Pre-eclampsia hypertension is managed by the drug ______ first line as anti-HTN.
Second line drug is _______
1st line: Labetolol
2nd line: Nifedipine
What drug can be used as a critical-care anti-HTN in severe pre-eclampsia/eclampsia?
IV hydralazine
What drug is given IV during labour and 24hr after to prevent eclampsia seizures?
IV magnesium sulfate
____ _____ is used during labour in severe pre-eclampsia/eclampsia to avoid fluid overload
Fluid restriction
What drug is given to women having premature birth to help mature the fetal lungs?
Corticosteroids
AFTER delivery, what drug is given 1st line to control BP in pre-eclampsia?
Enalapril
Nifedipine/amlodipine first-line in black African/Carrib patients
What is HELLP syndrome?
What does it stand for?
Combination of pre-eclampsia/eclampsia features
H - Haemolysis
EL - Elevated Liver enzymes
LP - Low Platelets
How is HELLP syndrome best treated?
Deliver the baby ASAP
What are complications of HELLP syndrome?
Stroke
Organ problems (pulmonary oedema, kidney failure, liver failure)
DIC
Baby delivered early -> neonatal respiratory distress
Stillbirth
_____ insulin sensitivity during pregnancy causes _____ _____
Reduced
Gestational diabetes
What are the most significant complications of GDM?
LGA (macrosomia)
Neonatal hypoglycaemia
What is a long-term complication of GDM?
T2DM later after pregnancy
Anyone with risk factors for GDM should be screened with an _________ at 24-28 weeks gesetation.
OGTT
When is the OGTT carried out?
24-28 weeks gestation
What are risk factors for GDM?
List 5
Previous GDM
Previous macrosomic baby (>4.5kg)
BMI > 30
Ethnic origin
Family history of DM (1st degree relative)
If no risk factors, when is OGTT used?
LGA fetus
Polyhydramnios
Glucose on urine dipstick
When are the blood sugar measurements taken for OGTT?
Before 75g glucose drink (fasting BG)
After 2 hours post-drink
What are normal results for blood sugar in the OGTT?
Fasting <5.6mmol/l
At 2 hours >7.8mmol/l
Results higher means GDM
*(remember results cutoff using 5,6,7,8)
When are the 4 USS scans done with GDM?
Between 28 to 36 weeks
The scans monitor fetal growth and amniotic fluid volume.
GDM: Fasting glucose less than 7 mmol/l
How is it managed?
Diet and exercise 1-2 weeks then Metformin then Insulin
GDM: Fasting glucose more than 7 mmol/l
How is it managed?
Insulin
then
Metformin
GDM: Fasting glucose above 6 mmol/l plus macrosomia
How is it managed?
Insulin
then
Metformin
If a woman declines insulin or cannot tolerate metformin, what drug can be given?
Glibenclamide (sulfonylurea)
What are the NICE target levels for blood sugar?
- Fasting
- 1 hour post-meal
- 2 hours post-meal
- Avoid levels ___ or below
- 5.3 mmol/l
- 7.8 mmol/l
- 6.4 mmol/l
- 4 mmol/l
What supplement should women with existing diabetes take when concieving?
When should this be taken?
5mg Folic acid
From preconception until 12 weeks gestation
How are women with existing T2DM managed in pregnancy?
Metformin + insulin only (other oral diabetic meds are stopped!)
How does planned delivery differ between woman with pre-existing diabetes and GDM?
Pre-existing diabetic women - must give birth 37 - 38+6 weeks
GDM can give birth up to 40+6
What medication therapy is given to women in labour who have T1DM?
(also for women with poor control of BG in GDM or T2DM)
Insulin sliding-scale regime
Dextrose and insulin titrated to blood sugar levels
What screening is important during pregnancy for women with existing diabetes?
Retinopathy
When can GDM women stop their diabetic meds?
When should they follow up their fasting glucose after the baby is born?
Can stop meds immediately after birth
6 weeks post birth
Why does neonatal hypoglcaemia occur in the neonate with a GDM mother?
Increased insulin sensitivity after birth and with breastfeeding
(Babies become accustomed to large supply of glucose during pregnancy. After birth, they struggle to maintain the supply they are used to with oral feeding alone)
Babies of mothers with diabetes are at risk of:
List 5
Neonatal hypoglycaemia Polycythemia Jaundice Congenital heart disease Cardiomyopathy
How are babies monitored for neonatal hypoglycaemia?
What is the cutoff blood sugar?
Regular BG checks and frequent feeds
Maintain 2+ mmol/l
How is neonatal hypoglycaemia treated?
IV dextrose via NG tube
Anaemia is defined as a low _____ in the blood
Haemoglobin
When are women routinely screened for anaemia during pregnancy?
(Hint there are 2 times)
- Booking clinic
2. 28 weeks gestation
Why does anaemia occur in pregnancy?
Plasma volume increases
Hb concentration reduces (blood diluted due to higher plasma volume)
Why is it important to treat anaemia during pregnancy?
To ensure woman has enough blood reserves in case there is significant blood loss during delivery.
Give features of anaemic women presenting.
SOB
Fatigue
Dizziness
Pallor
What are normal ranges for Hb during pregnancy at:
- Booking bloods
- 28 weeks gestation
- Post-partum
- > 110 g/l
- > 105 g/l
- > 100g/l
What blood test measurement can indicate the CAUSE of the anaemia?
MCV
What does low MCV in anaemia show?
Iron deficiency
What does normal MCV in anaemia show?
Physiological anaemia due to increased plasma voluime of pregnancy
What does raised MCV in anaemia show?
B12/folate deficiency
What other blood tests apart from FBC can establish cause of anaemia?
Ferritin
B12
Folate
aka Haematinics
What are women with anaemia in pregancy started on?
Ferrous sulphate (iron replacement)
Women with low B12 should be tested for what condition? And how?
Perniciuous anaemia
Check for Intrinsic Factor antibodies
How is low B12 treated in anaemia?
Give 2 drugs
IM hydroxocobalamin injections
Oral cyanocobalamin tablets
How much folic acid should women take normally per day?
400mcg per day
Women with folate deficiency are started on how much folic acid per day?
5mg daily (5000mcg)
What supplements should be given to women with thalassaemia or sickle cell anaemia?
5mg folic acid daily
Close monitoring and transfusions when required
Requires specialist haematologist input
How is SCD detected prenatally?
Chorionic villus sampling
Screening partners of heterozygotic pregnant women
What are maternal complications of SCD?
Acute painful crsises
Pre-eclampsia
Thrombosis
What are fetal complications of SCD?
Miscarriage
FGR
Preterm labour
Death
What lab test detects SCD?
Hb electrophoresis
How is SCD managed:
a) conservatively
b) medically
a) avoid dehydration
b) penicillin V, folic acid. aspirin vs pre-eclampsia, LMWH
monthly urine cultures
Why is hydroxycarbamide stopped pre-pregnancy for SCD?
Teratogenic
Why is iron avoided in SCD pregnancies?
Iron overload
Can lead to pregnancy loss
Does obstretric cholestasis resolve after ______ of the baby?
Delivery
Obstretric cholestasis usually develops _____ in pregnancy - around __ weeks
Later (28 weeks)
Obstetric cholestasis is the results of increased ______ and ______ levels
Oestrogen
Progesterone
Obstetric cholestasis is more common in women of _________ ethnicity
South Asian
Itching of the palms and soles of feet in pregnancy can indicate what?
Obstetric cholestasis
What is the danger of untreated obstetric cholestasis?
Increased risk of stillbirth
Fatigue, dark urine, pale greasy stools and jaundice in pregnancy indicate what?
Obstetric cholestasis
Is there a rash with obstetric cholestasis?
No
If there is: consider either polymorphic eruption of pregnancy or pemphigoid gestationis
List differentials of obstetric cholestasis
Gallstones
Acute fatty liver
Autoimmune hepatitis
Viral hepatitis
Which investigations are needed for obstetric cholestasis?
LFTs (deranged ALT, AST, GGT) *ALP normally raised in pregnancy due to placental production, doesn’t indicate liver pathology
Bile acids (raised)
What is the primary treatment for obstetric cholestasis?
Ursodeoxycholic acid
Itching: emollients, antihistamines for sleeping
If clotting (prothrombin time) is deranged, what medication can be given?
Water-soluble vitamin K
How would obstetric cholestasis affect delivery?
Planned delivery after 37 weeks considered (especially if LFTs/bile acids deranged)
Stillbirth difficult to predict, early delivery reduces risk
What are maternal risks associated with obesity?
VTE Pre-eclampsia Diabetes C-section delivery Would infections Difficult surgery PPH Maternal death
What are fetal risks associated with obesity?
Congenital abnormalities (NTD)
Perinatal mortality
USS is less accurate
What advice can be given to obese women before pregnancy?
Lose weight before conception
*Weight loss DURING pregnancy not advised!
What medication/supplement can be given to obese pregnant women?
Folic acid high dose (5mg) Vitamin D VTE prophylaxis (if BMI >40)
What are the 3 most common causes of antepartum hemorrhage?
Placental abruption
Placenta praevia
Vasa praevia
An APH is small and painless but the placenta is not praevia.
What is the likely cause?
Impossible to find a cause.
USS is useless. Perhaps is a minor placental abruption.
What is placenta praevia?
Placenta attached in lower part of the uterus, lower than the presenting part of the foetus.
It is a cause of APH.
(placenta is OVER the internal cervical os)
*Low-lying placenta is used when placenta is within 20mm of internal cervical os. (RCOG guidelines)
What are causes of spotting or minor bleeding in pregnancy?
Cervical ectropion
Infection
Vaginal abrasions (intercourse/procedures)
What are risks of placenta praevia for the mother?
APH
Emergency C-section
Emergency hysterectomy
Maternal anaemia/transfusions
What are risks of placenta praevia for the foetus?
Preterm birth
Low birth weight
Stillbirth
What are risk factors for placenta praevia?
Previous C-sections Previous placenta praevia Older maternal age Maternal smoking Fibroids (+ other uterine structure issues) IVF
When and how is placental praevia diagnosed in the UK?
20-week anomaly scan assesses position of placenta (diagnoses placenta praevia)
How would women with placenta praevia present usually?
Mostly asymptomatic
Perhaps painless vaginal bleeding around 36 weeks+
How is low-lying/placenta praevia managed?
Repeat transvaginal USS (32, 36 weeks)
Corticosteroids (mature fetal lungs)
Planned delivery (reduce risk of spontaneous labour, bleeding)
C-section (planned or emergency)
How is hemorrhage with placenta praevia managed?
Emergency C-section Blood transfusions Intrauterine balloon tamponade Uterine artery occlusion Emergency hysterectomy
What is placental abruption?
Placenta separates from wall of uterus during pregnancy.
Site of attachment bleeds extensively after placenta separates.
It is a cause of APH.
How is the severity of antepartum haemorrhage graded? (Hint: 4 points)
- Spotting (blood on underwear)
- Minor haemorrhage (<50ml)
- Major haemorrhage (50-1000ml)
- Massive haemorrhage (1000ml+ or shock)
What are risk factors for placental abruption?
Previous placental abruption Pre-eclampsia Bleeding early in pregnancy Trauma (?domestic violence) Multiple pregnancy Fetal growth restriction Multigravida Increased maternal age Smoking Cocaine or ampetamine
Sudden onset, continuous, severe abdo pain
Vaginal bleeding
Shock (hypotension and tachycardia)
CTG shows foetal distress
“Woody” abdomen on palpation (suggesting large haemorrhage)
All these features suggest what pathology?
Placental abruption
What is concealed placental abruption vs revealed placental abruption?
Concealed = cervical os closed, any bleeding contained within uterine cavity.
Revealed = cervical os opened, blood loss observed coming out of vagina
How is placental abruption diagnosed?
Clinical diagnosis based on presentation
*no reliable test for diagnosis
The urgency of placental abruption depends on which 4 factors?
- Amount of placental separation
- Extent of bleeding
- Haemodynamic stability of mother
- Condition of foetus
In placental abruption, if a major/massive occurs what are the initial management steps?
Senior obs, midwife, anaesthetist all involved
Cannulate
Bloods (FBC, U&E, LFT, coag)
Crossmatch 4 units of blood
Fluid and blood resuscitation as required
CTG monitoring
Close monitoring of mother
Is USS useful for diagnosing or assessing abruption?
No, but can exclude other causes of APH (placenta praevia)
What test detects the amount of foetal blood mixed with maternal blood?
(Done in order to determine dose of anti-D required)
Kleihauer test
What is a major complication after delivery in women with placental abruption?
PPH
What is vasa praevia?
When foetal vessels travel across the internal cervical os, thus being exposed.
The vessels are therefore unprotected by either the umbilical cord (Wharton’s jelly) or placenta
What vessels does the umbilical cord contain?
Umbilical arteries and vein
What is Wharton’s jelly?
Which condition is it implicated in?
Layer of soft connective tissue that surrounds blood vessels in umbilical cord, protecting them
Wharton’s jelly does not protect the vessels in vasa praevia
What 2 instances can occur with vasa previa involving the position of the blood vessels?
Type 1. Velamentous umbilical cord (vessels run from placenta to umbilical cord)
Type 2. Multi-lobed placenta with vessels running between the 2 lobes of placenta
What are risk factors for vasa praevia?
Low-lying placenta
IVF
Multiple pregnancy
How is vasa praevia diagnosed and why is this done?
USS - not always reliable however
Allows planned C-section to reduce risk of hemorrhage
How can vasa praevia present?
What can be found on examination?
APH
Vaginal examination = pulsating fetal vessels seen in the membranes through the dilated cervix
During labour, how may vasa praevia present?
Why is this important?
Fetal distress
Dark-red bleeding following rupture of membranes
Very high fetal mortality, even with emergency C-section
For asymptomatic women with vasa praevia, what management is recommended?
Corticosterids (@32wks,
mature fetal lungs)
Elective C-section (34-36 wks)
After stillbirth or unexplained fetal compromise during delivery, why may the placenta be examined?
?vasa praevia as a possible cause
What is ectopic pregnancy?
Pregnancy implanted outside uterus - most commonly fallopian tube.
*can also be ovary, cervix or abdomen
What are risk factors for ectopic pregnancy?
Previous ectopic pregnancy
Previous PID
Previous surgery to fallopian tubes
Intrauterine devices (coils)
Older age
Smoking
What gestational age does ectopic pregnancy usually present?
6-8 weeks gestation
What are the classic features of an ectopic pregnancy?
Missed period
Constant lower abdo pain in RIF or LIF
Vaginal bleeding
Lower abdo or pelvic tenderness
Cervical motion tenderness (pain when moving cervix during bimanual exam)
*sometimes dizziness/syncope - blood loss or shoulder tip pain (peritonitis)
What USS findings can be seen with ectopic pregnancy?
Empty gestational sac (blob sign)
Tubal ectopic pregnancy (mass moves separate to ovary - unlike corpus luteum which moves with ovary)
Empty uterus
Fluid in uterus - pseudogestational sac
What is pregnancy of unknown location?
Positive pregancy test and no evidence of pregnancy on USS
How can normal and ectopic/miscarriage pregnancy be differentiated on hCG?
hCG doubles every 48 hours with intrauterine pregnancy
does not double with miscarriage or ectopic pregnancy!
How are ectopic pregnancies managed?
List the 3 broad options
Expectant management (await natural termination)
Medical management (methotrexate)
Surgical management (salpigectomy or salpingotomy)
Why is methotrexate used to manage ectopic pregnancies?
Highly teratogenic
Given IM into buttock - halts pregnancy and results in spontaneous termination
Which hormone produced by placenta is responsible for hyperemesis gravidarum?
hCG (higher = worse)
Hyperemesis gravidarum worse in what kind of pregnancies due to high hCG?
Molar pregnancies
Multiple pregnancies (twins etc)
Worse in first pregnancy and with obese women)
How is hyperemesis gravidarum diagnosed?
History taking
Protracted Nausea and vomiting in pregnancy (NVP)
More than 5% weight loss compared with before pregnancy
Dehydration
Electrolyte imbalance
Ketosis (sometimes)
Which score is used to determine the severity of hyperemesis gravidarum?
Pregnancy-Unique Quantification of Emesis (PUQE)
Which medications can be used to manage hyperemesis gravidarum?
Antiemetics - e.g. cyclizine and ondanestron
Anti-acids - Ranitidine/omeprazole if acid reflux is a problem
Severe cases of hyperemesis gravidarum need to be managed with what?
EPAU or admission to hospital
IV fluids (normal saline with added potassium chloride)
Daily monitoring of U&Es while having IV therapy
Thiamine supplementation to prevent deficiency (Wenicke-Korsakoff syndrome)
Thromboprophylaxis (TED stocking + LMWH during admission)
