Health Complications in Pregnancy Flashcards
Cause of hypertensive disorders of pregnancy
Largely unknown - increasing difficulty for screening
Risk factors for gestational HTN
- nullipara
- first pregnancy with new partner
- previous pregnancy with HTN/pre-eclampsia
- history of chronic HTN, CKD, SLE
- poor nutrition
- BMI > 30
- ethnicity (race v racism)
- age > 40
- multi gestation/use of ART
- pre-gestational diabetes
- previous stillbirth, IUGR, abruption
Chronic Hypertension
Hypertension that develops either before pregnancy or at <20 weeks
True or false: pregnancy can cause HTN at any point
False: Pregnancy can cause HTN but not until 20 weeks
Gestational Hypertension diagnostic values and criteria
Systolic ≥ 140 mmHg and/or Diastolic ≥ 90 mmHg
20 weeks and up to 12 weeks PP
Severe Hypertension diagnostic values
systolic ≥160 mmHg and/or diastolic ≥110 mmHg
Pre-Eclampsia diagnostic criteria
systolic ≥ 140 mmHg and/or diastolic ≥ 90 mmHg
proteinuria (2+ or greater) or 1 or more adverse conditions or severe complications
How does pre-eclampsia differ from gestational hypertension
Other organ involvement - not just CVS/PVS
What is eclampsia?
Seizure cause by over-perfusion of neurological system (cerebral edema - pressure on brain)
aka seizures that occur in those with pre-eclampsia
What 3 adverse conditions are most important to assess for in a woman with PIH?
- headache
- visual disturbances
- Abdominal/Epigastric/RUQ pain
Besides headache, visual disturbances and RUQ pain, what other adverse conditions should be assessed for in woman with PIH?
- Nausea/Vomiting
- Chest pain/SOB
- Abnormal maternal lab values
- Fetal morbidity – not growing, thriving in utero, poor tracing
- Edema / Weight gain?
- Hyperreflexia?
Why are edema/weight gain and hyper-reflexia not always the most predictive of pre-eclampsia in pregnancy?
Edema and weight gain are common in pregnancy - pitting edema in knees and swelling in the face most indicative
There are variations in reflex responses so it is difficult to assess without baseline; clonus is sign of problem
Maternal consequences of preeclampsia
- Stroke
- Pulmonary edema
- Hepatic failure
- Jaundice
- Seizures
- Placental abruption
- Acute renal failure
- HELLP syndrome & DIC
Fetal consequences of preeclampsia
- IUGR
- Oligohydramnios
- Absent or reversed end diastolic umbilical artery flow by Doppler
- Placental abruption
- Prematurity (iatrogenic)
- Fetal compromise (metabolic acidosis)
- Intrauterine death
Etiology/cause of pre-eclampsia
Primarily abnormal placentation in combination with excessive fetal demand
Spiral arteries that normally supply placenta become fibrous/vasoconstrict (like other arteries in the body do with HTN) and can not meet the fetal/placental demand
pathophysiology of pre-eclampsia
- abnormal placentation + excessive fetal demands
leads to
- mismatch between uteroplacental supply + demand
= poorly perfused placenta that releases pro inflammatory proteins that cause…
- maternal endothelial dysfunction (vasoconstriction + increased permeability) and kidneys to retain more salt
> protein leakage - water follows - increased blood volume
- HYPERTENSION maternal/fetal pre-eclampsia manifestations
VASOCONSTRICTION leading to HYPOPERFUSION OF ORGANS
Why is RUQ/epigastric pain a cardinal sign of pre-eclampsia?
Reduced blood flow (hypoperfusion due to vasoconstriction) to the liver causing damage and swelling and elevate liver enzymes and stretches out capsule around liver
Prevention of Preeclampsia
- Low Dose Aspirin
- Calcium Supplementation
- Lifestyle
Explain the dosage of aspirin for pre-eclampsia prevention
In patients with increased risk low-dose aspirin (75 – 100 mg/day) starting pre-pregnancy or before 16 weeks’ gestation until delivery.
Explain the dosage of calcium supplementation for pre-eclampsia prevention
For all clients with low dietary intake of calcium (<900 mg/d), oral calcium supplementation of at least 500 mg/d is suggested
Why is calcium supplementation necessary for pre-eclampsia prevention?
o Works on negative feedback – if blood level is low there would be increased amount causing excessive contraction of vessels (calcium works in muscle contraction)
Initial Management of Preeclampsia
- Assessment of pregnant client and fetus
- Stress reduction/reduced activity (used to be bedrest)
- Treat blood pressure w antihypertensives
- Treat symptoms
- Nausea & vomiting
- Epigastric pain
- Consider seizure prophylaxis if borderline symptoms
- Consider timing / mode of delivery (>36 weeks) – decrease rx of consequences
Describe management of non-severe PIH
Home care
- Client monitors own blood pressure
- Measures weight and tests urine protein daily
- NST’s performed daily or bi-weekly – for fetal assessment
- Advised to report signs of adverse conditions
Describe management of severe HTN/pre-eclampsia
- Fetal evaluation – more intensive workup:
- Fetal movement counting, NST, Biophysical profile, ultrasound, measurement of AFI, serial U/S to assess growth, umbilical artery doppler flow,
- Hourly intake and output
- Frequent BP, pulse, resp
- Blood work (liver enzymes, platelets, Hct)
- Monitor for Adverse Conditions
- DELIVERY is the definitive treatment
Most common antihypertensives used in pregnancy and class
- Labetalol – adrenergic blocker
o Most common - Nifedipine (Adalat) – calcium channel blocker
o Common
Other antihypertensives used in pregnancy
- Hydralazine (Apresoline) - Arteriolar dilators
o More high alert - Aldomet (Methyldopa)-Centrally-acting sympatholytic
o More high alert
What anti-hypertensive medications are contraindicated in pregnancy?
ACE-I
What is magnesium sulfate used for in pregnancy?
treatment of seizures in pregnancy NOT HTN effect but has large CVS effect – increase monitoring!
GOAL: reduce CNS irritability and prevent seizures
MOA of magnesium sulfate
anti convulsant
relaxing muscles/reducing neuromuscular irritability
Dose of magnesium sulfate for eclampsia
4g IV (in 100ml NS) over 20 min using pump then 1g/h IV
Effects of magnesium sulfate
- tachycardia
- monitor reflexes
- monitor u/o (excreted by kidneys)
- can slow labor r/t relaxing muscles/reducing nm irritability
- muscle weakness
- lack of energy/drowsiness
- respiratory depression
- lower BP (not reason its given)
4 Signs of Magnesium Toxicity
- CNS depression
- RR < 12
- Oligouria < 30ml/h
- Diminished/absent DTR
Therapeutic serum magnesium
4.8 - 9.6 mEq
Magnesium Sulfate Antagonist
Calcium Gluconate
Treatment of Eclampsia
- Anticonvulsant: bolus of magnesium sulfate
- sedation/other anticonvulsants: dilantin
- treatment of pulmonary edema if present (diuretics)
- treatment of circulatory failure: digitalis
- ICU
DELIVER
If forced to deliver due to eclampsia what must be administered to the fetus and why?
if fetus < 34 weeks give corticosteroids to increase fetal lung maturity
Not effective after 34 weeks
What is HELLP syndrome?
Severe complication of preeclampsia
Hemolysis
Elevated
Liver Enzymes
Low
Platelets
Why is hemolysis seen in HELLP?
RBC rupture due to slamming into thrombus, forced to move through constricted vessels
Why are elevated liver enzymes seen in HELLP?
Injury and swelling occur as a result of reduced blood flow (hypoperfusion), causing capsule to stretch and release enzymes into blood
Why are low platelets seen in HELLP syndrome?
Platelets aggregate at sites of endothelial injury, using them all up
When should platelets be administered in HELLP?
if < 20 10^9/L
What may not be an option during labour for HELLP patient and why?
Epidural; contraindicated in thrombocytopenia
What is DIC and patho?
Worst case of preeclampsia - Disseminated Intravascular Coagulation
- Over-activation of normal clotting mechanism
- Mini clots develop
- Depletes platelets and clotting factors leads TO EXCESSIVE BLEEDING
o Counter intuitive in a way – but TOO MUCH clotting DEPLETES platelets leading to BLEED
True or False: Preeclampsia develops during pregnancy
False: Preeclampsia may develop for the first time postpartum
When should BP be measured PP if patient had HTN?
At least 2x in first 2 weeks following delivery
Can anti-hypertensives be taken for lactating clients?
Yes
labetalol, methyldopa, nifedipine, enalapril, and captopril
3 Types of Diabetes patients present with
- pre-existing (type 1 or 2)
- gestational
- pre-existing undiagnosed
What is gestational diabetes?
Glucose intolerance with ONSET or FIRST RECOGNITION during pregnancy
How to differentiate between pre-existing undiagnosed and gestational diabetes
if continues following pregnancy it is likely pre-existing
if FIRST RECOGNITION during pregnancy will be classified as gestational
In what 2 ways does pregnancy alter carbohydrate metabolism
- Fetus continually takes glucose from the mother – increases glucose demand
- Placenta creates hormones, which alter effects of and resistance to insulin and glucose tolerance
Diabetogenic Effect of Pregnancy in First Trimester and result
rise in hormones stimulates insulin production and increases sensitivity to tissues
result: maternal insulin needs decrease because everything is working more efficiently
When do we see effects of gestational diabetes on pregnancy and why?
20th week
In first trimester insulin needs decreases due to alterations in hormones
Diabetogenic Effect of Pregnancy in 2nd and 3rd Trimester
- Placenta secretes hPL which:
- increases resistance to insulin for mom to assure
- facilitate transfer to fetus for growth because fetal growth needs increase and thus glucose needs increase - Insulin needs increase because mom needs glucose too
Maternal Effects of Gestational Diabetes
- pre-eclampsia and eclampsia
- polyhydraminos, PROM
- preterm labor
- shoulder dystocia/c-section
- worsening myopathies of vessels, renal, retinal
- if pre-existing diabetic, increases ketosis
- gestational HTN
- diabetes later in life
Fetal Effects of Gestational Diabetes
- macrosomia/LGA
- IUGR
- Fetal Demise
- Congenital Anomalies
Why is macrosomia/LGA seen in gestational diabetes?
Not enough insulin for mom to use excessive glucose but baby produces own insulin so will gladly take on glucose and grow
Why is IUGR seen in gestational diabetes?
Vascular changes can effect blood flow to fetus, decreasing
Neonatal effects of gestational diabetes
- hypoglycemia
- hyperbilirubinemia
- immature respiratory development
why is hypoglycemia seen as neonatal effect of gestational diabetes?
Fetus is used to high levels of blood sugar, cutting of cord cuts this off. Need to adjust high insulin that they have been producing
why is hyperbilirubinemia seen as neonatal effect of gestational diabetes?
Insulinase produced by placenta helps fetus hold on to RBC – when fetus is delivered they have more RBC to breakdown and thus have more risk of jaundice
why is immature respiratory development/RDS seen as neonatal effect of gestational diabetes?
High insulin production interferes with surfactant development
What are the childhood effects of gestational diabetes?
Increased risk of developing diabetes and obesity
“being” risk factors for gestational diabetes
- 35 years of age or older
- from a high-risk ethnic population (African, Arab, Asian, Hispanic, Indigenous, South Asian)
“using” risk factors for gestational diabetes
- Corticosteroid use (asthma, rheumatological conditions)
“having” risk factors for gestational diabetes
Obesity (BMI ≥30 )
Prediabetes
GDM in a previous pregnancy
Previous newborn > 4 kg
A parent, brother or sister w type 2 diabetes
Polycystic ovary syndrome
Recommendation regarding gestational diabetes prevention
breastfeeding immediately after birth and for a minimum of 4 months in order to prevent hypoglycemia in your newborn, obesity in childhood, and diabetes for both you and your child.
Screening steps for gestational diabetes
- 24–28 weeks of gestation with a non-fasting 50 g glucose challenge test (GCT) 1 hr. post glucose
- If between 7.8-11, patients will do a 75g fasting GTT
Values and interpretation of gestational diabetes screening test
o <7.8 mmol/L (140 mg/dL) NORMAL
o 7.8 -11.0 mmol/L then you will do a 75 g fasting GTT performed
o >11.1 mmol/L GDM diagnosis
Blood sugar goals for gestational diabetes management
to attain and maintain a euglycemic state
o (Glycated hemoglobin A1C less than 7%)
o Aim for fasting of ‹5.3 mmol/L, 1 hr pc ‹ 7.8 mmol/L
Care and management of gestational diabetes in pregnancy
- diet controlled
- insulin as drug of choice if necessary
- increased folic acid (up to 5mg r/t increased risk for congenital anomalies)
- antenatal steroid if early delivery anticipated to mature lungs
- risk for infection r/t high glucose
Intrapartum/labor care of gestational diabetes
If euglycemic on diet, no special considerations in labour
For IDDM (insulin dependent):
Balance insulin with need for ↑ energy in labor
Monitor blood sugars q 1 – 2 h
Individualize IV glucose and IV insulin
True or false: insulin needs increase in post partum period
False: decrease significantly but 20% will have IGT
Incidence of T2DM post partum of those with gestational
45-50%
Why is a 75g OGTT recommended between 6 weeks and 6 months if gestational diabetic?
values usually normal in 24-48 hours we see them but as body normalizes at home values can change – need for monitoring
Iron deficiency occurs in more than _____ of pregnancies
30%
Symptoms of iron deficiency anemia
fatigue, weakness, dizziness, irritability, hair loss, dyspnea (often attributed to pregnancy not anemia)
Adverse outcomes associated with iron deficiency anemia in pregnancy
o LBW, SGA, PTB in infant
o PPH, blood transfusion in PP client
o Long term neurocognitive effects in child
Lab values indicative of iron deficiency anemia
ferritin (<30) and HgB (<110)
Treatment of iron deficiency anemia in pregnancy
Oral iron is first line treatment; parenteral iron is safe in 2nd trimester onward. Treatment continues postpartum.
What 2 reasons are multiple gestation rates increasing?
- assisted reproduction (ART)/in-vivo: by product of technologies – implantation of more than egg to assure success of technology
- increasing maternal age: people are waiting until later in life to have children and potential to release more than one egg increases with age
Multiple gestations are at increased risk for (8):
- Preterm labor – overdistention of uterus triggering physiological response of onset
- Anemia and hypertension of pregnancy
- Abnormal presentation
- Twin-to-twin transfusion syndrome
- Uterine dysfunction: if stretched to maximum can interfere with contraction pattern
- Abruptio placenta / placenta previa: if overdistended, (large or multiple) placenta may separate and move to a place it should not be
- Prolapsed cord
- Postpartum hemorrhage r/t overdistention
What is the safest way to deliver multiple gestation?
c-section
As number of gestations in multiple gestation increases ______ and ______decrease and _____ and risk for ____ and _____ increase
weight and gestational age
mortality, CP, IUGR
Effects of multiple gestations on mother
- increased risk of c/s, HTN, PPH
- increased intensity of complaints
- SOB
- Edema
- NV, heartburn
- Insomnia, fatigue
- weight gain
Dizygotic
Twins from 2 eggs
Diamniotic
Twins in seperate amniotic sacs
Dichorionic
Twins with 2 placentas
What is twin to twin transfusion syndrome
Whenever identical twins share a placenta
During development, anastomoses occur and shunt blood from one twin to the other
Effects of twin to twin transfusion syndrome on “donor” twin
under-perfused, small, anemic
accelerate development as response to stress/protective response
Effects of twin to twin transfusion syndrome on “recipient” twin
over-perfused, large
Complications of Obesity in pregnancy
Spontaneous Abortion/Stillbirth
Hypertension
Diabetes
Preterm or Posterm
Complications of obesity intrapartum
Stillbirth
Macrosomia causing Shoulder Dystocia
Challenges in assessing fetus/contractions
↑ Cesarean
Anesthesia challenges
Neonatal complications of obesity
- Macrosomia
- Hypoglycemia r/t macrosomia
- Breastfeeding issues r/t positioning
- Congenital anomalies
Postpartum complications of obesity
- Depression
- PPH
- Infection
- Thrombosis
- Lifelong effects of obesity
What is the most common cause of obesity later in life for woman
Excessive limitless weight gain in pregnancy is the most common cause of obesity in later life.
Women who gain ________ in pregnancy have a very difficult time losing PP weight and often it remains a lifelong struggle
> 25kg
Possible link to hypertension, diabetes and obesity in later life for ____________
for children borne of obese mother
SOGC recommendations beginning weight for pregnancy
BMI < 30
recommended weight gain during pregnancy if > 30BMI
7kg
Pre‐conceptual assessment and counseling for obese clients
- recommended weight gain (7kg)
- increase folic acid if coming into pregnancy obese
- exercise
- knowledge of risk
- anesthesiologist consult
- VTE risk
Physical risks in adolescent pregnancy
Preterm birth
Low birth weight infant
CPD
Anemia
GHTN
Psychosocial risks in adolescent pregnancy
Interruption of developmental tasks
Substance abuse,
Poverty
Interruption or cessation of education
Less prenatal visits
Considerations for pregnant clients > 35
- decline in fertility
- increase in chronic diseases
- increase difficulties in pregnancies
- increased rx of c-section/induction
- increased rx of genetic conditions
In general, pregnant women with substance use disorders are less likely to ________, and they have higher rates ________
seek prenatal care
of infectious diseases
Effects of methadone on pregnant client
- Better than opioid, use of more controlled substance – rx vs benefit
o Blocks withdrawal symptoms
o Reduces or eliminates the craving for narcotics
o Crosses the placenta
Methadone use in pregnancy is associated with
pregnancy complications and abnormal fetal presentation
Prenatal exposure to methadone causes
o Reduced head circumference and lower birth weight
o Withdrawal symptoms – can be treated (known vs unknown entity)
Cannabis can negatively effect
fertility
Does cannabis cross the placenta?
Yes
o May harm a developing fetus (preterm delivery, low birth weight, birth defects)
o Associated with negative long-term effects in childhood and beyond (poor memory and verbal skills, behavioral issues)
Does cannabis cross into breastmilk
Yes
may cause negative developmental effects (lethargy, poor feeding habits)
Care of mother with substance use
Education and Support
Watch for signs of withdrawal
Watch for signs of drug use
Leave unit, leave baby unattended, high
Care of infant with maternal substance use
Watch for signs of withdrawal
Active use
NICU for observation and treatment?
NAS Scoring?
Caffeine recommendations in pregnancy
Pregnant women and breastfeeding mothers should have no more than 300mg of caffeine per day from all sources. This is approx.. 2 (250ml) cups of coffee
Large amounts of caffeine in pregnancy increases risk of
- Miscarriage
- Premature delivery
- Low birth weight
- Withdrawal symptoms in newborn
How do maternal infections infect newborn during pregnancy, in labor and post partum?
- During Pregnancy
o Can cross placenta - In Labour
o If born through vagina - Postpartum
o breastmilk
4 Teratogen categories
- Alcohol
- Drugs
- (Certain) Prescribed Medications
- Pathogens/infections
Infections of significant risk to infant
C: Chickenpox & shingles
H: Hepatitis B, C, D, E
E: Enteroviruses
A: AIDS
P: Parvovirus B19 (aka 5th disease)
T: Toxoplasmosis
O: Other (GBS, listeria, candida)
R: Rubella
C: Cytomegalovirus
H: Herpes simplex virus
E: Every STI (gonorrhea, chlamydia)
S: Syphilis
Infections in pregnancy may cause
- Spontaneous abortions
- Preterm delivery
- Maternal and fetal morbidity and mortality
When is vaginal/rectal GBS screening done?
35-37 weeks
Who is the risk to with maternal GBS infection?
Infant
When are antibiotics administered for GBS
> 4 hr before birth for adequate cover
Modes of HIV transmission in pregnancy
- in utero (through the placenta)
- during childbirth and delivery
- postpartum through breastfeeding
Risk of HIV transmission to infant with and without treatment
Without treatment: ≈ 25% chance of transmission
With proper treatment: less than 2% chance of transmission
Factors reducing HIV transmission to infant
- behaviours that support healthy immune system
- CART
- mode of delivery dependent on maternal viral load and CART
- complimentary treatment
Describe 3 part antiretroviral prophylaxis regimen to reduce risk of HIV to infant
pregnancy: cart
labor: add IV ZDV during birth/3 hr to c-section
infant: ZDV oral suspension
How long is ZDV administered following birth from maternal HIV positive mother and when is testing done?
6 weeks
testing at 1 month, 3 month, 18 month
True or false: following birth a baby who tested positive for HIV definitively has HIV
Positive antibody titer - Babies can test positive/have antibody response without being positive
o Reflects the passive transfer of maternal antibodies rather than HIV infection
Function of hPL
Hormone secreted by placenta
hPL increases maternal insulin resistance and reduces maternal glucose utilisation, elevating maternal blood glucose levels (supporting transplacental glucose transfer and adequate fetal nutrition).
