High Risk Pregnancy Flashcards
What main factors are there contributing to high risk pregnancy?
-Maternal conditions (eg obesity, diabetes, HTN, VTE)
-Social factors (eg young/old, high parity + low inter pregnancy interval, alcohol + drug abuse)
-Poor obstetric history (eg CS, preterm, RPL, pre-eclampsia)
-Problems in current pregnancy (eg multiple, SGA, placenta praevia, GDM)
-Problems during labour (eg meconium/blood-stained liquor, worrying CTG, oxytocin infusion)
What are the 3 categories of hypertension in pregnancy?
CHRONIC = pre-existing, uncommon
GESTATIONAL = common, good prognosis, no proteinuria
PRE-ECLAMPSIA = common, serious, proteinuria +++
NB in pre-eclampsia, diastolic BP = high
How is chronic hypertension in pregnancy defined?
-Raised BP >140/90 before conception / before 20 weeks (pre-placenta)
-Must monitor as 1/3 develop pre-eclampsia
How is gestational HTN in pregnancy defined?
-Presents after 20 weeks, high BP measured on more than one occasion
-Usually resolves within 2 weeks of delivery
-Monitor for pre-eclampsia, target BP = <150/90
What are the definitions and distinctions between eclampsia, pre-eclampsia, severe pre-eclampsia and significant proteinuria?
ECLAMPSIA = convulsive condition associated with pre-eclampsia, pain, N+V and visual disturbance
PRE-ECLAMPSIA = new HTN + significant proteinuria
SEVERE PRE-ECLAMPSIA = pre-eclampsia with BP >160 + significant symptoms / altered deranged blood tests
SIGNIFICANT PROTEINURIA = urine creatinine ratio >30 or 24h urine with >300mg protein
What risk factors are there for pre-eclampsia?
-Previous pre-eclampsia
-First pregnancy
-Twin pregnancy
-SLE / APL
-Diabetes
-Chronic HTN
-Obesity
-FHx
-CKD
What is pre-eclampsia a disease of?
-The placenta
-Resolves within a few days after delivery ie after delivery of placenta
How should pre-eclampsia be managed?
-Admission
-Measure BP (aim is to treat BP to prevent stroke)
–4x a day if mild/moderate
–>4x a day if severe
-Bloods (U+Es, LFTs, FBCs)
–2x a week if mild
–3x a week if moderate/severe
-Delivery
–Aim to deliver after 34 weeks if possible unless v high BP, impaired renal / hepatic function, signs of foetal distress
–Give maternal steroids up to 34w
What drugs are used to treat pre-eclampsia?
-200mg oral labetalol BD
–If unsuccessful –> IV
–DO NOT GIVE TO ASTHMATICS
-2nd line = 10mg oral nifedipine
-Magnesium sulphate to prevent seizures (until 24h post-delivery or since last seizure)
–Monitor reflexes and RR
-Hydralazine (for BP, smooth muscle relaxant)
What foetal and maternal complications can arise from pre-eclampsia?
FOETAL
-IUGR
-IUD
-Premature delivery (induced)
MATERNAL
-Stroke
-HELLP Syndrome = haemolysis elevated liver enzymes and low platelets
-Multi-organ failure
-Eclampsia
What effects does pregnancy have on pre-existing diabetes?
-Increased insulin requirement –> increased resistance
-Must stop oral treatment (apart from metformin)
-Acceleration of retinopathy
-Deterioration in renal function (if pre-existing)
-Maternal hypoglycaemia in early pregnancy
Who is at risk of developing GDM?
Women with:
-PCOS
-Obesity
-Previous GDM
-Previous macrosomia
-FHx of diabetes
-Ethnicity with high prevalence
How is GDM diagnosed?
-OGTT is gold standard (screened at 24-28 weeks, fasting VG measured + 2h following 75g oral glucose)
–Fasting glucose >5.6 OR 2h glucose >7.8
-If previous GDM, test sooner
Who is selected for GFM screening?
-BMI >30
-Previous GDM
-PCOS
-Previous large baby >4.5kg
-First degree relative with diabetes
-Population with high prevalence diabetes
-Previous unexplained stillbirth
-Polyhydramnios
-LGA
How should pre-existing diabetes be managed in pregnancy?
-Pre-conceptual counselling ie 5mg folic acid, BG control
-Metformin
-Folic acid until 12 weeks
-Aspirin 75mg from 12 weeks
-Detailed anomaly scan at 20 weeks
-Stop any ACEis, statins or gliclazide
-Screen for and monitor any vascular complications
-Early viability scan
How should GDM be managed?
-Diabetic ANC within a week
-Counselling on self-monitoring and diet / exercise
-If targets not met within 1-2 weeks - start metformin
-Add on insulin if targets still not met
-If fasting glucose >7 at diagnosis –> start insulin
-Glibenclamide only considered if cannot tolerate metformin / insulin
-If fasting is 6.0-6.9 + macrosomia / polyhydramnios –> start insulin immediately
What complications could arise from diabetes?
ANTEPARTUM
-Miscarriage + congenital malformations (pre-existing only)
-Pre-eclampsia
-Macrosomia
-Polyhydramnios
-IUD
-Neuropathy + retinopathy
-VTE risk
INTRAPARTUM
-Shoulder dystocia
-CS / instrumental delivery / induction
-3rd degree perineal tears
POSTPARTUM
-Neonatal hypoglycaemia
-PPH
-Child has increased risk of adolescent / adult obesity
-Maternal risk of persistent hyperglycaemia - check BG soon after
What risk factors are there for developing VTE in pregnancy?
NB 90% in left leg and 70% above knee
-Pregnancy
-Previous VTE
-Trauma to pelvic veins at delivery
-Venous stasis eg immobility
-Thrombophilia
-Age >35 / BMI >30 / parity >3
-Gross varicose veins
-IVF pregnancy
-Inflammatory disorders
-Hyperemesis / dehydration
-Pre-eclampsia
-Severe infection
-Prolonged labour
-FHx of unprovoked VTE
How should you investigate a ?VTE in pregnancy?
-Obs
-USS
-ECG / CXR / ABG if PE suspected
-Leg doppler
-CTPA (increased breast Ca risk for mum)
-VQ scan (increased risk of leukaemia for baby)
How should a VTE be managed in pregnancy?
-Heparins (do not cross placenta)
–Continue for 3 months if occurs shortly before delivery
–Do not give spinal / epidural if had heparin in last 12h
How should VTEs be managed postnatally?
Previous recurrent VTE / previous VTE + FHx –> LMWH antenatally and >6w post partum
Previous VTE –> LMWH for 6w post partum
4+ RFs –> LMWH immediately until 6w post partum
3 persisting RFs –> LMWH from 28w until 6w post partum
2 RFs –> LMWH 10 days post partum
How do you diagnose pre-eclampsia?
-BP >140/90
-Urine PCR >30
-Symptoms (facial oedema, headache, visual disturbance, epigastric pain)
-Signs (high bp, low symphysis-fundal height, brisk reflexes, clonus)
When should a woman be reviewed for VBAC?
-At 36 weeks by obstetrician unless indicated sooner
What risks are associated with LSCS?
-Infection
-Bleeding
-Injury to bowel, bladder
-RDS and scalpel injury to baby
-VTE risk increased by 5x
-Anaesthetics complications
-More complex abdominal surgery in the future
-Risks to future pregnancies:
–Higher risk of rupture
–Adherent placenta
–Stillbirth
–Discouraged from having vaginal delivery
What is the main risk associated with VBAC?
-Uterine rupture - 1 in 200
–3 in 100 in augmented / induced labour
-VBAC is contraindicated if previous uterine rupture
What adaptations are made for VBAC compared to a normal vaginal delivery?
- Deliver on labour ward
- Increased monitoring (CTG)
- Do not induce (so greater risk of emergency C-section, which carries greater morbidity than elective)
What signs and symptoms would a woman with previous poor cardiac history have in pregnancy?
-Fatigue
-Syncope
-Chest pain
-SOB
-Difficulty with breathing when sleeping / PND
-Palpitations
NB those with prosthetic heart valves may have to continue taking warfarin while pregnant
What advice should be given to pregnant women with epilepsy?
- Folic acid 5mg
- Oral vitamin K given in last 4 weeks
- Breastfeed to help baby with medication withdrawal
- Must continue medication - safest = carbamazepine + lamotrigine
What risks are there in maternal epilepsy?
-Foetal abnormalities from drugs (especially sodium valproate) eg NTDs, cardiac + facial defects
-Worse seizure control due to increased stress and poor sleep
What risks does chronic hypertension bring in pregnancy?
Increased risk of:
-Pre-eclampsia
–Preterm delivery
-Placental abruption
-IUGR
-Maternal morbidity eg stroke, retinopathy
What drugs are best for treating hypertension in pregnancy?
-1st line = labetalol 100mg BD (CI in asthma)
-Nifedipine
-Methyldopa
-Consider 75mg aspirin from 12/40
What risks are there for drug abuse in pregnancy?
Increased risk of:
-Maternal death from overdose
-BBVs
-IUGR and stillbirth
-Placental abruption (cocaine)
-Preterm delivery
-Neonatal withdrawal syndrome
What psychiatric disorder has a known link to early postpartum psychosis?
-Bipolar affective disorder
What drugs are used to treat UTIs in pregnancy?
-Nitrofurantoin
–AVOID IN 3RD TRIMESTER - haemolytic disease on newborn
-Trimethoprim
–AVOID IN 1ST TRIMESTER - folic acid antagonist
-Avoid tetracyclines - neonatal tooth discolouration
What abx are safe in pregnancy and what should be avoided?
-Penicillins, cephalosporins and macrolides are all safe
-Avoid co-amoxiclav due to risk of necrotising enterocolitis of newborn
What is the protocol if a pregnant woman is exposed to chicken pox?
-If previous infection - no action needed
-If unsure:
–Check antibodies, if not immune give IV Ig asap
-If presents within 24h of rash onset:
–Give oral aciclovir
What role does HbA1c have in pregnancy?
-Measure at booking - higher risk of complications if >48
-Measure when diagnosed with GDM to screen for pre-existing diagnosis
