High-Risk Pregnancy Part 1 Flashcards
Babies born to mothers with diabetes have been conditioned to high levels of glucose and therefore have high basal levels of insulin. This puts them at risk of what complication at delivery?
Hypoglycaemia
Babies born to diabetic mothers are at risk of what long-term complications?
Obesity and diabetes
Foetal hypoxia which occurs as a result of hypoglycaemia at birth leads to erythropoiesis and polycythaemia- this in turn leads to what clinical sign?
Jaundice
What are the three main maternal complications associated with diabetes in pregnancy?
Miscarriage, pre-eclampsia and polyhydramnios
Other than neonatal hypoglycaemia, what are the three main foetal complications associated with diabetes in pregnancy?
Congenital anomalies, intra-uterine death and macrosomia/shoulder dystocia
Screening for gestational diabetes is carried out when? What test is used for this?
OGTT at 24-28 weeks
What are the screening options for women who have had gestational diabetes in a previous pregnancy?
OGTT at booking, or self-monitoring of blood glucose levels
What are the four biggest risk factors for the development of gestational diabetes?
Previous macrosomic baby or gestational diabetes, BMI > 30, first degree relative with diabetes, ethnic origin with a high prevalence
Gestational diabetes can be diagnosed if a woman has a fasting glucose of what?
5.6mmol/L or more
Gestational diabetes can be diagnosed if a woman has a 2-hour OGTT glucose of what?
7.8mmol/L or more
For those with pre-existing diabetes, what is the target HbA1c pre-pregnancy?
48mmol/mol
Pregnancy is not advised in women with an HbA1c of more than what?
86mmol/mol
How long should folic acid be given for pre-conception in women with pre-existing diabetes? What dose is given?
3 months, 5mg
What are some medications, commonly used in diabetic patients, which should be stopped pre-pregnancy?
Statins and ACE inhibitors
Screening for which complications of diabetes must always be done, ideally pre-pregnancy, but definitely in early pregnancy, for those with pre-existing diabetes?
Retinopathy and nephropathy
In women with diabetes, after the 18-20+6 week foetal anomaly scan, how often are growth scans carried out?
Every 4 weeks from 28 weeks
If a woman is diagnosed with gestational diabetes and she has a fasting blood glucose of < 7mmol/l, what is the first line management?
Trial of diet and exercise
What are two oral hypoglycaemic agents which can be used in pregnancy in women with type 2 or gestational diabetes?
Metformin and glibenclamide
If insulin treatment is required in pregnancy, what regimen should ideally be used?
Basal bolus regimen
How are type 2 diabetics managed during pregnancy?
Oral hypoglycaemic agents, except metformin, are stopped and insulin is commenced
If a woman is diagnosed with gestational diabetes and glucose targets are not met within 1-2 weeks of diet and exercise management, what should be done next?
Start metformin
What medication is offered to women with gestational diabetes who cannot tolerate metformin or who fail to meet the glucose targets with metformin but decline insulin treatment?
Glibenclamide
If a woman is diagnosed with gestational diabetes and the fasting blood glucose is 7mmol/l or more, what treatment is offered?
Insulin
If a woman is diagnosed with gestational diabetes and the fasting blood glucose is 6-6.9mmol/l and there is evidence of complications, what treatment is offered?
Insulin
What treatment are women with pre-existing diabetes given in pregnancy in order to try and prevent the development of pre-eclampsia?
75mg aspirin from 12 weeks
Mothers with diabetes are delivered of their baby by what gestation?
38 weeks
Macrosomic babies in diabetic mothers are delivered by C-section to reduce the risk of what complication?
Shoulder dystocia
Women with gestational diabetes stop all medication immediately after delivery. What follow-up do they receive and why?
Fasting blood glucose is checked at 6 weeks to screen for underlying type 2 diabetes
Hypertension, with or without proteinuria, which is present before pregnancy or < 20 weeks gestation is defined as what?
Chronic hypertension
Hypertension, without proteinuria, which occurs after 20 weeks gestation is defined as what?
Gestational hypertension
Hypertension, with proteinuria, which occurs after 20 weeks gestation is defined as what?
Pre-eclampsia
What are the two main features of pre-eclampsia? What is a possible third?
Hypertension and proteinuria, possibly oedema
Pre-eclampsia develops after what gestation?
20 weeks
What is eclampsia?
The onset of generalised seizures in a woman with pre-eclampsia
Seizures in the third trimester of pregnancy are considered to be what until proven otherwise?
Eclampsia
Taking what medication, and from what gestation, is used to reduce the risk of pre-eclampsia in high-risk women?
75mg aspirin from 12 weeks
What four conditions are the major risk factors for pre-eclampsia, and women with these conditions should always be started on aspirin therapy in pregnancy?
Hypertension (including previous gestational hypertension), diabetes, CKD, autoimmune conditions
What are two of the main symptoms of pre-eclampsia that women may experience before an eclamptic seizure?
Headaches and visual disturbance
What defines severe hypertension in pregnancy?
> 160/110
A protein: creatinine ratio of greater than what indicates significant proteinuria?
30mg/mmol
What are the features of HELLP syndrome?
Haemolysis, raised liver enzymes, low platelets
What condition is the greatest risk factor for developing HELLP syndrome?
Pre-eclampsia
What is the first line anti-hypertensive for use in pregnancy?
Oral labetalol
Which anti-hypertensive medications suitable for use in pregnancy can be given IV?
Labetalol and hydralazine
Other than labetalol and hydralazine, what are two other anti-hypertensive medications which are safe to use in pregnancy?
Nifedipine and methyldopa
Why is methyldopa the last-line anti-hypertensive medication to use in pregnancy?
Risk of depression
What medication is given to women who are high risk of developing eclampsia, and to treat eclamptic seizures when they occur?
Magnesium sulphate
How is magnesium sulphate given to women with eclampsia and pre-eclampsia?
IV bolus followed by IV infusion
What is the main side effect of treatment with magnesium sulphate?
Respiratory depression
What medication is given to treat respiratory depression as a result of magnesium sulphate?
Calcium gluconate
Treatment with magnesium sulphate in women with eclampsia should be given until when?
24 hours after the last seizure or delivery
What extra ultrasound scans are indicated in women with chronic hypertension?
28 and 32 weeks
If gestational hypertension is diagnosed at < 34 weeks gestation, what additional investigation should be done?
Ultrasound scan
What is the only definitive treatment for pre-eclampsia and eclampsia?
Delivery
If delivery is being induced for pre-eclampsia or eclampsia, if the mother’s condition allows, this should be delayed by 24-48 hours to give time for what?
Maternal steroids to be administered to mature the foetal lungs
How long does it usually take for gestational hypertension and pre-eclampsia to resolve after delivery?
6 weeks
When in pregnancy does obstetric cholestasis occur?
Third trimester
Obstetric cholestasis is associated with an increased risk of what complication?
Premature delivery
What is the major clinical feature of obstetric cholestasis?
Itching, predominantly the palms, soles and abdomen
If unexplained itching occurs in pregnancy, what investigation should be carried out and how often?
LFTs every 1-2 weeks
What is the most specific test for obstetric cholestasis?
Bile acids
What happens to the level of bile acids in obstetric cholestasis?
Increased
Which LFTs are most likely to be raised in an individual with obstetric cholestasis?
ALT, GGT and bilirubin
What is an important differential diagnosis of obstetric cholestasis, which causes severe vomiting and abdominal pain in association with significant increases in ALT and ALP?
Acute fatty liver of pregnancy
What is the only curative treatment option for obstetric cholestasis?
Delivery
What are some medications which can be used for symptomatic management of obstetric cholestasis?
Emollients, anti-histamines and ursodeoxycholic acid
What can be given to women with obstetric cholestasis who have abnormal clotting?
Vitamin K
In women with obstetric cholestasis, delivery is induced when?
37 weeks
When are repeat LFTs taken after delivery in women who had obstetric cholestasis, to ensure resolution?
10 days after delivery
What is meant by the term polyhydramnios?
The presence of excess fluid around the foetus
Polyhydramnios is classified according to the single deepest pool depth. This can be diagnosed if it is greater than what value?
8cm
What maternal condition can cause polyhydramnios and is screened for in every woman with polyhydramanios?
Gestational diabetes
What happens to the maternal abdomen and uterus in a woman with polyhydramnios?
The abdomen is stretched and shiny, and the uterus is tense
What is the first sign of polyhydramnios that is likely to be detected?
Symphyseal fundal height is greater than expected for gestation
In women with polyhydramnios, inhibition of the movement of the diaphragm by the enlarged uterus can lead to what clinical sign?
Shortness of breath
What investigation is used in women with polyhydramnios to measure the amniotic fluid pool depth and to screen for foetal anomalies?
Ultrasound
If a chromosomal abnormality is suspected in a woman with polyhydramnios, what investigation is performed?
Amniocentesis
Maternal blood is checked for what in women with polyhydramnios?
Atypical antibodies and TORCH infection
What investigation is carried out to screen for gestational diabetes in women with polyhydramnios?
OGTT
What medication can be used to decrease the amniotic fluid volume in women with polyhydramnios?
Indomethacin
What is the disadvantage of using indomethacin to manage polyhydramnios?
Causes premature closure of the ductus arteriosus
How can polyhydramnios be managed in symptomatic women? What is the risk of this?
Amniocentesis- risk of miscarriage
