High risk pregnancy: Raised blood pressure Flashcards
Define Mild, Moderate and Severe hypertension.
Mild hypertension diastolic blood pressure 90–99 mmHg, systolic blood pressure 140– 149 mmHg.
Moderate hypertension diastolic blood pressure 100–109 mmHg, systolic blood pressure 150–159 mmHg.
Severe hypertension diastolic blood pressure 110 mmHg or greater, systolic blood pressure 160 mmHg or greater.
Define Chronic hypertension
Chronic hypertension is hypertension that is present at the booking visit or before 20 weeks or if the woman is already taking antihypertensive medication when referred to maternity services. It can be primary or secondary in aetiology.
Define Eclampsia
Eclampsia is a convulsive condition associated with pre-eclampsia.
Define HELLP syndrome
HELLP syndrome is haemolysis, elevated liver enzymes and low platelet count.
Define Gestational hypertension
Gestational hypertension is new hypertension presenting after 20 weeks without significant proteinuria.
Define Pre-eclampsia
Pre-eclampsia is new hypertension presenting after 20 weeks with significant proteinuria.
Severe pre-eclampsia is pre-eclampsia with severe hypertension and/or with symptoms, and/or biochemical and/or haematological impairment.
Pre conception counselling for women with hypertension
Tell women who take angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs):
• that there is an increased risk of congenital abnormalities if these drugs are taken during pregnancy
• to discuss other antihypertensive treatment with the healthcare professional responsible for managing their hypertension, if they are planning pregnancy.
2. Stop antihypertensive treatment in women taking ACE inhibitors or ARBs if they become pregnant (preferably within 2 working days of notification of pregnancy) and offer alternatives.
3. Tell women who take chlorothiazide:
• that there may be an increased risk of congenital abnormality and neonatal complications if these drugs are taken during pregnancy
• to discuss other antihypertensive treatment with the healthcare professional responsible for managing their hypertension, if they are planning pregnancy.
4.Tell women who take antihypertensive treatments other than ACE inhibitors, ARBs or chlorothiazide that the limited evidence available has not shown an increased risk of congenital malformation with such treatments.
Diet
• Encourage women with chronic hypertension to keep their dietary sodium intake low, either by reducing or substituting sodium salt, because this can reduce blood pressure.
Outline risk factors for pre-eclampsia
Moderat risk Nulliparity age 40 or older pregnancy interval of more than 10 years family hx pre-eclampsia multiple pregnancy BMI >35kg/m2 or more
High risk Hypertensive disease during previous pregnancy Chronic kidney disease Autoimune diease such as SLE or APLS Type 1 or 2 diabeties chronic hypertension
Modified Panderson hypothesis - effects of diabetes on the foetus
Maternal Hyperglycemia–> Fetal Hyperglycemia–>
–> Fetal pancreatic beta cell –> Hyperplasia Fetal –>Hyperinsulinaemia
Leads to Macrosomia Organomegaly Polycythaemia Hypoglycaemia RDS Jaundice
Physiological changes in glucose tolerance in pregnancy
- physiological insulin resistance and relative glucose intolerance
- Altered Glucose handling
- 2nd and 3rd trimester progressive insulin resistance
Normal woman doubling of insulin production - diabetic women insufficient secretion to compensate for insulin resistance
Preconception Planning & Care for diabetic patients
- Avoid unplanned pregnancy
- Lose weight if BMI >27
- Take folic acid 5mg till 12 weeks pregnant
- Maintain fasting plasma glucose level of 5–7 mmol/litre on waking and a plasma glucose level of 4– 7 mmol/litre before meals at other times of the day.
- Advise women with diabetes who are planning to become pregnant to aim to keep their HbA1c level below 48 mmol/mol (6.5%)
Risk factors and diagnosis for gestational diabetes
Risk factors:
• BMI above 30 kg/m2
• previous macrosomic baby weighing 4.5 kg or above
• previous gestational diabetes
• family history of diabetes (first-degree relative with diabetes)
• minority ethnic family origin with a high prevalence of diabetes Diagnosis:
• a fasting plasma glucose level of 5.6 mmol/litre or above or
• a 2-hour plasma glucose level of 7.8 mmol/litre or above
Antenatal care for Women with Diabetes
• Offer immediate treatment with insulin, with or without metformin, as well as changes in diet and exercise, to women with gestational diabetes who have a fasting plasma glucose level of
7.0 mmol/litre or above at diagnosis
• Consider immediate treatment with insulin, with or without metformin, as well as changes in diet and exercise, for women with gestational diabetes who have a fasting plasma glucose level of between 6.0 and 6.9 mmol/litre if there are complications such as macrosomia or hydramnios.
Intrapartum Care for patients with diabetes
- Women with type 1 or type 2 diabetes and no other complications –an elective birth by IOL, or by El C/S if indicated, b/w 37+0 - 38+6
- Elective birth before 37+0 weeks – with type 1 or type 2 diabetes if there are metabolic or any other maternal or fetal complications
- Advise women with GDM to give birth no later than 40+6 weeks, and offer elective birth (by IOL, or by C/S if indicated) if not given birth by this time.
- Consider elective birth before 40+6 weeks for women with GDM if there are maternal or fetal complications
Differential diagnosis of epilepsy in women.
• The diagnosis of epilepsy and epileptiform seizures should be made by a medical practitioner with expertise in epilepsy, usually a neurologist.
• Women with epilepsy (WWE), their families and healthcare professionals should be aware of the different types of epilepsy and their presentation to assess the specific risks to the mother and baby.
• Differential Diagnosis:
1. Eclampsia management until a definitive diagnosis is made by a full neurological assessment.
2. cardiac,
3. metabolic
4. intracranial conditions
5. Neuropsychiatric conditions including non-epileptic attack disorder should also be considered.
Describe the Clinical presentation of Tonic-clonic seizures and the
Effects on mother and baby
Dramatic events with stiffening, then bilateral jerking and a post-seizure state of confusion and sleepiness. Sudden loss of consciousness with an an uncontrolled fall without prior warning. Associated with a variable period of fetal hypoxia.This seizure type is associated with the highest risk of SUDEP
Describe the Clinical presentation of Absence seizures and the
Effects on mother and baby
Generalised seizures that consist of brief blank spells associated with unresponsiveness, which are followed by rapid recovery.
Effects mediated through brief loss awareness although physiological effects are modest. Worsening absence seizures place the woman at high risk of tonic-clonic seizures
Describe the Clinical presentation of Juvenile myoclonic epilepsy and the
Effects on mother and baby
Myoclonic jerks are the key feature of this form of epilepsy and often precede tonic-clonic convulsion. These jerks present as sudden and unpredictable movements and represent a generalised seizure. Occurs more frequently after sleep deprivation and in the period soon after waking or when tired. The sudden jerks may lead to falls or to dropping of objects including the baby.
Describe the Clinical presentation of Focal seizures, (previously defined as ‘complex partial’ if seizure impair consciousness and ’simple partial’ if consciousness not impaired).and the
Effects on mother and baby
Symptoms are variable depending on the regions and networks of the brain affected. Within an individual, the attacks are recognisable and stereotypical. Seizures may impair consciousness. Primary focal seizures can undergo secondary generalisation. An aura is a primary focal seizure.
Impairment of consciousness increases risk of injury such as long bone fracture, dental or head injury, electrocution or burns seizures compared with if consciousness is retained ( an epileptic aura only). They can be associated with a variable period of hypoxia and risk of SUDEP
What is the effect of pregnancy on seizures in WWE?
- Inform that two-thirds will not have seizure deterioration in pregnancy.
- Pregnant women who have experienced seizures in the year prior to conception require close monitoring for their epilepsy.
- WWE should be provided with verbal and written information on prenatal screening and its implications,the risks of self- discontinuation of AEDs and the effects of seizures and AEDs on the fetus and on the pregnancy, breastfeeding and contraception.
- WWE should be informed that the introduction of a few safety precautions may significantly reduce the risk of accidents and minimise anxiety.
- Healthcare professionals should acknowledge the concerns of WWE and be aware of the effect of such concerns on their adherence to AEDs.
Phsyiological changes in thyroid function in pregnancy
Pregnancy - no change in TSH, free T4 and free thyroxine but increase in total T4 and T3.
Hyperthyroidism - decerase in TSH. increase in free T4, free thyroxine, Total T4 and total T3.
Hypothyroidism - increase in TSH, decrease in everything else.
Effect of hyperthyroidism in pregnancy.
•Thyrotoxicosis improves in second and third trimester
•If untreated, risk of miscarriage, fetal growth restriction, preterm labour and perinatal mortality.
Note in relation to pregnancy:
•Stimulation of thyroid by HCG•Reduced plasma iodine concentration•Increase in thyroid binding globulin –Less free T4
Management if hyperthyroidism.
- Carbimazole 15-40mg or Propylthiouracil 150-400mg for 4-6 weeks. •Dose then reduced to 5-15 mg for Carbimazole and 50-150 mg for PTU. •Β-blockers
- Surgery
- Radioactive iodine (contraindicated in pregnancy and breastfeeding).
effect of hypothyroidism on pregnancy.
no effect if treated. if untreated risk of miscarried, anaemia, pre eclampsia.
Thyroid storm symptoms and signs.
fever,
tachycardia out of proportion to the fever, normal blood pressure, high output cardiac failure ,
restlessness, coma, seizures,
gastrointestinal: pain, diarhoea, vomiting
