Hypertensive Disorders and Diabetes in Pregnancy Flashcards
What is chronic hypertension?
Hypertension pre-pregnancy or at booking (<20 weeks)
How is hypertension classed in pregnancy?
Mild (diastolic 90-99 systolic 140-49)
Moderate (diastolic 100-109 systolic 150-59)
Severe (diastolic >110 systolic >160)
What is gestational hypertension?
Hypertension developed after 20 weeks gestation
What is pre-eclampsia?
New hypertension > 20 weeks in association with significant proteinuria
What are the classifications for significant proteinuria?
24 hour urine protein collection >300mg/day
Spot urinary protein: creatinine ratio >30mg/mmol
Automated reagent strip urine protein estimation >1+
How is chronic hypertension managed during pregnancy?
Change anti-hypertensive drugs if indicated
Aim to keep BP<150/100
Monitor for superimposed pre-eclampsia
Monitor foetal growth
How is pre-eclampsia diagnosed?
Mild hypertension of 2 occasions more than 4 hours apart
Proteinuria
What is the pathophysiology of pre-eclampsia?
Reduced placental perfusion
Imbalance between vasoconstrictors/vasodilators in pregnancy
What are the risk factors for developing pre-eclampsia?
First pregnancy Extremes of maternal age Pre-eclampsia in a precious pregnancy Pregnancy interval >10 years BMI>35 Family history of PET Multiple pregnancy
What are the maternal complications of pre-eclampsia?
Eclampsia, seizures
Severe hypertension (cerebral haemorrhage, stoke)
Renal failure
Pulmonary oedema, heart failure
HELLP (hemolysis, elevated liver enzymes, low platelets)
DIC (disseminated intravascular coagulation)
What are the foetal complications of pre-eclampsia?
Impaired placental perfusion (foetal distress, prematurity, increase PN mortality)
What are the symptoms and signs of pre-eclampsia?
Headache Blurring vision Epigastric pain Vomiting Sudden swelling of hands, face, legs Reducing urine output Clonus/brisk reflexes Severe hypertension Convulsions
What are the biochemical abnormalities found in pre-eclampsia?
Raised liver enzymes, bilirubin if HELLP present
Raised urea and creatinine
Raised urate
What are the haematological abnormalities of pre-eclampsia?
Low platelets
Low haemoglobin, signs of haemolysis
Features of DIC
How is pre-eclampsia managed?
Frequent BP checks, urine protein Check symtomatology Check for hyper-reflexia Blood investigations Foetal investigations
What is the treatment for eclampsia seizures?
Magnesium sulphate bolus and IV infusion
Control of blood pressure (IV labetolol, hydrallazine)
Avoid fluid overload
What occurs during pregnancy with pre-existing diabetes?
Insulin requirements of mother increase
Foetal hyperinsulinemia occurs
What are the effects of diabetes on the mother?
Miscarriage Pre-eclampsia Polyhydramnios Operative delivery Worsening of maternal nephropathy, retinopathy, hypoglycaemia Infections
What are the effects of diabetes on the foetus?
Foetal congenital abnormalities
Foetal macrosomia
Shoulder dystocia
Stillbirth
What are the effects of diabetes on the neonate?
Impaired lung maturity
Neonatal hypoglycaemia
Jaundice
How is diabetes managed pre conception?
Better glycaemic control
Folic acid
Dietary advice
Retinal and renal assessment
How is diabetes managed during pregnancy?
Optimise glucose control
Watch for ketonuria/infections
Repeat retinal assessments at 28 and 34 weeks
Watch foetal growth
How is diabetes managed during labour?
Observe for PET
Induced labour at 38-40 weeks
Consider C section for foetal macrosomia
Maintain BG in labour with insulin-dextrose infusion
Continuous CTG monitoring in labour
Early feeding of baby to reduce neonatal hypoglycaemia
What are the risk factors for gestational diabetes?
Increased BMI>30 Previous macrocosmic baby >4.5kg Previous GDM Family history of diabetes Polyhydramnios or big baby in current pregnancy Recurrent glycosuria
How is gestational diabetes managed?
Control blood sugars
Annual HbA1C check
Check OGTT 6-8 weeks PN
Why is there an increased risk of venous thrombosis-embolism in pregnancy?
Hypercoaguable state as a protective mechanism
Increase in fibrinogen, factor VIII, VW factor, platelets
Decrease in natural anticoagulants (antithrombin III)
Increase in fibrinolysis
Who is at an increased risk of developing a VTE in pregnancy?
Older mothers Increasing parity Increased BMI Smokers IV drugs users PET Dehydration Decreased mobility Infections Operative delivery or prolonged labour Previous VTE Sickle cell disease
What is the prophylaxis and treatment of VTE?
TED stockings
Advice increased mobility
Prophylactic anticoagulants with 3 or more risk factors
What are the signs and symptoms of VTE
Pain in calf Breathlessness Pain on breathing Cough Tachycardic Hypoxic Increased girth of affected leg Calf muscle tenderness Pleural rub
