Hypertensive Disorders and Diabetes in Pregnancy

Question 1

What is chronic hypertension?

Answer 1

Hypertension pre-pregnancy or at booking (<20 weeks)

Question 2

How is hypertension classed in pregnancy?

Answer 2

Mild (diastolic 90-99 systolic 140-49)
Moderate (diastolic 100-109 systolic 150-59)
Severe (diastolic >110 systolic >160)

Question 3

What is gestational hypertension?

Answer 3

Hypertension developed after 20 weeks gestation

Question 4

What is pre-eclampsia?

Answer 4

New hypertension > 20 weeks in association with significant proteinuria

Question 5

What are the classifications for significant proteinuria?

Answer 5

24 hour urine protein collection >300mg/day
Spot urinary protein: creatinine ratio >30mg/mmol
Automated reagent strip urine protein estimation >1+

Question 6

How is chronic hypertension managed during pregnancy?

Answer 6

Change anti-hypertensive drugs if indicated
Aim to keep BP<150/100
Monitor for superimposed pre-eclampsia
Monitor foetal growth

Question 7

How is pre-eclampsia diagnosed?

Answer 7

Mild hypertension of 2 occasions more than 4 hours apart

Proteinuria

Question 8

What is the pathophysiology of pre-eclampsia?

Answer 8

Reduced placental perfusion

Imbalance between vasoconstrictors/vasodilators in pregnancy

Question 9

What are the risk factors for developing pre-eclampsia?

Answer 9

First pregnancy 
Extremes of maternal age 
Pre-eclampsia in a precious pregnancy 
Pregnancy interval >10 years 
BMI>35 
Family history of PET 
Multiple pregnancy

Question 10

What are the maternal complications of pre-eclampsia?

Answer 10

Eclampsia, seizures
Severe hypertension (cerebral haemorrhage, stoke)
Renal failure
Pulmonary oedema, heart failure
HELLP (hemolysis, elevated liver enzymes, low platelets)
DIC (disseminated intravascular coagulation)

Question 11

What are the foetal complications of pre-eclampsia?

Answer 11

Impaired placental perfusion (foetal distress, prematurity, increase PN mortality)

Question 12

What are the symptoms and signs of pre-eclampsia?

Answer 12

Headache 
Blurring vision 
Epigastric pain 
Vomiting 
Sudden swelling of hands, face, legs
Reducing urine output
Clonus/brisk reflexes 
Severe hypertension 
Convulsions

Question 13

What are the biochemical abnormalities found in pre-eclampsia?

Answer 13

Raised liver enzymes, bilirubin if HELLP present
Raised urea and creatinine
Raised urate

Question 14

What are the haematological abnormalities of pre-eclampsia?

Answer 14

Low platelets
Low haemoglobin, signs of haemolysis
Features of DIC

Question 15

How is pre-eclampsia managed?

Answer 15

Frequent BP checks, urine protein 
Check symtomatology 
Check for hyper-reflexia 
Blood investigations 
Foetal investigations

Question 16

What is the treatment for eclampsia seizures?

Answer 16

Magnesium sulphate bolus and IV infusion
Control of blood pressure (IV labetolol, hydrallazine)
Avoid fluid overload

Question 17

What occurs during pregnancy with pre-existing diabetes?

Answer 17

Insulin requirements of mother increase

Foetal hyperinsulinemia occurs

Question 18

What are the effects of diabetes on the mother?

Answer 18

Miscarriage 
Pre-eclampsia 
Polyhydramnios 
Operative delivery 
Worsening of maternal nephropathy, retinopathy, hypoglycaemia
Infections

Question 19

What are the effects of diabetes on the foetus?

Answer 19

Foetal congenital abnormalities
Foetal macrosomia
Shoulder dystocia
Stillbirth

Question 20

What are the effects of diabetes on the neonate?

Answer 20

Impaired lung maturity
Neonatal hypoglycaemia
Jaundice

Question 21

How is diabetes managed pre conception?

Answer 21

Better glycaemic control
Folic acid
Dietary advice
Retinal and renal assessment

Question 22

How is diabetes managed during pregnancy?

Answer 22

Optimise glucose control
Watch for ketonuria/infections
Repeat retinal assessments at 28 and 34 weeks
Watch foetal growth

Question 23

How is diabetes managed during labour?

Answer 23

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

Question 24

What are the risk factors for gestational diabetes?

Answer 24

Increased BMI>30 
Previous macrocosmic baby >4.5kg 
Previous GDM 
Family history of diabetes 
Polyhydramnios or big baby in current pregnancy 
Recurrent glycosuria

Question 25

How is gestational diabetes managed?

Answer 25

Control blood sugars
Annual HbA1C check
Check OGTT 6-8 weeks PN

Question 26

Why is there an increased risk of venous thrombosis-embolism in pregnancy?

Answer 26

Hypercoaguable state as a protective mechanism
Increase in fibrinogen, factor VIII, VW factor, platelets
Decrease in natural anticoagulants (antithrombin III)
Increase in fibrinolysis

Question 27

Who is at an increased risk of developing a VTE in pregnancy?

Answer 27

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

Question 28

What is the prophylaxis and treatment of VTE?

Answer 28

TED stockings
Advice increased mobility
Prophylactic anticoagulants with 3 or more risk factors

Question 29

What are the signs and symptoms of VTE

Answer 29

Pain in calf 
Breathlessness 
Pain on breathing 
Cough 
Tachycardic 
Hypoxic 
Increased girth of affected leg 
Calf muscle tenderness 
Pleural rub