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Maternal Complications Flashcards

1
Q

What is target BP in pregnancy?

A

<150/80-100

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2
Q

What is pregnancy induced hypertension (PIH)/gestational hypertension?

A

Hypertension developing over 20 weeks gestation, without proteinuria

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3
Q

What is pre-eclampsia?

A

Pregnancy induced hypertension with associated organ damage, notably proteinuria

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4
Q

Describe the pathophysiology of pre-eclampsia

A

Failure of invasion of maternal spiral arterioles by trophoblasts, causing reduced placental perfusion, resulting in an abnormal placenta

Hypo-perfused placenta releases pro-inflammatory proteins and so maternal vascular endothelial cells become dysfunctional, resulting in vasoconstriction

Vasoconstrictors take over and women’s BP is increased dramatically due to imbalance between vasodilators and vasoconstrictors

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5
Q

What percentage of the pregnant population is effected by pre-eclampsia?

A

5/10%

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6
Q

Give risk factors for pre-eclampsia

A

High

Preexisting HTN

Previous PET or gestational HTN

Existing autoimmune conditons, such as SLE and antiphospholipid syndrome

DM

CKD

Moderate

Age over 40

BMI>35

First pregnancy or more than 10 years since first pregnancy

FH

Multiple pregnancy

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7
Q

How does pre-eclampsia present?

A

Headache

Blurred vision/papilloedema

RUQ/epigastric pain

N&V

Oedema

Brisk reflexes

Oliguria

Convulsions, if eclampsia development

Jauncide, due to HELLP syndrome

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8
Q

What is the NICE guidelines for PET diagnosis?

A

BP above 140/90 plus any of

Proteinuria (1+ more on dipstick)

Organ dysfunction (HELLP, U&E dysfunction)

Placental dysfunction

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9
Q

What investigations are used for pre-eclampsia diagnosis?

A

Frequent BP and protein urine checks/24 urinary protein

FBC

  • Thrombocytopenia,
  • Anaemia

LFT

  • Elevated liver enzymes
  • Elevated bilirubin

U&E

  • Increased urea and creatinine

US

  • IUGR
  • Oligohydramnios

Group and save, if delivery thought to be likely

PIGF (placental growth factor)

  • Low in PET
  • Assess during 20-35 weeks to rule out
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10
Q

Give maternal complications of pre-eclampsia

A

Eclampsia/seizures

Severe hypertension, causing cerebral haemorrhage and stroke

HELLP syndrome

  • Haemolysis
  • Elevated liver enzymes
  • Low platelets

DIC

Renal and Hepatic failure

Pulmonary oedema and cardiac failure

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11
Q

Give foetal complications of pre-eclampsia

A

Intrauterine growth restriction

Intrauterine death

Iatrogenic preterm delivery

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12
Q

What is the prophylactic management of pre-eclampsia?

A

75mg aspirin daily from 12 weeks gestation until birth to women with a single high risk factor or 2 or more moderate risk factors

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13
Q

What is the management of pre-eclampsia?

A

BP monitoring at least every 48 hours

US, doppler and aminocentesis monitoring of fetus every 2 weeks

IV labetalol

Planned early delivery with corticosteroids for fetal lung maturity

Fluid restriction during labour

IV magnesium sulphate within 24 hours of labour and 24 hours after

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14
Q

When is delivery reccomended in PET?

A

Delivery within 24-48 hours in those women who has pre-eclampsia with mild or moderate hypertension after 37 weeks

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15
Q

What is used in PET instead of labetalol if patient is asthmatic?

A

Nifedipine, second line to labetalol

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16
Q

What is the management of eclampsia?

A

IV magnesium sulphate

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17
Q

How long can magnesium sulphate be given?

A

Continue for 24 hours after delivery or after last seizure

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18
Q

Give side effect of magnesium sulphate

A

Respiratory depression

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19
Q

How is magnesium sulphate induced respiratory depression managed?

A

Calcium gluconate

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20
Q

How long after delivery does the risk of pre-eclampsia last?

A

6 weeks after delivery

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21
Q

What should labetalol be switched to after delivery in PET?

A

Elanapril

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22
Q

What can also reduce BP in induced labour?

A

Epidural anaesthesia

23
Q

What is gestational diabetes?

A

Diabetes/increased blood glucose occuring over 20 weeks gestation, that reverts to normal after delivery

24
Q

Describe the pathophysiology of gestational diabetes

A

Insulin requirements of the mother increase

Human placental lactogen, Progesterone, Human chorionic gonadotrophin and cortisol from the placenta have anti-insulin action and so reduce insulin sensitivity

25
Q

Describe the screening system for gestational diabetes

A

Women who’ve previously had gestational diabetes OGTT should be performed as soon as possible after booking and at 24-28 weeks if the first test is normal

Women with any of the other risk factors should be offered an OGTT at 24-28 weeks

26
Q

Give risk factors for gestational diabetes

A

BMI >30

Previous macrosomic baby > 4.5kg

Previous GDM

Increased age

FH of diabetes

Ethnic origin, asian or black carribean

Polyhydramnios or macrosomia in current pregnancy

Recurrent glycosuria in current pregnancy

27
Q

When are women screened for gestational diabates?

A

Anyone with risk factors should be screened with an OGTT at 24-28 weeks gestation

Women with previous gestational diabetes also have an OGTT soon after the booking clinic

28
Q

Give the diagnostic thresholds for gestational diabetes

A

5678

Fasting >5.6mmoles/l

2 hour glucose >7.8mmoles/l

29
Q

Describe the management of patients with pre-existing diabetes

A

Weight loss

5mg folic acid/day from preconception to 12 weeks

Aim for gestational diabetes targets

Stop oral hypoglycaemic agents, apart from metformin, and commence insulin

Retinopathy screening at booking and 28 weeks

Adviced planned delivery at 37 weeks

Detailed anomaly scan at 20 weeks

30
Q

How is gestational diabetes managed?

A

Lifestyle advice

Folic acid 5mg/day

Regularly blood glucose monitoring

Medication

  • Metformin
  • Insulin

Oral glucose tolerance test 6-8 weeks postnatal

Yearly check on HbA1C

Retinal and renal assessment

Provide glucagon injections and glucose solution

Induce labour if concerns

31
Q

What are the glucose targets in gestational diabetes?

A

Fasting 5.3mmoles/l

1 hour glucose 7.8mmoles/l

2 hour glucose 6.4mmoles/l

32
Q

How often should patients measure blood glucose?

A

Daily fasting, pre-meal, 1 hour post meal and bedtime tests

33
Q

When should insulin be used in management of gestational diabetes?

A

If at the time of diagnosis the fasting glucose level is >= 7 mmol/l insulin should be started

if the plasma glucose level is between 6-6.9 mmol/l, and there is evidence of complications such as macrosomia or hydramnios, insulin should be offered

34
Q

When should metformin be used in management of gestational diabetes?

A

Fasting glucose <7mmol/l, after lifestyle trial

If glucose targets are not met within 1-2 weeks of altering diet/exercise metformin should be started

35
Q

When is insulin used in gestational diabetes over metformin?

A

Metformin if fasting glucose <7mmol/l, after lifestyle trial

Insulin if fasting glucose >7mmol/l

36
Q

When and how much folic acid should be given in diabetic patients?

A

Folic acid 5 mg/day from pre-conception to 12 weeks gestation

37
Q

Give fetal complications of gestational diabetes

A

Fetal congenital abnormalities

Miscarriage

Fetal macrosomia

Polyhydramnios

Operative delivery

Shoulder dystocia, baby can get nerve palsy if damage

Stillbirth

38
Q

Give maternal complications of gestational diabetes

A

Pre-eclampsia

Type 2 Diabetes

  • Nephropathy
  • Retinopathy
  • Hypoglycaemia

Infection

Perineal tear

Haemorrhage

39
Q

Give neonate complications of gestational diabetes

A

Impaired lung maturity and respiratory distress

Neonatal hypoglycaemia

Jaundice

Polycythaemia

Cardiomyopathy

40
Q

Why is VTE risk increased in pregnancy?

A

Pregnancy is a hypercoagulable state to protect mother against bleeding post delivery

  • Increase in clotting factors (fibrinogen, vwf, platelets)
  • Decrease in natural anticoagulants (antithrombin III)
  • Increase in fibrinolysis

Increased blood stasis

  • Progesterone
  • Enlarging uterus
41
Q

Give risk factors for VTE in pregnancy

A

>Age

>BMI

FH

Immobility

Trauma

Smoking

Thrombophilia

Parity over 3

Multiple pregnancy

PET

IVF pregnancy

42
Q

How does VTE present?

A

Calf pain/tenderness

Calf swelling

Dyspnoea

Acute chest pain

Cough

Tachycardia

Hypoxia

Pleural rub

43
Q

When is VTE prophylaxis indicated in pregancy?

A

All women should have VTE risk assessment at booking

28 weeks if 3 risk factors

First trimester/soon as possible if 4 or more, or if one significant risk factor

44
Q

What anticoagulant is used in VTE prophylaxis?

A

LMWH

  • Dalteparin
  • Enoxaparin
45
Q

How long is VTE prophylaxis continued in pregnancy?

A

6 weeks postpartum

46
Q

What VTE investigation is not suitable in pregnancy?

A

D dimer, as pregnancy increases this in all women

47
Q

How is PE/VTE managed in pregnancy?

A

LMWH, even before confirmed diagnosis with imaging

48
Q

What trimester is obstetric cholestasis seen?

A

3rd

49
Q

Give features of obstetric cholestasis

A

Pruritus, often in the palms and soles

No rash, although skin changes may be seen due to scratching

Raised bilirubin

50
Q

How is obsteteic cholestasis managed?

A

Ursodeoxycholic acid is used for symptomatic relief

Weekly liver function tests

Vitamin K supplements

Women are typically induced at 37 weeks

51
Q

Give complications of obstetric cholestasis

A

Stillbirth

52
Q

What trimester does acute fatty liver of pregnancy occur?

A

3rd, or the period immediately following delivery

53
Q

Give features of acute fatty liver of pregnancy

A

Abdominal pain

N&V

Headache

Jaundice

Hypoglycaemia

Severe disease may result in pre-eclampsia

Elevated ALT

HELLP

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