Maternal Complications Flashcards
What is target BP in pregnancy?
<150/80-100
What is pregnancy induced hypertension (PIH)/gestational hypertension?
Hypertension developing over 20 weeks gestation, without proteinuria
What is pre-eclampsia?
Pregnancy induced hypertension with associated organ damage, notably proteinuria
Describe the pathophysiology of pre-eclampsia
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
What percentage of the pregnant population is effected by pre-eclampsia?
5/10%
Give risk factors for pre-eclampsia
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
How does pre-eclampsia present?
Headache
Blurred vision/papilloedema
RUQ/epigastric pain
N&V
Oedema
Brisk reflexes
Oliguria
Convulsions, if eclampsia development
Jauncide, due to HELLP syndrome
What is the NICE guidelines for PET diagnosis?
BP above 140/90 plus any of
Proteinuria (1+ more on dipstick)
Organ dysfunction (HELLP, U&E dysfunction)
Placental dysfunction
What investigations are used for pre-eclampsia diagnosis?
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
Give maternal complications of pre-eclampsia
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
Give foetal complications of pre-eclampsia
Intrauterine growth restriction
Intrauterine death
Iatrogenic preterm delivery
What is the prophylactic management of pre-eclampsia?
75mg aspirin daily from 12 weeks gestation until birth to women with a single high risk factor or 2 or more moderate risk factors
What is the management of pre-eclampsia?
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
When is delivery reccomended in PET?
Delivery within 24-48 hours in those women who has pre-eclampsia with mild or moderate hypertension after 37 weeks
What is used in PET instead of labetalol if patient is asthmatic?
Nifedipine, second line to labetalol
What is the management of eclampsia?
IV magnesium sulphate
How long can magnesium sulphate be given?
Continue for 24 hours after delivery or after last seizure
Give side effect of magnesium sulphate
Respiratory depression
How is magnesium sulphate induced respiratory depression managed?
Calcium gluconate
How long after delivery does the risk of pre-eclampsia last?
6 weeks after delivery
What should labetalol be switched to after delivery in PET?
Elanapril
What can also reduce BP in induced labour?
Epidural anaesthesia
What is gestational diabetes?
Diabetes/increased blood glucose occuring over 20 weeks gestation, that reverts to normal after delivery
Describe the pathophysiology of gestational diabetes
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
Describe the screening system for gestational diabetes
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
Give risk factors for gestational diabetes
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
When are women screened for gestational diabates?
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
Give the diagnostic thresholds for gestational diabetes
5678
Fasting >5.6mmoles/l
2 hour glucose >7.8mmoles/l
Describe the management of patients with pre-existing diabetes
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
How is gestational diabetes managed?
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
What are the glucose targets in gestational diabetes?
Fasting 5.3mmoles/l
1 hour glucose 7.8mmoles/l
2 hour glucose 6.4mmoles/l
How often should patients measure blood glucose?
Daily fasting, pre-meal, 1 hour post meal and bedtime tests
When should insulin be used in management of gestational diabetes?
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
When should metformin be used in management of gestational diabetes?
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
When is insulin used in gestational diabetes over metformin?
Metformin if fasting glucose <7mmol/l, after lifestyle trial
Insulin if fasting glucose >7mmol/l
When and how much folic acid should be given in diabetic patients?
Folic acid 5 mg/day from pre-conception to 12 weeks gestation
Give fetal complications of gestational diabetes
Fetal congenital abnormalities
Miscarriage
Fetal macrosomia
Polyhydramnios
Operative delivery
Shoulder dystocia, baby can get nerve palsy if damage
Stillbirth
Give maternal complications of gestational diabetes
Pre-eclampsia
Type 2 Diabetes
- Nephropathy
- Retinopathy
- Hypoglycaemia
Infection
Perineal tear
Haemorrhage
Give neonate complications of gestational diabetes
Impaired lung maturity and respiratory distress
Neonatal hypoglycaemia
Jaundice
Polycythaemia
Cardiomyopathy
Why is VTE risk increased in pregnancy?
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
Give risk factors for VTE in pregnancy
>Age
>BMI
FH
Immobility
Trauma
Smoking
Thrombophilia
Parity over 3
Multiple pregnancy
PET
IVF pregnancy
How does VTE present?
Calf pain/tenderness
Calf swelling
Dyspnoea
Acute chest pain
Cough
Tachycardia
Hypoxia
Pleural rub
When is VTE prophylaxis indicated in pregancy?
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
What anticoagulant is used in VTE prophylaxis?
LMWH
- Dalteparin
- Enoxaparin
How long is VTE prophylaxis continued in pregnancy?
6 weeks postpartum
What VTE investigation is not suitable in pregnancy?
D dimer, as pregnancy increases this in all women
How is PE/VTE managed in pregnancy?
LMWH, even before confirmed diagnosis with imaging
What trimester is obstetric cholestasis seen?
3rd
Give features of obstetric cholestasis
Pruritus, often in the palms and soles
No rash, although skin changes may be seen due to scratching
Raised bilirubin
How is obsteteic cholestasis managed?
Ursodeoxycholic acid is used for symptomatic relief
Weekly liver function tests
Vitamin K supplements
Women are typically induced at 37 weeks
Give complications of obstetric cholestasis
Stillbirth
What trimester does acute fatty liver of pregnancy occur?
3rd, or the period immediately following delivery
Give features of acute fatty liver of pregnancy
Abdominal pain
N&V
Headache
Jaundice
Hypoglycaemia
Severe disease may result in pre-eclampsia
Elevated ALT
HELLP
