Medical Complications in Pregnancy

Question 1

What are the demographics risk factors for gestational diabetes?

Answer 1

SEA, Middle Eastern, Afro Caribbean; Age >40; BMI >30

SEA refers to Southeast Asian populations.

Question 2

What current obstetric factors are associated with gestational diabetes?

Answer 2

Glycosuria; Polyhydramnios; Macrosomia

Glycosuria indicates glucose in urine, which can signal diabetes.

Question 3

What past obstetric history increases the risk of gestational diabetes?

Answer 3

Previous gestational diabetes mellitus (GDM)

OGGT refers to Oral Glucose Tolerance Test.

Question 4

Which past gynecological history is a risk factor for gestational diabetes?

Answer 4

Polycystic Ovary Syndrome (PCOS)

PCOS is a hormonal disorder causing enlarged ovaries with small cysts.

Question 5

What past medical history can increase the risk of gestational diabetes?

Answer 5

Long-term steroid use

Long-term steroids can affect insulin sensitivity.

Question 6

What family history is a risk factor for gestational diabetes?

Answer 6

First-degree relative with diabetes mellitus

A first-degree relative includes parents and siblings.

Question 7

What is the diagnostic test for gestational diabetes and when is it performed?

Answer 7

Oral Glucose Tolerance Test (OGTT) at 28 weeks gestation

Fasting from midnight for at least 8 hours is required.

Question 8

What is required during the OGTT procedure?

Answer 8

75g glucose load in 250-300 ml water; Measure plasma glucose at fasting, 1hr, and 2hr post-load

Positive results occur if any one of the following values is raised.

Question 9

What values indicate a positive OGTT?

Answer 9

• Fasting ≥5.1 mmol/L
• 1 hr ≥10.0 mmol/L
• 2 hr ≥8.5 mmol/L

These thresholds are used to diagnose gestational diabetes.

Question 10

What is the management approach for gestational diabetes?

Answer 10

• MDT management
• Measure glucose 4-6 times per day
• Group education with diabetes nurse specialist
• Diabetes diet with a dietician
• Insulin if needed

MDT stands for Multidisciplinary Team.

Question 11

When should insulin be started in gestational diabetes management?

Answer 11

• Pre-meal glucose >6.0 mmol/L
• 1hr post-prandial glucose >7.5 mmol/L
• AC >95th centile despite good control

AC refers to antenatal care.

Question 12

What postpartum considerations are there for gestational diabetes?

Answer 12

• Stop insulin and glucose infusions
• Check glucose prior to discharge
• Arrange OGTT at 6 weeks postpartum
• Education on risk of developing Type 2 Diabetes Mellitus (T2DM)

50% risk of developing T2DM over the next 25 years.

Question 13

How does the delivery timing relate to gestational diabetes control?

Answer 13

• Poor control or abnormal parameters → <38 weeks
• Good control → 38-40 weeks

IOL refers to Induction of Labor.

Question 14

What complications can arise for the mother due to gestational diabetes?

Answer 14

• Polyhydramnios
• Increased risk of cesarean section
• Pre-eclampsia (PET)
• Infections
• 3rd/4th degree tears / episiotomy
• Recurrent GDM/postpartum T2DM

Macrosomia refers to a baby with a birth weight greater than 4,000 grams.

Question 15

What complications can arise for the infant due to gestational diabetes?

Answer 15

• Stillbirth (SB)
• Macrosomia and shoulder dystocia
• Respiratory Distress Syndrome (RDS)
• Hyperinsulinaemia
• Hypoglycaemia, hypocalcaemia, hypomagnesaemia

Hyperbilirubinaemia refers to jaundice in infants.

Question 16

What is acute fatty liver of pregnancy and how common is it?

Answer 16

Occurs in 1 in 7000-16000 pregnancies; presents in the 3rd trimester

Symptoms include vomiting, abdominal pain, anorexia, jaundice.

Question 17

What are the diagnostic criteria for acute fatty liver of pregnancy?

Answer 17

• ↑ AST <500 IU/L
• ↑ bilirubin <5 mg/dl
• Prolonged PT and PTT, ↓ fibrinogen

Liver biopsy is diagnostic after correcting coagulation defects.

Question 18

What is the management for acute fatty liver of pregnancy?

Answer 18

Delivery is the most important part of treatment

Consider sliding scale insulin if on steroids.

Question 19

What is the incidence of venous thromboembolism (VTE) in pregnancy?

Answer 19

Occurs in 1/1000-2000 pregnancies

VTE includes Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE).

Question 20

What are the risk factors for venous thromboembolism in pregnancy?

Answer 20

• Virchow’s triad
• Age >35
• Weight >80kg
• Multiparity
• Family history of VTE
• Antithrombin, Protein C and S deficiencies
• Gene variants (Factor V Leiden, Prothrombin)
• Lupus anticoagulant

Virchow’s triad includes stasis, hypercoagulability, and endothelial injury.

Question 21

What are the symptoms of Deep Vein Thrombosis (DVT)?

Answer 21

• Leg swelling and discomfort
• Calf circumference difference >2 cm
• Signs of superficial phlebitis
• Homan’s sign

Homan’s sign is pain in the calf upon dorsiflexion of the foot.

Question 22

What diagnostic tests are used for DVT?

Answer 22

• Blood tests: FBC, U&E, LFTs, coags, thrombophilia screen
• Ultrasound (compression or duplex)
• Contrast venography
• MRI

D-dimers are not used due to potential elevation in pregnancy.

Question 23

What are the symptoms of Pulmonary Embolism (PE)?

Answer 23

• Mild dyspnoea
• Tachycardia
• Cardiopulmonary collapse

Most cases occur postpartum.

Question 24

What are the diagnostic tests for Pulmonary Embolism?

Answer 24

• Chest X-ray (CXR)
• ECG
• V/Q scan

The classic S1Q3T3 pattern on ECG is associated with PE.

Question 25

What is the management for Pulmonary Embolism?

Answer 25

• Anticoagulation (UFH or LMWH)
• Warfarin (does not cross the placenta)
• Continue treatment for at least 6 weeks postpartum

Warfarin can cause fetal damage in the first trimester but is safe for breastfeeding.

Question 26

What is Disseminated Intravascular Coagulation (DIC)?

Answer 26

A serious condition involving abnormal blood clotting

DIC can lead to multiple organ failure and requires urgent management.

Question 27

DVT Flowchart:

Answer 27

Question 28

PE Flowchart:

Answer 28