medical disorders of pregnancy Flashcards
what is Pre-eclampsia?
when does it occur?
a PLACENTAL DISEASE new onset of hypertension in pregnancy
over 140 mmHg systolic or over 90 mmHg diastolic
+ end-organ dysfunction, notably with proteinuria It occurs after 20 weeks gestation
pathophysiology of Pre-eclampsia?
normally, the spiral arteries dilate 10x more their size and develop into utero-placental arteries, to deliver lots of blood to the uterus
in pre-eclampsia–> these arteries become FIBROUS and NaRROW–> less blood gets to the placenta–>placenta release pro-inflammatory proteins–> gets into the circulation and causes endomethial dysfunction–>which causes vasoconstriction and kidney retain more salt–>HYPERTENSION
risk factors of Pre-eclampsia
(high (5) vs moderate(6)
HIGH
- Hx of hypertensive D. in previous pregnancy.
- CKD
- Autoimmune disease, ex: as SLE or antiphospholipid syndrome.
- Type 1 or type 2 diabetes.
- Chronic hypertension.
MODERATE
- Older than 40
- BMI > 35
- > 10 years since previous pregnancy
- TWIN pregnancy (
- FIRST pregnancy (body has never made a placenta)
- FHx of pre-eclampsia
what is involved in the assessment if a women who is considered to be at high risk of pre-eclampsia?
(involve referral)
- Refer for consultant-led care at booking for specialist input to assess and manage the obstetric risk.
- Ensure that ASPIRIN 75—150 mg daily is prescribed from 12 weeks’ gestation until birth.
- Offer advice about healthy lifestyle (including rest, work, exercise, and weight)
aspirin helps with forming the placenta,Aspirin inhibits thromboxane a hormone which raises blood pressure
symptoms of Pre-E (6)
- Severe headache.
- Vision problems ex: blurring or flashing b4 the eyes.
- Severe pain just below the ribs. (liver swelling)
- Vomiting.
- edema of the face, hands or feet.
- hyper-reflelxia?>> indicates an increased risk of eclamptic seizure)
Signs of Pre-eclampsia
- Sustained sys BP more than 160 and diastolic more than 110
- Tachycardia
- Tachypnea
- Rales
- Hyper-reflexia
- Papilledema
- Oligouria or anuria
- RUQ tenderness on palpation
Diagnosis of Pre-eclampsia:
how can Proteinuria can be quantified?
BP
- Systolic blood pressure above 140 mmHg
- Diastolic blood pressure above 90 mmHg
PLUS any of:
Proteinuria (1+ or more on urine dipstick)
Organ dysfunction (e.g. raised creatinine, High LFT’s, seizures, thrombocytopenia or haemolytic anaemia)
Placental dysfunction (e.g. fetal growth restriction or abnormal Doppler studies)
Proteinuria can be quantified using:
- Urine protein:creatinine ratio (above 30mg/mmol is significant)
- Urine albumin:creatinine ratio (above 8mg/mmol is significant)
The NICE guidelines (2019) recommend the use of placental growth factor (PlGF) testing on one occasion during pregnancy in women suspected of having pre-eclampsia. Placental growth factor is a protein released by the placenta that functions to stimulate the development of new blood vessels. In pre-eclampsia, the levels of PlGF are low. NICE recommends using PlGF between 20 and 35 weeks gestation to rule-out pre-eclampsia.
Bedside tests performed at every antenatal appt?
· Blood pressure
· Urine dipstick
- ++/+++
- If +1 or more, further testing
further Investigations ?
URINE
- Urine dipstick, and then quantified through a 24-hour urinary collection.
- do MSU: rule out UTI
BLOODS
- FBC: ↓ Hb, ↓ platelets.
- U & E: ↑ urea, ↑ creatinine, ↑ urate, ↓ urine output.
- LFT’s: ↑ ALT, ↑ AST.
USS doppler
CTG
Abdominal USS to assess foetal size
Management of Pre-eclampsia (4)
- Healthy lifestyle--> ( Restriction of dietary salt)
- Review meds–> stop ACE or ARBs–> risk of adverse fetal outcomes
- Alternative anti-hypertensive:
- 1st -line is LABETALOL if not contraindicated.
- 2nd-line nifedipine (modified-release) if asthmatic & diabetics
- 3rd-line methyldopa (avoid post natally)
- Ensure that ASPIRIN 75—150 mg daily is prescribed from 12 weeks’ gestation until birth.
- safety net her about delivery options (early delivery may be required)
* bc decreases hypoawarness if they get hypoglycemia*
* give it modified release bc can lower bp 7AIL*
Target blood pressure following antihypertensive treatment in pregnancy
Target BP following antihypertensive treatment in pregnancy 135/85 mmHg.
Monitoring in pre-eclampsia?
- USS scan every 2-3 weeks
- Bloods every 2-3 days
- Monitor proteinuria
what is HELLP Syndrome
Tx?
endothelial infjury causes the formation of tiny thrombi, its uses up platelets and therefore HEMOLYSIS
- Haemolysis
- Elevated Liver enzymes >> deposition of fibrin in the sinusoids cx obstruction
- Low Platelets
Treatment
- delivery of the baby
complication of Pre-eclampsia
child vs mum
Mummy (related to end organ damage)
- CNS: Intracranial haemorrhage, cerebral edema, Haemorrhage beneath capsule (RUQ pain)
- Renal: AKI
- Liver: HELLP,
- Coagulation: DIC
FETUS
- Prematurity (iatrogenic and idiopathic)
- IUGR
- IU fetal DEATH
- placental abruption
what is Eclampsia?
Tx if occured during labor? what complication can that treatment cause? how to treat?
SEIZURES + pre-eclampsia.
A-E–> put her in the left lateral position (shift pressure of uterus of the IVC) + high flow oxygen
Treatment
IV magnesium sulphate is used to manage seizures
►should continue for 24 hours after last seizure or delivery
RESPIRATORY DEPRESSION can occur!!!!!!
Tx: calcium gluconate is the first-line treatment for Mg sulphate induced respiratory depression
what is Obstetric Cholestasis?
when does it occur?
intrahepatic cholestasis of pregnancy.
reduced outflow of bile acids from the liver.
occurs LATER in pregnancy (Starts from 28 weeks gestation onwards)
The condition resolves after delivery of the baby.
Clinical Features of Obstetric Cholestasis (5)
Itching (pruritis)>>worse at night is the main symptom, particularly affecting the palms of the hands & soles of the feet.
Other symptoms are related to cholestasis and outflow obstruction in the bile ducts:
- Fatigue
- Dark urine
- Pale, greasy stools
- Jaundice
there is NO rash associated w/ obstetric cholestasis.
If a rash is present…what alternative diagnosis would u consider?
polymorphic eruption of pregnancy
or
pemphigoid gestationis.
Investigations of Obstetric Cholestasis (2)
referrel?
_Same-day referral_ to a local maternity unit may be required for these blood tests and to check fetal wellbeing
- LFT’s–> rasied ALT, AST and GGT
- serum Bile Acids–> Raised
TOM TIP: It is normal for (ALP) to increase in pregnancy. This is because the placenta produces ALP.
A rise in ALP without other abnormal LFT results is usually due to placental production of ALP, rather than liver pathology.
Management of obstetric cholestasis (5)
Monitoring?
follow up?
1st line: Ursodeoxycholic acid improves LFTs, bile acids and symptoms.
Symptoms of itching can be managed with:
- Emollients (i.e. calamine lotion) to soothe the skin
- sedating Antihistamines (e.g. chlorphenamine) can help sleeping (but does not improve itching)
- Water-soluble vitamin K can be given if clotting (prothrombin time) is deranged
- Elective early delivery from 37 w_èeks_’ gestation may be considered on an individual basis.
Monitoring
- if confirmed obstetric cholestasis: ongoing monitoring of serum bile acid levels/ LFTs and fetal wellbeing, via the maternity unit, until delivery.
- If unexplained itch but bile acids and/or LFTs are NORMAL–> levels should be monitored weekly (via the obstetrics team) until the itch resolves.
Follow up
- postnatal LFT test 10 days after delivery
What is the role of giving Vit K if prothrombin time is deranged?
Vitamin K is a fat-soluble vitamin.
Bile acids are important in the absorption of fat-soluble vitamins in the intestines.
A lack of bile acids –> lead to vitamin K deficiency.
Vitamin K is an important part of the clotting system, and deficiency can lead to impaired clotting of blood.
Risk of Obstetric cholestasis on mum and baby
Gestational diabetes
Gestational diabetes refers to diabetes triggered by pregnancy. It is caused by reduced insulin sensitivity during pregnancy, and resolves after birth.
Products of the placenta, including TNF-alpha) and human placental lactogen (also known as human chorionic somatomammotropin), are thought to play key roles in inducing maternal insulin resistance
RF of GD (5)
- Previous gestational diabetes
- Previous macrosomic baby (≥ 4.5kg)
- BMI > 30
- Ethnic origin (black Caribbean, Middle Eastern and South Asian)
- Family history of diabetes (first-degree relative)
Screening for GD
Diagnostic values
oral glucose tolerance test (OGTT)
An OGTT should be performed in the MORNING after a fast (they can drink plain water).
The ptx drinks a 75g glucose drink at the start of the test–>The blood sugar level is measured B4 the sugar drink (fasting) and then at 2 hours.
Normal results are:
- Fasting: < 5.6 mmol/l
- At 2 hours: < 7.8 mmol/l
- Results higher than these values are used to diagnose gestational diabetes.*
- TOM TIP: It is really easy to remember the cutoff for gestational diabetes as simply 5 – 6 – 7 – 8.*
Management and Monitoring of GD
- Patient Education
- They need 4 WKLY USS to monitor the fetal growth and amniotic fluid volume from 28 - 36 weeks gestation.
- Fasting glucose less than 7 mmol/l: trial of diet and exercise for 1-2 weeks, followed by metformin, then insulin
- Fasting glucose above 7 mmol/l: insulin ± metformin
- Fasting glucose above 6 mmol/l + macrosomia (or other complications): insulin ± metformin
what if women cannot tolerate Metaformin?
Glibenclamide (a sulfonylurea) is suggested as an option for women who decline insulin or cannot tolerate metformin.
⚠️⚠️⚠️it should be discontinued at least 2️⃣ weeks before the expected delivery date
Management of pre-existing diabetes (4)
- 💊 5mg folic acid from preconception until 12 weeks gestation.
- 👁 Retinopathy screening should be performed shortly after booking and at 7 months
-🤰🏻 planned delivery between 37 and 38 + 6 weeks for women with pre-existing diabetes.
- 🙅🏻♀️if type 2 stop oral hypoglycaemic agents, apart from metformin, and commence insulin
Fetal Complications of Gestational Diabetes (5)
Macrosomia – this can cause complications during labour, such as shoulder dystocia, obstructed/delayed labour, and/or higher rates of instrumental deliveries.
Neonatal hypoglycaemia
Organomegaly (particularly cardiomegaly)
Erythropoiesis (resulting in polycythaemia)
Polyhydramnios
Increased rates of pre-term delivery
Postnatal Care
- what happens to insulin sensitivity after birth?*
- what happens to fetus after delivery?*
Diabetes improves immediately after birth.
Women with gestational diabetes can stop their diabetic medications immediately after birth.
They need follow up to test their fasting glucose after at least 6 weeks.
Women with existing diabetes should lower their insulin doses and be wary of hypoglycaemia in the postnatal period.
The insulin sensitivity will INCREASE after birth and with breastfeeding.
After delivery, the fetus still has high insulin levels, but no longer receives glucose from its mother. This results in an increased risk of hypoglycaemia – and therefore regular feeding is important.
Babies need close monitoring for neonatal hypoglycaemia
- what is the glucose aim?*
- Treatment if it was LOWER than that?*
Must have regular BG checks and frequent feeds.
The aim is to maintain their blood sugar ABOVE✌🏼 mmol/l, and if it falls below this….
Tx: they may need IV dextrose of nasogastric feeding.
why do pregnant women get VTE?
Thrombosis occurs as a result of stagnation of blood, and in hyper-coagulable states, such as pregnanc
Risk Factors of VTE (12)
- Smoking
- Parity ≥ 3
- Age > 35 years
- BMI > 30
- Reduced mobility
- Multiple pregnancy
- Pre-eclampsia
- Gross varicose veins
- Immobility
- Family history of VTE
- Thrombophilia
- IVF pregnancy
when should you start and end prophylaxis for VTE?
- 28 weeks if there are 3 risk factors
- 1st trimester if there are 4 or more risk factors
continued throughout the antenatal period and for 6 weeks postnatally.
what prohpylactic treatment is given for VTE? (2)
what about when women goes into labor?
who is exempted from continuing Tx after birth?
LMWH--> enoxaparin, dalteparin and tinzaparin.
if contraindicated:
- Intermittent pneumatic compression
- Anti-embolic compression stockings
Stopped at BIRTH, then continued after until 6 wks post birth
Except with :
- postpartum haemorrhage
- spinal anaesthesia and epidurals
Presentation of VTE (5)
- UNILATERAL Calf or leg swelling
- Dilated superficial veins
- Tenderness to the calf (particularly over the deep veins)
- Edema
- Colour changes to the leg
how do you examine for leg swelling?
measure the circumference of the calf 10cm below the tibial tuberosity.
More than 3cm difference between calves is significant.
When and where are women screened for anaemia in pregnancy?
What happens to Hb in pregnancy? Why
- Booking clinic
- 28 wks gestation
During pregnancy, the plasma volume increases. This results in a reduction in the haemoglobin concentration. Bc the blood is diluted
Risk factors for anaemia in pregnancy (6)
- Low iron stores before pregnancy
- Pre-existing haematological condition
- IBD/coeliacs disease (reduced ability to absorb iron)
- <20 years old
- Multiple pregnancy
- Previous anaemia in pregnancy
Investigations of anemia
Women are offered haemoglobinopathy screening at the booking clinic for
thalassaemia (all women) and sickle cell disease (women at higher risk)
Both are causes of significant anaemia in pregnancy.
Additional investigations:
- Ferritin–> low MCV
- B12–> raised MCV
- Folate–>
Managment of anemia
Iron
- ferrous sulphate 200mg 3X daily
if nOT anaemic, but have low ferritin (indicating low iron stores), they may be started on supplementary iron.
B12
The increased plasma volume and B12 requirements often result in a low B12 in pregnancy. Women with low B12 should be tested for pernicious anaemia (checking for intrinsic factor antibodies).
Advice should be sought from a haematologist regarding further investigations and treatment of low B12 in pregnancy. Treatment options for low B12 are:
- IM hydroxocobalamin injections
- Oral cyanocobalamin tablets
Folate
- ALLL women should already be taking folic acid 400mcg per day.
- women with folate deficiency are started on folic acid 5mg daily.
Thalassaemia and Sickle Cell Anaemia
Women with a haemoglobinopathy will be managed jointly with a specialist haematologist. They require high dose folic acid (5mg), close monitoring and transfusions when required.
clinical consequences of anaemia in pregnancy, labour and
purperium?
- Stillbirth
- FGR
- Low birth weight
- Pre-term labour
- Low reserve - small bleed can be fatal as they decompensate quickly
Effect of pregnancy on epilepsy
what to tell mums?
managment
- ¤ Physiological changes in preg alter the PK of AED*
- ¤ risk of congenital abnormalities is dependent on the type, number and dose of AEDs*
- Sodium Vaporate >> NTD**, developmental delay
- Phenytoin >> Cleft lip & palate
Managment : BEFORE and INTRAPRTUM
- Folic acid 5mg daily for >3 months prior to conception, until delivery
- Sodium valproate changed to an alternative ASAP
- Vitamin K (10mg daily) in last 4 wks if on hepatic enzyme- inducing AEDS
- AIM with lowest dose of AED as possible!
DURING BIRTH
- Benzodiazepines if seizure not self-terminating (lorazepam 4mg IV, diazepam 10–20mg rectal or IV)
POST-PARTUM
- Give baby vitamin K 1mg IM to reduce haemorrhagic disease of the newborn
- Avoid early discharge: stay in hospital for 24 hrs when seizure risk high
asthma
effects of pregnancy on it?
Managments
For most women asthma remains unchanged or improved, but it may worsen (especially if poorly controlled to start with).
Changes in respir:
- TV and RR increase in later pregnancy, to meet the increased O2 demands.
Physiological changes in pregnancy that may improve asthma:
o Progesterone-mediated bronchodilation
o Increased serum free cortisol levels
Managment>> follow BTS guidlines
- Most meds r safe in pregnancy (but DO NOT start leukotriene receptor antag).
- Remember to check inhaler technique and give smoking cessation advice.
- Asthma attacks in pregnancy are RARE due to endogenous steroid production, continue usual medication and treat as for non-pregnant patient.
impact of pregancy on cardiac disease
what happens to th thyroid in pregnancy? how would you treat that?
Thyroid gland becomes more vascular in pregnancy – there is an increase in TBP and increase in overall T3 and 4 but normal levels of free T3 and T4.
Hyperthyroidism is best managed with propylthiouracil in pregnancy
