New-onset Medical Disorders

Question 1

What is gestational diabetes?

Answer 1

-Carbohydrate intolerance of variable severity with onset or first recognition during the current pregnancy
-The diagnosis is arbitrary depending on where the cut-off is placed on the normal spectrum of glucose intolerance in pregnancy

Question 2

Risk factors for gestational diabetes

Answer 2

-Obesity (BMI > 30 kg/m2)
-Family origin with high prevalence of diabetes (South Asian, Caribbean, Middle Eastern)
-Family history of type 2 diabetes or GDM in a 1st degree relative
-Previous macrosomic baby > 4.5kg
-PCOS
-Multiple pregnancy
-Increasing maternal age

Question 3

Global prevalence of GDM

Answer 3

-SEA: 25.9%
-Northern America: 20.7%
-Europe: 15%
-Africa: 13%

Question 4

Clinical features of GDM

Answer 4

-Asymptomatic
-Develops in 2nd or 3rd trimester
-Diagnosed by screening (1 or more risk factors)
-No increase in congenital anomaly

Question 5

Why does GDM matter?

Answer 5

-Increases risk of type 2 diabetes in later life (40-60% in10-15 years)
-A small number identified with GDM will actually have pre-existing diabetes
-Women with GDM have a higher chance of macrosomia and adverse pregnancy outcome
=There is no threshold effect
=We know treatment improves outcomes
=Birth weight has life-long implications for the offspring
=Linear relationship between maternal hyperglycaemia and adverse outcome with no threshold

Question 6

Overall GDM management

Answer 6

-Dietary modification
-Exercise
-Metformin
-Insulin

Question 7

GDM diet

Answer 7

-Choose healthier carbs
-Reduce sugar
-Limit carbohydrate portion size
-Choose sensible snacks
-Understand Glycaemic Index (GI)
=How quickly foods affect your blood sugar

Question 8

Exercise in GDM

Answer 8

-A brisk walk after meals will lower blood sugar –even just 2 minutes!
-Ideally 30 mins at least 3times per week

Question 9

Pharmacotherapy in GDM

Answer 9

-In addition too, not instead of, dietary modification
-1st line metformin (no difference in perinatal outcomes, women prefer oral therapy to insulin_
-2nd line insulin (in addition to metformin, not tolerated instead of)
-Always discontinued after birth

Question 10

Postnatal management of GDM

Answer 10

-Contraception
-Breast feeding support
-HbA1C or OGTT 3 months after birth
-Encourage weight loss and maintenance of healthy eating
-Advise of risk of recurrence of GDM and of future risk of T2DM

Question 11

Classification of gestational hypertension

Answer 11

1. Gestational hypertension (without proteinuria)
2. Gestational proteinuria (without hypertension)
3. Gestational proteinuric hypertension (pre-eclampsia)

Question 12

What is pre-eclampsia?

Answer 12

-Hypertension developing after 20 weeks’ gestation with one or more of the following: proteinuria, maternal organ dysfunction or fetal growth restriction.
-This new definition means that proteinuria is no longer essential for diagnosis.

Question 13

Potential forms of maternal organ dysfunction in pre-eclampsia

Answer 13

-Renal insufficiency (creatinine >90 µmol/L)
-Liver involvement (elevated transaminases—at least twice the upper limit of normal ± right upper quadrant or epigastric abdominal pain)
-Neurological complications (examples include eclampsia, altered mental status, blindness, stroke or, more commonly, hyperreflexia when accompanied by clonus, severe headaches when accompanied by hyperreflexia, persistent visual scotomata)
-Haematological complications (thrombocytopenia—platelet count below 150,000/dL, disseminated intravascular coagulation, haemolysis).

Question 14

Epidemiology of chronic hypertension and pre-eclampsia

Answer 14

-Chronic hypertension is estimated to affect 1% to 5% of pregnant women and is frequently diagnosed for the first time during antenatal care.
-The prevalence of pre-eclampsia varies with the definition used and the population studied; however, pre-eclampsia occurs in less than 5% of an average antenatal population.
-The incidence of non-proteinuric PIH is approximately three times greater

Question 15

Features of superimposed pre-eclampsia

Answer 15

-A rapid rise in hypertension
-New onset or doubling of proteinuria
-Other laboratory parameters, for example, low platelets, or raised liver enzymes or creatinine

Question 16

Risk factors for pre-eclampsia

Answer 16

-First pregnancy
-Family history—mother/sister (x4-8 risk)
-Extremes of maternal age (40+)
-Obesity

-Medical factors:
=Pre-existing hypertension (20%)
=Renal disease
=Acquired thrombophilia—antiphospholipid antibodies
=Inherited thrombophilia
=Connective tissue disease (e.g., systemic lupus erythematosus)
=DM

-Obstetric factors
=Multiple pregnancy
=Previous pre-eclampsia (particularly requiring delivery before 37 weeks: 20% chance redeveloping)
=Hydatidiform mole
=Triploidy
=Hydrops fetalis (immune and non-immune)
=Inter-pregnancy interval of >10 years

Question 17

Symptoms of pre-eclampsia

Answer 17

-Severe headache
-Severe right upper quadrant and epigastric abdominal pain
-Sudden swelling of the face, hands or feet
-Visual disturbances, including blurring, flashing or scotoma
-Vomiting
-Restlessness or agitation

Question 18

Signs of pre-eclampsia

Answer 18

-Hypertension and proteinuria
-Hyperreflexia
-Serum creatinine raised
-Platelet count decreased
-Clonus
-Haemolytic anaemia
-Elevated liver enzymes
-Retinal haemorrhages and papilloedema

Question 19

Assessment/ investigation of pre-eclampsia

Answer 19

-BP

-Urinary protein
=exceeds 30 mL/dL, a level that usually correlates with 1+ on a urine dipstick
=Gold standard confirmation of the diagnosis would be 24-hour collection of urine (with >300 mg proteinuria in 24 hours being considered elevated).
=Albumin:creatinine ratio (ACR) and protein:creatinine ratio (PCR) are commonly used in clinical practice to quantify urinary protein, with 30 mg/mmol used as a threshold for significant proteinuria.

-Blood test
=FBC (reduced platelets, haemoglobin, haemolysis)- HELLP
=Renal function (reduced UO, increased urate, urea, creatinine)
=Coagulation system (prolonged coagulation indices)
=Hepatic (elevated ALT and AST)

-Fetal assessment
=Fundal height
=Fetal movements
=Fetal growth ultrasound

Question 20

Pre-eclampsia prophylaxis

Answer 20

-Low-dose aspirin (100-150mg daily from 12 weeks- 15% reduction in incidence)
-Possibly of Value: Calcium supplementation
-Not of Value
=Diet with high protein content
=Restriction of salt in diet
=Restriction of weight gain
=Vitamins C and E

Question 21

Clinical management of pre-eclampsia

Answer 21

-Fetal advantages to conservative management before 34 weeks if the blood pressure, laboratory values and fetal condition are stable
-Control maternal blood pressure
-Assess maternal fluid balance
-Prevent seizures/ eclampsia
-Consider delivery
-Optimise postnatal care

Question 22

Controlling maternal BP in Pre-eclampsia

Answer 22

-Reduce the diastolic blood pressure to <100 mmHg using labetalol, nifedipine, hydralazine or methyldopa
-Effective control of hypertension is essential to prevent cerebrovascular accidents.
=As intracerebral haemorrhage contributes to a significant proportion of deaths, systolic blood pressure should always be <150 mmHg and treated aggressively if not.
-Labetalol is now recommended as first-line treatment. Regimens vary, but NICE guidelines now recommend a standard approach to hypertensive management.

Question 23

Assess maternal fluid balance in pre-eclampsia

Answer 23

-Pre-eclampsia is associated with an increased vascular permeability and a reduced intravascular compartment.
=Administering too little fluid risks maternal renal failure and giving too much fluid may cause pulmonary oedema.
-Fluid input and urine output should be monitored.
-In severe pre-eclampsia, the maternal oxygen saturation (SaO 2 ) should also be monitored, along with serum urea and electrolytes, liver function tests, haemoglobin, haematocrit, platelets and coagulation.
-If there is marked oliguria, central venous pressure monitoring may be helpful to differentiate intravascular volume depletion from renal impairment.

Question 24

Preventing eclampsia

Answer 24

-The use of magnesium sulphate (MgSO 4 ) in severe pre-eclampsia halves the risk of subsequent eclampsia and may reduce the risk of maternal death.
- MgSO 4 given to those who have had an eclamptic seizure prevents further seizures.

Question 25

Timing of delivery in pre-eclampsia

Answer 25

-Depends on the maternal condition, fetal condition and gestational age.
-Maternal indications for delivery include
=gestation ≥37 weeks
=an inability to control hypertension
=deteriorating liver or renal function
=progressive fall in platelets
=Neurological complications.

-Fetal indications include
=abnormal fetal heart rate monitoring or a fetal condition that is clearly deteriorating.

-If pre-term delivery is being considered at <34 weeks’ gestation, corticosteroids should be administered to the mother to reduce the risks associated with prematurity unless there is acute compromise requiring immediate delivery

Question 26

Optimising postnatal care in pre-eclampsia

Answer 26

-Women with pre-eclampsia who remain hypertensive in the initial postpartum period are still at risk of pre-eclampsia-related complications, particularly for the initial 72 hours following delivery when the blood pressure often peaks.
-Continued vigilance is advisable during this period, as an inpatient if necessary.

Question 27

Maternal complications of pre-eclampsia

Answer 27

-Placental rupture
-Disseminated intravascular coagulation
-HELLP syndrome
-Pulmonary oedema
-Aspiration
-Eclampsia
-Liver failure or haemorrhage
-Stroke
-Death
-Long-term cardiovascular morbidity

Question 28

Neonatal complications of pre-eclampsia

Answer 28

-Pre-term delivery
-Intrauterine growth restriction
-Hypoxia-neurological injury
-Perinatal death
-Long-term cardiovascular morbidity (associated with low birth weight)

Question 29

What is HELLP?

Answer 29

-HELLP syndrome (which affects 10%–20% of eclamptic pregnancies) is defined by the presence of haemolysis, elevated liver enzymes and a low platelet count.
-Associated morbidity commonly includes disseminated intravascular coagulation, placental abruption and acute renal failure.
-It is also associated with maternal mortality in between 1.1% and 25% of cases (with the most common causes of mortality being haemorrhage and stroke).

Question 30

Long term implications of pre-eclampsia

Answer 30

-3x risk of hypertension (6x if recurrent pre-eclampsia)
-2x risk IHD
-2-3x risk of T2DM

Question 31

Presentation of obstetric cholestasis

Answer 31

-Usually presents after 30 weeks’ gestation, possibly due to a genetic predisposition to the cholestatic effect of oestrogens.
-Pruritus affects the limbs and trunk, and it is often severe.
-Pale stools, dark urine

Question 32

Investigation and diagnosis of obstetric cholestasis

Answer 32

-There may be a positive family history in up to 35% of cases.
-Serum total bile acid concentration is increased early in the disease and is the optimum marker for the condition.
-Transaminases may be increased (<3-fold).
-Bilirubin is usually <100 µmol/L

Question 33

Risks and management of obstetric cholestasis

Answer 33

-There are no serious long-term maternal risks, but there is a risk of pre-term birth, fetal distress, and intrauterine fetal death.
-Birth at 37–38 weeks should be discussed with the woman, if bile acids are markedly elevated, in an effort to prevent fetal death.