PBL 6 - Pregnancy II Flashcards
A woman comes into the antenatal clinic with BP of 160/110 and 3+ protein in urine dipstick. She has a symphysio fundal height of 26cm, what is the diagnosis?
Pre-eclampsia as she has a raised blood pressure, protein in her urine and a small symphysio fundal height. These are all signs of pre-eclampsia and the diagnostic criterea are high BP and proteinurea after 20 weeks gestation. Fundal height should be the same as the number of weeks of pregnancy.
What questions would you ask about her past and present pre-eclampsia to determine its severity?
How long has she been experiencing headache for?Has she had any previous pregnancies or
pregnancies with her current partner?
Does she have any pre-existing renal or cardiovascular disease, as this may be exacerbated by her high blood pressure? This includes any clotting disorders
Is she taking any hypertensives?
What are the clinical examination and investigations for pre-eclampsia?
Retake blood pressure and urine protein to recheck. Also check the protein-creatine ratio in order to determine if it may be a UTI.
Remeasure symphysio fundal height and do an ultrasound to assess fetal weight and health of foetus.
Check for clonus and hyper-reflexia that may indicate neuronal hyperactivity.
Test blood for platelet levels (may be lowered) and look for DIC (disseminated intravascular coagulation), check liver and renal function as well as uric acid.
ALP would be high with pregnancy as placenta gives it off
What is the most likely management for pre-eclampsia?
Most likely treated with anti-hypertensives e.g. hydralzine. Fluid restriction would also be combined with prevention and treatment of seizures with magnesium sulphate.
Only definitive treatment is to deliver the baby.
What are the possible foetal and neonatal complications of pre-eclampsia?
Maternal complications include eclampsia and seizure, pulmonary oedema, renal and liver failure, cerebral haemorrhage, DVT and PE, and HELLP
- HELLP is haemolysis with raised liver enzymes and low platelets. This raises the risk of haemorrhage and DIC, a serious condition requiring transfusion.
Foetal complications include risk of placental abruption and asphyxiation, IUGR, prematurity, respiratory distress, hypoglycaemia, hypothermia, and increased risk of miscarriage and still birth. Most of these complications are iatrogenic because we are delivering the baby early.
Does being born too small or too big affect the babies later in life?
It increases the likelihood of metabolic disease, obesity, hypertension and diabetes later in life.
What histopathological features would you expect of the womans fetus with pre-eclampsia?
The placenta and decidua would show very poor spiral artery conversion, infarcts and clots in the placenta.
What are the risk factors for gestational diabetes mellitus?
- Ethnicity, particularly south Asian, Afro Caribbean, or Middle Eastern
- Age (over 40)
- High blood pressure
- High BMI (over 30)
- First degree relative with diabetes
- Multiple pregnancy
- Previous unexplained miscarriage or stillbirth
How will you monitor a patient with gestational diabetes mellitus during pregnancy?
Set strict glycaemic targets to keep the glucose settled. More frequent assesment of foetal growth and having the foetus deliered early usually.
What treatments are available for gestational diabetes?
Diet restriction is used initially; following this metformin will be given. If glucose control is still not adequate, insulin can be used.
Why should the targets for diabetes control be stricter during pregnancy than when not pregnant?
As the consequences of poor glycaemic control are more worrying, and can lead to miscarriage and raised levels of maternal mortality.
Diabetic mothers higher chance of shoulder dislocation because the majority of the fat is on the shoulders and so they can get stuck. Brachial plexus injury and erbs palsy.
What is the plan for postnatal treatment of gestational diabetes mellitus?
Women in postpartum period rarely require insulin because insulin resistance resolves quickly; hypoglycaemic medication should therefore be removed straight after the delivery of the placenta.
Breastfeeding improves glycaemic control and should be encouraged.
