Physiological complications of pregnancy

Question 1

What is gestational hypertension?

Answer 1

Hypertension that develops after 20 weeks

Question 2

What is pre-eclampsia?

Answer 2

New hypertension >20 weeks in association with significant proteinuria

Question 3

What is meant by significant proteinuria?

Answer 3

Automated reagent strip urine protein estimation >1
Spot urinary protein:creatinine ratio.30mg/mmol
24 hours urine protein collection >300mg/day

Question 4

How do you manage normal hypertension?

Answer 4

Ideally pre patient care
Change inappropriate antihypertensive drugs e.g. ACE inhibitors, angiotensin receptor blockers
Diuretics
Lower dietary sodium
Aim to keep BP<150/100
Monitor for superimposed pre-eclampsia
Monitor fetal growth

Question 5

How does one develop preeclampsia?

Answer 5

Secondary invasion of maternal spial arterioles by throphoblasts
Impaired/reduced placental perfusion
Imbalance between vasodilators/vasoconstrictors in pregnancy

Question 6

What are the risk factors for developing pre-eclampic toxaemia?

Answer 6

First pregnancy
Extremes of maternal age
Pre-eclampsia in a previous pregnancy  
pregnancy interval>10 years
BMI>35
Family history of PET
multiple pregnancy (twins/triplets)
Chronic hypertension
Pre-existing renal disease
Pre-existing diabetes

Question 7

What are some of the complications of preeclampsia?

Answer 7

eclampsia- seizures
Severe hypertension
HELLP(heamolysis, elevated liver enzymes, low platelets)
DIC
renal failure
Pulmonary oedema, cardiac failure

Impaired placental perfusion, IUGR fetal distress, prematurity

Question 8

What are the signs and symptoms of severe PET?

Answer 8

Headache, blurry vision, vomiting
Severe hypertension, >3+ uine proteinuria
CClonus,brisk reflexes, papillodema, epigastric tenderness
Reduced urine output
Convulsions
Raised liver enzmes
bilirubon if HELLP present
Raised urea and creatinine, raised urate

Question 9

How do you investigate PET?

Answer 9

Frequent BP checks, urine protein
Check symptomatology- headaches, epigsatric pain, visual disturbances
Check for clonus, liver tenderness
FBC, LFT’s, renal function tests (serum urea, creatinine, urate
Coagualtion tests if indicated
Scan for fetal growth

Question 10

How do you manage PET?

Answer 10

Delivery of baby and placenta
Aim for fetal maturity whilst closely observing clinical signs
Give anti hypertensives (labetolol, methyldopa, nifedipine)
Steroids for fetal lung maturity if gestation <36 weeks

Consider induction of labour if maternal or fetal condition detriorates, irrespecitve of gestation

Continue to monitor post partum

Question 11

How do you treat impending pre-eclamptic seizure

Answer 11

Magnesium sulphate bolus +IV infusion
Control of blood pressure- iv labetolol, hdrallazne (>160/110)
Avoid fluid overload, aim for 80mls per hour fluid intake

Question 12

What prophylaxis do you give for PET in subsequent pregancies

Answer 12

low dose aspirin for 12 weeks until delivery

Question 13

Define gestational diabetes?

Answer 13

Carbohydrate intolerance with onset in pregnancy
Abnormal glucose tolerance that reverts to normal after delivery, however more at risk of developing type II later in life

Question 14

What risks does maternal diabetes bring?

Answer 14

Fetal congenital abnormlities e.g. caridac and sacral angenesis
Miscarriage
Fetal macrsomia, polyhydroaminos (excess amniotic fluid)
Shoulder dystocia
Still birth increased
Increased infeciton risk

Question 15

How do you manage diabetes in a mother?

Answer 15

Better glycemic control, ideally keep blood sugar around 4-7mol/l pre conception and HbA1c <6.5% (,48 mmol/mol)
folic acid 5 mg
dietary advice
retinal and renal assessment
continue oral anti-diabetic agents but maintain tight glucose control

Question 16

What monitoring should be carried out around delivery

Answer 16

Observe for PET
induce labour at 38-40 weeks
Consider elective caeserian if baby is massive
Maintain blood sugar in labour with insulin
continuous CTG fetal monitoring in labour
Early feeding of the baby to reduce neonatal hypoglycemia
Can go back to pre-pregnancy regime of insulin post delivery

Question 17

What are the risk factors for gestational diabetes?

Answer 17

BMI>30
Previosu macrosomic baby >4.5kg
Pervious GDm
FH of diabetes
Polyhydroaminos
Recurrent glycosuria in current pregnancy

Question 18

How do you screen for gestational diabetes?

Answer 18

Offer HbA1c estimation (.43mmol/mol) if that’s positive repeat OGTT at 24-28 weeks

Question 19

What are the normal blood sugar targets for pregnant woman?

Answer 19

<5.3mmol/l-fasting
<7.8mmol/l- 1 hour postprandial
<6.4 mmol/l- 2 hours postprandial (after food)
<6 mmol/l- before bedtime

Question 20

What is Virchow’s triad?

Answer 20

Stasis, vessel wall injury, hypercoagulability

Question 21

Why is pregnancy a hypercoagubel state?

Answer 21

Increased fibronogen, factor VIII, vWF, platelets

Decrease in natural anticoagulants

Increase in fibrinolysis

Increased stasis (progesterone, effects of enlarging uterus)

May be vascular/tissue damage at delivery/ C-section

Question 22

What increased a woman srisk of VTE?

Answer 22

Older mother, increasing parity
Increaed BMI/smokers
IV drug users
PET
Dehydration (hypermesis gravdarum)
Decreased mobility
Infections
Prolonged labour/surgery
Previous VTE

Question 23

How does a VTE present in pregnancy?

Answer 23

Pain in calf, increased girth
Breathlessness, 
painful bretahing
cough 
tachycardia
hypoxia
pleural rub

Question 24

How do you investigate a VTE?

Answer 24

EC, blood gases, doppler
CPTA
V/Q scan

Question 25

how do you prevent VTE?

Answer 25

TED stockings
Advice on mobility, hydration
Prophylactic anticoagulation with 3 or more risk factors
May need to continue post partum