Physiological complications of pregnancy Flashcards
What is gestational hypertension?
Hypertension that develops after 20 weeks
What is pre-eclampsia?
New hypertension >20 weeks in association with significant proteinuria
What is meant by significant proteinuria?
Automated reagent strip urine protein estimation >1
Spot urinary protein:creatinine ratio.30mg/mmol
24 hours urine protein collection >300mg/day
How do you manage normal hypertension?
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
How does one develop preeclampsia?
Secondary invasion of maternal spial arterioles by throphoblasts
Impaired/reduced placental perfusion
Imbalance between vasodilators/vasoconstrictors in pregnancy
What are the risk factors for developing pre-eclampic toxaemia?
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
What are some of the complications of preeclampsia?
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
What are the signs and symptoms of severe PET?
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
How do you investigate PET?
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
How do you manage PET?
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
How do you treat impending pre-eclamptic seizure
Magnesium sulphate bolus +IV infusion
Control of blood pressure- iv labetolol, hdrallazne (>160/110)
Avoid fluid overload, aim for 80mls per hour fluid intake
What prophylaxis do you give for PET in subsequent pregancies
low dose aspirin for 12 weeks until delivery
Define gestational diabetes?
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
What risks does maternal diabetes bring?
Fetal congenital abnormlities e.g. caridac and sacral angenesis
Miscarriage
Fetal macrsomia, polyhydroaminos (excess amniotic fluid)
Shoulder dystocia
Still birth increased
Increased infeciton risk
How do you manage diabetes in a mother?
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
What monitoring should be carried out around delivery
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
What are the risk factors for gestational diabetes?
BMI>30 Previosu macrosomic baby >4.5kg Pervious GDm FH of diabetes Polyhydroaminos Recurrent glycosuria in current pregnancy
How do you screen for gestational diabetes?
Offer HbA1c estimation (.43mmol/mol) if that’s positive repeat OGTT at 24-28 weeks
What are the normal blood sugar targets for pregnant woman?
<5.3mmol/l-fasting
<7.8mmol/l- 1 hour postprandial
<6.4 mmol/l- 2 hours postprandial (after food)
<6 mmol/l- before bedtime
What is Virchow’s triad?
Stasis, vessel wall injury, hypercoagulability
Why is pregnancy a hypercoagubel state?
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
What increased a woman srisk of VTE?
Older mother, increasing parity Increaed BMI/smokers IV drug users PET Dehydration (hypermesis gravdarum) Decreased mobility Infections Prolonged labour/surgery Previous VTE
How does a VTE present in pregnancy?
Pain in calf, increased girth Breathlessness, painful bretahing cough tachycardia hypoxia pleural rub
How do you investigate a VTE?
EC, blood gases, doppler
CPTA
V/Q scan
how do you prevent VTE?
TED stockings
Advice on mobility, hydration
Prophylactic anticoagulation with 3 or more risk factors
May need to continue post partum
