Pre-eclampsia and GD

Question 1

What is pre-eclampsia?

Answer 1

• One of several hypertensive disorders that can occur during pregnancy.
• Placental disease - can cause maternal/foetal compromise.
• Poor placental perfusion secondary to abnormal presentation, in normal placentation - trophoblast invades myometrium and the spiral arteries of uterus.
• Spinal arteries dilated and unable to constrict providing pregnancy with high flow, low resistance and circulation.
• In pre-eclampsia - remodelling of spinal arteries is incomplete - high resistance, low-flow uteroplacental circulation.
• Increase in blood pressure combined with hypoxia and oxidative stress from inadequate perfusion can lead to systemic inflammatory response and endothelial cell dysfunction (leaky blood vessels).

Question 2

Moderate risk factors for pre-eclampsia?

Answer 2

Risk factors for pre-eclampsia can be divided into moderate and high risk.

1) Nuliparity
2) Pregnancy interval >10 years
3) Maternal age >40
4) Maternal BMI >35
5) Family history of pre-eclampsia
6) Multiple pregnancy

Question 3

High risk factors for pre-eclampsia?

Answer 3

1) Chronic hypertension
2) HTN, pre-eclampsia or eclampsia in previous pregnancy
3) Pre-existing chronic kidney disease
4) Diabetes Mellitus
5) Autoimmune diseases (SLE, APS)

Question 4

How is prophylaxis for pre-eclampsia given?

Answer 4

• Aspirin 75mg daily
• From 12 weeks gestation until birth
• IF 1 high risk factor, or 2 or more moderate risk factors

Question 5

Diagnosis criteria for pre-eclampsia?

Answer 5

For a woman to be diagnosed with pre-eclampsia three criteria must be met:

1) Hypertension (Systolic BP >140mmHg OR diastolic BP >90mmHg) on two occasions at least 4 hours apart.
2) Significant proteinuria >300mg protein in 24 hour urine sample OR >30mg/mmol urinary protein:creatinine.
3) In a woman greater than 20 weeks gestation.

Question 6

Other clinical features of pre-eclampsia?

Answer 6

1) Headache
2) Visual disturbance
3) Epigastric pain
4) Sudden onset non-dependant oedema
5) Hyperreflexia

Question 7

Classification for pre-eclampsia?

Answer 7

Classified as mild, moderate or severe. Based on degrees of hypertension, proteinuria and symptoms.
- Mild - BP - 140/90 - 149/99
- Moderate - BP - 150/100 - 159/109
- Severe - BP - 160/110 + proteinuria > 0.5g/day (500mg)
OR > 140/90 + proteinuria + symptoms

Question 8

Complications of pre-eclampsia?

Answer 8

Maternal:

1) HELLP syndrome - haemolysis, elevated liver enzymes, low platelets
2) Eclampsia
3) Acute kidney injury
4) Disseminated intravascular coagulation (DIC)
5) Hypertension (risk postpartum increases 4 fold)
6) Acute Respiratory Distress Syndrome (ARDS)
7) Cerebrovascular haemorrhage
8) Death

Foetal:
- Prematurity, IUGR, placental abruption, IU foetal death.

Question 9

Ddx in pre-eclampsia?

Answer 9

1) Essential hypertension (<20wks)
2) Pregnancy induced hypertension (PIH) - new onset HTN presenting post 20 weeks gestation, without significant protein urea.
3) Eclampsia - Pre-eclampsia + seizure (obstetric emergency)

Question 10

Investigations in pre-eclampsia?

Answer 10

• Diagnosed by hypertension and proteinuria, protein in urine detected by DIPSTICK, and then quantified through a 24-HOUR URINARY COLLECTION.
• Other investigations used for organ dysfunction monitoring:
  1) FBC - Hb and platelets
  2) LFTs - ALT and AST
  3) U+Es - increased urea, creatinine and decreased urinary output

Question 11

Management of pre-eclampsia?

Answer 11

Two aims - minimise risk of foetal and maternal complications AND prevent development of eclampsia.

• Regular BP monitoring, urinalysis, blood tests, CTG and foetal growth scans.
  1) Venous thromboembolism prevention - LMW Heparin
  2) Antihypertensives - reduce risk of maternal haemorrhage stroke.
  3) Delivery - only definitive cure - prolonging pregnancy in pre-eclampsia if for the foetus alone.

Question 12

Anti-hypertensive medications used in pre-eclampsia??

Answer 12

• Achieve adequate blood pressure control, as severity of hypertension correlates to risk of stroke.
• Main hypertensives used: Labetalol (1st line beta-blocker), Nifedipine, Methydopa
• ACE-inhibitors contraindicated due to association with congenital abnormalities.

Question 13

Post-natal care in pre-eclampsia?

Answer 13

• Resolves following delivery of the placenta - important to monitor the mother for at least 24 hours postpartum (risk of eclamptic seizures).
• Blood pressure monitored daily for first 2 days postpartum, and once 3-5 days post partum , generally considered safe after 5 days.
• Re-assess hypertensives.
• RISK OF PIH and PRE-ECLAMPSIA IN FUTURE PREGNANCIES.

Question 14

What is Gestational Diabetes?

Answer 14

• Defined as any degree of glucose intolerance with onset or first recognition during pregnancy.
• Can have negative effects if untreated.
• Occurs when the body is unable to produce enough insulin to meet the needs of pregnancy (promotes uptake of glucose from blood and storage as glycogen).
• In pregnancy - INSULIN RESISTANCE - higher volume of insulin needed in response to a normal level of blood glucose (30% increase).
• Woman with borderline pancreatic reserve is unable to respond to increased insulin requirements resulting in transient hyperglycaemia.
• After pregnancy - insulin resistance falls and hyperglycaemia usually resolves.

Question 15

Risk factors for poor pancreatic reserve?

Answer 15

1) BMI > 30
2) Asian ethnicity
3) Previous gestational diabetes
4) 1st degree relative with diabetes
5) PCOS
6) Previous macrocosmic baby (>4.5kg)

Question 16

Clinical features of gestational diabetes?

Answer 16

MOST will be asymptomatic with no signs.

If present - will present the same as other forms of diabetes: polyuria, polydipsia, fatigue

Question 17

Foetal complications of gestational diabetes?

Answer 17

In pregnancy glucose is transported across the placenta but insulin is not - this can cause foetal hyperglycaemia if there is a high level of glucose in maternal circulation - and foetus will release its own insulin to compensate - hyperinsulinaemia.

1) Macrosomia - delivery complications
2) Organomegaly - cardiomegaly
3) Erythropoeisis - polycythaemia
4) Polyhydramnios
5) Increased rates of pre-term delivery
- After delivery foetus still has high insulin levels but no longer receives glucose from mother - risk of hypoglycaemia. Regular feeding important.
- Risk of transient tachypnoea of the new born, as foetus raised insulin levels reduce pulmonary phospholipids - reduced surfactant production.

Question 18

Investigations of gestational diabetes?

Answer 18

• ORAL GLUCOSE TOLERANCE TEST - fasting plasma glucose followed consumption of energy drink and by
  repeat measurement 2 hours.
• GDM diagnosed if:
  Fasting glucose >5.6mmol/L and 2hrs post-prandial glucose >7.8mmol/L.
• OGTT offered at:
  1) Booking - previous GD
  2) 24-28weeks - if risk factors present
  3) Any point in pregnancy if 2+ glycosuria on one occasion or 1+ on two occasions, or pre- and post-prandial blood sugar monitoring can be performed.
• Growth scans at 28,32,36 weeks to monitor for macrosomia/polyhydramnios.

Question 19

Management of gestational diabetes?

Answer 19

• Lifestyle - diet and exercise - BM 4 times a day
• Medication:
  1) Metformin - first line, suitable in pregnancy and breastfeeding.
  2) Glibenclamide - if netformin not tolerated (GI s/e?) and insulin has been declined.
  3) Insulin - consider starting at diagnosis if the fasting glucose >7mmol/L, or introduce later in pregnancy if:
  pre-meal glucose >6mmol/L, post-meal glucose >7.5mmol/L, foetal abdominal circumference > 95th gentile.
• Aim to deliver at 37-38 weeks if on treatment and advised to consider delivery (induction of labour or caesarian section) before 40 weeks and 6 days if GDM managed by diet.

Question 20

Post-natal care of GDM?

Answer 20

• ALL anti-diabetic medication stopped immediately after delivery and blood glucose measured before discharge to check it has returned to normal.
• Fasting glucose test at 6-13 weeks, and annual tests due to an increased risk in developing type 2 DM in future.
• OGTT offered at booking and 24-28 weeks gestation.