Pre-eclampsia; Gestational Diabetes

Question 1

Define pre-eclampsia [1]

Answer 1

Pre-eclampsia:
- new-onset hypertension (≥ 140 systolic, ≥ 90 diastolic) - or superimposed on chronic hypertension - after 20 weeks gestation AND one of:
- proteinuria
- other organ involvement: renal insufficiency (creatinine ≥ 90 umol/L), liver, neurological, haematological, uteroplacental dysfunction
- It should be noted that pre-eclampsia may occur up to 4-6 weeks after giving birth.

Question 2

What is the very basic pathophysiology of pre-eclampsia? [1]

What is the triad of presenting features of pre-eclampsia? [3]

Answer 2

It occurs after 20 weeks gestation, when the spiral arteries of the placenta form abnormally, leading to a high vascular resistance in these vessels.

Pre-eclampsia features a triad of:
* Hypertension
* Proteinuria
* Oedema

Question 3

What is gestational hypertension ? [1]

Answer 3

Gestational hypertension: new-onset hypertension (≥ 140 systolic, ≥ 90 diastolic) after 20 weeks gestation.

Question 4

Which pathologies make a women high risk of pre-eclampsia? [5]

What aare the moderate risk factors? [6]

Answer 4

High risk factors:
* History of hypertensive disease during a previous pregnancy
* Chronic kidney disease
* Autoimmune disease (e.g. systemic lupus erythematosus or antiphospholipid syndrome)
* Type 1 or type 2 diabetes
* Chronic hypertension

Moderate-risk factors are:
* Older than 40
* BMI > 35
* More than 10 years since previous pregnancy
* Multiple pregnancy
* First pregnancy
* FHx of pre-eclampsia

Question 5

Women with one high risk or two moderate risk factors should be offered [drug, dose, frequency] prophylaxis for pre-eclampsia - from which week? [1]

Answer 5

Women with one high risk or two moderate risk factors should be offered aspirin 75-150mg daily prophylaxis from 12 weeks until birth

Question 6

D

Describe the clinical features of pre-eclampsia [+]

Answer 6

Symptoms
* Headache
* Visual disturbance - scotomata
* Oedema (facial, peripheral)
* Abdominal pain (typically upper abdominal/epigastric)
* Vomiting

Signs
* Altered mental status
* Dyspnea
* Raised ALTs due to liver involvement
* Cardiac failure
* Clonus
* Oedema

Question 7

What are the features of severe pre-eclampsia? [+]

Answer 7

• hypertension: typically > 160/110 mmHg and proteinuria
• proteinuria: dipstick ++/+++
• headache
• visual disturbance
• papilloedema
• RUQ/epigastric pain
• hyperreflexia
• platelet count < 100 * 106/l, abnormal liver enzymes or HELLP syndrome

Question 8

The NICE guidelines (2019) advise a diagnosis can be made with …? [4]

Answer 8

Systolic blood pressure above 140 mmHg
Diastolic blood pressure above 90 mmHg

PLUS any of:
* Proteinuria (1+ or more on urine dipstick)
* Organ dysfunction (e.g. raised creatinine, elevated liver enzymes, seizures, thrombocytopenia or haemolytic anaemia)
* Placental dysfunction (e.g. fetal growth restriction or abnormal Doppler studies)

Question 9

What consitutes proteinuria for pre-eclampsia? [2]

Answer 9

Urine protein:creatinine ratio (above 30mg/mmol is significant)

Urine albumin:creatinine ratio (above 8mg/mmol is significant)

Question 10

What is the significance of placental growth factor for diagnosing pre-eclampsia? [1]
When should it be tested? [1]

Answer 10

Placental growth factor is a protein released by the placenta that functions to stimulate the development of new blood vessels.

In pre-eclampsia, the levels of PlGF are low.

Question 11

How would pre-eclampsia show on blood tests:
- FBC [1]
- Renal function [1]
- LFTs [1]

Answer 11

FBC:
- Falling platelets (indicating HELPP syndrome)

Renal function - risk of AKI

LFTS - deranged ALT/ASTs

Question 12

How do you manage pre-eclampsia? [2]
What about if patient is asthmatic? [1]

Answer 12

oral labetalol is now first-line following the 2010 NICE guidelines. Nifedipine (e.g. if asthmatic) and hydralazine may also be used

delivery of the baby is the most important and definitive management step. The timing depends on the individual clinical scenario. IV MgS is given during labour and in the 24hrs after to prevent seizures

Question 13

What symptom would represent the onset of eclampsia? [1]

How would you manage eclampsia? [2]

Answer 13

Seizures represent the onset of eclampsia. This is an obstetric emergency requiring an immediate response, commencement of oxygen and securing of the airway.

Magnesium sulphate is the first-line treatment for eclamptic seizures.

Delivery is the definitive management.

Question 14

What is HELLP syndrome? [1]

Answer 14

Haemolysis Elevated Liver enzymes Low Platelets syndrome is a severe complication of pregnancy that normally occurs in patients suffering with pre-eclampsia

Haemolysis
Elevated Liver enzymes
Low Platelets

Question 15

Which drug should be given in pre-term babies to mature the fetal lungs? [1]

Answer 15

Corticosteroids should be given to women having a premature birth to help mature the fetal lungs.

Question 16

Patient had previous gestational hypertension / pre-eclampsia. Baby is born. What is the next rec. managment? [3]

Answer 16

Enalapril (first-line)
Nifedipine or amlodipine (first-line in black African or Caribbean patients)
Labetolol or atenolol (third-line)

Question 17

At what blood pressure is treatment offered in pregnancy? according to NICE

≥ 160/110mmHg
≥ 150/100mmHg
≥ 140/90mmHg
≥ 130/80mmHg
≥ 120/70mmHg

Answer 17

≥ 140/90mmHg

NB: treatment target - 110-135/70-85

Question 18

What should you monitor for when giving labetalol treatment? [1]

Answer 18

Neonatal hypoglycaemia

Question 19

Mother’s who suffer from pre-eclampsia have an increased risk of

Ischaemic heart disease
Breast cancer
Fatty liver
Chronic kidney disease
Type II DM

Answer 19

Mother’s who suffer from pre-eclampsia have an increased risk of

Ischaemic heart disease
Breast cancer
Fatty liver
Chronic kidney disease
Type II DM

Question 20

How do you screen for gestational diabetes? [1]
What would indicate positive for GD? [1]

Answer 20

the oral glucose tolerance test (OGTT) is the test of choice:
* fasting glucose is >= 5.6 mmol/L
* 2-hour glucose is >= 7.8 mmol/L

Question 21

Describe the pathophysiology of gestational diabetes

Question 22

What are the risks of having gestational diabetes? [3]

Answer 22

large for dates fetus and macrosomia –> can lead to shoulder dystocia

Women also develop risk of DMT2

Question 23

How do you manage gestational diabetes:
- Fasting glucose less than 7 mmol/l: [3]
- Fasting glucose above 7 mmol/l [2]
- Fasting glucose above 6 mmol/l plus macrosomia [2]

Answer 23

Fasting glucose less than 7 mmol/:
- trial of diet and exercise for 1-2 weeks
- followed by metformin
- then insulin

Fasting glucose above 7 mmol/l:
- start insulin ± metformin

Fasting glucose above 6 mmol/l plus macrosomia (or other complications)
- start insulin ± metformin

Question 24

[] is suggested as an option for women who decline insulin or cannot tolerate metformin in gestational diabetes [1]

Answer 24

Glibenclamide (a sulfonylurea) is suggested as an option for women who decline insulin or cannot tolerate metformin.

Question 25

Targets for self monitoring of pregnant women (pre-existing and gestational diabetes) for [3]
Fasting
1hr after meals
2hrs after meals

Answer 25

Fasting: 5.3 mmol/l
1 hour after meals: 7.8 mmol/l, or:
2 hour after meals: 6.4 mmol/l

Question 26

Which medication should people with pre-existing diabetes take before conception? [1]

Answer 26

Before becoming pregnant, women with existing diabetes should aim for good glucose control.** They should take 5mg folic acid from preconception until 12 weeks gestation.**

Question 27

What screening (asides from glucose levels) should be offered and when if a patient suffers from diabetes and is pregnant?

Answer 27

Retinopathy screening should be performed shortly after booking and at 28 weeks gestation.

This involves referral to an ophthalmologist to check for diabetic retinopathy. Diabetes carries a risk of rapid progression of retinopathy, and interventions may be required.

TOM TIP: It is worth remembering the importance of retinopathy screening during pregnancy for women with existing diabetes. This is an exam favourite, and will score you extra points with your seniors if you mention it in the antenatal clinic.

Question 28

How do you manage DMT1 patients during labour? [1]

Answer 28

A sliding-scale insulin regime is considered during labour for women with type 1 diabetes.

A dextrose and insulin infusion is titrated to blood sugar levels, according to the local protocol.

This is also considered for women with poorly controlled blood sugars with gestational or type 2 diabetes.

Question 29

How do people with pre-existing diabetes manage their insulin doses after birth? [1] Why? [1]

Answer 29

Women with existing diabetes should lower their insulin doses and be wary of hypoglycaemia in the postnatal period. The insulin sensitivity will increase after birth and with breastfeeding.

Question 30

How do you manage babies of gestational diabetes after birth? [2]

Answer 30

Babies need close monitoring for neonatal hypoglycaemia, with regular blood glucose checks and frequent feeds.

The aim is to maintain their blood sugar above 2 mmol/l, and if it falls below this, they may need IV dextrose of nasogastric feeding.

Babies become accustomed to a large supply of glucose during the pregnancy, and after birth they struggle to maintain the supply they are used to with oral feeding alone.

Question 31

TOM TIP: If you remember two complications of gestational diabetes, remember [2].

Answer 31

TOM TIP: If you remember two complications of gestational diabetes, remember macrosomia and neonatal hypoglycaemia.

Babies become accustomed to a large supply of glucose during the pregnancy, and after birth they struggle to maintain the supply they are used to with oral feeding alone.