Pre-eclampsia, PIH, Obesity and diabetes Flashcards
What is Gestational diabetes?
-Dm that is first diagnosed in pregnancy
-requires insulin or diet control
What are the risk factors for gestational diabetes?
-advanced maternal age
-obesity
-history of DM
-hx of stillbirth, neonatal death, fetal malformation/macrosomia
-occurs when pts can’t mount a sufficient compensatory insulin response during pregnancy
When is gestational diabetes more prevalent?
-2nd and 3rd trimesters
- after delivery, most pts return to normal glucose tolerance
- high recurrence rate with subsequent pregnancies
What are some acute complications of gestational DM?
-DKA
-hyperglycemic nonketotic state (primarily type 2s)
-hypoglycemia
What are the chronic complications of gestational DM?
Macrovascular:
-coronary
-cerebrovascular
-peripheral vascular
microvascular:
-retinopathy
-nephropathy
Neuropathy:
-autonomic
-somatic
What is gestational DM associated with?
-gestational HTN
-polyhydramnios
-c-section
Early glycemic control is the best way to prevent fetal structural abnormalities
At what A1c does the risk of vascular disease increase?
6.5%
what’s a normal A1C?
4-6%
When does stiff joint syndrome occur?
Long-standing type 1
- associated w nonfamilial short stature, joint contractions and tight skin
DL can be difficult d/t c-spine rigidity in the atlantooccipital joint
Maternal insulin requirements _______ progressively during the 2nd and 3rd trimesters and decrease at the _______ and continue to decrease following delivery
Increase
onset of labor
What are the symptoms of Diabetic autonomic neuropathy?
-HTN
-Orthostatic Hypotension
-Painless MI
-Decreased HR variability
-Decreased response to medications- (Atropine and propanolol)
-Resting tachycardia
-Neurogenic atonic bladder
-Hemoglobin A1C
-Gastroparesis with delayed emptying
What should you maintain a pts BG at?
> 100 mg/dL and < 180 mg/dL
How would you manage blood sugar in the OR?
Begin D5W 1-1.5 ml/kg/hr as an IV piggy back into crystalloid solution
One-half of the total daily dose as intermediate form (NPH) plus an intraoperative “sliding scale
Continuous infusion of regular insulin
Start infusion based on serum glucose using formula:
Units/hr = Plasma glucose/150+ (desired range of 150 etc)
i.e. glucose of 220/150 = 1.4 units/hr (usually delivered in 250 units regular insulin/250 ml 09% NaCl solution
When could you see anaphylaxis d/t protamine?
in pts taking NPH or protamine zinc insulin
stop protamine, supportive care, epi
What is placental insufficiency?
Uteroplacental blood flow index is reduced by 35-45% (more with poor glucose control)
what are the 4 categories of hypertension in pregnancy?
-Chronic HTN
-Pregnancy induced hypertension
-Preeclampsia- eclampsia
-preeclampsia superimposed on chronic HTN
(most common medical issue during pregnancy)
Increase in maternal and fetal morbidity and remains a leading source of maternal mortality
Leading causes of maternal mortality:
-thromboembolism
-non-obstetric injuries
-HTN
What is a maternal DBP > 110 associated with?
increased risk of placental abruption and fetal growth restriction
what causes most maternal morbidity?
Superimposed preeclampsia
What is PIH?
Sustained BP increase to SBP> 140 or DBP >90
-usually mild and later in pregnancy
-no renal or other systemic involvement
-resolves 12 wks postpartum
-May evolve to preeclampsia
What is pre-eclampsia?
New onset HTN after 20 wks gestation or early postpartum.
-Usually resolves within 48 hrs postpartum
-Proteinuria >300mg/24 hrs
-Oliguria or serum plasma creatinine ratio > 0.09 mmol/L
- headaches w hyperreflexia, eclampsia, clonus, or visual disturbances
- increased LTFs, glutathione-S-transferase alpha 1-1, alanine aminotransferase, or right abdominal pain
-thrombocytopenia, increased LDH, hemolysis, DIC
-Swelling (edema)
-excessive wt. gain (2-3 lbs)
- 10% in primigravida
-20-25% w Hx of chronic HTN
Maternal risk factors for pre-eclampsia
-first pregnancy
-younger than 18 or older than 35
-prior hx of pre-eclampsia
-Black race
- chronic HTN
-renal disease
-diabetes
-anti-phospholipid syndrome
-twins
-family hx
What are the characteristics of DKA?
Plasma glucose >300
HCO3 < 15
pH <7.30
Acetone positive: 1:2
Ketones cross the placenta and decrease fetal oxygenation
maintain continuous fetal heart monitoring
What are the complications of obesity in the parturient?
Risk for medical, obstetrical, and anesthetic complications
difficulty with intubation
problems with the placement of neuraxial anesthesia
-Higher sensory blockade with no difference in pain score
-Greater distribution of epidural local anesthetic within epidural spaces
What is the most common medical issue during pregnancy?
Hypertension
Which signs are consistent with a diagnosis of preeclampsia? (select 3)
-Seizures
-Increased thromboxane
-Increased prostacyclin
-Proteinuria
-Vasoconstriction
-Impaired platelet aggregation
-Increased thromboxane
-Vasoconstriction
-Proteinuria
Pts also have enhanced platelet aggregation (not impaired) and decreased prostacyclin
The pt w eclampsia has seizures, and the pt with preeclampsia does not- although she is at risk.
will have: visual disturbances, headache, epigastric pain, rapidly increasing nondependent edema, and rapid weight gain (a result of edema d/t capillary leak as well as renal Na+ and fluid retention)
When will preeclampsia develop?
After 20 weeks gestations or early postpartum
What are the characteristics or mild preeclampsia?
SBP: 140-160
DBP: 90-110
urinary protein: <5g/24 hr
Dipstick: + or 2+
Urine output: >500 mL/24 hrs
Headache: NO
visual disturbances: NO
epigastric pain: NO
What are the characteristics of severe preeclampsia?
SBP: >160
DBP: >110
Urinary protein: > 5g/24 hrs
Dipstick: 3+ or 4+
Urine output: < 500mL/24hrs
Headache: yes
Visual disturbances: yes
Epigastric pain: yes
What are the cardiac complications of preeclampsia?
Increased CO and SVR
CVP normal/slightly increased
Plasma volume reduced
What causes pulmonary edema in someone w preeclampsia?
Decreased oncotic/colloid pressure
capillary/endothelial damage = leak
vasoconstriction
Increased PWP, and CVP
What are the renal complications of preeclampsia?
-Proteinuria
-decreased GFR & Crcl
-Increased BUN
-decreased RBF
-Acute renal failure w oliguria –> PIH, DIC, HELP
Oliguria and renal failure may occur in the absence of hypovolemia
-be careful w hydration (can cause pulm. edema)
What are the uterine complications of preeclampsia?
-Activity increased
-Hypersensitive to oxytocin
-frequent preterm labor
-uterine/placental blood flow decreased by 50-70%
-Increased incidence of abruption
What are the fetal complications of PIH/ preeclampsia?
-Abruptio placentae
-Intrauterine growth restriction
-premature delivery
-intrauterine fetal death
What does HELLP stand for?
H: hemolysis
EL: elevated liver enzymes
LP: low platelet count
Occurs <36 weeks
other symptoms are: malaise, epigastric pain , N/V-
usually self-limiting
When is the platelet count back to normal in after delivery in someone who has HELLP?
within 72 hrs.
Which maternal condition would most likely be be an indication for immediate delivery of the fetus?
A. HELLP syndrome
B. diabetes mellitus
C. preeclampsia
D. supine hypotension syndrome
A. HELLP syndrome
HELLP Syndrome is a complication of preeclampsia that often leads to the progressive, often sudden deterioration of both mother and fetus. The acronym HELLP represents a condition consisting of Hemolysis, Elevated Liver enzymes, and Low Platelets. Approximately 5-10% of preeclamptic women develop this syndrome, and it is generally an indication for immediate delivery of the fetus due to increased maternal morbidity and mortality.
The incidence of placental abruption is much higher in patients with
A. multiple sclerosis B. rheumatoid arthritis C. preeclampsia D. HELLP syndrome
C. preeclampsia
Placental abruption is the separation of an implanted placenta after 20 weeks of pregnancy. It can result in massive blood loss and is one of the most common causes of fetal demise. If the abruption is mild, a vaginal delivery may be attempted, but at any sign of fetal distress an emergency cesarean section must be carried out. It is more common in patients with preeclampsia (up to 1 in 4).
Which of the following is a predictor of difficult epidural placement in obese parturients? (select two)
A. The ability of the patient to flex their back
B. Body mass index
C. The practitioner’s experience level
D. The ability to palpate bony landmarks
A. The ability of the patient to flex their back
D. The ability to palpate bony landmarks
Studies have shown that the ability to palpate bony landmarks and the ability of the patient to flex their back were predictive of difficulty in placing an epidural in a parturient. The body mass index of the patient and the experience level of the practitioner were not predictive of difficulty.
In general, regional anesthesia is not contraindicated in obstetric patients with mild preeclampsia if the platelet count is at least
A. 25,000 per microliter
B. 50,000 per microliter
C. 80,000 per microliter
D. 100,000 per microliter
C. 80,000 per microliter
A platelet count less than 75,000-80,000 is considered too low to perform a neuraxial anesthetic.
The drug of choice for treating hypertension during anesthesia in a parturient with preeclampsia is
A. labetolol B. metoprolol C. nitroglycerin D. morphine 20 mg IV
A. labetolol
The first line drug for treating hypertension during anesthesia for preeclamptic patients is labetolol. Esmolol may also be used during induction. Large doses of opioids are avoided as they could produce maternal and fetal respiratory depression.
