preg Flashcards
which diabetic complication can worsen in pregnancy?
diabetic retinopathy
screening shortly after booking + at 28wks
aspirin for diabetic mothers?
low dose aspirin from12wks until delivery
post natal care of diabetic mothers
women with GD - can stop medications immediately after birth
- follow up fasting glucose after 6wks
pre-existing - lower insulin doses + wary of hypoglycaemia
- insulin sensitivity will increase after birth + with breastfeeding
monitor baby for neontal hypoglycaemia
monitoring neonate for hypoglycaemia
maintain their blood sugar aboove 2mmol/l
if falls below - IV dextrose of nasogastic feeding
delivery in women with pre-existing diabetes
planned delivery between 37+38+6wks
(GD up to 40+6wks)
sliding scale insulin regime considered during labour for women with T1DM
- dextrose + insulin infusion titrated to blood sugar levels - also considered with poorly controlled GD or T2DM
criteria of hypertension in pregnancy
> =140/90 on 2 occasions
or
160/110 once
(>30 systolic >15 diastolic increased compared to 1st trimester)
when to admit pregnant mums with hypertension
sBP >160
abnormal blood tests
- creatinine >90
- ALT >70
- platelet count <150
signs of impending eclampsia or pulmonary oedema
suspected fetal compromise
complications of preexisting hypertension in pregnancy
PET x2
fetal growth restriction
abruption
management of pre-existing hypertension in pregnancy
STOP ACEi, ARBs + thiazides
start - labetalol or nifedipine (CCB)
gestational hypertension
2nd half of pregnancy (>20wks) - resolves within 6 weeks postnatally
- no proteinuria or PET features
- 15% progress to pre-eclampsia
- high rate of recurrnece
mangement of gestational hypertension
urine dip + blood tests weekly
serial growth scans
admit those with BP >160/110
postnatal Mx for pre-existing hypertension/gestational hypertension
birth usually >37wks unless poorly controlled hypertension
- monitor BP daily after birth
- stop methyldopa within 2 days
for GH - reduce if BP <130/80
- continue antihypertensives - review 2 weeks post-natal by GP
- further review 6-8wks post natal
pre-eclampsia
pregnancy indiced hypertension assoc with organ damage, notably proteinuria
- occurs after 20wks gestation when spiral arteries of placenta form abnormally
–> leads to high vascular resitance in these arteries
without treatment - maternal organ damage, fetal growth restriction, seizures, early labour, death
pre-eclampsia risk factors
preexisting hypertension
previous hypertension in pregnancy
existing autoimmune conditions - SLE
diabetes
Chronic kidney disease
older than 40 bmi >35
more than 10yrs since previous pregnancy
multiple pregnancy
first pregnancy
FH of pre-eclampsia
pathophysio of pre-eclampsia
spiral arteries fail to adapt to become high capaticance, low resitance vessels
- high vascular resitance + poor perfusion of placenta
-> oxidative stress on placenta leads to release of inflammatory chemicals -> systemic inflammation + impaired endothelial function
stage 1 - abnormal placental perfusion - placental ischaemia
stage 2 - maternal syndromes - anti-angiogenic state assoc with endothelial dysfunction
- vasoconstriction
- increased -
— capillary permeability
— expression of CAM
— prothrombotic factors
— platelet aggregation
pre-eclampsia presentation
triad
- hypertension
- proteinuria
- oedema
headache, N+V
visual disturbances or blurriness
RUQ or epigastric pain - liver swelling
reduced urine output
brisk reflexes
SGA fetus
can be asymptomatic at time of 1st presentation
diagnosis of preeclampsia
Systolic BP >140mmHg
Diastolic BP >90mmHg
Plus any of –
o Proteinuria (1+ or more on urine dipstick)
o Organ dysfunction – raised creatinine, elevated liver enzymes, seizures, haemolytic anaemia
o Placental dysfunction – fetal growth restriction or abnormal Doppler studies
management of pre-eclampsia (pre-birth)
150mg aspirin from 12wks gestation until birth if they have
- 1 high risk factor
- 2 or more moderate RF
1st = labetolol
2nd = nifedipine
3rd = methyldopa - stop within 2 days of birth
IV hydralazine - antihypertensice in critical care _ in severe pre-eclampsia or eclampsia
IV magnesium sulphate - given during labour + 24hrs after to prevent seizures
management of pre-eclampsia (birth + post-natally)
Fluid restriction during labour in severe pre-eclampsia or eclampsia to avoid fluid overload
o Restrict input to 80ml/hr
Planned early birth may be necessary if BP is uncontrolled or complications
o Corticosteroids given to women having premature birth
After delivery, switch to one or a combo of –
o Enalapril – first line
o Nifedipine or amlodipine – first line in black African or caribbean patients
o Labetolol or atenolol – 3rd line
HELLP syndrome
Combination of features that occurs as a complication of pre-eclampsia + eclampsia
Haemolysis
Elevated Liver enzymes
Low Platelets
Eclampsia
Tonic clonic (grand mal) seizures assoc with pre-eclampsia
>1/3 will have seizure before onset of hypertension/proteinuria
More common in teenagers
IV magnesium sulphate is used to manage seizures
o 4g IV over 5-15min
o If further seizure – 2-4g Mg SO4
o Admin for 24hrs
pregnant women with no previous history of epilepsy presenting after first trimester with seizure
eclampsia management -> IV mag sulphate
heart disease in pregnancy
3-4x risk of MI in pregnancy
sinus tachycardia - part of normal pregnancy, Ix
ectopic beats - common “thumping, relieved by exercise
is warfarin contraindicated to breastfeeding
NO
drugs contraindicated in pregnancy
NSAIDs >32weeks
cyclophosphamide
methotrexate
Gold
penicillamine
MMF
drugs okay in pregnancy
steriods
azathioprine
sulfasalazine
hyrozychloroquine
aspirin
etanercept/infliximab/adalimumab
rituximab
management of antiphospholipid disease in pregnancy
No thrombosis/adverse pregnancy outcome
o Low dose aspirin (LDA)
o Maternal + fetal surveillance
Previous thrombosis
o On warfarin -> stop warfarin
o LDA + LMWH (treatment dose)
Recurrent early pregnancy loss
o LDA + LMWH (prophylaxis dose)
Late fetal loss / severe PET / FGR
o LDA + LMWH (prophylaxis dose)
teratogenic impacts of antiepileptics
sodium val - neural tube defects
- facial cleft
- hypospadias
cardiac malformations - phenobarbital + phenytoin
cleft palate - phenytoin + carbamazepine
management of maternal epilepy
benzodiaxepine -> to terminate seizure ASAP
left lateral tilt
IV lorazepam/diazepam
PR diazepam/buccal midazolam
no history of epilepsy -> MgSO4
