Pregnancy complications 2 Flashcards
Types of disorders (3)
Hypertensive disorders
Thrombosis
Diabetes
Hypertensive disorders in pregnancy - chronic hypertension
Hypertension either pre-pregnancy or at booking (≤ 20 weeks gestation
Values for hypertension , mild moderate and severe
Mild HT– Diastolic BP 90-99, Systolic BP 140-49
Moderate HT- Diastolic BP 100-109, Systolic BP 150-159
Severe HT- Diastolic BP ≥110, Systolic BP ≥ 160
Hypertensive disorders in pregnancy - what is gestational hypertension, when does it develop?
Gestational hypertension (PIH – pregnancy induced hypertension)
- BP as above but new hypertension (develops after 20 weeks)
Pre eclampsia is defined as?
they will have a headache - describe features
protein in urine level is greater than?
New hypertension > 20 weeks in association with
significant proteinuria
Mild HT on two occasions more than 4 hours apart
Moderate to severe HT
+ proteinuria of more than 300 mgms/ 24 hours (protein urine > +
protein:creatinine ratio > 30mgms/mmol)
Pathophysiology
Significant Proteinuria - reagent strip
Automated reagent strip urine protein estimation > 1+
Significant Proteinuria- Spot Urinary Protein
Creatinine Ratio > 30 mg/mmol
24 hour urine protein collection - significant score
> 300mg/ day
Essential/ Chronic hypertension
- more common in?
- patients should have?
older patients ie older mothers
- pre-pregnancy care
Change of antihypertensive drugs should be changed if indicated - how should you do this ?
Change anti-hypertensive drugs if indicated
eg. - ACE inhibitors (eg. Ramipril / Enalopril cause birth defects impaired growth)
- Angiotensin receptor blockers (eg losartan, Candesartan)
- anti diuretics
- lower dietary sodium
Aim to keep BP < 150/100 (labetolol, nifedipine, methyldopa)
Monitor for superimposed pre-eclampsia
Monitor fetal growth
May have a higher incidence of placental abruption
Where should you aim to keep blood pressure?
- what should you monitor for?
Aim to keep BP < 150/100 (labetolol, nifedipine, methyldopa)
Monitor for superimposed pre-eclampsia
Monitor fetal growth
May have a higher incidence of placental abruption
Pathophysiology of PET
- why does this happen (2)
- Immunological
- Genetic predisposition
- secondary invasion of maternal spiral arterioles by trophoblasts
impaired reduced placental perfusion - imbalance between vasodilators / vasoconstrictors in pregnancy
(prostocyclin / thromboxane
Risk factors for developing PET (lots to choose from )
First pregnancy
Extremes of maternal age
Pre-eclampsia in a previous pregnancy (esp. severe PET, delivery <34
weeks, IUGR baby, IUD, abruption)
Pregnancy interval >10 years
BMI > 35
Family history of PET
Multiple pregnancy
Underlying medical disorders
- chronic hypertension
- pre-existing renal disease
- pre-existing diabetes
- autoimmune disorders like – eg. antiphospholipid antibodies, SLEPET is multi organ - systems affected are?
renal, liver, vascular, cerebral, pulmonary
Complications of PET? MATERNAL (6)
- eclampsia - seizures - severe hypertension
- cerebral haemorrhage, stroke
- HELLP (hemolysis, elevated liver enzymes, low platelets)
- DIC (disseminated intravascular coagulation)
- renal failure
- pulmonary odema, cardiac failure
Severe PET - SYMPTOM SIGNS
– headache, blurring of vision, epigastric pain, pain below ribs, vomiting,
sudden swelling of hands face legs
- Severe Hypertension; > 3+ of urine proteinuria
- clonus / brisk reflexes ; papillodema, epigastric tenderness
- reducing urine output
- convulsions (Eclampsia)
Biochemical abnormalities in PET? (2)
- raised liver enzymes, bilirubin if HELLP present
- raised urea and creatinine, raised urate
Haematological abnormalities (3)
- low platelets
- low haemoglobin, signs of haemolysis
- features of DIC
management for PET
FETAL INESTIGATIONS (2)
- frequent BP checks, Urine protein
- Check symptomatology – headaches, epigastric pain, visual disturbances
- Check for hyper-reflexia (clonus), tenderness over the liver
- Blood investigations – Full Blood Count (for hemolysis, platelets)
Liver Function Tests
Renal Function Tests – serum urea, creatinine, urate - Coagulation tests if indicated
- Fetal investigations - scan for growth
cardiotocography (CTG)
- Fetal investigations - scan for growth
Conservative management of PET
anti-hypertensives (labetolol, methyldopa, nifedipine)
- steroids for fetal lung maturity if gestation < 36wks
PET & Eclampsia
- 5-8% of pregnant women have PET
- 0.5% women have severe PET & 0.05% have eclamptic seizures
- 38% of seizures occur antepartum, 18% intrapartum, 44% postpartum
Treatment of seizures/ impending seizures for PET ?
Magnesium sulphate bolus + IV infusion
Control of blood pressure – IV labetolol, hydrallazine (if > 160/110)
Avoid fluid overload – aim for 80mls/hour fluid intake
Diabetes and pregnancy
- What is gestational diabetes
Pre-existing diabetes (type I & less often type II)
- carbohydrate intolerance with onset (or first recognised) in pregnancy
- abnormal glucose tolerance that reverts to normal after delivery
- however, more at risk of developing type II diabetes later in life
Pre-existing diabetes and pregnancy - what requirements of the mother increase?
what has anti-insulin action?
Insulin requirements of the mother increase
human placental lactogen, progesterone, human chorionic gonadotrophin,
and cortisol from the placenta have anti-insulin action
Fetal hyper-insulinemia occurs when?
what does it cause?
what is more likely post delivery?
- Maternal glucose crosses the placenta and induces increased insulin production in the fetus. The fetal hyperinsulinemia causes macrosomiaPost delivery – more risk of neonatal hypoglycaemia = increased risk of respiratory distress
Effects of diabetes on mother, fetus & neonate - what are increased risks and give examples?
Fetal congenital abnormalities e.g – cardiac abnormalities, sacral agenesis
(especially if blood sugars high peri-conception
- Miscarriage
- Fetal macrosomia polyhydramnios
- Operative delivery, shoulder dystocia
- Stillbirth, increased perinatal mortality
Complications (contd) - for mother and fetes/neonate (4)
- increased risk of pre-eclampsia
- Worsening of maternal nephropathy, retinopathy, hypoglycaemia,
- reduced awareness of hypoglycaemia Infections
neonatal - Impaired lung maturity, neonatal hypoglycemia, jaundice
Management - preconception - diabetes - glycemic controls should be what values?
better glycemic control, ideally blood sugars should be around 4 – 7 mmol/l pre-conception and HbA1c < 6.5% ( < 48 mmol/mol)
- folic acid 5mg - dietary advice - retinal and renal assessment
During pregnancy - diabetes - insulin requirements will increase to?
optimise glucose control – insulin requirements will increase < 5.3 mmol/l - Fasting < 7.8 mmol/l - 1 hour postprandial < 6.4 mmol/l - 2 hours postprandial < 6 mmol/l – before bedtime
to get tighter glucose control you may change?
what may you give?
can continueoral anti-diabetic agents (metformin) but may need to change to insulin
glucagon injections/ conc. glucose solution to reduce risk of hypoglycaemia
- watch for ketonuria
when will repeat retinal assessments be given
28 and 34 weeks
Management continured- diabetes - how will you help prevent macrsomia?
observe for PET
labour usually induced 38-40 weeks, earlier if fetal or maternal
concerns
consider elective caesarean section if significant fetal
macrosomia
maintain blood sugar in labour with insulin – dextrose insulin
infusion
continuous CTG fetal monitoring in labour
Early feeding of baby to reduce neonatal hypoglycemia
Can go back to pre-pregnancy regimen of insulin post delivery
Risk factors for GDM / consider screening for GDM
increased BMI >30
Previous macrosomic baby > 4.5kg
Previous GDM
Family history of diabetes
Women from high risk groups for developing diabetes – eg. Asian origin
Polyhydramnios or big baby in current pregnancy
Recurrent glycosuria in current pregnancy
GDM associated with some increase in maternal complications (eg PET) and fetal complications (macrosomia) but much less than type 1 or 2
GDM is associated with?
GDM associated with some increase in maternal complications (eg PET) and fetal complications (macrosomia) but much less than type 1 or 2
Screening for GDM?
If risk factor present, offer HbA1C estimation at booking, if > 6% (43 mmol/mol), 75gms OGTT to be done. If OGTT normal, repeat OGTT at 24 -28 weeks
Can also offer OGTT at around 16 weeks and repeat at 28 weeks if significant risk factors (eg. Previous GDM) present
Management of GDM
- pre and post delivery
control blood sugars – diet
- metformin/ insulin if sugars remain high
Post delivery – check OGTT 6 to 8 weeks PN
Yearly check on HbA1C/ blood sugars as at a higher risk of developing overt diabetes
The risk of thrombo-embolism increased in pregnancy - it is a hypercoaguable state to protect mother against bleeding - what changes occur? (5)
- increase in fibrinogen, factor VIII, VW factor, platelets
- decrease in natural anticoagulants – antithrombin III
- increase in fibrinolysis
-Increased stasis – progesterone, effects of enlarging uterus
May be vascular damage at delivery/ caesearean section
Increased risks with? (TE and DVT) (11)
- Older mothers, increasing parity
- Increased BMI, smokers
- IV drug users
- PET
- Dehydration – hyperemesis
- Decreased mobility
- Infections
- Operative delivery, prolonged labour
- Haemorrhage, blood loss > 2 l
- Previous VTE (not explained by other predisposing eg. fractures,
injury), those with thrombophilia (protein C, protein S, Anti thrombin
III deficiencies, etc), strong family history of VTE - Sickle cell disease
VTE prophylaxis in pregnancy (3)
TED stockings
Advice increased mobility, hydration
Prophylactic anti-coagulation with 3 or more risk factors (may be indicated even with one risk factor if significant
Signs/ symptoms of VTE (
- pain in calf, increased girth of affected leg, calf muscle tenderness
- breathlessness, pain on - breathing, cough, tachycardia, hypoxic, pleural rub, etc
Investigate appropriately if any suspicion of VTE?
treatment
- ECG, Blood gases, doppler
V/Q (ventilation perfusion) lung scan
CTPA
computed tomography pulmonary angiogram)
Appropriate treatment with anticoagulation
if VTE confirmed
