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Pregnancy Complications - Hypertension / DM Flashcards

1
Q

What is gestational hypertension?

A

Hypertension that develops >20 weeks
No proteinuria / oedema
Increased risk of PET
Resolves after birth

Pre-pregnancy if <20 weeks
BP usually falls in 1st trimester

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2
Q

What is mild hypertension

A

140-149 / 90-99 OR >30 / >15 from booking bloods

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3
Q

What is mod and severe hypertension

A 
Mod = >150/100 
Severe = >160 / >110 
Severe = Medical emergency
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4
Q

What suggests high risk of PET of booking

A

FH or RF

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5
Q

What do you get if high risk of PET

A

Consultant clinic

Regular growth scans

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6
Q

What must you exclude for new hypertension

A 
Coarctation
Renal artery stenosis
Cushing's
Conn's
Phaeochromocytoma
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7
Q

How do you screen for complications of hypertension antenatal

A 
BP
Urine dip 
Fetal growth - SFH via USS
Monitor for signs of PET - oedema etc
Fetal movement
CTG if activity abnormal 
Monitor for PET / abruption
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8
Q

What do you do for mild hypertension

A 
No Rx - can Rx
Regular BP check
Exercise
Healthy eating 
Aspirin from conception (stop before labour) 
Low Na diet
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9
Q

What do you do for moderate or severe and how do you monitor

A 
Aim BP 150/90
Labetalol = 1st line
Repeat BP 1 week after start on Rx
Nifidipine (CCB) = 2nd line 
Methyldopa = 3rd line but must stop postpartum 
IV labetalol and hydrazine if severe

Monitor
2x weekly BP and urine until target
FBC, U+E, LFT weekly
Target = 135 / 85

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10
Q

When is labetalol CI

A

Asthma

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11
Q

If high BP what do you do with regards to delivery

A

Induce around EDD
Operative delivery if severe
Syntocin in 3rd stage NOT ergometrine

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12
Q

What are risks of hypertension

A

Abruption
IUGR
Prematurity
Higher risk of PET

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13
Q

When is methyldopa CI and what other hypertensives are CI

A

Post natal depression so must stop within 2 days of delivery

ACEI / ARB / thiazide

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14
Q

When would you admit to hospital

A

Severe HTN
HTN with proteinuria
New proteinuria even if no HTN
Evidence of IUGR on USS

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15
Q

What is pre-eclampsia

A

NEW hypertension >20 weeks
2 separate occasions 4 hours apart of SEVERE
+
Significant proteinuria urine +1 or 24 hour urine >300mg
+
Oedema

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16
Q

What is classed as severe PET

A 
>170 / >110
Protein +3 
>1000m 
SYMPTOMS 
Biochemical / haematological  / HELLP
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17
Q

What are symptoms of PET

A 
Oedema 
Frontal headache
Visual disturbance - blurred / glitter / lights 
Papilloedema - fundoscopy 
Epigastric pain RUQ
Vomiting
Clonus
Hyperreflexia
Confusion 
Reduced urine 
Reduced movement 
HELLP
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18
Q

What should you beware of in PET

A

Don’t overload if oedema

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19
Q

What are major RF

A 
Chronic hypertension
Previous PET
DM 
Autoimmune - SLE
CKD
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20
Q

What are minor RF

A 
1st pregnancy
>40
Obesity BMI >35
FH - 1st degree
Multiple pregnancy
Pregnancy interval >10 years
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21
Q

What do you do if protein found on dip

A 
Admit to hospital for assessment / possible delivery 
FBC, U+E, LFT, urate
USS for growth
CTG
Urine culture
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22
Q

What are PET bloods

A 
FBC - look for HELLP 
LFT - ALP rise normal 
U+E 
Urate 
Coagulation 
Bloods may be abnormal for 6 weeks
MSSU for protein
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23
Q

What is normal rate of urate

A

10x gestation

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24
Q

What other investigations

A 
Pregnancy Hx / gestation and PET sx
Abdo exam 
Fundoscopy 
Reflexes
USS fetal growth
CTG
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25
Q

What should you do if PET discovered / how do you monitor in pregnancy

A 
Admit for BP monitoring / day case + urine 
24 hour urine
Monitor
- BP 
- PET bloods
- Growth scan
- Urine dip
- Symptoms
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26
Q

What are biochemical abnormalities

A

Raised liver enzyme
Raised bilirubin
Raised U+E - kidney failure
Raised urate

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27
Q

What are haematological abnormalities

A

Low platelet
Low Hb
Signs of haemolytic
DIC

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28
Q

What should you always do at pregnancy check

29
Q

What is only cure for PET

What do you give during delivery

A

Delivery
Aim for IOL + SVD but no IOL if fatal distress or severe
Emergency C-section if fatal distress
During delivery = magnesium sulphate and labetalol to control

30
Q

What does decision to delivery depend

A

Gestation
Mother’s health

If <160 and no signs of end organ damage e.g. seizure / papilloedema/ clonus 
If >37 weeks = delivery 
If <37 weeks 
- Control HTN e.g. IV labetalol 
- Close observation - BP and urine

If severe or signs of end organ

  • IV labetalol
  • Mg sulphate
  • Plan urgent delivery
  • IV dex if <34 weeks
  • CTG
31
Q

When would you delivery <34 weeks

A

If refractory to Rx or indications

32
Q

When do you give steroids

A

<36 weeks but >25 weeks to prevent RDS

33
Q

How do you treat during pregnancy

A 
Prevent complications but not Rx
Control BP as above 
Fluid restrict of risk of oedema
VTE prohylaxis 
Magnesium sulphate
34
Q

When do you start magnesium sulphate

A

If within 24 hours of birth or think eclampsia
Tocolytic effect and reduced cerebral palsy
Give 24 hours after delivery or last seizure to prevent seizures

35
Q

When and why do you give low dose aspirin

A

At 12 weeks to reduce risk of PET / IUGR
If previous PET or 1 high RF or two moderate
Gestational hypertension

36
Q

What do you do post natal

A

Check BP

Urine dip 6-8 weeks

37
Q

What are complications of PET

A 
Eclampsia
Cerebral haemorrhage 
Placental abruption 
Pulmonary oedema 
Stroke 
MI 
HELLP 
DIC
Renal failure 
Retinal damage in DM
Liver failure
Cardiac failure 
Hypertension
VTE
C-section
38
Q

What is HELLP

A

Haemolysis
Elevated liver enzymes
Low platelet

39
Q

How does HELLP present

A

N+V
RUQ
Lethargy
Must deliver

40
Q

What are fetal complications

A 
Impaired placental perfusion
IUGR
Placental abruption 
Pre-term
IUD / distress
Still birth
41
Q

How do you treat eclampsia

A 
ABCDE
Senior
IV access
Magnesium sulphate bolus + IV infusion = 1st line (continue until 24 hours post seizure) 
Control BP 
Avoid overload
42
Q

What if doesn’t work

A

Phenytoin

Diazepam

43
Q

What do you do if eclampsia antenatal period

44
Q

What do you do if resp depression due to low magnesium sulphate

A

Calcium gluconate

45
Q

How do you monitor for magnesium sulphate toxicity

A

Resp effort as may decrease
Tendon reflex
O2 sats
Urine output

46
Q

Why do insulin requirements increase in pregnancy

A 
HPL
Progestogen
b-HCG
Cortisol
All anti-insulin 
Pregnancy is a state of insulin resistance
47
Q

Do you worry about glycosuria in pregnancy

A

No as common

48
Q

What must you exclude in unwell mother

49
Q

What do you do for pre-existing DM pre-pregnancy

A

Folic acid 5mg
Aim HbA1c <10% for 1-3 months before pregnancy
Rubella immunisation
Weight reduction
Stop oral hypoglycaemic as CI
Treat retinopathy / neprhopathy as may worsen
Regular screening of retinopathy

50
Q

What hypoglycaemic CI

A

All except metformin

51
Q

What may you need to start

52
Q

What do you do once pregnant

A 
Tight glycemic control
Increase monitoring 
Aspirin from 12 weeks to reduce PET 
Folic acid 
Renal and retinal assesment
Regular MSSU - ketones / infection
HbA1c
U+E
Watch growth 
Detailed scans and regular clinic
53
Q

What do you do in labour

A

Induce at 38-40 to reduce shoulder dystocia
Earlier if growth concern or poor control
Steroid if pre-term
Avoid hyperglycaemia
Insulin dextrose infusion to maintain - siding scale
CTG

54
Q

What do you do if macrosomia

A

Shoulder dystocia risk

55
Q

What do you do postpartum

A

Early feeding
Regular BM
Pre-pregnancy regime

56
Q

Why do you avoid hyperglycaemia

A

Cause foetal hypo

57
Q

What are fetal complications of DM

A 
Fetal hyperinsulinaemia in preg as maternal glucose crosses 
Macrosomia 
Placental insufficiency 
IUGR 
Polyhydramnio 
Jaundice
Neonatal hypoglycaemia
IRDS 
Pre-term
IUD 
Shoulder dystocia 
Congenital abnormalities
58
Q

What do macrosomic babies have higher risk of

A

C-section
Traumatic birth
Shoulder dystocia

59
Q

What are complications to the mother

A 
PET
Nephropathy
Retinopathy
Infection 
Decreased awareness of hypo 
DKA
60
Q

What can cause hypo

A

Decreased awareness

Insulin - suggests need delivery

61
Q

What is gestational DM

A

Carb intolerance with onset of pregnancy that reverts to normal
Develops in 3rd
If develops before more likely 1 or 2

62
Q

What are RF for gestational DM

A 
Increased BMI 
Previous macrosomia
Previous GDM 
FH DM - 1st degree
Recurrent glycosuria
PCOS
63
Q

How do you screen for GDM

A

OGTT asap / booking and at 28 weeks if previous or at risk

At 28 weeks if at risk

64
Q

What is target

A

HbA1c ,48

BG >5.3 fasting

65
Q

How do you treat GDM

A 
Consultant clinic
Monitor growth and blood glucose levels 
Diet and exercise = 1st line 
Metformin
Insulin if still not controlled 
Growth scan 
IOL if Rx
66
Q

What do you do post partum

A

Check OGTT at 6-8 week
Diet
Follow up due to risk of type II

67
Q

What is diagnostic of gestational DM

A

Fasting >5.6

2h >7.8

68
Q

Pathology of PET

A

Suboptimal uteroplacental perfusion
Leads to inflammatory response in mother
Causes increased permeability = proteinuria / oedema
Decreased placenta blood flow = IUGR / oligohydramnio
Decreased cerebral perfusion to mother = eclampsia / seizure

Obs & Gynae (23 decks)

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