problems in pregnancy Flashcards
how are UTIs treated in pregnancy?
avoid nitrofurantoin in last trimester
what is pre-eclampsia?
multisystem disorder characterised by new onset HTN and proteinuria that occurs in second half of pregnancy and resolves with delivery.
one of many hypertensive disorders of pregnancy
what is the normal pattern of blood pressure seen during pregnancy?
Normally BP drops in T1 and T2 due to progesterone and reduced vascular resistance. It then slowly rises back to normal in T3. with delivery there is a drop in BP which gradually rises over 4 days.
what is the pathophysiology behind pre-eclampsia ?
Thought to be due to abnormal blood flow through the uteroplacental circulation due to inadequate placentation.
normally trophoblasts invade the myometrium and spiral arteries and result in breakdown of the tunica muscularis such that spiral arteries cannot contract. this results in reduced resistance and increased flow.
in pre-eclampsia there is insufficient remodelling of the spiral arteries. Therefore there is high resistance and low flow. The increased BP and low perfusion of the uteroplacental circulation results in systemic inflammatory response and endothelial cell dysfunction.
what are the moderate and high risk factors to pre-eclampsia?
moderate:
- nulliparous, multiple pregnancy, >10 yrs between pregnancies, BMI >35, age >40, FHx of pre-eclampsia
severe:
- chronic HTN, pre-eclampsia/ HTN in previous pregnancy, diabetes, chronic kidney disease, SLE/antiphospholipid
others: thrombophilia, hydrops fetalis, triploidy, hydatidiform mole
what are the 3 clinical criteria that must be met for pre-eclampsia?
- systolic BP
- > 140 systolic or >90 diastolic on 2 separate occasions (>4 hours apart)
- OR >160 systolic or >110 diastolic on one occasion
- > 140 systolic or >90 diastolic on 2 separate occasions (>4 hours apart)
- proteinuria:
- significant proteinuria >300mg in a 24 hour urine sample
- OR >30mg/UM protein: creatinine ratio
- > 20 weeks gestation
what are the symptoms that occur with pre-eclampsia?
headache
visual disturbance - blurring, double, flashing lights
epigastric pain/ RUQ - due to hepaticcapsule enlargement/ infarction
vomiting
sudden onset non dependant oedema
hyperreflexia
confusion
may be asymptomatic - which is why BP and urine checked at every appointment.
what is a poor prognostic factor for pre-eclampsia?
onset of pre-eclampsia before 34 weeks
how is pre-eclampsia categorised into mild, moderate and severe ?
mild: BP 140-149/90-99
moderate: BP 150-179/100-109
severe: BP > 160/110 + proteinuria >0.5g/day
or >140/90 + proteinuria + symptoms
what are the fetal complications of pre-eclampsia?
intrauterine growth restriction
intrauterine fetal death
placental abruption, placental infarct
risk of cerebral palsy
risk of prematurity
list some differentials for pre-eclampsia?
pregnancy induced HTN - HTN without proteinuria >20 weeks
essential HTN - HTN <20 weeks gestation
what investigations should be carried out to assess pre-eclampsia?
BP recording - sitting down (use korakoff sound V for diastolic (usually IV)
24 hour proteinuria recorded or dipstick - if >300mg or +1 or more on dipstick.
FBC - low platelets and low Hb U+Es - raised creatinine, urea and lower urine output. LFTs - elevated (AST and ALT) in HELLP INR Group and save
what is HELLP syndrome?
haemolysis
elevated liver enzymes
low platelets
what is classed as eclampsia?
seizures due to pre-eclampsia during pregnancy, labour or within 7 days of birth.
what prophylaxis is can be given to those at risk of pre-eclampsia? who is chosen for this prophylaxis?
aspirin 75mg
those with 1 high risk factor or 2 moderate risk factors
given from 12 weeks onwards
any type of HTN in pregnancy will require aspirin in next pregnancy too
how is pre-eclampsia treated?
monitoring: regularly check BP, proteinuria, fetal grown scan and CTG - how often depends on severity of pre-eclampsia
treating HTN to reduce risk of cerebral haemorrhage:
1st line = labetolol
2nd line = nifedipine
3rd line = methyl dopa
preventing complications:
- VTE = LMWH and fluids
- seizures = MgSO4
what are the side effects of:
a) labetolol
b) nifedipine?
c) methyldopa?
labetolol - postural hypotension, fatigue, headaches, N+V, epigastric pain
nifedipine - peripheral oedema, dizziness, flushing, headaches, constipation
methyldopa - drowsiness, headaches, oedema, GI disturbances, dry mouth, postural hypotension, bradycardia and hepatotoxicity
can ACEi be used for HTN in pregnancy?
no contraindication - cause congenital abnormalities
also avoid diuretics
what is the only definitive cure for pre eclampsia?
delivery of baby
the pregnancy only benefits the baby - therefore weight up the risks and benefits.
if delivered <34 weeks give steroids.
when should a patient with pre-eclampsia be admitted ?
if BP >160/110
OR >150/100 + proteinuria
when should a patient with pre-eclampsia be admitted ?
if BP >160/110
OR >150/100 + proteinuria
admit for 4 hourly obs
what drugs are used for emergency BP control in pregnancy?
hydralazine
labetolol
nifedipine
what post natal care is required in pre-eclampsia?
monitor mother for atleast 24 hours post delivery - still at risk of eclampsia
monitor BP regularly for first 2 days and then atleast once a day till day 5
then the need for anti-HTN treatment can be reassessed
warn mum of risk of pre-eclampsia in next pregnancy + need to take aspirin
what is pregnancy induced HTN
HTN post 20 weeks but no significant proteinuria