WEEK 4 Flashcards
how does pregnancy affect asthma in women?
1/3 remin stable
1/3 get better
1/3 get worse
what is the most common causes of respiratory distress in pregnancy?
Asthma most common
- tuberculosis rising
- smoking and obesity
- cystic fibrosis
what are the risks of uncontrolled asthma in pregnancy?
increase in maternal mobidity and mortality
- higher risk of gestational hypertension
- gestational diabetes
- placental abruption
- pulmonary embolism
increased risk of babies who are premature and have low birth weight
What are the respiratory changes during pregnancy?
• Metabolic rate increases 20% • increase O2 consumption • increase CO2 release • increase pulmonary blood flow due to increase cardiac output • increase ventilation (40%) • increase tidal volume (30-40%)
What are the respiratory physiological changes seen in pregnancy?
• As uterus grows, diaphragm displaced
upwards by 4 cm
- Diameter of rib cage increases outwards
- Total lung capacity 5%
• Breathing becomes thoracic not abdominal
– decreased functional residual capacity
– decreased residual volume
• Slight hyperventilation
what causes changes in ventilation drive in pregnancy?
Progesterone and oestrogen increase sensitvity or respiratory centre to CO2
Define asthma?
chronic reversible airway disease characterised by constriction of airway smooth muscles & swelling of airways
what is the pathophy of asthma?
– Bronchial inflammation – Reducing airway diameter – Constriction bronchial smooth muscle – Causing further narrowing – Therefore decreased airway size – Bronchial muscles & mucous glands enlarge – Thick tenacious sputum produced
What are the characteristics of asthma
> bronchoconstriction > oedema > inflammation > mucous secretion > narrowing of airways
what are some reasons for mental health issues during pregnancy?
• Misconceptions and pre-conceived notions about
pregnancy
• Tokophobia
• Can be pre-existing or develop during pregnancy
• New onset thought to be less of a risk
• Suicide highest during the 3rd trimester
what are some mental health risk factors during pregnancy?
• Women late in pregnancy (and first 3 months post partum) • Previous mental health problems • Social isolation • Previous puerperal psychosis • Recent termination • Unwanted pregnancy
How do you manage suicide attempts with pregnant patients?
Suicide attempts
• If there is a need for peri mortem c-section then transport
immediately
• IV fluids withheld unless SBP <100mmhg (unless evidence of
>500ml blood loss – service dependant)
• Transport in left lateral tilt (15-30 degrees)
define gestational diabetes mellitus (GDM)
GDM is defined as glucose intolerance of variable severity
with onset or first recognition during pregnancy.
What causes GDM
▪ Thought to be due to placental hormones of pregnancy
causing insulin resistance, leading to higher maternal
glucose levels in order to provide nutrition to the growing
fetus
▪ Insulin levels are usually increased to counteract the
increased resistance and normalise BSL’s.
▪ In some women there is not a large enough increase in
insulin levels and these women develop GDM
▪ Temporary condition that is normally treated with
how many pregnancies (%) develop GDM?
2-12%
when does GDM often develop?
Onset usually occurs 3rd trimester, detected at routine 24-
28 week glucose challenge test (screening)
How is GDM diagnosed
• Diagnosed with glucose tolerance test (OGTT)
What BGL leves are used in diagnosing GDM?
No diabetets
- Fasting = >6
- 2 hour = <7.8
Pre diabetes
- Fasting = 6.1 - 6.9
- 2 hour = 7.8 - 11.0
Diabetes
- Fasting = >7
- 2 hour = >11.1
What are the results of GDM for mothers?
– Pre-term births; inductions at 38-39/40; caesarean
sections; hypertension & longer stays in hospital
What are the results of GDM for babies?
– miscarriage/stillbirth; congenital abnormalities (cardiac
in particular); prematurity; lower APGAR scores;
resuscitation; high birth weight; larger torso size;
increased likelihood of shoulder dystocia; IUGR;
hypoglycaemia; admission to SCN or NICU; longer
stay in hospital
What are the risk factors for gestational diabetes?
▪ Age > 30
▪ Multiple pregnancy (large placenta = increased HPL = increased insulin
resistance = increased glucose levels)
▪ PCOS
▪ BMI >30
▪ Previous macrosomic baby weighing >4.5kg
▪ Previous GDM
▪ Family Hx of diabetes
▪ Family origin with a high prevalence of diabetes (ie South
Asian, Black Caribbean, Middle Eastern)
What are the effects of diabetets on pregnancy?
- increased risk of miscarriage
- risk of congenital malformation
- risk of macrosomia
- increased risk of pre-eclampsia
- increased risk of stillbirth
- increased risk of infection
- increased operative delivery rate
What happens during preganancy in women with type 1 diabetets
▪ Hypoglycaemia- especially in 1st trimester – Higher than normal levels of progesterone & oestrogen – Morning sickness – Rapid growth of fetus – Precautions - driving/exercise – Check for hypo awareness – Glucagon kit (teach partners) – Review Ketone testing – Regular meals
What happens during preganancy in women with type 2 diabetets
▪ Increased insulin resistance during pregnancy
▪ Increased requirement of insulin
▪ Increased requirement to check BSL’s – 4x daily compared
to previous regime may have been daily or bi-weekly
▪ All oral hypoglycaemics other than Metformin must be
ceased prior to pregnancy (previously it was thought that
Metformin must be ceased prior to 20/40)
▪ Anti-lipid medications must also be ceased
How does metablosim change during pregnancy?
Changes in carbohydrate and lipid metabolism occur during pregnancy to
ensure a continuous supply of nutrients to the growing fetus despite
intermittent maternal food intake
How does metablosim change during early pregnancy?
▪ Early pregnancy - Low BSL’s
– Normal glucose production, but exaggerated insulin response post
meals
– Changes to lipid metabolism to enhance maternal fat stores
How does metablosim change during late pregnancy?
▪ Late pregnancy - High BSL’s
– High glucose production to meet increasing needs of placenta &
fetus
– Insulin doubled, but insulin resistance high due to increased levels
of oestrogen, progesterone & HPL
– Lipid metabolism changes due to HPL to promote fat burning as
alternate energy source for mother
– All serve to increase availability of glucose for fetal use
What changes occur during pregnancy regarding oestrogen?
▪ Oestrogen
– Levels rise exponentially after 24/40
– Increase insulin production & enhances peripheral glucose
usage = lowers BSL
– Increases plasma cortisol second trimester = increases BSL
What changes occur during pregnancy regarding progesterone?
▪ Progesterone – Levels rise exponentially after 32/40 – Increase insulin resistance – Exaggerated insulin release after meals – Net result is increased BSL
What changes occur during pregnancy regarding cortisol?
▪ Cortisol
– Depletes hepatic glycogen stores & increases hepatic glucose
production = increased BSL
What changes occur during pregnancy regarding Human Placental Lactogen (hCS)?
▪ Human Placental Lactogen (aka hCS)
– Correlates with fetal & placental weight so highest levels as
pregnancy progresses but drops off from 37/40
– Big placenta (large baby/twins) = more HPL produced
– Increases insulin resistance (antagonist), decreases insulin
production = increased BSL’s
• Glucose sparing mechanism
• More glucose enabled for placenta
– Increases synthesis & availability of lipids (instead of CHO)
• Used as alternate maternal fuel (keeps glucose for baby)
what percentage of pregnancies will have hypertention?
10-15%
How many women die globally from eclampsia annually?
50-75k
how does the heart change during pregnancy?
▪ Rotates up and to the left ≈ 1-1.5cm as uterus
enlarges and causes diaphragm to elevate
▪ Apex located at the 4th not the 5th I/C space
▪ Left axis shift on ECG
▪ ECG changes in lead 3 –
– Q wave &
– inverted T wave
what are the cardiovascular changes in pregnancy?
▪ Resting heart rate may increase by 10-15 bpm
▪ Systolic murmurs may be heard
– gentle, soft & usually heard best in the pulmonic area and apex
▪ Plasma volume ↑ 50%
▪ RBC volume ↑ 18-20% by 30-34 weeks
gestation
How does cardiac output change during pregnancy?
▪ ↑ 35-50% in CO plateaus @ 24/40
▪ Heart volume increases from 70ml → 80ml
▪ Due to ↑ stroke volume & ↑heart rate
▪ Blood flow to:
– kidneys, brain & coronary arteries no change
– Uterus ↑’s 3%-17% from 1st to 3rd trimester
– Breast 1%-2% - early pregnancy to term
What changes occur in blood as a result of pregnancy?
▪ Blood Volume increases 30%-50%
– Protects mum & baby;
– meets foetal needs
– Assists perfusion & demands of other organs
– Safeguards against blood loss @ delivery
▪ Red cell mass increases 18-20%
▪ Produces haemodilution
– Leads to Physiological aneamia
• Decreased plasma proteins
–Decreased oncotic pressure
What blood pressure changes occur due to pregnancy?
▪ Arterial BP decreases due to: – decreased Peripheral & Pulmonary Vascular resistance • Lowest in 2nd trimester –nearly normal by term • Progesterone peaks by 32-34/40 ▪ Diastolic ↓’s in 1st trimester – ↓’s 10-15mmHg by 24/40 ▪ Systolic generally unchanged – ↓’s maximum of 5-10mmHg ▪ Pre-pregnant values return in 3rd trimester
What are the types of hypertension in pregnancy?
– Preeclampsia
• Eclampsia
• HELLP syndrome
– Non- proteinuric pregnancy induced hypertension (Gestational HTN)
– Chronic hypertension
WHat classifies Chronic hypertension in oregnancy?
Chronic Hypertension
▪Hypertension prior to pregnancy or
▪↑ BP >140/90 Hg < 20 weeks &
▪Persists up to 6 weeks post natal
What are the risk factors for Chronic hypertension in pregnancy?
oRenal disease oDiabetes oObesity oAge >40 oHTN on the OCP
WHat classifies gestational hypertension in pregnancy?
Gestational Hypertension
▪ Hypertension >140/90 on > 2 occasions
▪ No other signs of pre-eclampsia
▪ Occurs >20 weeks
What are the risk factors for gestational hypertension in pregnancy?
o Primiparity/first child with new partner o Obesity o Diabetes o Previous severe pre-eclampsia o Pre-existing cardiovascular disease o Age >40
WHat classifies pre-eclampsia in pregnancy?
WHat classifies gestational hypertension in pregnancy?
- renal involvement
- haematological involvement
- liver involvement
- neurological involvement
what are the renal factors involved with pre-eclampsia?
•Significant proteinuria – a spot urine
protein/creatinine ratio ≥ 30mg/mmol
•Serum or plasma creatinine > 90 μmol/L
•Oliguria: <80mL/4 hour
what are the haemotological factors involved with pre-eclampsia?
▪Thrombocytopenia
▪Haemolysis
▪DIC
what are the liver factors involved with pre-eclampsia?
- Abnormal LFTs
* Severe epigastric / RUQ pain
what are the neurological factors involved with pre-eclampsia?
- Convulsions (Eclampsia)
- Hypereflexia
- New headache
- Visual distrubances
- Stroke
Define pre-eclampsia
hypertension of at least 140/90 recorded on at least 2 seperate occasions and at least 300mg of protein in a 24 hor collection of urine, arising after the 20th week of pregnancy in a previously normotensive woman and resolving completely by the 6th postpartum week.
what is classified as MILD PRE-ECLAMPSIA?
DBP 90-99
SBP 140-149
what is classified as MODERATE PRE-ECLAMPSIA?
DBP 100-109
SBP 150-159
what is classified as SEVERE PRE-ECLAMPSIA?
DBP >110
SBP >160
What pathological changes occur during pre-eclampsia in the blood and cardiovascular system?
– H/T with endothelial cell damage affects
capillary permeability
– Plasma proteins leak → ↓ plasma colloid
pressure → oedema
– → hypo-volaemia & haemo-concentration
What pathological changes occur during pre-eclampsia in the coagulation system
Coagulation system
– Altered coagulation cascade
– ↑ platelet consumption → thrombocytopenia
• DIC → occludes kidneys; brain, liver &
placenta
What pathological changes occur during pre-eclampsia in the kidneys
– H/T → vasospasm of afferent arterioles – ↓ blood flow • → hypoxia & oedema of glomerulus allows plasma proteins to filter into urine – Oliguria a late sign
What pathological changes occur during pre-eclampsia in the brain
– H/T with CVS endothelial damage →
• ↑blood-brain permeability → oedema &
micro-haemorrhaging
– Headaches & convulsions
What pathological changes occur during pre-eclampsia in the Liver
– Vasoconstriction → hypoxia & oedema
– Epigastric pain & intracapsular haemorrhage
– ↓Albumin & ↑ liver enzymes
What pathological changes occur during pre-eclampsia in the Doetoplacental unit
– Vasoconstriction ↓ blood flow
– Vascular lesions can occur → abruptio
– Hypoxia → ↓ foetal growth
what is the presentation of pre-eclampsia?
▪ BP sharp rise >140/90 in – 2 nd half of pregnancy ▪ Proteinuria – Complains of ↓ output ▪ Oedema – Sudden severe • widespread – Non-dependent areas e.g. face ▪ Hyper-reflexia
What are the s&S of pre-eclampsia
▪ Complaints of other symptoms – Frontal/occipital headache; blurred vision; epigastric pain; headache; Visual disturbances; Drowsiness/confusion; Nausea & vomiting; Epigastric pain ▪ May indicate disease is deteriorating
What are some complications of pre-eclampsia?
▪ Eclampsia ▪ APH Placental abruption ▪ HELLP syndrome – Haemolysis, Elevated Liver enzymes, Low Platelets • Haemtological disturbances ▪ Blindness ▪ Intra uterine hypoxia – LBW infant; FDIU; Prem. Delivery
What is HELLP syndrome?
▪ Considered a variant / complication of preeclampsia Stands for: ▪ Haemolysis ▪ Elevated ▪ Liver enzymes ▪ Low ▪ Platelets
What are the risk factors for HELLP syndrome?
- Known pre-eclampsia
- Multiparity
- Previous Hx of HELLP
What is eclampsia?
New onset of convulsions in pregnancy
– May occur independent of pre-eclampsia
What are the 4 stages of eclampsia?
– Premonitory → Transient & quick
• Roll eyes; muscles twitch
– Tonic → 30secs.
• Violent spasm; Resps. cease → cyanosis
– Clonic → last up to 2 mins
• Jerky muscular movements; frothy blood
stained saliva; stertuous breathing
– Comatose → lasts few minutes to hours
• Deeply unconscious
What should we continue to look for on road in monitoring a partient with pre-eclampsia:
▪ Continue to assess for deterioration – Sharp rise in BP – Proteinuria → Urine Output – Frontal or occipital headache – Drowsiness or confusion – Visual disurbances – Nausea & vomiting; Epigastric pain – PV Bleeding → Abruption
What does HELLP syndrome stand for?
▪ Haemolysis ▪ Elevated ▪ Liver enzymes ▪ Low ▪ Platelets