week 4- medical disorders in pregnancy and hypertension in pregnancy Flashcards
What blood tests are done at the booking appointment in pregnancy?
FBC Blood group Antibodies Infection screen- hepatitis B, rubella, HIV, VDLR Random blood glucose
When is anti-D given?
28 weeks and 34 weeks
What happens at every antenatal clinic appointment?
Accurately document gestation BP Urinaylsis FSH Fetal heart/kicks
What hypertensive disorders can you get in pregnancy?
Hypertension
Pre-eclampsia
Severe pre-eclampsia
Eclampsia
When is hypertension described as being essential?
Hypertension has been present since booking appointment or at less than 20 weeks.
When is it classed as gestational hypertension?
New hypertension at > 20 weeks with no significant proteinuria.
When is it classed as pre-eclampsia?
New hypertension at >20 weeks with significant proteinuria.
What effect does pregnancy have on blood vessels?
A (possible) placental cause causes vasoconstriction, intravascular thrombosis and a hypercoaguble state. These all lead to reduced blood flow to the organs.
What effect does hypertension in pregnancy have on the kidneys?
Hypertension can cause chronic kidney damage and stenosis. This means GFR will be decreased. You may get proteinuria.
Acute renal failure
Acute tubular necrosis?
Where would pain from the liver present?
Epigastric/RUQ pain
If someone is suffering from liver disease caused by hypertension in pregnancy, what signs may they have?
Epigastric/RUQ pain
Abnormal liver enzymes
Hepatic capsule rupture
HELLP syndrome- usually related to pre-eclampsia. Haemolysis- breakdown of red-blood cells, Elevated Liver enzymes and Low Platelet count.
What issues with the placenta, caused by hypertension, can cause issues with the birth? How can you monitor these?
intra-uterine growth restriction
Placental abruption
Intrauterine death.
Growth scans
How would you manage someone with risk factors for pre-eclampsia?
Give them aspirin.
Survey them with scans, BP monitoring and urine testing.
What hypertensive medications should be stopped in pregnancy?
ARB’s and ACE inhibitors
What hypertensive medications are used in pregnancy?
Labetalol Methyldopla Nifedipine (usually used in conjunction with others if mono therapy doesn't work)
What medication can be used for severe hypertension?
Labetalol (oral or IV)
Hydralazine (IV)
Nifedipine
What is the target blood pressure control in pregnancy?
<150/80-100 is the aim
if there is organ damage aim for 140/90
If less than 140/90 is achieved consider reducing dose.
What effect can diabetes have on pregnancy?
If it isn’t well controlled then you can get a deterioration of renal function, ophthalmic disease and gestational DM.
This can cause miscarriage, fetal malformations, IUGR/macrosomia, unexplained intra-uterine death, preclampsia.
Do you make adjustments for delivery in diabetics?
Labour is induced between 37 and 38 weeks.
Describe the effects of diabetes on the fetus?
Maternal hyperglycaemia leads to
Fetal hyperinsulinaemia (too much insulin)
This causes increased fetal growth which in turn causes macrosomia, polyuria (therefore polyhydramnios), increased oxygen demands and neonatal hypoglycaemia
What effects can macrosomia, caused by diabetes, have on labour?
Can mean you get shoulder dystocia.
What effects can polyuria and polyhydramnios, caused by diabetes, have on labour?
Risk of preterm labour.
Risk of malpresentation and cord collapse.
What effects can increased oxygen demands, caused by diabetes, have on the fetus?
Risk of unexplained still birth.
What effects can hypoglycaemia, caused by diabetes, have on the fetus?
Risk of cerebral palsy.
What are the risk factors for gestational diabetes mellitus?
Previous GDM Family history Poor obstetric history Significant glycosuria Polyhydramnios Macrosomic infant in this pregnancy PCOS Weight>100kg or BMI>30 South asian, middle eastern or African origin.
How do you manage diabetes in pregnancy (e.g. they haven’t been diagnosed yet)?
Screening- USS
Diabetic control- diet, metformin or insulin
What is the target HbA1c in pregnancy?
What other screening is done?
<6%
Retinal screening.
How are the babies with mothers with diabetes managed immediately once they’ve been delivered?
A paediatrician checks for neonatal hypoglycaemia
How are the diabetic mothers managed post-natally?
Return to pre-pregnancy insulin/oral meds.
If gestational diabetes- then monitor for 48 hours to ensure return to normal.
What is the leading cause of maternal death?
Venous-thromboembolism (VTE).
Pregnancy increases the risk of this.
What medication decreases the risk of VTE?
Low molecular weight heparin.
Why are pregnant women more affected by VTE?
Go through virchows triad-
Stasis- secondary to venous compression by pregnant uterus
Hypercoagulability- effect of pregnancy
Vascular damage.
Which clotting factors are increased in pregnancy?
Increased levels of 7,8,9,10,12
Fibrinogen
and increased platelets.
What are the important risk factors for VTE in pregnancy?
Age of over 35
Obesity
Smoking
If you have 4 or more risk factors for VTE, what is the management?
If 3 risk factors are present, management is?
Prophaylaxis from 1st trimester.
if 3- prophylaxis from 28 weeks.
If there are fewer than 3 risk factors for VTE present, what is the management?
Mobilisation and avoidance of dehydration.
If someone has been post-natally assessed as being high risk, what is the management? Why are they high risk?
At least 6 weeks post-natal LMWH.
High risk if they’ve had previous VTE, high risk of thrombophillia, any treatment requiring LMWH.
What investigations would you do into DVT/ PE in pregnancy?
Ultrasound the leg
Wouldn’t do D dimer in pregnancy.
If suspected PE or DVT in pregnancy, when would you give therapeutic heparin?
Treat then see if you were right. So immediately.
Does heparin have any affect on the fetus?
It doesn’t cross the placenta so is safe in pregnancy. There is no anticoagulation effect.
What are some side effects of heparin?
Haemorrhage Hypersensitivity Allergy at injection site Heparin induced thrombocytopenia Osteopenia
What investigations would you do into pulmonary emboli?
Blood gases chest xray ECG Dupplex ultrasound the lower limbs Ventilation/perfusion scans
What will a chest X-ray of a pulmonary embolism look like? If its abnormal, what is the next step of management?
Normal in 50% of cases
May show effusion, focal opacities
If abnormal and high clinical suspicion to CT pulmonary angiogram.
If a chest Xray looking for a PE is negative, what is the next stage of management?
Do duplex ultrasound of both legs.
What should you do with the heparin when the lady is giving birth?
Heparin should be stopped because of risk of haemorrhage.
Should therapy for DVT/PE during pregnancy be continued after birth?
Yes- should be continued 6 weeks post-natally. Use either warfarin or LMWH.
Why is warfarin avoided during pregnancy?
Teratogenic in the first 6-12 weeks, can cause miscarriage, neurological problems, still birth.
Can you take warfarin when breast-feeding?
Yes