Antenatal Problems 3 Flashcards
(77 cards)
What are the effects of diabetes on pregnancy?
- Maternal hyperglycaemia leads to fetal hyperglycaemia which is potentially harmful to the fetus = leads to hyperinsulinaemia through beta cell hyperplasia in fetal pancreatic cells
- Insulin in fetus acts as a growth promoter = macrosomia, organomegaly and increased erythropoiesis
- Fetal polyuria = polyhydraminos (esp in poor control)
- High levels of insulin in fetus + removal of glucose supply after birth = neonatal hypoglycaemia
- Early feeding and regular blood glucose monitoring should be performed to minimise the risk of cerebral damage
- Surfactant deficiency occurs through reduced production of pulmonary phospholipids = clinically manifests as respiratory distress syndrome (more common in babies born to diabetic mothers)
What happens to insulin requirements during pregnancy?
Insulin requirements increase throughout pregnancy and are maximal at term
There is progressive insulin resistance because the placenta produces hormones such as cortisol, hCG, progesterone, placental lactogen which are all insulin antagonists - therefore, a higher volume is needed than normal - the requirements rise by 30%
What may be associated with ketoacidosis in those with diabetes in pregnancy? (4)
(Rare)
- Hyperemesis gravidarum
- Infection
- Tocolytic agents eg terbutaline (used to suppress premature labour)
- Steroid therapy
What effect may pregnancy have on retinopathy in those who are pregnant and have diabetes?
- Exacerbation and complication of diabetic retinopathy
- All diabetic women should have retinopathy assessment and proliferative retinopathy requires treatment
- Early changes usually revert after delivery
What effect may pregnancy have on nephropathy in those who are pregnant and have diabetes?
- Renal function and proteinuria may worsen during pregnancy
- This is usually temporary
What effect may pregnancy have on IHD in those who are pregnant and have diabetes?
- Pregnancy increases cardiac workload
- Women who have had a previous MI should avoid pregnancy (50% mortality)
- Women with symptoms should be assessed by a cardiologist before conception
How many times a day should a pregnant woman with gestational diabetes monitor her glucose? What are the target levels?
Pre-prandial (before eating) glucose levels <6
One hour post-prandial (after eating) glucose levels <7.8
Two hours post-prandial glucose levels <6.4
Fasting glucose levels <5.3
What antenatal surveillance may be required for diabetic women?
Serial USS every 2-4 weeks to detect:
- Polyhydraminous
- Macrosomia
- IUGR
Extra-detailed anomaly scan at 18-22 weeks
What presentations in a pregnant woman would make you concerned about potential gestational diabetes?
Recurrent infections
Persistent glycosuria
Large for date foetus with macrosomia or polyhydraminos
What is the method of OGTT? Also, when is it done in pregnancy?
OGTT done in a woman with any risk factors at 24-28 weeks. If they’ve previously had gestational diabetes, do OGTT asap after booking and again at 24-28 weeks if first test was normal
- Overnight fasting - 8hrs minimum, water only and no smoking
- Do fasting blood glucose measurement
- 75g load in 250-300ml water
- Take blood glucose measurement 2 hours later
What are the diagnostic thresholds for gestational diabetes?
Fasting >5.6mmol/L = diabetes diagnosis
2 hour >7.8mmol/L = diabetes diagnosis
What is the management of gestational DM depending on their fasting blood glucose result?
If fasting blood glucose <7 = 2 week trial of diet and exercise
- If this doesn’t work give metformin
- Then short-acting insulin if this doesn’t work
If fasting glucose >7 = give insulin straight away
If fasting glucose 6-6.9 and evidence of macrosomia/polyhydramnios = give insulin straight away
Glibenclamide if cannot tolerate metformin or decline insulin
What risks do women who have had gestational DM pose in the future?
Inc risk of developing T2DM
What is the leading cause of maternal morbidity and mortality in developed countries?
VTE
= Leading cause of direct maternal death
Why is pregnancy a hypercoagable state?
1) Clotting factors increase
2) Decreased fibrinolysis in preparation for labour
3) Venous stasis due to large pelvic mass
4) Immobility
5) Medications e.g. warfarin would have to have been stopped
When is a woman most at risk from a VTE?
First 10 days post natally
Where are clots most commonly formed in pregnancy?
Ileofemoral on L side
Where the left common iliac artery crosses over the iliac vein
What is the medication of choice for antenatal thrombopropylaxis?
LMWH
Who may be offered antenatal thrombopropylaxis?
Previous VTE
Thrombophilia e.g. antiphospholipid syndrome
Family history
Antithrombin III deficiency
Those who experience excessive blood loss or a blood transfusion
Medical comorbidities e.g. HF
Surgeries
What is the management of an intrauterine death?
Labour induced using prostaglandins and / or oxytocin infusion (but do not rush delivery unless maternal health at risk - spontaneous labour can begin within 2 weeks of intrauterine death)
Occasionally CS required if mother is unwell and delivery needs to be earlier
4 weeks after foetal death, there is 1/4 risk of develop coagulopathy so assess platelets and coagulation screens regularly
What can be given to following a stillbirth to suppress lactation?
Cabergoline
What is defined as recurrent pregnancy loss? How common is it?
Recurrent miscarriage = loss of 3+ consecutive pregnancies with the same partner
What can cause recurrent pregnancy loss?
Antiphospholipid syndrome
Chromosomal defects
Anatomical factors e.g. uterine abnormalities, cervical incompetence
What investigations may be performed in cases of recurrent pregnancy loss?
· Blood tests for antiphospholipid antibodies and thrombophilia screen
· Transvaginal ultrasound to identify uterine abnormalities
· Cytogenetic analysis of products of conception - if this is abnormal then the parents should be karyotyped
