Complications of Pregnancy 2

Question 1

what is chronic/essential hypertension in pregnancy?

Answer 1

This is HT that exists either pre-pregnancy or at booking (≤20 weeks gestation).

Question 2

hypertension in pregnancy: mild

Answer 2

diastolic 90-99

systolic 140-49

Question 3

hypertension in pregnancy: moderate

Answer 3

diastolic 100-9

s 150-9

Question 4

hypertension in pregnancy: severe

Answer 4

d >=110

s >= 160

Question 5

what antihypertensive drugs can cause birth defects and impaired growth?

Answer 5

ramipril
enalopril
ARBs - lostartan, candestartan
diuretics

Question 6

what anti-hypertensive drugs are suitable during pregnancy?

Answer 6

labetolol
nifedipine
methyldopa

Question 7

what is gestational hypertension?

Answer 7

Aka pregnancy induced hypertension (PIH). This is the classified in the same way as chronic but develops after 20 weeks

Question 8

what is pre-eclampsia

Answer 8

New hypertension > 20 weeks in associate with significant proteinuria.
Definition:
Mild HT on two occasions more than 4 hours apart
or
Moderate to severe HT
+
Proteinuria of more than 300 mgms/24 hours

Question 9

define significant proteinuria

Answer 9

• Automated reagent strip urine protein estimation >1+
• Spot urinary protein creatinine ratio >30mg/mmol
• 24 hours urine protein collection >300mg/day

Question 10

pathophysiology of pre-eclampsia

Answer 10

It can be immunological or a genetic predisposition. Some theories include secondary invasion of maternal spiral arterioles by trophoblasts impaired resulting in reduced placental perfusion or an imbalance between vasodilators/vasoconstrictors in pregnancy. Prostacyclin/thromboxane.

Question 11

risk factors for developing pre-eclampsia

Answer 11

• First pregnancy
• Extremes of maternal age
• Previous pre-eclampsia (esp. severe PET, delivery <34 weeks, IUGR baby, IUD, abruption)
• Pregnancy interval > 10 years
• BMI > 35
• Family history of PET
• Multiple pregnancy
• Underlying medical disorders
o Chronic hypertension
o Pre-existing renal disease
o Pre-existing diabetes
o Autoimmune disorders e.g. antiphospholipid antibodies, SLE

Question 12

pre-eclampsia: what organs does it affect?

Answer 12

kidneys
liver
vascular
cerebral
pulmonary

Question 13

pre-eclampsia: complications maternal

Answer 13

eclampsia
severe HT
HELLP
DIC
renal failure
pulmonary oedema, cardiac failure

Question 14

what is HELLP syndrome?

Answer 14

haemolysis
elevated liver enzymes
low platelets

Question 15

pre-eclampsia: complications foetal

Answer 15

impaired placental perfusion:

Question 16

severe pre-eclampsia: symptoms/signs

Answer 16

o Headache, blurring of vision, epigastric pain, pain below ribs, vomiting, sudden
swelling of hands, face and legs
o Severe hypertension > 3+ proteinuria
o Clonus/brisk reflexes, papilledema, epigastric tenderness
o Reducing urine output
o Convulsions (eclampsia)

Question 17

severe pre-eclampsia: biochemical abnormalities

Answer 17

raised liver enzymes, bilirubin if HELLP present

raised urea and creatinine, raised urate

Question 18

severe pre-eclampsia: haematological abnormalities

Answer 18

low platelets
low haemoglobin, signs of haemolysis
features of DIC

Question 19

management of pre-eclampsia

Answer 19

• Frequent BP checks, urine protein
• Check symptomatology
o Headaches
o Epigastric pain
o Visual disturbances
• Check for hyper-reflexia (clonus), tenderness over the liber
• Blood investigations
o FBC (for haemolysis, platelets)
o LFTs
o U+Es
o Coagulation tests if indicated
• Foetal investigations
o Scan for growth
o CTG
• The only cure for PET is delivery of the baby and placenta
• Conservative (aim for foetal maturity)
o Close observation of clinical signs and investigations
o Anti-hypertensives (labetolol, methyldopa, nifedipine)
o Steroids for foetal lung maturity if gestation <36 weeks
• Consider induction of labour/CS if maternal or foetal condition deteriorates, irrespective of
gestation

Question 20

treatment of eclampsia

Answer 20

• Seizures can happen at any time – during pregnancy, labour
• Treatment of seizures/impending seizures
o Magnesium sulphate bolus + IV infusion
o Control of BP – IV labetolol, hydralazine if >160/110
o Avoid fluid overload – aim for 80mls/hr fluid intake

Question 21

prophylaxis for PET in subsequent pregnancy

Answer 21

low dose aspirin from 12 weeks till delivery

Question 22

what is gestational diabetes

Answer 22

b. Abnormal glucose tolerance that reverts to normal after delivery
c. However, more at risk of developing type II diabetes later in life

Question 23

discuss pre-existing diabetes and pregnancy

Answer 23

Insulin requirements of the mother increase as human placental lactogen, progesterone, human
chorionic gonadotrophin and cortisol from the placenta have anti-insulin actions. Foetal hyperinsulinemia
occurs as maternal glucose crosses the placenta and induces increased insulin production
in the foetus. The foetal hyperinsulinemia causes macrosomia. Post-delivery there is a greater risk of
neonatal hypoglycaemia.

Question 24

effects of diabetes on mother, foetus and neonate

Answer 24

• Increased risk of:
o Foetal congenital abnormalities (especially if blood sugars high peri-conception)
o Miscarriage
o Pre-eclampsia
o Foetal macrosomia, polyhydramnios
o Operative delivery, shoulder dystocia
o Worsening of maternal nephropathy, retinopathy, hypoglycaemia, reduced
awareness of hypoglycaemia
• Infections
• Stillbirth, increased perinatal mortality
• Neonatal
o Impaired lung maturity, neonatal hypoglycaemia, jaundice

Question 25

management of diabetes and pregnancy: preconception

Answer 25

``` o Better glycaemic control, ideally blood sugars should be around 4-7 mmol/l preconception o HbA1c < 6.5% (<48 mmol/mol) o Folic acid 5mg o Dietary advice o Retinal and renal assessment ```

Question 26

management of diabetes and pregnancy: during pregnancy

Answer 26

o Optimise glucose control – insulin requirements will increase § <5.3 mmol/l fasting § <7.8 mmol/l 1 hour postprandial § <6.4 mmol/l 2 hours postprandial § <6 mmol/l before bedtime o Could continue oral anti-diabetic agents (metformin) but may need to change to insulin for tighter glucose control o Should be aware of the risk of hypoglycaemia – provide glucagon injections/conc. Glucose solution o Watch for ketonuria/infections o Repeat retinal assessments 28 and 34 weeks o Watch foetal growth

Question 27

management of diabetes and pregnancy: labour

Answer 27

* Observe for PET * Labour usually induced 38-40 weeks, earlier if foetal or maternal concerns * Consider elective C-section if significant foetal macrosomia * Maintain blood sugar in labour with insulin – dextrose insulin infusion * Continuous CTG foetal monitoring in labour * Early feeding of baby to reduce neonatal hypoglycaemia * Can go back to pregnancy regimen of insulin post delivery

Question 28

risk factors for gestational diabetes

Answer 28

• Increased BMI >30 • Previous macrosomic baby > 4.5 kg • Previous GDM • Family history of diabetes • Women from high risk groups for developing diabetes e.g. Asian origin • Polyhydramnios or big baby in current pregnancy • Recurrent glycosuria in current pregnancy GDM associated with some increase in maternal complications (e.g. PET) and foetal complications (macrosomia) but much less than with type I or II diabetes.

Question 29

screening for gestational diabetes

Answer 29

If risk factors present offer HbA1C estimation at booking, if >6% (43 mmol/mol), 75gms OGTT to be done. If OGTT normal, repeat OGTT at 24-28 weeks. Can also offer OGTT at around 16 weeks and repeat at 28 weeks if significant risk factors (e.g. previous GDM present).

Question 30

management of gestational diabetes

Answer 30

• Control of blood sugars o Diet o Metformin/insulin if sugars remain high • Post-delivery check OGTT 608 weeks PN • Yearly check on HbA1C/blood sugars as at a higher risk of developing overt diabetes

Question 31

why are pregnant women more at risk of VTE?

Answer 31

Pregnancy is a hypercoagulable state to protect the mother against bleeding post-delivery. However, this puts women at a greater risk of VTE. There is an increase in fibrinogen, factor VIII, VW factor and platelets. Decrease in natural anticoagulants such as antithrombin III. Finally, there is an increase in fibrinolysis.

Question 32

risk factors for VTE in pregnancy

Answer 32

* Older mothers, increasing parity * Increased BMI, smokers * IVDU * PET * Dehydration – hyperemesis * Decreased mobility * Infections * Operative delivery, prolonged labour * Haemorrhage, blood loss > 2l * Previous VTE (not explained by other predisposing injuries e.g. fractures), those with thrombophilia (protein C, protein S, anti-thrombin III deficiencies etc), strong family Hx of VTE * Sickle cell disease

Question 33

VTE in pregnancy prophylaxis and treatment

Answer 33

• TED stockings • Advise increased mobility • Prophylactic anti-coagulation with 3 or more risk factors (may be indicated even with one risk factor if significant risk), may need to continue 6 weeks postpartum o Dalteparin Appropriate treatment with anticoagulation if VTE confirmed

Question 34

signs and symptoms of VTE in pregnancy

Answer 34

``` o Pain in calf o Breathlessness o Pain on breathing o Cough o Tachycardia o Hypoxic o Increased girth of affected leg o Calf muscle tenderness o Pleural rub ```

Question 35

investigations of VTE in pregnancy

Answer 35

``` o ECG o BG o Doppler o V/Q lung scan o CTPA ```