Complications of Pregnancy 2

Question 1

What is chronic hypertension in pregnancy?

Answer 1

HTN at pre-pregnancy or booking <20wks gestation

Question 2

What is gestational HTN?

Answer 2

BP above but new HTN after 20 weeks

Question 3

What is pre-eclampsia?

Answer 3

New hypertension >20 weeks in association with significant proteinuria

Question 4

What is significant proteinuria?

Answer 4

Strip urine protein >1+
Urinary protein:creatinine ratio >30mg/mmol
24hr urine protein collection >300mg/day

Question 5

How should HTN be managed pre-pregnancy?

Answer 5

Stop ACEI/ARBs
Diuretics
Lower dietary sodium
Keep BP <150/100
Monitor for pre-eclampsia
Monitor fetal growth

Question 6

Hypertensive mothers have an increased risk of what?

Answer 6

Abruption

Question 7

How is Pre-eclampsia defined?

Answer 7

Mild HTN on 2 occasions more than 4hrs apart
Moderate to severe HTN
+
Proteinuria >300mgms

Question 8

What is the case of pre-eclampsia?

Answer 8

Immunological
Genetic predisposition
Secondary invasion of maternal spiral arterioles impaired
Imbalance between vasodilators/vasoconstrictors in pregnancy

Question 9

What ar ethe risk factors for pre-eclampsia?

Answer 9

First pregnancy
Extremes of maternal age
PMH
BMI >35
Multiple pregnancy
Chronic HTN
Pre-existing renal disease
Diabetes 
Autoimmune disorders

Question 10

Which systems are involved in pre-eclampsia?

Answer 10

Renal
Liver
Vascular
Cerebral
Pulmonary

Question 11

What are the compliactions of pre-eclampsia?

Answer 11

Eclampsia
Stroke/intracerebral haemorrhage
HELLP
DIC
Renal failure
Oedema
IUGR
Fetal distress

Question 12

What is HELLP?

Answer 12

Hemolysis
Elevated liver enzymes
Low platelets

Question 13

How does severe pre-eclampsia present?

Answer 13

Headache, blurred vision, vomiting, swelling hands, epigastric pain
Severe HTN
Clonus, papilloedema
Reduced urine output
Convulsions

Question 14

How does severe pre-eclampsia present on blood testing?

Answer 14

Raised liver enzymes
Raised urea and creatinine
Low platelets
How Hb
Features of DIC

Question 15

What is DIC?

Answer 15

Disseminated intravascular coagulation

Question 16

How is pre-eclampsia managed?

Answer 16

Frequent BP, urine protein
Check for symptoms - headaches, epigastric pain, visual disturbances
Check for clonus
Bloods
LFTs
RFTs
Coagulation screen
CTG
Growth scans for fetus

Question 17

How is pre-eclampsia managed?

Answer 17

Antihypertensives
Close monitoring
Steroids for baby if early delivery
Consider induction of labour of condition deteriorates
MONITOR MOTHER as risks persist post delivery

Question 18

Which hypertensives are indicated in pre-eclamptic women?

Answer 18

Labetolol
Methyldopa
Nifedipine

Question 19

How are seizures treated in eclampsic women?

Answer 19

Magnesium sulphate bolus + IV infusion
IV Labetolol, hydrallazine
Avoid fluid overload

Question 20

What prophylaxis is given in subsequent pregnancies for eclamptic women?

Answer 20

Low dose aspirin from 12 weeks til delivery

Question 21

What is gestational diabetes?

Answer 21

Diabetes onset in pregnancy
Abnormal glucose tolerance (returns to normal after delivery)
Increased risk T2DM later in life

Question 22

How does diabetes management change in pregnancy?

Answer 22

Increased insulin requirements

Question 23

What are the post-delivery effects of pre-existing diabetes in pregnancy?

Answer 23

Increased risk of neonatal hypoglycaemia

Increased risk of respiratory distress

Question 24

What are the risks of diabetes in a pregnant mother?

Answer 24

Fetal congenital abnormalities
Miscarriage
Fetal macrosomia, polyhydramnios 
Operative delivery
Stillbirth

Question 25

What congenital abnormalities are more common with maternal diabetes?

Answer 25

Cardiac abnormalities | Sacral agenesis

Question 26

What complications are associated with maternal diabetes?

Answer 26

Increased risk of pre-eclampsia Worsened maternal nephropathy, retinopathy, hypoglycaemia (less aware of hypos) Infections Neonatal impaired lung maturity

Question 27

How is maternal diabetes managed?

Answer 27

``` Better glycaemic control Folic acid 5mg Dietary advice Retinal/renal assessment Metformin (may need to change to insulin) Glucagon injections Ketonuria/infection awareness Monitor fetal growth Observe for pre-eclampsia Macrosomia - c-section ```

Question 28

What are the risk factors for gestational diabetes?

Answer 28

``` BMI >30 Previous macrosomic baby >4.5kg Previous GDM FH diabetes Asian women Polyhydramnios Recurrent glycosuria ```

Question 29

How is GDM screened for?

Answer 29

HbA1c at booking - OGTT if >43 | Repeat at 24wks

Question 30

How is GDM managed?

Answer 30

Controlled blood sugars Meformin/insulin OGTT post-delivery Yearly HbA1c

Question 31

What is the risk of VTE?

Answer 31

Virchow's Triad: Stasis Hypercoagulability Vessel wall injury

Question 32

Why is the risk of VTE increased in pregnancy?

Answer 32

Hypercoagulable state Increased stasis Vascular damage at delivery

Question 33

Why is pregnancy a hypercoagulable state?

Answer 33

Increased fibrinogen, factor VIII, VW factor, platelets Decreased anticoagnulants Increased fibrinolysis

Question 34

What are the risk factors for VTE in pregnancy?

Answer 34

``` Older mothers Smokers High BMI IVDA Pre-eclampsia Dehydration/hyperemesis Infections Haemorrhage Previous VTE Sickle cell disease ```

Question 35

What VTE prophylaxis is used in pregnancy?

Answer 35

TED stockings Advise increased mobility, hydration Prophylactic anticoagulation if >3 risk factors

Question 36

What are the signs of VTE?

Answer 36

``` Pain in calf Swollen leg Calf muscle tenderness Breathlessness Pain on breathing Tachycardia Hypoxic Pleural rub ```

Question 37

How should VTE be investigated?

Answer 37

``` Doppler ECG Blood gasses V/Q scan CTPA ```