GDM and preeclampsia

Question 1

Define gestational HTN?

Answer 1

a Dx of hypertension after 20weeks without proteinuria (benign)

Question 2

Define chronic HTN in pregnancy?

Answer 2

known hypertension before pregnancy or the development of hypertension before 20 weeks’ gestation.

Question 3

Define precclampsia?

Answer 3

a multisystem disorder unique to pregnancy whereby the diagnosis is based on the presence of new-onset hypertension after 20weeks, accompanied by new-onset proteinuria and/or other evidence of organ dysfunction.

• New-onset HTN = systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg on two occasions 4 hours apart) in a woman whose blood pressure readings were previously normal, after the 20th week of pregnancy
• New-onset proteinuria = ≥0.3 g of protein in a timed 24-hour urine collection or a protein/creatinine ratio ≥0.3 after the 20th week of gestation

Question 4

define HELLP syndrome? Symtoms and signs?

Answer 4

a serious complication regarded by most as a variant of severe
pre-eclampsia which manifests with haemolysis (H), elevated liver
enzymes (EL), and low platelets (LP).

S ymptoms include:
• epigastric or RUQ pain (65%)
• nausea and vomiting (35%)
• urine is ‘tea-coloured’ due to haemolysis.

Signs include:
• tenderness in RUQ
• raised BP and other features of pre-eclampsia.

Question 5

define eclampsia

Answer 5

the occurrence of a tonic-clonic seizure in association

with a diagnosis of pre-eclampsia.

Question 6

Name the criteria for severe pre-clampsia?

Answer 6

• Severe hypertension (systolic BP ≥160 mm Hg or diastolic BP ≥110 mm Hg) at rest on two occasions at least 4 hr apart - 4-hr delay not required if antihypertensive therapy is initiated.
• Renal insufficiency (serum Cr >1.1 mg/dL or doubling of baseline values)
• Cerebral or visual disturbances
• Pulmonary edema
• Epigastric or right upper quadrant pain
• Elevated liver enzymes (AST or ALT at least two times normal level)
• Thrombocytopenia (platelet count <100,000/µL)

Question 7

Preeeclampsia complications?

Answer 7

• Maternal:
  o CVS – Eclampsia, Intracranial haemorrhage/stroke, cortical blindness
  o Renal tubular necrosis (AKI)
  o Pulmonary oedema
  o Liver - HELLP syndrome, liver capsule haemorrhage, liver rupture
  o Haematological: DIC, VTE
  o Placental abruption
• Fetal: Stillbirth, SFGA, prematurity

Question 8

PPx of preeclampsia?

Answer 8

Failed trophoblastic invasion and adaptation of spiral arteries –> Reduced placental perfusion and ischaemia –> oxidative stress –> endothelial dysfunction

Question 9

RFs for preeclampsia?

Answer 9

moderate RFs:
primigravida
first pregnancy with new partner
>10years since last pregnancy
40yo or greater at booking
BMI>35 at booking
family history of PET
multiple pregnancy
molar pregnancy

High risk factors:
previous preeclampsia, HTN now or in previous pregnancy, CKD, autoimmune disorder, diabetes

Question 10

How to reduce risk of preeclampsia?

Answer 10

• Reduce possible RFs
• Pre-conception counselling and optimisation of pre-existing condition (eg. Diabetes, CKD)
• Aspirin 150mg daily from 12wks until 38wks for those at risk
• Use of dalteparin if prothrombotic disorder (eg. Antiphospholipid syndrome)

Question 11

Symptoms and signs of preeclampsia?

Answer 11

Headache, visual disturbance, sudden increase in swelling (esp. face), generally unwell, vomited, reduced fetal movements, abdo pain, bleeding

Signs: HTN, proteinuria, non-dependent oedema, hyperreflexia/clonus (sign of cerebral irritability), fetal growth restriction, olgihydramnios, abnormal fetal doppler,
epigastric tenderness or RUQ (Indicating liver involvement and capsule distension)

Question 12

preeclampsia Ix?

Answer 12

bloods - FBC (platelets), U+Es (vascular volume), LFTs, coagulation profile (DIC), PCR, 24hrs collection

Fetal: Growth velocity (fetal growth USS) fetal wellbeing (CTG, amniotic fluid volume, fetal doppler)

Question 13

Mx of preeclampsia?

Answer 13

Control of BP
- If BP severely high (>160/110mmHg) – treat
- If BP is sustained above 140/90mmHg – offer treatment
o With medication, aim for BP of 135/85mmHg
o R/v medication if BP stays below 110/70mmHg

• Oral Tx: Labetalol, MR nifedipine, methyldopa
• For severe HTN: IV labetalol, IV hydralazine

mild/moderate - 4 hourly BP.
24h urine collection for protein.
• Daily urinalysis.
• Daily fetal assessment with CTG.
• Regular blood tests (every 2–3 days unless symptoms or signs worsen).
• Regular ultrasound assessment (fortnightly growth and twice weekly
Doppler/liquor volume depending on severity of pre-eclampsia).

Question 14

Mx of severe/fulminating preeclampsia?

Answer 14

• Anticonvulsant – IV magniesium sulphate
• Antihypertensives - start with PO nifedipine 10mg (can be given twice 30mins apart) - if BP remains high - start IV labetalol infusion
  start maintenence therapy with labetalol (methyldopa if asthmatic)
• If early birth (<34wks) is considered likely within 7 days in women with pre-eclampsia, offer a course of antenatal corticosteroids
• Strict fluid balance (Foley’s catheter)
• HDU care

Question 15

Eclampsia Dx?

Answer 15

Seizures occurring in pregnancy or within 10days of delivery with at least 2 of the following features documental within 24hrs of seizure:

• HTN
• Proteinuria (1+ on dipstick or at least 0.3g/24hrs)
• Thrombocytopenia <100000/microlitre
• Raised transaminases

Question 16

Mx of eclampsia?

Answer 16

• ABCDE
• IV access
• 4g Magnesium sulphate bolus
• Continuous Magnesium sulphate infusion (1g per hour)
• Control HTN
• If antenatal – plan delivery by most appropriate route - If parous and near term – IOL – however most need CS
• Fluid balance
• HDU care

Question 17

Postnatal Mx of eclampsia?

Answer 17

• May req antihypertensive Tx for 6-12wks postnatally
• Increased risk of VTE, particularly if severe proteinuria
• If severe PE – followup bloods
• Postnatal HTN clinic if appropriate
• Discuss contraception before discharge
• Implications for future pregnancy
• Write to GP with Tx details, delivery and aftercare

Question 18

in preeclampsia, indications for immediate delivery?

Answer 18

W orsening thrombocytopaenia or coagulopathy.
• W orsening liver or renal function.
• S evere maternal symptoms, especially epigastric pain with abnormal LFTs.
• H ELLP syndrome or eclampsia.
• F etal reasons such as abnormal CTG or reversed umbilical artery end diastolic flow.

Question 19

risk of hyperglycaemia in pregnancy?

Answer 19

associated with: miscarriage, congenital abnormalities, macrosomia, preeclampsia, preterm birth, CS

o Maternal complications: Retinopathy, nephropathy, DKA, gastroparesis
at birth: increase monitoring, increased interventions, IOL, operative delivery and birth trauma

Increased obesity in children and into adulthood

Question 20

Describe the mechanism behind pregnancies diabetogenic state?

Answer 20

Placental hormone production  Increased insulin resistance. This causes:

• Increased glucose levels  increased insulin secrtion
• Increased triglyceride levels
• Increased amino acid turnover

RFs for DM –> increased insulin resistance, decrease insulin production –> increased glucose and free fatty acids –> increased substrates for fetal growth –> increase fetal insulin production (insulin acts as growth factor therefore increased fetal growth.

Question 21

describe prepregnancy care of diabetes?

Answer 21

All women should be offer pre-pregnancy care 3mo before conception.

• Aim for HbA1c of <48 (6.5%) - if greater than 10% strongly advise to avoid pregnancy
• Retinal assesssment (defer rapid optimisation of blood glucose until after retinal assessment)
• renal assessment
• Medications: Folic acid 5mg/day (3mo before and after conception), aspirin 75mg after 12wks gestation, if BMI >35 - recommend vit D supplements

for T1, T2 and previous GDM:
refer to pre-conception diabetes clinic
discuss effects of diabetes on pregnancy
Pregnancy is associated with:
 Increased rates of hypoglycemia (and decreased hypoglycemic awareness)
 Increased rates of diabetic ketoacidosis
 Worsening of diabetic retinopathy and nephropathy.

Measure HbA1c monthly - advise to avoid pregnancy if >10%

offer - folic acid 5mg daily until week 12 (3mo before and after conception), retinal assessment ( unless had one in last 6mo), renal assessment

In women with T1DM - - Measure TSH, free thyroxine and thyroid peroxidase antibodies

Question 22

Which extra scans and appointments do you need for pre-existing DM?

Answer 22

detailed anomaly scan at 20wks including four-chamber view of the heart and outflow tracts
Growth and liquor volume – every 4wks from 28wks
Seen in joint MDT clinic including obstetricians, midwives, endocrinologists, diabetic nurses, dieticians every 1-2wks
Repeat retinal assessment at 28wks – earlier if first assessment was abnormal

Question 23

Blood glucose targets for pre-existing DM?

Answer 23

Pre-meal <5.3
1hr post <7.8
2hr post <6.4

Question 24

mode and timing of delivery in pre-existing DM? Monitoring?

Answer 24

37 to 38+6wks

• IOL
• elective CS: 38-39wks

if diet controlled - check blood glucose hourly (If glucose >6.0mmol/L,
start sliding scale)
if insulin dependent - continue SC insulin until in established labour, then
convert to insulin sliding scale. If induction of labour or CS, continue normal insulin until day of procedure, then start sliding scale
in early morning.

Question 25

mode and timing of delivery for GDM?

Answer 25

Women with GDM – should not give birth later than 40+6 weeks - offer elective birth (by induction of labour, or by caesarean section if indicated) - Consider elective birth before 40+6 weeks for women with gestational diabetes if there are maternal or fetal complications.

Question 26

RFs for GDM?

Answer 26

BMI>30, previous GDM, previous macrosomia baby, first degree relative with DM, family origin with high DM prevalence (south asian, middle east, afro-carribean)

Question 27

When to screen for GDM? What to do if positive?

Answer 27

between 26-28wks if RFs - For women with BMI>40 or had previous GDM – do OGTT at 16-18wks and repeat at 26-28wks - If RFs for GDM – offer OGTT. Normal values: o Fasting glucose <5.6 o 2-hour glucose <7.8  5, 6, 7, 8 - If fasting glucose above 7.0 mmol/l or 2 hour glucose above 11.0 mmol/l, same day telephone referral should be made to the diabetes team and electronic referral.

Question 28

What to explain to women after GDM Dx?

Answer 28

o The implications (both short and long term) of the diagnosis for both her and her baby. o That good blood glucose control throughout pregnancy will reduce the risks tothe fetus o That treatment involves both diet and exercise and could include medications. o Teach self-monitoring of blood glucose and use the same capillary blood glucose targets as women with pre-existing diabetes.

Question 29

Mx of GDM?

Answer 29

explain to woman refer to dietician - Attendance at ANC clinic 1wk after Dx + every 1-4wks after that - Advise women to adopt a healthy diet with low GI foods, lean meats, oily fish, balance poly and unsaturated fats, moderate exercise (eg. 30mins walking after meals) measure glucose 4-6x/day - If fasting plasma glucose <7.0mmol/L at Dx - Offer a trial of change of diet and exercise o Offer metformin if blood glucose targets are not met using changes in diet and exercise after 1 – 2 weeks. o Offer additional insulin if blood glucose targets are not met using metformin, changes in diet and exercise.

Question 30

Medical Mx of GDM?

Answer 30

- If fasting plasma glucose <7.0mmol/L at Dx - Offer a trial of change of diet and exercise o Offer metformin if blood glucose targets are not met using changes in diet and exercise after 1 – 2 weeks. o Offer additional insulin if blood glucose targets are not met using metformin, changes in diet and exercise. - If fasting plasma glucose>7.0mmol/L - Offer immediate treatment with insulin and/or metformin, as well as changes to diet and exercise o Same for women with a fasting plasma glucose between 6.0 and 6.9mmols/l at diagnosis if there are fetal complications such as macrosomia or polyhydramnios

Question 31

Risks of GDM?

Answer 31

- Fetal macrosomia - Birth trauma (mother and baby) - IOL, C-section - Transient neonatal morbidity - Neonatal hypoglycaemia - Perinatal death - Obesity and/or diabetes developing later in the baby’s life.

Question 32

Postnatal GDM Mx?

Answer 32

- Stop all treatment and BG monitoring at delivery - Do FBC at 6-13wks - Do HbA1c at 13wks and yearly thereafter - Lifestyle advice - Contraception and need for pre-conception care in future

Question 33

Four effects of diabetes on pregnancy?

Answer 33

Maternal hyperglycaemia: leads to fetal hyperglycaemia. • Fetal hyperglycaemia: leads to hyperinsulinaemia (through β -cell hyperplasia in fetal pancreatic cells). Insulin acts as a growth promoter: • macrosomia • organomegaly • increased erythropoiesis • fetal polyuria (polyhydramnios). Neonatal hypoglycaemia: caused by the removal of maternal glucose supply at birth from a hyperinsulinaemic fetus. Respiratory distress syndrome: more common in babies born to diabetic mothers due to surfactant deficiency occurring through reduced production of pulmonary phospholipids.

Question 34

Effect of pregnancy on diabetes?

Answer 34

Ketoacidosis retinopathy increased risk nephropathy - increased maternal risk of pre-eclampsia and fetal risk of IUGR IHD

Question 35

Maternal complications of diabetes in pregnancy?

Answer 35

``` U TI. R ecurrent vulvovaginal candidiasis. P regnancy-induced hypertension/pre-eclampsia. O bstructed labour. O perative deliveries: CS and assisted vaginal deliveries. increased Retinopathy (15%). increased Nephropathy. Cardiac disease. ```

Question 36

Fetal complications of diabetes in pregnancy?

Answer 36

``` M iscarriage* • Congenital abnormalities: neural tube defects, microcephaly, cardiac abnormalities, sacral agenesis, renal abnormalities. • Preterm labour. • Polyhydramnios (25%). • Macrosomia (25–40%). • IUGR. • Unexplained IUD. ```

Question 37

Neonatal complications of diabetes in pregnancy?

Answer 37

``` P olycythaemia. J aundice. H ypoglycaemia. H ypocalcaemia. H ypomagnesaemia. H ypothermia. C ardiomegaly. B irth trauma: shoulder dystocia, fractures, Erb’s palsy, asphyxia. R espiratory distress syndrome. ```

Question 38

Dx criteria of GDM?

Answer 38

fasting glucose is >= 5.6 mmol/l | 2-hour glucose is >= 7.8 mmol/l