Hypertension and Diabetes in Pregnancy

Question 1

why does BP routinely decrease during pregnancy

Answer 1

decreased systemic vascular resistance

lowest in mid second trimester–> increases back to baseline by around term (should not be higher than pre pregnancy)

Question 2

what two conditions are associated with HTN and liver injury in pregnancy

Answer 2

HELLP syndrome and acute fatty liver of pregnancy (AFLP)

Question 3

what is the classic triad of symptoms in preeclampsia

Answer 3

nondependent edema, HTN, proteinuria in the pregnant woman

• nondependent edema is no longer part of the diagnosis, though it is often how women present
• classic presentation is of a nulliparous woman in her third trimester

Question 4

is there a definitive known cause for preeclampsia

Answer 4

no

Question 5

what is the presumed pathophysiology of preeclampsia

Answer 5

underlying pathology involved a generalized arteriolar constriction (vasospasm) and intravascular depletion secondary to a generalized transudative edema that can produce symptoms related to ischemia, necrosis, and hemorrhage of organs

• one of the fundamental aspects of the disease is VASCULAR DAMAGE and an imbalance in the relative concentrations of PROSTACYCLIN and THROMBOXANE –> primarily thought to be related to circulating antibodies or antibody-antigen complexes (i.e like SLE) that damage the endothelial lining of vessel walls leading to exposure of the underlying collagen structure
• vascular injury may also be related to the hyperdynamic state of pregnancy rather than immune

Question 6

list the possible hypertensive states of pregnancy

Answer 6

gestational/pregnancy induced HTN

preeclampsia

severe preeclampsia

chronic hypertension

chronic hypertension with superimposed preeclampsia

HELLP syndrome

AFLP

Question 7

list the maternal manifestations/complications of preeclampsia

Answer 7

seizure

cerebral hemorrhage

DIC and thrombocytopenia

renal failure

hepatic rupture or failure

pulmonary edema

*these complications are due to the generalized arteriolar vasoconstriction affecting the organs

Question 8

list the obstetric manifestations/complications of preeclampsia

Answer 8

uteroplacental insufficiency–> can lead to fetal hypoxia, or if chronic, may lead to IUGR

placental abruption

increased premature deliveries

increased C/S deliveries

Question 9

how do you diagnose severe preeclampsia

Answer 9

severely elevated BPs–> sBP above 160 and dBP above 110 or presence of any of the clinical findings

Question 10

what % of patients with severe preeclampsia develop HELLP syndrome

Answer 10

10%

Question 11

what is HELLP syndrome

Answer 11

subcategory of preeclampsia in which the patient presents with HEMOLYSIS, ELEVATED LIVER ENZYMES, LOW PLATELETS

HTN and proteinura may be minimal in these patients

uncommon but patients who get it decline rapidly and have poor maternal and fetal outcomes

even with careful management–> results in high rate of stillbirth (10-15%) and neonatal death (20-25%)

Question 12

what % of live births experience preeclampsia

Answer 12

5-6%

Question 13

when does preeclampsia typically develop

Answer 13

can develop any time after 20th week but most common in third trimester near term

Question 14

what should you consider if HTN presents early in the second trimester (14-20 weeks)

Answer 14

hydatidiform mole or previously undiagnosed chronic HTN should be considered

Question 15

what % of patients who develop HELLP were first diagnosed with preeclampsia

Answer 15

80%–> but the remainder of HELLP patients present with no previous history of HTN and will present with just symptoms of RUQ pain

*these women need to make sure to have HELLP ruled out despite benign initial presentation

Question 16

what are the risk factors for preeclampsia

Answer 16

1. those related to the manifestations of the disease
   - -chronic HTN
   - -renal disease
   - -african american race (more likely to have T2DM, chronic HTN and obesity)
   - -collagen vascular disease (SLE)
   - -pregestational diabetes
   - -maternal age below 20 or above 35
2. those related to the immunogenic nature of preeclampsia
   - -nulliparity
   - -previous preeclampsia
   - -multiple gestation
   - -abnormal placentation
   - -new paternity
3. family history
   - -female relative of parturient
   - -mother in law
   - -cohabitation less than 1 year (“tolerance effect”)
   - -parental ethnic discordance

Question 17

how do you diagnose gestational HTN

Answer 17

BPs elevated above sBP 140/dBP 90 mmHg needed to diagnose PIH/GH

should be elevated on at least two occasions 4-6 hours apart and taken while patient seated

*if patients 24 hour urinary protein total is less than 300 mg, preeclampsia is ruled out and patient can be managed expectantly, but these patients are at risk of developing preeclampsia so follow closely with labs etc

Question 18

fetal complications of preeclampsia

Answer 18

complications related to prematurity, if early delivery necessary

acute uteroplacental insufficiency–> placental infarct and/or abruption, intrapartum fetal distreass, stilbirth

chronic uteroplacental insufficiency–> asymmetric and symmetric SGA fetuses, IUGR

oligohydramnios

Question 19

diagnosis definition of mild preeclampsia

Answer 19

sBP above 140 mmHg
dBP above 90 mmHg
proteinuria above 300 mg/24 hours or above 1 but less than 2 on dipstick

Question 20

diagnosis of severe preeclampsia

Answer 20

by symptoms

neuro–> severe headache not relieved by acetaminophen

visual changes, scotoma

CV–> sBP above 160, dBP above 110

pulmonary edema
acute renal failure with rising creatinine

oliguria less than 500 mL/24hours

proteinuria or more than 5 g/24 hours or more than 3+ on dipstick

RUQ pain

elevation of transaminases, AST, ALT

hemolytic anemia

thrombocytopenia less than 100 000 platelets/mL

DIC

IUGR, abnormal fetal dopplers

Question 21

diagnosis of eclampsia

Answer 21

preeclampsia with seizures

Question 22

how do you diagnose HELLP

Answer 22

1. hemolytic anemia–> schistocytes on peripheral blood smear, elevated LDH, elevated total bili
2. elevated liver enzymes–> increase in AST, ALT
3. low platelets–> thrombocytopenia

Question 23

is urine dipstick a good way to rule out preeclampsia

Answer 23

no, especially not in the setting of HTN–> a clean urine dip does not mean they wont have elevated 24 hour protein in their urine

a better predictor in acute setting is spot urine-to-creatinine ratio because creatinine secretion is relatively constant –> ratio of 0.2 to 0.3 is concerning for preeclampsia and should warrant prompt further evaluation

Question 24

what should you screen for in a woman with HELLP who presents with frank hepatic failure

Answer 24

AFLP

Question 25

what is AFLP

Answer 25

unclear whether own disease, or on the spectrum of preeclampsia more than 50% of people with AFLP will also have HTN and proteinura high mortality rate

Question 26

how do you differentiate AFLP from HELLP

Answer 26

lab tests associated with liver failure--> elevated ammonia level, blood glucose less than 50 mg/dL, markedly reduced fibronogen and antithrombin III levels

Question 27

how do you manage AFLP

Answer 27

supportive liver transplant has been used but some studies report AFLP can be treated in many patients without this aggressive intervention

Question 28

what is the ultimate treatment of preeclampsia

Answer 28

delivery --> induction of labour is the treatment of choice for pregnancies at term, unstable preterm pregnancies or pregnancies where there is evidence of fetal lung maturity vaginal delivery may be attempted with assistance of prostaglandins, foley bulb, oxytocin or amniotomy as needed C/S only for obstetric indications

Question 29

how would you manage a patient with preeclampsia who is stable and preterm

Answer 29

bed rest and expectant management until delivery at 37 weeks or until delivery otherwise indicated most commonly manage in hospital betamethasone given to enhance fetal lung maturity

Question 30

what medication is often started in women with preeclampsia and what is the dosing

Answer 30

magnesium sulfate should continue for 12 -24 hours after delivery this is for seizure prophylaxis during labour and delivery --> 4 g load and 1g/hour maintenance // some places still use 4-6 g load and 2g/hour maintenance

Question 31

what are the goals of treatment in severe preeclampsia

Answer 31

prevent eclampsia, control maternal BP and deliver the fetus management varies depending on gestational age

Question 32

describe an approach to managing a patient with severe preeclampsia

Answer 32

1. stabilize with magnesium sulfate for seizure prophylaxis, hydralazine for ateriolar dilation and labetolol for BP control 2. once stable--> if gestational age between 24-32 weeks, expectant management to allow time for treatment with betamethasone and further fetal maturity 3. beyond 32 weeks or in severe preeclamptic patients with signs of renal failure, pulm edema, hepatic injury, HELLP or DIC--> delivery should ensue immediately

Question 33

what is the point of using magnesium sulfate in the setting of preeclampsia

Answer 33

seizure prophyalxis

Question 34

what 3 meds are commonly used to treat severe preeclampsia

Answer 34

magnesium sulfate hydralazine labetolol

Question 35

does preeclampsia resolve immediately after delivery

Answer 35

no--can have effects lingering for several weeks can even worsen acutely in the immediate post partum phase, possibly due to increased placental antigen exposure during labour and delivery seizure prophylaxis is thus continued 24 hours post partum or until patient is markedly improved

Question 36

what meds are usually used in the setting of chronic HTN in pregnancy

Answer 36

labetolol and nifedipine (adalat)

Question 37

what is the recurrence rate of preeclampsia in subsequent pregnancies

Answer 37

25-33% in patients with both chronic HTN and preeclampsia, recurrence up to 70%

Question 38

how do you manage patient to try and reduce risk of recurrence of preeclampsia

Answer 38

low doses of aspirin prior to and during subsequent pregnancies calcium supplementation

Question 39

define eclampsia

Answer 39

grand mal seizures in the preeclamptic patient that cannot be attributed to other causes *eclampsia may also occur without proteinuria

Question 40

complications of eclampsia

Answer 40

cerebral hemorrhage aspiration pneumonia hypoxic encephalopathy thromboembolic events

Question 41

what is the clinical manifestation of eclampsia

Answer 41

tonic clonic seizures may or may not be proceeded by aura 25% before labour, 50% during labour, 25% after delivery most post partum seizures will occur within 48 hours of delivery but can occur as late as weeks later

Question 42

how does magnesium sulfate achieve seizure prophylaxis in the eclamptic patient

Answer 42

decreases hyperreflexia raises seizure threshold *as good or better than phenytoin, carbamazepine, and phenobarbital in prevention of recurrence of seizures in eclamptic patients

Question 43

how long do you treat eclamptic patients with magnesium sulfate for

Answer 43

initiate at time of diagnosis and continued until 12-24 hours after delivery

Question 44

how do you treat magnesium sulfate overdose

Answer 44

10 mL of 10% calcium chloride or calcium gluconate should be rapidly administered through IV *cardiac protection*

Question 45

what % of women with chronic HTN will develop preeclampsia

Answer 45

1/3

Question 46

what are the risks to mom and baby with chronic HTN

Answer 46

IUGR in fetus due to poor vascular development superimposed preeclampsia, premature delivery and placental abruption in mom

Question 47

how do you treat women with chronic HTN who are pregnant

Answer 47

if BP 140/90 or below consistently, can manage expectantly use antihypertensives in those with persistently elevated BPs or in those who were already on meds prior to pregnancy two most common meds: labetolol nifedipine

Question 48

what type of med is labetolol

Answer 48

beta blocker with concomitant alpha blockade

Question 49

what type of med is nifedipine

Answer 49

(adalat) peripheral calcium channel blocker

Question 50

what is the risk of labetolol in pregnancy

Answer 50

associated with low birth weight but unclear if it is the med or the severity of the HTN that causes this

Question 51

define true gestational diabetes

Answer 51

impairment of carbohydrate metabolism that first manifests during pregnancy may have borderline impairments at baseline or be entirely normal in non pregnant state

Question 52

why does gestational diabetes happen

Answer 52

in pregnancy, human placental lactogen and other hormones produced by the placenta act as anti-insulin agents leading to increased insulin resistance and generalized carb intolerance this increased insulin resistance occurs in all pregnant women but those in whom the balance tips in favour of insulin resistance will have elevated post prandial BG and occasionally elevated fasting glucose *in animal models, there has been shown to be pancreatic beta cell hyperplasia in the first part of pregnancy, possibly to overcome this insulin resistance from the placental hormones, but not sure if this is the case in humans

Question 53

when is GDM usually diagnosed and why is this important

Answer 53

late second, early third trimester (placental hormones increase in volume with size of placenta) therefore, women with GDM are usually not at risk for congenital anomalies like those with pregestational diabetes *there is still an increased risk of fetal macrosomia and birth injuries as well as neonatal hypoglycemia, hypocalcemia, hyperbilirubinemia and polycythemia like those with pregestational diabetes

Question 54

do women who develop GDM go on to get T2DM?

Answer 54

they can--4 to 10x increased risk of developing it in their lifetime

Question 55

what is the incidence of GDM

Answer 55

1-12% of pregnant women depending on population 5-8% in USA more common in women of hispanic/latina origin, asian/pacific islander and native american descent paternal ethnicity in these groups can also contribute

Question 56

what are the risk factors for developing GDM

Answer 56

race/ethnicity maternal BMI/obesity increasing maternal age family history of diabetes previous infant weighing more than 4000 g previous stillborn infant

Question 57

when is the best time to screen for GDM

Answer 57

end of second trimester between 26-28 weeks in women low risk for GDM those with one or more risk factors however should be screened at first prenatal visit as part of initial lab tests

Question 58

how is GDM screened for

Answer 58

most common: 50 g glucose load given and plasma glucose measured 1 hour later--> if positive (BG above 130-140 mg/dL), do glucose tolerance test

Question 59

how do you do the GTT

Answer 59

3 days of special carb diet--> 8 hour fast--> measure BG before admin of load--> give 100g glucose load--> measure BG at 1, 2, and 3 hours after load if 2 or more of the 4 values are elevated, diagnosis of GDM made

Question 60

describe a classification system for diabetes during pregnancy

Answer 60

white classification Class A1, A2, B etc --> T Class A1--> GDM, diet controlled Class A2--> GDM, insulin dependent other classes are various types of diabetes with ages of onset, symptoms etc

Question 61

how do you manage GDM once diagnosed

Answer 61

patient usually started on diet recommended for patients with diabetes --> total carb intake is most important recommended carb intake is approx 200-220 g per day monitor BG 4 times per day (1 fasting, 3 post prandial)

Question 62

when should you start diabetic meds in a GDM patient

Answer 62

if more than 25-30% of her BG readings are elevated start insulin or another oral hypoglycemic agent

Question 63

what insulin should be used in the true GDM patient

Answer 63

usually fasting BG is fine--> there isnt a problem with baseline metabolism, but with dealing with large carb boluses--> thus post prandial values are high can thus use a short acting insulin in combo with an intermediate acting insulin in morning to cover breakfast and lunch (short acting at dinner) * short acting--> Lispro (Humalog) * intermediate acting--> NPH

Question 64

what else needs to be done in the management of Class A2 GDM patients once started on insulin

Answer 64

fetal monitoring with NSTs or modified BPPs begun between 32-36 weeks and continued until delivery weekly or biweekly often get obstetric U/S between 34-37 weeks due to risk of macrosomia *those with Class A1 GDM are not commonly offered fetal monitoring

Question 65

when do GDM patients on insulin usually get induced

Answer 65

39 weeks patients with poor glycemic control are offered delivery between 37-39 weeks after verification of fetal lung maturity

Question 66

what is the recurrence rate of GDM in subsequent pregnancies

Answer 66

50% 25-35% will go on to develop overt diabetes within 5 years

Question 67

what is the effect of GDM on the kids in childhood

Answer 67

increased incidence of childhood obesity and T2DM later in life

Question 68

what is the relationship between pregestational diabetes and preeclampsia?

Answer 68

4x more likely to get preeclampsia or eclampsia

Question 69

list the possible obstetric complications from pregestational diabetes in pregnancy

Answer 69

polyhydramnios preeclampsia miscarriage infection PPH increased C/S

Question 70

list the possible diabetic emergencies than can occur with pregestational diabetes in pregnancy

Answer 70

hypoglycemia ketoacidosis diabetic coma

Question 71

list the possible vascular and organ involvement complications that can happen to mom in the setting of pregestational diabetes in pregnancy

Answer 71

cardiac renal ophthalmic peripheral vascular

Question 72

list the possible neuro complications that can happen to mom due to pregestational diabetes in pregnancy

Answer 72

peripheral neuropathy GI disturbance

Question 73

what are the possible fetal complications of pregestational diabetes in pregnancy

Answer 73

1. macrosomia--> traumatic delivery, shoulder dystocia, Erb palsy 2. delayed organ maturity--> pulm, hepatic, neuro, pituitary-thyroid axis 3. congenital malformations--> CV defects, NTDs, caudal regression syndrome, situs inversus, duplex renal ureter, IUGR 4. IUFD * 5x increase in perinatal death * 2-3x increase in risk of congenital malformations, depending on glycemic control

Question 74

what is the risk of perinatal mortality in a woman with poor glycemic control in pregestational diabetes in pregnancy

Answer 74

as high as 30% | decreases to 1% with careful management

Question 75

how can you use HbA1c to predict perinatal outcomes

Answer 75

less than 6/5%--> generally good outcomes above 12%--> poorer outcomes, and 25% rate of congenital anomalies

Question 76

why dont we generally use oral hypoglycemics in pregnancy

Answer 76

concerns regarding fetal hypoglycemia or potential teratogenicity not shown to actually be much of a problem in some studies *but also, likely wont be enough to control hyperglycemia in pregnant patients