Pre-eclampsia, PIH, Obesity and diabetes

Question 1

What is Gestational diabetes?

Answer 1

-Dm that is first diagnosed in pregnancy
-requires insulin or diet control

Question 2

What are the risk factors for gestational diabetes?

Answer 2

-advanced maternal age
-obesity
-history of DM
-hx of stillbirth, neonatal death, fetal malformation/macrosomia

-occurs when pts can’t mount a sufficient compensatory insulin response during pregnancy

Question 3

When is gestational diabetes more prevalent?

Answer 3

-2nd and 3rd trimesters
- after delivery, most pts return to normal glucose tolerance

• high recurrence rate with subsequent pregnancies

Question 4

What are some acute complications of gestational DM?

Answer 4

-DKA
-hyperglycemic nonketotic state (primarily type 2s)
-hypoglycemia

Question 5

What are the chronic complications of gestational DM?

Answer 5

Macrovascular:
-coronary
-cerebrovascular
-peripheral vascular

microvascular:
-retinopathy
-nephropathy

Neuropathy:
-autonomic
-somatic

Question 6

What is gestational DM associated with?

Answer 6

-gestational HTN
-polyhydramnios
-c-section

Early glycemic control is the best way to prevent fetal structural abnormalities

Question 7

At what A1c does the risk of vascular disease increase?

Answer 7

6.5%

Question 8

what’s a normal A1C?

Answer 8

4-6%

Question 9

When does stiff joint syndrome occur?

Answer 9

Long-standing type 1

• associated w nonfamilial short stature, joint contractions and tight skin

DL can be difficult d/t c-spine rigidity in the atlantooccipital joint

Question 10

Maternal insulin requirements _______ progressively during the 2nd and 3rd trimesters and decrease at the _______ and continue to decrease following delivery

Answer 10

Increase
onset of labor

Question 11

What are the symptoms of Diabetic autonomic neuropathy?

Answer 11

-HTN
-Orthostatic Hypotension
-Painless MI
-Decreased HR variability
-Decreased response to medications- (Atropine and propanolol)
-Resting tachycardia
-Neurogenic atonic bladder
-Hemoglobin A1C
-Gastroparesis with delayed emptying

Question 12

What should you maintain a pts BG at?

Answer 12

> 100 mg/dL and < 180 mg/dL

Question 13

How would you manage blood sugar in the OR?

Answer 13

Begin D5W 1-1.5 ml/kg/hr as an IV piggy back into crystalloid solution

One-half of the total daily dose as intermediate form (NPH) plus an intraoperative “sliding scale
Continuous infusion of regular insulin
Start infusion based on serum glucose using formula:
Units/hr = Plasma glucose/150+ (desired range of 150 etc)

i.e. glucose of 220/150 = 1.4 units/hr (usually delivered in 250 units regular insulin/250 ml 09% NaCl solution

Question 14

When could you see anaphylaxis d/t protamine?

Answer 14

in pts taking NPH or protamine zinc insulin

stop protamine, supportive care, epi

Question 15

What is placental insufficiency?

Answer 15

Uteroplacental blood flow index is reduced by 35-45% (more with poor glucose control)

Question 16

what are the 4 categories of hypertension in pregnancy?

Answer 16

-Chronic HTN
-Pregnancy induced hypertension
-Preeclampsia- eclampsia
-preeclampsia superimposed on chronic HTN

(most common medical issue during pregnancy)
Increase in maternal and fetal morbidity and remains a leading source of maternal mortality

Question 17

Leading causes of maternal mortality:

Answer 17

-thromboembolism
-non-obstetric injuries
-HTN

Question 18

What is a maternal DBP > 110 associated with?

Answer 18

increased risk of placental abruption and fetal growth restriction

Question 19

what causes most maternal morbidity?

Answer 19

Superimposed preeclampsia

Question 20

What is PIH?

Answer 20

Sustained BP increase to SBP> 140 or DBP >90
-usually mild and later in pregnancy
-no renal or other systemic involvement
-resolves 12 wks postpartum
-May evolve to preeclampsia

Question 21

What is pre-eclampsia?

Answer 21

New onset HTN after 20 wks gestation or early postpartum.
-Usually resolves within 48 hrs postpartum

-Proteinuria >300mg/24 hrs
-Oliguria or serum plasma creatinine ratio > 0.09 mmol/L
- headaches w hyperreflexia, eclampsia, clonus, or visual disturbances
- increased LTFs, glutathione-S-transferase alpha 1-1, alanine aminotransferase, or right abdominal pain
-thrombocytopenia, increased LDH, hemolysis, DIC
-Swelling (edema)
-excessive wt. gain (2-3 lbs)

• 10% in primigravida
  -20-25% w Hx of chronic HTN

Question 22

Maternal risk factors for pre-eclampsia

Answer 22

-first pregnancy
-younger than 18 or older than 35
-prior hx of pre-eclampsia
-Black race
- chronic HTN
-renal disease
-diabetes
-anti-phospholipid syndrome
-twins
-family hx

Question 23

What are the characteristics of DKA?

Answer 23

Plasma glucose >300
HCO3 < 15
pH <7.30
Acetone positive: 1:2
Ketones cross the placenta and decrease fetal oxygenation
maintain continuous fetal heart monitoring

Question 24

What are the complications of obesity in the parturient?

Answer 24

Risk for medical, obstetrical, and anesthetic complications

difficulty with intubation
problems with the placement of neuraxial anesthesia

-Higher sensory blockade with no difference in pain score
-Greater distribution of epidural local anesthetic within epidural spaces

Question 25

What is the most common medical issue during pregnancy?

Answer 25

Hypertension

Question 26

Which signs are consistent with a diagnosis of preeclampsia? (select 3) -Seizures -Increased thromboxane -Increased prostacyclin -Proteinuria -Vasoconstriction -Impaired platelet aggregation

Answer 26

-Increased thromboxane -Vasoconstriction -Proteinuria Pts also have enhanced platelet aggregation (not impaired) and decreased prostacyclin The pt w eclampsia has seizures, and the pt with preeclampsia does not- although she is at risk. will have: visual disturbances, headache, epigastric pain, rapidly increasing nondependent edema, and rapid weight gain (a result of edema d/t capillary leak as well as renal Na+ and fluid retention)

Question 27

When will preeclampsia develop?

Answer 27

After 20 weeks gestations or early postpartum

Question 28

What are the characteristics or mild preeclampsia?

Answer 28

SBP: 140-160 DBP: 90-110 urinary protein: <5g/24 hr Dipstick: + or 2+ Urine output: >500 mL/24 hrs Headache: NO visual disturbances: NO epigastric pain: NO

Question 29

What are the characteristics of severe preeclampsia?

Answer 29

SBP: >160 DBP: >110 Urinary protein: > 5g/24 hrs Dipstick: 3+ or 4+ Urine output: < 500mL/24hrs Headache: yes Visual disturbances: yes Epigastric pain: yes

Question 30

What are the cardiac complications of preeclampsia?

Answer 30

Increased CO and SVR CVP normal/slightly increased Plasma volume reduced

Question 31

What causes pulmonary edema in someone w preeclampsia?

Answer 31

Decreased oncotic/colloid pressure capillary/endothelial damage = leak vasoconstriction Increased PWP, and CVP

Question 32

What are the renal complications of preeclampsia?

Answer 32

-Proteinuria -decreased GFR & Crcl -Increased BUN -decreased RBF -Acute renal failure w oliguria --> PIH, DIC, HELP Oliguria and renal failure may occur in the absence of hypovolemia -be careful w hydration (can cause pulm. edema)

Question 33

What are the uterine complications of preeclampsia?

Answer 33

-Activity increased -Hypersensitive to oxytocin -frequent preterm labor -uterine/placental blood flow decreased by 50-70% -Increased incidence of abruption

Question 34

What are the fetal complications of PIH/ preeclampsia?

Answer 34

-Abruptio placentae -Intrauterine growth restriction -premature delivery -intrauterine fetal death

Question 35

What does HELLP stand for?

Answer 35

H: hemolysis EL: elevated liver enzymes LP: low platelet count Occurs <36 weeks other symptoms are: malaise, epigastric pain , N/V- usually self-limiting

Question 36

When is the platelet count back to normal in after delivery in someone who has HELLP?

Answer 36

within 72 hrs.

Question 37

Which maternal condition would most likely be be an indication for immediate delivery of the fetus? A. HELLP syndrome B. diabetes mellitus C. preeclampsia D. supine hypotension syndrome

Answer 37

A. HELLP syndrome HELLP Syndrome is a complication of preeclampsia that often leads to the progressive, often sudden deterioration of both mother and fetus. The acronym HELLP represents a condition consisting of Hemolysis, Elevated Liver enzymes, and Low Platelets. Approximately 5-10% of preeclamptic women develop this syndrome, and it is generally an indication for immediate delivery of the fetus due to increased maternal morbidity and mortality.

Question 38

The incidence of placental abruption is much higher in patients with A. multiple sclerosis B. rheumatoid arthritis C. preeclampsia D. HELLP syndrome

Answer 38

C. preeclampsia Placental abruption is the separation of an implanted placenta after 20 weeks of pregnancy. It can result in massive blood loss and is one of the most common causes of fetal demise. If the abruption is mild, a vaginal delivery may be attempted, but at any sign of fetal distress an emergency cesarean section must be carried out. It is more common in patients with preeclampsia (up to 1 in 4).

Question 39

Which of the following is a predictor of difficult epidural placement in obese parturients? (select two) A. The ability of the patient to flex their back B. Body mass index C. The practitioner's experience level D. The ability to palpate bony landmarks

Answer 39

A. The ability of the patient to flex their back D. The ability to palpate bony landmarks Studies have shown that the ability to palpate bony landmarks and the ability of the patient to flex their back were predictive of difficulty in placing an epidural in a parturient. The body mass index of the patient and the experience level of the practitioner were not predictive of difficulty.

Question 40

In general, regional anesthesia is not contraindicated in obstetric patients with mild preeclampsia if the platelet count is at least A. 25,000 per microliter B. 50,000 per microliter C. 80,000 per microliter D. 100,000 per microliter

Answer 40

C. 80,000 per microliter A platelet count less than 75,000-80,000 is considered too low to perform a neuraxial anesthetic.

Question 41

The drug of choice for treating hypertension during anesthesia in a parturient with preeclampsia is A. labetolol B. metoprolol C. nitroglycerin D. morphine 20 mg IV

Answer 41

A. labetolol The first line drug for treating hypertension during anesthesia for preeclamptic patients is labetolol. Esmolol may also be used during induction. Large doses of opioids are avoided as they could produce maternal and fetal respiratory depression.