Pregnancy Complications - Hypertension / DM Flashcards
(68 cards)
1
Q
What is gestational hypertension?
A
Hypertension that develops >20 weeks
No proteinuria / oedema
Increased risk of PET
Resolves after birth
Pre-pregnancy if <20 weeks
BP usually falls in 1st trimester
2
Q
What is mild hypertension
A
140-149 / 90-99 OR >30 / >15 from booking bloods
3
Q
What is mod and severe hypertension
A
Mod = >150/100 Severe = >160 / >110 Severe = Medical emergency
4
Q
What suggests high risk of PET of booking
A
FH or RF
5
Q
What do you get if high risk of PET
A
Consultant clinic
Regular growth scans
6
Q
What must you exclude for new hypertension
A
Coarctation Renal artery stenosis Cushing's Conn's Phaeochromocytoma
7
Q
How do you screen for complications of hypertension antenatal
A
BP Urine dip Fetal growth - SFH via USS Monitor for signs of PET - oedema etc Fetal movement CTG if activity abnormal Monitor for PET / abruption
8
Q
What do you do for mild hypertension
A
No Rx - can Rx Regular BP check Exercise Healthy eating Aspirin from conception (stop before labour) Low Na diet
9
Q
What do you do for moderate or severe and how do you monitor
A
Aim BP 150/90 Labetalol = 1st line Repeat BP 1 week after start on Rx Nifidipine (CCB) = 2nd line Methyldopa = 3rd line but must stop postpartum IV labetalol and hydrazine if severe
Monitor
2x weekly BP and urine until target
FBC, U+E, LFT weekly
Target = 135 / 85
10
Q
When is labetalol CI
A
Asthma
11
Q
If high BP what do you do with regards to delivery
A
Induce around EDD
Operative delivery if severe
Syntocin in 3rd stage NOT ergometrine
12
Q
What are risks of hypertension
A
Abruption
IUGR
Prematurity
Higher risk of PET
13
Q
When is methyldopa CI and what other hypertensives are CI
A
Post natal depression so must stop within 2 days of delivery
ACEI / ARB / thiazide
14
Q
When would you admit to hospital
A
Severe HTN
HTN with proteinuria
New proteinuria even if no HTN
Evidence of IUGR on USS
15
Q
What is pre-eclampsia
A
NEW hypertension >20 weeks
2 separate occasions 4 hours apart of SEVERE
+
Significant proteinuria urine +1 or 24 hour urine >300mg
+
Oedema
16
Q
What is classed as severe PET
A
>170 / >110 Protein +3 >1000m SYMPTOMS Biochemical / haematological / HELLP
17
Q
What are symptoms of PET
A
Oedema Frontal headache Visual disturbance - blurred / glitter / lights Papilloedema - fundoscopy Epigastric pain RUQ Vomiting Clonus Hyperreflexia Confusion Reduced urine Reduced movement HELLP
18
Q
What should you beware of in PET
A
Don’t overload if oedema
19
Q
What are major RF
A
Chronic hypertension Previous PET DM Autoimmune - SLE CKD
20
Q
What are minor RF
A
1st pregnancy >40 Obesity BMI >35 FH - 1st degree Multiple pregnancy Pregnancy interval >10 years
21
Q
What do you do if protein found on dip
A
Admit to hospital for assessment / possible delivery FBC, U+E, LFT, urate USS for growth CTG Urine culture
22
Q
What are PET bloods
A
FBC - look for HELLP LFT - ALP rise normal U+E Urate Coagulation Bloods may be abnormal for 6 weeks MSSU for protein
23
Q
What is normal rate of urate
A
10x gestation
24
Q
What other investigations
A
Pregnancy Hx / gestation and PET sx Abdo exam Fundoscopy Reflexes USS fetal growth CTG
25
What should you do if PET discovered / how do you monitor in pregnancy
```
Admit for BP monitoring / day case + urine
24 hour urine
Monitor
- BP
- PET bloods
- Growth scan
- Urine dip
- Symptoms
```
26
What are biochemical abnormalities
Raised liver enzyme
Raised bilirubin
Raised U+E - kidney failure
Raised urate
27
What are haematological abnormalities
Low platelet
Low Hb
Signs of haemolytic
DIC
28
What should you always do at pregnancy check
BP
| MSSU
29
What is only cure for PET
What do you give during delivery
Delivery
Aim for IOL + SVD but no IOL if fatal distress or severe
Emergency C-section if fatal distress
During delivery = magnesium sulphate and labetalol to control
30
What does decision to delivery depend
Gestation
Mother's health
```
If <160 and no signs of end organ damage e.g. seizure / papilloedema/ clonus
If >37 weeks = delivery
If <37 weeks
- Control HTN e.g. IV labetalol
- Close observation - BP and urine
```
If severe or signs of end organ
- IV labetalol
- Mg sulphate
- Plan urgent delivery
- IV dex if <34 weeks
- CTG
31
When would you delivery <34 weeks
If refractory to Rx or indications
32
When do you give steroids
<36 weeks but >25 weeks to prevent RDS
33
How do you treat during pregnancy
```
Prevent complications but not Rx
Control BP as above
Fluid restrict of risk of oedema
VTE prohylaxis
Magnesium sulphate
```
34
When do you start magnesium sulphate
If within 24 hours of birth or think eclampsia
Tocolytic effect and reduced cerebral palsy
Give 24 hours after delivery or last seizure to prevent seizures
35
When and why do you give low dose aspirin
At 12 weeks to reduce risk of PET / IUGR
If previous PET or 1 high RF or two moderate
Gestational hypertension
36
What do you do post natal
Check BP
| Urine dip 6-8 weeks
37
What are complications of PET
```
Eclampsia
Cerebral haemorrhage
Placental abruption
Pulmonary oedema
Stroke
MI
HELLP
DIC
Renal failure
Retinal damage in DM
Liver failure
Cardiac failure
Hypertension
VTE
C-section
```
38
What is HELLP
Haemolysis
Elevated liver enzymes
Low platelet
39
How does HELLP present
N+V
RUQ
Lethargy
Must deliver
40
What are fetal complications
```
Impaired placental perfusion
IUGR
Placental abruption
Pre-term
IUD / distress
Still birth
```
41
How do you treat eclampsia
```
ABCDE
Senior
IV access
Magnesium sulphate bolus + IV infusion = 1st line (continue until 24 hours post seizure)
Control BP
Avoid overload
```
42
What if doesn't work
Phenytoin
| Diazepam
43
What do you do if eclampsia antenatal period
C-section
44
What do you do if resp depression due to low magnesium sulphate
Calcium gluconate
45
How do you monitor for magnesium sulphate toxicity
Resp effort as may decrease
Tendon reflex
O2 sats
Urine output
46
Why do insulin requirements increase in pregnancy
```
HPL
Progestogen
b-HCG
Cortisol
All anti-insulin
Pregnancy is a state of insulin resistance
```
47
Do you worry about glycosuria in pregnancy
No as common
48
What must you exclude in unwell mother
DKA
49
What do you do for pre-existing DM pre-pregnancy
Folic acid 5mg
Aim HbA1c <10% for 1-3 months before pregnancy
Rubella immunisation
Weight reduction
Stop oral hypoglycaemic as CI
Treat retinopathy / neprhopathy as may worsen
Regular screening of retinopathy
50
What hypoglycaemic CI
All except metformin
51
What may you need to start
Insulin
52
What do you do once pregnant
```
Tight glycemic control
Increase monitoring
Aspirin from 12 weeks to reduce PET
Folic acid
Renal and retinal assesment
Regular MSSU - ketones / infection
HbA1c
U+E
Watch growth
Detailed scans and regular clinic
```
53
What do you do in labour
Induce at 38-40 to reduce shoulder dystocia
Earlier if growth concern or poor control
Steroid if pre-term
Avoid hyperglycaemia
Insulin dextrose infusion to maintain - siding scale
CTG
54
What do you do if macrosomia
Shoulder dystocia risk
55
What do you do postpartum
Early feeding
Regular BM
Pre-pregnancy regime
56
Why do you avoid hyperglycaemia
Cause foetal hypo
57
What are fetal complications of DM
```
Fetal hyperinsulinaemia in preg as maternal glucose crosses
Macrosomia
Placental insufficiency
IUGR
Polyhydramnio
Jaundice
Neonatal hypoglycaemia
IRDS
Pre-term
IUD
Shoulder dystocia
Congenital abnormalities
```
58
What do macrosomic babies have higher risk of
C-section
Traumatic birth
Shoulder dystocia
59
What are complications to the mother
```
PET
Nephropathy
Retinopathy
Infection
Decreased awareness of hypo
DKA
```
60
What can cause hypo
Decreased awareness
| Insulin - suggests need delivery
61
What is gestational DM
Carb intolerance with onset of pregnancy that reverts to normal
Develops in 3rd
If develops before more likely 1 or 2
62
What are RF for gestational DM
```
Increased BMI
Previous macrosomia
Previous GDM
FH DM - 1st degree
Recurrent glycosuria
PCOS
```
63
How do you screen for GDM
OGTT asap / booking and at 28 weeks if previous or at risk
| At 28 weeks if at risk
64
What is target
HbA1c ,48
| BG >5.3 fasting
65
How do you treat GDM
```
Consultant clinic
Monitor growth and blood glucose levels
Diet and exercise = 1st line
Metformin
Insulin if still not controlled
Growth scan
IOL if Rx
```
66
What do you do post partum
Check OGTT at 6-8 week
Diet
Follow up due to risk of type II
67
What is diagnostic of gestational DM
Fasting >5.6
| 2h >7.8
68
Pathology of PET
Suboptimal uteroplacental perfusion
Leads to inflammatory response in mother
Causes increased permeability = proteinuria / oedema
Decreased placenta blood flow = IUGR / oligohydramnio
Decreased cerebral perfusion to mother = eclampsia / seizure
