Flashcards in week 4- medical disorders in pregnancy and hypertension in pregnancy Deck (121):
What blood tests are done at the booking appointment in pregnancy?
Infection screen- hepatitis B, rubella, HIV, VDLR
Random blood glucose
When is anti-D given?
28 weeks and 34 weeks
What happens at every antenatal clinic appointment?
Accurately document gestation
What hypertensive disorders can you get in pregnancy?
When is hypertension described as being essential?
Hypertension has been present since booking appointment or at less than 20 weeks.
When is it classed as gestational hypertension?
New hypertension at > 20 weeks with no significant proteinuria.
When is it classed as pre-eclampsia?
New hypertension at >20 weeks with significant proteinuria.
What effect does pregnancy have on blood vessels?
A (possible) placental cause causes vasoconstriction, intravascular thrombosis and a hypercoaguble state. These all lead to reduced blood flow to the organs.
What effect does hypertension in pregnancy have on the kidneys?
Hypertension can cause chronic kidney damage and stenosis. This means GFR will be decreased. You may get proteinuria.
Acute renal failure
Acute tubular necrosis?
Where would pain from the liver present?
If someone is suffering from liver disease caused by hypertension in pregnancy, what signs may they have?
Abnormal liver enzymes
Hepatic capsule rupture
HELLP syndrome- usually related to pre-eclampsia. Haemolysis- breakdown of red-blood cells, Elevated Liver enzymes and Low Platelet count.
What issues with the placenta, caused by hypertension, can cause issues with the birth? How can you monitor these?
intra-uterine growth restriction
How would you manage someone with risk factors for pre-eclampsia?
Give them aspirin.
Survey them with scans, BP monitoring and urine testing.
What hypertensive medications should be stopped in pregnancy?
ARB's and ACE inhibitors
What hypertensive medications are used in pregnancy?
Nifedipine (usually used in conjunction with others if mono therapy doesn't work)
What medication can be used for severe hypertension?
Labetalol (oral or IV)
What is the target blood pressure control in pregnancy?
<150/80-100 is the aim
if there is organ damage aim for 140/90
If less than 140/90 is achieved consider reducing dose.
What effect can diabetes have on pregnancy?
If it isn't well controlled then you can get a deterioration of renal function, ophthalmic disease and gestational DM.
This can cause miscarriage, fetal malformations, IUGR/macrosomia, unexplained intra-uterine death, preclampsia.
Do you make adjustments for delivery in diabetics?
Labour is induced between 37 and 38 weeks.
Describe the effects of diabetes on the fetus?
Maternal hyperglycaemia leads to
Fetal hyperinsulinaemia (too much insulin)
This causes increased fetal growth which in turn causes macrosomia, polyuria (therefore polyhydramnios), increased oxygen demands and neonatal hypoglycaemia
What effects can macrosomia, caused by diabetes, have on labour?
Can mean you get shoulder dystocia.
What effects can polyuria and polyhydramnios, caused by diabetes, have on labour?
Risk of preterm labour.
Risk of malpresentation and cord collapse.
What effects can increased oxygen demands, caused by diabetes, have on the fetus?
Risk of unexplained still birth.
What effects can hypoglycaemia, caused by diabetes, have on the fetus?
Risk of cerebral palsy.
What are the risk factors for gestational diabetes mellitus?
Poor obstetric history
Macrosomic infant in this pregnancy
Weight>100kg or BMI>30
South asian, middle eastern or African origin.
How do you manage diabetes in pregnancy (e.g. they haven't been diagnosed yet)?
Diabetic control- diet, metformin or insulin
What is the target HbA1c in pregnancy?
What other screening is done?
How are the babies with mothers with diabetes managed immediately once they've been delivered?
A paediatrician checks for neonatal hypoglycaemia
How are the diabetic mothers managed post-natally?
Return to pre-pregnancy insulin/oral meds.
If gestational diabetes- then monitor for 48 hours to ensure return to normal.
What is the leading cause of maternal death?
Pregnancy increases the risk of this.
What medication decreases the risk of VTE?
Low molecular weight heparin.
Why are pregnant women more affected by VTE?
Go through virchows triad-
Stasis- secondary to venous compression by pregnant uterus
Hypercoagulability- effect of pregnancy
Which clotting factors are increased in pregnancy?
Increased levels of 7,8,9,10,12
and increased platelets.
What are the important risk factors for VTE in pregnancy?
Age of over 35
If you have 4 or more risk factors for VTE, what is the management?
If 3 risk factors are present, management is?
Prophaylaxis from 1st trimester.
if 3- prophylaxis from 28 weeks.
If there are fewer than 3 risk factors for VTE present, what is the management?
Mobilisation and avoidance of dehydration.
If someone has been post-natally assessed as being high risk, what is the management? Why are they high risk?
At least 6 weeks post-natal LMWH.
High risk if they've had previous VTE, high risk of thrombophillia, any treatment requiring LMWH.
What investigations would you do into DVT/ PE in pregnancy?
Ultrasound the leg
Wouldn't do D dimer in pregnancy.
If suspected PE or DVT in pregnancy, when would you give therapeutic heparin?
Treat then see if you were right. So immediately.
Does heparin have any affect on the fetus?
It doesn't cross the placenta so is safe in pregnancy. There is no anticoagulation effect.
What are some side effects of heparin?
Allergy at injection site
Heparin induced thrombocytopenia
What investigations would you do into pulmonary emboli?
Dupplex ultrasound the lower limbs
What will a chest X-ray of a pulmonary embolism look like? If its abnormal, what is the next step of management?
Normal in 50% of cases
May show effusion, focal opacities
If abnormal and high clinical suspicion to CT pulmonary angiogram.
If a chest Xray looking for a PE is negative, what is the next stage of management?
Do duplex ultrasound of both legs.
What should you do with the heparin when the lady is giving birth?
Heparin should be stopped because of risk of haemorrhage.
Should therapy for DVT/PE during pregnancy be continued after birth?
Yes- should be continued 6 weeks post-natally. Use either warfarin or LMWH.
Why is warfarin avoided during pregnancy?
Teratogenic in the first 6-12 weeks, can cause miscarriage, neurological problems, still birth.
Can you take warfarin when breast-feeding?
If a women with hypothyroidism gets pregnant, what should the management be?
Increase the dose of levothyroxine by 25-50mcg.
Repeat thyroid function tests every trimester.
What consequences can hyperthyroid have on pregnancy?
Can cause intra-uterine growth restriction. Also preterm labour and thyroid storm
What effect does pregnancy have on pre-existing hyperthyroidism?
It makes the hyperthyroidism worse at first due to the levels of HCG.
Then it gets better in the 2nd and 3rd trimester.
How do you treat hyperthyroidism in pregnancy?
Beta blockers if they have IUGR.
What occurs to the respiratory rate in pregnancy? What are the consequences of this change?
Increased respiratory rate causes respiratory alkalosis.
The pH increases
the pCo2 and the bicarb decrease.
What other respiratory changes occur?
Increased oxygen consumption- increased by 20%.
Tidal volume increases
Inspiratory capacity increases
Residual volume decreases
Expiratory reserve decreases
Marked reduction in functional residual capacity (due to diaphragm elevation, increase in subcostal angle)
FEV1 and PEFR are the same.
How does asthma affect pregnancy?
Can remain unchanged, get worse or better.
In mild disease- you are unlikely to have problems
Severe disease- greater risk of deterioration especially in the third trimester.
Can asthma affect the fetus? If so, what effects are these?
If severe, uncontrolled asthma, hypoxia may affect the fetus.
Can cause IUGR, PET, preterm labour, low birth weight
How do you treat asthma in pregnancy?
No difference to how you would treat them normally.
What effect can epilepsy have on pregnancy?
Major malformations can occur- NTD, orofacial and mouth defects.
Is it a risk taking epileptic drugs in pregnancy?
Yes, any one drug increases your risk by 6-7%, two drugs by 15% and 3 drugs by 50%.
When are you at an increased chance of having epileptic seizures in pregnancy?
1st trimester due to hyperemesis and haemodilution.
What precautions do you take with epileptic patients in pregnancy?
Give them 5mg folic acid.
Also give them vitamin K from 36 weeks if they are on liver enzyme inducing drugs.
What effect can pregnancy have on epilepsy?
25-30% increase seizure risk
54% experience no change
If seizure free- unlikely to have seizures unless they change the medication.
Poorly controlled epilepsy is likely to deteriorate
Risk of seizures highest in peripartum periods.
What reasons are there for a decrease in compliance with epileptic drugs in pregnancy?
Fears of teratogenecity
Nausea and vomiting decreasing drug levels
Decreased drug levels due to increased volume of distribution and increased drug clearance
Lack of sleep towards term and during labour
Lack of absorption of drugs during labour
Hyperventilation during labour
If the mother is having a seizure, how does this affect the fetus?
Fetus is usually quite resistant to short term hypoxia. There is no increased risk of miscarriage or obstetric complications.
What type of epilepsy is really dangerous for both mother and baby?
Status epilepticus- needs treatment vigorously.
What is the issue with anti-convulsant therapy in pregnancy?
They are all teratogenic. Newer drugs were thought to be safe however they have now been shown to have risks associated with them.
Major malformations- neural tube defects, orofacial defects and cardiac defects.
Minor malformations- dsymorphic features, hypertelorism, hypo plastic nails
How do you manage epileptics pre conceptually then?
Give folic acid 5mg a day 12 weeks prior to conception.
How do you manage epileptics during pregnancy?
Continue folic acid throughout as risks of folic deficiency anaemia
Continue current drugs if well controlled, except- phenobarbitone- wean off or stop due to neonatal withdrawal convulsions
Detailed fetal scan at 20 weeks
Advise shallow baths or showers (because of risks of drowning if they fit).
Vitamin K orally at 34-36 weeks
What is the during labour management of epileptics during pregnancy?
Most have normal deliveries.
Do a C section if recurrent seizures occur late in pregnancy.
What should the neonate be given after birth from an epileptic mother?
1mg IM vitamin K immediately.
When does the biggest cardiovascular stress occur in pregnancy?
In the first 12 weeks
Describe the changes to blood pressure in pregnancy?
Systemic resistance falls due to vasodilation meaning the blood pressure falls in the first 12 weeks.
Its lowest at about 22-24 weeks. From here it starts to rise until term.
BP will then fall after delivery.
When is someone considered to be hypertensive in pregnancy?
When they have a bp > 140/90 on two occasions
160/110 on one occasion.
What are the three types of hypertension you can get in pregnancy? What is the difference between each kind?
Pre-existing hypertension- hypertension that they already had before pregnancy
Pregnancy induced hypertension- hypertension without other symptoms of pre-eclampsia e.g. proteinuria
Pre-eclampsia- hypertension + oedema + proteinuria
When is a women likely to have had pre-existing hypertension?
When there is hypertension in early pregnancy. Pregnancy induced hypertension and pre-eclampsia don't tend to manifest until the second trimester.
Does pre-existing hypertension have any risks associated with it in pregnancy?
It doubles your risk of getting pre-eclampsia.
Also IUGR, abruption and
When someone has suspected primary hypertension in pregnancy, what should you do?
Look for secondary causes e.g. renal, cardiac, endocrine (cushings and conns).
When does pregnancy induced hypertension present? Does it resolve?
It resolves within 6 weeks of giving birth.
Do people with pregnancy induced hypertension have a risk of developing pre-eclampsia?
Yes- 15% greater risk.
What is pre-eclampsia?
Hypertension (bp of 140/90 on two occasions or 160/110 on one)
Proteinuria- urinary protein: creatinine ratio of above 30.
NOTE-you don't need all three to have pre-eclampsia
Describe the pathogenesis of pre-eclampsia?
There are two stages.
Stage 1 is abnormal placental perfusion leading to placental ischaemia.
Stage 2 is maternal syndrome- an antiangionic state associated with endothelial dysfunction
Describe the processes that affect placenta in pre-eclampsia?
Normally in the placenta the spiral arteries, which are covered by a layer of muscle, open up due to cyto-trophoblast infiltration. However in pre-eclampsia the cytotrophoblasts fail to infiltrate meaning the arteries don't open up.
Normally when the arteries open up this leads to a high flow, low resistance system, however in pre-eclampsia they have a high resistance and therefore low flow network.
This leads to the maternal blood pressure being put up to try and push blood into the placenta (leading to endothelial damage), and also hypoxia of the fetus.
How can pre-eclampsia be classified?
Early pre-eclampsia (less than 34 weeks)
Late pre-eclampsia (> or = 34 weeks)
Which pre-eclampsia type is more severe? Why is this?
Its associated with extensive villous and vascular lesions of the placenta. Also haas a higher risk of complications.
Which type of pre-eclampsia is most common?
Which systems can pre-eclampsia effect?
All of them- its a multi system disorder.
Also can affect the placenta.
What CNS disease can pre-eclampsia cause?
Cranial nerve palsies.
How does pre-eclampsia affect the kidney?
It decreases GFR
Increase in serum uric acid
Increase in creatinine
Oligouria/anuria- this is in severe disease.
Acute renal failure- acute tubular necrosis and renal cortical necrosis.
How can pre-eclampsia affect the liver? How will this present in a pregnant women?
Women may have subcapsular liver haemorrhage,
HELLP syndrome- Haemolysis, elevated liver enzymes, low platelets
Liver pain will be epigastric/RUQ.
May have abnormal liver enzymes.
How can pre-eclampsia affect the blood?
Decrease in plasma volume
Thrombophillia- could be congenital or acquired.
In most severe cases- disseminated intravascular coagulation pathways- need to fix this before birth because of risk of bleeding.
What cardiac/pulmonary issues can pre-eclampsia cause?
Capillaries become leaky so can cause pulmonary oedema.
Pulmonary emboli may occur.
What placental disease can pre-eclampsia cause?
Fetal growth restriction
What symptoms does someone with pre-eclampsia present with?
Some may not have symptoms.
Nausea and vomiting
Rapidly progressing oedema
Why are pre-eclampsia symptoms relatively unhelpful?
You can get most of the symptoms in normal pregnancy.
E.g. RUQ pain- get when the fetus grows pushing on the abdominal muscles.
Nausea and vomiting- get with hyperemesis
Oedema is common in normal pregnancy.
What signs will a patient with pre-eclampsia have?
SGA- small for gestational age.
What investigations would you do into pre-eclampsia?
Serum urate- likely to be the first thing raised- could be due to renal disease or placental ischaemia
Urine Protein creatinine ratio
How do you manage pre-eclampsia?
Assess their risk at booking
If they are hypertensive at less than 20 weeks then look for a secondary cause
Antenatal screening- bp, urine
Maternal and fetal surveillance
Timing of delivery
What are the social risk factors for developing pre-eclampsia?
Maternal age (>40 increase risk by two fold)
Maternal BMI (>30 increase risk by two fold)
Parity (first pregnancy increases risk)
Birth interval >10 years
What are the medical risk factors for developing pre-eclampsia?
Pre-existing renal disease
Diabetes (preexisting and gestational)
Connective tissue disease
What do you give to patients at high risk of developing pre-eclampsia?
75mg of Aspirin
Commence before 12 weeks
When you use a doppler to look at the uterine artery, what will a pre-eclamptic patients doppler look like?
Due to the high resistance, it won't look like Toblerone like it should. It could have reversed end diastolic flow (where the resistance is too high and the blood flows back towards the baby so the line goes underneath)
Or it could have absent end diastolic flow where there is a gap between each peak. Means the resistance is too high for blood to passively flow in diastole.
When should you refer a women to the antenatal day care unit?
When the bp > 140/90
When there is proteinuria
When there is oedema
or symptoms- especially persistent headache
When should you admit a women to hospital in pre-eclampsia?
BP of greater than 170/110 or 140/90 with proteinuria.
Need for antihypertensive therapy
Risk of fetal compromise.
How is the women with pre-eclampsia assessed/monitored in hospital?
Blood pressure- 4 hourly
Input/output fluid balance chart
Urine PCR- if urinalysis shows proteinuria
Bloods at a minimum of twice a week.
When is there significant risk of cerebral haemorrhage in hypertension?
When MAP > 150.
At what BP should you start treating hypertension at?
150/90 (not 140/80 because the higher bp is there for a reason to perfuse the baby and you don't want to compromise the fetus).
What is the target bp for patients with hypertension in pregnancy?
Which drugs can you use to treat hypertension in pregnancy? What classes of drugs are these?
Labetalol- Alpha and beta antagonist
Nifedipine- calcium channel blocker
Methyldopla- centrally acting alpha agonist
When shouldn't you use methyldopla in pregnancy?
Use with caution in people with mental health histories. It can worsen depression.
When shouldn't you use labetalol in pregnancy?
In someone with asthma.
Is there a cure for pre-eclampsia?
Only cure is birth.
When should you deliver the baby in a pre-eclamptic individual?
What must you give the baby before delivery?
Mother must be stabilised. Aim for birth 2 weeks after diagnosis.
Give steroids to mature the lungs and be protective for other organ systems.
When is birth indicated in pre-eclampsia?
Inability to control bp
Rapidly deteriorating biochemistry
Eclampsia- medical emergency
What are 'crises' in pre-eclampsia?
Acute renal failure
What is eclampsia?
who is it most common in?
Tonic clonic seizure occurring with features of pre-eclampsia.
Most common in teenagers
How do you manage eclampsia?
Which antihypertensives would you use in eclampsia?
What do you need to be careful of?
Be careful with hypotension.
How do you treat the seizure in eclampsia?
Magnesium sulphate 4g IV over 5 mins.
Maintenance dose- 1g IV infusion/hour
If further seizures- 2g Magnesium sulphate
If still seizing- diazepam 10mg IV
How much fluid is the patient allowed to have in hospital with eclampsia?
How would you deliver a baby in eclampsia?
Aim for vaginal birth if possible.
Control BP and give epidural anaesthesia