Antenatal Problems 2 Flashcards by Rachel Eggleton

What happens to BP during the first 24 weeks of pregnancy?

BP decreases early in pregnancy until 24 weeks due to decrease in systemic vascular resistance (due to progesterone)

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What happens to BP in pregnancy after 24 weeks?

BP increases after 24 weeks until delivery due to an increase in stroke volume

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What happens to BP after delivery?

BP decreases after pregnancy but may peak again 3-4 days post-partum (post-partum HTN)

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What is PIH?

> 140/90mmhg in the second half of pregnancy in the absence of proteinuria or other markers of pre-eclampsia

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What are those with PIH at an increased risk of developing?

Pre-eclampsia

Increased risk with earlier onset of HTN

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In post-partum HTN, what are symptoms such as epigastric pain, visual disturbances or new onset proteinuria indicative of?

Post-partum pre-eclampsia

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What investigations should be done for PIH?

Urinalysis = look for protein
Bloods = FBC, U&Es, urate, LFTS, coagulation screen (normal if essential HTN in pregnancy)
USS - foetal assessment
Investigate underlying cause

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What antihypertensives are safe in pregnancy?

First line:
- Labetalol

Second line:
- Nifedipine

Others:
- Methyldopa

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A BP of what in pregnancy is a medical emergency?

> 160/110

If proteinuria develops = super-imposed pre-eclampsia

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Which antihypertensives are contraindicated in pregnancy?

ACEi and ARBs = teratogenic

Beta blockers (except labetalol and oxprenolol) and calcium channel blockers (except nifedipine) should be avoided

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Methyldopa:

Dose
SE

250mg BD up to 1g TDS

SE: depression - postnatally

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Nifedipine:

Dose
SE

10mg BD up to 30mg TDS

SE: tachycardia, flushing, headache, peripheral oedema

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Hydralazine:

Dose
SE

25mg TDS up to 75mg QDS

SE: tachycardia, pounding heartbeat, headache, diarrhoea

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Labetalol

Dose
Avoid when?

100mg BD up to 600mg QDS

IV infusion for severe refractory HTN

Avoid in asthma

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ACEi = given when?

Postpartum only as fetotoxic

Captopril safe in breastfeeding

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What 3 criteria must be met to diagnose pre-eclampsia?

Hypertension (>140/90) on 2 occasions at least 4 hours apart
Significant proteinuria >300mg protein in a 24h urine sample OR >30mg/mmol PCR (urinary protein:creatinine)
Greater than 20 weeks gestation

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What is the pathophysiology of pre-eclampsia?

Mechanism poorly understood but the placenta plays a pivotal role

Suboptimal uteroplacental perfusion associated with a maternal inflammatory response and maternal vascular endothelial dysfunction. This leads to vascular hypermermeabiltiy, thrombophilia and HTN, which may compensate for reduced flow in uterine arteries.

Increased vascular resistance = HTN
Increased vascular permeability = proteinuria
Reduced placental blood flow = IUGR and reduced cerebral perfusion

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How is mild/moderate/severe pre-eclampsia categorised?

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Mild - BP 140/90 - 149/99

Moderate - BP 150/100 - 159/109

Severe - BP > 160/110 + proteinuria 0.5g/day
or
BP > 140/90 + proteinuria + symptoms

What are the moderate and the high risk factors for pre-eclampsia?

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Moderate Risk Factors
• Nulliparity 
• Extremes of maternal age
• BMI >35 
• Family history pre-eclampsia - mother or sister 
• Pregnancy interval > 10 years
• Multiple pregnancy

High Risk Factors
• Chronic hypertension
• Previous hypertension, pre-eclampsia, eclampsia in previous pregnancy
• Pre-existing CKD
• Diabetes mellitus
• Autoimmune disease - SLE, antiphospholipid syndrome

What are the main symptoms of pre-eclampsia?

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Frontal headaches
Visual disturbances - flashing lights
Epigastric pain - hepatic capsule distension/infarction
Sudden onset non-dependent oedema - puffy face
Breathlessness - pulmonary oedema
Nausea, vomiting

What are some maternal complications of pre-eclampsia?

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Eclampsia = tonic-clonic seizures resulting from cerebrovascular vasospasm
Cerebral haemorrhage
Liver / renal failure
DIC
Pulmonary oedema
HELLP syndrome
AKI
Retinal detachment

What is HELLP syndrome and what is the characterised by?

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A complication of pre-eclampsia

Haemolysis
Elevated Liver enzymes
Low Platelet count

What are some fetal complications of pre-eclampsia? (5)

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IUGR
Morbidity and mortality
Placenta abruption
Pre-term birth
Hypoxia

What might an FBC show in pre-eclampsia?

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Thrombocytopenia - due to platelet aggregation on damaged endothelium, indicates impending HELLP or DIC
Anaemia = if haemolysis
Relative high Hb due to haemoconcentration

What would a clotting screen show in pre-eclampsia?

Prolonged PT and APTT

What would biochemistry investigations show in pre-eclampsia?

- Raised urate - Raised urea and creatinine - Abnormal LFTs - high AST and ALT - Raised LDH = a marker for haemolysis - Urinalysis = proteinuria

What is the cure of pre-eclampsia? When is it indicated?

Delivery of the placenta Indicated if >34 weeks or <34 weeks with maternal/foetal instability

When is out-patient management of pre-eclampsia appropriate? What is the management plan?

- BP <160/110 - No or low (<0.3g / 24hrs) proteinuria - Asymptomatic - Pregnancy < 34 weeks Management: - Warn about the development of symptoms - Review BP and urine every 1-2wks - Weekly review of blood biochemistry

What is the management of mild-moderate pre-eclampsia, where BP <160 systolic and <110 diastolic with significant (2+) proteinuria and no maternal complications? ie what should happen when significant proteinuria arises?

Admission advised: - 4 hourly BP - 24hr urine collection for protein - Daily urinalysis - Daily fetal assessment with CTG - Regular blood tests (every 2-3 days unless symptoms/signs worsen) - Regular USS = fortnightly growth and twice weekly doppler / liquor volume (depending on severity)

What is the management of pre-eclampsia where BP > 160/110?

Antihypertensives First line - labetalol Second line - nifedipine Third line - methyldopa Team involves senior obstetric, anaesthetic and midwifery staff Aim to get to 34 weeks gestation (if need to deliver before 35 weeks, ensure IM steroids administered to aid foetal lung development)

What is the target BP in the management of pre-eclampsia?

140/90mmHg

What are some indications for immediate delivery in severe pre-eclampsia? (4)

- Worsening thrombocytopenia or coagulopathy - Worsening liver or renal function - Severe maternal symptoms esp epigastric pain - Fetal reasons eg distress / reversed umbilical artery flow - HELLP syndrome eclampsia

What is the usual method of delivery in severe pre-eclampsia?

Before 34wks = CS | After 34wks = IOL

What should be given to prevent seizures during delivery in a woman with pre-eclampsia?

IV magnesium sulphate - reduces risk of eclampsia by more than half Consider epidural as this lowers BP

What is given to control seizures?

Magnesium sulfate Loading dose of 4g given by infusion pump over 5-10mins, followed by a further infusion of 1g/hr maintained for 24hrs after the last seizure

What is eclampsia?

The occurrence of 1+ convulsions in a pre-eclamptic woman in the absence of any other neurological or metabolic causes

How is eclampsia managed?

Resuscitation: - Pt put in left lateral position and airway secured - 15L Oxygen via NRBM Treatment and prophylaxis of seizures: - Magnesium sulfate - IV Lorazepam if unresponsive Treatment of HTN: - IV labetalol (both may precipitate fetal distress = continuous CTG) Fluid therapy: - Close monitoring of fluid intake and urine output - Do not preload with colloid prior to regional anaesthesia Urgent delivery

What can be given as prophylaxis of pre-eclampsia?

Low dose aspirin - 75mg OD from 12 weeks until birth

When does HELLP syndrome occur in pregnancy?

Usually rapid onset in second half of pregnancy

How does HELLP syndrome present?

Symptoms usually nonspecific - 50% have headache - 20% have visual symptoms - Malaise, fatigue, RUQ / epigastric pain, n&v, flu-like symptoms - Some have easy bruising / purpura - On examination, oedema, HTN and proteinuria may be present - Characterised by exacerbations of symptoms at night and relief during the day - +/- hepatomegaly

What blood results would indicate HELLP syndrome?

- Haemolysis with fragmented RBC on film (due to microangiopathic) haemolytic anaemia - Raised LDH >600 IU / L with a raised bilirubin (due to destruction of RBC) - Liver enzymes are raised with AST or ALT level >70IU/L (due to liver injury) - Decreased platelets due to activation and increased consumption

What is the treatment of HELLP?

* IV fluids * Blood transfusions * Antihypertensive agents * Magnesium sulphate * Delivery if >34 weeks or <34 weeks if maternal/foetus compromise

What are the signs found on examination in pre-eclampsia?

* Hypertension * Proteinuria, oliguria * Hyper-reflexia, clonus * Pulmonary oedema

Antenatal Problems 2 Flashcards

(43 cards)