complications of pregnancy: pre-eclampsia, gestational diabetes, alloimmunization

after 20 weeks

to be defined as gestational hypertension, onset of HTN must be

Abnormal placentation → placental ischemia → systemic endothelial dysfunction

what is the core mechanism of the pathophys of preeclampsia-eclampsia

Kidneys: glomerular endotheliosis → proteinuria

Liver: ischemia → elevated LFTs, RUQ pain

Brain: cerebral edema/vasospasm → headaches, seizures

Placenta: hypoperfusion → IUGR, abruption

describe the multisystem effects of HTN in pregnancy

first pregnancy has greatest risk

is there a greater risk of preeclampsia depending on how many pregnancies you've had?

Multiple gestation

Molar pregnancy

IVF / assisted reproduction

pregnancy related risk factors for preeclampsia

≥300 mg/24 hr urine

Protein/creatinine ratio ≥0.3

define proteinuria indicative of preeclampsia

Platelets <100,000

Creatinine >1.1 or doubling

Elevated AST/ALT

Pulmonary edema

New-onset headache or visual changes

signs of end organ dysfunction defining preeclampsia

delivery

definitive treatment of preeclampsia

placental

preeclampsia is a ________ disease

not if there are severe features present/end organ dysfunction

is proteinuria required to define preeclampsia

Hospitalization

Magnesium sulfate (seizure prophylaxis)

Control severe BP (≥160/110):

IV labetalol

IV hydralazine

PO nifedipine

immediate management of preeclampsia with severe features

Deep tendon reflexes

Respiratory rate

Urine output

how to look for magnesium sulfate toxicity

A severe variant of preeclampsia characterized by:

Hemolysis Elevated Liver enzymes Low Platelets

define HELLP syndrome

↑ LDH

Schistocytes

Indirect hyperbilirubinemia

signs of hemolysis in HELLP syndrome

no

is proteinuria and severe HTN required to diagnose HELLP

≥160/110

define severe HTN

RUQ or epigastric pain

Nausea/vomiting

Malaise

Headache

Hypertension (often)

Can progress rapidly

typical clinical presentaiton of HELLP

Immediate delivery (regardless of gestational age)

Magnesium sulfate

Control BP

management of HELLP

Liver hematoma or rupture

DIC

Renal failure

Placental abruption

Maternal death

complications of HELLP

no, prevents seizures

does magnesum sulfate lower BP?

HELLP until proven otherwise

RUQ pain + ↓ platelets in pregnancy=

Affects ~6–10% of pregnancies in the U.S.

incidence of gestational diabetes

Typically develops in 2nd or 3rd trimester

when does gestational diabetes usually develop?

fetal osmotic diuresis

why is polyhydramnios bigger risk in gestational diabetes

fetal hyperinsulinemia

what causes macrosomia in GDM

↑ placental hormones (hPL, cortisol, progesterone)

→ progressive insulin resistance

pathophys of gestational diabetes

24–28 weeks gestation (earlier if high risk)

when to screen for gestational diabetes

Step 1: Screening Test

50-g oral glucose load (non-fasting)

Measure glucose at 1 hour

Abnormal if ≥130–140 mg/dL (institution dependent)

Step 2: Diagnostic Test

100-g oral glucose tolerance test (fasting)

Abnormal if ≥2 values elevated

most common test for GD

75-g OGTT (fasting)

Diagnosis if any value elevated

one step method to test for GD

Obesity

Prior GDM

Known impaired glucose tolerance

indications for early testing of GDM

Dietary modification

Exercise

Glucose monitoring

first line management of GDM

Fasting: <95 mg/dL

1-hr PP: <140 mg/dL

2-hr PP: <120 mg/dL

glucose targets in tolerance test

insulin

if diet control fails for GDM, this treatment is gold standard

Well-controlled on diet → deliver by 40 weeks

Insulin-treated or poorly controlled → 39 weeks

delivery timing for GDM

75-g OGTT at 6–12 weeks postpartum

Counsel on future type 2 DM risk

postpartum management of GDM patients

neonatal hypoglycemia

most common neonatal complication

insulin

safest GDM med

IgG anti-D antibodies

Abs associated alloimmunization

Fetal anemia

Hydrops fetalis

Heart failure

Stillbirth (severe cases)

complications of alloimmunization

indirect coombs test (maternal serum); positive=maternal antibodies present

-antibody titer

tests for diagnose alloimmunization

maternal antibodies

indirect coombs identifies

fetal/neonatal RBCs with antibodies

direct coombs tests for

Binds fetal Rh-positive RBCs in maternal circulation

Prevents maternal immune system from recognizing antigen

Passive immunity — not effective once sensitized

MOA of rhogam

28 weeks gestation

Within 72 hours postpartum if infant is Rh-positive

After sensitizing events

timing to give Rhogam

Vaginal bleeding

Abortion or miscarriage

Ectopic pregnancy

Trauma

Amniocentesis/CVS

External cephalic version

sensitiing events indicating need for RhoGAM therapy

Standard: 300 mcg

Covers ~30 mL fetal whole blood

standard dose of RhoGAM

cell free DNA

how can you test fetal Rh

Middle cerebral artery (MCA) Doppler

↑ velocity = fetal anemia

fetal surveillance method for alloimmunization

Hydrops fetalis

Ascites

Pleural/pericardial effusion

in alloimmunization you ultrasound to check for

Intrauterine transfusions

Early delivery if viable

Neonatal intensive care at birth

mgmt of moderate-severe alloimmunization

hydrops fetalis

end-stage hemolytic disease