Pre-eclampsia, Diabetes and Pregnancy

What is Pre-Eclampsia

When the mother has persistent hypertension and proteinuria.-endothelial cell disorder caused by XS inflammatory response to pregnancy

2.Caused by pregnancy.

3. Cured by delivery (of placenta).

Can hypertension develop during pregnancy?

Yes, or pre-existing.
- Carry risks for woman and baby, complicating 5-10% of pregnancies.
- The no. of women with hypertension during pregnancy is rising, linked to obesity and maternal age increase).

What is defined as hypertension in pregnancy?

BP >140/90 mmHg on 2 occasions, 6 hours apart.

Is classed as severe if BP is >160/110 mmHg on 2 occasions, 6 hours apart.

What BP levels do pregnant women with essential hypertension have?

An increase of 30 mmHg or more in systolic BP or 15 mmHg or more in diastolic BP.

Is pre-eclampsia considered in a pt. presenting with hypertension at booking?

No, should consider secondary causes or essential hypertension.

Why does hypertension in pregnancy need to be controlled?

to prevent organ damage in long-term

What are key features of pre-eclampsia?

Hypertension
2. Proteinuria
3. Oedema
4. Multi-organ involvement (blood test abnormalities)
5. Fetal compromise

What are the risk factors for pre-eclampsia? (4)

Sociodemographic - reproductive age extremes + ethnic groups

2. Pregnancy factors - multiple pregnancy, primagravida, assisted conception and prev. pre-eclampsia

3. Personal history - obesity, CKD, chronic hypertension, DM and connective tissue diseases, thrombophilias.

4. Genetic factors

What drug can be given to reduce incidence of pre-eclampsia?

After regarding risk factors, consider aspirin (75mg), reducing incidence by around 20%. (CLASP study).

→ better blood flow to the placenta

What are the pathophysiological mechanisms in pre-eclampsia? (4)

Abnormal placentation

2. Endothelial cell dysfunction

3. Organ hypoperfusion

4. Plasma vol loss (low albumin, oedema formation)

What is abnormal placentation

• Incomplete invasion of trophoblasts into the endo/myometrium→ poor placental perfusion. → causes hypoperfusion of placenta

• thick muscle wall

• reduced perfusion of the placenta with maternal blood and maybe vasospasm

• increases apoptosis

• release circulating factors → into maternal circulation → endothelial cell dysfunction

What can endothelial cell dysfunction cause?

Endothelium becomes more permeable, fluid leaks out causing tissue oedemas.

- Causes hypertension 2º to altered vasodilator production and disturbed vascular tone control by endo cells (vasospasms).

- Causes clotting dysfunction 2º to abnormal coagulant production by endo cells and activation + clumping of platelets.

- Leads to plasma vol loss and organ hypoperfusion

What are possible symptoms of endothelial cell dysfunction in pre-eclampsia? (5)

Headaches - usually frontal but maybe occipital, due to cerebral oedema and hypertension.

2. Visual disturbances - vision blurring, light flashes or blindness.

3. Epigastric or RUQ pain - enlargement + subcapsular haemorrhage of liver.

4. N&V - congestion of gastric mucosa + cerebral oedema.

5. Oliguria/anuria - kidney pathology.

What are maternal complications of pre-eclampsia

Neurological: Eclampsia, retinal detachment, cerebral hemorrhage.

Cardiovascular: LVF, pulmonary edema.

Hepatic: Liver rupture, HELLP syndrome.

Renal: Oliguria, renal failure.

What are fetal complications of pre-eclampsia? (6)

Asymmetric FGR (abnormal growth = small)

2. Intrauterine hypoxia

3. Prematurity - born (iatrogenic cause)

4. Abruption

5. Stillbirth / intrauterine death

6. Hypertension/IHD/metabolic disease in later life - fetal programming.

How is a mother with pre-eclampsia monitored? (5)

1. BP 4-6 hourly.
2. Urinalysis for proteinuria (PCR, 24hr collection)
3. Signs and symptoms
4. Blood tests (FBC, U&E, LFT, fibrinogen)
5. Fluid balance

How is a foetus monitored if the mother has pre-eclampsia? (6)

Movements
2. U/S size and growth
3. Umbilical aa doppler (blood flow measurements which give you a longer term measure)
4. Liquor vol
5. Biophysical tests
6. CTG (>26w) - check how baby is in the current moment

What medications are given for treatment in hypertension during pregnancy? Which are avoided?

Methyldopa, labetalol and nifedipine SR are given first line.

- Atenelol, doxazocin.

• ACE inhibitors {risk to baby - kidney}, diuretics {intravascular volume depeleted so unsafe for mum}

Which medications are given for emergency BP control in pregnancy {first line}

Hydralazine
2. Labetalol
3. Nifedipine SR

what are the aims of treatment of hypertension during pregnancy? (3)

Aim to keep BP <150/100 mmHg.

2. Decrease maternal cerebral and CV complications but not fetal outcomes.

3. Consider MgSO4 to reduce seizure risk and mortality in severe pre-eclampsia.

What are the indications for delivery in pre-eclampsia? (6)

Uncontrolled BP despite using maximal drugs

2. Develops eclampsia

3. Renal, hepatic or coagulation impairment

4. Pulmonary oedema - rare

5. Foetal distress - common

6. Milder pre-eclampsia at term

What should be considered to be given to patient if there is a pre-term birth due to pre-eclampsia?

Consider giving steroids.

What is the mode of delivery during pre-eclampsia dependent on? (3)

Severity
2. Gestation
3. Prev. obstetric history.

What changes occur to carbohydrate metabolism in a normal pregnancy? (2

Feto-placental unit will use glucose so pregnant women have a lower fasting BG.

2. Pregnancy hormones increase peripheral resistance to insulin eg. HPL, oestrogen, progesterone, cortisol. This increases with gestation, causing higher post prandial glucose

What are the risk factors of getting diabetes in pregnancy

• High BMI (>30), macrosomia in previous pregnancy, family history of diabetes, ethnic predisposition.

Effects of pregnancy on diabetes

• Increased risk of hypoglycemia, retinopathy, nephropathy.

• increasing insulin dose at 18-28 weeks

• May loose signs of hypo

• risk of deterioration in existing retinopathy

• Insulin requirements rise between 18-28 weeks.

What are the effects of diabetes in terms of maternal and fetal complications?

Maternal Complications:

Hypoglycemia, UTI, pre-eclampsia, preterm labour.

Increased C-section rates, delayed wound healing.

Fetal Risks:

Congenital abnormalities (CNS, cardiac).

Macrosomia, polyhydramnios, stillbirth, growth restriction (IUGR

What are the pre pregnancy care - management for diabetes

1. Pre-pregnancy Care:

   • Optimize HbA1c (<6.5%), folic acid (5 mg).

   • Assess retinopathy, nephropathy, cardiac disease.

What are the during pregnancy care - management for diabetes

• Dietary advice, glucose monitoring, medications (Metformin, Insulin injections ).

• Anomaly scans, regular fetal growth assessments.

What are the delivery time, care steps - management for diabetes

• Offer delivery by 37-38 weeks (T1/T2 DM) or before 40+6 for GDM.

What are the time, care steps for a - management for diabetes

• Stop hypoglycemics in GDM.

Resume pre-pregnancy treatment (T1/T2 DM).

What types of diabetes in pregnancy are there?

Pre-existing - T1 (7.5%) and T2 (5%). MODY.

In pregnancy - 87.5%, can be new onset of T1 or T2DM, or gestational diabetes.

Affects 5-10% of all UK pregnancies.

How is gestational diabetes screened?

Population based screening on risk factors (but maybe move to universal screening which picks up more women).

A 2hr glucose tolerance test at 24th-28th week. An additional test is done in 1st/2nd trimester for those with history of prev. GDM

What are the risk factors for GDM? (6)

BMI above 30kg/m2
2. Prev macrosomic baby >4.5kg
3. Prev. GDM
4. 1º relative with diabetes
5. Ethnic origin (South asian, black Caribbean, Middle eastern)
6. If glycosuria is >+2 on 1 occasion or > +1 on 2+ occasions.

What is macrosomia

• when a baby grows much larger than average during pregnancy

• Linked to maternal hyperglycemia.

  • Birth weight >4000 g or 90th centile.

  • Risk: Shoulder dystocia, IUFD.

• IUGR: Common in women with longstanding diabetes or vascular disease.