Week Ten - Medical Conditions in Pregnancy

Respiratory Changes in Pregnancy

• diaphragm ^ 4cm

• rib cage diameter increases 2cm

• breathing becomes thoracic not abdominal

• O2 consumption and RR ^

• tidal volume increases

• increased CO2 release

Pulmonary Thromboembolic Disease

• Leading cause of maternal mortality accounting for approximatley 10% of pregnancy related deaths

• It results from a blood clot that obstructs the pulmonary artery, often originating from deep vein thrombosis. Risk factors include prolonged immobility, cesarean delivery, and obesity.

Most common chronic medical condition in pregnancy?

Asthma

Reasons for Respiratory Distress in Pregnancy

• asthma

• tuberculosis

• smoking & obesity

• cystic fibrosis

• viruses

• anemia

• pulmonary embolus

Pulmonary Oedema

• A condition characterized by excess fluid in the lungs, leading to breathing difficulties. It can be caused by heart problems, high blood pressure, or fluid overload, particularly in pregnant women.

• Can be contributed to by left heart failure, preclampsia etc..

How does Preeclampsia result in Pulmonary Oedema?

• increased LV afterload

• reduced systolic or diastolic function = reduced CO

• pulmonary hypertension

Uncontrolled Asthma in Pregnancy Risks

• higher risk of gestational diabetes

• higher risk of gestational hypertension

• risk of placental abruption

• risk of pulmonary admissions

• increased risk of babies being born premature or low birth weight

COVID 19 Maternal Risk

• mild disease

• higher risk of developing higher risk illness

COVID 19 Fetal Risk

• increases risk of complications for baby (ie. stillbirth, prematurity)

• no risk of congential defects or miscarriadge in early pregnancy

How is Stable Asthma managed in pregnancy

• symptom relievers (ie. ventolin)

• symptom preventers (ie. symbicort)

Asthma in Pregnancy Management AV

SAME AS NON PREGNANT PATIENTS - but be aware of quick deterioration (get backup!)

Diabetes T1 VS T2

T1: chronic condition in which pancrease stops producing insulin, genetic

T2: body becomes resitant to insulin/doesnt make enough, life style

T1DM Management in Pregnancy

• continuous BSL monitoring

• manage morning sickness and vomiting

• precautions around excercise

• glucagon kit on hand

• regular small meals

T2DM Management in Pregnancy

• increase insulin requirements

• increased BSL checks

• no oral hypogylcaemics other than Metformin!

• anti lipid medications to be ceased

Gestational DM

Diabetes diagnosed in the second or third trimester of pregnancy that was not clearly overt diabetes prior to gestation.

Pathophysiology of Glucose Regulation in HEALTHY PREGNANCY

• early pregnancy = increase insulin sensitivity, higher risk of hypoglycemia. glucose being stored in adipose tissue for later in pregnancy

• later pregnancy = hormones work to create state of insulin resitance

  • bsl is elevated allows for easy transfer to fetus

  • promotes endogenous glucose production and breakdown of fat stores

Pathophysiology of GDM

• b cell dysfunction: reduced B cell mass, number or general dysfunction (or all 3!)

• insulin resistance: rate of insulin stimulated glucose uptake is reduced by 54% in GDM

GDM Risk Factors

• ethnic backgrounds of any kind

• close family history of diabetes

• >30 >40

• high BMU

• big baby

• PHx of GDM

• PHx of PCOS

• rapid weight gain in early preg

Maternal Risks in GDM

• preterm birth

• preeclampsia

• increased risk of t2dm

• increased risk of induction and csection

Maternal Risks in GDM

• big baby

• neonatal hypoglycemia

• stillbirth

• increased risk of obesity, t2dm and gdm in females in future

How is GDM tested for

• via oral glucose test (26-28 weeks)

  • 0 hour: >/= 5.1, 1 hour >/= 10.0, 2 hour >/= 8.5

GDM Treatment AV

• left lateral tilt

• standard bsl management

• alert obstetric team

General GDM Management

• increased care visits

• increased scans

• promote low gi diet

• excercise for 30min gentle every day post meals

• metformin, insulin

Intrapartum Care

• bsl monitoring every 2 hours

• induction for poorly controlled GDMs

• CTG monitoring in labour

Maternal Postnatal Care GDM

• diabetic diet lifelong change

• bsl monitoring

• another glucose test after 6wks

Neonate Postnatal Care GDM

• frequent breastfeeding

• bsl monitoring every 3 hours until 3 stable bsls in a row

Heart Changes in Pregnancy

• rotates up and to the left as uterus enlarges and causes diaphragm to elevate (apex at 4th ICS)

• lext axis shift on ECG

• systolic murmurs due to increased load, diasoltic murmurs due to increased blood flow

Why does CO increase during pregnancy?

• 30-50% increase due to HR

• preload is increased due to the associated rise in blood volume

• afterload reduced due to decline in systemic vascular resistance

CVS Changes Per Trimester

1st: systemtic vasodialtion, SVR drops, CO rises, HR slow rises

2nd: SVR plateus, CO rises, HR slow rises

3rd: CO peaks, HR peaks

Plasma & Red Blood Cell changes in pregnancy

• plasma volume increases in 1st trimester, rapidly expands until 30-34/40 which helps to protect mum & baby, and meet perfusion demands

• begins to increase at 8/40 and rises steadilty, supports higher oxygen metabolism

3 Kinds of Hypertension in Pregnancy

• chronic hypertension

• non-proteinuric pregnancy induced hypertension (GHTN)

• preeclampsia

Chronic Hypertension

• hypertension prior to pregnancy or BP >140/90 diagnosed before 20/40

Chronic Hypertension Risk Factors

• renal disease

• diabetes

• obesity

• age >40

• HTN on OCP

Gestational Hypertension Definition

• HPT > 140/90 on >2 occasions

• no others signs of pre-eclampsia

• occurs >20 weeks

Gestational Hypertension Risk Factors

• first child with partner

• obesity

• diabetes

• previous pre eclampsia

• pre existing cardiovascular disease

• age >40

Pre-eclampsia Definition

• hypertension after 20 weeks gestation with other symptoms

• other symptoms such as high protien urine content, DIC, convulsions, new headache, visual disturbance..

Pre-eclampsia Risk Factors

• first pregnancy

• pre-eclampsia in previous pregnancy

• > 40 y/o

• 10 years since last baby

• MBI >35

• family history

Pre-eclampsia Pathophysiology

How does PreEclampsia alter the body?

• CVS: hypertension with endothelial cell damage affects capilliary permeability, plasma protiens leak resulting in decreased plasma colloid pressure, hypovoleamia and haemoconentration

• Coagulation: altered, increased platelet consumption which can result in DIC

• Kidneys: hypertension results in vasospasm of afferent arterioles

• Brain: Hypertension with CVS endothelial damage, headaches & convulsions

• Liver: vasoconstriction, epigastric pain, lowered albumin and increased liver enzymes

• Foeto-Placental: vasoconstriction decreased, vascular leisons can occur, hypoxia can lower fetal growth

Pre-Eclampsia Presentation

• sharp rise in BP to >140/90 in 2nd half of pregnancy

• increased protien in urine, lessened output

• swelling sudden and severe, widespread

• hyper-refexia

• other symptoms such as headache, blurred vision, epigastric pain, visual disturbance, N&V, epigastric pain

HELLP Syndrome

• complication of preeclampsia

• stands for Haemolysis, Elevated, Liver Enzymes, Low Platelets

HELLP Risk Factors

• known preclampsia

• multiparity

• previous Hx

Eclampsia

• new onset convulsions in pregnancy

4 stages of Eclampsia

• premonitory: eyes rolling, muscles twitching

• tonic: violent spasm, resps cease

• clonic: jerky movements, frothy bloody saliva

• comatose: deeply unconscious

How do paramedics manage Pre-Eclampsia

• EPOMS

• monitor & prevent complications

• rest and reassure, left lateral tilt, o2 8L hudson mask

• manage eclampsia as per seizure CPG