Late Pregnancy

    Pregnancy Induced Hypertension

    • Definition: Multisystem disorder characterized by wide spread vasoconstriction (aka pre-eclampsia toxemia)
    • Etiology:
      • Prevalence 10% in Canada
      • Genetic (Race: black, phillipino)
      • Family Hx
      • Nulliparous/1st pregnancy with partner
      • Multiparous
      • Previous PIH
      • Diabetes
    • Dx:
      1. BP > 140/90 (or sBP incr by 30 or dBP incr by 15)  [target 150/100]?
      2. Proteinuria >3g/L, 300 mg/24hrs
      3. Edema (face & hands, non-dependent)
      • MUST BE >20weeks pregnant!
      • Order labs: (also see below for orders)
        • CBC (Hb, platelets)
        • Renal Function (Lytes, BUN, Cr, uric acid [most sensitive], LDH)
        • Coag Profile (INR, PTT, d-dimer, FDP [fibrin degr. products])
        • 24hr urine for protein
        • Check reflexes, fundoscopy and do pelvic exam
      • Fetal Assessment
        • Movements
        • FHR
        • USS for growth
        • Amnionic fluid volume
        • BPP
        • Doppler flow studies

     

    Hypertension in Pregnancy Approach

    HTNinPregnancy4.png

     

     

     System  Effects
     CNS - Headache
    - Blurred Vision
    - Scotoma
    - Hyperreflexia
    - Seizures (eclampsia)
    - CVA
     Cardiovascular - Widespread vasoconstriction
    - Increased BP
    - CVA
     Hepatic Any RUQ pain?
    - Local Vasoconstriction
    - Damage to Liver Cells
    - Release of Enzymes
    - Liver Swelling
    - Possible Liver Rupture
     Renal
    - Local Vasoconstriction
    - Decreased Perfusion
    - Proteinuria
    - Oliguria (<500ml/day)
     Hematologic - MAHA
    - DIC
    - Thrombocytopenia
     Uteroplacental - Local Vasoconstriction
    - Decreased placental flow
    - Decr Amniotic Fluid Volume (AFV)
    - Intrauterine growth restriction (IUGR)
    - Fetal distress
    - Abruption
    - Fetal Death

     

    Preeclampsia

    • Mild (OUTPATIENT), Severe - ADMIT
    • Severe Preeclampsia
      • BP >160/110
      • Proteinuria >5g/24hrs (3-4+ on dipstick)
      • Oliguria <400/24hrs
      • CNS - Visual Disturbance or Hyperreflexia/clonus
      • Pulmonary Edema
      • Epigastric Pain
      • Thrombocytopenia
      • Hemolysis
    • Atypical presentations:
      • Headache
      • Scotoma
      • Blurred Vision
      • HELLP Syndrome (No BP increase)
      • DIC
      • Eclampsia
    1. Admit to 7S under Dr. S
    2. Dx: Preeclampsia
    3. Bedrest w bathroom privileges (BRBP) - max bedtime = max blood flow to fetus
    4. DAT
    5. Vitals - Call M.D. if BP >150/110
    6. CBC, LFT, coag profile, uric acid, Creatinine
    7. Daily urine dip for protein
    8. 24hr Urine for protein
    9. Daily NST (nonstress test)
    10. U/S BPP (biphysical profile)
    11. Meds (to lower BP, may buy more time)
    12. IV
    • Uric Acid: Most sensitive sign (first to go up)
    • Tx
      • Assess + stabilize mother
      • Evaluate fetal well being
      • Delivery (induction or C/S)
      • (Mother's health overrides baby's)
      • Keep sBP 130-155mmHg and dBP 80-105 (lower with comorbid conditions)
      • 1. IV NS (perfuse kidneys, reverse oliguria)
      • 2. anti-HTN
        • Initial therapy: methyldopa (Aldomet), labetalol
        • Other B-blockers (acebutolol, metoprolol, pindolo, and propranolol)
        • CCB (nifedipine, nisoldipine)
        • Lifestyle Modifications for all women:
        •  Intervention:  Details
           Healthy heart diet - Apply the DASH diet (which emphasizes fruits, vegetables, low-fat dairy products, reduced in saturated fat and cholesterol) in addition to dietary and soluble fibre, whole grains, and protein from plant sources

           Regular Physical Activity  - Exercise for 30–60 minutes of moderate intensity dynamic exercise (such as walking, jogging, cycling or swimming) on 4–7 days/week

           Alcohol Consumption  - Reduce alcohol consumption to < 2 drinks/day and < 8/week

           Weight Reduction  - BMI 18.5-24.9

           Reduce waist circumference  - Waist circ <88cm 

           Salt intake  - Reduce intake to <100 mmol/d

           Smoking cessation  
          • Healthy Heart Diet - Apply the DASH diet (which emphasizes fruits, vegetables, low-fat dairy products, reduced in saturated fat and cholesterol) in addition to dietary and soluble fibre, whole grains, and protein from plant sources
          • Regular Physical Activity: Exercise 30-60min
        •  
           
      • 3. Anticonvulsant
        • MgSO4 IV loading: 4-5g over 20min (in 100ccs of NS)
          • Then 1-2g qhr until 24hrs after birth
          • Increases Seizure threshold
          • MgSO4 toxicity:
            • Somnolence
            • Resp Depression
            • Weakness/Hypotonia
            • heart block
            • Absent Deep Tendon reflexes
              • SEVERE: (esp with Ca channel blockers)
              • Renal Failure
              • Oliguria
          • Treat Mg toxicity with 10% calcium gluconate 10mL over 3min (10-10-3) + do ECG
        • Can use valium, but not recommended
      • 3.5: ?PRBC's, platelets FFP (if indicated, if DIC)
      • 4. Delivery (consult anesthesia/peds)

    HELLP Syndrome

    1. Hemolysis
    2. Elevated Liver enzymes
    3. Low Platelets
    • Variant of severe preeclampsia, about 10% of pre-eclampsia pts develop HELLP.
    • BP often normal
    • Epigastric pain (Beware of heartburn)
    • Blood Smear: low platelets, fragments (Schistocytes)
    • Mechanism:
      • Endothelial activation
      • Fibrin deposition causing piano-wire type strands cause RBCs to fragment and get broken apart.
    • Tx:
      • Typically once get HELLP, try to do emergent delivery.
      •  If symptoms persist after delivery, can think about plasma exchange. 

    Eclampsia

    • OB Emergency
    • Pregnant Mother w/ seisure is Elcampsia until proven otherwise
    1. ABC
    2. Control seizure MgSO4, valium (protect airway)
    3. Stabilize and deliver
     

    Routine Screening/Tests

    Gestational Diabetes

    • Physiologic changes of pregnancy apparent 24-29 wks
    • Screen at 27-29 wks
    • Anti-insulin factors produced by placenta + high serum cortisol = insulin resistance
    • Glucose challenge test
      • 50g oral glucose, check serum in 1hr
        • if <7.8 = normal
        • if 7.8-10.3 = do glucose tolerance (GTT)
        • if >10.3 = Gest. diabetes mellitus (GDM) present
    • Glucose tolerance test (GTT) - if GCT 7.8-10.3
      • fasting blood sugar + 75g oral, check serum glucose (details later)

    Rh Immune Globulin

    • ka Rhogam, RHig
    • Indicated if mother is Rh- and no Rh antibodies
    • Prevents mounting immune reaction against fetal Rh+ red cells
    • Give 300ug IM at 28wks (protects against 25mL of fetal blood)
    • Protection lasts 12 weeks
    • If >25mL of fetal blood in maternal circulation do Betke-Kleihauer test to see how much Rhogam to give (300ug/25mL of fetal blood)
    • Rh Antibody testing at 20 and 26-28 weeks
    • Given at 28 weeks or if possibility of feto-maternal hemorrhage:
      • Spontaneous abortion
      • Termination
      • Ectopic
      • CVS/amniocentesis
      • Antepartum Hemorrhage
      • Post-partum
    • Protection lasts 12 weeks (antibody screen will be positive)
    • Test father (if Rh-, then baby is Rh- too, Ab not required- make certain of parternity)
    Other Serum antibodies can be identivied with group&screen, refer to high-risk clinic if +'ve
    .

    CBC

    -  Consider Hb and MCV (iron def, B12, folate)
    -  Repeat 28-30 weeks and 36wks

    GBS (Group B Strep)

    -  Done at 36wks
    -  GBS - Strep. agalactiae
    -  Repeat 28-30 weeks and 36wks
    -  Many women carriers, status can change (10-30%)
    -  If negative within 5 weeks of delivery, no antibiotics
    -  Give antibiotics (Ancef) to prevent neonatal GBS infection
     
    • Neonatal GBS infection:
      • Strep. agalactiae - normally in gut flora, only infects immunocompromised people, can give mastitis in cows causing no milk (hence called "agalactiae" meaning "no milk").
      • Early septicimia: 0-7days: often accompanied by pneumonia (if aspirated during birth)
      • Late septicimia: 7-90 days: often accompanied by meningitis
    • GBS Prophylaxis criteria: (2010 CDC guidelines - US)
      •  gestation of <37 weeks
      •  the membranes have been ruptured 18 hours or longer, or
      •  a temperature of 38°C (100.4°F) or greater.
      • intrapartum nucleic acid amplification test (NAAT) is positive for GBS
      • Previous infant with invasive GBS disease
      • GBS bacteriuria during any trimester of the current pregnancy
      • Positive GBS vaginal-rectal screening culture in late gestation during current pregnancy
      • Unknown GBS status at the onset of labor (culture not done, incomplete, or results unknown) and any of the following:
        • Delivery at <37 weeks’ gestation
        • Amniotic membrane rupture ≥ 18 hours

        • Intrapartum temperature ≥ 100.4°F (≥ 38.0°C)
        • Intrapartum NAAT positive for GBS
     

     

    Antepartum Hemorrhage

    • SVD (Spont Vag. Delivery) > 500ml blood loss (maternal blood  volume expands 1-2L)
    • C/S = 1000mL
    • This is item 3

    Placental Previa

    Abnormal location of placental at or near internal cervical os
    • PAINLESS vaginal bleeding in 2nd trimester
    • If painful: abruption has occurred
    Classification:
    • Total
    • Partial
    • Marginal
    • Low-lying
     
    • Epidemiology
      • 1/250 deliveries
      • 50% of women bleed in pregnancy, 50% of continuous bleeding is miscarriage??
      • RF's:
        • Multiparity
        • Previous uterine surgery (C/S, myomectomy, etc..)
        • Previous:
          • placenta accreta (through endometrium, touching myometrium), 
          • increta (grew into muscle),
          • percreta (grew perforating muscle)
    • Dx:
      • Ultrasound; NO VAGINAL EXAM b/c can cause placental abruption
      • If ultrasound not sure if previa, can do speculum exam but need to have OR read to c/s if needed
    • Tx:
      • Avoid exercise, intercourse
      • Avoid vag exams
      • May migrate, so repeat U/S
      • Weight risks/benefits/blood loss, may need C/S, or admit+monitor to buy more tme
    • Marginal
     
     

    Placenta Abruptio

    • Premature separation of normally implanted placenta
    • Causes:
      • Trauma (car accident / abuse - shearing)
      • Recurrence
      • Hypertension
      • Multiple gestation
      • Uterine anomaly (i.e. implants in septum)
      • Fibroids
      • Substance use (cocaine) - vasoconstriction - ischemic separation
      • Idiopathic
    • Dx:
      • Clinical Dx (often no time for U/S, need urgent delivery)
      • +/- bleeding (can be hidden)
      • Pain (severe!)
      • Shock
      • DIC (Disseminated Intravascular Coagulation)
      • Renal Failure
    • Tx:
      • Stabilize mother
      • Deliver if fetal distress
      • if fetal death: vaginal delivery (no value of C/S)

    Vasa Previa

    • Placental vessels pass over the cervix, if breaks start losing fetal blood
    • Can usually feel on vaginal exam
    • Tx:
      • Delivery: C/S
     
     

    DIC

    • Disseminated Intravascular Coagulation
    • Causes:
      • Abrupio placenta
      • Fetal death in utero
      • PIH (Pregnancy-induced HTN)
      • PPH (Post-partum Hemorrhage)
    • Depleting coagulation factors (coagulation & fibrinolysis)
    • Tx:
      • Supportive care: fluid, blood product replacement
      • Cryopreciptate, FFP, platelets, blood
      • *** TREAT UNDERLYING CAUSE***
      •  

    Spontaneous Abortion

    aka miscarriage (use "miscarriage" when patients are around)
    • Tell patients:
      • "There is nothing you have done to prevent it"
      • "There is nothing you could have done to cause it"
      • "Nature's way"

    Vaginal Exam In Pregnancy

     

    • Pre-term --> NO VAGINAL EXAM! (do not want to induce labour)
    • If ruptured:
      • If in labour --> can do exam (already in labour)
      • if not in labour --> NO VAGINAL EXAM!  (can increase risk of infection
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