Table of contents
- 1. Pregnancy Induced Hypertension
- 2. Hypertension in Pregnancy Approach
- 3. Preeclampsia
- 3.1. HELLP Syndrome
- 3.2. Eclampsia
- 4. Routine Screening/Tests
- 4.1. Gestational Diabetes
- 4.2. Rh Immune Globulin
- 4.3. CBC
- 4.4. GBS (Group B Strep)
- 5.
- 6. Antepartum Hemorrhage
- 6.1. Placental Previa
- 6.2. Placenta Abruptio
- 6.3. Vasa Previa
- 6.4. DIC
- 7. Spontaneous Abortion
- 8. Vaginal Exam In 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:
-
- BP > 140/90 (or sBP incr by 30 or dBP incr by 15) [target 150/100]?
- Proteinuria >3g/L, 300 mg/24hrs
- 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
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
Admit to 7S under Dr. S
Dx: Preeclampsia
Bedrest w bathroom privileges (BRBP) - max bedtime = max blood flow to fetus
DAT
Vitals - Call M.D. if BP >150/110
CBC, LFT, coag profile, uric acid, Creatinine
Daily urine dip for protein
24hr Urine for protein
Daily NST (nonstress test)
U/S BPP (biphysical profile)
Meds (to lower BP, may buy more time)
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
- MgSO4 IV loading: 4-5g over 20min (in 100ccs of NS)
- 3.5: ?PRBC's, platelets FFP (if indicated, if DIC)
- 4. Delivery (consult anesthesia/peds)
HELLP Syndrome
- Hemolysis
- Elevated Liver enzymes
- 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
- ABC
- Control seizure MgSO4, valium (protect airway)
- 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
- 50g oral glucose, check serum in 1hr
- 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)
.
CBC
- Consider Hb and MCV (iron def, B12, folate)
- Repeat 28-30 weeks and 36wks
- 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
- 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:
- 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
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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