Pregnancy-specific diseases

Chao Gu M.D., Ph.D.

Dept of Ob/Gyn

OB/GYN Hospital, Fudan University

CASE 1

What is your next step?

Repeat another blood pressure measurement to ascertain the diagnosis

of hypertension complicating pregnancy.

A 35 year old lady at 32 weeks of gestation in her first pregnancy goes

to your office for a minor upper respiratory tract infection. Incidentally,

her blood pressure is found to be 155/90 mmHg with a pulse rate of

85/min. The cardiovascular examination and chest examinations are

otherwise unremarkable. The size of uterus is appropriate for gestational

age.

What are the classification of hypertension in pregnancy?

• Gestational hypertension

• Preeclampsia

• Eclampsia

• Superimposed preeclampsia on chronic hypertension

• Chronic hypertension in pregnancy

CASE 1

CASE 1What is the definition of various types of hypertension ?

Chronic hypertension in pregnancy

• BP 140/90 mm Hg before pregnancy or diagnosed before 20 weeks' gestation not attributable to

gestational trophoblastic disease or

• Hypertension first diagnosed after 20 weeks' gestation and persistent after 12 weeks postpartum

Gestational hypertension

• Systolic BP 140 or diastolic BP 90 mm Hg for first time during pregnancy

• No proteinuria

• BP returns to normal before 12 weeks postpartum

• Final diagnosis made only postpartum

.

CASE 1What is the definition of various types of hypertension ?

Preeclampsia

• BP 140/90 mm Hg after 20 weeks' gestation

• Proteinuria 300 mg/24 hours or 1+ dipstick

Increased certainty of preeclampsia• BP 160/110 mm Hg

• Proteinuria 2.0 g/24 hours or 2+ dipstick

• Serum creatinine >1.2 mg/dL unless known to be previously elevated

• Platelets < 100,000/ L

• Microangiopathic hemolysis—increased LDH

• Elevated serum transaminase levels—ALT or AST

• Persistent headache or other cerebral or visual disturbance

CASE 1What is the definition of various types of hypertension ?

Eclampsia

• Seizures that cannot be attributed to other causes in a woman with preeclampsia

Superimposed Preeclampsia On Chronic Hypertension

• New-onset proteinuria 300 mg/24 hours in hypertensive women but no proteinuria before 20 weeks' gestation

• A sudden increase in proteinuria or blood pressure or platelet count < 100,000/ L in women with hypertension

and proteinuria before 20 weeks' gestation

What is the management?

Evaluation

• Severity

• Gestational age

• Presence of preeclampsia

• Outpatient

• Hospitalization

Termination of pregnancy is the only cure for preeclampsia

CASE 1

What is the management?

High-risk chronic hypertension iassociated maternal and peri-natal complications,

• superimposed pre-eclampsia

• abruptio placentae

Careful monitoring for proteinuria and renal function.

Hospitalization should be considered if the blood pressure is not under control.

Anti-hypertensive drugs should be considered.

Once pre-eclampsia is diagnosed, hospitalization is indicated,

progress rapidly to multi-system involvement, including eclampsia

CASE 1

INDICATION OF MAGNESIUM SULFATE

• Control eclampsia convulsions

• Prevent preeclampsia develop into eclampsia

CASE 1

THE USES OF MAGNESIUM SULFATE

DAY 1 ：

• loading dose ： 25% MgSO4 20ml ＋ 10% GS 20ml IV in 5-10min

• Maintenance dose: 25% MgSO4 60ml ＋ 5%GS 1000ml IV in 10h

Day 2 to 24h Postpartum

• 25% MgSO4 60ml ＋ 5% GS 1000ml IV in 10 h

CASE 1

CASE 1

• absent or very sluggish knee jerk

• a respiratory rate below 16/min

• a urinary output of less than 100ml in the preceding 4 hours (25ml/hr)

Contraindication as follow :

Indications of Antihypertensive drugs

• BP ≥150/100mmhg, <160/110mmhg ， Oral 。

• BP ≥ 160/ 或 /110mmhg,IV 。

Control to

130-140/85-100 mmhg。

CASE 1

What are the antihypertensive drugs commonly use in pregnancy?

Labetalol combined alpha- and beta-adrenoceptor blocker.

Nifedipine Calcium Channel Blockers Nifedipine

Beta-blockers

Methyldopa

Sodium nitroprusside

Hydralazine

ACEI (血管紧张素转换酶抑制剂 ) can’t use!!!

胎儿生长受限（ fetal growth restriction ， FGR

ARDS

CASE 1

Too early --- Can fetus survive ？ Complication ？

Too late ---Can mother survive ？ Complication？

• preeclampsia patient has no response following medical management for 24-48 hours .

• preeclampsia patient after 34 weeks of gestation

• preeclampsia patient before 34 weeks of gestation with impaired fetoplacental unit function

and matured fetus.

• preeclampsia patient before 34 weeks of gestation with impaired fetoplacental unit function

and immatured fetus, use Dexamethasone to promote fetal lung maturity before the

termination of pregnancy.

Eclampsia control over 2h.

CASE 1 Termination of pregnancy

A 26-year-old female at 32 weeks of gestation presented to the clinic with

complaints of generalized itching. Patient reported no rash or skin changes.

She denied any change in detergent, soaps, or perfumes. She denied nausea

and vomiting .There was no history of any drug intake or previous allergies.

There was no fever or any other medical illness.

On physical examination, there were no rashes apparent on her skin and

only some excoriations were there from itching.

Laboratory investigations revealed slightly elevated serum transaminases

and bilirubin levels, Alkaline phosphatase levels were much higher than

normal.

CASE 2

What is the patient’s likely diagnosis?

Intrahepatic Cholestasis of Pregnancy. (ICP)

What is the cause of the patient’s generalized itching?

• Increased serum bile salts and accumulation of bile salts in the dermis of the skin are responsible

for generalized itching.

• Generalized pruritus in pregnancy and a characteristic enzymeprofile

• High alkaline phosphatase is a marker of cholestasis

• Slightly high transaminases (AST, ALT) differentiate it from viral hepatitis

• Bilirubin is high due to intrahepatic obstruction as a result of cholestasis.

CASE 2

Intrahepatic cholestasis of pregnancy (ICP)

•benign disorder that occurs in the second or third trimester

and resolves spontaneously after delivery.

• Cholestasis of pregnancy is a condition in which the normal

flow of bile from the gall bladder is impeded, leading to

accumulation of bile salts in the body.

CASE 2

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Bed rest, left lateral position

Drug

• Adenosylmethionine 腺苷蛋氨酸

• Ursodeoxycholic acid 熊去氧胆酸

• Dexamethasone 地塞米松

• Phenobarbital 苯巴比妥

NST (Nonstress Test)

CASE 2

Therapeutic Principle

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Jaundice (+) 36 weeks of gestation

Jaundice (-) 37 weeks of gestation

Significantly decreased placental function or

Fetal distress Immediately

Cesarean section

Termination of pregnancy

CASE 2

CASE 3

30 years old

First pregnancy

8 weeks gestation by LMP

Persistent vomiting for past week

Unable to tolerate food or fluids for past 24 hours

Passing little urine

Urien ketones 3+

Nausea (70%) and vomiting (60%) common in 1st trimester, Hyperemesis = fluid and electrolyte imbalance and nutritional deficiency

Persistent and severe vomiting

More severe in:

• Multiple gestation• Hydatidiform mole

Without treatment can lead to CNS disturbance, liver and renal failure

CASE 3

What is the patient’s likely diagnosis?

Hyperemesis Gravidarum

PRESENTATION

•Severe nausea and vomiting

•Dehydration

•Weight loss

•Ketosis

•Ptyalism (unable to swallow saliva)

CASE 3

DIAGNOSIS

Consider other causes e.g. UTI, gastritis, ketoacidosis, peptic ulceration, Addison’s disease, pancreatitis

Investigations:

• FBC (raised haematocrit)

• U&E (hyponatraemia, hypokalemia, hypouraemia)

• LBP (raised transaminases, found in up to 50% cases)

• TFTs (thyrotoxicosis)

• Urinalysis and MSU for culture and sensitivity

• USS (if not done yet)

• Weight

CASE 3

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Serious Complications

Wernicke syndrome （ Wernicke 脑病）： Vit B1 deficiency

• A type of brain damage in which the initial symptoms appear.

• Abnormal gait and eye movements.

• Psychiatric disorder, includes dementia and psychosis.

coagulation disorder （凝血功能障碍）： Vit K deficiency

CASE 3

INDICATIONS FOR TERMINATION OF PREGNANCY

• Continuing jaundice

• Continuing proteinuria

• Fever continuing over 38 ° C

• Tachycardia (≥ 120 beats / min)

• Wernicke syndrome appears

CASE 3

19 year old G1 P0+0

39 weeks - antenatal care outside your area

Contractions 3-4 in 10 minutes

Excessive weight gain during pregnancy

Recent generalized oedema

CASE 4

ON EXAMINATION

Facial & generalised oedema +++

Admission BP = 164/102 (repeat 160/100)

Urine = +++ protein

VE : Cervix = 4 cm dilated, 100% effaced,

station ‘0’, membranes intact

- contractions 3-4 in 10 mins,

- baseline FHR = 140bpm

- normal variability,

- no decelerations

CASE 4

What concerns you about with this situation?

likely to have severe pre-eclampsia

both fetal & maternal risks such as

• risk of ECLAMPSIA

• intracranial haemorrhage

• risk of pulmonary oedema (iatrogenic fluid overload)

• hepatorenal failure

CASE 4

What lab investigations would you order?

Full Blood Count

(Coagulation)

Group & Save for X-match

Urea, Creatinine & Electrolytes

Liver Function Tests

Urate

MSU (inc Gram Stain)

CASE 2

What other data do you need at this point?

her handheld antenatal records

CASE 4

Would you give antihypertensive and/or magnesium

sulphate at this point?

1. Antihypertensives –persistent systolic BP >160mmHg should be

treated

2. Magnesium Sulphate – most units would start MgSO4 at this stage

(ref MAGPIE study)

…. IN THIS CASE, NEITHER IS GIVEN…..

CASE 4

30 MINUTES LATER…

While awaiting laboratory results, you are called urgently to

delivery suite

The patient has a grand mal seizure that lasts about 1 minute

CTG shows a fetal bradycardia of 80 bpm

after the seizure

CASE 4

WHAT WOULD YOU DO AT THIS POINT?

CALL FOR HELP +++++

INITIATE BASIC ABCs

remember left lateral tilt!!

‘A’ – airway can’t be inserted during a fit

‘C’ – includes x2 large bore cannulae

Initiate unit ‘Eclampsia protocol’

DO NOT NURSE IN THE DARK!!

Give loading dose MgSO4 (…what dose?)

Foley catheter/fluid balance

Keep NBM – review need to treat BP

CASE 4

How would you deliver when stable - LSCS versus induction with vaginal delivery?

Labour induction can usually be considered if:

gestation >32 weeks

cervix reasonably favourable (i.e. delivery likely within 12 hours) – cervix is often favourable in pre-eclampsia

fetal condition stable (i.e. no severe IUGR)

CASE 4

AFTER THE SEIZURE...

Meticulous attention to fluid balance -

intake / output assessed hourly

4g loading dose MgSO4 then infusion at 1-2 g/hr

Total IV fluids limited to 80-85ml/hr or 1 ml/kg/hr

Foley catheter

CASE 4

Fetal bradycardia recovers with control of seizures, oxygen and left lateral positioning

Contracting 4-5 in 10; lasting 60-90 seconds

ARM - meconium-staining

FHR = 160bpm with decreased variability

Consultant Anaesthetist / Obstetrician and theatre aware of situation

BP = 180/110

CASE 4

What would you do next?

Control Blood Pressure

Analgesia as appropriate

CASE 4

Are you worried about her blood pressure?

YES – in this case, BP>180/110 puts maternal CNS at risk

(intracranial haemorrhage)

CASE 4

How would you control the blood pressure?

can you name 2 drugs you could consider using?

• SL Nifedepine

• IV hydralazine (bolus +/- infusion)

CASE 4

What are the signs of magnesium toxicity?

IN ORDER

loss of reflexes

somnolence

respiratory depression

paralysis

finally cardiac arrest

CASE 2

What is the antidote for magnesium toxicity?

Calcium gluconate 1g IV over 3 minutes

(10mls 10% calcium gluconate)

CASE 4

What action should be taken for absent reflexes?

Stop MgSO4 until reflexes return

CASE4

What action should be taken for

respiratory depression / somnolence?

Stop MgSO4

Give O2

Recovery position (as reduced level of consciousness)

Monitor closely

CASE 4

THE BLOOD RESULTS RETURN…

Observations BP 140/95

Pulse - 90bpm

Resp rate - 12/min

Temp - 37.8°C

Urine output 30ml over past hour

Blood results Hb 12.0g/dl

WBC 21x109

Platelets 185x109

Coagulation normal / LFTs Normal

Magnesium level is therapeutic

CASE 4

The patient has another grand mal seizure

What would you do next?

general supportive measures (ABCs)

second bolus MgSO4 (2g) should be given even if levels are therapeutic, as long as no signs of toxicity

consider another neuroleptic if seizures continue despite second bolus

Case Presentation BPCASE 4

Would you deliver – if so how?

once stable, delivery by urgent LSCS may be appropriate

after this 2nd fit (assuming vaginal delivery is not imminent)

CASE 2

Is she septic ?

(T = 37.8°C WCC = 21 x 109)

NO - WCC and pyrexia are more likely related to the grand mal fit

Should antibiotics be started ?

NO - unless there are other overt signs of infection

CASE 4

Does she have HELLP syndrome?

NO – HELLP typically presents with:

Haemolysis

Elevated Liver enzymes (ALT/AST)

Low Platelets

CASE 4

THE DELIVERY… AND THEN?

• VE confirms cervix 7cm dilated

• Oxytocin augmentation

• Normal delivery within 1 hour

• Healthy 3.8kg baby boy

• Apgars = 6 (1 min) + 9 (5 min)

• Placenta delivered & appears intact

• No uterine atony or perineal trauma

Case Presentation BPCASE 4

When would you discontinue MgSO4?

continue for minimum 24 hours post-delivery

(possibly 48 hours if recovery is protracted)

More than 40% of all eclampsia occurs post-delivery

POST-DELIVERY

CASE 4