Preeclampsia and Diabetes Management in Pregnancy

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Questions and Answers

What is the defining characteristic of severe preeclampsia?

Systolic blood pressure below 140 mm Hg

Persistent oliguria without hypertension

Protein excretion of more than 5 g/24 h (correct)

Diastolic blood pressure below 90 mm Hg

What is the recommended caloric intake for pregnant women managing diabetes?

2400 - 3000 Kcal/d

3000 - 3200 Kcal/d

1500 - 1800 Kcal/d

1800 - 2400 Kcal/d (correct)

Which of the following is NOT a clinical type of preeclampsia?

Severe preeclampsia

Mild preeclampsia

Gestational diabetes-related preeclampsia (correct)

Chronic hypertension-related preeclampsia

What is the main focus of prenatal management for diabetic patients?

Regular dietary control and insulin therapy Signup and view all the answers

What symptom would suggest a shift from outpatient management to hospitalization during pregnancy for diabetic patients?

Any signs of complications Signup and view all the answers

What is the blood pressure threshold for diagnosing hypertension during pregnancy?

140/90 mm Hg Signup and view all the answers

Which of the following best describes preeclampsia?

Hypertension with proteinuria occurring after the 20th week of pregnancy Signup and view all the answers

What percentage of pregnant women are estimated to develop preeclampsia?

5-8% Signup and view all the answers

Which factor is NOT considered a risk factor for developing preeclampsia?

High physical activity levels Signup and view all the answers

What is HELLP syndrome characterized by?

Hypertension, elevated liver enzymes, and low platelet count Signup and view all the answers

What condition describes the occurrence of new proteinuria in women with chronic hypertension?

Superimposed preeclampsia or eclampsia Signup and view all the answers

Which statement accurately reflects an aspect of proteinuria in pregnancy?

A minimum of 0.3 g protein in a 24-hour specimen indicates proteinuria Signup and view all the answers

Which factor related to placental abnormalities can increase the risk of preeclampsia?

Hyperplacentosis Signup and view all the answers

What is the recommended iron supplementation for pregnant women with adequate iron stores?

30 - 60 mg/d Signup and view all the answers

Which diagnostic method is considered the best for assessing fetal wellbeing?

Biophysical profile (BPP) Signup and view all the answers

What is the primary cause of iron deficiency anemia in pregnancy?

Increased demand for iron Signup and view all the answers

In the management of hyperglycemia during labor, which is the appropriate treatment?

5% glucose with crystalline insulin every 5 hours Signup and view all the answers

What hematocrit level is indicative of anemia in pregnancy?

Hb% < 10.5 g% Signup and view all the answers

If there are repeated unexpected intrauterine fetal deaths (IUFD), what is advised regarding delivery timing?

Termination 1-2 weeks before the date of IUFD Signup and view all the answers

What is the average daily iron absorption in pregnant women?

5-6 mg Signup and view all the answers

Which of the following symptoms is commonly associated with iron deficiency anemia?

Red glazed tongue Signup and view all the answers

Study Notes

Medical Disorders with Pregnancy

Presented by Prof. Dr. Mohamed S. Fahmy, Professor of Obstetrics & Gynecology, Head of the Obstetrics & Gynecology Department, Aswan University.

Hypertensive Disorders with Pregnancy

Classification:
- Hypertension: Blood pressure (BP) ≥140/90 mmHg measured twice with a 6-hour interval.
- Proteinuria: Urinary protein excretion ≥0.3g protein/24 hours or 0.1 g/L.
- Gestational hypertension: BP ≥140/90 mmHg for the first time during pregnancy after 20 weeks, without proteinuria.
- Preeclampsia: Gestational hypertension with proteinuria.
- Eclampsia: Preeclampsia complicated by grand mal seizures and/or coma.
- HELLP syndrome: Hemolysis (H), Elevated liver enzymes (EL), Low platelet count (LP).
- Chronic hypertension: Known hypertension before pregnancy or diagnosed for the first time before 20 weeks of pregnancy.
- Superimposed preeclampsia or eclampsia: New onset of proteinuria in women with chronic hypertension.

Preeclampsia

Definition: A multisystem disorder of unknown etiology characterized by the development of hypertension (≥140/90 mmHg) and proteinuria after 20 weeks in a previously normotensive, nonproteinuric woman. Preeclamptic features may appear before 20 weeks in some cases, such as hydatidiform mole and acute polyhydramnios.
Incidence: 5-8%

Preeclampsia Risk Factors

Primigravida (first-time pregnancy), young or elderly age.
Family history of hypertension or preeclampsia.
Placental abnormalities, including hyperplacentosis (excessive exposure to chorionic villi), and placental ischemia.
Obesity (BMI >35 kg/m²), insulin resistance.
Pre-existing vascular disease.
Thrombophilias (e.g., antiphospholipid syndrome, protein C/S deficiency, Factor V Leiden).

Preeclampsia Clinical Types

Mild: Rise in blood pressure (BP) more than 140/90 mmHg but less than 160 mmHg systolic or 110 mmHg diastolic without significant proteinuria.
Severe: Persistent systolic BP above or equal to 160 mmHg or diastolic BP above 110 mmHg, protein excretion over 5g/24 hours, Oliguria (<400 mL/24 hours), Platelets <100,000/mm³, Cerebral or visual disturbances, Persistent severe epigastric pain, Retinal hemorrhages, exudates or papilledema. Intrauterine growth restriction of the fetus. Pulmonary edema.

Preeclampsia Symptoms

Swelling (edema) over the ankles, face, abdominal wall, vulva and even the whole body, appearing in a gradual manner.
Alarming symptoms:
- Headache (occipital or frontal).
- Disturbed sleep.
- Diminished urinary output (<400 mL in 24 hours).
- Epigastric pain.
- Visual disturbances (e.g., blurring, scotomata, dimness, or complete blindness).

Preeclampsia Signs

Rise of blood pressure
Abnormal weight gain.
Edema.
Pulmonary edema.
Abdominal examination showing signs of chronic placental insufficiency (scanty liquor or growth retardation of the fetus).

Preeclampsia Investigations

Urine: Proteinuria is the last feature of preeclampsia to appear.
Ophthalmoscopic examination.
Blood values: Serum uric acid, creatinine, abnormal coagulation profile, hepatic enzymes (may be increased).
Antenatal fetal monitoring: Clinical examination, daily fetal kick count, Ultrasonography (fetal growth and liquor pockets), Cardiotocography, Umbilical artery flow velocimetry, Biophysical profile.

Preeclampsia Complications

Immediate (Maternal)
- Eclampsia (convulsions & coma) more in acute instances.
- Accidental hemorrhage.
- Oliguria and anuria.
- Visual impairment and blindness.
- Pre-term labor.
- HELLP syndrome.
- Cerebral hemorrhage.
- Acute Respiratory Distress Syndrome (ARDS).
Remote (Maternal)
- Residual hypertension.
- Recurrent preeclampsia.
- Thrombophilia.
- Chronic renal disease.
Fetal (related to severity, duration and degree of proteinuria)
- Intrauterine fetal death.
- Intrauterine growth restriction due to chronic placental insufficiency.
- Asphyxia.
- Prematurity.

Preeclampsia Management

Primarily empirical & symptomatic, aiming to stabilize hypertension and prevent complications, including eclampsia.
Objectives: -Stabilize hypertension. -Prevent complications. -Prevent eclampsia. -Optimal time for delivery. -Restoration of maternal health in the puerperium.

Eclampsia

Definition: Preeclampsia complicated by grand mal seizures (generalized tonic-clonic convulsions) and/or coma.
Types:
- Antepartum (70-80%)
- Intrapartum (15-20%)
- Postpartum (5-10%, considered the most dangerous)

Eclampsia Stages

Prodromal: 15-30 seconds, Semi-coma, Severe headache, hallucinations, Twitches in facial, hand and foot muscles, eyeballs rolling.
Tonic: 30-60 seconds, All body muscle contractions (opisthotonus), cyanosis, respiratory arrest, exhaustive heart failure, hindrance to venous return, limbs stretched.
Clonic: 60-120 seconds, Intermittent contraction and relaxation.
Comatose: Minutes to multiple hours. Status eclampticus: Patient shifts from one coma to the next without regaining consciousness.

Eclampsia Differential Diagnosis of Fits

Epileptic fit of grand mal epilepsy: Past history of epilepsy, absence of pre-eclampsia symptoms.
Hysterical fit: Not a classic fit, Psychogenic cause
Cerebral stroke fit: Lateralization, CT scan required
Strychnine poisoning: History of drug intake.

Eclampsia Treatment

Prophylaxis: Good control of pre-eclampsia (PE).
First Aid: At home: IV sedation, transfer to hospital (avoid light & noise). At ICU: Semi-dark, quiet room, side-lying position, VD observation. During fit: IV sedation, anti-convulsants, prevent trauma to airway.

Eclampsia Anti-hypertensive Treatment

IV Hydralazine (10 mg every 20 minutes, drug of choice).
IV Labetalol (10 mg every 10 minutes).
IV sodium nitroprusside, Diazoxide, Nifedipine.
Avoid Diuretics in cases of heart failure and pre-eclampsia toxins (due to hemoconcentration).

Eclampsia Anti-convulsant Treatment

MgSO₄ (Magnesium Sulfate): CNS depressant, skeletal muscle relaxant, vasodilation, cerebral dehydration, Initial dose: 4g / 20 min IV, then continuous infusion (dose based on clinical response, toxicity signs - checking for absent ankle and knee reflexes etc.). Antidote: 10 ml of 10% Calcium gluconate.
Diazepam: Dose: 10-20mg IV, then drip: More rapid, but has more risk for neonatal hypotension and respiratory difficulty.

Eclampsia Intra-partum Control

Induction of labor (if expected to be rapid): First stage: semi-sitting, analgesia, 125mL/hr fluid, epidural anesthesia. Second stage: forceps for quicker delivery.
If delivery is delayed > 6hrs or associated indications= Cesarean section (CS).
Post-partum: Anti-convulsant therapy (1-2 days) + Antihypertensive medications.
Care of the neonate involves specialized remote care , kidney function & blood pressure monitoring 6-weeks post-partum.

Diabetes with Pregnancy

Definition: A chronic metabolic disorder characterized by either insulin deficiency (relative or absolute) or due to peripheral tissue resistance (decreased sensitivity) to insulin.

Diabetes with Pregnancy Classification

Type 1 (IDDM): Young onset, absolute insulin deficiency, autoimmune-related, genetic predisposition, presence of autoantibodies.
Type 2 (NIDDM): Late onset, overweight, peripheral tissue resistance (skeletal muscle, liver), hyperinsulinemia..
Gestational Diabetes Mellitus (GDM): Carbohydrate intolerance, develops during the current pregnancy.

Diabetes with Pregnancy Effects on DM

Pregnancy is diabetogenic: DM may emerge or become harder to control during pregnancy.
Diabetic complications may worsen (renal and retinal).
Risk of hypoglycemia is increased.

Diabetes with Pregnancy Complications (Maternal)

Abortion.
Pre-term labor.
Polyhydramnios (excessive amniotic fluid).
Abruptio placenta (premature separation).
Placenta previa (placenta covering the cervix).
Pre-eclampsia (PE).
Infections (e.g., vulvovaginitis, pyelonephritis).
Pre-term labor.
Prolonged or obstructed labor.
Postpartum hemorrhage (PPH).
Sepsis.
Subinvolution of the uterus.
Pulmonary complications.
Defective Lactation.

Diabetes with Pregnancy Complications (Fetal)

Intrauterine fetal death (IUFD).
Intrauterine growth restriction (IUGR).
Congenital malformations (e.g., neural tube defects, cardiac defects).
Macrosomia (excessive fetal size).
Shoulder dystocia (difficulty during birth).
Congenital heart disease.
Birth injuries.
Polycythemia
Hypoglycemia, hypothermia
Hypocalcaemia and tetany
Hypomagnesaemia

Diabetes with Pregnancy Complications (Neonatal)

Respiratory distress syndrome (RDS).
Jaundice.
Birth injuries..
Prematurity.
Hypoglycemia.
Hypocalcaemia and tetany
Hypomagnesaemia, Hypothermia (low body temperature)

Diabetes with Pregnancy Investigations

Screening tests: 1-hour postprandial glucose test (glucola test) - 50 gm of glucose, then measured after 1 hour.
If >140 mg/dL, further testing.
Confirmatory test (3 hrs glucose tolerance test (GTT)): 50-75 gm glucose solution given in 300-400 mL water. Measures blood glucose levels at 1 hr, 2 hr, and 3 hrs intervals, in order to diagnose Type 2 diabetes and Gestational diabetes

Diabetes with Pregnancy Management

Pre-conception management: Maintain HbA1c ≤6%. Control complications and consider adjusting medications before pregnancy.
In pregnancy. Better control of DM and avoid complications.
Diet control: Caloric intake 1800-2400 kcal/day (30 kcal/kg/day ±300 kcal in 3rd trimester).
Insulin therapy: Dosage adjustments as needed.
Antenatal frequency: Increased frequency for monitoring fetal growth and maternal health (every 2 weeks until week 32), then weekly until week 36 in pregnancy.
Antenatal fetal surveillance: Regular assessments (fetal kicks, Doppler, CTG, BPP, u/s) to detect potential problems
Intra-partum control: IV glucose drip for hyperglycemia. Delivery timing based on assessment of fetal maturity to ensure appropriate timing to minimize potential fetal complications and optimize for vaginal delivery.

Anemia with Pregnancy

Iron deficiency anemia is the most common type of anemia during pregnancy.

Iron Deficiency Anemia with Pregnancy Physiology

Increased iron demand during pregnancy.
Insufficient or decreased dietary intake of iron.
Increased blood loss (e.g., parasitic infestations). Non-pregnant daily absorption is 1-2 mg, Early pregnancy 2-5mg, Late pregnancy 5-6mg.
WHO recommendation 30-60mg/d for pregnancy with adequate iron stores, 120-240mg/d for pregnancy without adequate iron stores.

Iron Deficiency Anemia with Pregnancy Clinical Picture

Angular stomatitis.
Red glazed tongue.
Brittle nails.
Splenomegaly.
Headache.
Fatigue.

Iron Deficiency Anemia with Pregnancy Investigations

To diagnose anemia: Hg ≤10.5 g%
To diagnose iron deficiency: Blood picture (microcytic, hypochromic), Serum iron, and Serum Ferritin.

Iron Deficiency Anemia with Pregnancy Treatment

Prophylactic: Oral iron preparations (30–60 mg daily), eliminate predisposing factors and treat underlying causes.
Active treatment: Oral iron (120–240 mg/d), Folic acid. Blood transfusion if severe.

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Description

Test your knowledge on preeclampsia and diabetes management during pregnancy. This quiz covers defining characteristics, clinical types, recommended intakes, and management strategies crucial for expectant mothers with diabetes. Understand the risks and thresholds related to hypertensive disorders in pregnancy.