Bahrain Pakistan Doctors Group

07/07/2024

Pre-eclampsia
==========

Pre-eclampsia describes the emergence of high blood pressure during pregnancy that may be a precursor to a woman developing eclampsia and other complications. It is classically a triad of 3 things:

• new-onset hypertension
• proteinuria
• oedema

Definition
-------------

The current formal definition is as follows

• new-onset blood pressure ≥ 140/90 mmHg after 20 weeks of pregnancy, AND 1 or more of the following:
o proteinuria
o other organ involvement (see list below for examples): e.g. renal insufficiency (creatinine ≥ 90 umol/L), liver, neurological, haematological, uteroplacental dysfunction

Features
-----------

Potential consequences of pre-eclampsia

• eclampsia
o other neurological complications include altered mental status, blindness, stroke, clonus, severe headaches or persistent visual scotomata
• fetal complications
o intrauterine growth retardation
o prematurity
• liver involvement (elevated transaminases)
• haemorrhage: placental abruption, intra-abdominal, intra-cerebral
• cardiac failure

Features of severe pre-eclampsia
-------------------------------------

• hypertension: typically > 160/110 mmHg and proteinuria as above
• proteinuria: dipstick ++/+++
• headache
• visual disturbance
• papilloedema
• RUQ/epigastric pain
• hyperreflexia
• platelet count < 100 * 106/l, abnormal liver enzymes or HELLP syndrome

Prevention
-------------

NICE divide risk factors into high and moderate risk:

High risk factors
------------------

• hypertensive disease in a previous pregnancy
• chronic kidney disease
• autoimmune disease, such as systemic lupus erythematosus or antiphospholipid syndrome
• type 1 or type 2 diabetes
• chronic hypertension

Moderate risk factors
------------------------

• first pregnancy
• age 40 years or older
• pregnancy interval of more than 10 years
• body mass index (BMI) of 35 kg/m² or more at first visit
• family history of pre-eclampsia
• multiple pregnancy

Reducing the risk of hypertensive disorders in pregnancy
-----------------------------------------------------------------

• women with the following should take aspirin 75-150mg daily from 12 weeks gestation until the birth
o ≥ 1 high risk factors
o ≥ 2 moderate factors

Management
-----------------

Initial assessment
---------------------

• NICE recommend arranging emergency secondary care assessment for any woman in whom pre-eclampsia is suspected
• women with blood pressure ≥ 160/110 mmHg are likely to be admitted and observed

Further management
------------------------

• oral labetalol is now first-line following the 2010 NICE guidelines. Nifedipine (e.g. if asthmatic) and hydralazine may also be used
• delivery of the baby is the most important and definitive management step. The timing depends on the individual clinical scenario

06/07/2024

Second Youth Leadership Program (YLP) is organised by Bahrain Pakistan Doctors Group under patronage of Bahrain Pakistan Friendship Society and held today on 06-07-2024 at Ramada Hotel by Wyndham......
Childre actively participated...

06/07/2024

Hyperemesis gravidarum
---------------------------

Whilst the majority of women experience nausea (previously termed 'morning sickness') during the early stages of pregnancy it can become problematic in a minority of cases. The Royal College of Obstetricians and Gynaecologists (RCOG) now use the term 'nausea and vomiting of pregnancy' (NVP) to describe troublesome symptoms, with hyperemesis gravidarum being the extreme form of this condition.

It occurs in around 1% of pregnancies and is thought to be related to raised beta hCG levels. Hyperemesis gravidarum is most common between 8 and 12 weeks but may persist up to 20 weeks.

Risk factors
========

• increased levels of beta-hCG
• multiple pregnancies
• trophoblastic disease
• nulliparity
• obesity
• family or personal history of NVP

Smoking is associated with a decreased incidence of hyperemesis.

Referral criteria for nausea and vomiting in pregnancy
===================================

NICE Clinical Knowledge Summaries recommend considering admission in the following situations:
• Continued nausea and vomiting and is unable to keep down liquids or oral antiemetics
• Continued nausea and vomiting with ketonuria and/or weight loss (greater than 5% of body weight), despite treatment with oral antiemetics
• A confirmed or suspected comorbidity (for example she is unable to tolerate oral antibiotics for a urinary tract infection)
• They also recommend having a lower threshold for admission to hospital if the woman has a co-existing condition (for example diabetes) that may be adversely affected by nausea and vomiting.

Hyperemesis gravidarum
================

The Royal College of Obstetricians and Gynaecologists (RCOG) recommend that the following triad is present before diagnosis of hyperemesis gravidarum: RCOG
 5% pre-pregnancy weight loss
 dehydration
 electrolyte imbalance

Validated scoring systems such as the Pregnancy-Unique Quantification of Emesis (PUQE) score can be used to classify the severity of NVP.

Management

 simple measures
 rest and avoid triggers e.g. odours
 bland, plain food, particularly in the morning
 ginger
 P6 (wrist) acupressure

first-line medications
==============

• antihistamines: oral cyclizine or promethazine
• phenothiazines: oral prochlorperazine or chlorpromazine
• combination drug doxylamine/pyridoxine: pyridoxine (vitamin B6) monotherapy is actually used commonly outside of the UK as a first-line treatment for NVP. However, pyridoxine monotherapy is specifically not recommended in the RCOG guidelines

second-line medications
================

o oral ondansetron: ondansetron during the first trimester is associated with a small increased risk of the baby having a cleft lip/palate. The Medicines and Healthcare products Regulatory Agency (MHRA) advise that if ondansetron is used then these risks should be discussed with the pregnant woman
o oral metoclopramide or domperidone: metoclopramide may cause extrapyramidal side effects. It should therefore not be used for more than 5 days
o admission may be needed for IV hydration
o see criteria above for referral/admission
o normal saline with added potassium is used to rehydrate

Women with hyperemesis gravidarum may develop dehydration, weight loss and electrolyte imbalances. Other complications include:

 acute kidney injury
 Wernicke's encephalopathy
 oesophagitis, Mallory-Weiss tear
 venous thromboembolism
 fetal outcome CKS
 studies generally show little evidence of adverse outcomes for birth weight/other markers for mild-moderate symptoms

severe NVP resulting in multiple admissions and failure to 'catch-up' weight gain may be linked to a small increase in preterm birth and low birth weight.

03/07/2024

Second Youth Leadership Program is organized by Bahrain Pakistan Doctors Group under patronage of Bahrain Pakistan Friendship Society. It will start in 4 days

02/07/2024

Gestational diabetes
==============

Diabetes mellitus may be a pre-existing problem or develop during pregnancy, gestational diabetes. It complicates up to 1 in 20 pregnancies. NICE estimates the following breakdown:
87.5% have gestational diabetes
7.5% have type 1 diabetes
5% have type 2 diabetes

Gestational diabetes
----------------------

Gestational diabetes is the second most common medical disorder complicating pregnancy (after hypertension), affecting around 4% of pregnancies.

Risk factors for gestational diabetes
---------------------------------------

BMI of > 30 kg/m²
previous macrosomic baby weighing 4.5 kg or above
previous gestational diabetes
first-degree relative with diabetes
family origin with a high prevalence of diabetes (South Asian, black Caribbean and Middle Eastern)

Screening for gestational diabetes
--------------------------------------

the oral glucose tolerance test (OGTT) is the test of choice
women who've previously had gestational diabetes: OGTT should be performed as soon as possible after booking and at 24-28 weeks if the first test is normal. NICE also recommend that early self-monitoring of blood glucose is an alternative to the OGTTs
women with any of the other risk factors should be offered an OGTT at 24-28 weeks

Diagnostic thresholds for gestational diabetes
-----------------------------------------------------

these have recently been updated by NICE, gestational diabetes is diagnosed if either:
fasting glucose is >= 5.6 mmol/L
2-hour glucose is >= 7.8 mmol/L

Management of gestational diabetes
==========================

newly diagnosed women should be seen in a joint diabetes and antenatal clinic within a week
women should be taught about self-monitoring of blood glucose
advice about diet (including eating foods with a low glycaemic index) and exercise should be given
if the fasting plasma glucose level is < 7 mmol/l a trial of diet and exercise should be offered
if glucose targets are not met within 1-2 weeks of altering diet/exercise metformin should be started
if glucose targets are still not met insulin should be added to diet/exercise/metformin
gestational diabetes is treated with short-acting, not long-acting, insulin
if at the time of diagnosis the fasting glucose level is >= 7 mmol/l insulin should be started
if the plasma glucose level is between 6-6.9 mmol/l, and there is evidence of complications such as macrosomia or hydramnios, insulin should be offered
glibenclamide should only be offered for women who cannot tolerate metformin or those who fail to meet the glucose targets with metformin but decline insulin treatment

Management of pre-existing diabetes
==========================

weight loss for women with BMI of > 27 kg/m^2
stop oral hypoglycaemic agents, apart from metformin, and commence insulin
folic acid 5 mg/day from pre-conception to 12 weeks gestation
detailed anomaly scan at 20 weeks including four-chamber view of the heart and outflow tracts
tight glycaemic control reduces complication rates
treat retinopathy as can worsen during pregnancy

Targets for self monitoring of pregnant women (pre-existing and gestational diabetes)
=================================================

Time Target
----------------------------------------------------

Fasting 5.3 mmol/l
1 hour after meals 7.8 mmol/l, or:
2 hour after meals 6.4 mmol/l

01/07/2024

Pre-Diabetes is the Road to DM type II
===========================

Diabetes and prediabetes are mostly silent diseases (without any signs or symptoms). Know your numbers, risk factors, and family history! Prediabetes: Your Chance to Prevent Type 2 Diabetes! It’s common and reversible. You can prevent or delay prediabetes from turning into type 2 diabetes with simple, proven lifestyle changes.

What Is Prediabetes?
Prediabetes is a serious health condition where blood sugar levels are higher than normal, but not high enough yet to be diagnosed as type 2 diabetes. Most people with prediabetes don’t know they have it. Could this be you?

Prediabetes is a serious health condition. Prediabetes puts you at increased risk of developing type 2 diabetes, heart disease, and stroke.

What Causes Prediabetes?
Insulin is a hormone made by your pancreas that acts like a key to let blood sugar into cells for use as energy. If you have prediabetes, the cells in your body don’t respond normally to insulin. Your pancreas makes more insulin to try to get cells to respond. Eventually your pancreas can’t keep up, and your blood sugar rises, setting the stage for prediabetes—and type 2 diabetes down the road.

Pre-diabetes is a Silent Disease!
Pre-diabetes is common and underdiagnosed. You can have prediabetes for years but have no clear symptoms, so it often goes undetected until serious health problems such as type 2 diabetes show up. It’s important to talk to your doctor about getting your blood sugar tested if you have any of the risk factors for prediabetes.

Prediabetes = Prevent diabetes
Think of prediabetes as a fork in the road. If you ignore it, your risk for type 2 diabetes goes up. Lose a modest amount of weight and get regular physical activity, and your risk goes down. Modest weight loss means 5% to 7% of body weight, just 10 to 14 pounds for a 200-pound person. Regular physical activity means getting at least 150 minutes a week of brisk walking or similar activity. That’s just 30 minutes a day, five days a week.

28/06/2024

Hypertension in pregnancy
=====================

It's useful to remember that in normal pregnancy:
blood pressure usually falls in the first trimester (particularly the diastolic), and continues to fall until 20-24 weeks
after this time the blood pressure usually increases to pre-pregnancy levels by term

NICE published guidance in 2010 on the management of hypertension in pregnancy. They also made recommendations on reducing the risk of hypertensive disorders developing in the first place. Women who are at high risk of developing pre-eclampsia should take aspirin 75mg od from 12 weeks until the birth of the baby.

Hypertension in pregnancy in usually defined as:
systolic > 140 mmHg or diastolic > 90 mmHg
or an increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic

After establishing that the patient is hypertensive they should be categorised into one of the following groups

Pre-existing hypertension:
-----------------------------

A history of hypertension before pregnancy or an elevated blood pressure > 140/90 mmHg before 20 weeks gestation

No proteinuria, no oedema

Occurs in 3-5% of pregnancies and is more common in older women

If a pregnant woman takes an ACE inhibitor or angiotensin II receptor blocker (ARB) for pre-existing hypertension this should be stopped immediately and alternative antihypertensives started (e.g. labetalol) whilst awaiting specialist review

Pregnancy-induced hypertension
(PIH, also known as gestational hypertension)
------------------------------------------------------

Hypertension (as defined above) occurring in the second half of pregnancy (i.e. after 20 weeks)

No proteinuria, no oedema

Occurs in around 5-7% of pregnancies

Resolves following birth (typically after one month). Women with PIH are at increased risk of future pre-eclampsia or hypertension later in life

Pre-eclampsia
--------------------------------

Pregnancy-induced hypertension in association with proteinuria (> 0.3g / 24 hours)

Oedema may occur but is now less commonly used as a criteria

Occurs in around 5% of pregnancies

Management
-----------------

oral labetalol is now first-line following the 2010 NICE guidelines
oral nifedipine (e.g. if asthmatic) and hydralazine

25/06/2024

Bahrain Pakistan Doctors Group is arranging Second YOUTH LEADERSHIP PROGRAM under the patronage of Bahrain Pakistan Friendship Society for our young Leaders

18/12/2023