BMJ

BMJ Journals
BMJ Careers
BMJ Learning
Evidence Centre
doc2doc
BMJ Group

Print
Update your details
Signed in as:
lalitha Ganti
Log out
Upgrade
Redeem Voucher

GP CPD
In association with: Royal College of General Practitioners

Interactive case history

Section 8 of 9

Complications of pregnancy in primary

care: in association with NICE
10020725 45

next

1. Regarding the role of GPs in the care of pregnant women, which of the following is
correct?

Pre-test Your Correct

answer answer answer
a. Women who opt for a home birth should have the
majority of their antenatal care from their GP and
community midwife
b. Women with any pre-existing medical conditions
should have all their antenatal care in hospital
c. Women who have health concerns during their
pregnancy should consult their midwife or
obstetrician, rather than their GP
 d. Women who are acutely unwell during pregnancy
should contact hospital services, rather than their
GP
e. Women who have pre-existing health problems
should be offered pre-pregnancy counselling with
their GP

2. That's right.
3. Although the maternity care of women is usually offered by antenatal services, GPs
still have vital roles to play before pregnancy (such as pre-pregnancy counselling),
overseeing general medical problems, and recognising urgent problems during
pregnancy, and advising women on follow up of pregnancy related problems after
delivery.
4. Maternity services will often cover women having home births, and although some
GPs may be involved in this, it is not necessarily part of their role. Women with pre-
existing medical problems can often be managed well outside of hospital, especially if
their GPs communicate well with maternity services. Women with health problems
during pregnancy should feel able to talk to their GPs, as well as other services.
5. Learning bite: handheld medical records
6. It is common practice in the UK for women to have a separate maternity health
record, which they carry to appointments. This is an ideal opportunity to ensure that
all relevant medical and social information is available to other healthcare
professionals.
7. You should make use of the handheld record by recording anything which might be
useful for others involved in the patient's care to know. There are a few exceptions to
this, such as reports of domestic violence, where the abuser may read the record.

2. You are asked to perform a pregnancy test by a 32 year old woman, who you have
been seeing for several years for hypertension, which is controlled by captopril and
nifedipine. Her last menstrual period was about seven weeks ago, and her pregnancy
test is positive. This is her first pregnancy and she is happy to hear the news. What
should you do next?

Pre-test Your Correct

answer answer answer
a. Recheck her blood pressure now and if it
remains under control take no further action
b. Advise her to wait until her antenatal booking
appointment to discuss control of her blood
pressure
c. Make an appointment to review her anti-
hypertension medication
d. Start her on 75 mg aspirin as prophylaxis
against pre-eclampsia
e. Review her risk factors for pre-eclampsia and, if
she is at increased risk, start 75 mg aspirin

3. That's right.
4. It is important to manage any pre-existing medical conditions a woman has during
pregnancy, including hypertension. With hypertension it is important to review the
patient's drugs as soon as possible because some drugs are not recommended during
pregnancy: particularly angiotensin converting enzyme (ACE) inhibitors (such as
captopril) and angiotensin II receptor blockers (ARBs), which can lead to congenital
anomalies. There is also an increased risk of congenital anomalies and neonatal
complications if women take chlorothiazides during pregnancy.
5. NICE does recommend using low dose (75 mg) aspirin as a prophylactic measure to
reduce the risk of pre-eclampsia in patients with chronic hypertension. But NICE
recommends starting it after 12 weeks' gestation (normally around the patient's
antenatal booking visit).

3. Which of the following patients should be recognised at their antenatal booking visit
as being at highest risk of gestational diabetes?

Pre-test Your Correct

answer answer answer
a. A 25 year old woman, whose previous baby
weighed 4.1 kg
b. A 30 year old primiparous woman, whose
maternal aunt has type 2 diabetes
c. A 28 year old woman from India who has a body
mass index of 28
d. A 25 year old Polish woman, who tells you that
she had a borderline glucose tolerance test during
her last pregnancy
e. A 32 year old woman who used to be very obese
(BMI 35), but has lost weight over the past five
years and now has a BMI of 26

4. That's not right. The correct answer is c.

5. Women of ethnic origins where diabetes is more prevalent than those of European
descent (such as South Asian, Afro-Caribbean, or Middle Eastern) should be
identified as being at higher risk, and so offered a glucose tolerance test at their
antenatal booking visit.9
6. Other risk factors include previous gestational diabetes, obesity (BMI >30), previous
macrosomic baby (>4.5 kg), and a first degree relative with diabetes.9
7. Although you should not discount an oral report of a borderline result, without
knowing more about the actual result this is not a definite risk factor.

4. NICE guidance recommends that you consider complex social factors when planning
or giving medical care in relation to pregnancy. Which one of the following does the
guidance NOT regard as a complex social problem?

Pre-test answer Your answer Correct answer

a. Patients unable to read
b. Teenage pregnancy
c. Alcohol dependency
 d. History of domestic abuse
e. Lack of close supportive family

5. That's not right. The correct answer is e.

6. NICE encourages health professionals to consider the effects of their patients' social
circumstances on health. Lack of close supportive family is not mentioned in the
NICE guidelines. However, you should not be too rigid about categories of social
problems, which may have different impact on patients, depending on the context.
NICE guidance does not specifically mention lack of close family support as a
complex social problem, but you should not discount it if it was particularly important
in an individual patient's circumstances.
7. Inability to read (English) is included in "difficulty reading or speaking English,"
teenage pregnancy is included in patients under age 20, and alcohol dependency is an
example of a substance misuse, all of which are included in the NICE guidelines.13 In
reality, patients with one social problem commonly have several social problems -
recognising one problem may lead to uncovering others.

5. When is the best time to offer carrier testing to an Afro-Caribbean woman at higher
risk of sickle cell disease?

Pre-test Your Correct

answer answer answer
a. After delivery of her baby
b. At her booking visit to antenatal services
(around 13 weeks' gestation)
c. As soon as she has a positive pregnancy test
d. During pre-conception counselling

6. That's right.
7. Generally you should aim to offer carrier testing to women at higher risk of genetic
conditions like haemoglobinopathies as early as possible. Ideally this should be before
she becomes pregnant, so that she and her partner can make informed reproductive
choices. But if the issue is not recognised until she is pregnant, you should offer a
referral as soon as possible during pregnancy, and not wait until her booking visit. It
is certainly not ideal to wait until the delivery of a child with sickle cell disease, if you
knew about the risk beforehand.

6. What proportion of women in the United Kingdom of childbearing age are clinically
obese (BMI 30)?

Pre-test answer Your answer Correct answer

a. 2%
b. 5%
c. 10%
d. 15%
e. 20%
7. That's right.
8. In 2008 about half of UK women of childbearing age were overweight (BMI >25),
and 15.6% were obese.10 11 This is associated with increased risk to both mother and
child.
9. Learning bite: weight gain in pregnancy
10. Women gain weight due to the pregnancy itself, including the weight of fetal and
placental tissue; and increased volume of blood, amniotic fluid, and other body fluids.
However, women also commonly gain weight as adipose tissue during pregnancy
which they may retain afterwards. Women sometimes ask how much weight they
should expect to gain during pregnancy. There are no reliable data from Europe, but
guidelines from the US Institute of Medicine recommend the following levels of
weight gain during pregnancy, based on observational studies:
o Normal bodyweight (BMI 18.5-25): 11.5 to 16 kg
o Overweight women (BMI 25-30): 7 to 11.5 kg
o Obese women (BMI >30): 5 to 9 kg

7. Typically, how many additional calories (kcal) will a pregnant woman require above
her non-pregnant requirement?

Pre-test Your Correct

answer answer answer
a. About 500 kcal a day, throughout pregnancy
b. About 100 kcal a day in first trimester, 200 in
the second, and 500 in the third
c. No significant increase throughout pregnancy
d. No significant increase in first and second
trimesters, and about 200 kcal a day in the third
trimester

8. That's right.
9. During the embryonic and early fetal stages of development there is very little
increase in a woman's calorie requirements. In the third trimester this increases by
around 200 kcal a day. Women who feed their babies with breast milk alone require
about an extra 350-400 kcal a day.10

8. Which of the following is a red flag symptom which should alert you to the possibility
of severe pre-eclampsia requiring urgent assessment?

Pre-test answer Your answer Correct answer

a. Blurred vision
b. Heartburn
c. Chronically swollen feet
d. Mild intermittent headaches

9. That's right.
10. You should inform your pregnant patients that they should seek urgent medical advice
if they experience symptoms of pre-eclampsia. Such symptoms include:
o Severe headache
 o Blurred vision or flashing in front of the eyes
o Severe pain under the ribs (due to hepatomegaly)
o Vomiting
o Sudden swelling of face, hands, or feet (not chronic swelling, which is
common in pregnancy).

Learning bite: risk factors for pre-eclampsia6

A number of risk factors are recognised which lead to a high level of risk of pre-
eclampsia, including:

o Hypertensive disease during a previous pregnancy

o Chronic kidney disease
o Autoimmune disease such as systemic lupus erythematosus or
antiphospholipid syndrome
o Type 1 or type 2 diabetes
o Chronic hypertension.

Other risk factors lead to a moderate level of risk of pre-eclampsia, including:

o First pregnancy
o Age 40 years or older
o Pregnancy interval of more than 10 years
o BMI of 35 or more
o Family history of pre-eclampsia
o Multiple pregnancy.

The levels of risks are as follows6:

o For women who have had gestational hypertension, risks in future pregnancies
are:
16-47% risk of gestational hypertension
2-7% risk of pre-eclampsia
o For women who have had pre-eclampsia, risks in future pregnancies are:
13-53% risk of gestational hypertension
16% risk of pre-eclampsia
o For women who have had pre-eclampsia complicated by severe pre-eclampsia,
HELLP syndrome, or eclampsia and led to birth before 34 weeks, risks in
future pregnancies are:
25% risk of pre-eclampsia
o For women who have had pre-eclampsia, HELLP syndrome, or eclampsia and
led to birth before 28 weeks, risks in future pregnancies are:
55% risk of pre-eclampsia.

Learning bite: prophylactic aspirin in patients with pre-eclampsia

Women at higher risk of pre-eclampsia should be offered 75 mg aspirin at their

antenatal booking visit (at 12 weeks' gestation), to continue until delivery.
9. What are the recommended target ranges for blood glucose in pregnant women with
diabetes (presuming that they can be achieved safely in the individual patient)?

Pre-test Your Correct

answer answer answer
a. Fasting glucose 3.5 to 5.9 mmol/l and
HbA1c <6.1%
b. Fasting glucose 3.5 to 5.9 mmol/l and
HbA1c <10.5%
c. Fasting glucose 3.5 to 8.9 mmol/l and
HbA1c <6.1%
d. Fasting glucose 1.5 to 5.9 mmol/l and
HbA1c <6.1%

10. That's right.

11. Blood glucose targets should be set individually and take account of individual
patients' requirements, particularly their susceptibility to hypoglycaemic episodes.
However, NICE suggests target ranges which you should aim for if they can be
achieved safely in an individual. For pregnant women these recommendations are a
fasting glucose between 3.5 and 5.9 mmol/l; 1 hour post-prandial glucose below 7.8
mmol/l; and glycosylated haemoglobin (HbA1c) less than 6.1%.9
12. If a woman with diabetes is unable to maintain her HbA1c below 10%, you should
advise her against getting pregnant.9

10. Which of the following maternal risk factors is correctly paired with complications
with which they are associated?

Pre-test Your Correct

answer answer answer
a. Smoking: childhood cancers
b. Obesity: miscarriage
c. Hypertension: gestational diabetes
d. Drug misuse: pre-eclampsia
e. South Asian ethnicity: sickle cell
disease

11. That's right.

12. There are a number of well-established maternal factors which are associated with
increased risks of particular outcomes. These include:
o Smoking: miscarriage, increase in infant mortality by 40%, asthma in
childhood, attention deficit disorder
o Obesity: Miscarriage, impaired glucose tolerance, diabetes mellitus (both
gestational and type 2), pre-eclampsia, thromboembolism, maternal death,
congenital abnormalities, macrosomia (leading to shoulder dystocia),
childhood obesity, fetal death/stillbirth
o Hypertension: pre-eclampsia, eclampsia, maternal death, IUGR, pre-term
delivery, stillbirth6
 o Drug misuse: complications will vary with the drug(s) and may also be
associated with concordant problems, such as a chaotic lifestyle, or HIV
infection.
o Ethnicity: South Asian ethnicity is especially associated with beta-
thalassaemia, not sickle cell disease (which is commoner mainly in those of
Afro-Caribbean and West African ethnic origin).

Previous page
Save
Next page

ISSN 1752-8526

Contact us |
Website terms & conditions |
Privacy policy |
Home |
Top

BMJ Publishing Group Limited 2011. All rights reserved.

BMJ
BMJ Journals
BMJ Careers
BMJ Learning
Evidence Centre
doc2doc
BMJ Group

Print
Update your details
Signed in as:
lalitha Ganti
Log out
Upgrade
Redeem Voucher

GP trainee
Interactive case history

Section 5 of 9
Chronic kidney disease: early identification
and management in adults - in association
with NICE
10013214 45

next

Key points
Haemodialysis

To detect and identify proteinuria, use urine albumin:creatinine ratio in preference, as it has
greater sensitivity than protein:creatinine ratio for low levels of proteinuria. For
quantification and monitoring of proteinuria, protein:creatinine ratio can be used as an
alternative. Urine albumin:creatinine ratio is the recommended method for people with
diabetes.

Offer ACE inhibitors or angiotensin-II receptor blockers to non-diabetic people with chronic
kidney disease and hypertension and urine albumin:creatinine ratio 30 mg/mmol or more
(approximately equivalent to protein:creatinine ratio 50 mg/mmol or more, or urinary protein
excretion 0.5 g/24 h or more).

Stage 3 chronic kidney disease should be split into two subcategories defined by:

GFR 45-59 ml/min/1.73 m2 (stage 3A)

GFR 30-44 ml/min/1.73 m2 (stage 3B).

Stages of chronic kidney disease (updated)

Stage* GFR (ml/min/1.73 Description
m2)
1 90 Normal or increased GFR, with other evidence of kidney
damage
2 60-89 Slight decrease in GFR, with other evidence of kidney damage
3A 45-59 Moderate decrease in GFR, with or without other evidence of
kidney damage
3B 30-44
4 15-29 Severe decrease in GFR, with or without other evidence of
kidney damage
5 <15 Established renal failure
*Use the suffix (p) to denote the presence of proteinuria when staging CKD
(recommendation 1.2.1).

For the purposes of classifying the stages of CKD define proteinuria as urinary urine
albumin:creatinine ratio 30 mg/mmol or more, or protein:creatinine ratio 50 mg/mmol or
more (approximately equivalent to urinary protein excretion 0.5 g/24 h or more).

Offer people testing for chronic kidney disease if they have any of the following risk factors:

Diabetes
Hypertension
Cardiovascular disease (ischaemic heart disease, chronic heart failure, peripheral
vascular disease, and cerebral vascular disease)
Structural renal tract disease, renal calculi, or prostatic hypertrophy
Multisystem diseases with potential kidney involvement - for example, systemic lupus
erythematosus
Family history of stage 5 chronic kidney disease or hereditary kidney disease
Opportunistic detection of haematuria or proteinuria.

In the absence of the above risk factors, do not use age, sex, or ethnicity as risk markers to
test people for chronic kidney disease. In the absence of metabolic syndrome, diabetes, or
hypertension, do not use obesity alone as a risk marker to test people for chronic kidney
disease.

Take the following steps to identify progressive chronic kidney disease:

Obtain a minimum of three eGFR estimations over a period of not less than 90 days
In people with a new finding of reduced eGFR, repeat the eGFR within two weeks to
exclude causes of acute deterioration of GFR - for example, acute kidney injury or
initiation of ACE inhibitor therapy
Define progression as a decline in eGFR of more than 5 ml/min/1.73 m2 within one
year, or more than 10 ml/min/1.73 m2 within five years
Focus particularly on those in whom a decline of eGFR continuing at the observed
rate would lead to the need for renal replacement therapy within their lifetime by
extrapolating the current rate of decline.
In people with chronic kidney disease aim to keep the systolic blood pressure below 140 mm
Hg (target range 120-139 mm Hg) and the diastolic blood pressure below 90 mm Hg.

In people with chronic kidney disease and diabetes, and also in people with an urine
albumin:creatinine ratio 70 mg/mmol or more (approximately equivalent to protein:creatinine
ratio 100 mg/mmol or more, or urinary protein excretion 1 g/24 h or more) aim to keep the
systolic blood pressure below 130 mm Hg (target range 120-129 mm Hg) and the diastolic
blood pressure below 80 mm Hg.

Clinical tips
Matured arteriovenous fistula

Offer a renal ultrasound to all people with chronic kidney disease who:

Have progressive chronic kidney disease (eGFR decline more than 5 ml/min/1.73 m2
within one year, or more than 10 ml/min/1.73 m2 within five years)
Have visible or persistent invisible haematuria
Have symptoms of urinary tract obstruction
Have a family history of polycystic kidney disease and are aged over 20
Have stage 4 or 5 chronic kidney disease
Are considered by a nephrologist to require a renal biopsy.

Advise people with a family history of inherited kidney disease about the implications of an
abnormal result before a renal ultrasound scan is arranged for them.

If a patient with chronic kidney disease has anaemia you should first request haematinics to
find out the cause - you shouldn't automatically assume that it is anaemia due to chronic
kidney disease.
The algorithms
Algorithms on the investigation and management of chronic kidney disease in people with and without
diabetes
Taken from: http://www.nice.org.uk/CG073quickrefguide

Previous page
Save
Next page

ISSN 1752-8526

Contact us |
Website terms & conditions |
Privacy policy |
Home |
Top

BMJ Publishing Group Limited 2011. All rights reserved.