Medical Complications In Pregnancy

MEDICAL CONDITIONS COMPLICATING PREGNANCY

DIABETES MELLITUS

DEFINITION OF TERMS
OVERT DIABETES
- those known to have diabetes mellitus
before pregnancy
GESTATIONAL DIABETES
- those diagnosed during pregnancy

CLASSIFICATION DURING PREGNANCY
CLASS ONSET FBS 2-HR PP GL THERAPY
A1 Gestational <105 mg/dl <120 mg/dl Diet
A2 Gestational >105 mg/dl >120 mg/dl Insulin

CLASSIFICATION DURING PREGNANCY
CLASS AGE/ONSET DURATION VASCULAR THERAPY
(Years) DISEASE
B Over 20 < 10 None Insulin
C 10 – 19 10 – 19 None Insulin
D Before 10 > 20 Benign Insulin
Retinopathy
F Any Any Nephropathy Insulin
R Any Any Proliferative Insulin
Retinopathy
H Any Any Heart Insulin

GESTATIONAL DIABETES
carbohydrate intolerance of variable severity with onset or first recognition during pregnancy
disorder of late gestation
disorder induced by pregnancy:
from exagerrated physiological changes
in glucose metabolism
Type 2 DM unmasked during pregnancy

A 23 yr old markedly obese primigravida at 12 weeks gestation seeks consultation for her first prenatal check-up. She denies any family history of diabetes mellitus. As part of prenatal work-up, you would:
A. take a 50 gm glucose challenge test as soon as possible
B. order for 50 gm glucose challenge test at 24-28 weeks
C. take a 100 gm oral glucose tolerance test as soon as possible
D. order for a 100 gm oral glucose tolerance test at 24-28 weeks

WHO to screen ?

GDM - SCREENING
RISK FACTORS
Age over 30
Family Hx of DM
Prior macrosomic, malformed or stillborn infant
Obesity
Hypertension
Glucosuria

WHEN to screen ?

RECOMMENDED SCREENING STRATEGY BASED ON RISK ASSESSMENT FOR DETECTING GDM
LOW RISK
Blood glucose testing not routinely required if all of the ff characteristics are present:
Member of ethnic grp w/ low prevalence of GDM
No known DM in 1 st degree relative
Age less than 25 yrs
Weight normal before pregnancy
No Hx of abnormal glucose metabolism
No Hx of poor obstetrical outcome

AVERAGE RISK
Perform blood glucose testing at 24-28 wks:
Hispanic
African
Native American
South or East Asian origin

HIGH RISK
Perform blood glucose testing as soon as feasible . If normal, repeat at 24-28 wks or at any time pt has SSx suggestive of hyperglycemia:
Marked obesity
Strong family Hx of type 2 DM
Prior gestational diabetes
Glucosuria

HOW to screen ?

GDM - SCREENING
50-g GLUCOSE CHALLENGE TEST
> 140 mg/dl or > 130 mg/dl
– proceed to 100 gm 3 Hr Oral Glucose Tolerance Test

GDM - SCREENING
100-gm ORAL GLUCOSE TOLERANCE TEST (OGTT)
TIME NDDG CARPENTER & COUSTAN
(1979) (1989)
Fasting 105 95
1 hour 190 180
2 hours 165 155
3 hours 145 140
GDM is dxed with 2 or > abn values.

A 23 yr old markedly obese primigravida at 12 weeks gestation seeks consultation for her first prenatal check-up. She denies any family history of diabetes mellitus. As part of prenatal work-up, you would:
A. take a 50 gm glucose challenge test as soon as possible
B. order for 50 gm glucose challenge test at 24-28 weeks
C. take a 100 gm oral glucose tolerance test as soon as possible
D. order for a 100 gm oral glucose tolerance test at 24-28 weeks

GDM - ADVERSE EFFECTS
MACROSOMIA
Excessive fat deposition on shoulders/trunk
Predisposes to shoulder dystocia
Maternal hyperglycemia  transfer of excess glucose to fetus  stimulate fetal insulin secretion which is a potent growth factor
HYPOGLYCEMIA at birth

MACROSOMIA Pathogenesis

Fetal effects of persistent maternal fasting hyperglycemia include:
A. macrosomia
B. postterm pregnancy
C. oligohydramnios
D. hypoglycemia

GDM - MANAGEMENT
Type A1 – diet alone
Type A2 – diet + insulin
DIET
Goals: 1. to provide the necessary nutrients for
mother and fetus
2. to control glucose levels
3. to prevent starvation ketosis
EXERCISE
upper body cardiovascular training

Recommended postpartum follow-up for patients with gestational diabetes consists of:
A. daily blood sugar monitoring
B. fasting blood sugar on day of discharge
C. 50 gm glucose challenge test 1 week postpartum
D. 75 gm oral glucose tolerance test 6 weeks postpartum

GDM - PROGNOSIS
50% risk of developing overt DM w/in 20 yrs
Evaluate with 75-gm OGTT – 6-12 wks pp
TIME NO DIABETES IMPAIRED DIABETES
GL. TOL.
Fasting < 115 < 140 >/= 140
½, 1, 1-½ All < 200 1 value >/= 200 1 value >/=200
2 hr < 140 140 – 199 >/= 200
If 75-g OGTT is normal – take FBS yearly

Recommended postpartum follow-up for patients with gestational diabetes consists of:
A. daily blood sugar monitoring
B. fasting blood sugar on day of discharge
C. 50 gm glucose challenge test 1 week postpartum
D. 75 gm oral glucose tolerance test 6 weeks postpartum

OVERT DIABETES
Pregestational diabetes
Known diabetics before pregnancy

The diagnosis of overt diabetes is most probable in the gravida with which of the ff OGTT results (Fasting-1hr-2hr-3hr post glucose load – mg/dl):
A. 100 – 190 – 170 – 130
B. 90 – 195 – 140 – 120
C. 95 - 180 - 155 - 140
D. 130 - 170 - 160 - 135

OVERT DIABETES
DIAGNOSIS DURING PREGNANCY
RBS >200 mg/dl + Sx: polyuria, polydipsia, wt loss
Fasting glucose > 125 mg/dl
Strong likelihood in pts with:
strong family Hx of DM
previous large infants
persistent glucosuria
unexplained fetal losses

The diagnosis of overt diabetes is most probable in the gravida with which of the ff OGTT results (Fasting-1hr-2hr-3hr post glucose load – mg/dl):
A. 100 – 190 – 170 – 130
B. 90 – 195 – 140 – 120
C. 95 - 180 - 155 - 140
D. 130 - 170 - 160 - 135

OVERT DIABETES
EFFECTS ON FETUS
ABORTION – poor glycemic control
HbA1c > 12%
persistent pre-prandial glucose level > 120 mg/dl
MALFORMATIONS
Type 1 – 5-10% incidence
from poorly controlled DM preconceptionally and in early pregnancy

OVERT DIABETES
EFFECTS ON FETUS
UNEXPLAINED FETAL DEATH
HYDRAMNIOS
from fetal polyuria
RESPIRATORY DISTRESS
from prematurity
HYPOGLYCEMIA
from hyperplasia of fetal B-islet cells

OVERT DIABETES
EFFECTS ON FETUS
HYPOCALCEMIA
HYPOBILIRUBINEMIA
prematurity
polycythemia with hemolysis
CARDIAC HYPERTROPHY
INHERITANCE OF DM
Diabetic Mother – 1-3% risk
Diabetic Father – 6%
Diabetic Father and Mother – 20 % risk

OVERT DIABETES
EFFECTS ON MOTHER
DIABETIC NEPHROPATHY
inc. when HbA1c > 10%
microalbuminuria  overt proteinuria
 HPN  end-stage renal dse
DIABETIC RETINOPATHY
after 7 yrs – 50% chance of dev.
after 20 yrs – 90%
DIABETIC NEUROPATHY

OVERT DIABETES
EFFECTS ON MOTHER
PREECLAMPSIA
not related to glucose control
KETOACIDOSIS
result of: hyperemesis gravidarum
use of B sympathomimetic drugs
(tocolytics)
infections
use of corticosteroids
INFECTIONS – 80%

OVERT DIABETES MANAGEMENT
PRECONCEPTION
HbA1c – expresses an ave. of circulating
glucose for the past 4-6 wks
- assess metabolic control
- > 10% - inc. risk for malformations
Folate – 400 ug/day
- to decrease neural tube defects

OVERT DIABETES MANAGEMENT
PREGNANCY
Blood glucose monitoring
Precise fetal age determination
LMP, FH, FHT, U/S
Well established EDC – to assess accurately
macrosomia, hydramnios, FGR
Diet
Insulin

PULMONARY DISORDERS

NORMAL CHANGES IN PREGNANCY

PULMONARY TUBERCULOSIS

TUBERCULOSIS
Organism: Mycobacterium tuberculosis
DIAGNOSIS
Symptoms: cough w/ minimal sputum
low-grade fever
hemoptysis
weight loss

TUBERCULOSIS
DIAGNOSIS
Lab: Chest Xray
cavitations
mediastinal lymphadenopathy
extent of dse may be masked by lung compression
Sputum exam – acid-fast bacilli

Recommended initial treatment of active tuberculosis during pregnancy is:
A. INH, Ethambutol, Rifampin
B. INH, Ethambutol, Pyrazinamide, Rifampin
C. INH, Rifampin, Streptomycin
D. INH only

TUBERCULOSIS
MANAGEMENT
Isoniazid + Rifampicin + Ethambutol for a minimum of 9 months (WHO: + Purazinamide x 6 months)
EFFECT ON PREGNANCY
Preterm delivery
Low birthweight
Perinatal death
Neonatal tuberculosis – rare, fatal
Route: hematogenous
aspiration of inf secretion at del unlikely if Rxed

Recommended initial treatment of active tuberculosis during pregnancy is:
A. INH, Ethambutol, Rifampin
B. INH, Ethambutol, Pyrazinamide, Rifampin
C. INH, Rifampin, Streptomycin
D. INH only

URINARY TRACT DISORDERS

Which of the ff laboratory values is not normal during pregnancy and suggests an underlying renal disease:
A. Urinalysis: glucose +
B. mild right hydronephrosis on ultrasound
C. serum creatinine – 1.2 mg/dl
D. Urinalysis: protein - trace

Increased renal size
Dilatation of pelves, calyces and ureters
- not to be mistaken for obstructive uropathy
- predispose to serious upper urinary tract infections
Increased GFR and RPF
- Serum creatinine and urea nitrogen decrease

DIAGNOSTIC TESTS
Urinalysis
glucosuria
orthostatic proteinuria
Serum creatinine
> 0.9 mg/dl – suspect intrinsic renal dse
Ultrasonography
Intravenous pyelography
if indicated, one-shot pyelogram
Cystoscopy
Renal Biopsy (?)

Which of the ff laboratory values is not normal during pregnancy and suggests an underlying renal disease:
A. Urinalysis: glucose +
B. mild right hydronephrosis on ultrasound
C. serum creatinine – 1.2 mg/dl
D. Urinalysis: protein - trace

URINARY TRACT INFECTION

Acute Uncomplicated Cystitis is most likely in this case:
A. A 26-year-old G1P0 with fever,
dysuria and flank pains
B. A 35-year-old G3P2 with hematuria
and colicky right flank pain
C. An 18-year-old G3P0020 with
dysuria, urinary frequency & yellow-
green vaginal discharge
D. A 28-year-old G2P1 with dysuria and
urinary urgency

URINARY TRACT INFECTIONS
ASYMPTOMATIC BACTERIURIA
DIAGNOSIS
Clean-voided specimen containing >100,000 org/ml
MANAGEMENT
Nitrofurantoin (or Ampicillin, Amoxycillin, Cephalosporin)
If untreated, 25% develop acute Sxtic infection.

CYSTITIS AND URETHRITIS
DIAGNOSIS
Symptoms: dysuria
urgency
urinary frequency
Lab: UA – pyuria, bacteriuria, hematuria
MANAGEMENT
Ampicillin (or Sulfonamides,Nitrofurantoin, Cephalosporin)

ACUTE PYELONEPHRITIS
Leading cause of septic shock during pregnancy (endotoxemia)
More common after mid-pregnancy
Uslly right-sided
Uslly an ascending infection from lower UTI

DIAGNOSIS
Symptoms: fever
shaking chills
aching pain – lumbar areas
P.E.: costovertebral angle tenderness
Lab: UA – leukocytes in clumps
Urine culture – E. coli 77%
Klebsiella pneumoniae 11%
Enterobacter / Proteus 4%

MANAGEMENT
Hospitalization
Urine and blood cultures
CBC, Serum creatinine, and electrolytes
Rpt in 48 hrs
Chest Xray – if w/ dypnea or tachypnea
Monitor V/S, urine output (FBC)
IV crystalloid to establish UO to 30 ml/hr or >

MANAGEMENT
Antimicrobial therapy
Ampicillin + Gentamycin
or Cephalosporins
Intravenous
Change to po when afebrile – 7-10 days
Urine culture 1-2 wks after completion of Rx
30-40% - recurrent infection

Acute Uncomplicated Cystitis is most likely in this case:
A. A 26-year-old G1P0 with fever,
dysuria and flank pains
B. A 35-year-old G3P2 with hematuria
and colicky right flank pain
C. An 18-year-old G3P0020 with
dysuria, urinary frequency & yellow-
green vaginal discharge
D. A 28-year-old G2P1 with dysuria and
urinary urgency

THYROID DISORDERS

Moderate thyroid enlargement
- glandular hpl and vascularity
Inc. uptake of radioiodine by maternal thyroid
Inc. total serum thyroxine and triiodothyronine
Inc. thyroid binding globulin

HYPERTHYROIDISM
DIAGNOSIS:
Tachycardia
Thyromegaly
Failure to gain weight despite normal or increased food intake
Marked elevation of plasma thyroxine
Elevated sleeping pulse rate
exophthalmos

GRAVE’S DISEASE
Most common cause of thyrotoxicosis in pregnancy
Autoimmune process associated with thyroid stimulating antibodies
Autoantibodies mimic thyrotropin and stimulate thyroid function

A 37 yr old G2P1 12 weeks gestation presents for her first prenatal check-up. She had been diagnosed with Grave’s disease and maintained on propylthiouracil. Currently, she is euthyroid. Which of the ff statements is appropriate in counseling this patient:
She must discontinue PTU because it is associated with leukopenia.
Infants born to mothers on PTU may develop goiter and be clinically hypothyroid.
PTU does not cross the placenta.
Thyroid storm is a common complication in pregnant women with Graves disease.

GRAVE’S DISEASE
MANAGEMENT
Medical
Propylthyouracil / Methimazole
readily cross placenta & induce
fetal hypothyroidism & goiter
dose depends on total serum
thyroxine level which should
be in upper N range for preg

A 37 yr old G2P1 12 weeks gestation presents for her first prenatal check-up. She had been diagnosed with Grave’s disease and maintained on propylthiouracil. Currently, she is euthyroid. Which of the ff statements is appropriate in counseling this patient:
She must discontinue PTU because it is associated with leukopenia.
Infants born to mothers on PTU may develop goiter and be clinically hypothyroid.
PTU does not cross the placenta.
Thyroid storm is a common complication in pregnant women with Graves disease.

GRAVE’S DISEASE
MANAGEMENT
Surgical – Subtotal Thyroidectomy
after thyrotoxicosis is under control or pt nearly euthyroid
done in 2 nd tri or early 3 rd tri
elective
Indications:
1. women who cannot adhere to
medical Rx
2. women in whom drug therapy is toxic

GRAVE’S DISEASE
EFFECT ON PREGNANCY
Higher incidence of preeclampsia
heart failure
EFFECT ON NEONATE
Neonatal thyrotoxicosis
fr transplacental passage of maternal thyroid stimulating ab

HYPOTHYROIDISM
DIAGNOSIS
Absence of normal rise in serum thyroxine
Increased thyrotropin level
Uncommon in pregnancy because associated with infertility

HYPOTHYROIDISM
EFFECT ON PREGNANCY
Inc. incidence of abortion, SB, LBW
preeclampsia
placental abruption

HYPOTHYROIDISM
EFFECT ON NEONATE
Usually healthy
Simple Colloid goiter w/o hypothyroidism – no effect
Severe hypothyroidism sec. to maternal radioiodine Rx during pregn  destruction of fetal thyroid  cretinism

HYPOTHYROIDISM
MANAGEMENT
Thyroid hormones
dose adjusted so that serum thyrotropin level is w/in N range

Thyroid function tests showing an elevated serum thyrotropin, normal serum thyroxine and normal triiodothyronine in an asymptomatic woman at 14 weeks gestation is diagnostic of:
A. Hypothyroidism
B. Hyperthyroidism
C. Subclinical hypothyroidism
D. Subclinical hyperthyroidism

PUERPERAL INFECTION

10 days post cesarean section, a 23 yr old primipara complains of fever of 3 days duration associated with hypogastric pain. Temp – 40 C. Breasts are slightly tender. Pelvic exam shows tenderness over the area of the uterus and parametria. The most likely consideration is: A. Breast engorgement B. Acute pyelonephritis C. Metritis with pelvic cellulitis D. Septic pelvic thrombophlebitis

PUERPERAL MORBIDITY
temperature 38 C or higher, the temperature to occur on any 2 of the 1 st 10 days postpartum, exclusive of the first 24 hrs, and to be taken by mouth by a standard technique at least 4x daily
JOINT COMMITTEE ON MATERNAL WELFARE

Differential Diagnosis of Puerperal Fever
Genital tract infection
Respiratory complications
Pyelonephritis
Breast Engorgement
Bacterial Mastitis
Thrombophlebitis
Incisional wound abscess

Respiratory Complications
- seen within the 1 st 24 hours
- in women delivered by cesarean section
- use of general anesthesia
Atelectasis
Aspiration pneumonia
Bacterial pneumonia

Pyelonephritis
SSx: bacteriuria / pyuria
costovertebral angle tenderness
spiking temperature
Clinical Dx: Urinalysis
U/S
Rx: Antibiotics

Breast Engorgement
15 % of all postpartum women
Fever rarely goes > 39 C
Fever – not longer than 24 hrs

Thrombophlebitis
SSx:
painful swollen leg
calf / femoral angle tenderness
Mgt: Heparin

Uterine Infection
Infection involving the decidua, myometrium and parametrial tissues
Metritis with Pelvic
Cellulitis

Uterine Infection
The route of delivery is the single most significant risk factor for the development of postpartum uterine infection.
Incidence of Metritis:
ff C/S 13 – 50%
ff vaginal delivery 1.3 – 2.6%

Risk Factors for Metritis
Prolonged labor
Prolonged membrane rupture
Multiple cervical examination
Use of internal fetal monitoring
Intraamniotic infection
Bacterial colonization of lower genital tract
Group B streptococcus Mycoplasma hominis
Chlamydia trachomatis Gardnerella vaginalis

Bacteria Responsible for Genital Tract Infections
Aerobes
Grp A, B and D streptococci
Enterococcus
Gram (-) bacteria – E. coli, Klebsiella and Proteus sp
Staphylococcus aureus
Gardnerella vaginalis
Anaerobes
Peptococcus sp Clostridium sp
Peptostreptococcus sp Fusobacterium sp
Bacteroides fragilis Mobiluncus sp
Others
Mycoplasma sp Chlamydia trachomatis Neisseria gonorrhea

Clinical Course
Fever
Chills
Abdominal pain / tenderness
Foul-smelling lochia
B hemolytic streptococci – scanty odorless lochia
Leukocytosis – 15,000 – 30,000/cu mm

Treatment
BROAD SPECTRUM ANTIBIOTICS
Clindamycin + Gentamycin
most widely studied regimen
90 – 97% efficacy
plus ampicillin – if enterococcal infection suspected
Aztreonam – if with renal insufficiency

Causes of Persistent Fever Despite Antibiotic Rx
Wound infection
Peritonitis
Parametrial phlegmon
Pelvic abscess
Septic Thrombophlebitis

Wound Infection
3 – 5% post C/S
2% - with prophylactic antibiotics
SSx: fever
erythema, wound discharges
Rx: antibiotics
surgical drainage

Risk Factors for Wound Infection
Obesity
Diabetes
Corticosteroid therapy
Immunosuppression
Anemia
Poor hemostasis with hematoma formation

Peritonitis
Route: lymphatics
SSx: severe abdominal pain
bowel distension – ileus
Rx: antibiotics
fluid and electrolyte replacement
decompression
surgery – bowel lesion
uterine incisional necrosis

Parametrial Phlegmon
Dx: parametrial induration
unilateral
uterus fixed on
one side
Rx: antibiotics
surgery – uterine incisional necrosis

Pelvic Abscess
Dx: fluctuant broad ligament mass
Rx: Drainage
Colpotomy

Septic Thrombophlebitis
Route: hematogenous
Pathogenesis:
placental site infection 
thrombosed myometrial vs
SSx: enigmatic fever
lower abd’l / flank pain
tender mass beyond the cornu

Infections of Perineum, Vagina and Cervix
Rx: Drainage
Antibiotics
Analgesics
Foleybag catheter
Repair

10 days post cesarean section, a 23 yr old primipara complains of fever of 3 days duration associated with hypogastric pain. Temp – 40 C. Breasts are slightly tender. Pelvic exam shows tenderness over the area of the uterus and parametria. The most likely consideration is: A. Breast engorgement B. Acute pyelonephritis C. Metritis with pelvic cellulitis D. Septic pelvic thrombophlebitis

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Medical Complications In Pregnancy

by DJ CrissCross

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