This document discusses factors that can place a pregnancy at high risk and identifies various medical conditions that contribute to high risk pregnancies. It is divided into four main categories that can increase risk: existing health conditions, age, lifestyle factors, and conditions of pregnancy. Several existing health conditions are explained in more detail, including cardiovascular, hematologic, renal/urinary, respiratory, and rheumatic disorders. Complications associated with each condition for both the woman and fetus are provided.

1. IDENTIFYING
A HIGH RISK
PREGNANCY

2. • High-Risk Pregnancy - one in which a
concurrent disorder, pregnancy-related
complication, or external factor jeopardizes
the health of the woman, the fetus, or both
High Risk Pregnancy

3. Three Major Causes of Maternal Death:
• Hypertensive Disorders
• Infection
• Hemorrhage
Factors Related to Maternal Death:
• Age (Younger than 20 years and 35 years older)
• Lack of prenatal care.
• Low educational attainment
• Unmarried Status
High-Risk Pregnancy

4. Leading cause of death in the neonatal
period is CONGENITAL ANOMALIES.
Other Causes:
• Disorders related to short gestation and low
birth weight
• Sudden Infant Death Syndome
• Respiratory Distress Syndrome
• Effects of Maternal Complications
High-Risk Pregnancy

5. High-Risk Pregnancy
The factors that place a pregnancy at risk
can be divided into four categories:
1.Existing Health Conditions
2.Age
3.Lifestyle Factors
4.Conditions of Pregnancy

6. Existing Health Conditions
• Cardiovascular D/O
• Hematologic D/O
• Renal and Urinary
D/O
• Respiratory D/O
• Rheumatic D/O
• Gastrointestinal D/O
• Neurologic D/O
• Musculoskeletal D/O
• Endocrine D/O
• Cancer
• Mental Illness

7. Cardiovascular Disorder and
Pregnancy
• complicates only approximately 1% of all pregnancies
• responsible for 5% of maternal deaths during
pregnancy
• Most common disorders: valve damage caused by
rheumatic fever or Kawasaki disease and congenital
anomalies such as atrial septal defect or uncorrected
coarctation of the aorta.
• Increasing age of pregnancy increases the incidence of
coronary artery disease and varicosities during
pregnancy
• Peripartum heart disease rarely occurs

8. Cardiovascular Disorder and
Pregnancy
• A woman with cardiovascular disease
needs a team approach to care during
pregnancy, combining the talents of an
internist, obstetrician, and nurse.
• Blood volume and Cardiac output increase
30% to 50% during pregnancy
• Functional (innocent) murmurs are present
because of the increase in blood vol. and
cardiac output

10. Cardiovascular Disorder and
Pregnancy
• A woman with left-sided heart failure
– left ventricle cannot move the volume of blood forward
that it has received by the left atrium from the
pulmonary circulation.
– heart becomes so overwhelmed it fails to function
– Because of the limited oxygen exchange, women with
pulmonary hypertension are at extremely high risk for
spontaneous miscarriage, preterm labor, or maternal
death
– A woman experiences increased fatigue, weakness,
and dizziness (specifically from lack of oxygen in brain
cells)

11. Left-sided heart failure
• pulmonary edema becomes severe, a
woman cannot sleep in any position
except with her chest and head elevated
(orthopnea)
• paroxysmal nocturnal dyspnea—
suddenly waking at night short of breath
– With the more effective heart action, interstitial
fluid returns to the circulation and
overburdens the circulation, causing
increased left-side failure and increased
pulmonary edema

12. Right-Sided Heart Failure
• occurs when the output of the right
ventricle is less than the blood volume
received by the right atrium from the vena
cava
• Back-pressure from this results in
congestion of the systemic venous
circulation and decreased cardiac output
to the lungs.

13. Right-Sided Heart Failure
• Blood pressure decreases in the aorta because less blood is
reaching it; pressure is high in the vena cava from back-
pressure of blood;
• Both jugular venous distention and increased portal circulation
occur
• The liver and spleen become distended
• Liver enlargement can cause extreme dyspnea and pain in a
pregnant woman because the enlarged liver, as it is pressed
upward by the enlarged uterus, puts extreme pressure on the
diaphragm.
• Distention of abdominal vessels can lead to exudate of fluid
from the vessels into the peritoneal cavity (ascites)
• Fluid also moves from the systemic circulation into lower
extremity interstitial spaces (peripheral edema).

14. A Woman With Peripartum
Heart Disease
• An extremely rare condition, peripartal
cardiomyopathy can originate in pregnancy in
women with no previous history of heart disease
• Mortality rate as high as 50%
• occurs most often in African American
multiparas in conjunction with hypertension of
pregnancy
• signs of myocardial failure such as shortness of
breath, chest pain, and edema

15. Assessment of Woman with
Cardiac Disease
• Check for signs of poor circulation
• Assess edema
• Right-sided heart failure – assess for
liver enlargment
• Left-sided heart failure – assess for
pulmonary symptoms like cough
• ECG, chest radiography,
echocardiography

17. • Fetal Assessment
– poor perfusion level may also lead to an
acidotic fetal environment if the blood flow
becomes inadequate for carbon dioxide
exchange
– Preterm labor; prematurity
– Late deceleration patterns

18. Implementation
• Promote rest
• Promote healthy nutrition
• Educate regarding medication
– Close to the anticipated day of birth, some physicians
begin a course of an antibiotic for women with heart
disease such as penicillin because the postpartum period
always involves some mild invasion of bacteria from the
denuded placental site on the uterus into the blood-
stream.
• Educate Regarding Avoidance of Infection
• Be Prepared for Emergency Actions

19. Hematologic Disorders and
Pregnancy
• Anemia
– Pseudo-anemia of early pregnancy – blood
volume expands during pregnancy slightly
ahead of the red cell count
– True anemia – when a woman’s hemoglobin
concentration is less than 11 g/dL (hematocrit
33%) in the first or third trimester of
pregnancy or hemoglobin concentration is
less than 10.5 g/dL (hematocrit 32%)in the
second trimester

20. Hematologic Disorders and Pregnancy
• Iron-Deficiency Anemia
– anemia of pregnancy, complicating as many as 15% to 25% of
all pregnancies
– Ineffective oxygen transport – fatigue and poor exercise
tolerance
– Associated with LBW and preterm birth
– Some women develop pica (ice chips/starch)
– iron supplement of 60 mg elemental iron as prophylactic therapy
during pregnancy/ therapeutic– 120 to 200 mg elemental
iron/day)
– Intake of iron-rich foods
– Severe IDA – iron injections
– SE (iron supp) – constipation and gastric irritation/ black stools
• Increase roughage/ take pills with food

21. Hematologic Disorders and Pregnancy
• Folic Acid-Deficiency Anemia
– Folic acid – normal RBC formation in mothers and prevents NTDs
in fetus
• occurs most often in multiple pregnancies because of the increased
fetal demand
• in women with a secondary hemolytic illness in which there is rapid
destruction and production of new red blood cells
• in women who are taking hydantoin, an anticonvulsant agent that
interferes with folate absorption
• in women who have been taking oral contraceptives; and in women
who have had a gastric bypass for morbid obesity
– Megaloblastic Anemia
– may be a contributory factor in early miscarriage or premature
separation of the placenta.
– Tx – folic Acid supplement of 400 microgram daily to 600
microgram (pregnancy)

22. Hematologic Disorders and Pregnancy
• Sickle Cell Anemia
– a recessively inherited hemolytic anemia caused by
an abnormal amino acid in the beta chain of
hemoglobin [sickle hemoglobin (HbS) if valine is
replaced and nonsickling hemoglobin (HbC) if lysine
is replaced]
– majority of red blood cells are irregular or sickle
shaped so they cannot carry as much hemoglobin
as can normally shaped red blood cells
– Approximately 1 in every 10 African Americans has
the sickle cell trait (i.e., carries a recessive gene for
S hemoglobin but is asymptomatic)

23. Sickle Cell Anemia
• Women with the homozygous disease is at risk
for miscarriage, prematurity or perinatal mortality
rates
• Women with SCA are more prone to bacteriuria
– periodic U/A
• May cause low birth weight and possibly fetal
death
• Tx – Exchange transfusion, Folic Acid, adequate
hydration
• Avoid standing for long periods
• Elevate legs to facilitate venous return

24. • Thalassemia
– thalassemias are a group of autosomal
recessively inherited blood disorders that lead
to poor hemoglobin formation and severe
anemia
– Treatment: folic acid supplementation and
blood transfusion to infuse hemoglobin rich
red blood cells

25. • Malaria
– a protozoan infection that is transmitted to
people by Anopheles mosquitoes
– infection causes red blood cells to stick to the
surfaceof capillaries causing obstruction of
these vessels
– This can result in end organ anoxia when
blood can not reach organs effectively
– Tx: Chloroquine

26. • Coagulation Disorders
– Most coagulation disorders are sex linked or
occur only in males and so have little effect on
pregnancies.
– Von Willebrand disease – autosomal
dominant d/o which also occurs in females
(factor VIII deficiency)
• May cause spontaneous miscarriage or
postpartum hemorrhage
• Prolonged bleeding time
• Cryoprecipitate or fresh-frozen plasma before labor
to prevent excessive bleeding

27. • Hemophilia B (Christmas Disease)
– Sex-linked disorder and occurs only in males
– Factor IX deficiency
– Carrier women may have reduced factor IX level
making them prone to bleeding
– May cause spontaneous miscarriage or
hemorrhage during labor
– Tx – infusion of factor IX concentrate or fresh-
frozen plasma
– PUBS can be done to detect hemophilia in male
fetus
• Check for the presence of coagulation disorder
in fetus and if present, this procedure will be
contraindicated as it may result in extensive fetal
blood loss

28. • Idiopathic Thrombocytopenic Purpura (ITP)
– assumed to be an autoimmune disease where the
body releases antibodies to platelets causing
decreased platelet count
– minute petechiae or large ecchymoses appear on a
woman’s body
– Frequent nosebleeds may occur
– Laboratory studies reveal a marked
– thrombocytopenia (platelet count may be as low as
20,000/mm3 from a usual count of 150,000 mm3)
– Tx: Platelet transfusion or plasmapheresis to
increase platelet count; oral prednisone
– May cause bleeding at birth
– Antiplatelet may cross placenta

29. RENAL AND URINARY DISORDERS AND
PREGNANCY
• Urinary Tract Infection
– As many as 4% to 10% of non pregnant
women have asymptomatic bacteriuria
– In a pregnant woman, because the ureters
dilate from the effect of progesterone, stasis
of urine occurs
– minimal glucosuria that occurs with pregnancy
allows more than the usual number of
organisms to grow

30. • Asymptomatic infection may progress to
pyelonephritis and is associated with
preterm labor and premature rupture of
membranes
• Women with vesicouereteral reflux tend to
develop UTI or pyelonephritis more often
• E. coli – MC cause of ascending infections
• Strep B – may cause descending infection
and is associated with pneumonia in NB.

31. • Assessment (UTI)
– Pain on urination
– Pain on lumbar region (right)
– nausea and vomiting, malaise, pain, and
frequency of urination
– Fever
– Tx: antibitiotics such as amoxicillin, ampicillin
and caphalosphorins are safe during
pregnancy

32. • Chronic Renal Disease
– Women with chronic renal disease may
develop severe anemia during pregnancy
because their diseased kidneys do not
produce erythropoietin, which is necessary
for red cell formation
– Tx: synthetic erythropoeitin
– Dialysis may cause preterm labor

33. For women with kidney
transplant, criteria to
be evaluated include:
• A woman’s general
health and the time
since the trans-plant
(preferably +2
years)
• Serum creatinine
level
• The presence of
proteinuria or
hypertension or
signs of graft
rejection
• Medications taken to
reduce graft
rejection

34. RESPIRATORY DISORDERS AND
PREGNANCY
• Any respiratory condition can worsen in
pregnancy because the rising uterus
compresses the diaphragm, reducing the
size of the thoracic cavity and available
lung space.
• Common cold
• Severe pneumonia
• TB
• COPD

35. • A Woman With Acute Nasopharyngitis
– Common cold
– estrogen stimulation normally causes some
degree of nasal congestion

36. • A Woman With Influenza
– Caused by virus (A, B, C)
– S/S: high fever, extreme prostration, aching
pains in the back and extremities, and
generally a sore, raw throat
– Associated with preterm labor
– not been clearly correlated with congenital
anomalies in children
– Tx: antibiotics, antipyretics, influenza vaccine

37. • A Woman With Pneumonia
– bacterial or viral invasion of lung tissue by
pathogens such as S. pneumoniae,
Haemophilus influenzae, and Mycoplasma
pneumoniae
– Inflammatory response confines the bacteria
or virus within segments of the lobes of the
lungs but also fills alveoli with fluid, blocking
off breathing space
– Tx: antibiotic and oxygen therapy
– May cause preterm labor in late pregnancy
due to decreased oxygen supply

38. • A Woman With Severe Acute Respiratory
Syndrome
– a newly emerged infectious disease with the
clinical symptoms of persistent fever, chills,
muscle aches, malaise, dry cough, headache,
and dyspnea; decreased lymphocyte and
platelet counts.
– Caused by corona virus which originated from
China
– associated with high incidences of
spontaneous miscarriage, preterm birth, and
intrauterine growth restriction.
– no evidence of perinatal SARS infection among
infants born to these mothers.

39. • A Woman With Asthma
– reversible airflow obstruction, airway
hyperreactivity, and airway inflammation
– complicates about 5% to 9% of pregnancies
and is potentially associated with an
increased risk of perinatal complications
– reduced oxygen supply to a fetus leads to
preterm birth or fetal growth restriction if a
major attack should occur during pregnancy

40. • A Woman With Tuberculosis
– caused by Mycobacterium tuberculosis,an
acid-fast bacillus
– Symptoms of tuberculosis include:
• Chronic cough
• Weight loss
• Hemoptysis (coughing blood)
• Night sweats
• Low-grade fever
• Chronic fatigue
– PPD to be done in high risk areas
– Tx: Isoniazid (INH) and ethambutol hy-
drochloride (Myambutol),

41. • A Woman with Chronic Obstructive
Pulmonary Disease
– constriction of the airway associated most
often with long-term cigarette smoking
– If a woman have severe symptoms,
pregnancy is not advised

42. • A Woman With Cystic Fibrosis
– a recessively inherited disease in which there is
generalized dysfunction of the exocrine glands, this
dysfunction leads to mucous secretions, particularly in
the pancreas and lungs, becoming so viscid or thick
that normal lung and pancreatic function is
compromised
– men with cystic fibrosis are sterile because their
semen is so thick that sperm cannot be motile
– Women may have lessened fertility due to
thickened cervical mucus
– inability to digest fat and protein because the
pancreas cannot release amylase.
– Increased risk of preterm labor and perinatal death
– Tx: pancrelipase to supply pancreatic enzyme,,
bronchodilator, chest physiotherapyu

43. • Because pancrelipase may interfere with
iron absorption, a woman is at greater risk
for iron-deficiency anemia during
pregnancy than other women
• Persons with cystic fibrosis have a higher-
than-usual incidence of developing
diabetes mellitus because of pancreas
involvement

44. RHEUMATIC DISORDERS AND
PREGNANCY
• A Woman With Rheumatoid Arthritis
– Juvenile rheumatoid arthritis (chronic
rheumatoid arthritis), a disease of connective
tissue with joint inflammation and contracture,
is most likely the result of an autoimmune
response
– pathology involves synovial membrane
destruction, inflammation with effusion,
swelling, erythema, and painful motion of the
joints
– granulation tissue can fill the joint space,

45. • Tx: corticosteroids, NSAIDs, aspirin
• *use of salicylates (prolonged) may cause
bleeding at birth and prolonged pregnancy
– Salicylates interfere with prostaglandin
synthesis
– infant may be born with a bleeding defect
and may also experience premature closure
of the ductus arteriosus because of the drug’s
effects.
• Symptoms of the disease may improve during
pregnancy because of the naturally increased
circulating level of corticosteroids in the
maternal bloodstream during pregnancy

46. • A Woman With Systemic Lupus
Erythematosus
– a multisystem chronic disease of connective tissue
that can occur in women of child-bearing age: its
highest incidence is in women aged 20 to 40 years
– heart, kidneys, blood vessels, spleen, skin, and
retroperitoneal tissue are affected
– erythematous butterfly-shaped rash on the face
– In the kidneys, fibrin deposits develop, plugging and
blocking the glomeruli and leading to necrosis and
scarring.
– thickening of collagen tissue in the blood vessels
causes vessel obstruction
– Tx: corticosteroid, NSAIDs, heparin, and salicylates

47. GASTROINTESTINAL
DISORDERS AND PREGNANCY
• A Woman With Appendicitis
– typical sharp, peristaltic, lower right quadrant
pain (McBurney’s point), nausea and
vomiting
– Advise a woman not to take food, liquid, or
laxatives while she is waiting to be evaluated
for possible appendicitis, because increasing
peristalsis could cause an inflamed appendix
to rupture

49. • Surgery may be done if past 36 weeks and
UTZ reveals a mature fetus
• Ruptured appendicitis may cause fecal
material reach fetus thru fallopian tube;
generalized peritonitis may be difficult
for a woman to combat and even maintain
pregnancy; peritoneal adhesions may
cause subferility due to changes in the
location of FT.

50. • A Woman With Gastroesophageal
Reflux Disease or Hiatal Hernia
– GERD refers to the reflux of acid stomach
secretions into the esophagus
– Hiatal hernia is a condition in which a portion
of the stomach extends and protrudes up
through the diaphragm into the chest cavity,
trapping stomach acid and causing it to reflux
into the esophagus

51. • Symptoms include:
– Heartburn, which is particularly extreme when
lying supine after a full meal
– Gastric regurgitation
– Dysphagia (difficulty swallowing)
– Possible weight loss because of the inability
to eat
– Hematemesis (vomiting of blood) if extreme
esophageal irritation occurs from the reflux of
hydrochloric acid from the stomach
• Tx: Antacids, PPI, Histamine receptos
antagonist

52. • A Woman With Cholecystitis and
Cholelithiasis
– most frequently associated with women older
than 40 years, obesity, multiparity, and
ingestion of a high-fat diet
– S/S :constant aching and pressure in the right
epigastrium, perhaps accompanied by
jaundice
– Tx: low-fad diet, surgery if nonsurgical
management fails

53. • A Woman With Pancreatitis
– inflammation of the pancreas
– diagnosis may be difficult as serum amylase,
which rises with pancreatitis, is also normally
elevated during pregnancy.
– nasogastric suction, bowel rest, analgesia
(pancreatic pain is sharp), and intravenous
hydration through parenteral nutritional
supplementation.
– acidosis, hypovolemia, and fetal hypoxia

54. • A Woman With Hepatitis
– Hepatitis is a liver disease that may occur from
invasion of the A, B, C, D, or E virus.
– Hepatitis A is spread mainly by fecal–oral contact
• benign course and is not known to be
transmitted to the fetus.
– Hepatitis B and C are spread by exposure to
contaminated blood or blood products.
– Hepatitis D and E are apparently spread by the
same methods as hepatitis B but are rarely seen in
pregnant women.
– may lead to spontaneous miscarriage or preterm
labor.

55. • A Woman With Inflammatory Bowel
Disease
– Crohn’s disease (inflammation of the terminal
ileus) and ulcerative colitis (inflammation of the
distal colon) can also be seen in pregnancy
– associated with passiveand active smoking
– A woman experiences chronic diarrhea, weight
loss, occult blood in stool, and nausea and
vomiting
– with Crohn’s disease, malabsorption,
particularly of vitamin B occurs
– Monitor for weight gain
– TPN, sulfasalazine

56. NEUROLOGIC DISORDERS AND PREGNANCY
• A Woman With a Seizure Disorder
– anoxia may deprive fetus of oxygen
– The risk of adverse maternal or fetal outcome from
seizures during pregnancyis greater than the risk of
teratogenicity from taking anticonvulsant drugs
– Drugs used: Trimethadione, Valproic acid,
Carbamazepine, Ethosuximide, Phenytoin sodium
• Dilantin can cause a syndrome involving fetal
cognitive impairment and a peculiar facial proportion
not unlike that of fetal alcohol syndrome. This may
occur because of competition for folic acid binding
sites. Some infants have an increased danger of
neural tube disorders as a result of this folic acid
displacement. An ultrasound can rule out the
possibility of this.

57. • Infants are also prone to hemorrhagic
disease of the newborn because of
decreased levels of vitamin K coagulation
factors at birth from phenytoin. To
counteract this, women maybe prescribed
vitamin K during labor or the last 4 weeks
of gestation. Women who have been
taking phenytoin (Dilantin)may have
developed chronic hypertension.

58. • A Woman With Myasthenia Gravis
– an autoimmune disorder characterized by the
presence of an IgG antibody against
acetylcholine receptors in striated muscle.
– treated with anticholinesterase drugs such as
pyridostigmine (Mestinon) or
neostigmine(Prostigmin) and a
corticosteroid prednisone; Plasmapheresis
– Smooth muscles are not affected
– NO MgSO4

59. • A Woman With Multiple Sclerosis
– occurs predominantly in women of
childbearing age, usually between 20 and 40
years of age
– nerve fibers become demyelinated and
therefore lose function
– Women develop symptoms of fatigue,
numbness, blurred vision, and loss of
coordination
– Tx: ACTH or corticosteroid to strengthen
nerve function
– May improve during pregnancy

60. MUSCULOSKELETAL DISORDERS
AND PREGNANCY
• A Woman With Scoliosis
– lateral curvature of the spine
– Deformity interferes with respiration and heart action
because of chest compression
– Pelvic distortion can interfere with childbirth,
especially at the pelvic inlet
– If a woman’s spine is extremely curved, spinal or
epidural anesthesia may be difficult to administer for
pain management in labor
– cephalopelvic disproportion
– Tx: stainless steel rods and correction brace

61. ENDOCRINE DISORDERS AND
PREGNANCY
• A Woman With a Thyroid Dysfunction
– thyroid slightly increase in size during pregnancy
• Hypothyroidism
• a rare condition in young adults and especially in
pregnancy
• May lead to early spontaneous miscarriage
• may be associated with an increased incidence of
extreme nausea and vomiting
• Tx: levothyroxine
– her dose of levothyroxine will need to be increased as much
as 20% to 30% for the du-ration of the pregnancy to simulate
the increase that would normally occur in pregnancy

62. • separate thyroxine ingestion from any
medication containing iron, calcium, or soy
products by about 4 hours to be sure that
there is no problem with the absorption of
thyroxine
• Dose should be tapered back after
pregnancy

63. • A Woman With Hyperthyroidism
(Grave’s Disease)
– overproduction of thyroid hormone
– more prone to symptoms of hypertension of
pregnancy, fetal growth restriction, and
preterm labor than the average woman
– Radioactive Iodine uptake (RAIU) to test
thyroid function, should not be done during
pregnancy as it may destroy fetal thyroid
– Tx: PTU to reduce thyroid activity,
methimazole during pregnancy
– infant may be born with symptoms of
hyperthyroidism

65. • Woman with minimal dose may breastfeed
their infant, but not with woman taking
large dose as it may be passed into the
breastmilk.

66. • A Woman With Diabetes Mellitus
– an endocrine disorder in which the pancreas cannot
produce adequate insulin to regulate body glucose
levels
– leading cause of kidney failure, non-traumatic lower-
limb amputations, and new cases of blindness among
adults in the United States
– affects 3% to 5% of all pregnancies and is the most
frequently seen medical condition in pregnancy
– Before insulin was produced synthetically in 1921,
women with type 1 diabetes, or diabetes acquired in
childhood, died before reaching childbearing age,
were infertile, or had spontaneous miscarriages early
in pregnancy

67. • Now that diabetes can be well managed and
type 2 diabetes is occurring more frequently in
young adults, four new problems have
developed:
• How to care for women with both type 1 and type 2
diabetes during pregnancy
• How to bring a woman with type 1, type 2, and
gestational diabetes through a pregnancy with good
glucose and insulin control
• How to protect an infant in utero from the adverse
effects of the increased glucose levels
• How to care for the infant in the first 24 hours after
birth until the infant’s insulin-glucose regulatory
mechanism stabilizes

68. • Infants of diabetic women are five times
more apt to be born with heart anomalies
• Type 1 diabetes is due to pancreatic islet
B cell destruction predominantly by an
autoimmune process, and these persons
are prone to ketoacidosis
• Type 2 diabetes is the more prevalent
form and results from insulin resistance
with a defect in compensatory insulin
secretion
– As the need for insulin rises, the pancreas
gradually loses its ability to produce it.

69. – DM II – hyperglycemia and resulting from the
combination of resistance to insulin action,
inadequate insulin secretion, and excessive or
inappropriate glucagon secretion
– All women appear to develop an insulin resistance as
pregnancy progresses or insulin does not seem as
effective during pregnancy, a phenomenon that is
probably caused by the presence of the hormone
human placental lactogen (chorionic
somatomammotropin)and high levels of cortisol,
estrogen, progesterone, and catecholamines
– 3 P’s of DM
• Polyuria
• Polyphagia
• Polydipsia

70. • continued use of glucose by the fetus may
lead to hypoglycemia for the mother between
meals
• An increase in the amount of amniotic fluid
occurs in at least 25% of diabetic women
• a woman is at greater risk for pregnancy-
induced hypertension and infection
• Infants of women with poorly controlled
diabetes tend to be large(>10 lb) because the
increased insulin the fetus must produce to
counteract the overload of glucose he or she
receives acts as a growth stimulant

71. Gestational
Diabetes
occurs at
20th week of
pregnancy.

72. • A macrosomic infant may create birth
problems like cephalopelvic disproportion
and shoulder dystocia, thus, CS birth
• There is a high incidence of congenital
anomaly, especially caudal regression
syndrome (failure of the lower extremities to
develop), spontaneous miscarriage, and
stillbirth in infants of women with uncontrolled
diabetes
• At birth, the neonates are more prone to
hypoglycemia, respiratory distress
syndrome,hypocalcemia, and
hyperbilirubinemia.

73. • Monitoring DM patients
– glycosylated hemoglobin is used to detect the
degree of hyperglycemia present
• The upper normal level of HbA is 6% of total
hemoglobin
– Fasting plasma glucose 126 mg/dL or
nonfasting of 200 mg/dL – Diabetes
– Opthalmic examination to be done every
trimester as DM causes retinal changes
– Tx: insulin, blood glucose monitoring (A
fasting blood glucose level below 95 to 100
mg/dL and a 2-hour postprandial level
below 120 mg/dL are well-adjusted values)

74. • Hypoglycemia – intake of complex carbs
and less concentrated fluid to prevent
rebound hyperglycemia
• Acidosis should be prevented as maternal
acidosis may lead to fetal anoxia
• The most common time during pregnancy
for hypoglycemia is the second and third
months, before insulin resistance peaks;
for hyperglycemia, it is the 6th month, or
the time insulin resistance is becoming
most pronounced.

76. • Tests for Placental Function and Fetal Well-
Being
– MSAFP
– UTZ
– Creatinine clearance
• A normal creatinine clearance rate suggests that a woman’s
vascular system is intact because kidney function is normal,
this implies that uterine perfusion is also adequate
– Nonstress test
– Daily movements of fetus (atleast 10 movements per
hour)
– Oligohydramnios may indicate fetal growth
restriction or fetal renal abnormality, whereas
hydramnios may indicate gastrointestinal
malformation or poorly controlled disease

77. • L-S Ratio for fetal maturity (>2.0 to 2.5)
• CS birth for macrosomic babies/ shoulder
dystocia
– CS poses increased risk for RDS in newborns
due to immature lung surfactant
• Termination of pregnancy before was
done to prevent fetal loss from placental
insufficiency

78. MENTAL ILLNESS AND
PREGNANCY
• Schizophrenia tends to have its highest incidence in
adolescents and young adults and so occurs in young
pregnant women
• Depression occurs almost four times more commonly
in women than in men, and often in young adults.
– It is the most common mental illness seen in
pregnant women.
• lithium, a mainstay of therapy for mood disorders
such as bipolar disorder (manic depression),and
serotonin-reuptake inhibitors used to counteract
depression, are potentially teratogenic

79. CANCER AND PREGNANCY
• Cancer occurs in about 1 in 1000 pregnancies
• most commonly seen with pregnancy are:
– Cervical
– Breast
– Ovarian
– Thyroid
– Leukemia
Melanoma
– Lymphomas

80. • If a woman is in the first trimester of
pregnancy when a malignancy is diagnosed,
she and her partner are asked to make a
difficult decision: to delay treatment to
avoid teratogenic risks to a fetus from
treatment (possibly increasing a woman’s
risk); to end the pregnancy to allow
chemotherapy or radiation treatment to be
initiated; or to choose chemotherapy or
radiation treatment with the knowledge
that they may cause birth anomalies in the
fetus

81. • As a rule, women can receive
chemotherapy in the second and third
trimesters without adverse fetal effects
• Radiation therapy, in contrast, puts the
fetus at risk throughout pregnancy ift he
fetus is directly exposed
• Melanoma is the only type of cancer that
seems capable of spreading to the fetus
• Placenta serves as a barrier to other types
of cancer and fetus has the ability to resist
invading foreign cells