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1. Disease associated with pregnancy

2. Disease associated with pregnancy
Some of the disease associated with pregnancy are:
Anemia
Cardiac disease
Diabetic mellitus
Pulmonary tuberculosis
Malaria
UTI
2

3. Anemia in pregnancy
Definition: it is defined as a Hgb level of < 11g/dl
(Hct<33%) except during the second trimester,
when the cut-off point is reduced to 10.5 g/dl
It is said to be SEVER if the Hgb is < 7gm/dl
Incidence
Affect ~5%-50% of pregnant women in tropics and
< 2% in developed country
Majority are nutritional anemia
Iron deficiency account for 80-95% of nutritional
anemia during pregnancy
Megaloblastic anemia from folate & vitamin B12
deficiency account for only 3-4% of nutritional
3

4. Anemia in pregnancy…cont’d
Incidence … cont’d
Other cause of anemia (Hgb, Leukemia, hemolytic
anemia, anemia of chronic illness and the like) are
not common during pregnancy
Pathophysiology
 The requirement of iron during pregnancy is around
1000 mg
 There is additional needs for blood loss during
delivery (190 mg) & lactation (1mg/day)
 Assuming the stores are adequate, a pregnant
women’s average daily dietary requirement is 3.5
mg/day.
4

5. Anemia in pregnancy…cont’d
The predisposing factors for iron deficiency
anemia are
 Inadequate intake of iron: food taboos, poor
dietary habit, low socioeconomic status
 Low store at the beginning of pregnancy: short
interval b/n pregnancy, excess menstrual flow,
hookworm infestation
 Blood loss during pregnancy: early & late
pregnacy bleeding, hookworm
 Increased demand: multiple pregnancy , chronic
infections
5

6. Anemia in pregnancy…cont’d
Complication
Fetal: spontaneous abortion, preterm delivery, low
birth weight, IUGR, still birth
Maternal: CHF & pulmonary edema especially in
labour and postpartum period, PPH, puerperal
sepsis, delayed wound healing, apathy, increased
risk of other infections such as TB
Neonatal : anemia of infancy
6

7. Anemia in pregnancy…cont’d
Management
It depend on the cause, severity and gestational age
I. Iron deficiency anemia
 Ferrous sulfate 100 mg containing 60 mg elemental iron
w/h 10% are absorbed, Tid, po
Continue the treatment for 3 months till the Hgb
concentration return to normal
 Alternative are Ferrous fumarate & ferrous gluconate
 Follow up with weekly Hgb & reticulocyte
determination
 Parenteral route of treatment in cases of intolerance of
oral route or refractory to treatment by oral route and
7

8. Anemia in pregnancy…cont’d
Management … cont’d
 Indication for blood transfusion are:-
presence of CHF,
sever anemia with Hgb of < 4.4 gm/dl,
anemia with sepsis & renal failure,
anemic patient with Hgb of 6-7gm/dl seen for
the first time in labour, abortion or in the last 4
weeks of pregnancy
 Packed RBC should be used
 Underlying causes, if any (like hook worm, malaria
& chronic illness), other than nutritional deficiency
should also be treated
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9. Anemia in pregnancy…cont’d
Management … cont’d
II. Megaloblastic anemia
 Folic acid 5 mg tid/day & continued at a dose of
5mg/day for the rest of prregnancy
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10. Anemia in pregnancy…cont’d
Prevention of anemia
Improve diet and dietary habit, socioeconomic
status
Prevent and treat hook worm (deforming) &
malaria
Child spacing by FP
Universal supplementation of iron and folic acid
to all pregnant women throughout pregnancy
Iron fortification of staple diet
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11. Cardiac disease in pregnancy
Introduction
 A women with a known cardiac illness can become
pregnant or a healthy pregnant women can develop
cardiac illness while pregnant
 In a women with preexisting cardiac illness, the
increased homodynamic burden of pregnancy,
labour and delivery can aggravate the Sm of the
illness and/or precipitate complications
 The risk of CHF is highest around:
 24 week of gestation,
labour and
the immediate postpartum period
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12. Cardiac disease in pregnancy…cont’d
Significance
 Cardiovascular diseases are the most important
non-obstetric causes of disability and death of
pregnant women, 0.4-4% of pregnancies
 The most common form that complicate
pregnancy is rheumatic heart disease
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13. Cardiac disease in pregnancy…cont’d
Classification
The degree of functional disability due to cardiac
disease is graded
according to the New York Heart Association as
follow
Class I : No Sm limiting ordinary physical
activity
Class II: slight limitation with mild to moderate
activity with no symptom at rest
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14. Class III: marked limitation with less
than ordinary activity; dyspnea or pain
on minimal activity
Class IV: Sm at rest or with minimal
activity and Sm of frank CHF
Note: with rare exceptions, women in
class I and most in class II go
through pregnancy without
morbidity
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15. Cardiac disease in pregnancy…cont’d
Classification…
 As much as possible pt in class III & IV should
avoid pregnancy
Therapeutic abortion is an option in early
pregnancy
If pregnancy is continued, prolonged
hospitalization or bed rest is will often be
necessary
These women tolerate major surgical procedures
poorly
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16. Cardiac disease in pregnancy…cont’d
Management
Once diagnosed, these pt should be referred for
specialized care by obstetrician, internist and
neonatologist
The general principle in management are
I. Antepartum
Bed rest
Moderate dietary restriction
Provision of diuretics
Prophylactic digitalization /If the pulse rate exceeds 110
per minute in between uterine contractions, rapid
digitalization is done by intravenous digoxin 0.5 mg.
Frequent ANC for maternal and fetal monitoring
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17. Cardiac disease in pregnancy…cont’d
Management…
II. Intrapartum
 Unless contraindicated, vaginal route of delivery is prefered
 Conduct labour and delivery in lateral decubitus position
 Provide adequate pain relief
 Restrict IV fluid
 Provide O2 with breathing mask along with continuous
oxymeter
 Shorten the second stage by instrumental delivery
 Do not use ergometrin in the third stage
 Prevent postpartum pulmonary edema by keeping the
women in sitting position
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18. Cardiac disease in pregnancy…cont’d
Management…
II. Intrapartum …
Provide thrombus prophylaxis by early
ambulation and/or low dose asprin
Note: a pt with a known heart disease should
consult her physician before becoming pregnant
to determine the advisability & optimum timing
for pregnancy
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19. Cardiac disease in pregnancy…cont’d
Management…
II. Intrapartum …
In a pregnant women with cardiac disease :
Recognize the presence of preexisting cardiac
disease
Assess the degree of disability
Anticipate, prevent, diagnose and treat
complications such as arrhythmia, CHF when
they arise
Advise the pt regarding discontinuation or
continuation of pregnancy and risk of future
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20. Malaria in pregnancy
It is one of the infectious disease
 During pregnancy, immunity slackens
resulting in increased parasitemia and
relapse rate of dormant exocerythrocytic
stages
 Episode of malarial infection increase by 3
to 4 folds during the latter 2 trimesters of
pregnancy and 2 month postpartum
 Severity of falicparum malaria is increased
 Malarial attacks are severe and cerebral
malaria is common especially in nulliparous
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21. Malaria in pregnancy… cont’d
Effects
 They are related to pyrexia, haemolysis,
placental parasitization (in immune), and
transplacental infection (in nonimmune)
Maternal: increase number of attacks, anemia
from folic acid deficiency induced by
haemolysis, cerebral malaria, purperal pyrexia
Fetal: spontanous abortion, preterm labor and
prematurity, IUGR, intra uterine fetal death
(stillbirth), congenital maleria in nonimmune in
few days after delivery
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22. Malaria in pregnancy… cont’d
Diagnosis
 In immune women Symptom are stable
 Non immune women present with Symptom
with fever and chills
 Blood film(B/F) identifying the plasmodium
parasite confirm the diagnosis
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23. Malaria in pregnancy… cont’d
Treatment
 Once diagnosed, malaria should be treated
aggressively
 Sever form need inpatient treatment with
parenteral antimalarials
 Drug of choice depends on the type of
plasmodium parasite and the degree of
resistance in the community
 Chloroquine, sulfadoxine-pyrimethamine, mef
loquine and quinine are safe to be used in
pregnancy
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24. Malaria in pregnancy… cont’d
Prophylaxis
 This is given for nonimmune people traveling to
endemic areas
 The drug should be taken 1-2 weeks before
travel & continued for 4 weeks after return
 Depending on the pattern of resistance, drug
like chloroquine, mef loquine, sulfadoxine-
pyrimethamine, can be used
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25. Tuberculosis
Effect on pregnancy
 Preterm delivery, IUGR, & low birth weight
w/h increase perinatal mortality by 6 fold
 Adverse outcome on pregnancy correlate
with late diagnosis, incomplete or irregular
treatment and advanced disease
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26. Dx and management
 Diagnosis & management is similar to
non pregnant state
 With the exception of streptomycin &
pyrazinamide, all the first-line
antituberculosis drug are safe to be
used during pregnancy
 Streptomycin causes congenital defness
in the new born
 The safety of the use of pyrazinamide
during pregnancy is not ascertained
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27. Tubeculosis…cont’d
Dx and management…
 Drug used for treatment of tuberculosis
include
Isonizide (INH), rifampicin, and
ethambutol
 However pyrazinamide can be included into
the regimen if there is drug resistance
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28. Tubeculosis…cont’d
Neonatal TB
 Neonate, though rare, can get TB infection
in utero if the mother is suffering from active
tuberculosis
 The incidence of congenital infection
increases if the mother is HIV positive
 The TB lesions in the newborn are usually
found in the liver
 This can be prevented if the mother is
properly treated while pregnant
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29. Diabetic mellitus in pregnancy
 PREGESTATIONAL
 TYPE I: IDDM
 TYPE II: NIDDM
 GESTATIONAL
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30. Diabetic mellitus in pregnancy…cont’d
 Gestational diabetics(GDM):Glucose
intolerance of variable degree with onset or
first recognition during pregnancy
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31. Diabetic mellitus in pregnancy…cont’d
PHYSIOLOGIC CHANGE
 Pregnancy is characterized by insulin
resistance and hyperinsulinemia
 The resistance stems from placental
secretion of diabetogenic hormones
Human placental lactogen- most
responsible
Growth hormone
Corticotropin-releasing hormone
Progesterone
Estrogen
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32. Diabetic mellitus in pregnancy…cont’d
PHYSIOLOGIC CHANGE…CONT’D
 Glucose is transported to the fetus via carrier
mediated active transport
 Free fatty acid, triglycerides and ketones
increase resulting in accelerated starvation
 Glucose is spared for fetal consumption
 Decreased fasting glucose level in early
pregnancy
 Fetal glucose level is 80% of maternal value
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33. Diabetic mellitus in pregnancy…cont’d
SCREENING
 At 24-28 weeks but earlier if there is high
degree of suspicion
 Universal screening: All pregnant women
 Selective: based on risk factors
Age >30 yrs
Previous infant > 4 Kg
History of GDM
Family history Of diabetes
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34. Obesity
Polyhydramnios
Previous unexplained perinatal loss
 << birth of a malformed child
Glycosuria
Polycystic ovary syndrome
Current use of glucocorticoids
Personal birth weight of over 9 lbs
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35. Diabetic mellitus in pregnancy…cont’d
SCREENING… CONT’D
 SCREENING PROTOCOL
 50 gm glucose is taken po with out prior
preparation then
 If 1hr RBG is > 140 mg/dl
 100g 3hr OGTT should be done after 8-
14 hrs fasting
 This will identify 80% of women with
GDM
 If the value is >180mg/dl FBS should be
checked the next day
 OGTT is abnormal if >2 values are equal
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36. 36
Diabetic mellitus in pregnancy…cont’d
SCREENING… CONT’D

37. Diabetic mellitus in pregnancy…cont’d
COMPLICATIONS
 MATERNAL
Abortion
Pre-eclampsia
Infection- wound, UTI ( 3-4X increased
risk)
Polyhydramnios
APH & PPH
DKA
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38. Diabetic mellitus in pregnancy…cont’d
COMPLICATIONS
 FETAL & NEONATAL
 Fetal death
 Usually after 36 wks
 Usually In those having PE, poor glycemic
control, polyhydramnios & macrosomia
 Due to hypoxia & lactic acidemia
 Congenital anomaly
 Cardiac( most common)
 Neural tube defect
 Caudal regression syndrome (most
characteristic)
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39. Diabetic mellitus in pregnancy…cont’d
COMPLICATIONS
 FETAL & NEONATAL… cont’d
 Macrosomia
 Birth trauma
 Shoulder dystocia- due to disproportionate
growth
 Hypoglycemia
 RDS- due to reduced production of
surfactant
 Hypo calcemia & hypo magnesemia
 Polycythemia & hyperbilirubinemia
 Diabetes in later life
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40. Diabetic mellitus in pregnancy…cont’d
Management
 Diet
 Daily caloric intake of 30kcal/Kg with 3
meals 3 snacks
 10% breakfast, 30%lunch, 30%dinner &
30%snacks
 40-50% CHO, 30% fat & 20-30% protein
 Exercise
 Moderate exercise
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41.  Monitoring blood glucose
 Optimal values are FBS 70-95 mg/dl &
2hr post prandial <120 mg/dl
 Glycosylated hemoglobin (HbA1c) every
4 weeks to assess control
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42. Diabetic mellitus in pregnancy…cont’d
Management… cont’d
 Insulin
 If FBG is > 105 mg/dl or 2hr BG is > 120
mg/dl
 Starting dose
 0.6u/Kg, 0.7u/Kg & 0.8u/Kg in the 1st , 2nd
& 3rd trimester
 2/3 in the morning & 1/3 in the evening
 For the morning
 2/3 intermediate acting & 1/3 short acting
 For the evening
 1/2 intermediate acting & 1/2 short acting
 Oral hypoglycemic agent is not
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43. Diabetic mellitus in pregnancy…cont’d
Management… cont’d
 Pre conception & at first visit
 Pre conception counseling
 Standard prenatal test
 More frequent visits
 Base line renal function test,
electrocardiogram, etc
 Hb A1c( risk for congenital anomaly is high if
>10%)
 Serum α fetoprotein at 16 wks
 Antepartum surveillance
 Kick counts
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44. Diabetic mellitus in pregnancy…cont’d
Management… cont’d
 Timing of delivery
Depending on metabolic control & fetal
condition
Fetal monitoring especially for insulin
requiring
 Route of delivery
C/S for macrosomia( wt > 4500g) and
other obstetric indications
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45. Diabetic mellitus in pregnancy…cont’d
Management… cont’d
 Labor
Withhold morning insulin before an
elective induction or C/S
Intrapartum 5% or 10% glucose & regular
insulin infusion at a rate of 0.5-2u/hr
10u regular insulin in 5%/10% DNS at a
rate of 100-125ml/hr
Blood glucose measurement every 2 hrs
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46. Diabetic mellitus in pregnancy…cont’d
Management… cont’d
 Puerperium
Relax tight control
Honeymoon period with decreased
insulin requirement after delivery
GDM patients usually don’t need insulin
For pre-gestational diabetes 2/3 of the
pre-pregnancy dose or ½ of the present
dose
Blood glucose measurement every 6 hrs
Breast feeding is encouraged
75g OGTT at 6th wks for GDM- diabetes
diagnosed if
FBS is > 126mg/dl or
46

47. Diabetic mellitus in pregnancy…cont’d
Management… cont’d
 Contraception
Tubal ligation if family is completed
Barrier methods
Low dose OCPs- in well controlled cases
IUCD
DMPA & implant- not recommended
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48. Diabetic mellitus in pregnancy…cont’d
KETO ACIDOSIS DURING PREGNANCY
 Definition
Plasma glucose >300mg/dl,
HCO3<15mEq/l &
PH<7.3
 Risk factors
Infection, volume depletion, failure to take
insulin & C/S
 Management
Lab assessment
Insulin – regular insulin 10-20 u IV then
5-10 u/hr
IV fluid( 4- 6L in the 1st 12 hrs)
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49. Urinary problem during pregnancy
A) Asymptomatic bacteruria
 It is defined as the presence of >105 colony
forming unit (CFU) of bacteria of single
pathogen per ml of clean catch midstream
urine sample with no clinical Sm of urinary
tract diseas
Predisposing factors
Reduced peristalsis & dilatation of ureters &
the bladder causing incomplete emptying
and stasis of urine
Pregnancy induced glycosuria
49

50. Urinary problem during pregnancy
A) Asymptomatic bacteruria …
Significance
 If not treated, 25%-30% of pt with
asymptomatic bacteruria will latter develop
acute pyelonephritis as compared to 2%-
3% of pt who have been treated
 It’s also associated with preterm labor &
postpartum endometritis
 Acute pylonephritis is one of cause of
preterm birth, PROM, IUGR, & perinatal
death
50

51. Urinary problem during pregnancy
A) Asymptomatic bacteruria …
Etiology
 E. coli (80%-90%)
 Others are: Klebsiella, Proteus,
Pseudomonas, S. saprophyticus & C
trachomatis
Diagnosis & Management
 Routine urine culture is recommended in
ANC
 Once diagnosed, all women with
asymptomatic bacteruria should be treated
51

52. Urinary problem during pregnancy
A) Asymptomatic bacteruria …
Diagnosis & Management…
Commonly used antibiotics (since the
common pathogen is E coli):
Amoxicillin, Amoxicillin/clavulunate
potassium, Cephalexin, Nitrofurantoin,
Trimethoprim – sulfamethoxazole or
one of the third generation
cephalosporin
52

53.  The antibiotic should be safe to be used
during pregnancy
 Culture of urine should be done 1-2
weeks after therapy is begun & monthly
for the remaining of pregnancy
 Treatment failure can be due to
resistance & pt non compliance
53

54. Urinary problem during pregnancy
B) Acute pylonephritis
 It is infection of renal pelvis and kidneys
 The single most important predisposing
factor for acute pylonephritis during
pregnancy is asymptomatic bacteruria
 The etiological agent is similar with those of
asymptomatic bacteruria and cystitis
54

55. Clinical feature
Generally develop rapidly over a few hrs
or a day
Sm include fever (usually > 39 oc ),
shaking chills, nausea vomiting, bilateral
flank pain, and possibly diarhhea
Sm of cystitis may or may not be there
(frequency, urgency, dysuria, suprapubic
discomfort/pain)
55

56. Urinary problem during pregnancy
B) Acute pylonephritis…
Clinical feature …
 In some, hematuria may be evident
 On P/E, there is pyrexia and tachycardia along with
costovertabral angle (CVA) tenderness on one or both
side
56

57. Diagnosis
 Urine microscopy showing pyuria (in
centrifuged urin > 10 WBC per high
power field)
 Bacteruria, hematuria (1-2 RBC in
centrifuged urine or > 5 RBC in
uncentrifuged urin per high power field ),
Leukocytosis (WBC> 15,000/mm3) &
 Positive urine/blood culture
57

58. Urinary problem during pregnancy
B) Acute pylonephritis…
Complication
 Septic shock, acute renal failure, preterm
labor, PROM, IUGR& low birth weight baby
Management
Admit for parentral antibiotics
Start high dose parentral antibiotics until the
pt is affebril for 24-48 hrs (usually for 3-4
days) then continue orally for 7 -10 days
Antibiotics are initially started empirically
but latter can be adjusted according to
58

59. Urinary problem during pregnancy
B) Acute pylonephritis…
Management
Example: Ampicillin 1 gm qid + gentamycin
80 mg Tid or ceftriaxone 1-2 g daily
 Supportive care include
Correction of DHN
 antipyretics agent to control fever
Monitoring of V/S and urine out put
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