a brief seminar about medical diseases in pregnancy in regard to hematology, immunology, respiratory, gastrointestinal and dermatology.

1. N u r Am a l i n a Am i n u d d i n B a k i
0 8 2 0 1 2 1 0 0 0 6 7

3. A.Anaemia
 WHO: <11g/dl
 FIGOS : <10g/dl
 Definition of anemia
based on trimester:
 Classified based on
severity or etiology
Hemoglobin
level
Time
<10.5 g/dl Second
trimester
<11 g/dl 1st,3rd trimester
and 1st week
postpartum
<12 g/dl 8th week
postpartum
Category Hb (g/dl) [WHO]
Mild 9 -10.9
Moderate 7 – 9
Severe < 7

4. Physiological Pathological
Nutritional
Iron Deficiency Folic acid &
Vit B12
deficiency
Hemorrhagic Increased
destruction
Hereditary
Sickle cell disease
Thalassemia major
Spherocytosis
Acquired
Decreased production
Bone marrow
insufficiency

5. Causes Consequences
 Inadequate intake
 Iron loss
 Hookworm infestation ,
malaria
 Low iron storage
 Short interpregnancy
interval, multiparity
 Defective absorption
 Phosphates, phytates, vit C
and A deficiency
 Maternal
 Preterm delivery,
puerperal sepsis,
puerpural
thromboembolism,
postpartum depression
 Fetal
 Prematurity, perinatal
mortality, low birth weight
,reduced amniotic fluid,
death
1.Iron deficiency anemia

6.  Symptoms :
 Fatigue, headache,
giddiness,
palpation,edema
 Signs:
 Pallor, koilonychia, glossy
tongue, angular stomatitis,
splenomegaly
Tests Findings
Hemoglobin Low
Complete
blood count
Low RBC count
Normal/elevated WBC
Elevated platelet
Red cell
indices
Low MCV
Low MCHC
Peripheral
blood smear
Microcytic hypochromic
anemia
Iron studies Low serum ferritin and
iron level
Elevated TIBC

7. Prophylaxis Treatment
 Increase dietary iron
 Green leafy vegetables,
sprouts, jaggery,meat,
liver
 Iron supplementation
 Parasite control
measures
 Albendazole 400mg OD
 Mebendazole 500mg OD
1) Oral iron therapy
2) Parenteral iron
therapy
3) Blood transfusion
• <5g/dl at any gestation
age
• <7g/dl in late trimester
• Women with severe
anemia in labor

8. 1) Oral iron therapy
 Recommended: 120 -200mg/day of
elemental iron
 Preparation: ferrous fumarate/ sulfate/
gluconate
 Taken on empty stomach with orange juice
 30% : nausea, vomiting, disturbed bowel
habits
 Indicator: reticulocyte count, hemoglobin
level
 Reassess compliance, exclude other
causes if not responding

9. 2) Parenteral iron therapy
 Indications: unresponsive to oral therapy, non
compliance,intolerance, quick recovery
 Calculation : 2.2 X prepregnant weight(kg) X Hb
deficit (md/dl) + 1000mg
Intramuscular Intravenous
•Iron dextran
•Iron sorbitol citrate
•Iron dextran
•Ferric gluconate
•Iron sucrose
• Iron isomaltoside
•Painful, poorly absorbed,
staining,
•More preferred

10. 2. Megaloblastic anemia
Folic acid
deficiency
B12 deficiency
Inadequate
intake,
malabsorption,
hemolysis
Inadequate
intake,
absorption
Oral folic acid
1mg/dl
Parenteral
cobalamin 1 mg
daily for a week ,
then wekly for 4
weeks
Tests Findings
Hemoglobin Low
Complete
blood count
Low RBC count
Normal/low WBC
Low platelet
Red cell
indices
High MCV
Low MCHC
Peripheral
blood smear
Macrocytic hypochromic
anemia
Hypersegmented
neutrophils

11. Maternal complications Fetal complications
 PIH
 Abruptio placenta
 Fetal neural tube
defects
 Abortion
 IUGR

12. 3. Sickle Cell Disease
 Prepregnancy counselling
and immunization
 Prenatal care:
 Folic acid supplementation
 Frequent blood test and
uriine culture
 Serial ultrasound monitoring
 Complication of SCD in
pregnancy
 Gestational hypertension,
pre eclampsia, preterm labor,
postpartum infection, fetal
growth restriction
 Collect cord blood for
testing and storing

13. 4. Thalassemia
 Thalassemia trait
 Thalassemia intermedia
 Thalassemia major
 Alpha
 Beta
 Prepregnancy
counselling and
screening
 Advised to take 5 mg
folic acid daily
 Prenatal diagnosis to
assess fetal
hemoglobinopathy

14. B. Thrombocytopenia
 Platelet < 150,000 per
microlitre
 Preexisting , newly
discovered or acute
onset
 Gestational
thrombocytopenia:
 Mild thrombocytopenia
 Occurs late in pregnancy
 spontaneous resolution
after delivery
 Immune
thrombocytopenia:
 Persistent
thromboctopenia
 Normal/ increased
megakaryocytes

15. Follow up platelet count during pregnancy
and postpartum period
Antenatal:
Bleediing manifestations
Platelet < 30K
NO
No treatment till 36
weeks
YES
Prednisolone
1mg/kg daily
OR
IV Immunoglobulin
1g/kg
Near
term
Platelet <
80K
Oral prednisolone
20mg/kg/day , 10
days prior to
delivery
Imminent
delivery
Platelet
transfusion and IV
Immunoglobuliin
to maintain platelet
counts > 50K

17. Systemic Lupus Erythematosus
4/11
 Discoid rash
 Oral ulcers
 photosensitivity
 Arthritis
 Malar rash
 Immunological disorder
 Neurological disorders
 Renal disorders
 Antinuclear antibody
 Serositis
 Hematological disorders

18. Maternal Fetal
 Preeclampsia
 preterm labor
 Eclampsia
 HELLP syndrome
 Anemia
 Thrombocytopenia
 Renal failure
 Prematurity
 Fetal growth restriction
 Neonatal lupus
syndrome
 Congenital complete
heart block
Complications

19. Management
 Low dose aspirin
 Oral prednisolone

20. Rhesus Incompatibility
 Occurs during pregnancy when incompatibility
between the blood types of mother and fetus
resulting in hemolytic disease in newborn

24. Mother Fetus and Newborn
 Preeclampsia
 Ballantyne syndrome
 Hemolytic disease of
fetus and newborn
 Fetal anemia
 Fetal hydrops
 Hyperbilirubinemia
in newborn
Effect on:

25. Screening
 Indirect Coombs test
 Critical titre
 First pregnancy:
 First visit, 20, 24 weeks
 Subsequent
pregnancies:
 No/mild HDN: first
booking, every 4-6 weeks
 Severe HDN: test for fetal
anemia at 16-18 weeks

26. Nonimmunized mother Immunized mother
 Reduce risk of FMH
 Anti-D immunoglobulin
300 microgram IM at
28, 34 weeks and
within 72 hours of
delivery
 Start monitoring for
fetal anemia at 16-18
or 20 weeks
 Serial amniocentesis
and Liley curve
 Ultrasound
 Doppler ( MCA-PSV) at
16 or 20 weeks
Management

27. Management of
first affected
pregnancy
Monthly ICT till 28
weeks
Titre < 1:16
Deliver at term
Titre >1:16
< 1.5Mom
Deliver at 37-38
weeks
>1.5MoM
< 34 weeks : Fetal
blood sampling
>34 weeks: deliver
Doppler MCA-PSV
Then, ICT every 2-
3 weeks

28. Management of
pregnancy with
previosly
affected fetus
Doppler MCA-PSV
evry fortnight from 18-
20weeks
< 1.5 MoM
Continue Doppler
Deliver after 34 -36
weeks
> 1.5MoM
Fetal blood sampling
Fetal hemtocrit <
30%
Intrauterine
transfusion
Fetal hemtocrit >
30%
Repeat FBS
depending on weekly
MCA-PSV
Deliver at 34-36
weeks

30. Hepatobiliary and
Gastrointestinal
Disorders

31. Hepatobiliary Disorders
 Unique to pregnancy:
 Acute fatty liver of
pregnancy
 Intrahepatic cholestasis of
pregnancy
 HELLP syndrome
 Subcapsular hematoma/
hepatic rupture
 Can occur in pregnancy:
 Acute liver hepatitis
 Biliary disease
 Pre-existing liver
disease:
 Chronic viral hepatitis
 Cirrhosis and portal
hypertension

32. Acute Fatty Liver of Pregnancy
 Occur closer to term (36 weeks)
 Associated with maternal genetic mutation and fetal LCHAD
deficiency
 Symptoms: nausea, vomiting, anorexia, lethargy, abdominal
pain, jaundice
 Risk factors:
 Older maternal age
 Primiparity
 Multiple gestation
 pre eclampsia
 Male fetus
 underweight
 Previous history of AFLP

33.  Elevated serum aminotransferase and bilirubin
 Complications: acute renal failure, fulminant hepatic
failure, hypertension, hypoglycemia, DIC
 Mortality rate:
 Maternal 10%
 Perinatal 85%
 Definitive treatment: delivery

34. Intrahepatic Cholestasis of Pregnancy
 0.8 -1.2 %
 Manifest in 3rd trimester (30 weeks)
 Associated with estrogen, progesterone and genetic
factors
 Symptoms: pruritus in 2nd/3rd trimester, jaundice
 Elevated AST,ALT and bilirubin
 Complications: Prematurity, MSAF, IUD, Respiratory
Distress Syndrome
 Treatment:
 Pruritus: Ursodeoxycholic acid, Cholestyramine
 Delivery at 37-38 weeks

35. Hepatic Hematoma and Rupture
 1in 40,000
 Present in 2nd or 3rd trimester
 Exact causee unknown
 Complications of pre-eclampsia, eclampsia
 High maternal and perinatal mortality
 Clinical features: abdominal pain, shock
 Diagnosis: elevated liver enzymes, USG
 Management: Resuscitate, immediate laparotomy,
control bleeding from liver

36. Gallstones in Pregnancy
 10% develops while 1% become symptomatic
 Clinical features: RUQ pain, nausea, vomiting, fever
 Diagnosis: Ultrasonography
 Management:
 Uncomplicated: conservative therapy
 Complicated: laparoscopic cholecystectomy/ERCP

37. Chronic Autoimmune Hepatitis
 Leads to cirrhosis
 High risk of spontaneous miscarriage and fetal
demise
 Can relapse in pregnancy

38. Hyperemesis Gravidarum
 Persistent, severe vomiting in pregnancy, associated
with weight loss > 5% of prepregnancy weight,
dehydration and ketonuria
 Risk factors:
 Younger age
 Primigravida
 Multifetal pregnancy
 Past history of motion sickness, migraine, hyperemesis

39.  Clinical features:
 > 3 times a day
 Weight loss > 5% or > 3kg
 Ptyalism
 Complications
 Hypokalemia
 Hypochloremic alkalosis
 Ketosis
 Mallory –Weiss tears
 Dehydration
 Acute renal failure

40. Investigations: Management
 Serum electrolytes
 Urine for ketone bodies
 Hematocrit
 Ultrasonography
 Serum creatinine
 Modification of diet
 Supportive therapy
 10 mg pyridoxine + 10mg
doxylamine
 Refractory cases:
 TPN till vomiting stops
 IV chlorpromazine 25-50mg
4-6 hourly
 IV methylprednisolone 16mg
8 hourly for 48-72hours

41. Constipation Diarrhea
 Dietary changes
 >8 glasses of water
/day
 20-35 g/ d of fibers
 Bulking agents
 Laxatives
 Oral rehydration
 Correct potential
electrolyte imbalance
 Loperamide
 Treat cause of diarrhea

42. Hemorrhoids
 More frequent in last trimester
 Factors: enlarging gravid uterus, constipation
 Management:
 Relief of symptoms
 Hemorrhoidectomy

43. Gastroesophageal Reflux
 Worsen, then dissapears
after delivery
 Factors: intrinsic ,
mechanical
 Management:
 Lifestyle modification
 Antacids,
Sucralfate,histamine
blockers, proton pump
inhibitors

45. Rhinitis
 Causes:
 Pregnancy rhinitis
 Allergy rhinitis
 Rhinitis medicamentaso
 Sinusitis
 Treatment
 Saline nasal drops
 Steam inhalation
 Cromolyn sodium
 Antibiotics

46. Effect of pregnancy on
asthma
Effect of asthma on
pregnancy
 May worsen, improve,
or remain stable
 Higher risk of
preeclampsia, preterm
labor, fetal growth
restriction
Asthma

48.  Assess severity
 Patient education
 Identify and avoidance of triggers
 Acute asthma:
 Hospitalization,
 Oxygen,
 Beta agonist ,
 IV corticosteriod

51. Pruritic Urticarial Papules and Plaques of
Pregnancy ( PUPPP)
 Most common
pregnancy
dermatosis
Occur in 3rd
trimester
Papules within
striae coalescence
forming plaques
Abdomen, thigh,
buttock, arms
Associated with
itching
Resolve after
delivery
Treatment:
Antihistamines
 Topical steroid

52. Atopic Eruption of Pregnancy (AEP)
Appears in 2nd
trimester
Types of lesion:
 Eczematous
patches
 Erythematous
papules
 Follicular
lesions
Treatment :
 Antihistamines
 Topical
corticosteroids

53. Pemphigoid Gestationis ( Herpes
Gestationis)
Uncommon,autoimmu
ne disorder
Occur in 2nd trimester
Vesicle, bullae and
plaques
May persist for a few
months, worsen after
delivery
Recurs in next
pregnancy
Fetal complications:
prematurity, low birth
weight
Treatment:
 Topical steroids
 20-40mg/day oral
prednisolone

54. Pustular Psoriasis of Pregnancy (Impetigo
Herpetiformis)
Occur in 3rd
trimester
White, sterile
pustules on
erythematous
papules
Inframammary
areas, axillae, groin,
gluteal
Associated with
fever, nausea,
vomiting and
diarrhea
Resolves but recur
Treatment : 60-80
mg/d oral
prednisolone

55. References
 Essential of Obstetric , Lakshmi Seshadri, Gita Arjun,
2016
 Textbook of Obstetric , D.C.Dutta , sixth Edition ,
2004