Download to read offline
More Related Content
Similar to 8-Disease associated with pregnancy - Copy.ppt
8-Disease associated with pregnancy - Copy.ppt
- 1. Disease associated withpregnancy
- 2. Disease associated withpregnancy 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 Thepredisposing 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 Itdepend 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 8
- 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 9
- 10. Anemia in pregnancy…cont’d Preventionof 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 10
- 11. Cardiac disease inpregnancy 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 11
- 12. Cardiac disease inpregnancy…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 12
- 13. Cardiac disease inpregnancy…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 13
- 14. Class III: markedlimitation 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 14
- 15. Cardiac disease inpregnancy…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 15
- 16. Cardiac disease inpregnancy…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 16
- 17. Cardiac disease inpregnancy…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 17
- 18. Cardiac disease inpregnancy…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 18
- 19. Cardiac disease inpregnancy…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 19
- 20. Malaria in pregnancy Itis 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 20
- 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 21
- 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 22
- 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 23
- 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 24
- 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 25
- 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 26
- 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 27
- 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 28
- 29. Diabetic mellitus inpregnancy PREGESTATIONAL TYPE I: IDDM TYPE II: NIDDM GESTATIONAL 29
- 30. Diabetic mellitus inpregnancy…cont’d Gestational diabetics(GDM):Glucose intolerance of variable degree with onset or first recognition during pregnancy 30
- 31. Diabetic mellitus inpregnancy…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 31
- 32. Diabetic mellitus inpregnancy…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 32
- 33. Diabetic mellitus inpregnancy…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 33
- 34. Obesity Polyhydramnios Previous unexplained perinatalloss << birth of a malformed child Glycosuria Polycystic ovary syndrome Current use of glucocorticoids Personal birth weight of over 9 lbs 34
- 35. Diabetic mellitus inpregnancy…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 35
- 36. 36 Diabetic mellitus inpregnancy…cont’d SCREENING… CONT’D
- 37. Diabetic mellitus inpregnancy…cont’d COMPLICATIONS MATERNAL Abortion Pre-eclampsia Infection- wound, UTI ( 3-4X increased risk) Polyhydramnios APH & PPH DKA 37
- 38. Diabetic mellitus inpregnancy…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) 38
- 39. Diabetic mellitus inpregnancy…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 39
- 40. Diabetic mellitus inpregnancy…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 40
- 41. Monitoring bloodglucose Optimal values are FBS 70-95 mg/dl & 2hr post prandial <120 mg/dl Glycosylated hemoglobin (HbA1c) every 4 weeks to assess control 41
- 42. Diabetic mellitus inpregnancy…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 42
- 43. Diabetic mellitus inpregnancy…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 43
- 44. Diabetic mellitus inpregnancy…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 44
- 45. Diabetic mellitus inpregnancy…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 45
- 46. Diabetic mellitus inpregnancy…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 inpregnancy…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 47
- 48. Diabetic mellitus inpregnancy…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) 48
- 49. Urinary problem duringpregnancy 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 duringpregnancy 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 duringpregnancy 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 duringpregnancy 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 antibioticshould 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 duringpregnancy 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 developrapidly 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 duringpregnancy 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 microscopyshowing 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 duringpregnancy 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 duringpregnancy 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 59