This document provides information on various illnesses that can occur or be exacerbated during pregnancy, including anemia, tuberculosis, asthma, diabetes, HIV/AIDS, hepatitis, and others. It focuses in depth on anemia, discussing normal blood values, causes of anemia during pregnancy including iron deficiency and megaloblastic anemias, effects of anemia on pregnancy, diagnosis, and treatment options. It also provides a brief overview of hemoglobinopathies like sickle cell anemia.

1. Unit II- woman with preexisting or
newly acquired illness
1
By Ritbano Ahmed (BSc midwife, MSc
maternity in maternity nursing)

2. Contents
•Anemia
•Tuberculosis
•Asthma
•Diabetes mellitus
2
HIV/AIDS
Hepatitis
Cytomegalovirus
Herpes virus
Auto immune disease
and pregnancy
Thyroid disease
 Cardiac disease
 Renal disease
 Epilepsy
 Intestinal infestation

3. Anemia in pregnancy
3

4. Normal Blood Standards
A. Red blood corpuscles (RBCs):
1- Number:
•In females : 4.5-5 millions/mm
2- Haemoglobin (Hb%): In females : 12-14 gm/100 cc
(dl) blood.
During pregnancy: 10-12 gm/dl i.e. physiological
anaemia due to the increase in plasma volume more
than RBCs volume.
4

5. Normal Blood Standards…..
3- Haematocrit value:
•It is the volume of packed RBCs in 100 cc of blood.
In females: 42%.
4- Reticulocytes: 0-2%.
They are cells with remnants of the nucleus.
Reticulocytosis indicates over active bone marrow as
in haemolytic anaemia.
5

6. Normal Blood Standards …..
B. Leucocytes
1- Total leucocytic count: 4.000-10.000/mm3.
It increases during pregnancy to 9.500-10.500/mm3 and up
to 16.000/mm 3 during labour and the first week of
puerperium.
2- Differential leucocytic count:
• Basophils 0-1%.
•Eosinophils 3-5%.
•Monocytes 3-8%.
•Lymphocytes 20-30%.
• Neutrophils 60-70%.
6

7. Normal Blood Standards …
C. Platelets:
•200.000-400.000/mm3
D .Bleeding time: 2-4 minutes.
E. Coagulation time: 4-8 minutes.
7

8. Introduction
 Iron deficiency anemia is common affecting all
population.
 Pregnant mothers are at high risk b/c of increase
demand.
 Prevalence of anemia is (35-75%),average being(56%).
 Associated with preterm labor &LBW( 3x)
 WHO estimate that anemia contribute approximately 20
% maternal deaths worldwide(1995 report)
8

9. Definition
Anemia is defined as hemoglobin concentration less
11 g/dL during pregnancy or the puerperium.(WHO)
CDC defined anemia is less than 11g/dl in the first
& third trimester , less 10.5g/dl for second trimester
pregnancy.
Level Hb is affected by sex, race, pregnancy &iron
supplement.
9

10. Causes of Anemia during Pregnancy
10

11. Normal blood values in non-pregnant and
pregnant state
Non-pregnant Second half pregnancy
Hemoglobin (Hb) 14.8 gm/100 mL 11–14 gm/100 mL
Red blood cells (RBC) 5 million/cu mm (mm3 ) 4–4.5 million/mm3
cked cell volume (PCV) (Hematocrit) 39–42 percent 32–36 percent
Mean corpuscular hemoglobin (MCH) 27–32 micromicron (picogram-pg) 26–31 pg
Mean corpuscular volume (MCV) 75–100 cubic micron (m3 ) 75–95 m3
Mean corpuscular hemoglobin
concentration (MCHC)
32–36 percent 30–35 percent
Serum iron) mL) 60–120 mg/100 mL Slightly lowered (65–75
mg/100 mL
Total iron binding capacity (TIBC) 300–350 mg/100 mL Increased (300– 400
mg/100
Saturation percentage (Ratio— Serum
iron: TIBC)
30% Less than 16%
Serum ferritin 20–30 mg/L (mean) 15 mg/L (mean)
11

12. Causes of anemia
I)Common causes :(85 %)
*Physiological anemia
*iron deficiency anemia ( IDA)
II) Uncommon causes:
*folic acid deficiency
*heamoglbinopaties
*sickle cell disease
*B-thalassemia minor
12
III) Rare causes:
• B-thalassemia major
• A-thalassemia
• vit B 12 deficiency

13. Functional Causes of anemia
1. Inadequate diet:
*iron,folate or vit B 12 deficiency.
2. Malabsorption syndrome:
* pregnancy/ GI-disease/ food /drugs
3. Blood loss:
* hemorrhage/helementic infestation.
4) Increase red cell destruction:
* heamolysis
13

14. Anaemia can be classified according to severity as
mild, moderate, severe and very severe
14

15. Effects of anemia on pregnancy
• Low hct level associated with LBW
• Preterm delivery
• WHO estimate shows 20% contribution to maternal
death ( 1995 report)
• Depending cause anemia will be associated with high
MMR/PMR e.g. sickle-cell anemia, adverse outcome
related to vascular complication of sickling rather than
level of Hb.
15

16. Iron-Deficiency Anemia
•It is the most common type of anaemia (95%).
Daily Requirements:
•Normal iron requirement is 10 mg/day of which 1mg
is absorbed.
•Requirement increases during pregnancy to 15mg/ day.
16

17. Mechanism of IDA
Aetiology
1- Inadequate intake of iron.
2- Defective absorption of iron e.g. achlorhydria.
3- Increased demand e.g. menstruation and pregnancy.
4- Chronic blood loss e.g. abnormal uterine bleeding
and piles.
17

18. Contii…
Clinical Picture
A. Symptoms: general symptoms of anaemia as;
- easy fatigability,
- headache,
- dyspnea,
- palpitation.
18

19. Contii…
B. Signs:
Pallor which can be detected in the face, palm of the
hand, nail bed and mucus membranes of the mouth and
conjunctiva.
- Angular stomatitis and red glazed tongue.
- Nails are brittle, striated with loss of their luster.
- Spooning of the nails may occur in severe cases.
19

20. Contii…
Investigations:
1. RBCs , haemoglobin and haematocrit: below normal.
2. Serum iron concentration: below normal (n=125 m
g/dl).
3. Iron binding capacity :below normal (n=400 m g/dl).
4. Transferrin saturation: below normal (n= 30%).
5. Blood film: microcytic hypochromic anaemia
20

21. Contiii…
Treatment:
1. Diet: liver, meat, kidney, eggs and green vegetables are rich in iron.
2. Oral iron therapy: * one iron tablet/three time/day recommended
after meals.
* iron preparations with elemental iron.
#ferrous gluconate,325mg (37-39mg)
#ferrous sulfate, 325mg (60-65mg)
# ferrous fumerate,325mg( 107mg)
Side effects: nausea, vomiting and constipation.
. one tablet of ferrous sulfate daily provide prophylaxis, it contains
60mg of elemental iron (10% of it will be absorbed)
A) response of treatment is increase in Hb 1g/4wks or Hct by 3%/ 4
wks treatment if response is unsatisfactory look for other causes of
anemia.
21

22. Contii…
* ii) Parenteral therapy:
# indicated:
*non-compliant patient
* unable to take po medication( PUD)
*Severe anemia (requiring blood transfusion)
# Cases seen for the first time during the last 8–10
weeks with severe anemia.
22

23. Contii…
* intravenous therapy in pregnancy primarily deals with iron
sucrose.
*patient finishing course of treatment received a mean of
1000mg elemental iron.
* Hb increases an average of 1.6g/dl from the beginning of
to the end.
*ferritin level increase from 2.9ng/ml to 122.8ng/ml by the
end of therapy ( decrease only to mean 109.4ng/ml 2 weeks
later.
23

24. Contii…
iii) Erythropoietin(recombinant human) therapy:
*traditional approach for postpartum anemia has
been oral iron &transfusion both involves serious
disadvantage, other strategies is parental and
erithropiten therapy.
24

25. Co ntii…
iv) blood transfusion : rarely indicated,
* severe anemia (<5g/dl),preparing for delivery or
surgical intervention.
*poor response to available iron therapy
* congestive heart failure secondary to severe
anemia
*acute blood loss with hemodynamic instability
* anemia's following sickle cell/beta-thallasmeia
/ * one unit blood raise Hb/Hct (0.8-1g/ 3%/unit of
blood respectively.
* packed RBC is preferred to whole blood if there
is no associated hypovolumia.
25

26. Conti…
B) ante partum/postpartum treatment :
i) ante partum management
* high risk pregnancy/frequent visit
* iron therapy based on patient condition
* strong nutritional advice ( iron rich)
* prepare and plan for delivery
ii)intra-partum management:
* position / oxygen supplement
* control pain/ reduce anxiety
26

27. Contii…
* avoid fluid overload ( risk of CHF)
* shorten second stage of labor
*avoid excessive blood loss/ prevent PPH
* first 72 hrs after deliver risk CHF is very high due
to auto transfusion from closure of placenta bed,
follow up controlling IV-fluid is very important.
* determine Hb/Hct level after delivery and treat her
accordingly
27

28. Megaloblastic Anaemia
• These anemias are characterized by blood and bone-marrow
abnormalities from impaired DNA synthesis.
• It is caused by deficiency of folic acid and / or vitamin B12
Folic Acid Deficiency Anaemia: It is uncommon.
Daily Requirement:
• Normal folate requirement is 500 mg /day and a similar
amount is needed during pregnancy so that the daily
requirement during pregnancy is 1mg.
28

29. Megaloblastic Anaemia…..
Aetiology
1. Inadequate intake.
2. Defective absorption.
3. Increased demand e.g. pregnancy. Drugs: folic
acid antagonists as epanutin (anti-epileptic).
29

30. Contii…
Clinical Picture:
 General symptoms of anaemia (see before).
 GIT manifestations in the form of:
- dyspepsia,
- anorexia,
- nausea,
- vomiting,
- diarrhoea,
- beefy (red, glassed) tongue,
- hepatosplenomegaly.
30

31. Contii..
Investigations:
1. Blood film:
- Macrocytic hyper chromic RBCs.
- Hyper segmented neutrophilic nuclei (>5 lobes).
2. Serum folate level: is low measured by
radioimmunoassay.
3. Bone marrow: abnormal red cell precursors
(megaloblasts). 31

32. Treatment:
- Diet rich in folic acid as liver, kidney and meat.
- Folic acid 5-15 mg /day orally.
32

33. Vit. B 12 Deficiency Anaemia (Addisonian
Pernicious Anaemia):
•It is rare.
Daily Requirement: less than 1mg.
Aetiology:
•Inadequate intake (rare).
•Deficient intrinsic factor as in atrophic gastritis or
gastrectomy…… results in failure to absorb vitamin B12
•Malabsorption syndrome.
•Increased demand e.g. pregnancy.
33

34. Clinical Picture:
•General symptoms of anaemia.
•GIT manifestations: as folic acid deficiency.
•Nervous manifestations:
- Sub acute combined degeneration.
- Peripheral neuritis
34

35. Investigations:
• As folic acid deficiency + decreased serum vit. B12
Treatment:
• Vit. B12
• IM injection
N.B. Folic acid is never given alone for B12 deficiency
anaemia as it will increase the nervous manifestations.
35

36. Contii…
2. hemoglobinopathies: Sickle-Cell Hemoglobinopathies
 Hb a tetrameric protein composed of two pairs of polypeptide
chains with heme group attached to each chain.
 Normal adult Hb A1 comprises 95% of Hb, consists of two
alpha two beta chains, remaining 5% of Hb is HbA2( two
alpha two delta chains) and/or HbF( two alpha chain, two
gamma chains)
 Hemoglobinopathies arises when there is change in structure
or defect to synthesize a specific polypeptide chain.
a) Sickle hemoglobin (Hemoglobin S) results from a single -
chain substitution of glutamic acid by valine because of an A
for T substitution at codon 6 of the -globin gene
36

37. Contii…
 At low oxygen tension RBC containing Hb S assume sickle
shape.
 Sludging in small vessels occurs resulting in microifarction of
the affected organ.
 Sickle cell have life span of 10 days ( as compared to 120 days
of normal RBC) sickling is activated by dehydration, hypoxia
and acidosis.
 1:12 African- American adults are heterozygous for Hb S has
sickle cell traits.
 These individuals generally have 35-45% of HbS and are
asymptomatic, child of two sickle cell trait will have 50%
probability of inheriting triat and 25% having actual sickle cell
disease.
37

38. Conti…
 If women has HbS, spouse tasted for, if both carrier
prenatal diagnosis ( <20 wks) using DNA analysis(PCR).
 Painful vasooclusive episodes of multiple organs are the
clinical hallmark of sickle cell anemia.
 Risk of spontaneous abortion, IUGR, IUFD, UTI, PIH in
addition to vasooclusve episodes multiple organs.
 Antepartum folate prophylaxis, iron supplement is
contraindicated (risk of iron overload)
38

39. Contii…
 Prophylactic exchange transfusion (controversial)
* replace sickle cell with fresh RBC improves vaso-
oclussive episodes).???
 Avoid dehydration, hypoxia that triggers sickling.
 Vaginal delivery is preferred, c/s reserved for obstetrics
indications.
 Labor in LLP recumbent position /receive supplemental of
oxygen
 Adequate hydration maintained/fluid over load must be
avoided.
 conduction anesthesia recommended provide pain relief and
can be used for c/s.
39

40. Contii…
b) Hemoglobin SC diseases:
 Hb C another beta chain variant in which lysine is substituted
for glutamic acid at six position.
 Clinically significant disease occur in 1:833 african-americans
adults.
 Women with both S and C Hb suffers less morbidities in
pregnancy.
 Increase risk of spontaneous abortion,PIH.
 Because patient with SC disease have mild symptoms, may not
be undiagnosed.
 Crisis is following sequestration of large volume of RBC in
spleen accompanied by fall Hct.
 Because of increased spleenic activity mild thrombocytopenia
occurs.
40

41. Contii…
c. Thalassemia:
 Results from defect in rate of globulin chain synthesis, any
polypeptide chain can be affected.
 Thalassemias are classified according to the globin chain that is deficient, and several
hundred syndromes have been identified.
 The two major forms involve impaired production or instability either of -peptide
chains—causing -thalassemia or of -chains—causing –thalassemia
 Heterozygous patients are asymptomatic, thalassmeia can be
detected by prenatal diagnosis.
 Homozygous alpha thalassmeia results in the formation of
tetramers of beta chain known as Hb of brat. This pathology
results in hydrops fetalis.
41

42. 42

43. Contii…
 The umbilical vein diameter, velocity and blood
flow to the fetuses with Hb bratt were usually
higher than fetus from other cause of hydrops
fetalis.
 Beta-thallameia is most common, patient with
heterozygous state asymptomatic.
 Detected by increase of HbA2,in homozygous state
HbA1 suppressed, state is labeled as thalassmia
major.
 Patient with this disorder dependent on
transfusion.
 Marked hepatospleenomegaly, bone marrow
changes secondary to increased heamatopoiesis
 Individuals dies of infective CV- complications 43

44. Contii…
 Few patient who do become pregnant generally
develop severe anemia and CHF.
 Prenatal care is dependent on blood transfusion similar
to sickle cell anemia.
 Heterozygous beta-thalasemia has different expression.
 Thallasemia minima have microcytosis, asymptomatic.
 Thallasemia intermediate spleenomegaly, anemia, high
cardiac out put failure and may become dependent for
blood transfusion.
44

45. Aplastic Anemia
• Aplastic anemia describes a disorder of pluripotential bone marrow
stem cells that results in a reduction of all three hematopoietic cell
lines—red blood cells, white blood cells, and platelets. Pure red
cell aplasia, in which only the red cells are affected, rarely occurs.
• Anemia results from the failure of the marrow to replace senescent
red cells that are destroyed and leave the circulation, although the
cells that remain are of normal size and color.

46. • In most cases, aplastic anemia and pregnancy simultaneously occur
by chance.
• Management depends on gestational age, severity of disease, and
whether treatment has been given. Supportive care includes
continuous infection surveillance and prompt antimicrobial therapy.
Granulocyte transfusions are given only during infections. Red cell
transfusions are given to improve symptomatic anemia, and routinely
to maintain the hematocrit at approximately 20 volumes percent.
Platelet transfusions may be needed to control hemorrhage. Even
when thrombocytopenia is intense, the risk of severe hemorrhage
can be minimized by vaginal rather than cesarean delivery.
• Bone Marrow Transplantation
46

47. Prevention
•Routine screening for anaemia in adolescence,
nutritional education about foods rich in iron(meat,
liver, leafy green vegetables, legumes) and folate
(liver, egg yolk, yeast and leafy green vegetables) to
encourage consumption, early as well as regular
antenatal clinic attendances, iron, folate
supplementation in pregnancy and early treatment
of concomitant infections.
• In areas of high malaria endemicity, intermittent
prophylactic therapy with pyrimethamine
sulphodoxine for malaria should also be given at 16-
17 weeks and 4 weeks later.
•A third dose is given in HIV infection.
47

48. Diabetes Mellitus in pregnancy

49. Outline
•Introduction
•Definition
•Classification
•Clinical manifestation
•Diagnosis
•Managements

50. Introduction
•DM is the most common medical problem
complicating of pregnancy.
•Approximately 1% of all pregnant are diabetes.
•Majority is gestational diabetes mellitus (GDM).

51. Definition
♥ GDM is appearance of diabetes for the first time
during pregnancy and disappears postpartum..
♥ Pre-pregnancy diabetes is diagnosed prior to onset of
pregnancy.
•This can be type 1 or type 2.
Women can be separated into those who were known
to have diabetes before pregnancy—pregestational or
overt, and those diagnosed during pregnancy—
gestational.

52. Phases of Diabetes Mellitus
1. Potential diabetes: There is high risk of developing
diabetes e.g. if one or both parents is diabetic.
2. Prediabetes: The period preceding the development of
diabetes. It is a retrospective diagnosis.
3. Latent diabetes: Diabetes appears only under stress
conditions as pregnancy (gestational diabetes) or with
cortisone administration.
4. Chemical diabetes: An abnormal glucose tolerance test
without symptoms.
5. Clinical diabetes: An abnormal glucose tolerance test
with symptoms of diabetes. 52

53. Effect of Pregnancy on Diabetes
1. Pregnancy is diabetogenic due to increased
production of insulin antagonists as human placental
lactogen, placental insulinase, cortisol, oestrogens
and progesterone.
2. Insulin requirements: increases during pregnancy due
to increased production of insulin antagonists while it
decreases postpartum.
3. Reliance on urine for control of diabetes may lead to
insulin overdosage due to lowered renal threshold for
glucose. 53

54. Effect of Diabetes on Pregnancy
Maternal:
1. Pregnancy induced hypertension (30%).
2. Infections: as monilial vulvo-vaginitis, urinary
tract infections, puerperal sepsis and breast
infection.
3. Obstructed labour due to large sized baby.
4. Deficient lactation: is more common.
54

55. Effect of Diabetes on Pregnancy
Foetal:
1. Abortions.
2. Polyhydramnios (30%): due to large placenta and
foetal size.
3. Congenital anomalies(6%):This is about 4 times the
normal incidence(1.5%). Sacral dysgenesis is a
specific anomaly related to diabetes.
4. Macrosomia: i.e. foetal weight > 4 kg at term may
cause obstructed or traumatic delivery.
5. Preterm labour: with its complications mainly due to
polyhydramnios.
55

56. Effect of Diabetes on Pregnancy…
Fetal …..
6. Intrauterine foetal death (5%):especially in the last 4
weeks due to;
- ketosis,
- hypoglycaemia,
- pre-eclampsia,
- congenital anomalies,
- placental insufficiency.
56

57. Effect of Diabetes on Pregnancy…
Fetal………
7. Neonatal mortality and morbidity(5%): due to ;
• hypoglycaemia,
• respiratory distress syndrome,
•congenital anomalies,
• birth trauma,
•hyperbilirubinaemia due to immaturity of the foetal
liver
• hyperviscosity,
• hypocalcaemia and hypomagnesaemia which may
result from decreased parathyroid hormone.
57

58. Diagnosis
A. History:
•History of diabetes or symptoms suggesting it as loss
of weight, polydipsia (thirst), polyuria and polyphagia.
•History of frequent severe pruritis (recurrent monilial
infection).
•History of repeated abortions, intrauterine foetal
deaths or delivery of oversized babies.
58

59. Diagnosis …….
B. Investigations:
1. Positive urine test: during routine antenatal care.
2. Fasting and 2 hours postprandial venous plasma sugar.
59
Fasting 2h
postprandial
Result
<100mg/ dl <145mg/ dl Not diabetic
>145mg/ dl >200mg/ dl Diabetic
100-145 mg/d 145-200mg/ dl Border line
indicates glucose
tolerance test.
N.B. The whole blood glucose values are 15% lower.

60. Investigation ……
3. Glucose tolerance test (GTT):
• Prerequisites:
• Normal diet for 3 days before the test.
• No diuretics 10 days before.
• At least 10 hours fast.
• Test is done in the morning at rest.
60

61. 3. Glucose tolerance test (GTT)…..
(I) Oral glucose tolerance test:
• Giving 75 gm (100 gm by other authors) glucose in 250
ml water orally.
(II) Intravenous glucose tolerance test:
• Giving 25 gm rapid IV, has little practical value due to
bypassing the gut so there is no stimulus to gut hormone
production particularly glucagon.
61

62. Criteria for glucose tolerance test:
The maximum blood glucose values during
pregnancy:
• fasting 90 mg/ dl,
•one hour 165 mg/dl,
•2 hours 145 mg/dl,
•3 hours 125 mg/dl.
•If any 2 or more of these values are elevated, the
patient is considered to have an impaired glucose
tolerance test.
62

63. Indications of performing glucose tolerance test:
1. Positive urine test.
2. First degree family history of diabetes.
3. Gross obesity.
4. Previous Macrosomic babies.
5. Previous unexplained intrauterine or neonatal
deaths.
6. Previous 2 or more unexplained abortions.
7. Current or previous congenital anomalies.
8. Current or previous polyhydramnios.
63

64. Diagnosis …..
Investigation ……
4. Glycosylated haemoglobin (Hb A1):
•It is normally accounts for 5-6% of the total
haemoglobin mass.
•A value over 10% indicates poor diabetes control in
the previous 4-8 weeks.
•If this is detected early in pregnancy, there is a high
risk of congenital anomalies and in late pregnancy it
indicates increased incidence of macrosomia and
neonatal morbidity and mortality.
64

65. Differential Diagnosis of Glycosuria:
1. Lactosuria: may be present during pregnancy, labour
or puerperium. Lactose is differentiated by:
- Osazone test,
- it does not ferment yeast, and
- glucose oxidase test is negative.
2. Alimentary glycosuria:
- Usually occurs early in pregnancy due to rapid absorption of
glucose from the gut.
- No symptoms of diabetes.
- GTT is normal.
65

66. Differential Diagnosis of Glycosuria…..
3. Renal glycosuria:
- usually occurs in mid pregnancy due to lowered renal
threshold.
No symptoms of diabetes.
GTT is normal.
4. Reducing agents: as vitamin C, salicylates and
morphine.
5. Diabetes mellitus.
66

67. Management
A. Antenatal care:
1. Frequent antenatal visits: for maternal and foetal
follow up.
2. Control of diabetes:
I. Diet: is arranged to supply 1800 calories/ day with
restriction
of carbohydrates to 200 gm/ day, less fat and more
proteins and vitamines.

68. Management ….
II. Insulin therapy:
• Oral hypoglycaemics are contraindicated during
pregnancy, labour and early puerperium as they are
not adequate for controlling diabetes, have
hypoglycemia. teratogenic effects and may result in
neonatal
• Doses of insulin tend to increase in the first half of
pregnancy, then stabilise and finally rise in the last
quarter, to be decreased again postpartum.
68

69. • Twice daily ( before breakfast and before dinner)
injections of a combination of short and intermediate
acting insulins are usually sufficient to control most
patients otherwise a subcutaneous insulin pump is used.
• Monocomponent insulins which do not provoke
production of antibodies are preferable e.g. "Actrapid"
(short acting) and " Monotard“ (intermediate acting).
Management ….

70. .
The total first dose of insulin is calculated by;
•Starting with a low dose of 20 units combined insulin
then increase it according to the blood sugar level or,
according to the patient’s weight as follow:
• In the first trimester ............patient’s weight x 0.7
• In the second trimester.........patient’s weight x 0.8
• In the third trimester............patient’s weight x 0.9
Management ….

71. •If the total dose of insulin is less than 50 units/ day, it is
given in a single morning dose with the ratio:
•Short acting (regular or Actrapid)/Intermediate (NPH or
Monotard) = 0.5 In higher doses, 2/3 the dose is given
in the morning with the same ratio and 1/3 the dose is
given in the evening in a ratio 1:1.
71
Management ….

72. Blood sugar analysis is carried out 4 times daily to
regulate the doses as follow:
72
• The aim is to achieve normoglycaemic values as in
GTT.

73. 3- Hospitalization :if diabetics are not controlled as
outpatients or complications develop.
4- Evaluation of foetal well – being by:--
•ultrasound .................................................weekly,
•cardiotocography........................................ weekly,
•serial oestriol estimation ........... 3 times/ weekly,
•amniocentesis before delivery for detection of
phosphatidyl glycerol that indicates lung maturity. L/S
ratio is less reliable in diabetics. 73
Management ….

74. B. Delivery:
1. Timing: pregnancy is terminated at 37 completed
weeks to avoid intrauterine foetal death.
2. Mode of delivery: vaginal delivery is induced in
normal presentation, favorable cervix, average sized
baby and no foetal distress. Otherwise, caesarean
section is indicated.
74
Management ….

75. 3. Insulin therapy:
Day prior to delivery:
• Normal diet, - normal morning insulin, reduce evening
insulin by 25% or omit intermediate acting insulin.
Day of delivery:
5% glucose infusion in a rate of 125 ml/hour + short acting
insulin 1-2 units/hour.
Postpartum: Continue
5% glucose + insulin till oral feeding is established.
When oral feeding is allowed the pre-pregnancy dose of
insulin is given.
75
Management ….

76. 4. Neonatal care:
•The neonate is managed as a premature baby as it is
more liable for RDS.
•5% glucose may given IV at a rate of 0.24 gm / kg/
hour to guard against possible neonatal
hypoglycaemia. Pulsed IM glucose is not preferred
as they may sustain the output of insulin from the
foetal pancreas.
Management ….

77. C. Contraception:
•Mechanical and chemical methods or sterilization are
allowed but hormonal methods are diabetogenic and
IUDS may cause PID.
•Progestogen only contraception may be used if the
patient will accept the high possibility of menstrual
irregularity.
77
Management ….

78. Cardiac disease
•Introduction
•Changes in cardiovascular dynamics during
pregnancy.
•In normal pregnancy the haemodynamic profile
alters inorder to meet the increasing demands of
the growing fetoplacental unit.
Prepared by Shimeles Tsegaye
2005 E.C Dilla
78

79. Introduction ----
•Normal, healthy pregnant women are able to adjust to
those physiological changes quite easily. In women with
coexisting heart disease, however the added workload can
precipitate complications.
•The three peak periods of cardiovascular stress are:
•28-32 wks of pregnancy
•During labour
•12-24hrs post partum are the most critical and life
threatening for women with heart disease.
Prepared by Shimeles Tsegaye
2005 E.C Dilla
79

80. Types of heart disease
Prepared by Shimeles Tsegaye
2005 E.C Dilla
80
•Heart disease can be can be broadly classified in
to:
•Congenital heart disease
•Acquired heart disease
•Congenital heart disease is the principal
cardiovascular problem complicating pregnancy in
the many countries.

81. Type of heart disease ----
1. Congenital heart disease
•The most common congenital heart disease found
in pregnancy are:
•Atrial septal defect(ASD)
•Ventricular septal defect(VSD)
•Patent ductus arteriosus(PDA)
•Pulmonary stenosis
•Aortic stenosis and tetralogy of fallot
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82. Type of heart disease ----
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CHD is also associated with increase fetal
complications like with the maternal functional
class and the degree of cyanosis.
These include:
•Fetal loss
•Intrauterine growth restriction(IUGR)
•Pre-term birth
•An increased risk of fetal CHD

83. Type of heart disease ----
2. Acquired heart disease
These include the following
•Rhematic heart disease
•Myocardinal and ischaemic heart disease
•Aortic dissection(acute)
•Endocarditis
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84. Type of heart disease ----
A. Rhematic heart disease
•RHD remains the most common cardiac problem
in the most part of worlds.
•It causes inflammation and scaring of the heart
valves and results in valve stenosis, plus or minus
regurgitation, valve stenosis is often diagnosed
because of :
•Sever breathlessness
•Tiredness for the first time during pregnancy
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85. Type of heart disease ----
•Management
•Most women with valvular heart disease can be
manged medically which aims to reduce the work
rate of the heart during pregnancy.
•This involves:
•Bed rest
•Oxygen therapy
•Use of cardiac drug e.g diuretic(reduces fluid load),
digoxin(reduces and regulates the heart rate)
•Heparin(reduces risk of thromboembolic disease)
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86. Type of heart disease ----
•Women with more severe sympotomatic disease
may require surgical interventions such as vave
replacement
•Antibiotic prophylaxis is recommended for all
women with valvular lesions during labour.
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87. Type of heart disease ----
B. Myocardinal and ischaemic heart disease
•Myocardial infarction is most likely to occur in the
third trimesters and peri partum period
•Risk factors includes:
•Increased maternal age
•Obesity
•Diabetes
•Pre-existing hypertension
•Smoking and Family history
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88. Type of heart disease ----
Symptom
•Abdominal or epigastric pain
•Vomiting
•Abnormal elevated cardiac enzymes
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89. Type of heart disease ----
C. Endocarditis
•Is an inflammation of the heart usually involving
the heart valve.
•It is one of the most serious complications of the
heart disease.
•Predisposing factors
•Women with valvular heart disease
•History of endocarditis
•Intravenous substance misusers
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90. Type of heart disease ----
Prevention
•Recognition of risk factors and use of strategies to
minimize bacteraemia
e.g. - Good dental hygiene
- Avoidance of drug misuse
- Early treatment of sepsis and administration
of antibiotic prophylaxis to these with high risk
cardiac conditions.
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91. Classification of cardiac disease
•Classification of cardiac disease based on exercise
tolerance is useful for describing the extent of the
immediate problem but has little predictive value.
•Class I: No limitation of physical activity. Ordinary
activity does not cause fatigue, palpitations,
dyspnea, or angina
•Class II: Slight limitation of physical activity.
Comfortable at rest. Ordinary physical activity
results in fatigue, palpitations, dyspnea, or
angina
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92. Classification of cardiac disease---
•Class III : marked limitation of physical activity.
Comfortable at rest. Less than ordinary physical
avtivity results in fatigue, palpitations, dyspnea, or
angina.
•Class IV: Inability to carry any physical activity
without discomfort. Symptoms of cardiac
insufficiency or angina may be present even at
rest, are intensified by activity.
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93. Recognition of cardiac compromise
•Many of the symptoms of normal pregnancy
resemble those of heart disease.
•These include:
•Fatigue, cardiac enlargement,
•Shortness of breath(dyspnea)
•Difficulty in breathing
•Palpitations
•Bounding/collapsing pulsing
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94. Recognition of cardiac compromise --
•Chest pain, IUGR , tendency of preterm delivery
and prematurity
•Development of peripheral oedema
•Distended jugular veins and progressive limitation
of physical activity.
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95. Diagnosis
•Full cardiovascular examination, history and
assessment of life style risk factors
•Blood test- full blood count, clotting studies and
cardiac enzymes
•Chest cardiograph
•E cardiogram to look at cardiac chambers, valve
and great valves
•Other imaging –CT chest scan or MRI
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96. Complications
1. Maternal
•Pulmonary edema due to arterial failure
•Tachycardia due to emotion or exertion and
sudden increased blood volume following labour
•Congestive cardiac failure
•Myocardial failure due to mechanical obstruction
•Pulmonary edema
•Pulmonary embolism
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97. Complications ----
•Active rheumatic carditis death occurs
following delivery
•Obstetric shock
•Sub acute bacterial endocarditis
•Rupture of the cerebral aneurysm
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98. Complications ----
Usual times of maternal death are:-
•During 28-32 wks of pregnancy
•During labour
•Immediately following delivery or early
puerperium
•End of first week of puerperium
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99. Complications ----
2. Fetal
•Prematurity
•Dysmaturity
•Intrauterine death due to maternal anoxia
•High fetal loss.
•Abortion
•IUGR
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100. Management
Antenatal care
•Management requires a multidisciplinary
approach involving midwives, obstetricians,
cardiologists and anaesthetists
•More frequent ANC visit than healthy pregnant
women
•Visit to a joint clinic run by a cardiologist and
obstetrician are usually every 2wks until 30 wks’
gestation and weekly thereafter until birth.
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101. Management ----
•Evaluation of fetal well-bing include use of :
Ultrasound examination to confirm gestational
age and congenital abnormality
Assessment of fetal growth and amniotic fluid
volume both clinically and by ultrasound
Monitoring of fetal heart rate by CTG
Measurement of fetal and maternal placental
blood flow.
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102. Management ----
Physical and psychological care
•Advice with regard to modifying and adjusting
physical activity during pregnancy
•Dietary advice guidance should be given what
constitutes a well-balanced diet. Cholesterol,
sodium-rich foods and salt should be restricted.
Weight gain should be monitored.
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103. Management ----
•Prevention of infection:- infections often cause a
pyrexia and tachycardia, which will put an added
strain on the heart. In addition the infective
organism can cause further damage in women
with heart lesions by causing endocarditis.
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104. Management ----
•Intrapartum care:
•A coordinated team approach with good
communication between the midwife,
obstetrician, cardiologist, neonatologist,
anaesthetist, the woman and her family is
essential. women with heart disease may have
uncomplicated labours. Vaginal birth is preferred
unless there is an obstetric indication for
caesarean section.
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105. Management ----
•During labour
•The patient is confined to bed comfortable
•Oxygen should be kept by the side of the patient
and administered when required
•Patient should be sedated by IM by morphine 15g
or by peptidase 100mg
•Nutrition should be maintained by glucose drinks
•To check vital signs carefully if weak and fast pulse
is recorded _>100/minut, IV should be secured
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106. Management ----
•Forceps delivery or LSCS may be needed as the
combination of the mother. But LSCS the
anaesthesia should be given by expert anesthetist.
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107. Management ----
During puerperium:
•Closely observed for the 1st 24hrs
•Absolute bed rest in comfortable position
•Oxygen administration continuously to be given
•Pulse and RSR to be recorded frequently
•Prophylaxis antibiotic to be given to prevent
puerperal endocarditic
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108. Management ----
•Family planning oral pills and IUCD is
contraindicated for fear of infection
•Barrier method of contraceptive condom is best
to advised the mother
•If her heart is not well compensated the husband
is advised to do vasectomy.
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109. Respiratory disorders
Asthma
•Introduction
•Asthma, which may be the most common
potentially serious complication of pregnancy, is
characterized by chronic airway inflammation with
increased airway responsiveness to a variety of
stimuli, and airway obstruction that is partially or
completely reversible.[
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110. •It affects 2-12 % of pregnant women worldwide
with 5.8% of women hospitalized for asthma
during pregnancy. Prevalence is increasing mainly
due to environmental factors such as change in
indoor environment, smoking, family size, pollution
and diet
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111. •Effect of asthma on pregnancy
•Asthma, which may be the most common potentially
serious complication of pregnancy, is characterized by
chronic airway inflammation with increased airway
responsiveness to a variety of stimuli, and airway
obstruction that is partially or completely reversible.
•It affects 2-12 % of pregnant women worldwide with
5.8% of women hospitalized for asthma during
pregnancy. Prevalence is increasing mainly due to
environmental factors such as change in indoor
environment, smoking, family size, pollution and diet
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112. • Diagnosis
• The characteristic symptoms of asthma are:
• Chest tightness
• Dyspnea
• Wheezing and coughing
• Measuring peak expiratory flow (PEF) using a PEF meter is useful tool for
making a diagnosis and determining how well a person’s asthma is
controlled.
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113. Management
•The ultimate goal of asthma therapy is
maintaining adequate oxygenation of the fetus by
prevention of hypoxic episodes in the mother. The
effective management of asthma during
pregnancy relies on four integral components
outlined below.
•Objective Measures for Assessment and Monitoring
•Subjective measures of lung function by the patient and
physician provide an insensitive and inaccurate
assessment of airway hyperresponsiveness, airway
inflammation, and asthma severity.
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114. Avoid or Control Asthma Triggers
•Limiting adverse environmental exposures during
pregnancy is important for controlling asthma.
Irritants and allergens that provoke acute
symptoms also increase airway inflammation and
hyperresponsiveness. Avoiding or controlling such
triggers can reduce asthma symptoms, airway
hyperresponsiveness, and the need for medical
therapy.
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115. Patient Education
•Women should be made aware that controlling
asthma during pregnancy is especially important
for the well-being of the fetus. Education should
emphasize reduction of asthma triggers. The
patient should have a basic understanding of the
medical management during pregnancy.
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116. Pharmacologic Therapy
•The goal of asthma therapy is multiphasic:
•(1) Relieve bronchospasm,
•(2) protect the airways from irritant stimuli,
•(3) Prevent the pulmonary and inflammatory response to
an allergen exposure, and
• (4) Resolve the inflammatory process in the airways,
leading to improved pulmonary function with reduced
airway hyper responsiveness. The step care therapeutic
approach includes increasing the number and frequency
of medications with increasing asthma severity.
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117. Intrapartum care
•If an asthma attack does occur it should be
treated in the usual way. Women should continue
their usual asthma medications during labour and
it is important that they remain well hydrated.
Maternal and fetal condition should be monitored
closely such as:
•Respiratory function
•Pulse oximetry
•Oxygen therapy and
•Continuous fetal heart rate monitoring
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118. •NB. certain antihypertensive drug and use of
ergometrine or prostaglandinF2a for management
of PPH may cause bronchospasm and should be
avoided or use with caution.
•Oxytocin and prostaglandin E2 are safe to use for
induction of labour
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119. Postnatal care
•Breastfeeding should be encouraged, particularly
as it may protect infants from developing certain
allergic conditions.
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120. Pulmonary tuberculosis(TB)
•Tuberculosis (TB) is an air-born infectious disease
caused by the tubercule bacillus, Mycobacterium
tuberculosis. It is transmited through inhalation of
infected air-born droplets from a person with
infectious TB. It may also caused by consumption
of un boiled milk and dairy products.
•Pulmonary TB (PTB) = accounts for 80% of all TB
case
•Extra-Pulmonary TB (E PTB) = accounts 20%
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121. •Most cases occur in inner city areas where
additional social factors such as poverty,
homelessness, substance misuse, poor nutrition
and crowded living conditions contribute to the
transmission of the disease.
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122. • Diagnosis:
• The onset of primary TB is often insidious and the
symptoms are non-specific:
•Fatigue
•Malaise
•Loss of appetite
•Loss of weight
•These can be interpreted as usual symptoms
occurring in pregnancy leading to a delay in
diagnosis.
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123. The classic symptoms are:
• Persistent cough for more than two weeks
•Productive cough with or with out blood stained
sputum shortness of breath and chest pain
•Loss of wt, intermittent fever night sweats loss of
appetite fatigue and malaise
•Sputum and chest x-ray
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124. •Microscopic examination of sputum smears at
least 3 AFB are seen examined in two
consecutive days
•. Radiological examination: some individuals who
had TB previously that has been cured and there
for do not require treatment may have x ray
suggestive of active TB
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125. Management
•Standard anti-tuberculosis therapy is considered
safe in pregnancy. TB is treated in two phases.
•The first involves taking rifampicin, isoniazid,
pyrazinamide and ethambutol daily for 2
monthes.
• In the second (continuation) phase, rifampicin and isoniazid are taken for a
further 4 months.
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126. •Attention should also be placed on :
•Rest, Good nutrition and education with regard
to preventing the spread of the disease
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127. •Postnatal care
•After birth, babies born to mothers with infectious
TB should be protected from the disease by the
prophylactic use of isoniazid syrup(5mg/kg per day)
and pyridoxine(5-10mg/day) for 6 weeks and then
tuberculin tested. If negative, the neonatal Bacille
Calmette- Guerin(BCG) vaccination should be given
and drug therapy discontinued.
•The baby cannot be infected by the mother via the
breastmilk unless she has tuberculous mastitis.
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128. prevention of TB
•vaccination of children with BCG vaccine
•case finding continuous searching for new
patients
•case holding continuous treatment of known
cases
•health education about
•transmission of TB
•cover mouth when coughing
•spite in to a container with cover never spite in any
where
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129. •Prevention of malnutrition
•Avoid overcrowding
•all children under the age of 6 who have a family
member with pulmonary tuberculosis are properly
screened and receive either a full course of anti
TB treatment or preventive treatment by
Isonized drugs
•Isolation for pulmonary tuberculosis till patient
finished intensive phase of chemotherapy
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130. •concurrent disinfection hand washing and
good housekeeping practices
•pasteurize or boil milk before consumption
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