This document discusses the management of anemia and other preexisting or newly acquired illnesses during pregnancy. It covers iron deficiency anemia, folic acid deficiency, hemoglobinopathies, idiopathic thrombocytopenia, and tuberculosis. For anemia, it describes the causes, symptoms, diagnosis, and treatment, including oral iron supplementation or blood transfusions. For other conditions like tuberculosis, it outlines their effects on pregnancy, methods of diagnosis, and management approaches involving medical care and sometimes isolation during and after delivery.

1. Chapter Four
MANAGEMENING PREEXISTING OR
NEWLY ACQUIRED ILLNESS
DURING PREGNANCY

2. Anemia During
Pregnancy

3. ANAEMIA
is a reduction of the RBC volume or
hemoglobin concentration below the
age-adjusted reference range.
few clinical disturbances occur until the
hemoglobin level falls below 7–8g/dL.
may be present when the hemoglobin
level is within the normal range.
Anemia is not a specific disease entity
and may be acute or chronic.

4. • Pregnancy makes considerable nutritional
demands on the mother.
• As a consequence anemia is very common,
particularly when consecutive pregnancies are
not well spaced.
• The presence of anemia increases morbidity in
pregnancy, the risk of infection and, should it
occur, the hazards of post-partum hemorrhage.
• The main nutritional factors involved are iron,
folic acid and B group vitamins.

6. There are two main anemia's seen in
pregnancy: -
iron deficiency causes a
hypochromic,microcytic anemia and
folic acid deficiency is associated with
megaloblastic anemia.
• Automated assays for serum iron, ferritin,
folic acid and vitamin B12 levels have made
investigation of anemia in pregnancy more
rapid and allow correction of hematinic
deficiency early in pregnancy.

7. Haematinic deficiency may result
from:
1. Diminished intake.
2. Abnormal absorption.
3. Reduced storage.
4. Abnormal utilization.
5. Abnormal demand.

8. Cont…
The etiology of anemia must be considered in relation
to these principles.
 Heavy periods and the demands of pregnancy readily
lead to anaemia.
 The increased demands for iron amount to 1000 mg.
Factors operating to cause anaemia in pregnancy
Poor diet,
multiparity
menorrhagia are the commonest causes.

9. symptoms
• Fatigue
• Lethargy
• Dizziness
• Headaches
• Shortness of breath
• Ringing in ears
• Taste disturbances
• Restless leg syndrome
• Pallor
• Flattened, brittle nails
(spoon nail)
• Angular stomatitis (cracks
at mouth corners)
• Glossitis
• Blue sclera (whites of
eyes)
• Pale conjunctivae
• Pica (ice chewing)

10. IRON DEFICIENCY
• Iron deficiency anemia is characterized by :-
 a defect in hemoglobin synthesis, resulting in RBC that are
abnormally small (microcytic) and
 contain a decreased amount of hemoglobin (hypochromic)
Diagnosis
• Blood films will show hypo chromic microcytosis.
• The serum iron and ferritin will be reduced.
• Ferritin:-An iron-containing protein complex, found
principally in the intestinal mucosa, spleen, and liver, that
functions as the primary form of iron storage in the body.

11. Oral iron is the treatment of choice.
anemia is usually associated with failure to take
the preparation.
This may be simply:-
 poor compliance, or
 poor absorption, because of nausea and
vomiting. uncertainty of the time of delivery and
the possibility of preterm labour may require
transfusion to be given in severely anemic and
symptomatic women.

12. Treatment cont…..
• Packed red cells should be given slowly and may
be given in stages.
• The oxygen carrying capacity of transfused red
cells is low for the first 24 hours following
transfusion and it is important to remember that
the red cells are being given to prevent
complications of blood loss at the time of
delivery.
• In less severe cases blood should be available
during labour and transfused at or after delivery
depending on the clinical condition.

13. FOLIC ACID DEFICIENCY
• Folic acid is necessary for nucleic acid
formation and inadequate levels leads to a
reduction in cell proliferation.
• The main effects are seen in tissues which
rapidly proliferate such as the bone marrow.

15. etiology

16. Clinical Findings
• These depend on the severity of the
deficiency. There may be no symptoms and
only moderately low hemoglobin.
• Folic acid deficiency and iron deficiency often
co-exist and iron treatment given alone will
only increase hemoglobin levels slightly.

17. FOLIC ACID DEFICIENCY

18. • Severe folic acid deficiency is now less common than
formerly.
• The use of folic acid prophylaxis for prevention of neural
tube defects reduces the risk of anaemia in pregnancy.
• Unfortunately those most likely to take prophylaxis are not
the population at greatest risk of
• dietary deficiency.
• Consequently folic acid is now often prescribed in a
combined preparation with iron and
• given throughout pregnancy.
• When severe cases do present, the features may co-exist
with other signs of nutritional deficiency such as glossitis.

19. Laboratory Diagnosis
• Automated testing will reveal macrocytosis and
these cells may be hypo chromic.
• A blood film will occasionally show megaloblasts.
Hyper segmentation of the neutrophils may be
seen.
Treatment
• Established deficiency should be treated with oral
folic acid 5 mg three times daily throughout
pregnancy.
• Vitamin B12 deficiency is exceedingly rare in
pregnancy as pernicious anemia causes infertility.

20. HAEMOGLOBINOPATHIES
• The haemoglobinopathies are a group of genetic
disorders of globin synthesis.
• Heterozygote for haemoglobinopathies may be
mildly affected but homozygotes may be severely
anemic.
Sickle cell disease is seen in the African and Afro-
Caribbean communities and
Thalassaemia in those from the Mediterranean
and Far East. In these populations hemoglobin
electrophoresis may be offered at the booking
visit.

21. • In homozygous sickle cell disease there is chronic
anaemia and increased risk of haemolytic crises.
• Alpha thalassaemia is less common and, in the
homozygous form, lethal in utero.
• Homozygous beta thalassaemia causes death in
childhood but the heterozygous form causes
chronic anaemia and may only be diagnosed in
pregnancy. Folic acid should be given but iron is
not required.

22. • Women who are heterozygotes for a
haemoglobinopathy should be offered
screening of their partner to determine the
chance of an affected fetus.
• Chorion villus sampling or amniocentesis can
be used to establish the diagnosis in the fetus.

23. IDIOPATHIC THROMBOCYTOPENIA
• Idiopathic, or immune thrombocytopenic purpura (ITP) is
commoner in women and in those below 30 years.
• It is not rare in the obstetric population.
• The presence of antiplatelet IgG causes a reduction in both
maternal and fetal platelets.
• Treatment, if required, is by glucocorticoids.
• The risk to the fetus is difficult to assess but neonatal
handicap from intra-uterine intra-cranial haemorrhage has
been reported. Many obstetricians advocate elective
Caesarean section for these women to reduce this risk.
• Intravenous gammaglobulin may be given to the mother
some days before delivery as this transiently increases
platelet counts.

24. TUBERCULOSIS (TBC)
24

25. TB Cont…
• Definition: tuberculosis is an infectious disease caused
by the bacillus Mycobacterium tuberculosis and
characterized by the formation of the modular lesions
in the tissue.
• Facts about tuberculosis:
• Two billion or 1/3 of the world population have been
infected
• Nine million new cases of active disease annually
• Two million deaths annually especially in developing
countries
• The second killer infectious disease in the world
25

26. TB Cont…
• TB is of two types:
• Pulmonary tuberculosis (PTBC)and
• 2. Extra pulmonary tuberculosis (EPTBC)
• Pulmonary tuberculosis during pregnancy
• Transmission – through aerosol droplets which
are expelled when person with active TB
disease cough, sneeze, speak or spite
26

27. TB Cont…
• S/S of TB:
• Fatigue
• Wt loss
• Cough
• Night sweating
• Haemoptysis
• Dyspnoea
• Dullness on percussion
• Purulent sputum
• Low grade fever
• Anorexia etc
27

28. TB Cont…
• Diagnosis- by medical history, P/E, chest x-ray,
microscopic smear, tuberculin test etc
• Effect on the pregnancy
• Sing and symptoms mentioned above
deliberate the women and she become less
able to copy with pregnancy and her existing
family.
• Although the transplacental infection is rare,
risk of IUGR and abortion may be increased.
28

29. TB Cont…
• Management:
• The women will be under the care of obstetrician
and chest physician during her pregnancy
• If there is clinical signs of tuberculosis or the
women is known to have been in contact with
tuberculosis full-plate chest x-ray is performed at
3rd month 6th month and after delivery ( the
fetus is protected by lead apron)
• Sputum and pleural effusions should be taken for
diagnosis.
29

30. TB Cont…
• Most treatment is given in outpatient basis,
although the women may be admitted to
isolation unit if her sputum test is positive.
• The rest of house hold will also be referred for
investigation.
• Physical & emotional rest, hospitalization (for
moderate and advanced one), chemotherapy are
included in TB RX.
• A pregnant women with suspected or confirimed
TB should be placed on DOTS( Directly observed
chemotheraphy short course)
30

31. TB Cont…
• The currently accepted first line therapy is
2RHZE/4RH
• Some women are admitted for rest during the
last 2 wks of pregnancy.
• Except streptomycin that has adverse effect
on the fetal ear and kidney, all anti TB drugs
are not contraindicated during pregnancy.
31

32. TB Cont…
• Intrapartal care:
• If the mother is infections she should be allocated
a single room during her stay in hospital.
• Episiotomy and forceps delivery to reduce strain
of second stage of labour.
• Unnecessary blood loss should be avoided
• The interaction b/n her regular medication and
drug given in labour may be important; for
example streptomycin potentiates the effect to
tocolysis (muscle relating drugs)
32

33. TB Cont…
• Postnatal care:
• Separation of the baby from his family is not
always necessary.
• The baby can be vaccinated by ant-isonizid
resistant BCG(Bacillus Calamate Guerin)
• With out vaccination child has a 50% chance of
catching the disease.
• If any of baby’s family is infected with isonizid
resistant organism, separation of the baby is
mandatory.
33

34. TB Cont….
• Breast feeding is contraindicated if the women
has an active infection.
• Mothers taking anti tuberculosis therapy
should be encouraged to breast feed since the
infant will receive 2% of the normal infant
dose by this rout
34

35. TB Cont…
• The MW should advise to avoid further
pregnancies until the disease had been
quiescent for at least 2 years.
• The mw should be aware, and also teaches
the mother that Rifampicine reduces the
effectiveness of oral contraceptive pill.
35

36. TB cont…
• Normal breathing sounds
• Vesicular- from small air way
• Broncho vesicular- near by large air way.
• Bronchial breathing sound (BBS) on the head
of the sternum.
36

37. • Abnormal breathing sounds:
• Bronchial breath sounds (BBS): other than at
the head of sternum
• Crepitations: – pneumonia, TB, CHF
• Wheezing:- continuous expiratory sound- in
asthma & chronic bronchitis
• Friction rubs:- in pleurisy as a result of friction
b/n the visceral and parietal pleur
37

38. ASTHMA IN PREGNANCY
38

39. Cont…
• Asthma:
• Asthma is a condition characterized by
paroxysmal attacks of bronchospasm causing
difficulty in breathing.
• People with asthma have extra sensitive or
hyper responsive airways.
• These air ways react by narrowing or
obstructing when they become irritated.
• This makes difficulty in breathing.
39

40. Asthma Cont…
• This narrowing or obstruction can cause one
or a combination of the following symptoms.
• Wheezing
• Coughing
• Shortness of breathing
• Chest tightening
40

41. Asthma Cont…
• This narrowing or obstruction is caused by:
• Air way inflammation
• Bronchoconstriction
• Factors provoking asthma:
• Two factors provoke asthma:
• Triggers
• Causes
41

42. Asthma Cont…
• 1. Triggers: result in tightnining of air ways
(bronchoconstriction) common triggers
include; cold air, dust, strong fumes, exercise,
inhaled irritants, emotional upset, smoke
• 2. Causes (inducers): result in inflammation of
air ways common inducers include:
• Allergens example pollen, animal secretions (
cat & horse), molds, house dust mites
• Respiratory viral infections
42

43. • Asthma in pregnancy
• General facts
• Asthma is the most common respiratory disease
encountered during pregnancy, affecting 3% of all
women in their child bearing age.
• Morbidity and mortalities associated with it is largely
preventable
• Medications commonly used in the management of
asthma are not known to cause teratogenic effect.
• The risk of uncontrolled asthma are far greater than
the risks to the mother or fetus from the medications
used to control asthma
43

44. Asthma Cont…
• Effect of uncontrolled asthma on pregnancy:
• Premature birth
• Low birth weight
• Predisposition to pre-eclampsia
44

45. Asthma Cont…
• Management:
• Asthma attacks can be prevented by:
• Controlling the environment( avoiding triggers
and inducers)
• Continuing regular scheduled medication
during pregnancy, labour and delivery.
45

46. Asthma Cont….
• Any women identified at booking with
diagnosed or suspected asthma should be
referred to chest physician.
• If during pregnancy there are any difficulties in
controlling the asthma, the woman should be
admitted to hospital.
BY GEBREMARYAM TEMESGEN BSC IN MW
46

47. • NB: labour is not usually complicated by asthma
attacks due to an increase in cortisone and
adrenalin from the adrenaline glands during
labour.
• If an asthma attacks does occur during pregnancy,
it should be treated with the same rapidity and
medication as an asthma attack out side of
pregnancy.
• Intravenous, intra amniotic and transcervical
prostaglandins should be avoided in a woman
with asthma b/s of their brounchospasm action.
47

48. Quiz
• What are the two common types of anemia
during pregnancy
• What are the fetal complication of anemia
• What is the effect of tb on pregnancy
• Write triggering and inducing factors for
asthma.

49. CARDIAC DISEASE IN
PREGNANCY
49

50. Introduction
• A woman with a known cardiac illness can
become pregnant or a healthy pregnant woman
can develop cardiac illness while pregnant. In a
woman with a preexisting cardiac illness, the
increased homodynamic burden of pregnancy,
labor and delivery can aggravate the symptoms of
the illness and/or precipitate complications.
• The risk of congestive heart failure is the highest
around 24 weeks of gestation, labour and the
immediate postpartum period.
50

51. Risk factors for cardiac failure during
pregnancy
 Infection
 Anemia
 Obesity
 Hypertension
 Hyperthyroidism
 Multiple pregnancy

52. • During each uterine contraction in labor about
200-300 ml blood is squeezed from the
contracting uterine muscles, increasing the
cardiac output by about 20%.
Significance
• Cardiovascular diseases are the most important
non-obstetric cause of disability and death of
pregnant women, occurring in 0.4-4% of
pregnancies.
• The most common cardiovascular disease that
complicates pregnancy is rheumatic heart disease
52

53. • Patients with valvular heart disease may
develop sub acute infectious endocarditis. It is
also associated with adverse fetal outcome
like spontaneous abortion, preterm labour,
low birth weight, and intrauterine fetal death.
Classification
• The degree of functional disability due to
cardiac disease is graded according to the New
York Heart Association classification as follows
53

54. • Class I: No symptoms limiting ordinary physical
activity.
• Class II : Slight limitation with mild to moderate
activity with no symptoms at rest
• Class III: Marked limitation with less than
ordinary activity; dyspnea or pain on minimal
activity.
• Class IV: Symptoms at rest or with minimal
activity and symptoms of congestive heart failure
54

55. Prognosis depending on the
functional status
 In general, women in NYHA classes I and II lesions
usually do well during pregnancy and have a
favorable prognosis with a mortality rate of <1%.
 Patients in NYHA classes III and IV may have a
mortality rate of 5% to 15%. These patients should
be advised against becoming pregnant.

56. • Note: With rare exceptions, women in class I
and most in class II go through pregnancy
without morbidity. As much as possible
patients in classes III and IV should avoid
pregnancy. Therapeutic abortion is an option
in early pregnancy. If the pregnancy is
continued, prolonged hospitalization or bed
rest will often be necessary. These women
tolerate major surgical procedures poorly
56

57. With normal pregnancy:-
1) What are the causes for increased cardiac
output during a normal pregnancy?
2) What are the causes for fall in the peripheral
resistance?
3) What are physiological changes during labour
?

58. Management
• Once diagnosed, these patients should be referred for
specialized care by obstetrician, internist and
neonatologist. The general principles in the management
are:
I. Antepartum
• Bed rest
• Moderate dietary restriction
• Provision of diuretics (chlorothiazides are accepted) with
potassium supplementation
• Prophylactic digitalization
• Frequent ANC for maternal and fetal monitoring
58

59. II. Intrapartum
• Unless contraindicated vaginal route of delivery
is preferred
• Conduct labour and delivery in lateral decubitus
position
• Provide adequate pain relief
• Restrict intravenous fluids
• Provide oxygen with breathing mask along with
continuous pulse oxymetery
59

60. Decubites position

61. • Shorten the second stage by instrumental
delivery
• Do not use ergometrine in the third stage
• Prevent postpartum pulmonary edema by
keeping the woman in sitting position
• Provide thrombus prophylaxis by early
ambulation and/ or low dose aspirin
61

62. Antibiotic prophylaxis consists of
a. 2 gm ampicillin IV/plus
b. 1.5mg per kg gentamicin /IV prior to the
procedure , followed by one more dose of
ampicillin 8 hours later.
In the event of penicillin allergy 1 gm vancomycin
IV can be substituted.

63. Which is the ideal contraceptive for
women with heart disease ?
1. OC pills are not ideal as they can cause thrombo embolism.
2. IUCD can cause infection- endocarditis.
3. Barrier contraceptives – Have high failure rates.
4. Progestin only pills or Long acting injectable progesterone are
better
PILL - Desogestrel
INJECTABLES
a. Medroxy progesterone 150mg IM every 3 months.
b. Norethisterone.200 mg every 2 months
5. Sterilization is best.

64. Diabetes Mellitus/DM/
64

65. DM Cont…
• Definition: Diabetes is a disease characterized
by the inability to produce or use sufficient
endogenous insulin to metabolize glucose
properly
• Note: pregnancy is a diabetogenic state!
65

66. DM Cont…
Types of diabetes mellitus:
There are 3 types of diabetes
1. Type 1/ insulin dependent diabetic
mellitus/IDDM/ insulin deficiency/
• Pancreatic  – islets of Lengharn’s virtually do not
produce insulin
• Ketone prone
• Also called juvenile onset diabetes/Brittely
diabetes
66

67. DM Cont…
2. Types – adult onset diabetes/non insulin
dependent diabetes /NIDDM/
• Pancreatic  – in islets of langerhan’s produce
normal or increased amount of insulin.
• It takes higher level of insulin to open the
receptor and facilitate muscle glucose up take
• The pancreas is over loaded to meet the
increased demand of extra insulin.
• NB: the above two are pre gestational DM
67

68. DM Cont...
3. Type 3 Gestational Diabetic Mellitus(GDM)
• Carbohydrate intolerance that develops/first
recognized /during pregnancy, regardless of
severity (at least abnormal values on a 3 hr
oral glucose tolerance)
• Occurs when there is insufficient insulin
secretion to counteract the pregnancy related
decrease in insulin sensitivity.
68

72. DM Cont…
Women who are at risk of developing
gestational diabetes are those:-
• Diabetes in first degree relative (type two)
• With recurrent abortion
• With unexplained still birth
• A baby > 4.36kg at 40 wks
• Previous gestational diabetes
• Persisting glycoseuria
72

73. DM Cont…
Etiology of diabetes mellitus
• Insulin deficiency due to  -cell damage
• Inactivation of insulin by antibodies
• Increased insulin requirements
73

74. DM Cont…
• Type 1 DM is a chronic auto immune disorder
of the pancreatic islet cell that develops in
individuals who carry a genetic matter that
has been identified on chromosome 6, viral
induced ,immune stimulated antibodies
against the B-cell .
• In 80% to 85% of patients with type 2 DM,
obesity especially to the abdominal region,
causes their insulin resistance.
74

75. DM Cont….
• Carbohydrate metabolism in pregnancy /Normal
physiology/
• Pregnancy is a diabetogenic state
• Estrogen and progesterone stimulate pancreatic B-cells
hyperplasia->increased insulin secretion ->
glucose utilization is enhanced -> decreased fasting
glucose level in first trimester.
• During second and third trimesters HPL increase insulin
resistance -> increased post prandinal blood glucose
levels-> the increased glucose presence stimulates
pancreatic islets to hypertrophy -> hyperinsulinemia
75

76. DM Cont…
• The net effect is decreased insulin
effectiveness causing reduced peripheral up
take of glucose by mother, which facilitates
glucouse available to the fetus acceleration
fetal growth.
76

77. DM Cont…
Phathophysiology:
• Pre gestational diabetes
• In theory the cause of faulty metabolism in the
diabetic person is one or more of the following;
• Production of defective insulin
• Over production of insulin antagonist
• Increased tissue resistance to insulin production.
• Inadequate amount of insulin production.
• Inappropriate timing of insulin production
77

78. DM Cont…
• Functions of insulin
• Regulate glucose and transfer from blood to
blood cell.
• Stimulate protein synthesis and free acid
storage in the fate deposits.
78

79. DM Cont….
• Insulin deficiency compromises access
essential synthesis for all body tissue.
• Without insulin glucose circulation in the
blood stream unable to enter the cell .
• The energy starved cells catabolize fats from
fat wasting and negative nitrogen balance
from protein break down and muscle tissue
wasting/ ketones accumulation in the blood
stream/.
79

80. DM Cont…
• The high level of glucose leads to hyperglycaemia,
which exerts an osmotic force, puling intracellular
fluid in to the blood stream causing cellular
dehydration.
• when the circulating glucose level exceeds the
renal threshold, glucose splits in to the urine,
causing glycosuria.
• The urines high osmotic level prevents re
absorption of water in to renal tubules causing
extra cellular dehydration.
80

81. DM Cont…
These change produce the four classic sign and
symptoms of diabetes.
• Polyuria (frequent urination), Which develops b/s
the renal tubules do not re absorb water.
• Polydipsia (excessive thrust), which is caused by
the dehydration of polyuria
• Polyphagia (excessive hungry) which result from
tissue catabolism and inadequate cellular use of
glucose.
• Weight loss, which occur when the body burns fat
and muscle for energy.
81

82. DM Cont…
Glycosuria in pregnancy:
• Glucose is most liable to appear in the urine of
the pregnant women for the following
reasons:
1. In a non-diabetic the blood glucose level
remains with normal limit but the glumuerular
filtration rate increases and glucose passes
through the proximal convoluted tubule faster
than it can be re-absorbed.
82

83. DM Cont…
2. In the diabetic, the rise in blood glucose leads
to more glucose in the glumerular filtrate b/s
of lowering the renal through hold for glucose.
3. Renal tubular damage interferes with glucose
re absorption and may be revealed from the
first time during pregnancy.
83

84. DM Cont…
Note: Glycosuria in pregnancy is not a diagnostic of
diabetes nor can it be used as a monitor of
diabetes in the pregnancy women.
• Blood glucose level
• Normal: 80-120mg/dl
Indicates diabetes:
• Fasting blood sugar (FBS) >126mg/dl
• Random blood sugar (RBS)> 200mg/dl
• Higher than 200mg/dl 2 hours after OGTT
84

85. DM Cont…
• Detection of diabetes in pregnancy:
• Women considered to be at risk of gestation
diabetes should undergo a glucose tolerance
test.
(oral glucose tolerance test)OGTT) = A quantity
of glucose e.g. Locozade
85

86. • (353ml) which provides 75 gm of glucose is
given to the patient by mouth after a period of
fasting, and the concentration of sugar in
blood and urine is measured).
• The reading indicates the ability of patient’s
body to utilize glucose.
• Before proceeding to a full glucose tolerance
test a women is asked to fast a period of time
and fasting blood glucose level is estimated

87. Conversion of Glucose Values from
mg/dl to mmol/l
• mg/dl x 0.0555 = mmol/l
• mmol/lx 18.0182= mg/dl
87

88. DM Cont…
• It would be abnormal if b/n 28 and 34 weeks of
pregnancy, glucose in two out of four venous
samples exceeds the following.
• Fasting 8.0mmol/l
• 1 hour after ingestion of 75gm glucose
11.0mmol/l
• 2 hour after ingestion of 75mg glucose 9.0mmol/l
• 3 hour after ingestion of 75mg glucose 7.0mmol/l
88

89. DM Cont…
• The effect of pregnancy on diabetes
• In early pregnancy diabetes control may be
complicated by nausea and vomiting
• As pregnancy advances ketosis in induced easily
• The diabetic who is controlled by diet may
become dependent on insulin.
• Blood sugar must be kept within a narrow limits
in order to avoid exacerbating the effect of the
diabetes.
89

90. DM Cont…
Effect of diabetes on pregnancy:
• Spontaneous abortion,
• pre-eclampsia,
• pre term labor
• polyhydramnious,
• infection e.g. candida albicans
• caesarean/instrumental birth/
90

91. DM Cont…
Effects of diabetes on the fetus:
• Hypoglycemia
• Hyperglycemia
• Congenital anomalies
• Macrosomia(big baby)
• IUGR, unexplained IUFD
• Neonatal hypoglycemia,
• Neonatal hyperblirubinima,
• Neonatal polycythemia,
• Hearing disorders, ketoacidosis.
91

92. DM Cont…
Pathophysiology of effect of DM on the mother
and fetus:
High amount of glucose in the blood->
1. Pass with urine -> glycoseuria->
infection(UTI, fungal )
2. Also increased glucose in fetal circulation->
increased amount of urine-> polyhydraminu->
PROM and pre term delivery.
92

93. DM Cont…
3. Big baby (macrosomia) b/s of high glucose level and
hyperinsulineamia-> CPD-> caesarean or instrumental
delivery and neonatal hypoglycemia.
4. Contribute to synthesis of DNA & RNA-> congenital
abnormalities like NTD, congenital cardiac anomalies.
5. Body use fats to produce energy -> ketones and acid-
> ketoacidosis-> abortion or fetal death(IUFD)
6. Glycosaylated hemoglobin also interferes with
transport of oxygen and carbon dioxide-> decreased
fetal PH and increased PCO2->unexplained fetal death
93

94. DM Cont…
The pregnancy care of the known diabetic:
• A diabetic woman should consult her
physician for preconception care and advice
and also carefully examined for the presence
of renal, cardiovascular, or retinal changes
before becoming pregnant.
• Contraceptive methods that do not contain
estrogen may be given in order make her not
to get pregnant.
94

95. Antenatal care
• A woman with diabetes should be advised to book to have
her in a hospital with neonatal intensive care unit.
• She should be seen at combined antenatal and diabetic
clinics.
• ANC cheek up every 2 wks up to 28wks and then weekly.
• The MW should alert woman to the s/s of vaginal infections
and to keep her personal hygiene.
• Alpha-fetoprotein- to detect fetal abnormalities
• Examination of maternal wt and of her abdomen will help
the mw to detect polyhydramnious.
• Detection of any diabetic complication
95

96. DM Cont…
Control of diabetes in pregnancy:
The aims of diabetic control in pregnancy are
• To avoid hypoglycemia.
• To maintain the pre-prandial glucose b/n 4.0
and 5.5mmol/l
• To ensure that the post prandial peak does not
exceed 7.2mmlo/l
96

97. • Subcutaneous insulin provides the best method of control
for most women.
• A combination of short and intermediate acting insulin is
usually given twice daily before breakfast and the evening
meal.
• Insulin is absorbed more quickly from the upper arm than
from the abdomen and more slowly from the thigh.
• The women is usually give a kit containing glucagons which
can be administered subcutaneously in the event of the
severe hypoglycaemia.
• Admission to hospital may be needed if there is poor
diabetic control or there is complication.
97

98. Monitoring diabetic control
If possible women monitors her own diabetes
to:-
• Hyperglycaemia and hypoglycemia
• Measure changes in blood glucose during 24
hours period
• Assess blood glucose control in times of
special needs so that insulin dosage can be
adjusted accordingly.
98

99. Cont…
• Obtain a full blood glucose profile; samples
should be taken the following times;
– Before the morning injection
– 1-2 hours after breakfast
– Before bed time
– At some point during the night
– Before lunch
– Before the evening injection
– 1-2 hours after the evening meal

100. Management of labor and delivery
• Since fetal lung mature more slowly when the mother
is diabetic, tocolytics should be given when labor being
prematurely
Control of diabetes in labor
• The mw should monitor fetal condition though out
labor
• Pediatrician should be present
• Polyhydraminious, malperesentation, cord prolapse
birth asphyxia, big baby with birth injury (shoulder
distocia)should be expected and the staff should be
ready to manage these all
100

101. DM Cont…
Postnatal care
• Mother
• Carbohydrate metabolism returns to normal
very quickly after delivery of placenta
• Diabetic mother who is breast feeding should
be increase her carbohydrate in take by 50gm
a day.
101

102. DM Cont…
Gestational diabetes
• A woman with gestational diabetes requiring
insulin will stop this immediately after
delivery.
• A post partum glucose tolerance test should
be performed approximately after delivery
and the mother should be warned that it can
recur.
102

103. Baby
• Asphyxia is common in both macrocosmic and growth-retarded
babies.
• Macrocomic baby are prone to birth injuries
• The baby should be examined carefully at birth as
there is an increased risk of congenital abnormality.
• After birth the baby continues to prouduce more
insulin than he needs. As there he is no longer receving
glucose from his mother, hypoglycaemi may occur.
• To prevent hypoglycaemia the baby should feed after
delivery.
103

104. Diabetes in Pregnancy: Hypoglcemiaypoglycemia
Pathophysiology
May be related
to fetal
absorption of
glucose from
the maternal
bloodstream
via the
placenta,
particularly
during periods
of maternal
fasting
Risk Factors
History of severe
hypoglycemia
before pregnancy
Impaired
hypoglycemia
awareness
Longer duration of
diabetes
A1C ≤6.5% at first
pregnancy visit
High daily insulin
dosage1
Causes of
Iatrogenic
Hypoglycemia
Administration of
too much insulin or
other anti-hyperglycemic
medication
Skipping a meal
Exercising more
than usual2,3
Clinical
Consequences
Signs of
hypoglycemia:
anxiety, confusion,
dizziness, headache,
hunger, nausea,
palpitations,
sweating, tremors,
warmth, weakness4
Risks of
hypoglycemia:
coma, traffic
accidents, death1,5
Severe
hypoglycemia can
lead to maternal
seizures or hypoxia
Management
Inform patients of
increased risk of
severe hypoglycemia
during early
pregnancy4
Educate patients
on hypoglycemia
prevention:
Frequent SMBG
Regular meal
timing
Accurate
medication
administration
Careful
management of
exercise
programs4
1. Mathiesen ER, et al. Endocrinol Metab Clin N Am. 2011;40:727-738. 2. Inturrisi M, et al. Endocrinol Metab Clin N Am. 2011;40:703-26.
3. Jovanovic L, et al. Mt Sinai J Med. 2009;76(3):269-80. 4. Kitzmiller JL, et al. Diabetes Care. 2008;31(5):1060-79.
5. Hod M. Jovanovic L. Int J Clin Pract. 2010;64(166):47-52.

105. Thank You