High Risk Pregnancy in Physical Therapy

High-Risk Pregnancy

• High-risk pregnancy includes hypertension, diabetes, cardiac disease, and asthma.

Hypertension in Pregnancy

• Classification of hypertensive disorders:
• Gestational hypertension: hypertension without proteinuria, occurring for the first time during pregnancy, usually in the second half.
• Preeclampsia: hypertension and proteinuria, with or without edema, occurring mostly in the second half of pregnancy.
• Eclampsia: seizures, convulsions, or fits in addition to preeclampsia.
• Chronic hypertension: hypertension that is present prior to pregnancy or is diagnosed before the 20th week of gestation.

Preeclampsia

• Diagnosis:
• Mild preeclampsia: blood pressure > 140/90 mmHg and protein in urine > 0.3 gm/Liter.
• Severe preeclampsia: diastolic blood pressure > 110 mmHg and protein excretion > 3gm/day.

Diagnosis and Management of Preeclampsia

• Signs:
• Diaphratic breathing exercise: inhale slowly through the nose, raise the abdomen, and exhale slowly through the mouth.
• C. Exercises: upper and lower limb exercises (passive ROM) to avoid increasing intrabdominal pressure and uterine irritability.
• Vital signs should be monitored for 24 hours to avoid changing the case from mild to severe preeclampsia.
• Warning signs: headache, chest pain, dyspnea, vaginal bleeding, decreased fetal movement, and leakage of amniotic fluid.

Nutritional Management of Preeclampsia

• Salt restriction
• Supplementation of vitamin C & E
• Supplementation of calcium
• Supplementation of magnesium
• Omega 3

Diabetes and Pregnancy

• Definition: Rise in blood glucose level, usually detected at 24-28 weeks of gestation.
• Classification:
• Gestational diabetes
• Type I Diabetes
• Type II Diabetes
• Diagnosis: characterized by hyperglycemia (fasting blood glucose > 120 mg/dl, postprandial blood glucose > 200 mg/dl)
• Pathophysiology: placental levels increase during the late 2nd and 3rd trimesters of pregnancy.

Impact of Maternal Diabetes on Fetus and Mother

• Fetus: spontaneous abortion, congenital anomalies, macrosomia, neonatal morbidities, and intrauterine fetal death
• Mother: post-partum hemorrhage, C.S., infections, and persistence of diabetes type II later in life

Physical Therapy Management of Diabetes

• Exercises:
• Moderate exercise (walking on a treadmill for 30 minutes, 3 times a week) to decrease blood glucose levels
• Precautions: measure blood glucose levels before and after exercise, and monitor fetal movement and uterine contraction after exercise
• Contraindications for Exercise:
• Myocardial ischemia or arrhythmias
• Proliferative retinopathy
• Twins and multiple births
• Severe emotional stress
• Hydramnios and macrosomia

Medical Treatment of Diabetes

• If diet and exercise fail to maintain blood glucose levels within normal limits, medical treatment is necessary
• Insulin is the safest treatment

Cardiac Disease in Pregnancy

• Heart disease in pregnancy can be divided into two categories:
• Rheumatic heart disease
• Congenital heart disease
• Guidelines during the prenatal period:
• Avoid excessive weight gain and edema
• Encourage rest
• Avoid strenuous activity
• Avoid anemia
• Management of labor:
• Minimize the increase in cardiac output
• Sedation and epidural anesthesia are encouraged early in labor
• Monitor cardiovascular status during delivery

Asthma and Pregnancy

• Definition: shortness of breath, characterized by increased response of the tracheobronchial tree to various stimuli
• Clinical manifestations:
• Cough
• Dyspnea
• Wheezing
• Etiology:
• Allergens
• Exercise (especially in cold, dry atmosphere)
• Infections (respiratory tract)
• Occupational stress
• Environmental stress
• Emotional stress
• Pharmacological stress

Types of Asthma

• Allergic (extrinsic) asthma: begins in childhood, triggered by allergens
• Non-allergic (intrinsic) asthma: begins after the age of 35, more severe in nature

Effect of Pregnancy on Asthma

• Course of asthma during pregnancy is variable: may improve, stabilize, or worsen
• Women with severe asthma tend to have exacerbation with pregnancy, while those with mild asthma improve

Effect of Asthma on Pregnancy

• Toxemia
• Post-partum complications (prematurity, low birth weight, spontaneous abortion)

Obstetric Management of Asthma

• No drug therapy is needed for most asthmatics
• Women should have plenty of fresh air, avoid people with infections, and avoid smoking
• Adequate bed rest, treatment of respiratory infections, and minimizing stress or anxiety are recommended.