Medical and Surgical Complications in Pregnancy

• Dyspnea on exertion during pregnancy can be due to increased cardiac output.
• Medical management options for dyspnea include limiting physical activity, restricting sodium intake, beta-blockers to decrease heart rate, diuretics for heart failure, and anticoagulants for atrial fibrillation to prevent thrombosis.
• Surgical management for dyspnea may be considered if medical management fails. Percutaneous mitral balloon valvotomy is one option, often performed in the second trimester.
• Pregnancy-induced diabetes mellitus (GDM) increases the risk of pregnancy-induced hypertension (PIH), polyhydramnios, infections like asymptomatic bacteriuria, increased insulin resistance throughout pregnancy, and fetal macrosomia.

Diabetes in Pregnancy: Part 1

• Insulin resistance in pregnancy is influenced by hormones such as human placental lactogen, estrogen, progesterone, prolactin, and cortisol.
• Human chorionic gonadotropin (HCG) does not contribute to insulin resistance.
• Insulin resistance increases with progressing gestation due to rising human placental lactogen secretion.
• Gestational diabetes occurs when a normoglycemic woman develops insulin resistance after conception, becoming diabetic.
• Maternal thyroxine crosses the placenta, but maternal insulin does not.
• Maternal glucose crosses the placenta supplying the fetus's glucose needs.
• Glycosuria is considered normal during pregnancy.

Pregnancy Complications of Diabetes

• Both maternal and fetal complications are possible due to diabetes in pregnancy, with fetal complications including decreased glucose absorption.
• Maternal complications can involve fasting hypoglycemia, post-prandial hypoglycemia due to insulin resistance, and hypoglycemia resulting in ketone formation if fasting, vomiting, or diarrhea occurs.

High-Risk Pregnancy

• Hyperglycemia during pregnancy is fetotoxic increasing free radicals that cross the placenta, potentially leading to congenital malformations and ketosis.

Diabetes in Pregnancy: Part 2

Gestational Diabetes

• Gestational diabetes develops due to increased insulin resistance in individuals with normal blood sugar levels.
• Complications are similar to those of pre-gestational diabetes mellitus.
• Glycosylated hemoglobin A1c is not measured in GDM diagnosis.
• Follow-up is the same as for pre-gestational GDM.
• Investigations are the same as for pre-gestational GDM, except fetal echocardiography is not done.

Diagnosis (Dipsi Criteria)

• Initial testing is recommended at the first antenatal visit, repeated at 24-28 weeks, and finalized at 28 weeks.
• The minimum time gap between tests is 4 weeks.
• Universal screening is conducted.
• 75g of glucose dissolved in 300ml of water is administered to consume in 5-10 minutes.
• 2-hour postprandial (PP) blood glucose levels are checked using a plasma calibrated glucometer.
• If the patient vomits, the test should be repeated within 30 minutes and continue after 30 minutes.
• If previous tests were abnormal, the test should be repeated on another day.

Management of Gestational Diabetes

• Interpretation of 2-hour PP blood glucose Levels:

  • At the first antenatal visit:
    • Repeat test at 24-28 weeks.
    • Values ≥140 indicate GDM.
    • Values ≥200 indicate pre-GDM.
  • At 24-28 weeks:
    • If not diabetic:
      • Values ≥ 140 indicate GDM.
      • Values ≥200 require insulin treatment.

• Depending on 2-hour PP values:

  • Blood Glucose Level (mg/dL) | Action
  • 140-199 | Medical Nutrition Therapy (MNT) for 2 weeks.
  • ≥200 | Immediate 8U insulin.

Metabolic Goals

• Fasting Blood Sugar (FBS): < 95 mg/dL.

• 1-hour PP: <140 mg/dL.

• 2-hour PP: <120 mg/dL.

• HbA1c: < 6%.

• Average capillary glucose: < 100 mg/dL.

• If goals are met, continue MNT.

• If goals are not met, start metformin > insulin+MNT.

• Weight counseling is recommended.

• Additional instructions:

  • Advise 30 minutes of walking daily.
  • Check 2-hour PP levels:
    • Second trimester: every 2 weeks.
    • Third trimester: weekly.
    • Minimum: monthly.

• GOI guidelines for treatment:

  • Diagnosis before 20 weeks: Insulin.
  • Diagnosis after 20 weeks: Metformin.
  • 2-hour PP > 200 mg/dL (at any time): Insulin.

Classification of Diabetes in Pregnancy

Pre-Gestational Diabetes

• Also known as overt diabetes.
• This occurs when a diabetic female becomes pregnant.
• Blood sugar is elevated from day 1 of pregnancy, increasing the risk of congenital malformations due to free radical formation.
• Pre-gestational diabetes does not resolve after delivery.

Priscilla White Classification

• Type A Gestational diabetes → Non Type A Pregestational diabetes
  • Al (GDM controlled on diet)
    • Development of GDM: Usually at 24-28 weeks but can occur earlier.

Pregestational Diabetes

Criteria:

• Fast Blood Sugar (FBS) ≥ 126 mg/dL.
• 2-hour Postprandial Blood Sugar (PPBS) ≥ 200 mg/dL (clinically performed).
• Random Blood Sugar (RBS) ≥ 200 mg/dL.
• HbA1c ≥ 6.5%.
• DIPSI Test: Recommended by the Government of India at the 1st ANC visit.

HbA1c

• HbA1c is a risk assessment tool for congenital malformations and gross congenital anomalies (GCA).
  • HbA1c < 6.5%: No risk.
  • HbA1c > 6.5%: 3% risk.
  • HbA1c ≥ 10%: 15-20% risk.
• Goal of therapy: HbA1c < 6%.

Investigations

• Initial: Ultrasound (USG).
• Screening test: Level I USG.

Complications

Congenital Fetal Malformations

• Most commonly affected systems: Cardiovascular System > Central Nervous System.
• Most common congenital malformation: Ventricular Septal Defect (VSD) > Neural Tube Defect (NTD).
• Most common cardiac malformation/anomaly: VSD.
• Most specific cardiac malformation/anomaly: Transposition of Great Arteries (TGA).
• Most common cardiac finding: Hypertrophic Obstructive Cardiomyopathy (HOCM).

Diagnostic Tool:

• TIFFA.

Karyotyping:

• Not performed, as it detects chromosomal anomalies, not GCA.

Prevention of GCA

• Strict glucose control (HbA1c < 6.5%) is crucial to reduce the risk of GCA.
• Switching to insulin before conception or on confirmation of pregnancy is important.
• Folic acid 400 mcg/day is recommended:
  • Start 1 month prior to conception.
  • Continue for 3 months after conception.

Caudal Regression Syndrome

• No description of an image is provided in the text, but it is mentioned as a complication of pregnancy.

Thyroid Disorders in Pregnancy

Physiological & Pathological Thyroid Changes during Pregnancy

Physiological Changes

• Size of the thyroid gland: Increased (goiter is pathological).
• Thyroid profile: Pregnancy is an euthyroid state.
• TSH: Normal or slightly increased.
• α subunit of hCG is similar to the α subunit of TSH and stimulates the thyroid gland.
• Total T3, T4: Increased.
• Thyroid binding globulin (TBG): Increased due to estrogen.
• Free T3, T4: Normal (increased T3 and T4 bind to increased TBG).
• Recommended Daily Allowance (RDA) of iodine: 250 mcg/day.

Fetus

• Thyroid hormone: Crosses the placenta.
• Increased thyroid hormone requirement: Due to fetal growth and metabolism.

• Heart Diseases in Pregnancy

Scoring Systems for Heart Diseases in Pregnancy

• Carpreg score: Used for acquired heart disease.
• Zahara score: Used for congenital heart disease.
• WHO classification: Most commonly used classification system.

WHO Classification Table

• Class | Cardiac Review
• I | One/twice during pregnancy
• II | Review every trimester
• III | Review every 1-2 months
• IV | Pregnancy contraindicated. Admit the patient throughout the pregnancy.

Other Conditions in Pregnancy

Peripartum Cardiomyopathy

Diagnostic Criteria

• No prior heart disease.
• Heart failure between 36 weeks of pregnancy and 5 months after delivery.
• No other cause for heart failure.
• Echocardiogram (ECHO): Decreased Left Ventricular Ejection Fraction (LVEF).

Investigation of Choice (IOC):

• ECHO.

Decreased LVEF:

• Diagnostic criteria.

Dilatation:

• Left ventricle.

Risk Factors:

• Twin pregnancy.
• Preeclampsia.
• Increased gestational age.

Management

• Heart failure management + bromocriptine (Prolactin has a role in peripartum cardiomyopathy).

Mitral Stenosis

• Area of mitral stenosis | Inference

• 4-6cm² | Normal

• ≥1.5-4cm² | Mild mitral stenosis

• ≥1-1.5cm² | Moderate mitral stenosis

• <1cm² | Severe mitral stenosis

• Management:

  • Percutaneous mitral balloon valvotomy (Valve Replacement)

• Indications for surgery:

  • Severe symptomatic mitral stenosis: Dyspnea, hemoptysis

• Pregnancy contraindicated (Usually).