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What is a recommended management strategy for a patient experiencing dyspnea on exertion due to increased cardiac output during pregnancy?
Which medication is indicated for reducing heart rate in a pregnant patient with complications affecting the heart?
In cases of atrial fibrillation during pregnancy, what is the purpose of administering anticoagulants?
What surgical intervention may be necessary if medical management fails in a pregnant patient with cardiac complications?
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During which trimester is the surgical management of cardiac complications, such as percutaneous mitral balloon valvotomy, typically performed?
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Which complication is associated with undiagnosed Pre-Gestational Diabetes Mellitus (Pre-GDM)?
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What is the recommended frequency for monitoring blood glucose levels in the 3rd trimester?
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At what gestational age should a fetal echocardiogram (ECHO) be performed to rule out ventricular septal defect (VSD)?
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How often should growth scans be performed during pregnancy for patients with Pre-GDM?
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Which of the following is NOT a part of routine check at each antenatal visit for patients with diabetes in pregnancy?
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What are the primary indications for performing umbilical artery Doppler ultrasonography during pregnancy?
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Which treatment is considered the drug of choice for managing diabetes during pregnancy?
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At what gestational age is termination of pregnancy or induction of labor typically recommended?
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Which of the following is NOT typically done in gestational diabetes management according to the provided guidelines?
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What is the indication for performing a cesarean section in this context?
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Which scoring system is primarily used for congenital heart disease in pregnancy?
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What is the recommended frequency for cardiac review in a patient classified as Class III during pregnancy?
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Which of the following is NOT a diagnostic criterion for peripartum cardiomyopathy?
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Which of the following is a known risk factor for developing peripartum cardiomyopathy?
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What is the classification of mitral stenosis when the area is between 1.5 to 4 cm²?
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What hormone is primarily responsible for increasing insulin resistance as pregnancy progresses?
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During pregnancy, what is the fate of maternal glucose?
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Which of the following complications is associated with maternal fasting hypoglycemia during pregnancy?
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What is a potential risk for the fetus in a hyperglycemic mother during pregnancy?
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Why is glycosuria considered normal in pregnancy?
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What is the recommended action if a patient's 2 hr postprandial (PP) blood glucose level is between 140-199 mg/dL?
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What should be done if a patient's fasting blood sugar (FBS) is greater than 95 mg/dL?
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Which of the following metabolic goals should NOT be exceeded for a patient managing gestational diabetes?
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At what blood glucose level should a patient be treated with insulin immediately?
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What is the advised physical activity for a patient diagnosed with gestational diabetes?
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What is a characteristic feature of gestational diabetes?
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Which of the following is NOT part of the complication profile of gestational diabetes?
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When is the first test for diagnosing gestational diabetes recommended?
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What is the minimum time gap required between tests for gestational diabetes diagnosis?
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What should be done if a patient vomits during the gestational diabetes test?
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What does Pre-Gestational Diabetes NOT do post delivery?
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At what gestational weeks is Gestational Diabetes Mellitus (GDM) usually developed?
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Which type of diabetes does the Priscilla White classification categorize as 'Non Type A Pregestational diabetes'?
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What consequence can free radical formation from Pre-Gestational Diabetes lead to?
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Which statement is true regarding GDM that is controlled on diet during pregnancy?
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What is the goal of therapy for HbA1c in pregestational diabetes management?
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Which fetal malformation is reported as the most common cardiac anomaly in pregestational diabetes?
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What is the recommended daily dosage of folic acid for women with pregestational diabetes?
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Which screening test is considered the initial investigation for monitoring fetal health in pregestational diabetes?
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What is the risk of congenital malformations when HbA1c levels are equal to or greater than 10%?
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What is the normal condition of the thyroid profile during pregnancy?
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Which hormone stimulates the thyroid gland during pregnancy due to its similarity to TSH?
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What is the recommended daily allowance (RDA) of iodine for pregnant women?
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What physiological change occurs to the size of the thyroid gland during pregnancy?
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Why is the level of free T3 and T4 normal despite an increase in total T3 and T4 during pregnancy?
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Study Notes
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.
- If not diabetic:
- At the first antenatal visit:
-
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
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Fasting Blood Sugar (FBS): < 95 mg/dL.
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1-hour PP: <140 mg/dL.
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2-hour PP: <120 mg/dL.
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HbA1c: < 6%.
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Average capillary glucose: < 100 mg/dL.
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If goals are met, continue MNT.
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If goals are not met, start metformin > insulin+MNT.
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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.
-
Al (GDM controlled on diet)
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
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4-6cm² | Normal
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≥1.5-4cm² | Mild mitral stenosis
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≥1-1.5cm² | Moderate mitral stenosis
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<1cm² | Severe mitral stenosis
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Management:
- Percutaneous mitral balloon valvotomy (Valve Replacement)
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Indications for surgery:
- Severe symptomatic mitral stenosis: Dyspnea, hemoptysis
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Pregnancy contraindicated (Usually).
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Description
Explore the intricacies of medical and surgical complications that may arise during pregnancy. This quiz covers topics such as dyspnea on exertion, medical management options, and implications of pregnancy-induced diabetes. Navigate through potential interventions and understand the associated risks for both mother and fetus.
