Obstetrics Pg No 373 -382

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Questions and Answers

What is a recommended management strategy for a patient experiencing dyspnea on exertion due to increased cardiac output during pregnancy?

Limit physical activity (correct)

Administer corticosteroids

Increase physical activity levels

Encourage high sodium intake

Which medication is indicated for reducing heart rate in a pregnant patient with complications affecting the heart?

Anticoagulants

Beta-blockers (correct)

Diuretics

Calcium channel blockers

In cases of atrial fibrillation during pregnancy, what is the purpose of administering anticoagulants?

To manage blood pressure

To prevent thrombosis (correct)

To enhance diuresis

To increase heart rate

What surgical intervention may be necessary if medical management fails in a pregnant patient with cardiac complications?

Percutaneous mitral balloon valvotomy Signup and view all the answers

During which trimester is the surgical management of cardiac complications, such as percutaneous mitral balloon valvotomy, typically performed?

Second trimester Signup and view all the answers

Which complication is associated with undiagnosed Pre-Gestational Diabetes Mellitus (Pre-GDM)?

Pregnancy Induced Hypertension Signup and view all the answers

What is the recommended frequency for monitoring blood glucose levels in the 3rd trimester?

Every week Signup and view all the answers

At what gestational age should a fetal echocardiogram (ECHO) be performed to rule out ventricular septal defect (VSD)?

22-24 weeks Signup and view all the answers

How often should growth scans be performed during pregnancy for patients with Pre-GDM?

Every 3 weeks Signup and view all the answers

Which of the following is NOT a part of routine check at each antenatal visit for patients with diabetes in pregnancy?

Perform a CT scan Signup and view all the answers

What are the primary indications for performing umbilical artery Doppler ultrasonography during pregnancy?

Diabetic vasculopathy Signup and view all the answers

Which treatment is considered the drug of choice for managing diabetes during pregnancy?

Insulin Signup and view all the answers

At what gestational age is termination of pregnancy or induction of labor typically recommended?

≥39 weeks Signup and view all the answers

Which of the following is NOT typically done in gestational diabetes management according to the provided guidelines?

Fetal echocardiogram Signup and view all the answers

What is the indication for performing a cesarean section in this context?

Weight of the baby ≥24.5 kg Signup and view all the answers

Which scoring system is primarily used for congenital heart disease in pregnancy?

Zahara score Signup and view all the answers

What is the recommended frequency for cardiac review in a patient classified as Class III during pregnancy?

Every 1-2 months Signup and view all the answers

Which of the following is NOT a diagnostic criterion for peripartum cardiomyopathy?

History of prior heart disease Signup and view all the answers

Which of the following is a known risk factor for developing peripartum cardiomyopathy?

Twin pregnancy Signup and view all the answers

What is the classification of mitral stenosis when the area is between 1.5 to 4 cm²?

Mild mitral stenosis Signup and view all the answers

What hormone is primarily responsible for increasing insulin resistance as pregnancy progresses?

Human Placental Lactogen (HPL) Signup and view all the answers

During pregnancy, what is the fate of maternal glucose?

It crosses the placenta for the fetus Signup and view all the answers

Which of the following complications is associated with maternal fasting hypoglycemia during pregnancy?

Formation of acetone bodies Signup and view all the answers

What is a potential risk for the fetus in a hyperglycemic mother during pregnancy?

Fetal congenital malformations Signup and view all the answers

Why is glycosuria considered normal in pregnancy?

Hormonal changes affecting renal thresholds Signup and view all the answers

What is the recommended action if a patient's 2 hr postprandial (PP) blood glucose level is between 140-199 mg/dL?

Medical Nutrition Therapy (MNT) for 2 weeks Signup and view all the answers

What should be done if a patient's fasting blood sugar (FBS) is greater than 95 mg/dL?

Initiate metformin therapy Signup and view all the answers

Which of the following metabolic goals should NOT be exceeded for a patient managing gestational diabetes?

1 hr PP < 160 mg/dL Signup and view all the answers

At what blood glucose level should a patient be treated with insulin immediately?

2 hr PP ≥ 200 mg/dL Signup and view all the answers

What is the advised physical activity for a patient diagnosed with gestational diabetes?

30 minutes of exercise daily Signup and view all the answers

What is a characteristic feature of gestational diabetes?

It is associated with increased insulin resistance despite normal blood sugar levels. Signup and view all the answers

Which of the following is NOT part of the complication profile of gestational diabetes?

Development of glycosylated hemoglobin A1c. Signup and view all the answers

When is the first test for diagnosing gestational diabetes recommended?

At the first antenatal visit. Signup and view all the answers

What is the minimum time gap required between tests for gestational diabetes diagnosis?

4 weeks. Signup and view all the answers

What should be done if a patient vomits during the gestational diabetes test?

Repeat the test within 30 minutes or continue after 30 minutes. Signup and view all the answers

What does Pre-Gestational Diabetes NOT do post delivery?

Resolve Signup and view all the answers

At what gestational weeks is Gestational Diabetes Mellitus (GDM) usually developed?

24-28 weeks Signup and view all the answers

Which type of diabetes does the Priscilla White classification categorize as 'Non Type A Pregestational diabetes'?

Type C Signup and view all the answers

What consequence can free radical formation from Pre-Gestational Diabetes lead to?

Congenital malformations Signup and view all the answers

Which statement is true regarding GDM that is controlled on diet during pregnancy?

It is identified after 28 weeks typically Signup and view all the answers

What is the goal of therapy for HbA1c in pregestational diabetes management?

< 6.5% Signup and view all the answers

Which fetal malformation is reported as the most common cardiac anomaly in pregestational diabetes?

Ventricular Septal Defect (VSD) Signup and view all the answers

What is the recommended daily dosage of folic acid for women with pregestational diabetes?

400 mcg Signup and view all the answers

Which screening test is considered the initial investigation for monitoring fetal health in pregestational diabetes?

Level I USG Signup and view all the answers

What is the risk of congenital malformations when HbA1c levels are equal to or greater than 10%?

15-20% Signup and view all the answers

What is the normal condition of the thyroid profile during pregnancy?

Euthyroid state Signup and view all the answers

Which hormone stimulates the thyroid gland during pregnancy due to its similarity to TSH?

hCG Signup and view all the answers

What is the recommended daily allowance (RDA) of iodine for pregnant women?

250 mcg/day Signup and view all the answers

What physiological change occurs to the size of the thyroid gland during pregnancy?

Increased size Signup and view all the answers

Why is the level of free T3 and T4 normal despite an increase in total T3 and T4 during pregnancy?

Increased binding to TBG Signup and view all the answers

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.
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).

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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.