Medical Disorders in Pregnancy: Principles of Management (PDF)

Summary of MEDICAL DISORDERS IN PREGNANCY: PRINCIPLES OF MANAGEMENT; MALARIA, HYPERTENSION AND DIABETES MELLITUS (Prof Okeke) Outline: o Malaria o Anemia o Hypertension o Diabetes mellitus Malaria Introduction: o Causative organisms:  Plasmodium falciparum...

Summary of MEDICAL DISORDERS IN PREGNANCY: PRINCIPLES OF MANAGEMENT; MALARIA, HYPERTENSION AND DIABETES MELLITUS (Prof Okeke) Outline: o Malaria o Anemia o Hypertension o Diabetes mellitus Malaria Introduction: o Causative organisms:  Plasmodium falciparum  P. vivax  P. ovale  P. malariae o Pregnant women are more susceptible to malaria o Primigravidas are more susceptible to recrudescence of malaria than multiparas o Parasitemia is more common in the placenta than in the peripheral blood Management: o Diagnosis:  Peripheral blood film – thick and thin smear – is gold standard  PCR  Rapid Diagnostic Tests (RDTs) o Treatment:  Symptomatic:  Dehydration: oral or parenteral rehydration  Hyperpyrexia: bed rest, fanning, tepid sponging, antipyretic  Anemia: packed red cell transfusion (if PCV < 20%), folic acid supplement   History of antimalarial: get a history of the antimalarial she’s been on so you can modify your treatment plan  Drug treatment:  Quinine: for treatment; could be combined with SP or clindamycin  Chloroquine: for prophylaxis or treatment  Sulfadoxine-pyrimethamine (SP): used for prophylaxis after 1st trimester; don’t use after 34 weeks GA  Artemisinin-based Combination Therapy (ACT): for treatment  Severe malaria:  Admit in ICU  Monitor fluid balance  Monitor blood glucose (quinine can cause hypoglycemia)  Monitor vital signs and level of consciousness  Monitor Hb conc, urea, acid-base status, liver function  Manage any associated infection  Control fever  Treat seizures promptly  Oxygen inhalation (in respiratory failure) Prevention and Control: o Intermittent Preventive Treatment (IPT):  2 doses of SP every month after quickening (i.e. onset of fetal movement) o Insecticide-Treated Net (ITN) o Effective management of malaria Anemia Introduction: o Anemia in pregnancy is defined as a Hb level < 10g/dl (WHO cut-off is 11g/dl) o Anemia can be:  Nutritional (commonest in developing countries)  Hemolytic  Hemorrhagic Management: o Diagnosis:  Clinical diagnosis:   Symptoms: non-specific (fatigue, loss of appetite, palpitations etc.)  Signs: pallor, koilonychia etc.  Bedside lab tests:  Hb estimation  PCV, blood film  Special lab tests:  Serum iron, serum ferritin  Total Iron Binding Capacity (TIBC)  Serum folic acid, serum B12  Serum transferrin receptor (TfR), bone marrow exam  Others:  Hb electrophoresis, retic count, stool analysis (for hookworm eggs)  SEUCr, blood group and rhesus (for possible blood transfusion) o Treatment:  Iron and folic acid with balanced diet:  A pregnant woman needs 2 – 4.8mg of iron daily  The body only absorbs about 10% of dietary iron  So she needs 20 – 48mg of dietary iron  Correction of anemia:  Oral or parenteral hematinics (iron, folate, vit B12)  Blood transfusion (packed red cells)  Exchange blood transfusion Hypertension Introduction: o Hypertension is a blood pressure of 140/90 mmHg or more on at least 2 occasions at least 4 hours apart o A rise of 20 mmHg in mean arterial pressure (MAP) or MAP > 105 mmHg is suggestive of hypertension Classification: o Chronic hypertension:  Hypertension before pregnancy or before 20 weeks GA o Gestational hypertension (aka pregnancy-induced hypertension, or PIH):  Hypertension develops after 20 weeks GA Pathogenesis of PIH:  o Before pregnancy, the spiral arteries in the uterus are muscular, capable of vasoconstriction like other vessels o During pregnancy, the endothelial cells and smooth muscle of the spiral arteries are replaced by trophoblast cells (trophoblastic invasion) in 2 phases  First phase (10th – 16th week): trophoblastic invasion of spiral arteries in the endometrium  Second phase (16th – 22nd week): trophoblastic invasion of spiral arteries in the myometrium o Since there are no smooth muscle cells and trophoblasts cannot contract, the spiral arteries are now dilated vessels that are incapable of constriction o Anything that disrupts trophoblastic invasion of the maternal spiral arteries lead to PIH Management: o Diagnosis:  Routine BP measurement at antenatal visits  If she develops severe hypertension (in the absence of multiple pregnancy and gestational trophoblastic disease) do other tests to rule out other causes (like SLE, Cushing syndrome, renal artery stenosis etc.) o Investigations:  SEUCr, uric acid levels, urine protein  LFTs, platelet count  Funduscopy, echocardiography (in hypertension of > 4yrs)  Serial USS (monthly to monitor fetal growth) o Antenatal care:  Antenatal testing begins at 32 weeks or sooner (if complications arise)  Delivery should be by 37th – 39th week or sooner if pre-eclampsia or IUGR is detected, or if fetal test results are not reassuring o Treatment:  Mild hypertension:  Conservative treatment  Antihypertensives:  Methyldopa: most commonly used and safe for the fetus  Beta-blocker: commonest is Labetalol; there’s increased risk of IUGR  Ca channel blocker: commonest is Nifedipine  Moderate hypertension:  Antihypertensives  Close monitoring   Severe hypertension:  Same as for moderate  Hospital admission in latter part of pregnancy  If condition worsens, terminate pregnancy or deliver baby (depending on gestational age) o Drugs to be avoided:  ACE inhibitors: risk of fetal urinary tract abnormalities  Adreno-receptor blockers: risk of fetal renal dysfunction, lung hypoplasia, skeletal malformations, IUGR, death  Aldosterone antagonists: feminization of male fetus  Diuretics: reduce blood volume o Post-natal care:  Most maternal deaths occur after delivery mainly due to pulmonary edema  Close monitoring and management is thus essential o Follow-up:  If BP does not normalize after 6 weeks post-partum, refer for further investigations to identify underlying cause Diabetes Mellitus Introduction: o Gestational Diabetes Mellitus (GDM) is defined as carbohydrate intolerance of variable severity that started during pregnancy o Categories of pregnancy-associated DM:  Pregestational DM: DM started before the pregnancy  GDM: DM started during the pregnancy o Another classification of DM in pregnancy is the Whites classification Screening: o Selective screening:  Recommended by the American Diabetes Association  Women with all 4 of the following don’t need to be screened:  Age < 25yrs  No family history of DM  Normal body weight  Not a member of an ethnic group / race with a high prevalence for DM o Universal screening:   WHO criteria (same as for the general population):  After a 75g oral glucose load following an overnight fast, a 2hr plasma glucose level is done  ≥ 11mmol/L (or 200mg/dl) is diabetes  8 – 11mmol/L (or 140 – 200mg/dl) is prediabetes  < 8mmol/L (or 140mg/dl) is normal Risk factors for DM: These are the also the Indications for OGTT (oral glucose tolerance test): o Previous GDM o Symptoms of DM o Glycosuria o Family history of DM o History of macrosomic babies o History of unexplained stillbirth o Recurrent miscarriage o Previous congenital anomalies o Obesity Management: o Aim:  To normalize blood glucose level so that an optimum pregnancy outcome is achieved. o General measures:  Caloric restriction  Liberal exercise program  Monitoring of maternal glucose levels  Insulin therapy: use human insulin o Antenatal care:  Should be done in a tertiary center where all the facilities are available  May require hospitalization to stabilize woman (with insulin therapy and glucose monitoring)  Patients are seen 2-weekly up to 28 weeks GA and then weekly up to delivery  Blood glucose, urinalysis, mid-stream urine, edema, BP, hydramnios are checked every visit  Early USS in 1st trimester to accurately date the pregnancy   USS at 18 – 20wks GA to exclude fetal anomalies  Fetal echocardiography at 20 – 22wks to detect cardiac defects  Serial USS in the 3rd trimester every 3 – 4wks to evaluate fetal growth and amniotic fluid volume  If fetus is at risk of dying in-utero, the following should be done:  Maternal assessment of fetal movements  Non stress test  Biophysical profile  Doppler ultrasound o Labor and delivery:  Vaginal delivery is aimed at  Labor should be monitored and not be prolonged (else opt for CS)  IV 5% dextrose water and insulin to control blood glucose level  Monitor blood glucose hourly and adjust rate of dextrose infusion accordingly  Neonatologist should be present to collect baby to manage as soon as it’s delivered o Puerperium:  Insulin requirements are lower after delivery  Frequent blood glucose measurement should be done to calculate the insulin requirement  OGTT should be done 6 weeks after delivery for women with GDM as they are at risk of type 2 DM  No contraindications to breastfeeding  For contraception, the lowest dose of combined estrogen and progesterone pill should be prescribed.  Use progestin-only pill in women with vasculopathy or ischemic heart disease