High Risk Pregnancy PDF

DR. HEND SAKR LECTURER OF PHYSICAL THERAPY FOR WOMEN’S HEALTH, BUC. HIGH RISK PREGNANCY By the end of this lecture, each student should know: 1. Classification of high-risk pregnancy....

DR. HEND SAKR LECTURER OF PHYSICAL THERAPY FOR WOMEN’S HEALTH, BUC. HIGH RISK PREGNANCY By the end of this lecture, each student should know: 1. Classification of high-risk pregnancy. 2. Definition, classification, and P.T. management of hypertension during pregnancy. 3. Definition, classification, and P.T. management of diabetes during pregnancy. 4. Definition, precautions, and P.T. management of cardiac and asthmatic diseases during pregnancy. 1  High Risk pregnancy Risk pregnancy Pregnancy Cardiac Gestational Asthma and related disease in diabetes pregnancy hypertension pregnancy 1. Pregnancy Related Hypertension Classification of hypertensive disorders: Gestational hypertension:- It is hypertension alone, without proteinuria, occurring for the first-time during pregnancy usually in the second half. Preeclampsia: It is hypertension and proteinuria, with or without edema occurring mostly in the second half of pregnancy. Eclampsia: It is the occurrence of seizures, convulsions, or fits. 2  Chronic hypertension: Is defined as hypertension that is present prior to pregnancy or is diagnosed before the 20th week gestation. PRE-ECLAMPSIA Preeclampsia is a form of hypertension that is unique to pregnancy. Mild PE is diagnosed when the blood pressure is greater than 140/90 mmHg and there is more than 0.3 gm/Liter of protein in urine. Severe PE is characterized by diastolic blood pressure which exceeds 110 mmHg and protein excretion greater than 3gm/day. 3 Diagnosis of PE: A- Signs: 1. Elevation of blood pressure: 140/90 or more, observed on at least 2 different occasions at least 6 hours apart. 2. Proteinuria 3. Edema and weight gain B- Symptoms: PE is asymptomatic in the early and mild cases Symptoms usually occur late, and more commonly in severe or complicated cases: 1. Persistent headache. 2.Epigastric and right upper abdominal pain. 3. vomiting. 4.Visual disturbances. 5. Edema (lower limb, abdominal, or generalized edema). Etiology: It’s for unknown cause but there are some theories: 1. Hormonal theory: due to defective placentation and placental insufficiency leading to release chemical substances that cause vascular endothelial damage. 2. Nutritional theory: due to decrease calcium and insufficient fruits and vegetables. 3. Psychological theory: stress and lack of psychological support leading to stimulation of sympathetic system leading to vasoconstriction of blood vessels. Treatment of preeclampsia: The Goal of treatment is the prevention of the complications of PE The Only definitive treatment of PE is termination of pregnancy (delivery) 4 The Timing of termination depends on both Gestational age and the severity of PE. A. Mild PE: - Full term (37 weeks or more) delivery by induction of labor or CS - Preterm (˂ 37 weeks) expectant management until fetal lung maturity reassured. B. Severe PE: Induction of labor or CS Physical therapy management: If the patient has only signs of elevated blood pressure without PRECLAMPSIA. It includes: A. Patient education. B. Relaxation training. C. Exercise. D. Nutritional management. A. Patient Education: AVOID: 1. SUPINE lying position. 2. ABDOMINAL & PELVIC FLOOR Exercise to avoid increased intrabdominal pressure and increased blood pressure. 3. VALSALVA MANEUVER and bearing down. B. Relaxation training: Values: 1. Decrease blood pressure, respiratory rate, heart rate. 2. Decrease stress and anxiety. 3. Stimulation of parasympathetic system. Most common method used is “DIAPHRAGMATIC BRATHING EXERCISE” 5 METHOD: The patient is instructed to assume comfortable position with her hand applied on upper abdomen. The patient is instructed to inhale slowly through nose and raise her abdomen up and exhale slowly through the mouth feeling the tension is going with it. C. EXERCISE: In the form of upper and lower limb exercises, better to be in the form of passive ROM to avoid the increase in the intrabdominal pressure and uterine irritability. Vital signs should be monitored all over 24 hours to avoid changing the case from mild to severe preeclampsia. Program of the upper limb includes: ▪ All wrist movements. ▪ All forearm movement. ▪ Elbow flexion and extension. ▪ Shoulder flexion and extension, abduction and adduction, internal and external rotation. Program of the lower limb includes: ▪ All ankle movements. ▪ Knee flexion and extension. ▪ Hip flexion and extension, internal and external rotation, abduction and adduction. WARNING SIGNS 1. Headache 2. Chest Pain 3. Dyspnea 4. Vaginal Bleeding 5. Decreased fetal movement 6. Leakage of amniotic fluid If one or more of these signs occurred, you must STOP the exercise and consult the physician. 6  D. Nutritional Management: 1. Salt restriction. 2. Supplementation of vitamin C & E. 3. Supplementation of calcium. 4. Supplementation of magnesium. 5. Omega 3. 2.Diabetes and pregnancy Definition: Rise in blood glucose level usually detected at 24-28 weeks of gestation. Classification of diabetes in pregnancy: 1. Gestational diabetes. 2. Type I Diabetes. 3. Type II Diabetes. Diagnosis: characterized by hyperglycemia. Fasting blood glucose > 120 mg/dl Post prandial blood glucose > 200 mg/dl The patient complained from polyphagia, polydipsia, and easy fatigue. Pathophysiology: During late 2nd and 3rd trimesters of pregnancy, there is rise placental levels. Impact of maternal diabetes on the Impact of maternal diabetes on fetus mother 1. Spontaneous abortion 1. Post-partum hemorrhage 2. Congenital anomalies 2. C.S. 3. Macrosomia 3. Infections 7 4. Neonatal morbidities such as 4. Persistence of diabetes respiratory distress syndrome, type II later in life. hypoglycemia, and hypocalcemia. 5. Intrauterine fetal death. Physical Therapy Management 1. Exercise. 2. Diet. 3. Medical treatment. 1- Exercises: It was reported that exercises could lower blood glucose levels and improve acutely the tolerance to carbohydrate load in diabetic patient. A combination of exercises and insulin therapy produced a greater reduction in blood glucose levels than insulin alone. Exercises decrease blood glucose level by increasing muscle glucose uptake. Type of exercise recommended: Moderate exercise in the form of walking on treadmill for 30 minutes, 3 times / week. Women who are usually sedentary and have no experience with their own tolerance and endurance for various types of exercises, pregnancy is not the time to initiate such a program. Precautions 1. Measure blood glucose level before and after exercise. 2. Monitor fetal movement and uterine contraction after exercise. Contraindications for Exercise in pregnant women with Diabetes: 1.Myocardial ischemia or arrhythmias 8  2.Proliferative retinopathy 3.Twins and multiple birth 4.Severe emotional stress 5. Hydramnios and macrosomia. 2. Diet: a. Increase protein intake which is necessary for the fetus growth, and the increased size of the maternal blood volume, uterus, and breasts. b. Decrease fat and carbohydrate for instance 40% to 50% instead of 50% to 60%. c. Increase minerals and vitamins. 3. Medical treatment: If diet and exercise fail to maintain blood glucose level within normal; medical treatment become a MUST. All hypoglycemic drugs are contraindicated as it causes fetal complications because it crosses the placental barrier. The safest treatment is INSULIN. Mode of delivery: usually elective C.S. to avoid maternal and fetal complications especially if the size of the fetus exceeds 4.5 kg. Cardiac Disease in Pregnancy Heart disease in pregnancy can be divided into 2 categories: a- Rheumatic heart disease b- Congenital heart disease The important guidelines during the prenatal period are: 1.Avoidance of excessive weight gain and edema, so cardiac patient should be placed on a low-sodium diet (2gm per day) to prevent excessive expansion of blood volume. 9 2.Adequate rest should be encouraged 3.Avoidance of strenuous activity 4.Avoidance of anemia Management of labor: During labor. cardiac output increases when compared with prolabor levels To minimize the increase in cardiac output, sedation and epidural anesthesia are encouraged early in labor Women should be given oxygen by mask to reduce the risk of supine hypotension and increase the oxygen carrying capacity to the blood. Monitoring the cardiovascular status during delivery. Asthma and pregnancy Asthma is the most common obstructive pulmonary disease of pregnancy and is defined as shortness of breath and characterized by increased response of tracheobronchial tree to a variety of stimuli. Clinical manifestation: 1. Cough 10 2. Dyspnea 3. Wheezing Episodes may last few minutes and may persist for hours or days. Etiology: ❖ Allergens ❖ Exercise especially performed in cold -dry-atmosphere ❖ Infections (respiratory tract) ❖ Occupational stress ❖ Environmental stress (animals and home dust) ❖ Emotional stress ❖ Pharmacological stress Types of Asthma: Allergic of extrinsic Asthma Non-allergic or intrinsic Asthma Begins in childhood and is Begins after the age of 35 and is triggered by allergens. more severe in nature. Effect of pregnancy on Asthma: Asthma course during pregnancy is variable, it may improve, stabilize, or worsen. Women with severe asthma tend to have exacerbation with pregnancy, while those with mild asthma improve. Exacerbation tends to occur in the end of the 2nd trimester, with recovery before the end of 3rd trimester. Effect of Asthma on pregnancy: Toxemia Post-partum complications like prematurity, low birth weight, spontaneous abortion. 11 Obstetric management: In most asthmatics, no drug therapy is needed (because most of the medications the mother receives during pregnancy cross the uteroplacental barrier) Women should have plenty of fresh air, keep away from people with infections such as bronchitis and influenza. Cessation of smoking Adequate bed rest Treatment of respiratory infection Avoid exposure to cold Minimize stress or anxiety Exercises or hyperventilation induced asthma can be prevented by exercising in a moist humid environment. Management of labor and delivery ✓ It depends on the status of the mother and fetus. ✓ If pregnancy is well processing; it is advisable to wait spontaneous labor. ✓ If maternal condition is deteriorating; early delivery is recommended. ✓ For safety of both mother and fetus, cesarean section is recommended. 12 13