Medical Disorders in Pregnancy Lecture PDF

**LECTURE: MEDICAL DISORDERS IN PREGNANCY: PRINCIPLES OF MANAGEMENT; MALARIA, ANAEMIA, HYPERTENSION AND DIABETES MELLITUS** **MALARIA**: - A major killer in developing and under developed countries with far reaching medical, social and economic consequences for the countries. - Protoz...

**LECTURE: MEDICAL DISORDERS IN PREGNANCY: PRINCIPLES OF MANAGEMENT; MALARIA, ANAEMIA, HYPERTENSION AND DIABETES MELLITUS** **MALARIA**: - A major killer in developing and under developed countries with far reaching medical, social and economic consequences for the countries. - Protozoal disease caused by infection with parasites of genus plasmodium and transmitted by the bite of anopheles mosquitoes. - Blood transfusion or inoculation can also transmit malaria by infected syringe and trans-placental infection can occur in the child of non-immune mother. - Causative organisms plasmodium falciparum - Pregnant women are more susceptible to malaria. Primigravidas are more susceptible to recrudescene of infections than multiparas and placental parasitaemia is more common than peripheral parasitaemia due to impaired host defense - Giemsa -- Stained thick and thin smears by light microscopy. - Quantification of parasites by examination of blood smears - Fluorescent microscopy - PCR-based detection of plasmodium DNA in blood. **MANAGEMENT OF MALARIA IN PREGNANCY** - There should be prompt treatment of pregnant women with malaria because the disease is more severe and associated with higher parasitemia which is dangerous for both mother and fetus. - Evaluate individual patient with regard to the following general aspect before deciding on a specific line of action. - Hydration status; hyperpyrexia, vomiting and loss of appetite contribute to the dehydration; adequate rehydration either parentally or orally must be ensured before embarking on specific therapy. - Ability to take oral medication: for patients who are vomiting, administration of antimalarial should be preferably by parental route. - Hyperpyrexia: management of hyperpyrexia includes physical measures such as bedrest, removal of clothing, fanning and tepid sponging with antipyretic medication such as paracetamol. - Anaemia: Anaemia is commonly encountered in uncomplicated cases of malaria. Those with PCV \< 20% should be given slow packed cell transfusion. Folic acid should also be supplemented. - Hx of administration of antimalarial drug: to evolve effective treatment, it is very important to obtain a careful history of drugs administered. **Mgt principles in severe malaria:** - Admit patient in ICU. - Monitor fluid balance carefully. - Monitor blood sugar (Hypoglycaemia is common if patient is receiving quinine). - Monitor temperature, Respiration, BP, and level of consciousness. - Look for and manage any associated infections. - Reduce fever by tepid sponging and paracetamol. - Monitor Hb, Urea, electrolytes acid base status and liver function. - Treat seizures promptly. - Oxygen inhalation in case of respiratory failure. **DRUG TREATMENT IN PREGNANCY** - Antimalarial chemoprophylaxis is important to reduce (1) Risk of parasitaemia, (2) severe haemolytic and megaloblastic anaemia, (3) Folic acid should be supplemented. - In Nigeria Quinine: is the drug of choice for treatment of acute malaria, multidrug resistance malaria in travelers returning to no endemic areas that develop malaria for severe and complicated Pl. falciparum malaria. Quinine is safe in pregnancy and effective drug. - When oral treatment is possible: 8 --10 mg/kg three times a day for 7days. For IV route: slow IV administration in isotonic fluid 5% D/S over 8 hours and oral treatment should be resumed as soon as patient is able to take orally and continued for the completion of the course. Quinine is safe in 1^st^ trimester and could be combined with 1500mg sulfadoxine/75mg pyrimethamine or clindamycin (300mg qds x 5days). **Other drugs in treatment of malaria in pregnancy** - ACT: Artemesin based combination therapy and its derivatives. For treatment of malaria in 2^nd^ and 3^rd^ trimesters of pregnancy. Dose: 10mg/kg once a day for 5 days. **Prevention and control of malaria in pregnancy:** - Three interventions for prevention and control of malaria in pregnancy. 1. Intermittent preventive treatment (Two doses of sulfadoxine/pyrimethamine at monthly intervals after onset of fetal movement. (Three doses in HIV positive patients). 2. Insecticide treated nets. 3. Effective case mgt of malaria illness and anaemia. **ANAEMIA:** - A common condition in pregnancy. Present in 2 -- 20% of pregnant women. Associated with increased mortality and morbidity of both mother and baby with increased incidences of maternal infections, cardiac failure, premature labour and IUGR. - It is important to diagnose the type of anaemia and treat it accordingly. - Anaemia is generally divided into nutritional, haemolytic or haemorrhagic. - Nutritional Anaemia is the most common anaemia in developing countries. It is due to deficiency of iron and folate in diet or due to increased demand as in pregnancy. **Genesis of Nutritional Anaemia:** - Females are in precarious iron balance during the reproductive years in most developing countries. - Iron stores are not well developed because of poor nutritional intake, recurrent infections, excessive menstrual blood loss and short birth intervals. - Most women enter pregnancy state with depleted iron stores. **Diagnosis of Nutritional Anaemia:** \(1) Clinical methods \(2) Simple bedside laboratory test \(3) High-tec elaborate investigations **(1) Clinical Diagnosis:** Symptoms; nonspecific, ill health, fatigue, loss of appetite, exertions, palpitations etc. **Physical Examination:** pallor, pale nails, koilonyichia, pale tongue etc. Clinical examination is not very sensitive but has advantage of being both simple and non-invasive. Simple clinical diagnostic methods have low sensitivity but high specificity. **(2)Bed-side Lab. Investigations:** \(a) Hb and PCV estimation \(b) Study of peripheral smear **Methods for estimation of Hb conc:** \(1) Electronic counter (most sensitive and sophisticated method. High cost and high maintenance cost limit its use in developing countries) \(2) Sahli's Methods: largely used in most centres inspite of its limitations. \(3) Examinations of peripheral smear is fast becoming a lost art among clinicians -- Pale peripheral smear \- Microcytosis \- Hyper segmentation of neutrophils \- Fully haemoglobinized RBCs \- Polychromatic cells \- Stippled cells \- Target cells **Peripheral Smear:** Gives good idea about degree of anaemia and type of anaemia. \(3) Special Laboratory Investigations: These are highly specialized and expensive. Routine use not indicated but help in special cases or research. \(1) Serum Iron (SI), (2) Total Iron binding capacity (TIBC) of serum, (3) Serum fibritin (SF), (4) Serum folic acid, (5) serum B12, (6) serum transferin receptor (TFR), (7) Bone marrow etc. TFR: good marker of iron deficiency at cellular level. **Management of nutritional Anaemia:** Administration of iron and folic acid with balanced diet is the main approach for treatment of nutritional anaemia. A pregnant woman needs about 2 -- 4.8mg of Iron per day. The woman must consume 20 -- 48mg of dietary iron in order to absorb 2 -- 4.8mg of iron. This is impossible in developing countries because the average vegetarian diet does not contain more than 10 -- 15mg Iron. Secondly the high phytic acid content in cereal diet may further reduce absorption of iron. **Dietary Iron is found in 2 forms:** **Haem Iron:** found in foods of animal origin e.g. meat, fish, poultry etc **Nonhaem Iron:** found in foods of plant origin e.g. vegetables, tuber pulses, cereals etc. Absorption of haem iron is better than absorption of nonhaem iron. **HYPERTENSION IN PREGNANCY** **Introduction**: -Major causes of maternal and perinatal morbidity and mortality in developing countries. **- Causes** 12% of maternal mortalities worldwide. \- Complicates 5 -- 7% of all pregnancies. **Definitions:** **Hypertension** is a blood pressure of 140/90mmHg or more recorded on at least two occasions 4 hours or more apart. One measurement of diastolic BP more than110mm Hg. **Mean Arterial Pressure MAP (mm Hg)** MAP = [Systolic BP + 2 (Diastolic BP)] 3 Rise of 20mm Hg in MAP or more than 105 mmHg is significant and is suggestive of hypertension. In obese women, adequate sized cuff should be used. **Hypertension during pregnancy can be classified as one of the following:** - **Chronic:** BP is high before pregnancy or before 20 wk gestation. Chronic hypertension complicates about 1 to 5% of all pregnancies. - **Gestational:** Hypertension develops after 20 wk gestation it occurs in about 5 to 10% of pregnancies, more commonly in multifetal pregnancy. Both types of hypertension increase risk of preeclampsia, eclampsia and other causes of maternal mortality or morbidity, including hypertensive encephalopathy, stroke, renal failure, left ventricular failure, and the HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count). There is increased risk of fetal morbidity and mortality. **Diagnosis** - Tests to rule out other causes of hypertension BP is measured routinely at antenatal visits. If severe hypertension occurs for the first time in pregnant women who do not have a multifetal pregnancy or gestational trophoblastic disease, tests to rule out other causes of hypertension (eg, renal artery stenosis, coarctation of the aorta, Cushing syndrome, SLE, pheochromocytoma) should be considered. **Treatment** - For mild hypertension, conservative measures followed by antihypertensives if needed - Methyldopa, β-blockers, or Ca channel blockers tried first - For moderate or severe hypertension, antihypertensive therapy, close monitoring, and, if condition worsens, possibly termination of pregnancy or delivery, depending on gestational age Treatment of mild to moderate hypertension without renal insufficiency during pregnancy is controversial. Recommendations for chronic and gestational hypertension are similar and depend on severity. **Management of Severe Hypertension** **.** Individualized based on (1) duration of pregnancy, (2)sophistication of newborn special care unit (NBSCU) (3)Any signs and symptoms of severe pre-eclampsia. The aim of this treatment is to protect the mother enabling many pregnancies to continue to achieve fetal maturity. **.** Drug therapy is indicated. Risk of complications---maternal (progression of end-organ dysfunction, preeclampsia) and fetal (prematurity, growth restriction, stillbirth)---is increased significantly. Several antihypertensives may be required. **.** For systolic BP \> 180 mm Hg or diastolic BP \> 110 mm Hg, immediate evaluation is required. Multiple drugs are often required. Also, hospitalization may be necessary for much of the latter part of pregnancy. If the woman's condition worsens, pregnancy termination may be recommended. **.** All women with chronic hypertension during pregnancy should be evaluated for target organ damage. Evaluation, done at baseline and periodically thereafter, includes - Serum creatinine, electrolytes, and uric acid levels - Liver function tests - Platelet count - Urine protein assessment - Usually funduscopy Maternal echocardiography should be considered if women have had hypertension for \> 4 yr. Serial ultrasonography is done monthly to monitor fetal growth. **.** Antenatal testing begins at 32 wk or, if complications develop, sooner. Delivery should occur by 37 to 39 wk but may be induced earlier if preeclampsia or fetal growth restriction is detected or if fetal test results are non reassuring. **Drugs** First-line drugs for hypertension during pregnancy include - Methyldopa - β-Blockers - Ca channel blockers Initial methyldopa dose is 250 mg 8 hourly, increased as needed to a total of 2 g/day unless excessive somnolence, depression, or symptomatic orthostatic hypotension occurs. Most commonly used antihypertensive in pregnancy. It is safe for the fetus. Drawback is its low potency. It can be combined with hydralazine or labetalol. The most commonly used β-blocker is labetalol, which can be used alone or with methyldopa when the maximum daily dose of methyldopa has been reached. Usual dose of labetalol is 100 mg bid to tid, increased as needed to a total maximum daily dose of 2400 mg. Adverse effects of β-blockers include increased risk of fetal growth restriction, decreased maternal energy levels, and maternal depression. Extended-release nifedipine, a Ca-channel blocker, may be preferred because it is given once/day (initial dose of 30 mg; maximum daily dose of 120 mg); adverse effects include headaches, flushing and pretibial edema. **Drugs to be avoided:** Several classes of antihypertensives are usually avoided during pregnancy: - **ACE inhibitors** are contraindicated because risk of fetal urinary tract abnormalities is increased. - **ARBs** are contraindicated because they increase risk of fetal renal dysfunction, lung hypoplasia, skeletal malformations, and death. - **Aldosterone antagonists** (spironolactone and eplerenone) should be avoided because they may cause feminization of a male fetus. - **Diuretics are** contraindicated in pre-eclampsia as they further reduce circulating volume. **[Care After Delivery:]** Most maternal deaths occur after delivery and the main cause is pulmonary oedema. Therefore close monitoring and judicious management is essential. **Follow Up:** If BP fail to normalize after 6 weeks postpartum, refer patient for further investigations for underlying cause. There is risk of 10% recurrence of severe disease and 10 -- 15% of mild disease in next pregnancy. Screen for connective tissue disorder and antiphospholipid antibody syndrome if recurrent problems are found. **\ ** **DIABETES IN PREGNANCY** **Introduction:** - Pregnancy was uncommon prior to introduction of insulin in 1922 due to high mortality in these patients before the reproductive years and also due to infertility in mature diabetic females. - With introduction of insulin life expectancy for juvenile diabetic increased and fertility was restored to near normal. - With understanding of the pathophysiology and the implementation of medical care approaches emphasizing normalization of maternal glucose levels resulted in improvement in pregnancy outcome in pregnancy complicated with diabetis - Presently, with optimal care, in pregnant diabetic women, the prenatal mortality excluding major congenital malformations approaches that of the general population. - The rise in GDM can be attributed to improved screening and diagnostic tools, with increased rate of obesity worldwide. - Gestational diabetes mellitus is defined as CHO intolerance of variable severity with onset or first recognition during pregnancy. **Classification** Pregnancy associated DM may be divided into 2 broad categories. Pregestational DM (DM antedates the pregnancy) and gestational diabetes mellitus (The onset of the diabetes is during pregnancy). Various classifications have been advocated for DM in pregnancy. The most widely known is whites classification (Priscilla white 1949). -- This clinical classification is based primarily on the patient's condition prior to pregnancy, the age of onset of diabetes, its duration and the presence of vasculopathy or renal complications significantly influenced the prenatal outcome. **Screening for gestational diabetes** - Controversial (selective and universal screening). - **Selective screening** for CHO intolerance recommended by the American Diabetes Association in 1997. Women having all 4 of the following need not be screened: (1) Age \4kg at birth). - History of unexplained IUFD or stillbirth. - Hydramnios in the present pregnancy. - Recurrent abortions - Previous congenital anomalies - Obesity (91kg) **Management of a patient with gestational diabetes** **The objective:** Is to normalize the level of glycemia so that an optimum outcome of pregnancy is achieved. Once the diagnosis of GDM is established, the patient starts with 1. Dietary program with caloric restriction 2. Liberal exercise program results in glucose metabolism and decrease in lipid levels 3. Monitoring of maternal glucose levels FBS & 2HPP: Plasma glucose levels -- weekly. When FBS \>105mg/dl and 2HPP \>120mg/dl insulin therapy is recommended. (standard dietary mgt does not consistently maintain plasma glucose levels within normal limits). Human insulin is preferred (neutral protamine hagedorn or regular insulin) 1. decreased risk of antibody formation 2. decreased risk of macrosomia 3. decreased fetal pancreatic beta -- cell damage. 4. Profound clinical efficacy 5. No evidence of teratogenesis **Antenatal Care** - The management of a pregnant diabetic requires team work by obstetrician, diabetic physician, neonatologist and the dietician/patient herself. - Attention to the control of diabetes at every stage of pregnancy is very important. - Management should be in a tertiary care centre where all facilities are available. - Insulin is the mainstay of treatment. Oral hypoglycaemic agents are contraindicated in pregnancy as they cross the placenta and may cause fetal hyperinsulinemia and fetal hypoglycaemia. - Management and counseling of women with diabetes should begin before conception to prevent malformations as well as early pregnancy losses. - Hospitalization may be required to institute an individualized insulin regimen and for monitoring glucose levels (stabilization). - Patients are seen more often (every two weeks up to 28 weeks and then weekly thereafter up to delivery). - Glycosylated haemoglobin A (HbA1c) can be used to check glucose control in the preceding 8 to 12 weeks. - Blood glucose level, urinalysis and mid stream urine are checked at each visit. Oedema, hypertension, hydramnios and excessive weight gain are specially looked for at each visit. - Early ultrasound scan in first trimester to accurately date the pregnancy by measuring crown-rump length of the fetus. 18-20week scan to exclude fetal abnormality. - Fetal echocardiography at 20-22 weeks to detect possible cardiac defects. - In the 3^rd^ trimester, weekly antenatal visits are recommended. Serial ultrasound is carried out at 3 to 4 week intervals to evaluate fetal growth and amniotic fluid volume. - Antepartum fetal surveillance is initiated in the 3^rd^ trimester when the risk of IUFD is high. Maternal assessment of fetal movements (Fetal kicks record by the mother as from 32 weeks). Non stress test is done twice a week from 32 weeks onwards. Biophysical profiles and Doppler ultrasound, if available, would be useful in monitoring wellbeing in fetuses judged to be at risk. **Labour** - With better glycemic control and antepartum fetal surveillance, most patients are delivered at term, and vaginal delivery is aimed at except patients with definite obstetric indications. - Labour in pregnant diabetics is fully monitored one-on-one. Should not be allowed to be prolonged. Recourse to c/s is taken earlier in the interest of both mother and baby. - Diabetic control in labour is best maintained by administration of 5% Dextrose water (glucose) and insulin IV (insulin at a controlled rate by means of an infusion pump 1-2 units per hour). Blood glucose is measured hourly and rate of glucose infusion is varied accordingly. Serum ketone levels are measured 4 hourly. - If infusion pump is not available, half the dose of the morning requirement of insulin is given and infusion of 5% glucose is set up. Thereafter a "sliding scale" with blood glucose level estimation is used in giving the necessary doses of insulin. - Neonatologist should be invited and must be present at the delivery. The baby is handed over to him to manage as soon as it is delivered. **Puerperium** - Insulin requirements are significantly lower after delivery. - Frequent blood glucose measurements are used to calculate the insulin requirement. Insulin dose can be reduced to half that was required at the end of pregnancy. - Women with GDM should have a glucose tolerance test 6 weeks after delivery as they are at risk of maturity onset DM. - There are no contraindications to breastfeeding. - Puerperium infection should be looked for and treated promptly. **Contraception** The lowest dose of combined oestrogen and progesterone should be prescribed. Those women with vasculopathy and those with history of ischaemic heart disease should use progestin- only oral contraceptive. Intrauterine contraceptive devices are reluctantly used because of a risk of pelvic infections. **Prognostic consideration** - Women with GDM are at increased risk of developing recurrent GDM as well as overt DM, predominantly type II DM. - All women with GDM should be educated and counseled regarding lifestyle modifications. - Risk factors for development of overt diabetes have been identified, some of which are modifiable and others are not. - Modifiable risk factors are persistent obesity, future weight gain, levels of physical activity, dietary fat and factors that adversely influence insulin resistance. - Unmodifiable risk factors are ethnicity, pregnancy weight, age, parity, family history of diabetes and degree of hyperglycaemia in pregnancy and immediately postpartum. - With the advent of insulin and improved care of pregnant diabetics, maternal and fetal outcomes are excellent. ***Thank you for listening.***