High Risk Pregnancy & Childbirth PDF

High risk pregnancy & childbirth  Outline A Urinary Tract Infection (UTI) Renal disease: hydronephrosis Systemic lupus...

High risk pregnancy & childbirth  Outline A Urinary Tract Infection (UTI) Renal disease: hydronephrosis Systemic lupus erythematous Epilepsy Presentation title 2  Objectives Urinary tract infection( Pregnancy induced urinary tract infection, Diagnosis, Sings and symptom, Management, Asymptomatic bacteriuria, Cystitis and urethritis Acute pyelonephritis Renal disease: hydronephrosis, pyelonephritis, The normal physiological change in pregnancy, Chronic renal disease in pregnancy, Management, Effects of kidney disease on pregnanc Systemic lupus erythematous, Clinical manifestation and diagnosis, Lupus and pregnancy, Maternal and fetal risk, Management during pregnancy, Pharmacological treatment, Postpartum contraception Epilepsy, Pathophysiology, Focal seizure, Generalizes seizure, Preconceptional counselling ,Epilepsy during pregnancy, Maternal and fetal risk, Pharmacological treatment, Postnatal contraceptive Presentation title 3 Pregnancy-Induced Urinary Tract Infection (UTI):  Definition UTIs are common during pregnancy due to several physiological changes, such as bladder compression, hormonal shifts, and dilation of the urinary tract. These changes can increase the risk of bacterial growth and infection. The bacteria originate from the bowel and the most commonly encountered is Escherichia coli (E.coli) Presentation title 5  Diagnosis: UTI diagnosis generally involves: Urine dipstick test: Detects nitrites, leukocyte esterase, or blood. Urine culture: Confirms the presence and type of bacteria (usually E. coli). Urinalysis: Evaluates white blood cells (pyuria) and bacteria. In pregnancy: Urine culture screening is recommended in the first trimester even in asymptomatic cases. Presentation title 6  Signs and Symptoms: Lower UTI (Cystitis): Dysuria (painful urination) Increased urinary frequency and urgency Suprapubic discomfort Cloudy, foul-smelling urine Hematuria (blood in urine) Upper UTI (Pyelonephritis): Fever Flank pain Nausea and vomiting Chills Possible systemic signs (e.g., malaise) Presentation title 7  Management: Uncomplicated UTI: Antibiotics like nitrofurantoin, amoxicillin, or cephalexin. Increased fluid intake. In pregnancy, antibiotics are chosen carefully to avoid fetal harm. Complicated UTI or Pyelonephritis: Hospitalization may be necessary for IV antibiotics, especially in severe cases or pregnancy. Monitor for potential complications, including premature labor in pregnancy. Prevention: Cranberry products, adequate hydration, and wiping front to back. Regular urine culture screening during pregnancy to detect asymptomatic infections. Presentation title 8  Asymptomatic Bacteriuria (ASB) Significance in Screening Treatment Definition pregnancy Presence of ASB can lead to Recommended in Antibiotics, even bacteria in the pyelonephritis if all pregnant though no urine without untreated, which is women, typically symptoms are symptoms. dangerous for both between 12-16 present, to prevent mother and fetus weeks gestation. complications. Presentation title 9  Cystitis and Urethritis Cystitis: Inflammation of the bladder, typically associated with lower urinary tract symptoms like dysuria, frequency, and urgency. Urethritis: Inflammation of the urethra, often caused by sexually transmitted infections like Chlamydia trachomatis or Neisseria gonorrhoeae, leading to painful urination or urethral discharge. Treatment Presentation focuses title on antibiotics targeting the specific pathogen. 10  Renal Disease in Pregnancy: Hydronephrosis & Pyelonephritis F Normal Physiological Changes in Pregnancy: During pregnancy, the body undergoes several changes that affect the renal system: Increased renal blood flow: Renal blood flow increases by 50-80%, leading to increased glomerular filtration rate (GFR). Dilation of the urinary tract: Hormonal changes (primarily progesterone) and mechanical pressure from the enlarging uterus cause dilation of the renal pelvis and ureters, leading to hydronephrosis, which is more pronounced on the right side. Urinary stasis: Dilation of the urinary tract contributes to urinary stasis, increasing the risk of infections like pyelonephritis. Increased protein excretion: Pregnant women may have mild proteinuria due to increased GFR, but significant proteinuria requires further investigation for preeclampsia or underlying renal disease. Presentation title 11  Chronic Renal Disease in Pregnancy: Definition: Chronic kidney disease (CKD) is defined as kidney damage or decreased kidney function (GFR < 60 mL/min) persisting for more than three months. Impact on Pregnancy: Pregnant women with CKD are at higher risk for: Hypertension and preeclampsia Preterm birth Intrauterine growth restriction (IUGR) Worsening kidney function Anemia and electrolyte imbalances Maternal and fetal mortality Management in Pregnancy: Careful monitoring of kidney function and blood pressure. Medications that are safe in pregnancy, such as calcium channel blockers for hypertension, should be considered. Frequent fetal monitoring for growth and well-being. Presentation title 12  Incontinence in Pregnancy: Stress Incontinence: Due to increased intra-abdominal pressure from the growing uterus and hormonal effects that cause relaxation of pelvic floor muscles. Urge Incontinence: Increased bladder sensitivity and pressure on the bladder can lead to a frequent need to urinate. Management: Pelvic floor exercises (Kegel exercises) to strengthen muscles. Bladder training techniques. Avoiding excessive fluid intake before bedtime. Medications are generally avoided during pregnancy but may be considered postpartum if needed. Presentation title 13  Management of Hydronephrosis and Pyelonephritis: Hydronephrosis: Common in pregnancy due to physiological changes and generally does not require treatment unless there is infection or significant obstruction. In severe cases, a ureteral stent may be necessary to relieve obstruction. Pyelonephritis: Requires prompt treatment, especially in pregnancy, due to the risk of sepsis, preterm labor, or fetal distress. Management includes hospitalization, IV antibiotics (such as ceftriaxone or ampicillin with gentamicin), and hydration. Post-treatment, a urine culture should confirm the infection has cleared. Recurrences may warrant prophylactic antibiotics for the remainder of pregnancy. Presentation title 14  Effects of Kidney Disease on Pregnancy: Kidney disease in pregnancy can lead to complications such as: Preeclampsia: Women with pre-existing kidney disease are at increased risk of preeclampsia, a dangerous condition characterized by high blood pressure and proteinuria. Preterm birth: Increased risk of delivering the baby early due to complications like worsening kidney function or preeclampsia. Fetal complications: Poor fetal growth (IUGR), fetal distress, or stillbirth are more common in women with kidney disease. Worsening maternal kidney function: Pregnancy can accelerate the decline in kidney function in women with pre-existing kidney disease. Monitoring and management of pregnant women with kidney disease require a multidisciplinary approach involving obstetricians, nephrologists, and pediatricians to optimize both maternal and fetal outcomes. Presentation title 15  Systemic Lupus Erythematosus (SLE) Clinical Manifestation and Diagnosis: SLE is a chronic autoimmune disease that can affect multiple organ systems. It predominantly affects women of childbearing age. Presentation title 16  Clinical Manifestations: General: Fatigue, fever, weight loss. Skin: Malar (butterfly) rash, discoid rash, photosensitivity. Joints: Arthritis or arthralgia, typically symmetrical. Renal: Lupus nephritis (hematuria, proteinuria). Cardiovascular: Pericarditis, myocarditis, and increased risk of thromboembolism. Hematologic: Anemia, leukopenia, thrombocytopenia. Neurological: Seizures, psychosis, cognitive dysfunction. Other: Raynaud’s phenomenon, pleuritis, and recurrent miscarriages. Presentation title 17  Diagnosis: Autoantibodies: Presence of antinuclear antibodies (ANA), anti-double stranded DNA (anti-dsDNA), and anti-Smith (anti-Sm) antibodies are characteristic markers. Clinical Criteria: The diagnosis is often based on a combination of clinical features and laboratory tests. Criteria include skin involvement, arthritis, serositis, renal or neurological involvement, and positive immunological markers. Complement Levels: Low levels of complement (C3, C4) during flares. Presentation title 18  Lupus and Pregnancy: Impact of SLE on Pregnancy: Pregnancy can be successfully managed in women with SLE, but flares may occur, particularly if the disease was active before conception. Risk of flare is highest during the second and third trimesters, and postpartum. Increased risk of preeclampsia, especially in women with lupus nephritis or antiphospholipid syndrome. Preconception Counseling: Ideally, women should achieve at least 6 months of disease remission before conception. Flares during pregnancy are more likely if the disease is active at conception. Presentation title 19  Maternal and Fetal Risk: Maternal Risks: Increased risk of flares, particularly if SLE is not well-controlled. Higher risk of developing preeclampsia, especially in the presence of lupus nephritis. Increased risk of thromboembolic events, especially in women with antiphospholipid syndrome. Risk of pregnancy loss, preterm labor, and placental abruption. Fetal Risks: Miscarriage: Higher risk, especially with active lupus or antiphospholipid syndrome. Preterm birth: More common in women with SLE due to maternal complications. Intrauterine growth restriction (IUGR): Common, especially in women with renal disease or hypertension. Neonatal lupus: A rare condition in the newborn, usually caused by transplacental passage of maternal anti-Ro/SSA and anti-La/SSB antibodies, which can causetitle Presentation rash and congenital heart block. 20  Management During Pregnancy: Multidisciplinary Care: A team including an obstetrician, rheumatologist, and possibly a nephrologist should manage pregnancy in women with SLE. Disease Monitoring: Regular monitoring of lupus activity with blood tests (e.g., complement levels, anti-dsDNA) and renal function. Fetal Monitoring: Serial ultrasounds for fetal growth and assessments of placental function (e.g., Doppler studies). Monitor for signs of IUGR or distress. Prevention of Preterm Labor and Preeclampsia: Low-dose aspirin is often recommended to reduce the risk of preeclampsia. Presentation title 21  Pharmacological Treatment During Pregnancy: Safe Medications: Hydroxychloroquine: Recommended in all pregnant women with lupus to reduce the risk of flares and improve pregnancy outcomes. Low-dose aspirin: Used to lower the risk of preeclampsia. Glucocorticoids (e.g., prednisone): Can be used in the lowest effective dose to manage flares. Azathioprine: Safe for use in pregnancy and can be used for more severe disease. Calcium and vitamin D: To prevent glucocorticoid-induced osteoporosis. Medications to Avoid: Mycophenolate mofetil: Teratogenic, should be discontinued before conception. Methotrexate: Also teratogenic, must be stopped before conception. Cyclophosphamide: Contraindicated due to its teratogenic effects. NSAIDs: Should be avoided after the first trimester due to the risk of fetal Presentation title complications. 22  Postpartum Contraception: Non-hormonal Methods: Barrier methods (e.g., condoms, diaphragms) and copper intrauterine devices (IUDs) are safe and effective options. Hormonal Methods: Progestin-only contraceptives (e.g., mini-pill, injections): Safe and suitable for women with SLE, particularly those with antiphospholipid syndrome, as they do not increase the risk of thrombosis. Combined estrogen-progestin contraceptives: Should be avoided in women with antiphospholipid syndrome or those with a history of thrombosis, as estrogen can increase thrombotic risk. Long-acting reversible contraception (LARC): Progestin IUD: Effective and safe for women with SLE, offering a low systemic hormone exposure. Implants: Also safe for use in women with SLE without antiphospholipid syndrome. Postpartum follow-up should focus on lupus disease activity, breastfeeding support (certain Presentation title medications may need adjustments), and contraception counseling. 23  Epilepsy Pathophysiology of Epilepsy: Epilepsy is a neurological disorder characterized by recurrent, unprovoked seizures. Seizures occur due to abnormal, excessive electrical activity in the brain. Depending on the location of the abnormal activity, epilepsy can be classified as focal (affecting one part of the brain) or generalized (involving the whole brain). 1. Focal Seizures: Definition: Seizures that originate in a specific area of the brain. Symptoms: Simple focal seizures: Consciousness is not impaired. Symptoms may include motor, sensory, or autonomic manifestations, such as jerking of a limb, altered sensation, or visual disturbances. Complex focal seizures: Consciousness is impaired, often accompanied by automatisms (e.g., lip-smacking, repetitive movements) or confusion. Postictal state: Temporary confusion or drowsiness after the seizure. Presentation title 24  2. Generalized Seizures: Definition: Seizures that involve both hemispheres of the brain from the onset. Types: Tonic-clonic (Grand mal): Sudden loss of consciousness, followed by stiffening of the muscles (tonic phase) and rhythmic jerking (clonic phase). This is the most recognizable type of seizure. Absence (Petit mal): Brief loss of consciousness or “blanking out” episodes, usually lasting a few seconds. Myoclonic: Sudden, brief, shock-like muscle jerks. Atonic: Sudden loss of muscle tone, causing the individual to collapse. Tonic: Sustained muscle contraction without the clonic (jerking) phase. Presentation title 25  Preconceptional Counseling for Women with Epilepsy Preconceptional Counseling: Risk assessment: Women with epilepsy (WWE) planning pregnancy should be counseled early to optimize outcomes. Medication review: It is essential to review and adjust anti-seizure medications (ASMs) to ensure the safest regimen for the fetus while maintaining seizure control. Folic acid supplementation: High-dose folic acid (4-5 mg/day) is recommended before conception and during pregnancy, as anti-seizure medications can interfere with folate metabolism, increasing the risk of neural tube defects. Genetic counseling: Discuss the potential for inheritance of epilepsy and the risks of teratogenic effects from certain ASMs. Seizure control: Women should aim for optimal seizure control for at least 6 months before conception. Presentation title 26  Epilepsy During Pregnancy Maternal and Fetal Risk Maternal Risks: Seizure frequency: Pregnancy can either exacerbate, improve, or have no effect on seizure frequency. Hormonal fluctuations, sleep deprivation, and medication non-compliance can contribute to an increased risk of seizures. Status epilepticus: Prolonged, unremitting seizures can lead to life-threatening complications such as hypoxia, acidosis, or injury. Trauma: Seizures, especially generalized tonic-clonic seizures, can result in falls or injury, which may affect both mother and fetus. Preeclampsia: Women with epilepsy may have an increased risk of preeclampsia. Fetal Risks: Hypoxia: Seizures, particularly tonic-clonic seizures, can cause maternal hypoxia, which can affect fetal oxygenation. Preterm labor: Increased risk of preterm birth, particularly with poorly controlled epilepsy. Teratogenic effects: Certain anti-seizure medications (e.g., valproate) significantly increase the risk of congenital malformations, including neural tube defects, heart defects, and cleft lip/palate. Presentation title Fetal growth restriction: Poorly controlled seizures and the use of certain medications 27  Pharmacological Treatment During Pregnancy: First-line Medications: Lamotrigine and Levetiracetam are generally considered safer options during pregnancy, with a lower risk of teratogenic effects compared to other ASMs. Carbamazepine: Another option that may be used if seizure control is adequate. Avoid Valproate: Valproate is highly teratogenic and should be avoided if possible. It is associated with a significantly increased risk of neural tube defects, cognitive impairments, and other congenital malformations. Dosing Adjustments: Drug metabolism changes during pregnancy, often necessitating dose adjustments to maintain therapeutic levels. Regular monitoring of ASM blood levels is essential to ensure seizure control without increasing teratogenic risks. Folic Acid: High-dose folic acid (4-5 mg/day) should be continued throughout pregnancy to reduce the risk of neural tube defects. Vitamin K: Some ASMs (e.g., phenytoin, carbamazepine) can impair vitamin K metabolism, leading to an increased risk of neonatal hemorrhage. Vitamin K supplementation may betitle Presentation given to the mother in the last trimester and to the newborn at birth. 28  Postnatal Contraception Postnatal Contraceptive Options: Non-hormonal Methods: Barrier methods (e.g., condoms, diaphragms) and copper intrauterine devices (IUDs) are safe for women with epilepsy, as they do not interact with ASMs. IUDs (copper and hormonal) are highly effective and long-lasting options for contraception. Hormonal Methods: Progestin-only contraceptives (e.g., mini-pill, depot injection): These are generally considered safer than combined hormonal contraceptives for women with epilepsy, particularly for those on enzyme-inducing ASMs. Combined estrogen-progestin contraceptives: Certain ASMs (e.g., phenytoin, carbamazepine) induce hepatic enzymes and can reduce the effectiveness of these contraceptives. Higher doses of estrogen or alternative methods are often recommended. Long-acting reversible contraceptives (LARCs): Progestin-releasing IUDs or contraceptive implants are excellent options for women with epilepsy, offering reliable Presentation title 29 contraception without the concerns of drug interactions.  Summary: Epilepsy requires careful management before and during pregnancy. Preconception counseling focuses on optimizing seizure control, adjusting medication regimens, and providing adequate folic acid supplementation. During pregnancy, monitoring maternal and fetal health, adjusting ASM doses, and choosing the safest pharmacological treatments are key to reducing risks. Postnatal contraception should consider potential interactions with ASMs to ensure effective birth control. Presentation title 30  Myles Textbook foe Midwives seventeenth Referenc edition e Maternal- Newborn Nursing &Women Health (Across the lifepan) Ninth Edition