Download - Medical Complication Of Pregnancy
Medical complications of pregnancy
Introduction
Physiology adaptation to pregnancy involves the Physiology adaptation to pregnancy involves the Cardiovascular, pulmonary, endocrine, Cardiovascular, pulmonary, endocrine, hematologic, neurologic, renal, and hematologic, neurologic, renal, and gastrointestinal systems.gastrointestinal systems.
In a normal healthy woman, the adaptive In a normal healthy woman, the adaptive responses are approciate and well tolerated.responses are approciate and well tolerated.
When underlying pathology is present, organ When underlying pathology is present, organ failure may occur.failure may occur.
Chapter ninth, maternal physiologyChapter ninth, maternal physiology
Cardiovascular system
Physiologic changes during pregnancy
During human pregnancy, cardiac output During human pregnancy, cardiac output increases by almost 40%: 5000ml/min for increases by almost 40%: 5000ml/min for normal nonpregnant woman, and 7000ml/min normal nonpregnant woman, and 7000ml/min for pregnant woman.for pregnant woman. most of this increase is due to an increase in most of this increase is due to an increase in
stroke volumestroke volume Heart rate increase by only about 10 Heart rate increase by only about 10
beats/min during the third trimester.beats/min during the third trimester. Cardiac output peaks at around 18 to 24 weeks, Cardiac output peaks at around 18 to 24 weeks,
and then stabilizes.and then stabilizes.
Heart disease Internal medicineInternal medicine Types of CVSTypes of CVS
HypertensionHypertension Coronary heart diseaseCoronary heart disease Pulmonary heart diseasePulmonary heart disease ArrhythmiaArrhythmia Rheumatic heart diseaseRheumatic heart disease Congenital heart diseaseCongenital heart disease Cardiomyopathy Cardiomyopathy Pleral cavity problemPleral cavity problem Heart failure Heart failure
Rheumatic heart disease The leading factor of heart disease of pregnant The leading factor of heart disease of pregnant
womenwomen Mitral stenosisMitral stenosis
At higher risk of developing heart failure , At higher risk of developing heart failure , subacute bacterial endocarditis, and subacute bacterial endocarditis, and thrombolic diseasethrombolic disease
Cardiac output increases and the mechanical Cardiac output increases and the mechanical obstruction worsens. Patients may develop obstruction worsens. Patients may develop cardiac decompensation and pulmonary cardiac decompensation and pulmonary edemaedema
Atrial fibrillationAtrial fibrillation
Congenital heart disease The anatomic defects of most of the patients has been The anatomic defects of most of the patients has been
correctedcorrected The anatomic defect has not been correctedThe anatomic defect has not been corrected
Well tolerateWell tolerate Less well tolerateLess well tolerate
Patients with Patients with primary pulmonary hypertensionprimary pulmonary hypertension or or cyanotic cyanotic heart diseaseheart disease with residual pulmonary hypertension are with residual pulmonary hypertension are in danger of undergoing decompensation during in danger of undergoing decompensation during pregnancy.pregnancy. pulmonary hypertension from any cause is associated pulmonary hypertension from any cause is associated
with a 25% to 50% maternal mortality during with a 25% to 50% maternal mortality during pregnancy.pregnancy.
What is the right to left shunt for the congenital heart disease?
Cardiac arrhythmia Superventricular tachycardia is the most common Superventricular tachycardia is the most common
arrhythmiaarrhythmia Pregnancy (weight gain)Pregnancy (weight gain) AnemiaAnemia laborlabor
Ventricular premature constrictionVentricular premature constriction The cause of the arrhythmia and the The cause of the arrhythmia and the
hemodynamic changes due to the arrhythmiahemodynamic changes due to the arrhythmia Structural and functionalStructural and functional Asymptomatic and symptomaticAsymptomatic and symptomatic
Peripartum and postpartum cardiomyopathy It is very rare, but it is exclusively associated It is very rare, but it is exclusively associated
with pregnancy.with pregnancy. Patients have no underlying cardiac disease, and Patients have no underlying cardiac disease, and
symptoms of cardiac decompensation appear symptoms of cardiac decompensation appear during the last weeks of pregnancy or 2 to 20 during the last weeks of pregnancy or 2 to 20 weeks postpartumweeks postpartum
Patient with a history of pre-eclampsia or Patient with a history of pre-eclampsia or hypertension and poorly nourished are at high hypertension and poorly nourished are at high risk.risk.
Management of cardiac disease during pregnancy New York heart association’s functional New York heart association’s functional
classification of heart diseaseclassification of heart disease Cardiac decompensation may occur at any phase of Cardiac decompensation may occur at any phase of
pregnancy, it is most likely occur pregnancy, it is most likely occur during the period during the period of peak increase in cardiac output (18-24weeks), of peak increase in cardiac output (18-24weeks), during labor or delivery, or during the immediate during labor or delivery, or during the immediate postpartum period.postpartum period. Prenatal management Prenatal management Management of labor Management of labor Management of delivery and the immediate Management of delivery and the immediate
postpartum periodpostpartum period
New York heart association’s functional classification of heart disease
Class 1 no signs or symptoms of cardiac Class 1 no signs or symptoms of cardiac decompensationdecompensation
Class 2 no symptoms at rest, but minor Class 2 no symptoms at rest, but minor limitation of physical activitylimitation of physical activity
Class 3 no symptoms at rest, but marked Class 3 no symptoms at rest, but marked limitation of physical activitylimitation of physical activity
Class 4 symptoms present at rest, discomfort Class 4 symptoms present at rest, discomfort increased with any kind of physical activityincreased with any kind of physical activity
Prepregnant counseling and prenatal care The maternal and fetal risk for patients with class 1 The maternal and fetal risk for patients with class 1
and 2 disease is smalland 2 disease is small Permitted to conceptionPermitted to conception Intensive careIntensive care
Normal :term pregnancyNormal :term pregnancyAbnormal:Abortion or induction of laborAbnormal:Abortion or induction of labor
whereas they are greatly increased with class 3 and 4 whereas they are greatly increased with class 3 and 4 disease.disease. Not permitted to pregnancyNot permitted to pregnancy Abortion or induction of laborAbortion or induction of labor
Prenatal management A general principle: all pregnant cardiac patients A general principle: all pregnant cardiac patients
should be managed with the help of a cardiologist.should be managed with the help of a cardiologist. A number of guidelines:A number of guidelines:
Avoidance of excessive weight gain and edemaAvoidance of excessive weight gain and edema Avoidance of strenuous activityAvoidance of strenuous activity Avoidance of anemiaAvoidance of anemia Early detection of a problemEarly detection of a problem
InfectionInfectioncardiac decompensationcardiac decompensation pulmonary edemapulmonary edema
Management of labor During labor, cardiac output increase by about 40%-During labor, cardiac output increase by about 40%-
50% when compared with prelabor levels, and by 50% when compared with prelabor levels, and by about 80% to 100% when compared with about 80% to 100% when compared with prepregnancy levelsprepregnancy levels
The increase in the cardiac output is due to The increase in the cardiac output is due to catecholamine release brought about by pain and catecholamine release brought about by pain and apprehension, most of the increase is due to apprehension, most of the increase is due to abdominal and uterine muscle contraction.abdominal and uterine muscle contraction.
Sedation, epidural anesthesia, prophylactic Sedation, epidural anesthesia, prophylactic antibiotics, aterial and Swan-Ganz catheters, cardiac antibiotics, aterial and Swan-Ganz catheters, cardiac rhythm, fluid intake and urine output, arterial blood rhythm, fluid intake and urine output, arterial blood gas, hemoglobin concentration, electrolytes.gas, hemoglobin concentration, electrolytes.
Management of delivery and the immediate postpartum period
cardiac patients should be delivered vaginally unless cardiac patients should be delivered vaginally unless obstetric indication for cesarean section are present.obstetric indication for cesarean section are present. Second stage of laborSecond stage of labor
Avoid pushing during uterine contractionAvoid pushing during uterine contraction Cardiac output increase to 80% above prelabor values in Cardiac output increase to 80% above prelabor values in
the first few hours after a vaginal delivery and up to 50% the first few hours after a vaginal delivery and up to 50% after cesarean section.after cesarean section. After delivery of the placenta, the uterine contracts After delivery of the placenta, the uterine contracts
and about 500ml of blood is added to the effective blood and about 500ml of blood is added to the effective blood volume.volume.
If cardiac decompensation occurs, it should be managed If cardiac decompensation occurs, it should be managed as a medical emergency.as a medical emergency.
Cardiac dysfunction associated with pregnancy and labor during the period of 18-24weeks peak during the period of 18-24weeks peak
increase in cardiac output increase in cardiac output during labor or delivery especially the the during labor or delivery especially the the
second stage of laborsecond stage of labor during the immediate postpartum period.during the immediate postpartum period.
Thromboembolic disorder
superficial thrombophlebitissuperficial thrombophlebitis
deep venous thrombosisdeep venous thrombosis
pulmonary embolismpulmonary embolism
Conditions and mechanism of blood clots formation (pathology) Endothlial damage of the blood vesselsEndothlial damage of the blood vessels Decreasing of the velocity of the blood flowDecreasing of the velocity of the blood flow High blood coagulating statusHigh blood coagulating status
PlateletPlatelet Coagulation factorsCoagulation factors
superficial thrombophlebitis
IncidenceIncidence 1/600 during antepartum period1/600 during antepartum period 1/95 in the immediate postpartum peroid]1/95 in the immediate postpartum peroid]
High risk factorsHigh risk factors Varicose veinVaricose vein Obese patientObese patient Limited physical activityLimited physical activity
Calf area is the most common siteCalf area is the most common site
Diagnosis of superficial thrombophlebitis SymptomsSymptoms
Swelling and tenderness of the involved Swelling and tenderness of the involved extremityextremity
SignsSigns Erythema, tenderness, warmth, and a Erythema, tenderness, warmth, and a
palpable cord over the course of the palpable cord over the course of the involved superficial veinsinvolved superficial veins
Treatment of superficial thrombophlebitis Pain medication Pain medication Local Heat applicationLocal Heat application Elevation of the lower extremitiesElevation of the lower extremities Anti-inflammatory agentsAnti-inflammatory agents Anticoagulants is not indicatedAnticoagulants is not indicated Superficial thrombophlebitis is not lifethreatening Superficial thrombophlebitis is not lifethreatening
and does not lead to pulmonary embolization; but the and does not lead to pulmonary embolization; but the inflammatory process might extent to the deep veinsinflammatory process might extent to the deep veins
5-7 days is sufficient 5-7 days is sufficient
deep venous thrombosis
IncidenceIncidence 1/2000 antepartum period1/2000 antepartum period 1/700 postpartum period1/700 postpartum period
It is a high risk conditionIt is a high risk condition High risk factorsHigh risk factors
Vascular damage, infection, tissue traumaVascular damage, infection, tissue trauma Hypercoagulability and venous stasis of the Hypercoagulability and venous stasis of the
pregnancypregnancy
The site of deep venous thrombosis The deep calf venus and the iliofemoral The deep calf venus and the iliofemoral
veusveus The pelvic venous (Ovarian venus)The pelvic venous (Ovarian venus)
The leading cause of pulmonary The leading cause of pulmonary embolismembolism
Most of the deep venous thrombosis Most of the deep venous thrombosis occurred in the left leg and thighoccurred in the left leg and thigh
The pathologic type and outcome of thrombosis
Pathologic typePathologic type RedRed MixedMixed WhiteWhite
Pathologic outcomePathologic outcome ThrombolysisThrombolysis New clot formationNew clot formation OrganizationOrganization CalcificationCalcification RecanalizationRecanalization Shedding and leading to pulmonary embolismShedding and leading to pulmonary embolism
Diagnosis of the deep venous thrombosis Clinical diagnosisClinical diagnosis
Hotman sign: Pain in the calf areas in Hotman sign: Pain in the calf areas in association with dorsiflexion of the foot association with dorsiflexion of the foot is a clinical sign of deep venous is a clinical sign of deep venous thrombosis in the calf veinthrombosis in the calf vein
Acute swelling and pain in the thigh Acute swelling and pain in the thigh area and in the femoral triangle are area and in the femoral triangle are suggestive of iliofemoral thrombosissuggestive of iliofemoral thrombosis
Assistant diagnostic methods for deep venous thrombosis UltrasonographyUltrasonography MRIMRI venogramvenogram
Treatment of the deep venous thrombosis SurgerySurgery
Forgarty catheterForgarty catheter Within 48hrWithin 48hr
Medical therapyMedical therapy Thrombolysis (within 72hr)Thrombolysis (within 72hr) AnticoagulationAnticoagulation antiaggregationantiaggregation
Thrombolysis
Tissue type plasminogen activitor (short Tissue type plasminogen activitor (short half life time, and specific action on the half life time, and specific action on the clots sticking fibrin not the fibrin )clots sticking fibrin not the fibrin )
UrokinaseUrokinase streptokinasestreptokinase
Anticoagulation[1] HeparinHeparin
Low molecular and Large molecularLow molecular and Large molecular Do not cross the placentaDo not cross the placenta PPT (partial prothrombin time)[2 to 2.5 times of PPT (partial prothrombin time)[2 to 2.5 times of
normal control]normal control] PT-INRPT-INR Stopped before active labor phase and continued Stopped before active labor phase and continued
12 hours after delivery12 hours after delivery Hemorrhage tendency, thrombocytopenia, Hemorrhage tendency, thrombocytopenia,
osteoporosisosteoporosis
Anticoagulation[1]
WarfarrinWarfarrin Inhibit the production of coagulation Inhibit the production of coagulation
factors 2,7,9 and 10factors 2,7,9 and 10 Cross the placenta leading to fetal Cross the placenta leading to fetal
hemorrhagehemorrhage Stopped after the 36 gestational weeks Stopped after the 36 gestational weeks
and continued after deliveryand continued after delivery PT (Prothrombin time)PT (Prothrombin time)
Antiaggregation
Low molecular dextranLow molecular dextran 500ml bid500ml bid
AspirinAspirin
The aim of treatment of deep venous thrombosis
pulmonary embolism
IncidenceIncidence 1/2500 during pregnancy1/2500 during pregnancy The maternal mortality is less than 1% if The maternal mortality is less than 1% if
treated early and greater than 80% if left treated early and greater than 80% if left untreateduntreated
The source of the emboliThe source of the emboli 70% come from the deep venous 70% come from the deep venous
thrombosisthrombosis
Diagnosis of pulmonary embolism Clinical featuresClinical features
SymptomsSymptomsPleuritic chest pain, shortness of breath, air hunger, Pleuritic chest pain, shortness of breath, air hunger,
palpitation, hemoptysis, and syncope episodepalpitation, hemoptysis, and syncope episode SignsSigns
Tachypnea, tachycardia, low grade fever, a fleural Tachypnea, tachycardia, low grade fever, a fleural friction rub, chest splinting, pulmonary rales, accentuated friction rub, chest splinting, pulmonary rales, accentuated pulmonic valve second heart sound, signs of right pulmonic valve second heart sound, signs of right ventricular failureventricular failure
Assistant methodsAssistant methods Chest X filmChest X film Blood gas SPO2Blood gas SPO2 Computerized tomography and MRIComputerized tomography and MRI
Treatment of pulmonary embolism It is similar to the treatment of deep venous It is similar to the treatment of deep venous
thrombosisthrombosis But it more emergent than the deep venous But it more emergent than the deep venous
thrombosisthrombosis Hemorrhage of uterine,birth canal, abdominal Hemorrhage of uterine,birth canal, abdominal
incision and other site(nose,brain,gastric)incision and other site(nose,brain,gastric) Acute Acute Chronic or later onsetChronic or later onset
Pulmonary disorders
The basic function of respiratory system
The basic function is inspiration of the oxygen and The basic function is inspiration of the oxygen and expiration of the carbon dioxide. expiration of the carbon dioxide.
The types of respiratory dysfunctionThe types of respiratory dysfunction Central nerveCentral nerve Spinal nerveSpinal nerve Skeleton muscleSkeleton muscle Pleural cavityPleural cavity Perfusion of the lungPerfusion of the lung Air and blood barrier Air and blood barrier [pulmonary edema][pulmonary edema] Airway Airway [asthma][asthma]
bronchial asthma The incidence during pregnancy 1%The incidence during pregnancy 1% About 15% of these individuals have one or more About 15% of these individuals have one or more
severe attacks during pregnancysevere attacks during pregnancy Mild asthmaMild asthma Moderate asthmaModerate asthma Severe asthma is associated with an increased Severe asthma is associated with an increased
abortion rate and an increased incidence of abortion rate and an increased incidence of intrauterine fetal death and fetal growth restriction, intrauterine fetal death and fetal growth restriction, most probably as a result of intrauterine hypoxiamost probably as a result of intrauterine hypoxia
The effect of pregnancy on bronchial asthma is The effect of pregnancy on bronchial asthma is variablevariable
Obstetric management[1] Pregnant asthmatics should be followed closely Pregnant asthmatics should be followed closely
during pregnancy to ensure adequate maternal and during pregnancy to ensure adequate maternal and fetal assessmentfetal assessment
In most asthmatics, no drug treatment is needed.In most asthmatics, no drug treatment is needed. Adequate bed restAdequate bed rest Early and aggressive treatment of respiratory Early and aggressive treatment of respiratory
infectioninfection Avoidance of hyperventilationAvoidance of hyperventilation Avoidance of excessive physical activityAvoidance of excessive physical activity Avoidance of allergensAvoidance of allergens
Obstetric management[2]
For outpatient treatment of occasional mild For outpatient treatment of occasional mild asthma attacks, inhaled beta-agonist are often asthma attacks, inhaled beta-agonist are often sufficientsufficient Relaxation of the bronchial smooth muscle Relaxation of the bronchial smooth muscle
cellscells Inhibiting the releasing of the histamine Inhibiting the releasing of the histamine
from the mast cellfrom the mast cell Albuterol, pirbuterol, terbutalineAlbuterol, pirbuterol, terbutaline Uterine relaxation effectUterine relaxation effect
Obstetric management[3]
If the asthma could not controlled If the asthma could not controlled adequately with beta-agonists, a regimen of adequately with beta-agonists, a regimen of inhaled corticosteroids or cromolyninhaled corticosteroids or cromolyn should be started.should be started.
Inhaled cromolyn Inhaled cromolyn The asthma is triggered by inhaled agentsThe asthma is triggered by inhaled agents The asthma is induced by exciseThe asthma is induced by excise
Obstetric management[3]
If the asthma could not controlled If the asthma could not controlled adequately with beta-agonists, a regimen of adequately with beta-agonists, a regimen of inhaled corticosteroids or cromolyninhaled corticosteroids or cromolyn should be started.should be started.
Inhaled cromolyn Inhaled cromolyn The asthma is triggered by inhaled agentsThe asthma is triggered by inhaled agents The asthma is induced by exciseThe asthma is induced by excise
Obstetric management[4]
For severe exacerbation or for patients not For severe exacerbation or for patients not responding to acute bronchodilator therapy, a responding to acute bronchodilator therapy, a course of oral corticosteroids is indicatedcourse of oral corticosteroids is indicated
The dose is tappered gradually and is replaced by The dose is tappered gradually and is replaced by inhaled steroids for maintenance therapyinhaled steroids for maintenance therapy
For patients with refractory disease, a low to For patients with refractory disease, a low to moderate daily dose of oral corticosteroids may be moderate daily dose of oral corticosteroids may be continued for an indefinite period.continued for an indefinite period.
Obstetric management[5]
Mild statusMild status No drug]No drug] Inhaled beta2-agonistsInhaled beta2-agonists
Moderate statusModerate status Inhaled steroidsInhaled steroids Inhaled cromolynInhaled cromolyn
Severe statusSevere status Oral steroidsOral steroids
Obstetric management[6]
Fetal assessmentFetal assessment Fetal growth by ultrasonographyFetal growth by ultrasonography Biophysical scoreBiophysical score
The timing of delivery is dependent on the The timing of delivery is dependent on the status of both the mother and the fetusstatus of both the mother and the fetus
Management of labor and delivery
If the patient taking oral steroids during pregnancy, the If the patient taking oral steroids during pregnancy, the intravenous administration of glucocorticoids is intravenous administration of glucocorticoids is recommended during labor, delivery, and postpartum period.recommended during labor, delivery, and postpartum period.
A selective epidural block is beneficialA selective epidural block is beneficial PainPain AnxietyAnxiety Hyperventilation Hyperventilation Respiratory workRespiratory work
Vaginal delivery should be anticipated. Cesarean section is Vaginal delivery should be anticipated. Cesarean section is indicated only for obstetric reasons.indicated only for obstetric reasons.
pulmonary edema Pulmonary edema is very common in the patients Pulmonary edema is very common in the patients
with hypertensive disorder during pregnancy with hypertensive disorder during pregnancy especially during the immediate postpartum periodespecially during the immediate postpartum period
Low SPO2, and chest X-filmLow SPO2, and chest X-film Benign and self-limitedBenign and self-limited Within the first three days, the edema should Within the first three days, the edema should
diappear diappear Low albuminemia, increased capillary permeabilty, Low albuminemia, increased capillary permeabilty,
increased interstitial colloid osmolarity, magnesium increased interstitial colloid osmolarity, magnesium and fluid expansion.and fluid expansion.
Endocrine and metabolism disorders diabetes mellitusdiabetes mellitus thyroid diseasethyroid disease Adrenal gland diseaseAdrenal gland disease Other endocrine glands and tissues or Other endocrine glands and tissues or
cellscells
Diabetes Mellitus Incidence and classificationIncidence and classification ComplicationsComplications DiagnosisDiagnosis ManagementManagement
Incidence and definition Incidence 0.5%Incidence 0.5% DefinitionDefinition
Pregnancy complicated with diabetes mellitus Pregnancy complicated with diabetes mellitus (type 1 and type 2) [10%](type 1 and type 2) [10%]
Before pregnancy, during pregnancy, and Before pregnancy, during pregnancy, and after pregnancyafter pregnancy
Random glucose >200mg/dl, FPG >126mg/dlRandom glucose >200mg/dl, FPG >126mg/dl Gestational diabetes mellitus[90% ]Gestational diabetes mellitus[90% ]
Before pregnancy, Before pregnancy, during pregnancyduring pregnancy, and , and after pregnancy after pregnancy
Classification Class onset FPG 2h-PPG therapyClass onset FPG 2h-PPG therapy
A1 GDMA1 GDM <105 <120 diet<105 <120 diet
A2 GDMA2 GDM >105 >120 insulin>105 >120 insulin Class onset of age duration vascular disease therapyClass onset of age duration vascular disease therapy B >20 <10 None insulin B >20 <10 None insulin C 10~19 10~19 none insulin C 10~19 10~19 none insulin D <10 >20 benign retinopathy insulinD <10 >20 benign retinopathy insulin F any any nephropathy insulinF any any nephropathy insulin R any any roliferative retinopathy insulinR any any roliferative retinopathy insulin H any any heart insulinH any any heart insulin
The first step: 50 glucose The first step: 50 glucose loading testloading test
the aim of the test is to screen the gestational the aim of the test is to screen the gestational diabetes mellitusdiabetes mellitus
it is usually carried out during 24-28 it is usually carried out during 24-28 gestational week for the first timegestational week for the first time
the screening test:the screening test: 50g glucose load50g glucose load 1 hour, 130~140mg/dl[7.2~7.8mmol/L]1 hour, 130~140mg/dl[7.2~7.8mmol/L] Without regard to the time of the day or the Without regard to the time of the day or the
time of the mealtime of the meal
blood glucose test performed blood glucose test performed before the 24 gestational weeksbefore the 24 gestational weeks
older than 25 years oldolder than 25 years old ObesityObesity family history of DMfamily history of DM previous infant weight no less than 4000gprevious infant weight no less than 4000g previous stillbirth infantprevious stillbirth infant previous congenitally deformed infantprevious congenitally deformed infant previous polyhydranmiosprevious polyhydranmios history of recurrent abortionshistory of recurrent abortions
The second step: 100g glucose load test glucose level(mmol/l)glucose level(mmol/l) Fast 5.8Fast 5.8 1hour 10.551hour 10.55 2hour 9.162hour 9.16 3hour 8.053hour 8.05
if two values are abnormal, excluding the fasting if two values are abnormal, excluding the fasting blood glucose,the patients is classified as having blood glucose,the patients is classified as having gestational diabetes mellitusgestational diabetes mellitus
Only one step diagnostic method: 75g glucose load test Normal value Impaired tolerance DMNormal value Impaired tolerance DM Fast <6.1 Fast <6.1 ≥6.1 ≥6.1 ≥7.0≥7.0 2h 2h
postprandial <7.8 postprandial <7.8 ≥7.8~<11.1 ≥7.8~<11.1 ≥11.1≥11.1
Maternal complications Obstetric complicationsObstetric complications
PolyhydramniosPolyhydramnios Pre-eclampsiaPre-eclampsia
Diabetic emergencyDiabetic emergency HypoglycemiaHypoglycemia KetoacidosisKetoacidosis Diabetic comaDiabetic coma
Vascular and end-organ involvement [cardiac, renal, Vascular and end-organ involvement [cardiac, renal, ophthalmic, and peripheral vascular]ophthalmic, and peripheral vascular]
Neurologic [peripheral neuropathy and GIT disturbance] Neurologic [peripheral neuropathy and GIT disturbance] Infection(antepartum and postpartum)Infection(antepartum and postpartum)
Fetal complications Spontaneous abortionSpontaneous abortion premature delivery (premature preterm rupture of premature delivery (premature preterm rupture of
the membrane)the membrane) Unexplained intrauterine fetal demise and stillbirthUnexplained intrauterine fetal demise and stillbirth Macrosomia with traumatic delivery such as Macrosomia with traumatic delivery such as
cesarean section and shoulder dystociacesarean section and shoulder dystocia Delayed organ maturity (lung)Delayed organ maturity (lung) Congenital anomaliesCongenital anomalies Intrauterine growth restrictionIntrauterine growth restriction
Neonatal complications
Respiratory distressRespiratory distress HypoglycemiaHypoglycemia HypocalcemiaHypocalcemia HyperbilirubinemiaHyperbilirubinemia Cardiac hypertrophyCardiac hypertrophy Long-term cognitive developmentLong-term cognitive development Inheritance of diabetesInheritance of diabetes Altered fetal growthAltered fetal growth
The pathogenesis of the gestational diabetes mellitus Only maternal insulin decrease the Only maternal insulin decrease the
plasma glucoseplasma glucose The glucagon and hormones produced by The glucagon and hormones produced by
the placenta disturb the equilirium of the the placenta disturb the equilirium of the glucose metabolism glucose metabolism
Diabete mellitus with the fetus
High glucose and Ketoacidosis[across the placenta]High glucose and Ketoacidosis[across the placenta] First trimesterFirst trimester The second trimesterThe second trimester Third trimesterThird trimester laborlabor
Oral hypoglycemic agentsOral hypoglycemic agents Pancreatic islandPancreatic island Anomalies during the first trimesterAnomalies during the first trimester
Management
The diabetic teamThe diabetic team Achieving euglycemiaAchieving euglycemia Antepartum obstetric managementAntepartum obstetric management Timing of deliveryTiming of delivery Intrapartum managementIntrapartum management Postpartum periodPostpartum period
The diabetic team
PatientPatient Obstetrician Obstetrician Clinical nurse specialistClinical nurse specialist Psychosocial workerPsychosocial worker dietitiandietitian
Achieving euglycemia
DietDiet exerciseexercise Oral hypoglycemic agentsOral hypoglycemic agents Insulin Insulin
SubcutanieousSubcutanieous IntravenousIntravenous PumpPump adjustment of the dosage and the adjustment of the dosage and the
administration methodsadministration methods
Antepartum obstetric management Maternal statusMaternal status
Plasma glucosePlasma glucose KetouriaKetouria HypetensionHypetension Renal, cardiac, ophthalmicRenal, cardiac, ophthalmic
Fetal growth and developmentFetal growth and development UltrasonagraphyUltrasonagraphy Non-stimulating testNon-stimulating test Biophysical profile scoreBiophysical profile score
Timing of delivery
Well controlledWell controlled Term and spontaneous labor onsetTerm and spontaneous labor onset
Uncontrolled and bad controlled Uncontrolled and bad controlled Fetal statusFetal status Maternal statusMaternal status Gestational weekGestational week Other thingsOther things
Intrapartum management
Pain, anxiety, nervous, fautigue, diet, insulinPain, anxiety, nervous, fautigue, diet, insulin Intravenous nutrition and intravenous insulinIntravenous nutrition and intravenous insulin Fetal and maternal monitoringFetal and maternal monitoring
Maternal plasma glucose level 80~100mg/dlMaternal plasma glucose level 80~100mg/dl KetouriaKetouria Maternal blood gasMaternal blood gas Continuous contraction stimulating test for the Continuous contraction stimulating test for the
fetusfetus
Postpartum period
The dosage of insulin decreased The dosage of insulin decreased rapidly,even stoppedrapidly,even stopped
InfectionInfection
Long term things of GDM
Almost all of the GDM patients will get rid Almost all of the GDM patients will get rid of the intolerance glucose test status for of the intolerance glucose test status for several years or for all the life.several years or for all the life.
Almost all of the patients will develop Almost all of the patients will develop GDM during the following pregnancyGDM during the following pregnancy
About 50 percent of the GDM patients will About 50 percent of the GDM patients will become the overt 2 type diabetes mellitus become the overt 2 type diabetes mellitus 20 years later.20 years later.
Emphasis of GDM Predisposing factorsPredisposing factors 24-28 gestation week24-28 gestation week The glucose intolerance and insulinThe glucose intolerance and insulin
Prepregnant, the first/sencond and third trimester, Prepregnant, the first/sencond and third trimester, intrapartum, postpartumintrapartum, postpartum
Insulin dosageInsulin dosage Oral hypoglycemic agentsOral hypoglycemic agents The emergent statusThe emergent status
diabetes ketoacidosisdiabetes ketoacidosis The fetal, neonatal and maternal complicationsThe fetal, neonatal and maternal complications
thyroid disease
Normal thyroid physiology during Normal thyroid physiology during pregnancypregnancy
maternal hyperthyroidismmaternal hyperthyroidism maternal hypothyroidismmaternal hypothyroidism
Normal thyroid physiology during pregnancy Goiter during pregnancyGoiter during pregnancy
Renal glomerular filtration rate Renal glomerular filtration rate increaseincrease
renal excretion of iodine increaserenal excretion of iodine increase plasma inorganic iodine nearly halvedplasma inorganic iodine nearly halved benign hypertrophy of thyroid gland benign hypertrophy of thyroid gland
compensating for the iodine deficiencycompensating for the iodine deficiency
Maternal thyroid function tests during pregnancy
Hypothylamus (TRH and TIH)Hypothylamus (TRH and TIH) Pitutary (serum thyroid stimulating hormone: sTSH)Pitutary (serum thyroid stimulating hormone: sTSH) Thyroid glandThyroid gland
Total serum thyroixine(T4): bound and free Total serum thyroixine(T4): bound and free Serum triiodothyroning (T3): bound and freeSerum triiodothyroning (T3): bound and free Thyroxine binding globin (TBG)Thyroxine binding globin (TBG)
Thyroid stimulating immunoglobulins (TSIG)Thyroid stimulating immunoglobulins (TSIG) Nuclear action sites of the target cells: free T3 and Nuclear action sites of the target cells: free T3 and
T4, especially free T3T4, especially free T3
Fetal thyroid function test Fetal thyroid stimulating hormone, T4, and free Fetal thyroid stimulating hormone, T4, and free
thyroxine levels suggests that a mature and thyroxine levels suggests that a mature and autonomous thyroid pitutary axis exists as early as autonomous thyroid pitutary axis exists as early as 12 weeks gestation12 weeks gestation
Placenta transferPlacenta transfer Thyroid stimulating immunoglobulins (TSIG)Thyroid stimulating immunoglobulins (TSIG) Minimal transfer of T3 and T4Minimal transfer of T3 and T4 Thyroid hormone analogues with smaller Thyroid hormone analogues with smaller
molecular weight, decreased protein binding, and molecular weight, decreased protein binding, and increased fat solubility may transfer the placenta increased fat solubility may transfer the placenta and influence the fetal thyroid statusand influence the fetal thyroid status
Maternal hyperthyroidism
The incidence: 1/500The incidence: 1/500 Grave disease or toxic diffuse goiter is Grave disease or toxic diffuse goiter is
the most common cause of the most common cause of hyperthyroidism during pregnancyhyperthyroidism during pregnancy
Diagnosis of hyperthyroidism
Prepregnant hyperthyroid historyPrepregnant hyperthyroid history Clinical signs and symptomsClinical signs and symptoms
TachycardiaTachycardia Eye changesEye changes Weight lossWeight loss Heat intoleranceHeat intolerance
Laboratory testLaboratory test sTSHsTSH Free T3 and T4Free T3 and T4
Therapy of hyperthytoidism MedicalMedical
thiamides [Propylthioruacil and thiamides [Propylthioruacil and metimazole(tapazole)]metimazole(tapazole)]
Propylthioruacil cross the placenta freely, but the Propylthioruacil cross the placenta freely, but the children exposed to thiamides in utero attain full children exposed to thiamides in utero attain full physical and intellectual development and have physical and intellectual development and have normal thyroid function testnormal thyroid function test
Beta receptor blockerBeta receptor blockerPropranololPropranololFetal effectsFetal effects
Radioactive iodine(contraindicated during pregnancy)Radioactive iodine(contraindicated during pregnancy) Surgery: partial ablationSurgery: partial ablation
Thyroid storm Precipitating factorsPrecipitating factors
Infection,Labor,Cesarean section,Noncompliance with Infection,Labor,Cesarean section,Noncompliance with medicationsmedications
Clinical signs and symptomsClinical signs and symptoms Hyperthermia, marked tachycardia, perspiration, sever Hyperthermia, marked tachycardia, perspiration, sever
dehydrationdehydration Special treatmentSpecial treatment
Propranolol: beta receptor blockerPropranolol: beta receptor blocker Sodum iodine: thyroid hormone secretion blockerSodum iodine: thyroid hormone secretion blocker Propylthiouracil: thyroid hormone synthesis blockerPropylthiouracil: thyroid hormone synthesis blocker Dexamethasome: transfer of T4 to T3 blockerDexamethasome: transfer of T4 to T3 blocker Replacing fluid lossesReplacing fluid losses Hypothermic techniquesHypothermic techniques
Neonatal thyrotoxicosis
1% of maternal hyperthyroidism results 1% of maternal hyperthyroidism results from Grave diseasefrom Grave disease
Placental transfer of the thyroid Placental transfer of the thyroid stimulating immunoglobulinsstimulating immunoglobulins Long acting thyroid stimulatorsLong acting thyroid stimulators
The newborns may require antithyroid The newborns may require antithyroid treatment for several weeks until the treatment for several weeks until the TSIGs are degradedTSIGs are degraded
maternal hypothyroidism Uncommon during pregnancyUncommon during pregnancy Fetal and neonatal outcome are normally goodFetal and neonatal outcome are normally good Elevated serum TSHElevated serum TSH Cretinism(congenital hypothyroidism)Cretinism(congenital hypothyroidism)
1/4000 births1/4000 births Etiologic factorsEtiologic factors
Thyroid dysgenesisThyroid dysgenesisInborn errors of thyroid functionInborn errors of thyroid functionDrug induced endemic hypothyroidismDrug induced endemic hypothyroidism
The most common cause of neonatal goiter is maternal The most common cause of neonatal goiter is maternal ingestion of iodides present in cough syrupingestion of iodides present in cough syrup
Hematologic disorders
Anemia
DefinitionDefinition The homoglobin level is lower than The homoglobin level is lower than
11g/dl during the nonpregnant status11g/dl during the nonpregnant status 10g/dl during the pregnant status10g/dl during the pregnant status
Physiologic anemia in pregnancyPhysiologic anemia in pregnancy The blood volume increase by 40% to The blood volume increase by 40% to
50%50% The red cell mass increase by 25%The red cell mass increase by 25%
Classification and common causes of anemia during pregnancy
Lower production by bone marrow (MATERIAL DEFICIENCY)Lower production by bone marrow (MATERIAL DEFICIENCY) Iron deficiency anemiaIron deficiency anemia
(80%)(80%) Iron supplementIron supplement Preventive methods during antepartum periodPreventive methods during antepartum period Lower than 6g/dl is dangerous for the fetusLower than 6g/dl is dangerous for the fetus
Folic acid deficiency anemiaFolic acid deficiency anemia Combined iron and folate deficiencyCombined iron and folate deficiency
HemalysisHemalysis DICDIC
Blood lossBlood loss Antepartum, intrapartum andAntepartum, intrapartum and postpartum hemorrhagepostpartum hemorrhage
HEMORRHAGE AND SHOCK AND DICHEMORRHAGE AND SHOCK AND DIC
Leukemia
RARERARE VERY VERY POOR MATERNAL AND VERY VERY POOR MATERNAL AND
FETAL OUTCOMEFETAL OUTCOME
Hemoglobinopathies
SICKLE CELL DISEASESICKLE CELL DISEASE RARERARE DANGEROUS TO THE MOTHER AND DANGEROUS TO THE MOTHER AND
FETUSFETUS
disorders of blood coagulation
Inherited disorders of plasma coagulation Inherited disorders of plasma coagulation factorsfactors Hemophilia AHemophilia A Hemophilia BHemophilia B von Willebrand diseasevon Willebrand disease Congenital fibrinogen deficiencyCongenital fibrinogen deficiency
Thrombocytopenia
idiopathicidiopathic Hypertensive disorders during pregnancyHypertensive disorders during pregnancy
HELLP SYNDROMEHELLP SYNDROME Other factorsOther factors
ImmunologicImmunologic DIC (disseminated intravascular DIC (disseminated intravascular
coagulation status)coagulation status)
Clincal features of thrombocytopenia Lower than 100X10Lower than 100X1099/L,Lower than 30-/L,Lower than 30-
50X1050X1099/L,Lower than 10X10/L,Lower than 10X1099/L,Lower than /L,Lower than 2X102X1099/L/L
Maternal cerebral hemorrhage, and Maternal cerebral hemorrhage, and postpartum hemorrhagepostpartum hemorrhage
Fetal effectsFetal effects Anti-platelet antibodyAnti-platelet antibody rarerare
Treatment for thrombocytopenia
Corticosteroid hormoneCorticosteroid hormone Platelet infusionPlatelet infusion Immunoglobin infusion (1g/kg.day)Immunoglobin infusion (1g/kg.day) splenoectomysplenoectomy
DIC
Very very common and dangerous disease in obstetric practiceVery very common and dangerous disease in obstetric practice Common causeCommon cause
High coagulation status during pregnancyHigh coagulation status during pregnancy Abruptio placentae, severe preeclampsia and Abruptio placentae, severe preeclampsia and
eclampsia,intrauterine fetal demise, sepsis, transfusion eclampsia,intrauterine fetal demise, sepsis, transfusion reaction, and amniotic fluid embolismreaction, and amniotic fluid embolism
Clinical and laboratory features Clinical and laboratory features ThrombocytopeniaThrombocytopenia HypofibrinemiaHypofibrinemia increased D-dimersincreased D-dimers intra vascular hemolysisintra vascular hemolysis and hemorrhage tendencyand hemorrhage tendency Increased PT AND PPTIncreased PT AND PPT
Neurologic disorders SeizuresSeizures
MedicationMedication Injury to the pregnancyInjury to the pregnancy
Physical attack(maternal, uterus, placenta, and Physical attack(maternal, uterus, placenta, and even the fetus)even the fetus)
hypoxiahypoxia Eclampsia:Eclampsia: cerebral edema and hemorrhage cerebral edema and hemorrhage Cerebral tumor or vascular deformityCerebral tumor or vascular deformity Intracranial venous thrombosis due to high Intracranial venous thrombosis due to high
coagulation statuscoagulation status Easily mixed with eclampsiaEasily mixed with eclampsia
Pregnancy complicated with cerebral vascular disease (a very emergent condition) Hemorrhage or ischemiaHemorrhage or ischemia Aterial or venousAterial or venous Etiology and pathogenesisEtiology and pathogenesis SeveritySeverity Gestational weekGestational week The attitude of the woman and her familiesThe attitude of the woman and her families Cooperation of the obstetrician and neurologistsCooperation of the obstetrician and neurologists
Renal disorders
Acute renal failure
Prerenal,Renal and postrenalPrerenal,Renal and postrenal Postpartum hemorrhage and DIC are the most Postpartum hemorrhage and DIC are the most
common causescommon causes Causal manigement, recovery of the circulation Causal manigement, recovery of the circulation
and dialysis are the most important methodsand dialysis are the most important methods Reversible and irreversible Reversible and irreversible
AgeAge Severity and Duration of DICSeverity and Duration of DIC Treatment protocolTreatment protocol
Chronic renal failure
CovertCovert Associated and mixed with pregnancy Associated and mixed with pregnancy
induced hypertensive disordersinduced hypertensive disorders Magnesium sulfate toxicityMagnesium sulfate toxicity
Orthostatic or postural hypotension Orthostatic or postural hypotension (vascular smooth muscle)(vascular smooth muscle)
Dyspnea (skeletal muscle)Dyspnea (skeletal muscle)Muscle relxation (skeletal muscle)Muscle relxation (skeletal muscle)
Pregnancy following renal transplantation
RARERARE Main concernsMain concerns
Bad effects of Immunosuppressive agents Bad effects of Immunosuppressive agents to the fetusto the fetus
InfectionInfection Refer to the table in page 257 Refer to the table in page 257
Gastrointestinal disorders
nausea and vomiting during pregnancynausea and vomiting during pregnancy hyperemesis gravidarumhyperemesis gravidarum reflux esophagitisreflux esophagitis peptic ulcerpeptic ulcer acid aspiration syndromeacid aspiration syndrome gastrointestinal bypass and pregnancygastrointestinal bypass and pregnancy chronic inflammatory bowel diseasechronic inflammatory bowel disease
Nausea and vomiting during pregnancy
Morning sicknessMorning sickness 60%~80%60%~80% During first 8~12 gestational weeksDuring first 8~12 gestational weeks Mild and disappear during the early part of the Mild and disappear during the early part of the
second trimester second trimester The underlying causes are not well delineatedThe underlying causes are not well delineated A small part of patients with severe symptoms A small part of patients with severe symptoms
necessitates hospital admissionnecessitates hospital admission
Hyperemesis gravidarum Intractable nausea and vomittingIntractable nausea and vomitting 1%1% More frequent with first pregnancyMore frequent with first pregnancy Pregnancy outcome is usually goodPregnancy outcome is usually good Electrolyte disturbanceElectrolyte disturbance
HypokalemiaHypokalemia HyponatremiaHyponatremia Hypochloremia alkalosisHypochloremia alkalosis
Low energy and nutrition intakeLow energy and nutrition intake Vitamin B1 deficiencyVitamin B1 deficiency
Glucose metabolismGlucose metabolism Central and peripheral nervous damageCentral and peripheral nervous damage Lethal conditionLethal condition
Treatment SymptomaticSymptomatic
AntiacidsAntiacids Avoidance of recumbent positionAvoidance of recumbent position
H2 blockerH2 blocker CimetidineCimetidine
Proton pump blockerProton pump blocker OmeprazoleOmeprazole
Intravenous hydrationIntravenous hydration Correction of electrolytes and and acid base imbalanceCorrection of electrolytes and and acid base imbalance Intravenous nutrition and vitaminsIntravenous nutrition and vitamins Psychological counseling Psychological counseling
Hepatic disorders
Main factors associate with hepatic disordersMain factors associate with hepatic disorders AlbuminAlbumin Coagulationg factors (bleeding)Coagulationg factors (bleeding) BilirubinBilirubin Drug metabolismDrug metabolism Nutrition material metabolismNutrition material metabolism
Intrahepatic cholestasis of pregnancyIntrahepatic cholestasis of pregnancy Acute fatty liver of pregnancyAcute fatty liver of pregnancy DICDIC HELLP syndromeHELLP syndrome