chapter two preexi new illnesses

Chapter Four

MANAGEMENING PREEXISTING OR

NEWLY ACQUIRED ILLNESS

DURING PREGNANCY

Anemia During Pregnancy

ANAEMIA

is a reduction of the RBC volume or hemoglobin concentration below the age-adjusted reference range.

few clinical disturbances occur until the hemoglobin level falls below 7–8g/dL.

may be present when the hemoglobin level is within the normal range.

Anemia is not a specific disease entity and may be acute or chronic.

• Pregnancy makes considerable nutritional demands on the mother.

• As a consequence anemia is very common, particularly when consecutive pregnancies are not well spaced.

• The presence of anemia increases morbidity in pregnancy, the risk of infection and, should it occur, the hazards of post-partum hemorrhage.

• The main nutritional factors involved are iron, folic acid and B group vitamins.

There are two main anemia's seen in pregnancy: -

iron deficiency causes a hypochromic,microcytic anemia and

folic acid deficiency is associated with megaloblastic anemia.

• Automated assays for serum iron, ferritin, folic acid and vitamin B12 levels have made investigation of anemia in pregnancy more rapid and allow correction of hematinic deficiency early in pregnancy.

Haematinic deficiency may result from:

1. Diminished intake.

2. Abnormal absorption.

3. Reduced storage.

4. Abnormal utilization.

5. Abnormal demand.

Cont…

The etiology of anemia must be considered in relation to these principles.

Heavy periods and the demands of pregnancy readily lead to anaemia.

The increased demands for iron amount to 1000 mg.

Factors operating to cause anaemia in pregnancy

Poor diet,

multiparity

menorrhagia are the commonest causes.

symptoms

• Fatigue

• Lethargy

• Dizziness

• Headaches

• Shortness of breath

• Ringing in ears

• Taste disturbances

• Restless leg syndrome

• Pallor

• Flattened, brittle nails (spoon nail)

• Angular stomatitis (cracks at mouth corners)

• Glossitis

• Blue sclera (whites of eyes)

• Pale conjunctivae

• Pica (ice chewing)

IRON DEFICIENCY

• Iron deficiency anemia is characterized by :- a defect in hemoglobin synthesis, resulting in RBC that are

abnormally small (microcytic) and contain a decreased amount of hemoglobin (hypochromic)Diagnosis• Blood films will show hypo chromic microcytosis. • The serum iron and ferritin will be reduced.• Ferritin:-An iron-containing protein complex, found

principally in the intestinal mucosa, spleen, and liver, that functions as the primary form of iron storage in the body.

Oral iron is the treatment of choice. anemia is usually associated with failure to take

the preparation.This may be simply:- poor compliance, or poor absorption, because of nausea and

vomiting. uncertainty of the time of delivery and the possibility of preterm labour may require transfusion to be given in severely anemic and symptomatic women.

Treatment cont…..

• Packed red cells should be given slowly and may be given in stages.

• The oxygen carrying capacity of transfused red cells is low for the first 24 hours following transfusion and it is important to remember that the red cells are being given to prevent complications of blood loss at the time of delivery.

• In less severe cases blood should be available during labour and transfused at or after delivery depending on the clinical condition.

FOLIC ACID DEFICIENCY

• Folic acid is necessary for nucleic acid formation and inadequate levels leads to a reduction in cell proliferation.

• The main effects are seen in tissues which rapidly proliferate such as the bone marrow.

etiology

Clinical Findings

• These depend on the severity of the deficiency. There may be no symptoms and only moderately low hemoglobin.

• Folic acid deficiency and iron deficiency often co-exist and iron treatment given alone will only increase hemoglobin levels slightly.

FOLIC ACID DEFICIENCY

• Severe folic acid deficiency is now less common than formerly.

• The use of folic acid prophylaxis for prevention of neural tube defects reduces the risk of anaemia in pregnancy.

• Unfortunately those most likely to take prophylaxis are not the population at greatest risk of

• dietary deficiency.• Consequently folic acid is now often prescribed in a

combined preparation with iron and• given throughout pregnancy.• When severe cases do present, the features may co-exist

with other signs of nutritional deficiency such as glossitis.

Laboratory Diagnosis• Automated testing will reveal macrocytosis and

these cells may be hypo chromic. • A blood film will occasionally show megaloblasts.

Hyper segmentation of the neutrophils may be seen.

Treatment• Established deficiency should be treated with oral

folic acid 5 mg three times daily throughout pregnancy.

• Vitamin B12 deficiency is exceedingly rare in pregnancy as pernicious anemia causes infertility.

HAEMOGLOBINOPATHIES• The haemoglobinopathies are a group of genetic

disorders of globin synthesis.• Heterozygote for haemoglobinopathies may be

mildly affected but homozygotes may be severely anemic.

Sickle cell disease is seen in the African and Afro-Caribbean communities and

Thalassaemia in those from the Mediterranean and Far East. In these populations hemoglobin electrophoresis may be offered at the booking visit.

• In homozygous sickle cell disease there is chronic anaemia and increased risk of haemolytic crises.

• Alpha thalassaemia is less common and, in the homozygous form, lethal in utero.

• Homozygous beta thalassaemia causes death in childhood but the heterozygous form causes chronic anaemia and may only be diagnosed in pregnancy. Folic acid should be given but iron is not required.

• Women who are heterozygotes for a haemoglobinopathy should be offered screening of their partner to determine the chance of an affected fetus.

• Chorion villus sampling or amniocentesis can be used to establish the diagnosis in the fetus.

IDIOPATHIC THROMBOCYTOPENIA• Idiopathic, or immune thrombocytopenic purpura (ITP) is

commoner in women and in those below 30 years. • It is not rare in the obstetric population. • The presence of antiplatelet IgG causes a reduction in both

maternal and fetal platelets.• Treatment, if required, is by glucocorticoids.• The risk to the fetus is difficult to assess but neonatal

handicap from intra-uterine intra-cranial haemorrhage has been reported. Many obstetricians advocate elective Caesarean section for these women to reduce this risk.

• Intravenous gammaglobulin may be given to the mother some days before delivery as this transiently increases platelet counts.

TUBERCULOSIS (TBC)

24

TB Cont…

• Definition: tuberculosis is an infectious disease caused by the bacillus Mycobacterium tuberculosis and characterized by the formation of the modular lesions in the tissue.

• Facts about tuberculosis:• Two billion or 1/3 of the world population have been

infected• Nine million new cases of active disease annually• Two million deaths annually especially in developing

countries• The second killer infectious disease in the world

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TB Cont…

• TB is of two types:

• Pulmonary tuberculosis (PTBC)and

• 2. Extra pulmonary tuberculosis (EPTBC)

• Pulmonary tuberculosis during pregnancy

• Transmission – through aerosol droplets which are expelled when person with active TB disease cough, sneeze, speak or spite

26

TB Cont…

• S/S of TB:

• Fatigue

• Wt loss

• Cough

• Night sweating

• Haemoptysis

• Dyspnoea

• Dullness on percussion

• Purulent sputum

• Low grade fever

• Anorexia etc

27

TB Cont…

• Diagnosis- by medical history, P/E, chest x-ray, microscopic smear, tuberculin test etc

• Effect on the pregnancy

• Sing and symptoms mentioned above deliberate the women and she become less able to copy with pregnancy and her existing family.

• Although the transplacental infection is rare, risk of IUGR and abortion may be increased.

28

TB Cont…

• Management:

• The women will be under the care of obstetrician and chest physician during her pregnancy

• If there is clinical signs of tuberculosis or the women is known to have been in contact with tuberculosis full-plate chest x-ray is performed at 3rd month 6th month and after delivery ( the fetus is protected by lead apron)

• Sputum and pleural effusions should be taken for diagnosis.

29

TB Cont…

• Most treatment is given in outpatient basis, although the women may be admitted to isolation unit if her sputum test is positive.

• The rest of house hold will also be referred for investigation.

• Physical & emotional rest, hospitalization (for moderate and advanced one), chemotherapy are included in TB RX.

• A pregnant women with suspected or confirimed TB should be placed on DOTS( Directly observed chemotheraphy short course)

30

TB Cont…

• The currently accepted first line therapy is 2RHZE/4RH

• Some women are admitted for rest during the last 2 wks of pregnancy.

• Except streptomycin that has adverse effect on the fetal ear and kidney, all anti TB drugs are not contraindicated during pregnancy.

31

TB Cont…

• Intrapartal care: • If the mother is infections she should be allocated

a single room during her stay in hospital.• Episiotomy and forceps delivery to reduce strain

of second stage of labour.• Unnecessary blood loss should be avoided• The interaction b/n her regular medication and

drug given in labour may be important; for example streptomycin potentiates the effect to tocolysis (muscle relating drugs)

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TB Cont…

• Postnatal care:• Separation of the baby from his family is not

always necessary.• The baby can be vaccinated by ant-isonizid

resistant BCG(Bacillus Calamate Guerin) • With out vaccination child has a 50% chance of

catching the disease.• If any of baby’s family is infected with isonizid

resistant organism, separation of the baby is mandatory.

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TB Cont….

• Breast feeding is contraindicated if the women has an active infection.

• Mothers taking anti tuberculosis therapy should be encouraged to breast feed since the infant will receive 2% of the normal infant dose by this rout

34

TB Cont…

• The MW should advise to avoid further pregnancies until the disease had been quiescent for at least 2 years.

• The mw should be aware, and also teaches the mother that Rifampicine reduces the effectiveness of oral contraceptive pill.

35

TB cont…

• Normal breathing sounds

• Vesicular- from small air way

• Broncho vesicular- near by large air way.

• Bronchial breathing sound (BBS) on the head of the sternum.

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• Abnormal breathing sounds:

• Bronchial breath sounds (BBS): other than at the head of sternum

• Crepitations: – pneumonia, TB, CHF

• Wheezing:- continuous expiratory sound- in asthma & chronic bronchitis

• Friction rubs:- in pleurisy as a result of friction b/n the visceral and parietal pleur

37

ASTHMA IN PREGNANCY

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Cont…

• Asthma:

• Asthma is a condition characterized by paroxysmal attacks of bronchospasm causing difficulty in breathing.

• People with asthma have extra sensitive or hyper responsive airways.

• These air ways react by narrowing or obstructing when they become irritated.

• This makes difficulty in breathing.

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Asthma Cont…

• This narrowing or obstruction can cause one or a combination of the following symptoms.

• Wheezing

• Coughing

• Shortness of breathing

• Chest tightening

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Asthma Cont…

• This narrowing or obstruction is caused by:

• Air way inflammation

• Bronchoconstriction

• Factors provoking asthma:

• Two factors provoke asthma:

• Triggers

• Causes

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Asthma Cont…

• 1. Triggers: result in tightnining of air ways (bronchoconstriction) common triggers include; cold air, dust, strong fumes, exercise, inhaled irritants, emotional upset, smoke

• 2. Causes (inducers): result in inflammation of air ways common inducers include:

• Allergens example pollen, animal secretions ( cat & horse), molds, house dust mites

• Respiratory viral infections

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• Asthma in pregnancy• General facts• Asthma is the most common respiratory disease

encountered during pregnancy, affecting 3% of all women in their child bearing age.

• Morbidity and mortalities associated with it is largely preventable

• Medications commonly used in the management of asthma are not known to cause teratogenic effect.

• The risk of uncontrolled asthma are far greater than the risks to the mother or fetus from the medications used to control asthma

43

Asthma Cont…

• Effect of uncontrolled asthma on pregnancy:

• Premature birth

• Low birth weight

• Predisposition to pre-eclampsia

44

Asthma Cont…

• Management:

• Asthma attacks can be prevented by:

• Controlling the environment( avoiding triggers and inducers)

• Continuing regular scheduled medication during pregnancy, labour and delivery.

45

Asthma Cont….

• Any women identified at booking with diagnosed or suspected asthma should be referred to chest physician.

• If during pregnancy there are any difficulties in controlling the asthma, the woman should be admitted to hospital.

BY GEBREMARYAM TEMESGEN BSC IN MW46

• NB: labour is not usually complicated by asthma attacks due to an increase in cortisone and adrenalin from the adrenaline glands during labour.

• If an asthma attacks does occur during pregnancy, it should be treated with the same rapidity and medication as an asthma attack out side of pregnancy.

• Intravenous, intra amniotic and transcervicalprostaglandins should be avoided in a woman with asthma b/s of their brounchospasm action.

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Quiz

• What are the two common types of anemia during pregnancy

• What are the fetal complication of anemia

• What is the effect of tb on pregnancy

• Write triggering and inducing factors for asthma.

CARDIAC DISEASE IN PREGNANCY

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Introduction• A woman with a known cardiac illness can

become pregnant or a healthy pregnant woman can develop cardiac illness while pregnant. In a woman with a preexisting cardiac illness, the increased homodynamic burden of pregnancy, labor and delivery can aggravate the symptoms of the illness and/or precipitate complications.

• The risk of congestive heart failure is the highest around 24 weeks of gestation, labour and the immediate postpartum period.

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Risk factors for cardiac failure during pregnancy

Infection

Anemia

Obesity

Hypertension

Hyperthyroidism

Multiple pregnancy

• During each uterine contraction in labor about 200-300 ml blood is squeezed from the contracting uterine muscles, increasing the cardiac output by about 20%.

Significance • Cardiovascular diseases are the most important

non-obstetric cause of disability and death of pregnant women, occurring in 0.4-4% of pregnancies.

• The most common cardiovascular disease that complicates pregnancy is rheumatic heart disease

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• Patients with valvular heart disease may develop sub acute infectious endocarditis. It is also associated with adverse fetal outcome like spontaneous abortion, preterm labour, low birth weight, and intrauterine fetal death.

Classification

• The degree of functional disability due to cardiac disease is graded according to the New York Heart Association classification as follows

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• Class I: No symptoms limiting ordinary physical activity.

• Class II : Slight limitation with mild to moderate activity with no symptoms at rest

• Class III: Marked limitation with less than ordinary activity; dyspnea or pain on minimal activity.

• Class IV: Symptoms at rest or with minimal activity and symptoms of congestive heart failure

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Prognosis depending on the functional status

In general, women in NYHA classes I and II lesions

usually do well during pregnancy and have a

favorable prognosis with a mortality rate of <1%.

Patients in NYHA classes III and IV may have a

mortality rate of 5% to 15%. These patients should

be advised against becoming pregnant.

• Note: With rare exceptions, women in class I and most in class II go through pregnancy without morbidity. As much as possible patients in classes III and IV should avoid pregnancy. Therapeutic abortion is an option in early pregnancy. If the pregnancy is continued, prolonged hospitalization or bed rest will often be necessary. These women tolerate major surgical procedures poorly

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With normal pregnancy:-

1) What are the causes for increased cardiac output during a normal pregnancy?

2) What are the causes for fall in the peripheral resistance?

3) What are physiological changes during labour ?

Management• Once diagnosed, these patients should be referred for

specialized care by obstetrician, internist and neonatologist. The general principles in the management are:

I. Antepartum• Bed rest• Moderate dietary restriction• Provision of diuretics (chlorothiazides are accepted) with

potassium supplementation• Prophylactic digitalization• Frequent ANC for maternal and fetal monitoring

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II. Intrapartum

• Unless contraindicated vaginal route of delivery is preferred

• Conduct labour and delivery in lateral decubitusposition

• Provide adequate pain relief

• Restrict intravenous fluids

• Provide oxygen with breathing mask along with continuous pulse oxymetery

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Decubites position

• Shorten the second stage by instrumental delivery

• Do not use ergometrine in the third stage

• Prevent postpartum pulmonary edema by keeping the woman in sitting position

• Provide thrombus prophylaxis by early ambulation and/ or low dose aspirin

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Antibiotic prophylaxis consists of

a. 2 gm ampicillin IV/plus

b. 1.5mg per kg gentamicin /IV prior to the

procedure , followed by one more dose of

ampicillin 8 hours later.

In the event of penicillin allergy 1 gm vancomycinIV can be substituted.

Which is the ideal contraceptive for women with heart disease ?

1. OC pills are not ideal as they can cause thrombo embolism.

2. IUCD can cause infection- endocarditis.

3. Barrier contraceptives – Have high failure rates.

4. Progestin only pills or Long acting injectable progesterone are

better

PILL - Desogestrel

INJECTABLES

a. Medroxy progesterone 150mg IM every 3 months.

b. Norethisterone.200 mg every 2 months

5. Sterilization is best.

Diabetes Mellitus/DM/

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DM Cont…

• Definition: Diabetes is a disease characterized by the inability to produce or use sufficient endogenous insulin to metabolize glucose properly

• Note: pregnancy is a diabetogenic state!

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DM Cont…

Types of diabetes mellitus:

There are 3 types of diabetes

1. Type 1/ insulin dependent diabetic mellitus/IDDM/ insulin deficiency/

• Pancreatic – islets of Lengharn’s virtually do not produce insulin

• Ketone prone

• Also called juvenile onset diabetes/Brittelydiabetes

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DM Cont…

2. Types – adult onset diabetes/non insulin dependent diabetes /NIDDM/

• Pancreatic – in islets of langerhan’s produce normal or increased amount of insulin.

• It takes higher level of insulin to open the receptor and facilitate muscle glucose up take

• The pancreas is over loaded to meet the increased demand of extra insulin.

• NB: the above two are pre gestational DM

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DM Cont...

3. Type 3 Gestational Diabetic Mellitus(GDM)

• Carbohydrate intolerance that develops/first recognized /during pregnancy, regardless of severity (at least abnormal values on a 3 hr oral glucose tolerance)

• Occurs when there is insufficient insulin secretion to counteract the pregnancy related decrease in insulin sensitivity.

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DM Cont…

Women who are at risk of developing gestational diabetes are those:-

• Diabetes in first degree relative (type two)

• With recurrent abortion

• With unexplained still birth

• A baby > 4.36kg at 40 wks

• Previous gestational diabetes

• Persisting glycoseuria

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DM Cont…

Etiology of diabetes mellitus

• Insulin deficiency due to -cell damage

• Inactivation of insulin by antibodies

• Increased insulin requirements

73

DM Cont…

• Type 1 DM is a chronic auto immune disorder of the pancreatic islet cell that develops in individuals who carry a genetic matter that has been identified on chromosome 6, viral induced ,immune stimulated antibodies against the B-cell .

• In 80% to 85% of patients with type 2 DM, obesity especially to the abdominal region, causes their insulin resistance.

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DM Cont….

• Carbohydrate metabolism in pregnancy /Normal physiology/

• Pregnancy is a diabetogenic state

• Estrogen and progesterone stimulate pancreatic B-cells hyperplasia->increased insulin secretion -> glucose utilization is enhanced -> decreased fasting glucose level in first trimester.

• During second and third trimesters HPL increase insulin resistance -> increased post prandinal blood glucose levels-> the increased glucose presence stimulates pancreatic islets to hypertrophy -> hyperinsulinemia

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DM Cont…

• The net effect is decreased insulin effectiveness causing reduced peripheral up take of glucose by mother, which facilitates glucouse available to the fetus acceleration fetal growth.

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DM Cont…

Phathophysiology:

• Pre gestational diabetes

• In theory the cause of faulty metabolism in the diabetic person is one or more of the following;

• Production of defective insulin

• Over production of insulin antagonist

• Increased tissue resistance to insulin production.

• Inadequate amount of insulin production.

• Inappropriate timing of insulin production

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DM Cont…

• Functions of insulin

• Regulate glucose and transfer from blood to blood cell.

• Stimulate protein synthesis and free acid storage in the fate deposits.

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DM Cont….

• Insulin deficiency compromises access essential synthesis for all body tissue.

• Without insulin glucose circulation in the blood stream unable to enter the cell .

• The energy starved cells catabolize fats from fat wasting and negative nitrogen balance from protein break down and muscle tissue wasting/ ketones accumulation in the blood stream/.

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DM Cont…

• The high level of glucose leads to hyperglycaemia, which exerts an osmotic force, puling intracellular fluid in to the blood stream causing cellular dehydration.

• when the circulating glucose level exceeds the renal threshold, glucose splits in to the urine, causing glycosuria.

• The urines high osmotic level prevents re absorption of water in to renal tubules causing extra cellular dehydration.

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DM Cont…

These change produce the four classic sign and symptoms of diabetes.

• Polyuria (frequent urination), Which develops b/s the renal tubules do not re absorb water.

• Polydipsia (excessive thrust), which is caused by the dehydration of polyuria

• Polyphagia (excessive hungry) which result from tissue catabolism and inadequate cellular use of glucose.

• Weight loss, which occur when the body burns fat and muscle for energy.

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DM Cont…

Glycosuria in pregnancy:

• Glucose is most liable to appear in the urine of the pregnant women for the following reasons:

1. In a non-diabetic the blood glucose level remains with normal limit but the glumuerularfiltration rate increases and glucose passes through the proximal convoluted tubule faster than it can be re-absorbed.

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DM Cont…

2. In the diabetic, the rise in blood glucose leads to more glucose in the glumerular filtrate b/s of lowering the renal through hold for glucose.

3. Renal tubular damage interferes with glucose re absorption and may be revealed from the first time during pregnancy.

83

DM Cont…

Note: Glycosuria in pregnancy is not a diagnostic of diabetes nor can it be used as a monitor of diabetes in the pregnancy women.

• Blood glucose level

• Normal: 80-120mg/dl

Indicates diabetes:

• Fasting blood sugar (FBS) >126mg/dl

• Random blood sugar (RBS)> 200mg/dl

• Higher than 200mg/dl 2 hours after OGTT

84

DM Cont…

• Detection of diabetes in pregnancy:

• Women considered to be at risk of gestation diabetes should undergo a glucose tolerance test.

(oral glucose tolerance test)OGTT) = A quantity of glucose e.g. Locozade

85

• (353ml) which provides 75 gm of glucose is given to the patient by mouth after a period of fasting, and the concentration of sugar in blood and urine is measured).

• The reading indicates the ability of patient’s body to utilize glucose.

• Before proceeding to a full glucose tolerance test a women is asked to fast a period of time and fasting blood glucose level is estimated

Conversion of Glucose Values from mg/dl to mmol/l

• mg/dl x 0.0555 = mmol/l

• mmol/lx 18.0182= mg/dl

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DM Cont…

• It would be abnormal if b/n 28 and 34 weeks of pregnancy, glucose in two out of four venous samples exceeds the following.

• Fasting 8.0mmol/l

• 1 hour after ingestion of 75gm glucose 11.0mmol/l

• 2 hour after ingestion of 75mg glucose 9.0mmol/l

• 3 hour after ingestion of 75mg glucose 7.0mmol/l

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DM Cont…

• The effect of pregnancy on diabetes

• In early pregnancy diabetes control may be complicated by nausea and vomiting

• As pregnancy advances ketosis in induced easily

• The diabetic who is controlled by diet may become dependent on insulin.

• Blood sugar must be kept within a narrow limits in order to avoid exacerbating the effect of the diabetes.

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DM Cont…

Effect of diabetes on pregnancy:

• Spontaneous abortion,

• pre-eclampsia,

• pre term labor

• polyhydramnious,

• infection e.g. candida albicans

• caesarean/instrumental birth/

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DM Cont…

Effects of diabetes on the fetus: • Hypoglycemia• Hyperglycemia• Congenital anomalies• Macrosomia(big baby)• IUGR, unexplained IUFD• Neonatal hypoglycemia, • Neonatal hyperblirubinima, • Neonatal polycythemia, • Hearing disorders, ketoacidosis.

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DM Cont…

Pathophysiology of effect of DM on the mother and fetus:

High amount of glucose in the blood->

1. Pass with urine -> glycoseuria-> infection(UTI, fungal )

2. Also increased glucose in fetal circulation-> increased amount of urine-> polyhydraminu-> PROM and pre term delivery.

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DM Cont…

3. Big baby (macrosomia) b/s of high glucose level and hyperinsulineamia-> CPD-> caesarean or instrumental delivery and neonatal hypoglycemia.

4. Contribute to synthesis of DNA & RNA-> congenital abnormalities like NTD, congenital cardiac anomalies.

5. Body use fats to produce energy -> ketones and acid-> ketoacidosis-> abortion or fetal death(IUFD)

6. Glycosaylated hemoglobin also interferes with transport of oxygen and carbon dioxide-> decreased fetal PH and increased PCO2->unexplained fetal death

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DM Cont…

The pregnancy care of the known diabetic:

• A diabetic woman should consult her physician for preconception care and advice and also carefully examined for the presence of renal, cardiovascular, or retinal changes before becoming pregnant.

• Contraceptive methods that do not contain estrogen may be given in order make her not to get pregnant.

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Antenatal care• A woman with diabetes should be advised to book to have

her in a hospital with neonatal intensive care unit.• She should be seen at combined antenatal and diabetic

clinics.• ANC cheek up every 2 wks up to 28wks and then weekly.• The MW should alert woman to the s/s of vaginal infections

and to keep her personal hygiene.• Alpha-fetoprotein- to detect fetal abnormalities • Examination of maternal wt and of her abdomen will help

the mw to detect polyhydramnious.• Detection of any diabetic complication

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DM Cont…

Control of diabetes in pregnancy:

The aims of diabetic control in pregnancy are

• To avoid hypoglycemia.

• To maintain the pre-prandial glucose b/n 4.0 and 5.5mmol/l

• To ensure that the post prandial peak does not exceed 7.2mmlo/l

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• Subcutaneous insulin provides the best method of control for most women.

• A combination of short and intermediate acting insulin is usually given twice daily before breakfast and the evening meal.

• Insulin is absorbed more quickly from the upper arm than from the abdomen and more slowly from the thigh.

• The women is usually give a kit containing glucagons which can be administered subcutaneously in the event of the severe hypoglycaemia.

• Admission to hospital may be needed if there is poor diabetic control or there is complication.

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Monitoring diabetic control

If possible women monitors her own diabetes to:-

• Hyperglycaemia and hypoglycemia

• Measure changes in blood glucose during 24 hours period

• Assess blood glucose control in times of special needs so that insulin dosage can be adjusted accordingly.

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Cont…

• Obtain a full blood glucose profile; samples should be taken the following times;– Before the morning injection

– 1-2 hours after breakfast

– Before bed time

– At some point during the night

– Before lunch

– Before the evening injection

– 1-2 hours after the evening meal

Management of labor and delivery • Since fetal lung mature more slowly when the mother

is diabetic, tocolytics should be given when labor being prematurely

Control of diabetes in labor• The mw should monitor fetal condition though out

labor • Pediatrician should be present• Polyhydraminious, malperesentation, cord prolapse

birth asphyxia, big baby with birth injury (shoulder distocia)should be expected and the staff should be ready to manage these all

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DM Cont…

Postnatal care

• Mother

• Carbohydrate metabolism returns to normal very quickly after delivery of placenta

• Diabetic mother who is breast feeding should be increase her carbohydrate in take by 50gm a day.

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DM Cont…

Gestational diabetes

• A woman with gestational diabetes requiring insulin will stop this immediately after delivery.

• A post partum glucose tolerance test should be performed approximately after delivery and the mother should be warned that it can recur.

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Baby • Asphyxia is common in both macrocosmic and growth-

retarded babies.• Macrocomic baby are prone to birth injuries • The baby should be examined carefully at birth as

there is an increased risk of congenital abnormality.• After birth the baby continues to prouduce more

insulin than he needs. As there he is no longer recevingglucose from his mother, hypoglycaemi may occur.

• To prevent hypoglycaemia the baby should feed after delivery.

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Diabetes in Pregnancy: Hypoglcemiaypoglycemia

Pathophysiology

May be related to fetal

absorption of glucose from the maternal bloodstream

via the placenta,

particularly during periods

of maternal fasting

Risk Factors

History of severe hypoglycemia

before pregnancy

Impaired hypoglycemia

awareness

Longer duration of diabetes

A1C ≤6.5% at first pregnancy visit

High daily insulin dosage1

Causes of Iatrogenic

Hypoglycemia

Administration of too much insulin or

other anti-hyperglycemic

medication

Skipping a meal

Exercising more than usual2,3

Clinical Consequences

Signs of hypoglycemia:

anxiety, confusion, dizziness, headache,

hunger, nausea, palpitations,

sweating, tremors, warmth, weakness4

Risks of hypoglycemia:coma, traffic

accidents, death1,5

Severe hypoglycemia can lead to maternal

seizures or hypoxia

Management

Inform patients of increased risk of

severe hypoglycemia during early pregnancy4

Educate patients on hypoglycemia

prevention:

Frequent SMBG

Regular meal timing

Accurate medication

administration

Careful management of

exercise programs4

1. Mathiesen ER, et al. Endocrinol Metab Clin N Am. 2011;40:727-738. 2. Inturrisi M, et al. Endocrinol Metab Clin N Am. 2011;40:703-26.

3. Jovanovic L, et al. Mt Sinai J Med. 2009;76(3):269-80. 4. Kitzmiller JL, et al. Diabetes Care. 2008;31(5):1060-79.

5. Hod M. Jovanovic L. Int J Clin Pract. 2010;64(166):47-52.

Thank You