![Hematologic Disorders and Pregnancy
• Sickle Cell Anemia
– a recessively inherited hemolytic anemia caused by
an abnormal amino acid in the beta chain of
hemoglobin [sickle hemoglobin (HbS) if valine is
replaced and nonsickling hemoglobin (HbC) if lysine
is replaced]
– majority of red blood cells are irregular or sickle
shaped so they cannot carry as much hemoglobin
as can normally shaped red blood cells
– Approximately 1 in every 10 African Americans has
the sickle cell trait (i.e., carries a recessive gene for
S hemoglobin but is asymptomatic)](https://image.slidesharecdn.com/lesson-1-high-risk-pregnancy-230514235658-803c7b03/85/LESSON-1-High-Risk-Pregnancy-ppt-22-320.jpg)
LESSON-1-High-Risk-Pregnancy.ppt
- 2. • High-Risk Pregnancy - one in which a concurrent disorder, pregnancy-related complication, or external factor jeopardizes the health of the woman, the fetus, or both High Risk Pregnancy
- 3. Three Major Causes of Maternal Death: • Hypertensive Disorders • Infection • Hemorrhage Factors Related to Maternal Death: • Age (Younger than 20 years and 35 years older) • Lack of prenatal care. • Low educational attainment • Unmarried Status High-Risk Pregnancy
- 4. Leading cause of death in the neonatal period is CONGENITAL ANOMALIES. Other Causes: • Disorders related to short gestation and low birth weight • Sudden Infant Death Syndome • Respiratory Distress Syndrome • Effects of Maternal Complications High-Risk Pregnancy
- 5. High-Risk Pregnancy The factors that place a pregnancy at risk can be divided into four categories: 1.Existing Health Conditions 2.Age 3.Lifestyle Factors 4.Conditions of Pregnancy
- 6. Existing Health Conditions • Cardiovascular D/O • Hematologic D/O • Renal and Urinary D/O • Respiratory D/O • Rheumatic D/O • Gastrointestinal D/O • Neurologic D/O • Musculoskeletal D/O • Endocrine D/O • Cancer • Mental Illness
- 7. Cardiovascular Disorder and Pregnancy • complicates only approximately 1% of all pregnancies • responsible for 5% of maternal deaths during pregnancy • Most common disorders: valve damage caused by rheumatic fever or Kawasaki disease and congenital anomalies such as atrial septal defect or uncorrected coarctation of the aorta. • Increasing age of pregnancy increases the incidence of coronary artery disease and varicosities during pregnancy • Peripartum heart disease rarely occurs
- 8. Cardiovascular Disorder and Pregnancy • A woman with cardiovascular disease needs a team approach to care during pregnancy, combining the talents of an internist, obstetrician, and nurse. • Blood volume and Cardiac output increase 30% to 50% during pregnancy • Functional (innocent) murmurs are present because of the increase in blood vol. and cardiac output
- 10. Cardiovascular Disorder and Pregnancy • A woman with left-sided heart failure – left ventricle cannot move the volume of blood forward that it has received by the left atrium from the pulmonary circulation. – heart becomes so overwhelmed it fails to function – Because of the limited oxygen exchange, women with pulmonary hypertension are at extremely high risk for spontaneous miscarriage, preterm labor, or maternal death – A woman experiences increased fatigue, weakness, and dizziness (specifically from lack of oxygen in brain cells)
- 11. Left-sided heart failure • pulmonary edema becomes severe, a woman cannot sleep in any position except with her chest and head elevated (orthopnea) • paroxysmal nocturnal dyspnea— suddenly waking at night short of breath – With the more effective heart action, interstitial fluid returns to the circulation and overburdens the circulation, causing increased left-side failure and increased pulmonary edema
- 12. Right-Sided Heart Failure • occurs when the output of the right ventricle is less than the blood volume received by the right atrium from the vena cava • Back-pressure from this results in congestion of the systemic venous circulation and decreased cardiac output to the lungs.
- 13. Right-Sided Heart Failure • Blood pressure decreases in the aorta because less blood is reaching it; pressure is high in the vena cava from back- pressure of blood; • Both jugular venous distention and increased portal circulation occur • The liver and spleen become distended • Liver enlargement can cause extreme dyspnea and pain in a pregnant woman because the enlarged liver, as it is pressed upward by the enlarged uterus, puts extreme pressure on the diaphragm. • Distention of abdominal vessels can lead to exudate of fluid from the vessels into the peritoneal cavity (ascites) • Fluid also moves from the systemic circulation into lower extremity interstitial spaces (peripheral edema).
- 14. A Woman With Peripartum Heart Disease • An extremely rare condition, peripartal cardiomyopathy can originate in pregnancy in women with no previous history of heart disease • Mortality rate as high as 50% • occurs most often in African American multiparas in conjunction with hypertension of pregnancy • signs of myocardial failure such as shortness of breath, chest pain, and edema
- 15. Assessment of Woman with Cardiac Disease • Check for signs of poor circulation • Assess edema • Right-sided heart failure – assess for liver enlargment • Left-sided heart failure – assess for pulmonary symptoms like cough • ECG, chest radiography, echocardiography
- 17. • Fetal Assessment – poor perfusion level may also lead to an acidotic fetal environment if the blood flow becomes inadequate for carbon dioxide exchange – Preterm labor; prematurity – Late deceleration patterns
- 18. Implementation • Promote rest • Promote healthy nutrition • Educate regarding medication – Close to the anticipated day of birth, some physicians begin a course of an antibiotic for women with heart disease such as penicillin because the postpartum period always involves some mild invasion of bacteria from the denuded placental site on the uterus into the blood- stream. • Educate Regarding Avoidance of Infection • Be Prepared for Emergency Actions
- 19. Hematologic Disorders and Pregnancy • Anemia – Pseudo-anemia of early pregnancy – blood volume expands during pregnancy slightly ahead of the red cell count – True anemia – when a woman’s hemoglobin concentration is less than 11 g/dL (hematocrit 33%) in the first or third trimester of pregnancy or hemoglobin concentration is less than 10.5 g/dL (hematocrit 32%)in the second trimester
- 20. Hematologic Disorders and Pregnancy • Iron-Deficiency Anemia – anemia of pregnancy, complicating as many as 15% to 25% of all pregnancies – Ineffective oxygen transport – fatigue and poor exercise tolerance – Associated with LBW and preterm birth – Some women develop pica (ice chips/starch) – iron supplement of 60 mg elemental iron as prophylactic therapy during pregnancy/ therapeutic– 120 to 200 mg elemental iron/day) – Intake of iron-rich foods – Severe IDA – iron injections – SE (iron supp) – constipation and gastric irritation/ black stools • Increase roughage/ take pills with food
- 21. Hematologic Disorders and Pregnancy • Folic Acid-Deficiency Anemia – Folic acid – normal RBC formation in mothers and prevents NTDs in fetus • occurs most often in multiple pregnancies because of the increased fetal demand • in women with a secondary hemolytic illness in which there is rapid destruction and production of new red blood cells • in women who are taking hydantoin, an anticonvulsant agent that interferes with folate absorption • in women who have been taking oral contraceptives; and in women who have had a gastric bypass for morbid obesity – Megaloblastic Anemia – may be a contributory factor in early miscarriage or premature separation of the placenta. – Tx – folic Acid supplement of 400 microgram daily to 600 microgram (pregnancy)
- 22. Hematologic Disorders and Pregnancy • Sickle Cell Anemia – a recessively inherited hemolytic anemia caused by an abnormal amino acid in the beta chain of hemoglobin [sickle hemoglobin (HbS) if valine is replaced and nonsickling hemoglobin (HbC) if lysine is replaced] – majority of red blood cells are irregular or sickle shaped so they cannot carry as much hemoglobin as can normally shaped red blood cells – Approximately 1 in every 10 African Americans has the sickle cell trait (i.e., carries a recessive gene for S hemoglobin but is asymptomatic)
- 23. Sickle Cell Anemia • Women with the homozygous disease is at risk for miscarriage, prematurity or perinatal mortality rates • Women with SCA are more prone to bacteriuria – periodic U/A • May cause low birth weight and possibly fetal death • Tx – Exchange transfusion, Folic Acid, adequate hydration • Avoid standing for long periods • Elevate legs to facilitate venous return
- 24. • Thalassemia – thalassemias are a group of autosomal recessively inherited blood disorders that lead to poor hemoglobin formation and severe anemia – Treatment: folic acid supplementation and blood transfusion to infuse hemoglobin rich red blood cells
- 25. • Malaria – a protozoan infection that is transmitted to people by Anopheles mosquitoes – infection causes red blood cells to stick to the surfaceof capillaries causing obstruction of these vessels – This can result in end organ anoxia when blood can not reach organs effectively – Tx: Chloroquine
- 26. • Coagulation Disorders – Most coagulation disorders are sex linked or occur only in males and so have little effect on pregnancies. – Von Willebrand disease – autosomal dominant d/o which also occurs in females (factor VIII deficiency) • May cause spontaneous miscarriage or postpartum hemorrhage • Prolonged bleeding time • Cryoprecipitate or fresh-frozen plasma before labor to prevent excessive bleeding
- 27. • Hemophilia B (Christmas Disease) – Sex-linked disorder and occurs only in males – Factor IX deficiency – Carrier women may have reduced factor IX level making them prone to bleeding – May cause spontaneous miscarriage or hemorrhage during labor – Tx – infusion of factor IX concentrate or fresh- frozen plasma – PUBS can be done to detect hemophilia in male fetus • Check for the presence of coagulation disorder in fetus and if present, this procedure will be contraindicated as it may result in extensive fetal blood loss
- 28. • Idiopathic Thrombocytopenic Purpura (ITP) – assumed to be an autoimmune disease where the body releases antibodies to platelets causing decreased platelet count – minute petechiae or large ecchymoses appear on a woman’s body – Frequent nosebleeds may occur – Laboratory studies reveal a marked – thrombocytopenia (platelet count may be as low as 20,000/mm3 from a usual count of 150,000 mm3) – Tx: Platelet transfusion or plasmapheresis to increase platelet count; oral prednisone – May cause bleeding at birth – Antiplatelet may cross placenta
- 29. RENAL AND URINARY DISORDERS AND PREGNANCY • Urinary Tract Infection – As many as 4% to 10% of non pregnant women have asymptomatic bacteriuria – In a pregnant woman, because the ureters dilate from the effect of progesterone, stasis of urine occurs – minimal glucosuria that occurs with pregnancy allows more than the usual number of organisms to grow
- 30. • Asymptomatic infection may progress to pyelonephritis and is associated with preterm labor and premature rupture of membranes • Women with vesicouereteral reflux tend to develop UTI or pyelonephritis more often • E. coli – MC cause of ascending infections • Strep B – may cause descending infection and is associated with pneumonia in NB.
- 31. • Assessment (UTI) – Pain on urination – Pain on lumbar region (right) – nausea and vomiting, malaise, pain, and frequency of urination – Fever – Tx: antibitiotics such as amoxicillin, ampicillin and caphalosphorins are safe during pregnancy
- 32. • Chronic Renal Disease – Women with chronic renal disease may develop severe anemia during pregnancy because their diseased kidneys do not produce erythropoietin, which is necessary for red cell formation – Tx: synthetic erythropoeitin – Dialysis may cause preterm labor
- 33. For women with kidney transplant, criteria to be evaluated include: • A woman’s general health and the time since the trans-plant (preferably +2 years) • Serum creatinine level • The presence of proteinuria or hypertension or signs of graft rejection • Medications taken to reduce graft rejection
- 34. RESPIRATORY DISORDERS AND PREGNANCY • Any respiratory condition can worsen in pregnancy because the rising uterus compresses the diaphragm, reducing the size of the thoracic cavity and available lung space. • Common cold • Severe pneumonia • TB • COPD
- 35. • A Woman With Acute Nasopharyngitis – Common cold – estrogen stimulation normally causes some degree of nasal congestion
- 36. • A Woman With Influenza – Caused by virus (A, B, C) – S/S: high fever, extreme prostration, aching pains in the back and extremities, and generally a sore, raw throat – Associated with preterm labor – not been clearly correlated with congenital anomalies in children – Tx: antibiotics, antipyretics, influenza vaccine
- 37. • A Woman With Pneumonia – bacterial or viral invasion of lung tissue by pathogens such as S. pneumoniae, Haemophilus influenzae, and Mycoplasma pneumoniae – Inflammatory response confines the bacteria or virus within segments of the lobes of the lungs but also fills alveoli with fluid, blocking off breathing space – Tx: antibiotic and oxygen therapy – May cause preterm labor in late pregnancy due to decreased oxygen supply
- 38. • A Woman With Severe Acute Respiratory Syndrome – a newly emerged infectious disease with the clinical symptoms of persistent fever, chills, muscle aches, malaise, dry cough, headache, and dyspnea; decreased lymphocyte and platelet counts. – Caused by corona virus which originated from China – associated with high incidences of spontaneous miscarriage, preterm birth, and intrauterine growth restriction. – no evidence of perinatal SARS infection among infants born to these mothers.
- 39. • A Woman With Asthma – reversible airflow obstruction, airway hyperreactivity, and airway inflammation – complicates about 5% to 9% of pregnancies and is potentially associated with an increased risk of perinatal complications – reduced oxygen supply to a fetus leads to preterm birth or fetal growth restriction if a major attack should occur during pregnancy
- 40. • A Woman With Tuberculosis – caused by Mycobacterium tuberculosis,an acid-fast bacillus – Symptoms of tuberculosis include: • Chronic cough • Weight loss • Hemoptysis (coughing blood) • Night sweats • Low-grade fever • Chronic fatigue – PPD to be done in high risk areas – Tx: Isoniazid (INH) and ethambutol hy- drochloride (Myambutol),
- 41. • A Woman with Chronic Obstructive Pulmonary Disease – constriction of the airway associated most often with long-term cigarette smoking – If a woman have severe symptoms, pregnancy is not advised
- 42. • A Woman With Cystic Fibrosis – a recessively inherited disease in which there is generalized dysfunction of the exocrine glands, this dysfunction leads to mucous secretions, particularly in the pancreas and lungs, becoming so viscid or thick that normal lung and pancreatic function is compromised – men with cystic fibrosis are sterile because their semen is so thick that sperm cannot be motile – Women may have lessened fertility due to thickened cervical mucus – inability to digest fat and protein because the pancreas cannot release amylase. – Increased risk of preterm labor and perinatal death – Tx: pancrelipase to supply pancreatic enzyme,, bronchodilator, chest physiotherapyu
- 43. • Because pancrelipase may interfere with iron absorption, a woman is at greater risk for iron-deficiency anemia during pregnancy than other women • Persons with cystic fibrosis have a higher- than-usual incidence of developing diabetes mellitus because of pancreas involvement
- 44. RHEUMATIC DISORDERS AND PREGNANCY • A Woman With Rheumatoid Arthritis – Juvenile rheumatoid arthritis (chronic rheumatoid arthritis), a disease of connective tissue with joint inflammation and contracture, is most likely the result of an autoimmune response – pathology involves synovial membrane destruction, inflammation with effusion, swelling, erythema, and painful motion of the joints – granulation tissue can fill the joint space,
- 45. • Tx: corticosteroids, NSAIDs, aspirin • *use of salicylates (prolonged) may cause bleeding at birth and prolonged pregnancy – Salicylates interfere with prostaglandin synthesis – infant may be born with a bleeding defect and may also experience premature closure of the ductus arteriosus because of the drug’s effects. • Symptoms of the disease may improve during pregnancy because of the naturally increased circulating level of corticosteroids in the maternal bloodstream during pregnancy
- 46. • A Woman With Systemic Lupus Erythematosus – a multisystem chronic disease of connective tissue that can occur in women of child-bearing age: its highest incidence is in women aged 20 to 40 years – heart, kidneys, blood vessels, spleen, skin, and retroperitoneal tissue are affected – erythematous butterfly-shaped rash on the face – In the kidneys, fibrin deposits develop, plugging and blocking the glomeruli and leading to necrosis and scarring. – thickening of collagen tissue in the blood vessels causes vessel obstruction – Tx: corticosteroid, NSAIDs, heparin, and salicylates
- 47. GASTROINTESTINAL DISORDERS AND PREGNANCY • A Woman With Appendicitis – typical sharp, peristaltic, lower right quadrant pain (McBurney’s point), nausea and vomiting – Advise a woman not to take food, liquid, or laxatives while she is waiting to be evaluated for possible appendicitis, because increasing peristalsis could cause an inflamed appendix to rupture
- 49. • Surgery may be done if past 36 weeks and UTZ reveals a mature fetus • Ruptured appendicitis may cause fecal material reach fetus thru fallopian tube; generalized peritonitis may be difficult for a woman to combat and even maintain pregnancy; peritoneal adhesions may cause subferility due to changes in the location of FT.
- 50. • A Woman With Gastroesophageal Reflux Disease or Hiatal Hernia – GERD refers to the reflux of acid stomach secretions into the esophagus – Hiatal hernia is a condition in which a portion of the stomach extends and protrudes up through the diaphragm into the chest cavity, trapping stomach acid and causing it to reflux into the esophagus
- 51. • Symptoms include: – Heartburn, which is particularly extreme when lying supine after a full meal – Gastric regurgitation – Dysphagia (difficulty swallowing) – Possible weight loss because of the inability to eat – Hematemesis (vomiting of blood) if extreme esophageal irritation occurs from the reflux of hydrochloric acid from the stomach • Tx: Antacids, PPI, Histamine receptos antagonist
- 52. • A Woman With Cholecystitis and Cholelithiasis – most frequently associated with women older than 40 years, obesity, multiparity, and ingestion of a high-fat diet – S/S :constant aching and pressure in the right epigastrium, perhaps accompanied by jaundice – Tx: low-fad diet, surgery if nonsurgical management fails
- 53. • A Woman With Pancreatitis – inflammation of the pancreas – diagnosis may be difficult as serum amylase, which rises with pancreatitis, is also normally elevated during pregnancy. – nasogastric suction, bowel rest, analgesia (pancreatic pain is sharp), and intravenous hydration through parenteral nutritional supplementation. – acidosis, hypovolemia, and fetal hypoxia
- 54. • A Woman With Hepatitis – Hepatitis is a liver disease that may occur from invasion of the A, B, C, D, or E virus. – Hepatitis A is spread mainly by fecal–oral contact • benign course and is not known to be transmitted to the fetus. – Hepatitis B and C are spread by exposure to contaminated blood or blood products. – Hepatitis D and E are apparently spread by the same methods as hepatitis B but are rarely seen in pregnant women. – may lead to spontaneous miscarriage or preterm labor.
- 55. • A Woman With Inflammatory Bowel Disease – Crohn’s disease (inflammation of the terminal ileus) and ulcerative colitis (inflammation of the distal colon) can also be seen in pregnancy – associated with passiveand active smoking – A woman experiences chronic diarrhea, weight loss, occult blood in stool, and nausea and vomiting – with Crohn’s disease, malabsorption, particularly of vitamin B occurs – Monitor for weight gain – TPN, sulfasalazine
- 56. NEUROLOGIC DISORDERS AND PREGNANCY • A Woman With a Seizure Disorder – anoxia may deprive fetus of oxygen – The risk of adverse maternal or fetal outcome from seizures during pregnancyis greater than the risk of teratogenicity from taking anticonvulsant drugs – Drugs used: Trimethadione, Valproic acid, Carbamazepine, Ethosuximide, Phenytoin sodium • Dilantin can cause a syndrome involving fetal cognitive impairment and a peculiar facial proportion not unlike that of fetal alcohol syndrome. This may occur because of competition for folic acid binding sites. Some infants have an increased danger of neural tube disorders as a result of this folic acid displacement. An ultrasound can rule out the possibility of this.
- 57. • Infants are also prone to hemorrhagic disease of the newborn because of decreased levels of vitamin K coagulation factors at birth from phenytoin. To counteract this, women maybe prescribed vitamin K during labor or the last 4 weeks of gestation. Women who have been taking phenytoin (Dilantin)may have developed chronic hypertension.
- 58. • A Woman With Myasthenia Gravis – an autoimmune disorder characterized by the presence of an IgG antibody against acetylcholine receptors in striated muscle. – treated with anticholinesterase drugs such as pyridostigmine (Mestinon) or neostigmine(Prostigmin) and a corticosteroid prednisone; Plasmapheresis – Smooth muscles are not affected – NO MgSO4
- 59. • A Woman With Multiple Sclerosis – occurs predominantly in women of childbearing age, usually between 20 and 40 years of age – nerve fibers become demyelinated and therefore lose function – Women develop symptoms of fatigue, numbness, blurred vision, and loss of coordination – Tx: ACTH or corticosteroid to strengthen nerve function – May improve during pregnancy
- 60. MUSCULOSKELETAL DISORDERS AND PREGNANCY • A Woman With Scoliosis – lateral curvature of the spine – Deformity interferes with respiration and heart action because of chest compression – Pelvic distortion can interfere with childbirth, especially at the pelvic inlet – If a woman’s spine is extremely curved, spinal or epidural anesthesia may be difficult to administer for pain management in labor – cephalopelvic disproportion – Tx: stainless steel rods and correction brace
- 61. ENDOCRINE DISORDERS AND PREGNANCY • A Woman With a Thyroid Dysfunction – thyroid slightly increase in size during pregnancy • Hypothyroidism • a rare condition in young adults and especially in pregnancy • May lead to early spontaneous miscarriage • may be associated with an increased incidence of extreme nausea and vomiting • Tx: levothyroxine – her dose of levothyroxine will need to be increased as much as 20% to 30% for the du-ration of the pregnancy to simulate the increase that would normally occur in pregnancy
- 62. • separate thyroxine ingestion from any medication containing iron, calcium, or soy products by about 4 hours to be sure that there is no problem with the absorption of thyroxine • Dose should be tapered back after pregnancy
- 63. • A Woman With Hyperthyroidism (Grave’s Disease) – overproduction of thyroid hormone – more prone to symptoms of hypertension of pregnancy, fetal growth restriction, and preterm labor than the average woman – Radioactive Iodine uptake (RAIU) to test thyroid function, should not be done during pregnancy as it may destroy fetal thyroid – Tx: PTU to reduce thyroid activity, methimazole during pregnancy – infant may be born with symptoms of hyperthyroidism
- 65. • Woman with minimal dose may breastfeed their infant, but not with woman taking large dose as it may be passed into the breastmilk.
- 66. • A Woman With Diabetes Mellitus – an endocrine disorder in which the pancreas cannot produce adequate insulin to regulate body glucose levels – leading cause of kidney failure, non-traumatic lower- limb amputations, and new cases of blindness among adults in the United States – affects 3% to 5% of all pregnancies and is the most frequently seen medical condition in pregnancy – Before insulin was produced synthetically in 1921, women with type 1 diabetes, or diabetes acquired in childhood, died before reaching childbearing age, were infertile, or had spontaneous miscarriages early in pregnancy
- 67. • Now that diabetes can be well managed and type 2 diabetes is occurring more frequently in young adults, four new problems have developed: • How to care for women with both type 1 and type 2 diabetes during pregnancy • How to bring a woman with type 1, type 2, and gestational diabetes through a pregnancy with good glucose and insulin control • How to protect an infant in utero from the adverse effects of the increased glucose levels • How to care for the infant in the first 24 hours after birth until the infant’s insulin-glucose regulatory mechanism stabilizes
- 68. • Infants of diabetic women are five times more apt to be born with heart anomalies • Type 1 diabetes is due to pancreatic islet B cell destruction predominantly by an autoimmune process, and these persons are prone to ketoacidosis • Type 2 diabetes is the more prevalent form and results from insulin resistance with a defect in compensatory insulin secretion – As the need for insulin rises, the pancreas gradually loses its ability to produce it.
- 69. – DM II – hyperglycemia and resulting from the combination of resistance to insulin action, inadequate insulin secretion, and excessive or inappropriate glucagon secretion – All women appear to develop an insulin resistance as pregnancy progresses or insulin does not seem as effective during pregnancy, a phenomenon that is probably caused by the presence of the hormone human placental lactogen (chorionic somatomammotropin)and high levels of cortisol, estrogen, progesterone, and catecholamines – 3 P’s of DM • Polyuria • Polyphagia • Polydipsia
- 70. • continued use of glucose by the fetus may lead to hypoglycemia for the mother between meals • An increase in the amount of amniotic fluid occurs in at least 25% of diabetic women • a woman is at greater risk for pregnancy- induced hypertension and infection • Infants of women with poorly controlled diabetes tend to be large(>10 lb) because the increased insulin the fetus must produce to counteract the overload of glucose he or she receives acts as a growth stimulant
- 71. Gestational Diabetes occurs at 20th week of pregnancy.
- 72. • A macrosomic infant may create birth problems like cephalopelvic disproportion and shoulder dystocia, thus, CS birth • There is a high incidence of congenital anomaly, especially caudal regression syndrome (failure of the lower extremities to develop), spontaneous miscarriage, and stillbirth in infants of women with uncontrolled diabetes • At birth, the neonates are more prone to hypoglycemia, respiratory distress syndrome,hypocalcemia, and hyperbilirubinemia.
- 73. • Monitoring DM patients – glycosylated hemoglobin is used to detect the degree of hyperglycemia present • The upper normal level of HbA is 6% of total hemoglobin – Fasting plasma glucose 126 mg/dL or nonfasting of 200 mg/dL – Diabetes – Opthalmic examination to be done every trimester as DM causes retinal changes – Tx: insulin, blood glucose monitoring (A fasting blood glucose level below 95 to 100 mg/dL and a 2-hour postprandial level below 120 mg/dL are well-adjusted values)
- 74. • Hypoglycemia – intake of complex carbs and less concentrated fluid to prevent rebound hyperglycemia • Acidosis should be prevented as maternal acidosis may lead to fetal anoxia • The most common time during pregnancy for hypoglycemia is the second and third months, before insulin resistance peaks; for hyperglycemia, it is the 6th month, or the time insulin resistance is becoming most pronounced.
- 76. • Tests for Placental Function and Fetal Well- Being – MSAFP – UTZ – Creatinine clearance • A normal creatinine clearance rate suggests that a woman’s vascular system is intact because kidney function is normal, this implies that uterine perfusion is also adequate – Nonstress test – Daily movements of fetus (atleast 10 movements per hour) – Oligohydramnios may indicate fetal growth restriction or fetal renal abnormality, whereas hydramnios may indicate gastrointestinal malformation or poorly controlled disease
- 77. • L-S Ratio for fetal maturity (>2.0 to 2.5) • CS birth for macrosomic babies/ shoulder dystocia – CS poses increased risk for RDS in newborns due to immature lung surfactant • Termination of pregnancy before was done to prevent fetal loss from placental insufficiency
- 78. MENTAL ILLNESS AND PREGNANCY • Schizophrenia tends to have its highest incidence in adolescents and young adults and so occurs in young pregnant women • Depression occurs almost four times more commonly in women than in men, and often in young adults. – It is the most common mental illness seen in pregnant women. • lithium, a mainstay of therapy for mood disorders such as bipolar disorder (manic depression),and serotonin-reuptake inhibitors used to counteract depression, are potentially teratogenic
- 79. CANCER AND PREGNANCY • Cancer occurs in about 1 in 1000 pregnancies • most commonly seen with pregnancy are: – Cervical – Breast – Ovarian – Thyroid – Leukemia Melanoma – Lymphomas
- 80. • If a woman is in the first trimester of pregnancy when a malignancy is diagnosed, she and her partner are asked to make a difficult decision: to delay treatment to avoid teratogenic risks to a fetus from treatment (possibly increasing a woman’s risk); to end the pregnancy to allow chemotherapy or radiation treatment to be initiated; or to choose chemotherapy or radiation treatment with the knowledge that they may cause birth anomalies in the fetus
- 81. • As a rule, women can receive chemotherapy in the second and third trimesters without adverse fetal effects • Radiation therapy, in contrast, puts the fetus at risk throughout pregnancy ift he fetus is directly exposed • Melanoma is the only type of cancer that seems capable of spreading to the fetus • Placenta serves as a barrier to other types of cancer and fetus has the ability to resist invading foreign cells