MEDICAL CONDITIONS

COMPLICATING

PREGNANCY

DIABETES

MELLITUS

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DEFINITION OF TERMS

OVERT DIABETES

- those known to have diabetes mellitus

before pregnancy

GESTATIONAL DIABETES

- those diagnosed during pregnancy

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CLASSIFICATION DURING PREGNANCY

CLASS ONSET FBS 2-HR PP GL THERAPY

A1 Gestational <105 mg/dl <120 mg/dl Diet

A2 Gestational >105 mg/dl >120 mg/dl Insulin

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CLASSIFICATION DURING PREGNANCY

CLASS AGE/ONSET DURATION VASCULAR THERAPY

(Years) DISEASE

B Over 20 < 10 None Insulin

C 10 – 19 10 – 19 None Insulin

D Before 10 > 20 Benign Insulin

Retinopathy

F Any Any Nephropathy Insulin

R Any Any Proliferative Insulin

Retinopathy

H Any Any Heart Insulin

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GESTATIONAL DIABETES

carbohydrate intolerance of variable severity with onset or first recognition during pregnancy

disorder of late gestationdisorder induced by pregnancy:

from exagerrated physiological changes

in glucose metabolism

Type 2 DM unmasked during pregnancy

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A 23 yr old markedly obese primigravida at 12 weeks gestation seeks consultation for her first prenatal check-up. She denies any family history of diabetes mellitus. As part of prenatal work-up, you would:

A. take a 50 gm glucose challenge test as soon as possible

B. order for 50 gm glucose challenge test at 24-28 weeks

C. take a 100 gm oral glucose tolerance test as soon as possible

D. order for a 100 gm oral glucose tolerance test at 24-28 weeks

WHO

to screen ?

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GDM - SCREENING

RISK FACTORSAge over 30Family Hx of DMPrior macrosomic, malformed or

stillborn infantObesityHypertensionGlucosuria

WHEN

to screen ?

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RECOMMENDED SCREENING STRATEGY BASED ON RISK ASSESSMENT FOR DETECTING GDM

LOW RISK

Blood glucose testing not routinely required if all of the ff characteristics are present:

Member of ethnic grp w/ low prevalence of GDMNo known DM in 1st degree relativeAge less than 25 yrsWeight normal before pregnancyNo Hx of abnormal glucose metabolismNo Hx of poor obstetrical outcome

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RECOMMENDED SCREENING STRATEGY BASED ON RISK ASSESSMENT FOR DETECTING GDM

AVERAGE RISK

Perform blood glucose testing at 24-28 wks:

Hispanic AfricanNative American South or East Asian origin

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RECOMMENDED SCREENING STRATEGY BASED ON RISK ASSESSMENT FOR DETECTING GDM

HIGH RISK

Perform blood glucose testing as soon as feasible. If normal, repeat at 24-28 wks or at any time pt has SSx suggestive of hyperglycemia:

Marked obesityStrong family Hx of type 2 DMPrior gestational diabetesGlucosuria

HOW

to screen ?

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GDM - SCREENING

50-g GLUCOSE CHALLENGE TEST

> 140 mg/dl or > 130 mg/dl

– proceed to 100 gm 3 Hr Oral Glucose Tolerance Test

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GDM - SCREENING

100-gm ORAL GLUCOSE TOLERANCE TEST (OGTT)

TIME NDDG CARPENTER & COUSTAN (1979) (1989)Fasting 105 951 hour 190 1802 hours 165 1553 hours 145 140

GDM is dxed with 2 or > abn values.

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A 23 yr old markedly obese primigravida at 12 weeks gestation seeks consultation for her first prenatal check-up. She denies any family history of diabetes mellitus. As part of prenatal work-up, you would:

A. take a 50 gm glucose challenge test as soon as possible

B. order for 50 gm glucose challenge test at 24-28 weeks

C. take a 100 gm oral glucose tolerance test as soon as possible

D. order for a 100 gm oral glucose tolerance test at 24-28 weeks

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GDM - ADVERSE EFFECTS

MACROSOMIAExcessive fat deposition on shoulders/trunkPredisposes to shoulder dystociaMaternal hyperglycemia transfer of excess

glucose to fetus stimulate fetal insulin secretion which is a potent growth factor

HYPOGLYCEMIA at birth

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MACROSOMIAPathogenesis

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Fetal effects of persistent maternal fasting hyperglycemia include:

A. macrosomia

B. postterm pregnancy

C. oligohydramnios

D. hypoglycemia

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GDM - MANAGEMENT

Type A1 – diet alone Type A2 – diet + insulin

DIET

Goals: 1. to provide the necessary nutrients for

mother and fetus

2. to control glucose levels

3. to prevent starvation ketosis

EXERCISE

upper body cardiovascular training

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Recommended postpartum follow-up for patients with gestational diabetes consists of:

A. daily blood sugar monitoring

B. fasting blood sugar on day of discharge

C. 50 gm glucose challenge test 1 week postpartum

D. 75 gm oral glucose tolerance test 6 weeks postpartum

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GDM - PROGNOSIS

50% risk of developing overt DM w/in 20 yrs Evaluate with 75-gm OGTT – 6-12 wks pp

TIME NO DIABETES IMPAIRED DIABETES GL. TOL.Fasting < 115 < 140 >/= 140½, 1, 1-½ All < 200 1 value >/= 200 1 value

>/=2002 hr < 140 140 – 199 >/= 200

If 75-g OGTT is normal – take FBS yearly

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Recommended postpartum follow-up for patients with gestational diabetes consists of:

A. daily blood sugar monitoring

B. fasting blood sugar on day of discharge

C. 50 gm glucose challenge test 1 week postpartum

D. 75 gm oral glucose tolerance test 6 weeks postpartum

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OVERT DIABETES

Pregestational diabetesKnown diabetics before

pregnancy

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The diagnosis of overt diabetes is most probable in the gravida with which of the ff OGTT results (Fasting-1hr-2hr-3hr post glucose load – mg/dl):

A. 100 – 190 – 170 – 130

B. 90 – 195 – 140 – 120

C. 95 - 180 - 155 - 140

D. 130 - 170 - 160 - 135

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OVERT DIABETESDIAGNOSIS DURING PREGNANCY

RBS >200 mg/dl + Sx: polyuria, polydipsia, wt loss

Fasting glucose > 125 mg/dlStrong likelihood in pts with: strong family Hx of DM

previous large infants persistent glucosuria unexplained fetal losses

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The diagnosis of overt diabetes is most probable in the gravida with which of the ff OGTT results (Fasting-1hr-2hr-3hr post glucose load – mg/dl):

A. 100 – 190 – 170 – 130

B. 90 – 195 – 140 – 120

C. 95 - 180 - 155 - 140

D. 130 - 170 - 160 - 135

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OVERT DIABETES

EFFECTS ON FETUSABORTION – poor glycemic control

HbA1c > 12%

persistent pre-prandial glucose level > 120 mg/dl

MALFORMATIONS

Type 1 – 5-10% incidence

from poorly controlled DM preconceptionally and in early pregnancy

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OVERT DIABETES

EFFECTS ON FETUSUNEXPLAINED FETAL DEATH

HYDRAMNIOS from fetal polyuria

RESPIRATORY DISTRESS from prematurity

HYPOGLYCEMIA from hyperplasia of fetal B-islet cells

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OVERT DIABETESEFFECTS ON FETUSHYPOCALCEMIA

HYPOBILIRUBINEMIA prematurity polycythemia with hemolysis

CARDIAC HYPERTROPHY

INHERITANCE OF DM Diabetic Mother – 1-3% risk Diabetic Father – 6% Diabetic Father and Mother – 20 % risk

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OVERT DIABETESEFFECTS ON MOTHERDIABETIC NEPHROPATHY inc. when HbA1c > 10% microalbuminuria overt proteinuria HPN end-stage renal dse

DIABETIC RETINOPATHY after 7 yrs – 50% chance of dev. after 20 yrs – 90%

DIABETIC NEUROPATHY

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OVERT DIABETESEFFECTS ON MOTHERPREECLAMPSIA not related to glucose control

KETOACIDOSIS result of: hyperemesis gravidarum use of B sympathomimetic drugs (tocolytics) infections use of corticosteroids

INFECTIONS – 80%

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OVERT DIABETESMANAGEMENT

PRECONCEPTIONHbA1c – expresses an ave. of circulating

glucose for the past 4-6 wks

- assess metabolic control

- > 10% - inc. risk for malformations

Folate – 400 ug/day

- to decrease neural tube defects

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OVERT DIABETESMANAGEMENTPREGNANCYBlood glucose monitoring

Precise fetal age determination LMP, FH, FHT, U/S Well established EDC – to assess accurately macrosomia, hydramnios, FGR

Diet

Insulin

PULMONARY

DISORDERS

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NORMAL CHANGES IN PREGNANCY

PULMONARY

TUBERCULOSIS

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TUBERCULOSIS

Organism: Mycobacterium tuberculosis

DIAGNOSISSymptoms: cough w/ minimal sputum

low-grade fever

hemoptysis

weight loss

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TUBERCULOSIS

DIAGNOSISLab: Chest Xray

cavitations

mediastinal lymphadenopathy extent of dse may be masked by lung

compression

Sputum exam – acid-fast bacilli

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Recommended initial treatment of active tuberculosis during pregnancy is:

A. INH, Ethambutol, Rifampin

B. INH, Ethambutol, Pyrazinamide, Rifampin

C. INH, Rifampin, Streptomycin

D. INH only

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TUBERCULOSIS

MANAGEMENT Isoniazid + Rifampicin + Ethambutol for a minimum

of 9 months (WHO: + Purazinamide x 6 months)

EFFECT ON PREGNANCY Preterm delivery Low birthweight Perinatal death Neonatal tuberculosis – rare, fatal

Route: hematogenous

aspiration of inf secretion at del unlikely if Rxed

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Recommended initial treatment of active tuberculosis during pregnancy is:

A. INH, Ethambutol, Rifampin

B. INH, Ethambutol, Pyrazinamide, Rifampin

C. INH, Rifampin, Streptomycin

D. INH only

URINARY TRACT

DISORDERS

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Which of the ff laboratory values is not normal during pregnancy and suggests an underlying renal disease:

A. Urinalysis: glucose +

B. mild right hydronephrosis on ultrasound

C. serum creatinine – 1.2 mg/dl

D. Urinalysis: protein - trace

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NORMAL CHANGES IN PREGNANCY

Increased renal sizeDilatation of pelves, calyces and ureters - not to be mistaken for obstructive

uropathy - predispose to serious upper urinary

tract infections Increased GFR and RPF - Serum creatinine and urea nitrogen

decrease

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DIAGNOSTIC TESTS

Urinalysis glucosuria orthostatic proteinuriaSerum creatinine > 0.9 mg/dl – suspect intrinsic renal dseUltrasonography Intravenous pyelography if indicated, one-shot pyelogramCystoscopyRenal Biopsy (?)

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Which of the ff laboratory values is not normal during pregnancy and suggests an underlying renal disease:

A. Urinalysis: glucose +

B. mild right hydronephrosis on ultrasound

C. serum creatinine – 1.2 mg/dl

D. Urinalysis: protein - trace

URINARY TRACT

INFECTION

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Acute Uncomplicated Cystitis is most likely in this case:

A. A 26-year-old G1P0 with fever, dysuria and flank pains

B. A 35-year-old G3P2 with hematuria and colicky right flank pain C. An 18-year-old G3P0020 with dysuria, urinary frequency & yellow- green vaginal discharge D. A 28-year-old G2P1 with dysuria and urinary urgency

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URINARY TRACT INFECTIONSASYMPTOMATIC BACTERIURIA

DIAGNOSISClean-voided specimen containing

>100,000 org/ml

MANAGEMENTNitrofurantoin (or Ampicillin, Amoxycillin,

Cephalosporin)If untreated, 25% develop acute Sxtic

infection.

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URINARY TRACT INFECTIONCYSTITIS AND URETHRITIS

DIAGNOSISSymptoms: dysuria urgency urinary frequencyLab: UA – pyuria, bacteriuria, hematuriaMANAGEMENTAmpicillin (or Sulfonamides,Nitrofurantoin,

Cephalosporin)

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URINARY TRACT INFECTION

ACUTE PYELONEPHRITISLeading cause of septic shock

during pregnancy (endotoxemia)More common after mid-pregnancyUslly right-sidedUslly an ascending infection from

lower UTI

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URINARY TRACT INFECTION

ACUTE PYELONEPHRITISDIAGNOSISSymptoms: fever shaking chills aching pain – lumbar areasP.E.: costovertebral angle tendernessLab: UA – leukocytes in clumps Urine culture – E. coli 77% Klebsiella pneumoniae

11% Enterobacter / Proteus 4%

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URINARY TRACT INFECTION

ACUTE PYELONEPHRITISMANAGEMENTHospitalizationUrine and blood culturesCBC, Serum creatinine, and electrolytes Rpt in 48 hrsChest Xray – if w/ dypnea or tachypneaMonitor V/S, urine output (FBC) IV crystalloid to establish UO to 30 ml/hr or >

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URINARY TRACT INFECTION

ACUTE PYELONEPHRITISMANAGEMENTAntimicrobial therapy Ampicillin + Gentamycin or Cephalosporins Intravenous Change to po when afebrile – 7-10 daysUrine culture 1-2 wks after completion of Rx 30-40% - recurrent infection

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Acute Uncomplicated Cystitis is most likely in this case:

A. A 26-year-old G1P0 with fever,

dysuria and flank pains

B. A 35-year-old G3P2 with hematuria and colicky right flank pain C. An 18-year-old G3P0020 with dysuria, urinary frequency & yellow- green vaginal discharge D. A 28-year-old G2P1 with dysuria and urinary urgency

THYROID

DISORDERS

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NORMAL CHANGES IN PREGNANCY

Moderate thyroid enlargement

- glandular hpl and vascularityInc. uptake of radioiodine by

maternal thyroidInc. total serum thyroxine and

triiodothyronineInc. thyroid binding globulin

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HYPERTHYROIDISM

DIAGNOSIS: Tachycardia Thyromegaly Failure to gain weight despite

normal or increased food intake Marked elevation of plasma

thyroxine Elevated sleeping pulse rate exophthalmos

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GRAVE’S DISEASE

Most common cause of thyrotoxicosis in pregnancy

Autoimmune process associated with thyroid stimulating antibodies

Autoantibodies mimic thyrotropin and stimulate thyroid function

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A 37 yr old G2P1 12 weeks gestation presents for her first prenatal check-up. She had been diagnosed with Grave’s disease and maintained on propylthiouracil. Currently, she is euthyroid. Which of the ff statements is appropriate in counseling this patient:

A. She must discontinue PTU because it is associated with leukopenia.

B. Infants born to mothers on PTU may develop goiter and be clinically hypothyroid.

C. PTU does not cross the placenta.D. Thyroid storm is a common complication

in pregnant women with Graves disease.

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GRAVE’S DISEASE

MANAGEMENT Medical Propylthyouracil / Methimazole readily cross placenta & induce fetal hypothyroidism & goiter dose depends on total serum thyroxine level which should be in upper N range for preg

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A 37 yr old G2P1 12 weeks gestation presents for her first prenatal check-up. She had been diagnosed with Grave’s disease and maintained on propylthiouracil. Currently, she is euthyroid. Which of the ff statements is appropriate in counseling this patient:

A. She must discontinue PTU because it is associated with leukopenia.

B. Infants born to mothers on PTU may develop goiter and be clinically hypothyroid.

C. PTU does not cross the placenta.D. Thyroid storm is a common complication in

pregnant women with Graves disease.

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GRAVE’S DISEASE

MANAGEMENT Surgical – Subtotal Thyroidectomy after thyrotoxicosis is under control or pt

nearly euthyroid done in 2nd tri or early 3rd tri elective Indications: 1. women who cannot adhere to medical Rx 2. women in whom drug therapy is toxic

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GRAVE’S DISEASE

EFFECT ON PREGNANCY Higher incidence of preeclampsia heart failure

EFFECT ON NEONATE Neonatal thyrotoxicosis fr transplacental passage of

maternal thyroid stimulating ab

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HYPOTHYROIDISM

DIAGNOSIS Absence of normal rise in serum

thyroxine Increased thyrotropin level

Uncommon in pregnancy because associated with infertility

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HYPOTHYROIDISM

EFFECT ON PREGNANCY

Inc. incidence of abortion, SB, LBW

preeclampsia

placental abruption

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HYPOTHYROIDISM

EFFECT ON NEONATE Usually healthy Simple Colloid goiter w/o

hypothyroidism – no effect Severe hypothyroidism sec. to

maternal radioiodine Rx during pregn destruction of fetal thyroid cretinism

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HYPOTHYROIDISM

MANAGEMENT

Thyroid hormones

dose adjusted so that serum thyrotropin level is w/in N range

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Thyroid function tests showing an elevated serum thyrotropin, normal serum thyroxine and normal triiodothyronine in an asymptomatic woman at 14 weeks gestation is diagnostic of:

A. HypothyroidismB. HyperthyroidismC. Subclinical hypothyroidismD. Subclinical hyperthyroidism

PUERPERAL

INFECTION

73

10 days post cesarean section, a 23 yr old primipara complains of fever of 3 days duration associated with hypogastric pain. Temp – 40 C. Breasts are slightly tender. Pelvic exam shows tenderness over the area of the uterus and parametria. The most likely consideration is:

A. Breast engorgement B. Acute pyelonephritis C. Metritis with pelvic cellulitis D. Septic pelvic thrombophlebitis

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PUERPERAL MORBIDITY

temperature 38 C or higher, the temperature to occur on any 2 of the 1st 10 days postpartum, exclusive of the first 24 hrs, and to be taken by mouth by a standard technique at least 4x daily

JOINT COMMITTEE ON MATERNAL WELFARE

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Differential Diagnosis of Puerperal Fever

Genital tract infectionRespiratory complicationsPyelonephritisBreast EngorgementBacterial MastitisThrombophlebitisIncisional wound abscess

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Respiratory Complications

- seen within the 1st 24 hours

- in women delivered by cesarean section

- use of general anesthesia

AtelectasisAspiration pneumoniaBacterial pneumonia

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Pyelonephritis

SSx: bacteriuria / pyuria costovertebral angle tenderness spiking temperature

Clinical Dx: Urinalysis U/S

Rx: Antibiotics

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Breast Engorgement

15 % of all postpartum women

Fever rarely goes > 39 C

Fever – not longer than 24 hrs

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Thrombophlebitis

SSx:

painful swollen leg

calf / femoral angle tenderness

Mgt: Heparin

80

Uterine Infection

Infection involving the decidua, myometrium and parametrial tissues

Metritis with Pelvic

Cellulitis

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Uterine Infection

The route of delivery is the single most significant risk factor for the development of postpartum uterine infection.

Incidence of Metritis:

ff C/S 13 – 50%

ff vaginal delivery 1.3 – 2.6%

82

Risk Factors for Metritis

Prolonged laborProlonged membrane ruptureMultiple cervical examinationUse of internal fetal monitoringIntraamniotic infectionBacterial colonization of lower genital

tract Group B streptococcus Mycoplasma hominis

Chlamydia trachomatis Gardnerella vaginalis

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Bacteria Responsible for Genital Tract Infections

Aerobes Grp A, B and D streptococci Enterococcus Gram (-) bacteria – E. coli, Klebsiella and Proteus sp Staphylococcus aureus Gardnerella vaginalis

Anaerobes Peptococcus sp Clostridium sp Peptostreptococcus sp Fusobacterium sp Bacteroides fragilis Mobiluncus sp

Others Mycoplasma sp Chlamydia trachomatis Neisseria gonorrhea

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Clinical Course

FeverChillsAbdominal pain / tendernessFoul-smelling lochia B hemolytic streptococci – scanty odorless

lochia

Leukocytosis – 15,000 – 30,000/cu mm

85

Treatment

BROAD SPECTRUM ANTIBIOTICSClindamycin + Gentamycin most widely studied regimen 90 – 97% efficacy

plus ampicillin – if enterococcal infection suspected

Aztreonam – if with renal insufficiency

86

Causes of Persistent Fever Despite Antibiotic Rx

Wound infectionPeritonitisParametrial phlegmonPelvic abscessSeptic Thrombophlebitis

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Wound Infection

3 – 5% post C/S2% - with prophylactic antibioticsSSx: fever

erythema, wound discharges

Rx: antibiotics

surgical drainage

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Risk Factors for Wound Infection

ObesityDiabetesCorticosteroid therapyImmunosuppressionAnemiaPoor hemostasis with hematoma

formation

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Peritonitis

Route: lymphaticsSSx: severe abdominal pain bowel distension – ileusRx: antibiotics fluid and electrolyte replacement decompression surgery – bowel lesion uterine incisional necrosis

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Parametrial Phlegmon

Dx: parametrial induration

unilateral

uterus fixed on

one side

Rx: antibiotics

surgery – uterine incisional necrosis

91

Pelvic Abscess

Dx: fluctuant broad ligament mass

Rx: Drainage

Colpotomy

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Septic Thrombophlebitis

Route: hematogenousPathogenesis:

placental site infection

thrombosed myometrial vsSSx: enigmatic fever

lower abd’l / flank pain

tender mass beyond the cornu

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Infections of Perineum, Vagina and Cervix

Rx: Drainage

Antibiotics

Analgesics

Foleybag catheter

Repair

10 days post cesarean section, a 23 yr old primipara complains of fever of 3 days duration associated with hypogastric pain. Temp – 40 C. Breasts are slightly tender. Pelvic exam shows tenderness over the area of the uterus and parametria. The most likely consideration is:

A. Breast engorgement B. Acute pyelonephritis C. Metritis with pelvic cellulitis D. Septic pelvic thrombophlebitis

95

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