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