115876831 Obstetrics Study Guide 3 Mitra Ahmad Soltani 2008 (1)

7/28/2019 115876831 Obstetrics Study Guide 3 Mitra Ahmad Soltani 2008 (1)

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In the Name of God

Obstetrics Study Guide 3

Mitra Ahmad Soltani

2008


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References

Iranian Council for graduate Medical Education. Board and pre-board Exam questionsfor OBS and Gyn .2001-2006

Panda S . IUGR. Department of Obstetrics & Gynecology Medical College of India2002

Pritchard JA, MacDonald PC, Gant NF. Williams Obstetrics. 22nd ed. New York,NY: McGraw-Hill; 2005.

Tan T and Yeo G. IUGR. Current Opinion in Obstetrics and Gynecology 2005, 17: 135-142

emedicine e-journal:

Butler J. postterm delivery. emedicine. June 19. 2006

Gaufberg S. Abruptio placenta. emedicine. Aug 29. 2006

Gibson P. HTN in Pregnancy. emedicine. DEC 13 2007

Hernandez E . GTN. emedicine. Jan 26, 2007 Marinnan G. Placenta Previa. emedicine. Aug 26. 2005 Ross M. preterm. emedicine. 31 may 2007

Pictures and material of multiple pregnancy are adaptedwith permission from:

Zach T. multiple pregnancy.emedicine. Oct 2. 2007


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HTN in Pregnancy


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classification

Hypertension is the most common medical problemencountered during pregnancy, complicating 2-3% ofpregnancies.

HTN is classified into 4 categories

1) chronic hypertension,

2) preeclampsia-eclampsia,

3) preeclampsia superimposed on chronic hypertension

4) gestational hypertension (transient hypertension ofpregnancy or chronic hypertension identified in thelatter half of pregnancy).


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Chronic HTN

blood pressure exceeding 140/90

mm Hg before pregnancy or before

20 weeks' gestation. It persists after12 wks postpartum.


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Gestational Age

New-onset or worsening hypertensionafter 20 weeks' gestation should lead

to a careful evaluation for

manifestations of preeclampsia.The diagnosis of severe hypertension

or preeclampsia in the first or early

second trimester necessitatesexclusion of GTD and/or molar

pregnancy.


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Maternal Risk factors

First pregnancy

New partner/paternity

Age younger than 18 orolder than 35 years

History of preeclampsia Family history of

preeclampsia in a first-degree relative

Black race

Obesity (BMI >35)

Interpregnancyinterval less than 2 yearsor more than 10 years

Chronic hypertension Preexisting diabetes (type1 or type 2)

Renal disease

SLE

Obesity Thrombophilia


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Placental Risk factor

Multiple gestations

Hydrops fetalis

Gestational trophoblastic disease

Triploidy


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BP measurement

Blood pressure should be measured in the sitting

position, with the cuff at the level of the heart.

Women should be allowed to sit quietly for 5-10

minutes before each blood pressure

measurement.

Korotkoff sounds I (the first sound) and V (the

disappearance of sound) should be used todenote the systolic blood pressure (SBP) and DBP,

respectively.


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Indications of preg. termination

Mild Severe

Diastolic blood pressure


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CBC

Platelet counts less than 100,000/L

suggest preeclampsia or ITP.

Hemoglobin levels greater than 13g/dL suggest hemoconcentration.

Low Hbg levels may be due to

microangiopathic hemolysis or irondeficiency.


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Proteinurea

Trace levels to +1 proteinuria are acceptable, but

levels of +2 or greater are abnormal and should be

quantified with a 24-hour urine collection or spot

urine protein:creatinine ratio.

In a 24-hour urine collection, the reference range

for protein excretion in pregnancy is up to 300

mg/d.


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Coagulation tests

LDH,

bilirubin,

haptoglobin,

fibrinogen,

D-dimers

If:

PT/INR/aPTT results are abnormal,

thrombocytopenia is present,

the hemoglobin level is dropping


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Fetal Monitoring

Alternate a biophysical profile

with a fetal NST twice each

week.

Ask for Serial fetal ultrasound

starting at 18 weeks.


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Methyldopa (Aldomet)

Centrally acting antihypertensive agent widely considered the

first-line agent for treatment of hypertension during pregnancy.

250 mg PO bid/tid; increase q2d prn; not to exceed 3 g/d


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Hydralazine (Apresoline)

Intravenous form is useful when treating severehypertension due to preeclampsia/eclampsia.

10-20 mg/dose IV q4-6h prn initial; increase to 40 mg

per dose prn

BP >170/110 mm Hg: 0.1-0.2 mg/kg/dose IV q4-6h prn;

not to exceed 20 mg or 1.7-3.5 mg/kg/d IV divided q4-6h


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Life-threatening complications in

preeclampsia Seizures

Cerebral hemorrhage

Pulmonary edema

Acute renal failure

DIC

HELLP syndrome

Hepatic infarction/rupture and subcapsularhematoma


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IMP: mild preeclampsia

General: condition/position/diet =low salt,high prot

Lab: CBC ,BG, Rh, U/A,24hr urine (prot,cr,vol), BUN/Cr,PT,PTT,Fib, ALT,AST,Al P, Bil (T, D)

reserve of 2 units of PC

IV :Ringer at heparin lock

OTHER: Control of vital sign q4hrs, control of FHR, FAD chart ,

NST, sono OB, daily weight inform if BP>160/110, blurredvision, head ache, epigastric pain, seizure


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IMP: Severe preeclampsia General: condition/position/diet =NPO

Lab: CBC ,BG, Rh, BUN/Cr, PT, PTT,Fib ,ALT,AST,Al P, Bil (T, D)

prep 2 units of PC

IV :Ringer 1000cc +10 u of oxytocin

if BP>160/110,blurred vision, head ache, epigastric pain, seizure then amphydralazine 5 mg iv prn

MgSO4 (4 gr) in 200cc DW5% in 20 min then 10 gr(1/2) im ineach buttock then 5 gr im q4h

If platelet is below 100000 then 20 gr in 1000cc infused in100cc/hrs (check of I/O, RR, DTR, prep CPR set with 2 gr 20%MgSO4 ready) +Amp Dexa 6 mg bid for 4 doses

OTHER: Control of vital sign q15 min , control of FHR, fix foley,


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Preterm Pregnancy


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Definition

Preterm labor is defined as the presence of

uterine contractions of sufficient frequency

and intensity to effect progressive effacement

and dilation of the cervix prior to termgestation (between 20 and 37 wk).

It is the leading cause of neonatal mortality.


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Methods for predicting preterm birth home uterine activity monitoring (HUAM)

salivary estriol : DHEA increases before the onset of labor. This

results in an increase of maternal estriol.

FFN is a basement membrane protein that helps bindplacental membranes to the decidua. FFN has a predictive

value in identifying patients who will or will not deliver within

the subsequent 1-2 weeks.

A short cervical length in the early or late second trimester

has been associated with a markedly increased risk of preterm

labor and delivery.


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Contraindication to tocolysis

1-Fetal growth restriction

2-Oligohydramnios

3-Nonreactive NST,Positive CST

4-Absent or reversed diastolic flow uponDoppler examination of umbilical blood

flow

5-Repetitive severe variable decelerations6-Significant vaginal bleeding consistent with

abruption.


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Definition of IAI

(Intra Amniotic Infection)

A temperature greater than 38.0C (100.0F) and

2 of the 5 following signs:

1-WBC > 15,000 cells/mm3

2-Maternal HR> 100 (bpm)

3- Fetal HR> 160 bpm

4-Tender uterus

5-Foul-smelling discharge


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Chorioamnionitis Order

General: condition/position/diet=NPO

Lab: CBC diff, MP, WW, B/C X2, U/A , U/C,CXR,BUN/Cr

IV : 1000cc Ringer +10 units of oxytocin start at

2 drops /min, add 2 drops every 15 min if FHR andcontractions are normal

Amp ampicillin 2gr iv qid +gentamicin im 80mg stat then 60mg TDS

AMP clindamycin 900 mg iv TDS for allergic women topenicillin(continue antibiotics after delivery until themother is a febrile

OTHER: Control of vital sign hourly


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IMP:PLP before 37 weeks out patient:(contractions 4 in 20 min or 8 in 60 min +progressive change in cervix

cervical dilation of more than one

cervical effacement of more than 80 % or greater)

if:

Check of contractions:+

U/A, U/C: -

Fern:-

Then: Hydrate and sedate

Stop of contractions: discharge

With:isoxsuprine 10 mg TDS for10 days

Contractions persist: hospitalizeNext slide


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IMP:PLP before 37 weeks, hospitalized

General: condition/position/diet Lab: CBC, BG, Rh, U/A, U/C, fern, reserve of 2 units of PC

IV :

1-1000cc Ringer free

2-MgSO4 (4 gr) in 200cc DW5% in 20 min then 20 gr in 1000cc infused in

100cc/hrs (check of I/O, RR,DTR, prep CPR set- I/O with measure)3-Amp pethidine 25 mg iv 25 mg im

4-Amp ampicillin 2 gr IV qid

5-Amp erythromicin 400 mg QID

6- Amp betamethasone 12 mg im, repeat after 24 hrs for GA below 34 wks

OTHER: Control of vital sign q4hrs, Inform if LP, leakage, VB, ab VS or FHR


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Contraindication for beta mimetics

Maternal

cardiac disease

Diabetes Thyrotoxicosis

HTN


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Dosage of Ritodrine or Terbutaline for tocolysis

50-100 mcg/min increase by 50 mcg/min

every 10 min

max dose:350mcg/min

If labor is arrested continue the infusion for at

least 12 hrs

SC:

250 mcg q3-4 hrs


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Length of GA with multiple fetuses

Twin=36 wks

Triplets=33.5 wks

Quadruplets=31 wks


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Postterm


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Definition of postterm

Postterm pregnancies define

pregnancies extending up to or after

42 weeks. The reported frequency is 3-12%.


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Cause of postterm P.

The most frequent cause of postterm

pregnancy is inaccurate dating criteria

primiparity,

prior postterm pregnancy,

male gender of the fetus,

genetic factors


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surveillance

NST and AFI 2 times per week for pregnancies

continuing past 41 weeks.


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Intra Uterine Growth Retardation


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Definition Intrauterine growth restriction (IUGR)

occurs when the unborn baby is at orbelow the 10th weight percentile for his orher age (in weeks). The fetus is affected by

a pathologic restriction in its ability to grow.

Low birth weight (LBW) means a baby

with a birth weight of less than 2500Gms,which could be due to IUGR or Prematurity


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Etiology of IUGR

Idiopathic- In a majority of cases (40%)


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Maternal Risk Factors Has had a previous baby with IUGR

Extremes of age Small mothers (Ht & Wt)

poor weight gain and malnutrition during preg.

socially deprived Substance abuse (like tobacco,narcotics, alcohol)

low total blood volume during early pregnancy


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Maternal Risk Factors Multiple pregnancy

Living in High altitude locations Drugs like anticoagulants, anticonvulsants

Cardio-vascular disease:preeclampsia, HTN,

cyanotic heart disease, cardiac disease Gr III &

IV, diabetic vascular lesions

Chronic kidney disease

Chronic infection- UTI, Malaria, TB, genital

infections

Antibody abnormality like antiphospholipid

antibody syndrome, SLE


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Fetal Risk Factors

Intrauterine infection:German measles (rubella),

cytomegalovirus, herpes simplex, tuberculosis, syphilis, ortoxoplasmosis, TB, Malaria, Parvo virus B19.

Birth defect (cardiovascular, renal, anencephally,limb defect, etc).

Chromosome defect(trisomy-18 (Edwardssyndrome),21(Downs syndrome), 16, 13, xo (turnerssyndrome.)

Primary disorder of bone or cartilage.

Chronic lack of oxygen during development(hypoxia).

Developed outside of the uterus.

Placenta or umbilical cord defects.


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Placental Factors

Uteroplacental insufficiency:

Improper / inadequate trophoblastic invasion and

placentation in the first trimester.

Lateral insertion of placenta.

Reduced maternal blood flow to the placental bed. Fetoplacetal insufficiency due to:

Vascular anomalies of placenta and cord

Decreased placental functioning mass:

Small placenta, abruptio placenta, placenta previa,

post term pregnancy.


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Treatment

Bed rest

Aspirin before 20 wk GA

Nutritional supplementation: zinc , fish oil,

hormones

Oxygen therapy.


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For cases termination is indicated:

Corticosteroids with a delay in delivery for 2.4 days

Mode of delivery depends on the bishop score and

IUGR severity

For dichorionic twins : injection of KCl into the heart

of the weaker fetus ( in most cases management is

expectant)

For monochorionic twins photocoagulation of

anastomoses or diathermy in cases of TTTS and AAA

Short Term Risks of IUGR for the


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Short Term Risks of IUGR for the

neonate

Meconium Aspiration Syndrome,

infection,

hypoglycemia, hypothermia,

Sudden Infant Death Syndrome,


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Long term Prognosis Fetal Death

low blood sugar low body temperature

abnormal development of the nervous system

Adulthood aftermath :

CAD HTN

Diabetes II

Dyslipidemia

Stroke Depression

Suicide attempts


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Definition

Abruptio placentae (ie, placental abruption)

refers to separation of the normally located

placenta after the 20th week of gestation.

Abruptio placentae occurs in about 1% of all

pregnancies.


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Classification of abruptio

extent of separation (ie, partial vs

complete)

location of separation (ie, marginalvs central)

Clinical


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Causes1


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Causes1

Maternal HTN(44% of all cases)

Maternal trauma

Cigarette smoking

Alcohol consumption Cocaine use

Advanced maternal age


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Imaging Studies


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Imaging Studies

Ultrasonography is not very useful in

diagnosing placental abruption.

Retroplacental hematoma may be recognized in 2-

25% of all abruptions. Recognition of retroplacental hematoma depends

on the degree of hematoma and on the operator's

skill level.

IMP: R/O abruption


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IMP: R/O abruption

Condition/position/diet:NPO

Lab: CBD-BG-Rh-U/A-U/C-PT-PTT-Fib-FDP-D-Dimer- Prep 4 units of crossmatched packed red blood cells

Prep 5 units of platelets, prep 10 units of FFP

Continuous high-flow supplemental oxygen

One or 2 large-bore IV lines with normal saline (NS) or

lactated Ringer (LR) solution+10 units of oxytocin in 1 lit of

ringer start at 2 drops/min add 2 drops every 15 min if fetal

heart rate and uterine contractions are favorable.

perform amniotomy

Closely observe the patient. Monitor vital signs and urine

output, fetal heart rate and uterine height measurement.

Prepare OR for emergent C/S


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Placenta Previa


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subtypes

(1) complete or total: the placenta covers 360 of

the internal cervical os;

(2) incomplete or partial: 0-360 of the internal

cervical os is covered by placental tissue; (3) marginal: the placental tissue does not cover

the internal cervical os;

(4) low lying: the edge of the placenta liesabnormally close to but does not abut the

internal cervical os.


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Vaginal Bleeding


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Vaginal Bleeding

painless vaginal bleeding during the secondhalf of pregnancy (70%).

It can occur without an inciting cause,

although pelvic examination, intercourse, orlabor may provoke it.

The average gestational age at presentation is32 weeks.

Hemorrhage recurs, and, in nearly all cases, itis more severe the second time.


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management

Patients are treated expectantly, with:

volume replacement,

transfusions,

tocolytics,

emergent cesarean delivery

Without endangering the life of the mother,all attempts are made to delay delivery until

the fetal lungs mature.


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Preferred examination

TA sonography is the test of choice to confirmplacenta previa.

When the internal cervical os cannot be

visualized or when the results areinconclusive, transperineal or transvaginalsonography is recommended as an adjunct.

No increased risk of hemorrhage has beenassociated with transvaginal or transperinealsonography in this clinical setting.


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Blood loss classifications

Class 1 Class 2 Class 3 Class 4


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med-ed-online 2007

Blood Loss

Volume (mls) in

adult

750mls 800 - 1500mls 1500 - 2000mls >2000mls

Blood Loss

% Circ. blood

volume

40%

Systolic Blood

PressureNo change Normal Reduced Very low

Diastolic Blood

PressureNo change Raised Reduced

Very low /

Unrecordable

Pulse (beats /min)Slight tachy-

cardia100 - 120 120 (thready) >120 (very thready)

Capillary Refill Normal Slow (>2s) Slow (>2s) Undetectable

Respiratory Rate Normal Normal Raised (>20/min) Raised (>20/min)

Urine Flow

(mls/hr) >30 20 - 30 10 - 20 0 - 10


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med-ed-online 2007

Estimated

blood lossSuitable fluid regimes

1000 mls 3000 mls crystalloido

r1000 mls colloid

1500 mls1500 mls crystalloid & 1000mls

colloid

o

r4500 mls crystalloid

2000 mls1000 mls crystalloid, 1000mls colloid

& 2 units blood

o

r

3000 mls crystalloid & 2

units blood


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Multiple pregnancy

Pictures and material of multiple pregnancy are adapted from:Zach T. multiple pregnancy. emedicine. Oct 2. 2007

with permission

pathophysiology1


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pathophysiology1 Dizygotic twins(fraternal) are produced when 2

sperm fertilize 2 ova. Separate amnions, chorions,

and placentas are formed in dizygotic twins. The

placentas in dizygotic twins may fuse if the

implantation sites are proximate. The fused

placentas can be easily separated after birth. Monozygotic twins (Identical)develop when a single

fertilized ovum splits during the first 2 weeks after

conception. An early splitting (ie, within the first 2 d

after fertilization-30%) of monozygotic twinsproduces separate chorions and amnions. These

dichorionic twins have different placentas that can

be separate or fused.


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Diamniotic/dichorionic placentation

h h l
http://www.emedicine.com/ped/images/973235-977234-2964.jpg


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pathophysiology2

Later splitting (ie, 3-8 d after fertilization)results in monochorionic/diamniotic

placentation .

Approximately 70% of monozygotic twins aremonochorionic/diamniotic.


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Diamniotic/monochorionic placentation

h h i l 3


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pathophysiology3

If splitting occurs even later (ie, during 9-12 dafter fertilization),

monochorionic/monoamniotic placentation

occurs . Monochorionic/monoamniotic twins are rare;

only 1% of monozygotic twins have this form

of placentation.


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Monoamniotic/monoamniotic placentation

h h i l 4


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pathophysiology4

Monochorionic/monoamniotic twins have acommon placenta with vascular

communications between the 2 circulations.

th h i l 5


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pathophysiology5

Trizygotic triplets occur when 3 sperm fertilize3 ova.

Dizygotic triplets develop from one set of

monozygotic cotriplets and a third cotripletderived from a different zygote.

Finally, 2 consecutive zygotic splittings with

one split results in a vanished fetus andmonozygotic triplets.

F


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Frequency

The birth rate of monozygotic twinsis constant worldwide

(approximately 4 per 1000 births). Birth rates of dizygotic twins vary by

race. (Highest in Africans and

lowerest in Asians)

t lit


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mortality

low birth weight infants( due to prematurity and(IUGR)

congenital anomalies,

placenta previa, abruptio placenta,

preeclampsia, cord accidents,

malpresentations,

asphyxia/perinatal depression,

group B streptococcal (GBS) infections, hyaline membrane disease (HMD),

TTTS.

History


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y

excessive weight gain,

hyperemesis gravidarum,

sensation of more than one moving fetus

use of ovulation-inducing drugs

family history of dizygotic twins

Neonatal Lab Studies


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CBC count: In TTTS, the donor twin is frequentlyanemic at birth. The recipient twin ispolycythemic at birth.

Calcium level: Hypocalcemia is common inpremature infants, especially the donor twin inTTTS.

Glucose level: Hypoglycemia is common in

premature infants, especially if TTTS is present. Bilirubin level: Hyperbilirubinemia due to TTTS

may develop in polycythemic infants.

TRAP


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TRAP

Twin reversed arterial perfusion (TRAP)sequence occurs when an acardiac twin

receives all of the blood supply from the

normal "pump" twin. This only occurs in

monochorionic twins.


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Conjoined twins


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j

Incomplete late division of monozygotic twinsproduces conjoined twins.

Classification:

Thoracopagus - Joined at chest (40%) Xiphopagus/omphalopagus - Joined at abdomen (34%)

Pygopagus - Joined at buttocks (18%)

Ischiopagus - Joined at ischium (6%)

Craniopagus - Joined at head (2%)

Discordant


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Discordant

. Birth weight discrepancies of more

than 20-25% are considered

discordant. Discordant birth weightsoccur in 10% of twins.


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classification


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classification

hydatidiform mole : is the most common formof gestational trophoblastic neoplasia it can

behave in a malignant or benign fashion,

invasive mole (chorioadenoma destruens),

choriocarcinoma,

and placental site trophoblastic tumor (PSTT).


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staging


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staging

Stage I Confined to the uterus

Stage II Limited to the genital structures

Stage III Lung metastases

Stage IV Other metastases


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WHO prognostic criteria3


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WHO prognostic criteria3

Site of metastases is gastrointestinal tract = 2 points

Site of metastases is brain or liver = 4 points

Number of metastases is 1-4 = 1 point

Number of metastases is 5-8 = 2 points Number of metastases is more than 8 = 4 points

Prior chemotherapy with single drug = 2 points

Prior chemotherapy with multiple drugs = 4 points


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Sign and Symptoms


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Sign and Symptoms

Prolonged hyperemesis gravidarum

preeclampsia

Hyperthyroidism

signs and symptoms associated with the metastaticdisease, such as hematuria, hemoptysis, abdominal

pain, and neurologic symptoms

Physical Exam


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Physical Exam

a positive pregnancy test result occurs in theabsence of a fetus.

vesicles in the vagina is diagnostic

Enlarged ovaries secondary to theca luteincysts are found in up to 20% of cases.

The cysts regress after evacuation of the

hydatidiform mole for 12 weeks.

Cause


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Cause

A hydatidiform mole occurs when a haploidsperm fertilizes an egg that has no maternalchromosomes and then duplicates itschromosomal complement.

Most complete hydatidiform moles are 46,XX, and allthe chromosomes come from the male.

Of hydatidiform moles, 10-15% are 46,XY. This occurswhen 2 sperm, 1 carrying an X and the other carryinga Y, fertilize an "empty" egg.

Partial moles are 69,XXY, and 2 sets ofchromosomes are of paternal origin.


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Medical Care2


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Medical Care2

Patients with benign do not require medicaltherapy.

observing patients with weekly serum HCG

titers.

Only patients with rising or plateauing titers

should be treated with chemotherapy.

Medical care3


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Medical care3

Patients with malignant nonmetastatic or metastatic low-risk GTN are treated with single-agent chemotherapy likeMTX or actinomycin D in patients with poor liver function

During treatment, the serum HCG titers are monitoredevery week.

One additional course of chemotherapy is administeredafter a normal serum HCG titer.

After 3-4 normal serum HCG titers, the titers are followedonce per month for 1 year.

A switch from MTX to actinomycin D is made if the patientreceiving MTX for nonmetastatic or metastatic low-risk GTNdevelops rising or plateauing serum HCG titers.

Medical care4


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Medical care4

Patients with high-risk metastatic aresubdivided into 2 groups:

In patients with a WHO score of less than 8, a

combination of MTX, actinomycin D, andcyclophosphamide can be used. This is known as

the MAC regimen. This chemotherapeutic regimen

is administered every 19-21 days (from day 1 of

the previous chemotherapy cycle) until the serumHCG titers normalize.

Medical Care5


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Medical Care5

Patients with WHO scores of 8 or higher aretreated with a combination of etoposide, MTX,

and actinomycin D administered in the first week

of a 2-week cycle and cyclophosphamide and

vincristine (Oncovin) administered in the second

week. This is known as the EMA-CO regimen. Two

additional courses of EMA-CO or EMA-CE are

administered after a normal serum HCG titer in

very high-risk patients.

Medical care6


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Medical care6

Patients with metastasis to the brain receivewhole brain irradiation (3000 cGy) in combination

with chemotherapy. Corticosteroids (Decadron)

with systemic effect are administered to reduce

brain edema.

Patients with liver metastasis are considered for

liver irradiation (2000 cGy).

Surgical care


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Surgical care

The treatment of a hydatidiform mole isevacuation of the uterus by suction and sharp

curettage.

To avoid excessive bleeding, oxytocin isadministered intravenously at the initiation of the

suctioning of the uterine contents.

The largest possible suction curet is used, usually

a 10F or 12F.

Further Care


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Further Care

Obtain follow-up serum HCG titers :

once per week until 3-4 normal values are

obtained.

Then, obtain them once per month for 6months.

Have patients use reliable contraception, such

as oral contraceptives or depot progesteroneinjections, during the period of follow-up care.


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Prognosis2


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Prognosis2

The rate of occurrence of a repeat molar pregnancy isapproximately 1-2%.

The rate of occurrence of a repeat molar pregnancy ina patient with a history of 2 previous hydatidiformmoles is approximately 10-20%.

The pregnancy rate after chemotherapy with MTX andcyclophosphamide is 80%. Of women treated withEMA-CO, 46% have had at least 1 live birth afterchemotherapy.

Patients who become pregnant after treatment forGTN should have a pelvic ultrasound early during thepregnancy to confirm that the pregnancy is normal.


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ADAPTATION TO PREGNANCY


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ADAPTATION TO PREGNANCY

In early pregnancy Estrogen and Progesteronestimulate beta cell hyperplasia and increased

insulin secretion

Glycogenolyis and peripheral utilizationincrease

The net result is relative hypoglycemia

GLUCOSE LEVELS IN NORMAL PREGNANCY


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GLUCOSE LEVELS IN NORMAL PREGNANCY

Fasting levels decline by 10 11 mg/dl

Postprandial levels rarely exceed 120-140

mg/dl

Glucose excursions with meals 30 35 mg/dl

Marked increase in insulin levels with feeding

CHO METABOLISM 20- 24 WEEKS


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CHO METABOLISM 20 24 WEEKS

Increased human placental lactogendiabetogenic

Increased prolactin insulin resistance

Increased cortisol decreased glycogenstorage


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MATERNAL COMPLICATIONS


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MATERNAL COMPLICATIONS

Retinopathy Nephropathy

Chronic hypertension

Preeclampsia

RETINOPATHY


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RETINOPATHY

Remains the leading cause of blindness inwomen ages 24-64

Every patient with pre-gestational diabetes

should have a retinal examination in earlypregnancy

Laser therapy is safe and effective during

pregnancy Has a variable course during pregnancy


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CHRONIC RENAL FAILURE


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Pregnancy is possible even in patientsrequiring hemodialysis

Reliable contraception is advised

Fertility and successful pregnancy outcomesare reduced with serum Cr > 2.0


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SEVERE PREECLAMPSIA


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BP > 180/110 Proteinuria > 5 g/24 hours

Lab: elevated LFTs. thrombocytopenia

Sxs: headache, epigastric pain, blurred vision

Oliguria, pulmonary edema, fetal growth

restriction

PREGNANCY COMPLICATIONS


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Hydramnios Spontaneous abortions

Congenital malformations

Macrosomia

Diabetic ketoacidosis

Neonatal metabolic complications

HYDRAMNIOS


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1-2 % in normals and 18% of diabetics Fetal osmotic diuresis is etiologic

May also be due to fetal cardiac CNS

malformations

May be associated with preterm labor

?Associated with level of glycemic control

SPONTANEOUS ABORTIONS


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In well controlled patients the rate is similar tothe non-diabetic

Glycosylated hemoglobin levels are higher in

women who have a SAB Higher rates of spontaneous abortion in

diabetics with vascular disease


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MACROSOMIA


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Seen more frequently with GDM and IDDMwithout vascular complications

Related to level of 3rd trimester glucose

control May occur in up to 25% of diabetics

DIABETIC KETOACIDOSIS


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Seen in type I DM Infection, fever, beta agonists are frequent

predisposing factors

Suspected with +serum ketones and bloodglucose levels above 300

Fetal distress is common

NEONATAL METABOLIC COMPLICATIONS


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Hypoglycemia Hypocalcemia

Hypothermia

Hypomagnesemia

Hyyperbilirubinemia


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PRECONCEPTION GLUCOSE CONTROL


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Fasting blood glucose < 100 mg/dl Pre-meal levels


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Normal glucose levels Folic acid supplementation

Dose: 4 mg/day from 1 month pre-pregnancy

to 12 weeks

FOLIC ACID


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All women of reproductive age shouldconsume at least 0.4 mg of folic acid

High risk women should consume 4 mg/day

This reduces the risk of neural tube defects

Newer evidence suggests a lower risk of facial

clefting and congenital heart disease as well

INDICATIONS FOR HOSPITALIZATION


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Persistent nausea and vomiting Significant maternal infection

DKA

Poor control/compliance

Preterm labor


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FIRST PRENATAL VISIT


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Routine prenatal lab Baseline 24 hour UA for protein and Cr

Clearance

Baseline retinal exam EKG

Thyroid function tests in Type 1 Diabetics

Hemoglobin A1C Schedule 10-12 week USN

EARLY PREGNANCY CARE


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Diabetic education and dietary instruction Multi-disciplinary care is helpful

Calibrate reflectance meters

Adjust caloric needs for pregnancy and

lactation

Review benefits of physical activity

TIMING OF DELIVERY


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Well controlled IDDM: at term Poorly controlled: after documentation of fetal

lung maturity

If fetal surveillance reassuring, delivery before39 weeks should be unusual


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NERVE INJURY


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Rate varies from 4-40% following shoulderdystocia

Most (90%) resolve without sequelae

Can occur with EFW < 4000 g Can occur in utero and therefore not

preventable by cesarean

POSTPARTUM GLUCOSE CONTROL


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Insulin requirements may fall 50% in the 1st 24hours

Little need for treatment if under 200 mg/dl


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ACOG Low Risk


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Age < 25 Not a member of an at risk ethnic group

(Hispanic, African, Native American, South or

East Asian, Pacific Islanders) BMI < 25 (non-obese)

No history of abnormal glucose tolerance or

FH No adverse outcomes


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Summary


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Every practice should adopt a screeningstrategy, either by historical or laboratory

means

Screening best between 24-28 weeks Remember to screen post delivery

Some diabetic cases


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Bita Hazrati

A PLP case complicated by HTN and GD


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p y

24 yrs old G2 P1 L0 D1/ first fetal loss due to preterm c/sdelivery

( because of placenta previa)

GA on admission 32-33 w CC: LP ( contractions mild/20 seconds D/ 2 in a

10- minute interval)

WB: Intact

ROM: - ( detected by Fern test) Reduced fetal movement: -


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Ph E:PR= 86/min RR:16/min T:36

BP= 140/90 mmHg

BS:

FBS=112 /10am=134 /4pm=145 /8pm=163


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20-30 units total : 2/3 intermediate1/3 regular

Morning: 10 units of NPH- 4 units of regular

Afternoon: 4 units of NPH 4 units of regular


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Answer:


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Mg so4

Ampicillin+ ErythroIsoxsuprine

Sedation

FBS-BS

NST-FAD-OB US (AFI and GA)

Insulin


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Which is not a good method of contraception in a

diabetic woman?


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A-LD OCPB-medroxy progesterone acetate

C- HD OCP

D-norplant

Ans:C

What is the test for a 30 year old 10 wk pregnant

woman whose FBS is 85/ 2hr PP is 125?


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A- 3 hr GTTB-Repeat of FBS and 2hr PP next week.

C-Repeat of FBS and 2hr PP in 24-28 wk.

D-Repeat of FBS and 2hr PP in 34 wk.

Ans: C

Which is not a cause of PIH for a diabetic pregnant

woman?


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A-poor blood glucose controlB-albuminurea

C-high creatinine

D-chronic HTN

Ans: A


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What is one stage screening test for diabetes in

pregnancy?


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A-100 grs oral glucose in 24-28 wk.B-50 grs oral glucose in 20-22 wk.

C-75 grs oral glucose in 18-20 wk.

D-25 grs oral glucose in 30-32 wk.

Ans:A


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What is your management of a 30 yr old 35 wkpregnant woman class R diabetic with severe

retinopathy?


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p y

A-termination of pregnancyB-Laser photocoagulation

C- high dose steroids

D-No action is needed now.

Ans:B

Which is not among the complications of type A2

diabetes in pregnancy?


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A- macrosomiaB-increased C/S

C- still birth

D-malformations

Ans:D


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Points to remember about diabetic labor:


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BS below 100 mg/dl : no insulin is needed 100-140 mg/dl:1 unit insulin

140-180 mg/dl:1.5 units insulin

180-220 mg/dl:2 units insulin

More than 220 mg/dl:2.5 units insulin

BS more than 140 mg/dl needs NS as IV

Date post:	03-Apr-2018
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115876831 Obstetrics Study Guide 3 Mitra Ahmad Soltani 2008 (1)

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