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Pregnancy with internal

medical diseases

Department of
gynaecology and
obstetrics
 Digestive system disease
 Endocrine system disease
 Respiratory system diseases
 Blood system disease
 Urinary system disease
 Immunological diseases
Digestive system diseases
 Peptic ulcer disease
 Viral hepatiitis
Peptic system disease
 General consideration
 1. Pregnancy usually ameliorates
extension of ulceration
 2.an initial attack rarely occurs during
pregnancy
 3.the salutary effect of pregnancy may
be related to progesterone ‘s ability to
inhibit motility, because acis secretion
remains unchanged
 4. if activation of previously dormant
ulcer disease does occur,it is usually in
the puerperium.
CLINICAL FINDINGS
 1. The classic signs of gastric or
duodenal ulcer are related to a
burning epigastric pain that is
relieved by meals or antacids.
 2.patients with a gastric or duodenal
ulcer most often report discomfort
rather than pain and describe this
feeling as “acid”or burning or
indigestion.
 3.peptic ulcer disease must be
differentiated from reflex esophagitis
or simple heartburn,which commonly
occurs during pregnancy
DIAGNOSIS
 1. The above symptoms of peptic ulcer
disease are relieved by food and return
approximately 1-2h later,paralleling
gastric acidity .
 2likewise, antacids may relieve the pain
and help confirm the diagnosis.
 3.most commonly , the diagnosisis
confirmed by endoscopic visualization
of the ulcer crater in the stomach or
duodenum.
 4 although gastric carcinoma is
rare,many physicians recommend
biopsy during the endoscopic
procedure.
 5.Upper gastrointestinal X-ray with barium
studies are usually avoided because of
radiation exposure and because endoscopy
is a more direct diagnostic method .
 6. helicobacter pylori is an organism
associated with gastritis,ulcers,and possibly
gastric adenocarcinoma and
lymphoma.diagnosis is based on
biopsy,cultre,or urease test.Noninvasive
testing includes the C-urea breath test
,stool antigen,or serology.
Treatment
 1. Documented peptic ulcer disorders
are treated symptomatically during
pregnancy
by avoidance of symptom provoking
foods and use of antacids and
sucralfate.
 2. supportive advice may be given
regarding cessation of smoking ,bed
rest,avoidance of stress,and so on .
 3. for persisitent symptoms,an H2 antagonist
such as cimetidine or ranitidine can be given
.As a last resort,a proton pump inhibitor such
as lansoprazole can be added to the drug
regimen.

 4. Eradication of H pylori is 90% successful


with an antibiotic such as tetracycline,a
bismuth compound,and a proton pump
inhibitor.
Compications and prognosis
 1. In general,the fetus is not adversely
affected by peptic ulcer disease unless
maternal compromise ,such as
perforated ulcer with bleeding,occurs.
 2.particular vigilance in the postpartum
period is necessary because ulcers
become active again durring this time
and can become penetrating.
Viral hepatitis
 Geveral consideration
 1 Hepatitis may be caused by
numerous viruses,durgs,or toxic
chemicals ;
 2. Viral hepatitis complicates 0.2%
of all pregnancies
 3. the clinical manifestations of
all forms are similar .
 the most common viral agents causing
hepattis in pregnancy are hepatitis A
Virus,hepatitis B virus hepatitis C(non-
f,nonb hepatitis virus)hepatitis
E,hepatitis G.and epsteinbarr virus
.delta agent hepatitis has also received
increasing attention as a cause of
hepatitis.
Classification
 hepatitis A virus
 The belong to the picornavirus group
,which also Includes poliomyelitis virus
and coxsackievirus.it is a 27mm RNA
virus that is readily deactivated by
ultraviolet light or heat.
 2. the primary mode of transmission is
the fecal –oral route.
 3. Excretion of the virus in stool
normally begins approximately 2
weeks prior to the onset of clinical
symptoms and is complete within 3
weeks following onset of clinical
symptoms.
 4.no known carrier state exists for the
virus .
 5. both blood and stool are
infectious during the 2 to 6 week
incubation period.
 Hepatitis B
 the hepatitis B virus is a Dna hepadnavirus
 1.the 42nm dane particle,is the complete
infectious agent,which is composed of a surface
coat and 27nm central core,
 2. the surface antigen HBSAg of the done particle
is the marker usually measurred in blood.
 3.the presence of HbsAg is the first manifestation
of viral infection ;
 4it uausllay appears before clinical evidence of the
disease and lasts throughout the infection
 1.the core antibody HbcAb is produced
against the 27nm core of the dane particle
 2. core paticles and antigen are not normally
present in blood except in overwhelming
infections
 3. HBe antigen is a soluble ,nonparticulate
antigen that is found only when HBsAg is
present , servers as an accurate indicator of
viral replication and infectivity
 4. who are HBeAg positive in the third
trimester frequently transmit this
infection to the fetus in the absence of
immunoprophylaxis,whereas those
who are negative rarely infect the
fetus.
 transmitted by inoculation of
infected blood if blood products,or
sexual intercourse
 the clinical features of hepatitis A
and B are similar,although
hepatitis B is more insidious.
 Hepatitis C
 1.Up to 80% of infectied individuals
become chronic carrier.about 90% of
posttransfusion hepatitis is now
caused by hepatitis C.
 2.hepatitis C antibody is present in
approximately 90% of these patients
 delta agent
 Hepatiits delta agent virus is an
RNA virus that is smaller than all
other known RNA virus.the agent
can cause infection only when
HbsAg positivity exists
 hepatitis E
 Is transmitted via the oral/fecal
route.the disease is self-
limited.pregnant patients who are
acutely infected have a 15% risk of
fulminant liver failure with a 5%
mortality rate
 hepatitis G
 Is more likely to be found in people
infected with hepatits B or C with a
history of intravenous drug abuse.there
is no chronic carrier state.
 vertical transmission has been noted.
Clinical findings
 The clinical picture of hepatitis is
hightly variable;
 Most patients have asymptomatic
infection,while a few may present with
fulminating disease and die within a
few days.
 frequent symptoms include general
 malaise,myalgia,fatigue,anorexia,nau
sea and vomiting,
 right upper quadrant pain,and
lowgrade fever.mild hepatomegaly
and/or splenomegaly occur in 5%-
10%of affected patients.
 the white blood cell count is depressed
and mild proteinuria and bilirubinura
occur early in the cours of the disease.
 AST ALT,bilirubin,and alkaline
phosphatase are usually
elevated.prothrombin and partial
thromboplastin times may also be
prolonged with severe liver
involvement.
Diagnosis
 1. The diagnosis is made using
serologic markers-antiHa
IgM.HbsAg,HC PCR antiHBC IgM,HD
PCR,antiHE IgM,and anti HG IgM.
 2.liver biopsy shows extensive
hepatocellular injury and inflammatory
infiltrate.
 the differential diagnosis of viral
hepatitis should include
viruses A B Cand delta;epstein –barr
virus;cytomegalovirus
infection;cholestasis;acute fatty liver
of pregnancy; additionally intra-or
extrahepatic bile duct obstruction.
Treatment
 Bed rest should be instituted during
the acute phase of the illness if
mausea,vomiting .or anorexia is
prominent,
 intravenous hydration and general
supportive measure are instituted
 .all hepatotoxic agents should be
avoid.
 antepartum fetal assessment should
be instituted in the third trimester
because of the increased risks of
premature delivery and stillbirth
 Gamma globulin prophylaxis should be
given to pregnany women within 2
weeks of exposure to hepatitis A or
hepatitis C
 .hepatitis B immunoglobulin ,
intramuscularly with a repeat dose
should be administered to neonates
born of HBsAg positive mothers ,to
decrease the risk of vertical
transmission .
 these infants should also receive
hepatitis B vaccine at birth and at
1 and 6 months

 breastfeeding is nor
contraindicated with hepatitis B as
long as the infant has been
immunized
Complications and
prognosis
 The acute illness usually resolves
rapidlly in 2-3weeks,with complete
recovery usually occuring within
8weeks,in10% of cases of type B and C
hepatitis,chronic perisitent or chromic
active hepatitis develop acute fulminant
hepatitis.
 .the maternal courses of viral hepatitis
is unaltered by pregnancy,but
prematurity may be increased.
 all pregnant women should routinely
be tested for hdsag during an early
prenatal visit in each pregnancy
 perinatal loss rates are usually high
with a poor maternal
prognosis,particulary with poor liver
function or esopageal varices.
 Intrahepatic cholestasis of
pregnancy(icp)
 Intrahepatic cholestasis is a condition
characterized by accumulation of bile
acids in the liver,with subsequent
accumulation in the plasma,causing
pruritus and jaundice
 estrogen and progestone are therefore
considered to play a role in its etiology
 ultrasound examination of the gallbladder
helps rule out cholelithiasis
 .if hepatitis associated with
pregnancy..laboratory values show an
increased alkaline phosphatese.,bilirubin,and
serum bile acids Ast,and Alt may be mildly
elevated as well.
 Symptomatic treament of pruritus with
diphenhydramine is useful
a slight increase in preterm births and
stillbirth .the etiology is unclear,but
some refer to the fetal toxicity of bile
acids as a causative factor
 antenatal testing with a modified
biophysical profile two time per week
starting at the time of diagnosis is
suggested.
 there is no agreement as to whether
the pregnancy should be induced at
37-38weeks or whether to await
spontaneous labor
Acute fatty livery of
pregnancy
 1.Acute fatty liver of pregnancy is a
rare complication (1in 13.000)of the
third trimester.
 2. early recognition and termination of
the pregnancy(delivery)and extensive
supportive therapy have reduced the
mortality rate to approximately 20%.
 Symptoms and signs include nausea
and vomiting ,malaise ,epigastric pain
,and jaundice,
 an elevated LDH.ast alt ,bilirubin,and
prolonged prothrombin time
.glucose,platelets,cholesterol,triglyceri
des,and fibrinogen are notably
decreased
 liver biopsy reveals microvesicular
hepatic steatosis and mitochondrail
disruption on electron microscopy.
 complications such as acute renal
failue ,DIC,encephalopathy ,and sepsis
can be severe.
 Gestational diabetes
mellitus
General consideration
 Diabetes mellitus is the most
common medical complication of
pregnancy
 a clinical syndrome characerizes
by deficiency of or insensitiviy to
insulin and exposure of organs to
chronic hyperglycemia
 Hyperglycemia around the time of
conception and early organogenesis
results in the developing embryo
having a 6-fold increase in midline
birth defects.
 .ketoacidosis is an immediate threat to
life and is the leading cause of
perinatal morbidity in diabetic
pregnancies today ,accounting for 40%
of perinatal mortality
 complications of Gdm include fetal
macrosomia,which is associated with
inceased rates of secondary complications
such as operative delivery shoulder
dystocia,and birth trauma.in addition
,neonatal complications attributed to
gestational dabetes include respiratory
distress
syndrome(rds),hypocalcemia,hyperbilirubin
emia,and hypoglycemia
 with therapy beginning prior to
conception and continuing throughout
pregnancy, including nutrition
therapy,insulin when necessary ,and
eventual antepartum fetal
surveillancy,there is a marked decline
in overall morbidity and mortality
 Diagnosis criteria for diabetes
mellitus prior to pregnancy

 Diagnosis criteria for gestational


diabetes mellitus
Diagnosis criteria for diabetes
mellitus prior to pregnancy
 There are three ways to diagnosis
preexisting diabete mellitus and each way
must be confirmed by a followup test
.criteria for dagnosing diabetes mellitus
include;
 1.symptoms of
diabetes(polyuria/polydipsia/and or
unexplained weight loss) plus a casual
plasma glucose concentration of equal to or
greater than 200mg/dl
 2.fasting plasma glucose (at least 8 hs
without eating )equal to or greater than
126 mg/dl
 3. two –hour plasma glucose of equal to or
greater than 200mg/dl after drinking a
75gram glucose load.
 a positive value on any of these tests
should be confirmed on a subsequent day
by repeating any of these tests.
Diagnosis criteria for gestational
diabetes mellitus
 risk assessment for GDm is undertaken at
the first prenatal visit .
 women with risk factors ,including marked
obesity,personal history of gdm in prior
preggnancy ,glucosura,or strong family
history .should have a glucose tolerance
test ( GTT ) as soon as feasible.if results
of testing donot demonstrate diabetes,they
should be retested between 24and
28weeks’gestation
 a fasting plasma glucose of greater than
126mg/dl or a casual level of greater than
200mg/dl meets the criteria for diabetes if
confirmed on a subsequent day.

 Evaluatin of low-risk women during


pregnancy takes place between 24-
28weeks’gestation and typically follows a
two-step approach
 1. an initial screening is a blood glucose
concentration 1 h after the patient takes a
50grams oral glucose load.a value of greater
than 140mg/dl indetifies approximately 80%
of women with GDM
 2.if a screening value Is greater than
190mg/dl,a fasting blood glucose should be
checked on a subsequent day.a subsequent
fasting value of >= 98mg/dl would provide
two abnormal values ,as described below.
 3.If the result of the 1 hour screening
test falls between 141mg and
190mg/dl,a diagnostic 3 hours oral
glucose test is performed.the 3h 100g
oral glucose test is done after an
overnight fast for at least 8 hs.
 abnormal values are :
 1 fasting >=95mg/dl
 2.1hours >= 180
 3.2hours >= 155
 4.3hours >= 140
 At least two out of four value must be
abnomal to diagnose gestational
diabetes.
Definition
 The above definition applies regardless of
whether insulin or only diet modification is
used for treatmemt or whether the
condition comtinues after pregnancy .it is
possible that unrecongnized glucose
intolerance may have antedated or begun
concomitantly with pregnancy.
 Gestational diabetes may be screened for
by drawing a 1h glucose level following a
50grams glucose load ,but is definitively
diagnosed only by an abnormal 3h GTT
Significance
 The growth and maturation of the fetus are closely
associated with the delivery of maternal
nutrients,particulary glucose
 .this is most crucial in the third trimester and is
directly related to the duration and degree of maternal
glucose elevation.thus the negative impact is as highly
diverse as the variety of carbohydrate intolerance that
women bring to pregnancy.
 in those with severe abnormalities,there is an
increased rate of miscarriage,congenital
malformations,
prematurity,pyelonephritis,preeclampsia,in utero
meconium ,fetal distress,cesarean section
deliveries,and stillbirth.
Pathophysiology
 . Gestational diabetes is
pathophysiologically similar to type 2
diabetes
 approximately 90% of the persons identified
have a deficiency of insulin receptors or a
marked increase in weight in the abdominal
region the other 10% have deficient insulin
production and will proceed to develop
mature-onset insulin-dependent diabetes.
 Similarly to women with type 2
diabetes ,the women most likely to
develop gestational diabets are those
who are overweight ,with a body
habitus often described as “apple
shaped”
 insuline release is enhanced in an attempt
to maintain glucose homeostasis.
 the patient experiences increased hunger
due to the excess insulin release as a result
of elevated glucose levels.this insulin
release further decreases insulin receptors
due to elevated hormomal levels.thus the
vicious cycle of excess appetite with weight
gain occurs.few other symptoms mark this
condition
Diagnosis
 Glucosuria is a common finding in pregnancy due
to increased glomerular filtration and is therefore
unreliable as a means of diagnosis,
 glucose screening should be done in every
pregnnat patinet at or no later than28week’s
gestation,since risk factors are insufficient to
identify all women with gestational diabetes.
 ultrasound finding of fetal weight .>=74%for gestaional
age ,polyhydramnios(AFI>=20),midline congenital
anomalies,or an abdominal circumference measurement
anomalies,that exceeds the femur growth by 2weeks
merit an immediate 3 h GTT
 other clinical findings indicating possible diabetes are
edema developing gearly in pregnnacy and excessive
weight gain.
 Initial screening is accomplished by ingestion of
50grans of glucose at ay time of the day and
without regard to prior meal ingestion
 if screening is positive,the patient is advised to
follow a carbohydrate loading diet for 3 days and
the have a full 3 hour glucose tolerance test .
 For the GTT,the patients fasts,then receives
75g of glugose after a fasting glucose level is
obtained
 .a blood sample is then taken every h for 3
hs.the patient is asvised to sit quietly during
the test to minimize the impact of exercise
on glucose levels
 the values were set using whole blood and
required two values reaching or exceeding
the value to be positive .
Treatment
 1.The key to therapy in most patients is diet
and exercise(because of the paucity of
insulin receptors)
 2. Every care provider must stress the
importace of diet, fats must be reduced
because of their negative impact on insulin
receptors
 3. .calories should be prescibed at 20-
25kcal per kilogram of present body.
 4. insulin is added as needed for glulcose
control only after clear dietary errors are
noted and attempts at correction are done.
 5. The patient checks her glucose 4 times
daily (eg.fasting,and 1-h postprandial
breakfast,lunch,dinner ).the desired values
are fasting level of 70-90 mg/dl,and a 1h
level of 130mg/dl.the average glucose levels
should be 90mg/dl
Antepartum care
 Diabetics have triple the nomal rate of
asymptomatic bacteriuria.therefore,a
urine culture is obtained in intially,and
appropriate treatment initiated if it is
postive.
 after cessation of therapy ,urinary
culture is again obtained to confirm
elimination of the infection.
 inaddition to routine prenatal care,the
development of edema is closely
monitored.if edema occurs ,greater
attention to glucose control and
enhanced bed rest are necessities
 Assessment of the fetus by
glucose memory meters combined with
clinical/ultrasound assessment of fetal growth cannot be
replaced by other antenatal tests.
 fetuses in whom maternal glucose has been controllde
and whose mothers donot smoke or have other organ
damage will tolerate pregnancy well.
 Patients with poor glucose control,fetal macrosomia ,and
or polyhydramnios represent the patients at greatest risk
for morbiditiy and mortality
 .biweekly nonstress tests(NSTS)or weeks contraction
stress tests are begun at 32weeks for additional
monitoring of poorly controlled patients
 .weekly NSTs(also from 32weeks’geatation) are
recommended in patients with insulin-requiring
gestational diabetes,with an Increase to biweekly
recommended after 36weeks as well as the
addition of AFI evaluation.
 .for diet-controlled gestational diabetics,weekly
NSTs are usually begun at 36weeks.all patients
should be instructed, to make daily assessments of
fetal movements
 In the case of abnormal fetal testing ,the
practitioner should assess gestational age
and ,if the fetus is found to be mature
,should proceed to delivery
 Perterm labor is increased in patients with
diabetes
 the beta mimetics markedly influence
glucose control.corticosteroids increase
maternal glucose levels
 Glucose control at a level 100mg/dl for 24h
prior to delivery will reduce immediate
neonatal hypoglucemian
 insulin –requiring diabetics should be
induced at 40 weeks’gestation if
spontaneous labor has not occurred .in any
glucose-intolerant patient,the decision to
continue pregnancy longer than 40
weeks’geatation must be carefully
considered.
Intrapartum and postpartum
management
 it may be anticipated that women >160kg in
weight will require more glucose.Glucose-
containing fluids should not be used for
bolus prior to induction of condution
anesthesia.
 A bedside glucose reflectance monitor is
used to follow glucose levels every 2-4h with
the goal of maintaining levels at 70-95mg/dl.
 regular insulin is given by continuous
infusion at levels of 0.5-2u/h.
 Oxytocin is given for labor inducion similarly
to normal pregnancies
 the increase in wound infection in this
group
 .the patients is at increase risk of
thromboembolic events due to decreased
prostacyclin production by the platelets.
 breastfeeding is not affected by diabetes
and is generally encouraged.
Neonatal complicatons
 1.Early pregnancy exposure to higher
glucose levels results is enhanced rates of
abortion and an increased incidence of
congenital anomalies
 2..neonates whose mothers have higher
glucose levels over a longer duration of
pregnancy have higher incidence of
macrosomian,
hypoglycemia,hypocalcemia,polycythemia,r
espiratory difficulties,cardiomyopthy,and
congestive heart failure
 3. Macrosomic babies have increasing
intolerance to intrauterine compromise as
well as an enhanced rate of birth trauma
 4. in fact ,all organ maturation is delayed
indirect relation to the degree of
hyperglycemia.
 5. The fetal response to the intrauterine
environent such as fetal pancreatic
hyperplasia can make an impact on the
child into adulthood with an increased risk
Prognosis
 Women diagnosed with gestational
diabetes have an increased risk of
developing diabetes mellitus in the
future.if they require insulin for their
pregnancy ,there is a 50%risk of
diabetes within 10-15years still
perisists.however,evidence shows that
lifestyle alteration may delay or entirely
prevent the onset of diabetes.thus
these patients benefit from a reduction
of their risk factors
 Postpartum ,the patient should be placed
back on an ADA diet (with increased soluble
fiber and reduced fat).she should do a
lifestyle assessment and attempt to keep
her weight near ideal for her height.weight
reduction is generally necessary ,and thus if
the patient is not breastfeeding ,calories are
reduced to 1200-1500kcal with repeat
dietary instruction,and the same calorie ADA
diet is continused as the patient is
breastfeeding
 All gestationlly diabetic patients should have
a 75g 3hs glucose tolerance approximately
6 weeks after pregnancy to evaluate for
preexisting daibetes
 if the 1 hour value is high ,it represents
decreased Insulin capacity,whereas an
elevated 3hs value feflects decreased insulin
receptors.
 with an elevated 1 hs level ,limiting
simple sugars in the diet should
become a lifetime goal

 .with an elevated 3 level flucose


value,weight loss with increased
abdominal musculature should
significantly reduce the incresed risk of
diabetes