Concurrent Disorders During Pregnancy

• BMI greater than 25: weight gain of 15-25 lbs

  BMI greater than 30: weight gain of 11-20 lbs
• Age and High-Risk Pregnancy

  • Advanced maternal age is greater than 35
  • Increased risks of: spontaneous abortion/miscarriage, gestational diabetes mellitus, HTN, low birth weight, cesarean birth & instrumental vaginal delivery, placenta previa, preterm labor, PPH and autism.
• Diabetes Mellitus

  • Long-term complications: microvascular and macrovascular damage
  • At first, insulin levels increase while need for insulin can decrease hypoglycemia may occur.
  • Then, in second half-insulin resistance occurs so insulin needs increase due to sharp rise in placental hormones in mom and hyperglycemia may occur if body cannot keep up
• HbA1C goal is:

  less than 7%
• Antepartal Care Diabetes Mellitus

  • Frequent prenatal visits
  • NST, BPP, US starting 28 weeks
  • Glucose monitoring, diet, exercise, symptoms of hypo/hyperglycemia
• Preexisting Diabetes

  • Preexisting maternal vascular damage (micro and macro damage) and resulting decrease in perfusion to fetus
• Preexisting Diabetes

  Increased Maternal Risks:

  -Hypoglycemia, Gest HTN/PIH, preeclampsia, UTI, labor dystocia, C-section, PPH, birth injury to maternal tissue, PROM & ketoacidosis

  Increased Fetal/Neonatal Risks:

  -Congenital anomalies, macrosomia (greater than 4000 gm), IUGR, birth injury, hypoglycemia, polycythemia, hyperbilirubinemia, RDS and prematurity.
• Gestational Diabetes

  • Initial FBS, urine screen at every visit, 1 hr GTT at 24-28 weeks
  • If 1 hr GTT level exceeds 140 mg/dL a 3 hour oral glucose tolerance test is done
  • Diagnosed if pt has two or more of the following: Fasting (greater than 95), 1 hour (greater than 180), 2 hour (greater than 155), and 3 hour (greater than 140)
  • Management: diet & exercise, glucose monitoring & DKA monitoring, oral hypoglycemics (glyburide/metformin), and insulin
• Hemolytic Disease of the Fetus/Newborn

  • Syndrome associated with Rh isoimmunization
  • Fetal anemia with generalized edema (Hydrops Fetalis) can develop and lead to fetal pleural and pericardial effusions, ascites, heart failure and death
  • Hyperbilirubinemia (pathological)
• Indirect Coombs

  Done on MOM at 28 weeks to determine if they are sensitized (developed antibodies)
• Direct Coombs

  Test done on cord blood of NEWBORN at time of birth
• RhoGAM or Rhophylac

  • Given IM/IV to un-sensitized Rh - women
  • At 28 weeks gestation
  • Again within 72 hours after delivery if Rh + infant
  • Usual dose is 300 mcg
• ABO incompatibility

  • If baby is A or B or AB at risk if mom is O (anti-A and anti-B antibodies)
  • Maternal antibodies cross the placenta
• Cardiac disease-Pathology

  • Congenital 50% (mitral valve prolapse and septal wall defects)
  • Acquired (rheumatic heart disease-valve disease & ischemic CAD)
  • Peripartum cardiomyopathy
• Cardiac disease signs & symptoms

  Cough, dyspnea, orthopnea, rales/crackles in lower lobes, fatigue, palpitations, chest pain, edema/fluid retention/rapid weight gain and decrease in oxygen saturations
• Anemia

  • Iron supplementation FeSo4 325 mg/day take at night or on empty stomach may increase absorption, take with orange juice
  • Can lead to decrease oxygen delivery to fetus and PTL/PTB
  • Folic acid needed for RBC production
  • Folic acid supplementation for NTD prevention