MEDICAL DISEASES

IN PREGNANCY
HEMATOLOGICAL
DISORDER IN
PREGNANCY
NUR AMALIA AZRA BT AZAMAN
012012100101
IRON DEFICIENCY ANEMIA
CLINICAL FEATURES :

Leg Dyspnea Palpitati SIGNS

swelling on Pallor
Leg edema
SYMPTOM Soft systolic
Giddines Indigesti murmur at
s on mitral area
Basal
crepitation
Lethargic Anorexia
 INVESTIGATION
1. DEGREE OF ANEMIA

. Hemoglobin ( < 10.9gm% )

- Mild : 8 - 10 gm%
- Moderate : < 8 7 gm%
- Severe : < 7 gm%

. Total red cell count ( < 4 x 10^9 /mm3 )

. Packed cell volume ( < 30% )
2. TYPE OF ANEMIA
Peripheral Blood Smear :
- Hypochromic microcytic Anemia
- anisocytosis, poikilocytosis, increase
reticulocyte count
Hematological indices :
- MCHC (most sensitive index of IDA) < 30%
- MCV ( < 75 u3 )
- MCH ( < 25 pg )
Other blood values importance in IDA :
- serum iron : < 30ug/100mL
- TIBC : > 400ug/100mL
- percentage saturation : 10 % or less
3. CAUSE OF ANEMIA
Examination of stool :
- presence of helminthic (hookworm)
Urine examination
- Tro infection
- detect presence of protein, sugar and pus cells

If definite diagnosis as to the cause of anemia cannot be made with

the above, further investigations are made based on clinical findings.
E.g : Chest Xray in suspected pulmonary tuberculosis,
Serum protein in hypoproteinemia,
Osmotic fragility in hereditary spherocytosis
 Bone marrow studies
- indicated in cases not responding to therapy
- To diagnose hypoplastic anemia
- IDA : normoblastic character
 COMPLICATIONS (MOTHER)

PREGNANCY LABOR PUERPERIUM

Pre eclampsia Uterine Inertia Puerperal

Intercurrent Postpartum sepsis
infection hemorrhage Subinvolution
Heart failure Cardiac failure Poor lactation
Preterm labor Shock Puerperal
Venous
Thrombosis
Pulmonary
Embolism
 COMPLICATIONS (BABY)
Neonate does not suffer from anemia at birth
- Amount of iron transferred to the fetus is unaffected even if
mother
suffers from IDA.

Increase incidence of :
Low birth weight babies
Intrauterine death
 TREATMENT (PROPHYLACTIC)
1) Avoidance of frequent child-births
- min. interval at least 2 years
2) Iron supplementation
- T. ferrous Sulphate 200mg OD + Folic acid 1 mg
3) Balanced diet
- Iron rich food e.g liver, meat, green vegetables
4) Adequate treatment of causative disorders malaria,
UTI etc.
5) Hemoglobin estimation at 1st antenatal visit
 TREATMENT (CURATIVE)
ORAL THERAPY
T. ferrous sulphate 200mg BD / TDS + folic acid 1mg
Drawbacks :
- Intolerance e.g Nausea, vomiting, diarrhea
- Unpredictable absorption rate
- Difficulty in replenishing stores
Evidence of Response to therapy
- Sense of well being
- Increase appetite
- Hb increase
- Reticulocytosis within 7 10 days
 Rate of improvement
- Rise in Hb after 3 weeks of therapy, with expected Hb
concentration
increase 0.7 g/100mL per week
Causes of failure of improvement
- Improper typing of anemia
- Poor absorption
- Poor compliance
- Concurrent blood loss e.g hookworm
- Co-existent folate deficiency
Contraindication
- Intolerance
PARENTERAL THERAPY
Intravenous route
TDI (Total Dose Infusion) : deficit of iron is first
calculated and total amount of iron required to correct
deficit is administered by single sitting IV infusion.
Iron Sucrose (20mg/ml) 5ml ampules
Max 200 mg/day is given as slow IV injection or IV
infusion, repeated on alternate days
Calculations of total iron required (Formula)
0.3 x W (lb) (100 Hb%) + 50%
 Indication
- contraindication to oral iron
- Poor compliance
- Cases seen for the first time during last 8-10 weeks with severe
anemia
Advantage
- Eliminates repeated and painful IM injection
- Tx completed in a day, patient can discharged earlier
- Less costly compared to IM therapy
Limitation
- Not suitable if at least 4w time is not available
- Contraindicated for prev history of reaction to parenteral
therapy
 Intramuscular therapy
Iron dextran (Imferon)
Iron sorbitol complex - Jectofer
Stop oral iron at least 24h prior therapy to avoid
reaction
Drawbacks :
- Painful injection
- Abscess formation
- Skin staining
- Anaphylactic reactions
BLOOD TRANSFUSION
Indication
- To correct anemia due to blood loss and to combat PPH
- Severe anemia seen in later months of pregnancy (beyond 36w)
- Refractory anemia : not responding to either oral or parenteral
therapy
- Associated infection
Advantages
- Increases oxygen carrying capacity of the blood
- Hb from hemolysed red cells may be utilized for formation of new
red cells
- Supplies natural constituents of blood like proteins, antibodies etc
- Improvement 3 days
 Drawbacks
- Premature labor due to blood reaction
- Increase chance of cardiac failure with pulmonary
oedema
- Transfusion reaction
MANAGEMENT DURING LABOR
1ST STAGE
Propped up position
IV life line with bore needle
Oxygen inhalation / pulse oximetry
Analgesia
Antibiotic prophylaxis
Strict asepsis to minimize puerperal infection
2ND STAGE
Avoid prolongation (Vacuum / forceps application)
3RD STAGE
Consider active management
Replace blood loss if excessive
 THALASSEMIA
Genetic disorders of blood
Reduced rate of globin chain synthesis, result in
inadequate Hb
content
Deficient eryhtropoiesis, hemolysis and anemia.
Alpha thalassemia, Beta thalassemia.
ALPHA THALASSEMIA
A-peptide chain production is controlled by 4 genes, located on Ch 16

Syndromes : Parental
Mutation of one gene silent carrier diagnosis :
Mutation 2 gene a-thalassemia minor. CVS
Pregnancy well tolerated amniocentesis
Mutation 3 gene Hb H disease. Patient
suffer of hemolytic anemia. During
pregnancy anemia deteriorates further. Treatment :
Mutation 4 gene a thalassemia major. Oral iron
Fetus dies either in utero or soon after Folate
birth. supplementation
Blood transfusion
for low Hb
BETA THALASSEMIA MAJOR
Mutation of 2 genes
Red cell destruction, thus result in ineffective erythropoiesis
An infant needs repeated blood transfusion
Result in progressive hatosplenomegaly, impaired growth, CCF
and intercurrent infection
Iron overload overcome with iron chelation therapy
B minor : sickle cell trait
HEMATOLOGICAL
FINDINGS :
1)Low MCV and MCH,
normal MCHC
2)Serum iron and TIBC
normal or increase
3)Hb electrophoresis shows
raised conc. of HbA2 with
normal or raised Hb-F
4)Increase serum bilirubin
5)Mild anemia
TREATMENT :
Oral and IV iron therapy is
contraindicated in
thalassemia major
Labor and delivery
management are usual
Patient in thalassemia
major often with small in
stature, small pelvis often
needed caesarian delivery
Majority tolerate pregnancy
well with good maternal
and fetal outcome
 References :
DC Dutta's Textbook of Obstetrics
HEART DISEASE IN
PREGNANCY
MOHD ZARIF ASYRAAF RAHIM
INTRODUCTION
The incidence of cardiac lesion is <1% amongst hospital deliveries
Commonest cardiac disease
Rheumati Cardiomyopath
Congenital
c ies
Atrial or Patent
ventricul ductus
Peripartum
80% cardiomyopath
ar septal arteriosu
mitral ies
defect s
stenosis Pulmonar Coarctati
Myocardial
y on of
stenosis aorta infarction
aortic
stenosis
Fallots tetralogy
PREGNANCY effects ON HEART DISEASE
Hemodynamic changes in pregnancy affect heart disease
Damaged heart with good reserve can withstand the extra
load but if the reserve is poor cardiac failure may occur
Cardiac failure occurs
Pregnancy around 30 weeks
During labour
Mostly soon following delivery

EFFECTS OF HEART LESION ON PREGNANCY: tendency of

preterm delivery and prematurity. IUGR common in cyanotic
heart disease
 Factors for cardiac failure
Cardiac Left
Advanced
arrhythmia ventricular
age hypertrophy
s
Inadequat Appearance Risk
Previous
e factors
heart Anemia
supervisio Hypertension,
failure weight
n Infection
Multiple pregnancy
DIAGNOSIS
Anatomic and physiologic changes during pregnancy that mimic
cardiac disease
Hyperdynamic circulation
Systolic ejection murmur at left sternal border
Dyspnoea, decrease exercise tolerance, fatigue,
syncope
Tachycardia, shift of ventricular apex
Continuous murmur at 2nd to 4th intercostal space
Loud first sound with splitting
DIAGNOSIS
Diagnosis of heart disease in pregnancy
SYMPTOMS Breathlessness, syncope, chest pain
SIGNS Chest murmurspansystolic, late systolic, louder ejection systolic
or diastolic associated with a thrill
Arrhythmia
Chest x ray Cardiomegaly, increased pulmonary vascular markings, pulmonary
veins enlargment
ECG T-wave inversion, bi-atrial enlargement, dysrrhythmias
Echocardiogra Detects structural abnormalities (ASD , VSD), valve anatomy,
phy valve area, function , left ventricular ejection fraction ,
pulmonary artery systolic pressure
GENERAL MANAGEMENT
Consider in high
Antenatal care
maternal risk
Early booking & frequent antenatal visits
1.Eisenmengers
Assess and stratify maternal CVS risk
syndrome
Diet to restrict weight gain and prevent anaemia
Avoid infection
2.Marfans syndrome
with aortic
Hospitalisation: if sign of compensation occurs
involvement
To offer termination of pregnancy if indicated
3.Severe pulmonary
hypertension
4.Coarctation of aorta
with valvular
involvement
*Safest time for TOP is early in 1
st

trimester
 Risk of maternal mortality with heart
disease

Low risk: Can be managed at local centre after review by

family med specialist or cardiologist
Moderate risk: Should be managed at tertiary centre by
multidisciplinary team
High risk: Refer early to tertiary centre for assessment
 Risk of maternal mortality with heart
disease

NYHA

Modified WHO
CVS drugs in pregnancy
Beta-blockers Safe: control heart rates in pt with mitral stenosis & arrhythmia
associated with IHD
Digoxin Safe: indicated in AF and heart failure
Diuretics Use judiciously: use in cardiac failure with potassium supplements in
prolonged therapy

Ace-i Unsafe
Calcium Use judiciously
antagonist
Adenosine Safe
Lidocaine Safe
Procainamide Safe
Quinidine Safe
Amiodarone Unsafe
Role of anticoagulants
Anticoagulants
are necessary in cases of congenital heart
disease who have pulmonary hypertension, artificial
valve replacements or atrial fibrillation
Warfarin
has teratogenic effects and may cause foetal
embryopathy
Higher risk >5mg/day
Heparin is given in subcutaneous dose. No teratogenic
effects.
Higher risk for valve thrombosis in mechanical heart valve
MANAGEMENT OF LABOUR
Management should be obstetrician led
Vaginal delivery is preferred mode of delivery
Avoid prolonged labour
Lateral decubitus position to avoid aortacaval compression

Induction of labour
No indication purely on the basis of cardiac disease
Should be avoided in acute heart failure
Indicated if bishop score is favourable
Low amniotomy + oxytocin infusion

First stage monitoring

Haemodynamic cardiac monitor
O2 saturation & continuous foetal monitor
Strict input output chart
Epidural analgesic

Second stage
Limitactive pushing as it may cause haemodynamic unstability
Shortened stage by assisted delivery

Third stage
IM5 IU oxytocin and control cord traction
Oxytocin also used to prevent PPH
Indication for Caesarean section

Marfans Acute or Heart failure

Obstetric syndrome &
aortic diameter chronic aortic (NYHA III &
indications
> 45mm dissection IV)

Severe Pulmonary
obstructive hypertension &
Eisenmenger LVEF < 30%
cardiac
lesions syndrome
POSTPARTUM MANAGEMENT
Monitored
for 48 72 hours in HDU/ICU/CCU as significant
haemodynamic changes occur in 24 72 hours & cardiac failure may
occur
Monitor fluid overload by
Respiratory rate
O2 saturation & input output chart

Patient risk of thromboembolism should be managed with

Earlyambulation
Use of anti-embolism stocking
Use of LMW heparin where indicated

Contraception and contraceptive advice given prior discharge

PROGNOSIS of heart disease in
pregnancy
Prognosis depends on
1. Nature of lesion and functional capacity of the heart
2. Quality of medical supervision provided during pregnancy, labour
and puerperium
3. Appearance of the risk factors
 Prognosis
Maternal Foetal
Maternal mortality is lowest in rheumatic Rheumatic heart lesion
heart lesions and a cyanotic group of The foetal outcome is usually
heart diseases
50 % mortality in Eisenmengers
good and in no way different from
Syndrome (pulmonary hypertension with the patients without any heart
shunt through an open ductus, atrial or lesion.
ventricular defect)
Majorcause of death: CARDIAC Cyanotic group of heart lesion
FAILURE There is increased foetal loss
Other cause of death (45%) due to abortion, IUGR and
Pulmonary oedema prematurity
Pulmonary embolism
Active rheumatic carditis Foetal congenital malformation is
Subacute bacterial endocarditis increased by 3-10% if either of the
Rupture of cerebral aneurysm in parents have congenital lesions
coarctation of aorta
 Eisenmengers Syndrome
Patients
may have pulmonary hypertension with shunt (rt to lt) through
an open ductus (PDA), an atrial or ventricular defect.
Maternal motility and perinatal : 50%
Termination pregnancy should be considered.
Heparin
should be used throughout pregnancy risk of systemic and
pulmonary thromboembolism.
Epidural anaesthesia contraindicated.
Complications
CCF,
haemoptysis, cerebrovascular accidents, hypoxemia,
hyperviscosity syndrome and sudden death.
 Peripartum Cardiomyopathy
Definition

1. Development of heart failure

2. in the last month of pregnancy or within 5 months of delivery
3. in the absence of an identifiable cause and recognisable heart disease prior to the last
month of pregnancy

.Predisposing factors
Maternal age > 30years
Multiparous

Eclampsia

Twin

Hypertension

Nutritional deficiencies
 Peripartum Cardiomyopathy
A diagnosis of exclusion
Symptoms
Weakness
Shortness of breath
Cough
Nocturnal dypsnea
Palpitation

Examination
Tachycardia
peripheral
oedema
pulmonary rales

Pregnancy poorly tolerated in women with dilated cardiomyopathy

 Peripartum Cardiomyopathy
Treatment

Bed rest, digitalis, diuretics (preload reduction), hydralazine or

ACE inhibitor, Beta blocker, anticoagulant therapy
Vaginal delivery
Epidural anaesthesia is preferred

Mortality is high (20-50%) due to pulmonary embolism and

cerebral thrombosis.
DIABETES MELLITUS
AND PREGNANCY
M. ZAHIER
DIABETES MELLITUS AND
PREGNANCY
It is a chronic metabolic disorder due to either insulin
deficiency or due to peripheral tissue resistance.
Type 1 Characterized by young at onset (juvenile) and
absolute insulopenia. They have genetic predisposition
with presence of autoantibodies.
Type 2 Late age onset, overweight woman and
peripheral tissue insulin resistance. Genetic
predisposition is also observed.
1-14 % pregnancies are complicated by diabetes
mellitus and 90% of them are gestational diabetes.
EFFECTS OF DIABETES ON
PREGNANCY
During Pregnancy During Labour Puerperium
Miscarriage Prolongation of labour Puerperal sepsis
Congenital malformation Shoulder dystocia Lactation failure
Macrosomia Perineal injuries
Infection Postpartum hemorrhage
Pre-eclampsia Operative interference

Diabetic Retinopathy
Diabetic nephropathy
Ketoacidosis
MANAGEMENT

Pre-conceptional
Antenatal care Intrapartum care
counselling

Neonatal care Post-partum care

Pre-conceptional counselling
Goal:
to achieve the best possible glycaemic control before pregnancy.
a fasting plasma glucose level of 57 mmol/litre on waking and
a plasma glucose level of 47 mmol/litre before meals at other times of
the day
Hba1c <6.5%
to educate diabetic women about the implications of pregnancy.
explain the risks of pregnancy in diabetes,
and include advice to lose weight and take high dose (5 mg) folic acid pre-
conception and for the first 12 weeks.
ANTENATAL CARE
Monitoring blood glucose
Monitor their fasting pre-meal, 1hour postmeal and bedtime
blood glucose levels daily
Target : fasting: 5.3 mmol/litre
1 hour after meals: 7.8 mmol/litre or
2 hours after meals: 6.4 mmol/litre

Monitoring HbA1c
To assess risk of pregnancy
>6.5% increased the risk
ANTENATAL CARE
Insulin treatment
Advise about the risks of hypoglycaemia
Advise them to always have available a fastacting form of glucose

Ketone testing

Retinal assessment if DR is present at booking, perform an additional

retinal assessment at 1620weeks

Renal assessment
ANTENATAL CARE
Preventing pre-eclampsia - 75 mg of aspirin daily from 12
weeks until the birth of the baby

Detecting congenital malformations

Monitoring fetal growth and wellbeing every 4 weeks

from 28 to 36 weeks
INTRAPARTUM CARE
Timing and mode of birth
no complications: elective birth by induction of labour, or by
elective caesarean section if indicated, between
37+0weeksand 38+6weeksof pregnancy
Consider elective birth before 37+0weeksfor women with
type1 or type2 diabetes if there are metabolic or any other
maternal or fetal complications

Anaesthesia if GA is used, monitor blood glucose every 30

mins
NEONATAL CARE
Initial assessment and criteria for admission to intensive or special
care
Carry out blood glucose testing routinely in babies of women with diabetes
at 24hours after birth
Perform an echocardiogram for babies of women with diabetes if they show
clinical signs associated with congenital heart disease or cardiomyopathy

Preventing and assessing neonatal hypoglycemia

Women with diabetes should feed their babies as soon as possible after birth
(within 30minutes) and then at frequent intervals (every 23hours) until
feeding maintains prefeed capillary plasma glucose levels at a minimum of
2.0mmol/litre
POSTNATAL CARE
Blood glucose control, medicines and breastfeeding
Women with insulintreated preexisting diabetes should
reduce their insulin immediately after birth and monitor their
blood glucose levels carefully to establish the appropriate
dose
Advise them to have a meal or snack available before or
during feeds
Follow-up after birth
Refer back to their routine diabetes care arrangements
Remind the importance of contraception and the need for
preconception care when planning future pregnancies.
REFERENCES
https://www.nice.org.uk/guidance/ng3/chapter/1-Recom
mendations
DC Duttas Textbook of Obstetrics
MOHAMMAD FAIZ BIN
SHAMSURIEE
 Outline

Thyroid dysfunction and pregnancy

Jaundice in pregnancy

Viral hepatitis
 Hyperthyroidism
Occur in about 2 per 1000 pregnancies

Common cause: Graves' disease due to thyroid stimulating

antibodies

Other cause: nodular thyroid disease, sub-acute thyroiditis,

hyperemesis gravidarum, trophoblastic disease

Physiological changes during pregnancy such as increase in

cardiac output, oxygen consumption and heat may mimic
mild thyrotoxicosis
 Complication
Maternal Fetal/neonatal

Miscarriage IUGR

preterm delivery prematurity

pre-eclampsia stillbirth

CCF hyperthyroidism

Placental abruption hypothyroidism

thyroid storm morbidity

infection mortality
 Clinical diagnosis
Thyroid function test
Ultrasound of the fetal thyroid gland
Thyroid peroxidase antibodies
Antimicrosomal antibodies
Thyroid stimulating immunoglobulin
Radioactive
iodine uptake and scans should not be
done during pregnancy as it will cross the placenta and
damage the fetal thyroid gland permanently
 Treatment
Antithyroid drugs- propylthiouracil, methimazole, carbimazole
Methimazole is avoided in the first trimester because risk of
embryopathy
Carbimazoleis given orally with a daily dose of 10-40 mg and
maintained of between 5 mg and 15 mg daily
Propylthiouracilis given at a daily dose of 300-450 mg and
continued till the patient become euthyroid. Maintenance dose 50-
150 mg daily
Both drugs may cause fetal goiter and hypothyroidism
Propanolol- marked tacycardia or arrhythmias
 Thyroidectomy- when required to relieve the pressure
symptoms can be done safely in the second trimester with
prior biochemical control
 Monitoring
Fetal surveillance- seriel ultrasound, non-stress test, fetal
biopysical profile

The drugs are not contraindicated during breastfeeding

provided the dose is kept relatively low and close
monitoring of the neonatal thyroid function is carried out

Cord blood should be taken for TSH and free T4 at the time
of delivery to detect neonatal hyperthyroidism
 Preconceptional counseling

Important to considering the hazards during pregnancy

Adequate treatment should be instituted to bring down the

thyroid function profile to normal

Radioactive iodine therapy should not be given to patients

wanting pregnancy within one year
 Hypothyroidism
Primary hypothyroidism mostly related to Hashimoto
thyroiditis

Untreated in early pregnancy has a high fetal wastage in

the form of abortion, stillbirth and prematurity and deficient
intellectual development of child

Other complication like preeclampsia and anaemia are high

 Investigations

Serum thyroid peroxidase antibodies or antimicrosomal

antibodies are elevated in autoimmune thyroiditis

Serum TSH should be repeated at an interval of 6-8 weeks

as there is increased demand of thyroid hormone in the
second half of pregnancy
 Treatment

Levothyroxine- 2 to 2.4 mcg/kg/day

Maintainance dose 75-150 mcg of L-thyroxin per day

TSH repeated every 2-6 weeks

 Thyroid storm

Life threatening condition

Severe hyperpyrexia, tacycardia, CCF, neuropsychiatric

symptoms, nausea and vomiting

Mortality 25%
 Management
Supportivetherapy in an ICU: fluids and electrolytes
balance, oxygen therapy and acetaminophen for pyrexia
Management of CCF
B-blocker therapy to control hyperdynamic symptoms
Antithyroid drug to block thyroid hormone synthesis
Lugols iodine solution
Glucocorticoids to block peripheral conversion of serum
T4 to T3
Jaundice in pregnancy
 When the bilirubin level exceed 2 mg% (normal: 0.2-0.8 mg
%), visible yellow staining of the tissue appear

The cause divide into 3

 Obstetric cholestasis

Second most common cause of jaundice in pregnancy

The stasis in the bile canaliculi with rise in conjugated

bilirubin is probably due to excess circulation estrogen

Similar manifestation is also observed in women taking OCP

 Clinical Features
Appear in last trimester
Theonset is insidious; generalized pruritus is the
predominant symptom.
There may be weakness, nausea or even vomiting
Jaundice is slightly
AST, ALT and serum alkaline phosphatase
Bilirubin level rarely exceeds 5 mg%
Liver biopsy shows features of intrahepatic cholestasis
 Management
Cholestyramine is effective for itching

Vitamin K to reduce postpartum haemorrhage and neonatal

bleeding

The neonate should be given vitamin K as routine

Monitored prothrombin time

Ursodeoxycholic acid- increase bile acid excretion. Improves

pruritus
VIRAL HEPATITIS
 The most common jaundice in pregnancy in the tropics

Restricted to the ill-nourished mothers, living unhygienic

environment

In the tropics, is often occurs as an epidemic form

There is also increased incidence of its affection in the

pregnant state
 Types
Hepatitis A (RNA)

Hepatitis B (DNA)

Hepatitis C (RNA)

Hepatitis D (RNA)

Hepatitis E (RNA)

Hepatitis G (RNA)
 Hepatitis A
Spread by fecal-oral route
Diagnosis is confirmed by detection of IgM antibody to hepatitis A
Perinatal transmission is rare, chronic carrier state does not exist
The virus is not teratogenic
Pregnant
women exposed to HAV infection should receive
immunoglobulin 0.02 mL/kg within 2 weeks of exposure
Hepatitis A vaccine single dose0.06 mL IM
Safe in pregnancy
 Hepatitis B
Transmitted by parenteral route, sexual contact, vertical
transmission and rarely through breast milk

The risk of transmission to fetus ranges from 10% in first

trimester to as high as 90% in third trimester

Specially high to mother are seropositive to hepatitis B

surface antigen
 Neonatal transmission
Mainly occurs at around the time of delivery through mixing
of maternal blood and genital secretions

Approximately 25% of the carrier neonate will die from

cirrhosis or hepatic carcinoma, between late childhood to
early adulthood

Not teratogenic
 Diagnosis

Confirmed by serological detection of HBsAg, HbeAg and

antibody to hepatitis B core antigen

Liver enzymes are elevated during the initial phase

 Screening

All pregnant women should be screened for HBV infection at

first antenatal visit and it should be repeated during the
third trimester for high risk group
 Hepatitis C
It is recognised as the major cause of non-A, non-B hepatitis

Transmission is mainly blood borne and to a lesser extent by

fecal-oral route

Responsible for chronic active hepatitis and hepatic failure

Perinatal transmission (10-40%) is high and presence of

coinfection with HIV and HBV
 Detection is by antibody to HCV by EIA, which develops
usually late in the infection

Confirmation is done by recombinant immunoblot assay

Chronic carrier state is present

No effective vaccine against HCV is available

Women should be immunized against hepatitis A and B if

not immune

Breastfeeding is not contraindicated

 Hepatitis D
It
is seen in patients infected with HBV either as a co-
infection or super infection
Perinatal transmission is known
Chronic carrier state is seen
Neonatalimmunoprophylaxis for HBV is almost effective
against HDV
Acute infection with fulminant course
Results in high maternal mortality (2-20%) due to hepatic
failure
 Hepatitis E
It behaves similar to hepatitis A virus infection

It may lead to fulminant hepatitis

ELISA can detect HEV specific IgG and IgM antibodies or by

PCR

Chronic carrier state is present

Perinatal transmission is uncommon

Maternal mortality following acute infection is high (15-20%)

 Hepatitis G
Related to hepatitis C virus

More prevalent but less virulent than HCV

Coinfection with hepatitis A, B, C and HIV is common

Chronic carrier state is known and perinatal transmission is

documented
 Prognosis: fulminant hepatitis is more common in hepatitis
E, less common in hepatitis C and rare in hepatitis A

Mortality is very high in fulminant type

 Complication
Maternal fetal

Postpartum haemorrhage abortion

Renal failure preterm birth

coagulopathy intrauterine death

infection congenital malformation of the fetus

hepatorenal syndrome
Management
 Prophylaxis
Improvement sanitation, supply of safe drinking water and
adequate care of personal hygiene are essential

Use of disposable syringe or boiling of syringe prior to use

are the positive steps in prevention

Screening of blood donors for HBsAg should be routinely

done
 HBV management
Maternal
HB immunoglobulin 0.06 mL/kg IM
Recombinant DNA vaccine IM 1 mL, 3 doses at 0,1,6 month
Infants
HBIG 0.5 mL IM within 12 hours of birth
Active immunisation with HB vaccine 0.5 mL
Breastfeeding is not contraindicated
Other
Lamivudin and HIBG are effective to reduce the transplacental transmission
 Hepatitis A: both passive immunisation and active
immunisation with killed virus vaccine are available for the
mother

Health care worker: should receive hepatitis B vaccine and

they should avoid needle stick injury and blood to blood
product
Thank you
Kalichandren Arumugam
012013050221
Epilepsy in Pregnancy
 Introduction
Affect approximately 1 in 200(0.5%) of women of
childbearing age and is the commonest chronic
neurological disorder to complicate the
pregnancy
Most cases are idiopathic and no underlying
cause is found.
Approximately 30% of these patients have a
family history of epilepsy
 Causes
Eclampsia
Cerebral vein thrombosis
Thrombotic
thrombocytopenic purpura Infection
Postdural puncture
Stroke Gestational epilepsy
Subarachnoid haemorrhage Pseudo epilepsy
Drug and alcohol withdrawal
Hypoglycaemia
Hypocalcaemia
Hyponatremia
 Diagnosis
For the first seizure occurs in the following
investigation are appropriate for differential
diagnosis
Blood pressure
Urinalysis
Uric acid Blood film

Platelet count Serum electrolyte(serum calcium, magnesium)

Liver function test
Radiology- CT scan /MRI of brain
Clotting screening EEG
Management
Pre pregnancy counselling
Reassure the patient, they can have healthy babies
Offered them information that enable them to make
informed decision about minimizing risk factors for
themselves and baby
Preconception Issues
Planning a pregnancy teratogenic risk of AEDs important
of seizure control acid before conception (High dose
folic acid 5mg/day recommended in pre-conceptual
& at least 1st trimester)genetic counselling
If pregnancy is planned, it is possible to optimize
medication in term of maximize seizure control and
minimum risk of fetal development
 Antenatal care
Prenatal screening for congenital anomalies using nuchal
translucency scanning and detailed ultrasound at 18-20
weeks should be advised. Scanning should include fetal
cardiology assessment and screening for facial cleft
Advised to bathe in shallow water of to shower
Relatives or partners should be advised on how to place the
women in the recovery position to prevent aspiration in the
event of a seizures
Regular seizures doses of carbamazepine, valproate and
lamotrigine have to be increased due to altered
pharmacokinetics of pregnancy as the free drug level
reduce due to plasma expansion and increase renal and
hepatic clearance .
Vitamin k 10mh/day should be prescribed in the last 4
weeks of pregnancy for women with epilepsy to
 Intrapartum
Aim for vaginal delivery
Caesarean section is indicated only in recurrent
generalized seizures
Regular anti epileptic drug should be continue in labour
and women should not be left unattended
Early epidural analgesia should be considered to limit
precipating a seizure
For those who had seizure during previous deliveries
intravenous phenytoin, sodium valproate or rectal
carbamazepine may be given to replace the usual oral
 Postnatal
Neonatal should give vitamin k 1mg through intramuscular
(to reduce the risk of haemorrhagic disease of new born)
Breast feeding should encourage
If the anticonvulsant or anti epileptic dose increased in
pregnancy it should be reduced to pre pregnancy level
slowly postpartum
Should encourage the mother breastfeed before taking
anticonvulsants to avoid peak serum and breast milk level.
The mother should be strategies to minimize the risk of
herself and the baby in case she has seizure includes
changing nappies with the baby on the floor and bathing in
 Newly diagnosed idiopathic
epilepsy in pregnancy
All the secondary causes of seizures listed earlier
should be excluded
It is not obligatory to treat one isolated seizure
If treatment is required carbamazepine are
reasonable choice however generalized seizures
with myoclonus and photosensitivity respond to
sodium valproate
Common anti epileptic
drug and dosage
regimen
Asthma in Pregnancy
 Asthma is a chronic inflammatory disorder which
affects the passages or airways of the lungs,
which results in difficulty to breathe.
The prevalence of asthma on pregnancy ranges
from 1-4%.
However, it is one of the most common chronic
disease in pregnancy.
 Trigger for asthma
Allergens such as house dust, pollen
Smoking
Exercise
Occupational exposure
Pollution
Drug such as aspirin, b-blockers
Alcohol, peanuts, orange juice
Monosodium glutamate(Msg)
Medical condition rhinitis and gastric reflux
Hormonal such as premenstrual condition and pregnancy
 Dyspnoea in pregnancy
Extremely common and may effect either the
normal anatomical and physiological changes
that occur in pregnancy or anxiety or an
underlying pathology
So women with known asthma the cause of
increased breathlessness may be not due to
asthma
A healthy respiratory rate is 12-20 breath/minute
at rest
Differential diagnosis in pregnant
women with dyspnoea
Respiratory disease
Asthma
Chest infection or pneumonia
Thromboembolic disease
Interstitial lung disease, sarcoid or secondary to
a connective
Tissue disorder, pneumothorax
Amniotic fluid embolism
Differential diagnosis in pregnant
women with dyspnoea
Cardiac disease
Arrhythmias
Ischemic heart disease

Endocrine disease
Diabetes mellitus leading to hyperventilation
acute ketoacidosis
Acute thyrotoxicosis
Differential diagnosis in pregnant
women with dyspnoea
Haematological
Chronic anaemia
Acute haemorrhage

Renal disease
Hyperventilation to compensate for metabolic
acidosis
 Clinical features
Symptoms
Cough, breathlessness, wheezing and chest
tightness
Symptom are commonly worse at night and in
the early morning
Sign
Tachycardia, increased in respiratory rate,
wheeze, use of accessory muscle and inability to
complete sentences
 Poorly controlled asthma
Adverse Effect
Preeclampsia Congenital anomalies
Pregnancy-induced Fetal growth restriction
hypertension Low birth weight
Uterine hemorrhage Neonatal hypoglycemia,
seizures, tachypnea,
Preterm labor
and neonatal intensive
Premature birth care unit (ICU)
admission
 Diagnosis
Measure with PEFR or spirometry to measure
FEV1 and Forced Vital capacity(FVC)
High probability of asthma FEV1/FVC ratio is
more than 0.7
 General principle of asthma
management in pregnancy
No contraindication to most first line treatment
for asthma when used in pregnancy
Smoking cessation
The efficacy of inhaled corticosteroid is reduced
in asthmatic who smoke
 Exacerbation of asthma
Step 1
Mild intermittent asthma
Inhaled short acting beta 2 agonist as required
Step 2
Regular preventer therapy
Add inhaled steroid 2000-800 gm per day
400 gm is an appropriate starting dose for most
patient
 Exacerbation of asthma
Step 3
Initial add on therapy
Add inhaled long acting beta 2 agonist (LABA).
Asses control of asthma
Step 4
Persistent poor control
Increase inhaled steroid up to 2000 gm addition
of 4th drug leukotriene receptor antagonist,
theophylline
 Exacerbation of asthma
Step 5
Continue or frequent use of oral steroid
Use daily steroid tablet in lowest dose to control
Maintain high dose inhaled steroid at 2000
gm/day
Consider other treatment o minimise the use of
steroid tablets
 Asthma : Labour and
delivery
Should not discontinue inhaler during labour and
there is no evidence to suggest that B2 agonist
as inhaler impair the uterine contraction or delay
the onset of labour
Women who using oral steroid (prednisolone
>7.5mg per day for > 2 weeks prior to delivery
should receive parenteral hydrocortisone 50-
1000mg 3 times or 4 times / day ) to cover the
stress of labour and until oral medication is
restarted
 Asthma : Labour and
Prostaglandin E2delivery
used to induce labour or for
early termination of pregnancy, is a
bronchodilator and is safe to use.
Prostaglandin F2a can cause bronchospasm and
need to use with caution
Ergometrine and syntometrine may cause
bronchoconstriction and should be used with
caution
SLE in pregnancy
 Incidence
Women > men (ratio 9:1)
During the child-bearing years (ratio 15:1).
Incidence: 1 in 1000 women
 Signs and symptoms
Fatigue
Fever
Arthritis
Serositis
Photosensitive rash Raynaud phenomenon
Glomerulonephritis
Vasculitis
Hematologic abnormalities
 Signs and symptoms
In general, pregnancy does not cause flares of
SLE.
When flares do develop, they often occur during
the first or second trimester or during the first
few months after delivery.
The most common symptoms of these flares
include arthritis, rashes, and fatigue, and they
are often easily treated.
 Diagnosis
The following laboratory studies are recommended with
the first visit after or when pregnancy is confirmed:
Renal function tests
Urinalysis, and tests of the urinary protein-to-creatinine
(P/C) ratio
Complete blood count
Test for anti-Ro/SSA and anti-La/SSB antibodies
Lupus anticoagulant and anticardiolipin antibody studies
Antidouble-stranded DNA (anti-dsDNA) test
 Diagnosis
During the first 2 trimesters, a monthly platelet count or
CBC is recommended. In addition, the following studies
are recommended at the end of each trimester of
pregnancy:
Determination of the GFR and measurement of the
urinary P/C ratio
Anticardiolipin antibody measurement
Complement studies (CH50 or C3 and C4)
Anti-dsDNA study
 Diagnosis
In pregnant patients with renal disease, renal
biopsy should be performed to differentiate
preeclampsia from active lupus nephritis when
differentiation on clinical grounds is not possible.
Imaging studies
Ultrasonography: At first prenatal visit to
accurately estimate the gestational age
Serial fetal echocardiography: To detect fetal
heart block at an early stage
 Management
Preconception counselling
Counsel patients about the teratogenicity and
adverse effects of the medications used to treat
SLE before therapy is initiated.
Remind about the importance of using
contraception while they are taking
methotrexate,leflunomide, cyclophosphamide,
and mycophenolate.
 Management
Educate patients that, because of prolonged half-lives,
some medications may need to be discontinued several
months before the planned conception.
In addition, measures may need to be undertaken to
enhance elimination of some medications as soon as
pregnancy is detected.
 Management
Pharmacotherapy
None of the medications used in the treatment of
SLE is absolutely safe during pregnancy.
Therefore, whether to use medications should be
decided after careful assessment of the risks and
benefits in consultation with the patient.
During the first trimester, most of the drugs
should be avoided.
 Management
Patients can breastfeed if not
takingazathioprine,methotrexate, cyclophosphamide,
ormycophenolate.
Hydroxychloroquineis also secreted in breast milk;
therefore, this drug should be used with caution.
Prednisone (<15-20 mg/d) can be used safely during
breastfeeding
NSAIDs should be used with caution in newborns
without jaundice
Reference
Thank You
Syphilis in pregnancy.
Muhammad ruzaini bin ruslan
012012100141
Introduction
Its a sexually transmitted disease.
Infected by a Treponema pallidum.
Stages.
3 stages :
1. Primary : painless genital ulcer, with local
lympdenopathy, contagious at this stages.
2. Secondary : non-itchy maculopapular rashes affecting
palms and soles of feet,Condyolomata lata at
perigenital area, alopecia, uveitis, lympdenopathy.
3. Tertiary : neurosphylis, cardiovascular syphilis, fetal
transmission.
Effect on pregnancy and fetus.
Get infected if mother has a primary or secondary syphilis
during pregnancy.
1. Incidence of congenital infections is directly proportional to
the duration of maternal infections and degree of
spirochetemia.
2. Congenital infections present as hepatomegaly, joints
swelling, skin rash, anaemia, and jaundice.
3. Congenital syphilis can cause physical and neurological
impairments affecting the child's bones teeth , vision and
hearing.
.Causes : prematurity, miscarriage, low birth weight, still birth
and nonatal death.
 The risk of transmission from mother to baby declines
as maternal infections progress.
Risk ranges from 70-100% in primary syphilis, 40% in early
latent syphilis and 10% in late latent syphilis.
Diagnosis :
Antenatal : VDRL( used for routine screening), high titre in
primary and secondary stages, low in tertiary stages, false
positive in SLE and antiphospholipid syndrome.
Fluorescent Treponema antibody.
Management .
Aim to prevent maternal infection and prevent
congenital syphilis.
Early syphilis: ( primary and secondary)
IM benzathine penicillin 2.4million units as a single dose.
IM procaine penicillin 1.5g, daily for 10days.
Late syphilis)tertiary) :
Benzathine penicillin 1.8gIM, once weekly for 3 weeks
Procaine penicillin 1.5g IM , daily for 15 days.
In case for neurosyphilis, IV crystalline penicillin 3-4million units
for 2 weeks.
Intrapartum , cover with IM benzathine penicillin.
Tuberculosis in
pregnancy.
TB in Malaysia
Tuberculosis is a lung infections that cause by acid fast
bacilli mycobacterium tuberculosis which will result in
granulation tissue formation.
Clinical features
Fever
Chronic unresolved cough more than 6 weeks.
Significant loss of weight and appetite.
Night sweating.
Haemoptysis.
Malaise.
Shortness of breath.
Effect of TB infection in pregnancy.
Mother
High chance to developed pre-eclampsia, spontaneous
abortion, preterm labour.
Intrauterine fetal death.
Anaemia.
Fetus
Low apgar score.
Low birth weught.
IUGR
Apgar score
Management
The principle treatment of TB is same with non-pregnant
woman.
The treatment for TB is important for 2 reasons :
For serious consequences of untreated TB and the risk of its
spread to newborns.
The effect of drugs used in it treatment on the fetus.
In the first trimester anti-TB drugs should be continued.
The choice of drugs and the dosage have to be
modified.
Treatment of folic acid, B12 is necessary to improved
general condition of the patient.
Management.
Normal vaginal delivery is routine for woman with TB.
Spinal or epidural anaesthsia is preferred than
inhalation for fear of contamination.
Breast feeding is not contraindicated when woman is on
anti-TB drugs.
Breast feeding is should be avoided if the infant is taking anti-
TB drugs to prevent of drugs overdoses.
In active lesion, not only breast feeding contraindicated but
the baby is to be isolated from the mother following delivery.
Management
Baby should be given prophylactic isoniazid 10-
20mg/kg/day for 3 months
BCG should be given to infant as early as possible.
Thank you.
 PARASITIC AND PROTOZOAL
INFESTATIONS
&
PYELONEPHRITIS
IN PREGNANCY

NUR AMALINA BINTI ISMAIL

012012100102
 MALARIA

Tropical disease
India & other south east Asian countries

CONFIRMATORY TEST
Detection of malaria parasites in
peripheral thick blood smear
 MALARIA
PATHOLOGY

Infected Blockage of Infected red

erythrocytes microcirculatio cells are
become rigid, n due to broken down
irregular and sequestrated (hemolysis)
sticky red cells

MATERNAL HIV & TUBERCULOSIS

causes intense parasitization of
placenta
 MALARIA
EFFECT OF MALARIA ON EFFECT OF MALARIA ON
MOTHER FETUS
Anemia (megaloblastic) Miscarriage
due to hemolysis and Preterm labor
folic acid deficiency Pre-maturity
Hypoglycemia IUGR
Metabolic acidosis IUFD
Jaundice
Renal failure
Pulmonary edema and
respiratory distress
Convulsion and coma
(cerebral malaria)

Fetal effect due to HIGH FEVER & PLACENTAL PARASITIZATION

DIMINISHED PLACENTA BLOOD FLOW because INTERVILLOUS
SPACES BECOME BLOCKED WITH MACROPHAGES AND PARASITES
CONGENITAL MALARIA RARE UNLESS PLACENTA IS DAMAGED
 MALARIA

PREVENTION FROM
MOSQUITO BITE
CHEMOPROPHYLAXI
S
Chloroquine
MANAGEM Mefloquine (if
resistant to
ENT chloroquine)
Patient with severe
anemia may need
blood transfusion
Folic acid 10 mg
give daily to prevent
megaloblastic
anemia
 TOXOPLASMOSIS

Mode of
Protozoan transmission via
infestation caused eating infected raw
by Toxoplasma or uncooked meat
gondii or contact with
infected cat feces

Risk of fetal
The fetal risk of damage decrease
infection increase with duration of
with duration of pregnancy
pregnancy
 TOXOPLASMOSIS
COMPLICATION of PREGNANCY
Miscarriage
IUGR
Stillbirth
During parasitemia, transplacental
infection to fetus occurs
Hydrocephalus
Chorioretinitis
Cerebral calcification
Microcephaly
Mental retardation
 TOXOPLASMOSIS
INVESTIGATION
Amniocentesis & cordocentesis (detect IgM antibody in amniotic
fluid and fetal blood
PCR (detect T. gondii)
Ultrasonography at 20-22 weeks (detect ventricular dilatation,
hydrocephalus)
TREATMENT
Aim : reduce the risk of congenital infection and late
sequelae
Pyrimethamine 25 mg orally daily
Sulfadiazine 1 gm 4 times a day
Luncovorin (minimize toxicity)
Spiramycin 3mg orally daily
PREVENTION
Uncooked meat, unpasteurized milk, contact with stray
cat or cat litter (SHOULD AVOID)
 LISTERIOSIS
Listeria monocytogenes is an intracellular gram-
positive bacillus found in soil and vegetation.
DEFINITI Can grow and multiply in temperature as low of
ON
0.5 degree celcius

Eating infected food or through contact with

Mode of
transmiss infected miscarried products of animals
ion

Sympto Flu like or food poisoning

ms
 LISTERIOSIS
Late miscarriage
Preterm labour
OBSTETRIC Stillbirth
COMPLICAT Neonatal death due to septicemia
ION

COMBINED THERAPY WITH AMPICILIN & GENTAMYCIN

CAN ALSO USED TRIMETHOPRIM & SULFAMETHOXAZOLE
TREATMENT

Not to drink or take UNPASTEURIZED MILK, SOFT CHEESE, REFIGERATED

PREVENTIO SMOKED SEAFOOD (SALMON, TROUT, COD)
N
 INTESTINAL WORMS

HOOKWORMS (Ankylostoma)
ROUND WORMS (Ascaris
lumbricoids)
Dignosis: stool examination
Treatment: eradicating the worms +
treatment of anemia by iron therapy
DEWORMING is not
contraindicated during
 PYELONEPHRITIS IN PREGNANCY
Female more prone to get UTI compared to male
because of:
Short urethra (4 cm)
Close proximity of external meatus to the area (vulva
and lower third of vagina) contaminated heavily with
bacteria
Catheterization
S.I
INCIDENCE : 1-3%
PYELONEPHRITIS IN PREGNANCY
ETIOLOGY:
More common in primigravida than
multipara
Previous history of UTI
Presence of asymptomatic bacteriuria
Abnormality in the renal tract
Stasis due to compression to ureters
(mainly the right) by gravid uterus
PYELONEPHRITIS IN PREGNANCY
PREDISPOSING FACTORS

- Dilatation of ureters and renal pelves

- Stasis of urine in bladder and ureters

ORGANISM RESPONSIBLE
-E.coli(70%), Klebsiella pneumoniae(10%),
Enterobacter, Proteus, Pseudomonas and
Staphylococcus aureus group

Bacteremia following acute pyelonephritis (10%)

70%-80% occur on right side, 10-15% on Left side
Few bilateral
PYELONEPHRITIS IN PREGNANCY
CLINICAL
FEATURES

ACUTE OR
CHRONIC
SEVERE
TYPES
TYPES
 ACUTE PYELONEPHRITIS
CLINICAL FEATURES
Onset acute, appears beyond 16th week
Involvement bilateral but if unilateral
usually right side
Due to ENDOTOXEMIA
Chemical mediators (cytokines) released
are
IL-1, TNF and endogenous pyrogen
 ACUTE PYELONEPHRITIS
IMPORTANT FEATURES:
-Acute aching pain over loins,radiated to groin and
costovertebral angle tenderness, dysuria,hematuria
-FEVER(spicky 40) with chills &rigor followed by
hypothermia(34)
-DUE TO ENDOTOXIN INDUCED ALVEOLAR INJURY presented
with respiratory distress, pulmonary edema
-also presented with nausea, vomiting, anorexia, myalgia
ACUTE PYELONEPHRITIS
DIFFERENTIAL DIAGNOSIS
-acute appendicitis
-Abruptio placentae
-Red degeneration of fibroid
-Acute cholecystitis
-Labor
-Chorioamnionitis
INVESTIGATION
Serum creatinine, electrolyte, urine
C&S, FBC
COMPLICATION OF ACUTE PYELONEPHRITIS

MATERN
FETAL INCREASE FETAL
AL -ANEMIA LOSS DUE TO
-SEPTICEMIA -abortion
-RENAL -preterm labour
DYSFUNCTION -IUD
(hyperpyrexia)

-PULMONARY
INSUFFICIENCY -low birth weight
baby(prematurity
-ARDS FOLLOWING and dysmaturity)
SEPTICEMIA
 ACUTE PYELONEPHRITIS
MANAGEMENT

Intravenous fluid (crystalloid) for adequate hydration

Evaluate hemogram, serum electrolytes, creatinine
Acetaminophen for fever
Monitor urine output (> and equal to 60 mL/hr), temperature, BP
IV antibiotics- Cephalosporins, aminoglycoside (gentamicin), Cefazoline
or Ceftriaxone, for 48 hours till culture report available and then change
to oral therapy for another 10-14 days
Repeat urine culture after 2 weeks of antimicrobial therapy and is
repeated at each trimester of pregnancy
If symptom recur or dip stick test for nitrate and leukocyte esterase is
positive, urine culture is repeated. Treatment is needed if culture positive
Patient not respond to this therapy needs to be evaluated (USG, CT
scan, radiography) for URINARY TRACT OBSTRUCTION
Antimicrobial suppression therapy is continued till the end of
pregnancy to prevent recurrence (30-40%).
Nitrofurantoin 100mg daily at bed time is effective
 Asymptomatic
Bacteriuria (ASB)
Definition
Bacterial count of the same species over 105/mL in mid
stream clean catch specimen of urine on two occasions
is detected without symptoms of urinary infection.
Causative Organisms
E.Coli (90%)
Klebsiella pneumonae
Proteus
 To exclude pre-existent ASB urine culture (1st ANC)
(ACOG)
Incidence : 2 10%
Screening :
Urine look for nitrates & leucocytes esterase if either of
these is +ve urine culture is indicated
If left untreated acute pyelonephritis (3rd trimester)
incidence of hypertension & anemia
Chronic renal lesion premature labour & fetal growth
retarded babies
If recurrent ASB :
incidence of urinary tract abnormality (20%) congenital
/acquired
Greater risk of developing chronic renal lesion in later life
Treatment
Antimicrobial agents
Ampicillin : 500mg QID
Nitrofurantoin : 100mg QID
Cephalexin : 500mg TID
Amoxocylin-clavulanic acid : 375mg TID
Course : 10 to 14 days

Single dose theraphy

Nitrofurantoin 0.2gm or
Amoxycillin 3gm

Long term prophylaxis

Nitrofurantoin 50mg or
Amoxycillin 250mg at night
*continued until dilivery when the infection is reccurent
*recurrent UTI : imaging of upper urinary tract 3 month postpartum
 Proteinuria
Present in urine in about 5% of all pregnant
lady
Causes
Pre-eclampsia & ecalampsia
UTI
Chronic renal disease : nephritis/nephrotic
syndrome
Essential hypertension
Orthostatic

Investigation
To rule out infections & renal parenchymal lesion
 HEMATURIA
Presence of few red cells in urine
Examination : clean catch mid stream urine
*rule out contamination
Related to pregnancy Unrelated to pregnancy
1. Severe cystopyelitis 1. Urinary calculi
2. Rupture of bladder 2. Renal tuberculosis
varicosities 3. Renal neoplasm
3. Following rapid 4. Papilloma bladder
evacuation of urine in
acute retention with a
retroverted gravid
uterus
4. Lower segment scar
rupture involving the
bladder
 RETENTION OF URINE
Common complication during pregnancy

Causes
During early pregnancy
Incarcerated retroverted gravid uterus
Impacted pelvic tumors
During labour
Associated with abnormal uterine activity commonly with
incoordinated uterine action
Obstructed labour
During puerperium
Diminished bladder tone
Reflex from vulva injuries
Brusing and oedema of the blader neck

*if simple measures fails, catheterization is done

 VIRAL INFECTION

NURSHAHIRAH BT AHMAD SHUKRI

012012100093
 OUTLINES
RUBELLA
MEASLES
INFLUENZA
CHICKEN POX
CYTOMEGALOVIRUS
PARVA VIRUS
MUMPS
HSV
HIV
 RUBEL
LA
German measles Transmitted by respiratory
(RNA virus) droplet exposure

Maternal infection is
manifested by rash, Fetal infection is by
malaise, fever, transplacental route throughout
lymphadenopathy and pregnancy
polyarthritis
Congenital rubella syndrome : Risk of major anomalies
i) cochlear- sensorineural deafness when this infection occurs
ii) Cardiac- septal defects, PDA in first (50%), second
iii) Hematological- anemia, (25%), third (10%) month.
thrombocytopenia - Predominantly affects
iv) Liver & spleen- enlargement, fetus and extremely
jaundice teratogenic within the first
v) Opthalmic- cataract, retinopathy, trimester.
cloudy cornea
vi) Bone- osteopathy
Increased chance of abortion, stillbirth and congenital malformed baby.

Infants born with CRS shed the virus

for many months and is source of
infection to others

Test for rubella specific antibody (IgM)

should be done within 10 days of the
exposure

Rubella specific IgG If the patient no

antibodies are present for immune, question
life after natural infection of therapeutic
or vaccination termination should
be considered
Prenatal diagnosis of rubella virus infection using PCR can be
done from chorionic villi, fetal blood and amniotic fluid samples
Active immunity by giving live
attenuated rubella vaccine
preferably during 11-13 years
** Not recommended in pregnant
women
When given during the child
bearing period, pregnancy
should be prevented within 3
months by contraceptive
measure

However, if pregnancy occurs during the period ,

termination of pregnancy is not recommended
 MEASLES

The virus (RNA) is not teratogenic

However, high fever may lead to abortion, stillbirth or premature delivery

Non immunized women come with the contact with

measles may be protected by IM injection of
immune serum globulin (5ml) within 3 days
exposure

Active vaccination is not done in pregnancy

 INFLUENZA

No evidence of teratogenic effect even if it contacted in first trimester

However outbreak of Asian showed increased incidence of

anencephaly, when infection occurs in first trimester

Active vaccination is not done in pregnancy

The course of pregnancy remains unaffected,

but if the infection is virulent, it may cause
abortion or premature labour
 CHICKEN POX
Maternal motility is high due to varicella pneumonia

Varicella zoster virus (DNA) does cross placenta

and may cause congenital or neonatal chicken
pox
Risk of congenital malformation is nearly absent when
maternal infection occurs after 20 weeks.

Congenital Varicella syndrome

characterized by:
i) Hypoplasia of limb
ii) Limb deformity
iii) Choroidoretinal scarring
iv) Cataract
v) Microcephaly
vi) Cutaneous scarring
Varicella (live attenuated virus) vaccine is not recommended in pregnancy.

Investigations:
i) Varicella PCR can identify VRZ specific DNA from vesicular fluid
ii) ELISA can detect VRZ specific IgG and IgM

Varicella zoster immunoglobulin (VZIG) :

-given to non immune patients ( reduce motility)
-Also be given to newborn exposed within 5 days of
delivery
Oral acyclovir:
-safe in pregnancy
-Reduce duration of illness when given 24
hours of the rash
** however it cannot prevent congenital
infection
 CMV INFECTION
It is DNA Transmitted by:
virus sexual
Respiratory droplet
No vaccine May damage fetal
Transplacental (30-40%
affected) organs throughout
Consequences of gestation
Virus excreted with:
infection: Urine
Abortion Cervix
Stillbirth Breast milk
IUGR *congenital-affected infants excretes
Microcephaly virus through urine & nasopharynx for
Intracranial up to 5-7 y/o
calcification (confirmed by viral culture)
Hepatospleenomeg
aly CMV specific IgM is present with 80%
Thrombocytopenia infected infant.
Choroidoretinitis Prenatal diagnosis by amniocentesis is
Mental retardation possible using PCR.

Parvo virus B 19 PARVO VIRUS

(DNA) is associated
with human infection Fetal affected ( 33%) by
during pregnancy. transplacental route

Mainly affect the erythyroid Fetal loss is more when

precursor cells resulting in: infection occurs in <10
Anemia weeks pregnancy
Aplastic crises
Congenital heart failure Fetal transfusion may improve
Hydrops the outcome

Serial USG should be performed 10weeks after maternal

illness detect hydrops
Fetal middle cerebral artery peak Doppler velocity detect
any significant fetal anemia before hydrops develop
Diagnosis:
Detection of virus
specific IgM Maternal infection is usually self
PCR is more sensitive limited
 MUMPS
No teratogenic

No ill effect on the course of the pregnancy

MMR vaccine (live- attenuated) is contraindicated in pregnancy

Incidence to be low with the MMR vaccine to childhood vaccination programme

 HSV
Genital tract infection is due to HSV-
2.
HSV-1 usually herpes labialis.
Infection maybe:
Transmitted by sexual
Primary (occur during pregnancy)
contact
Nonprimary
in preg: Fetus becomes
first episode
effected by virus shed
Recurrent ( resulting in virus
from the cervix or low
shedding with/out symptomatic
genital tract during
lesions.)
vaginal delivery
Effect on pregnancy:
Increase risk abortion
If infection occur in last trimester- chance of premature
labour or IUGR.
Risk of fetal infection is high in primary genital HSV at term
due to virus shedding compared to a recurrent infection.
Cesarean delivery is indicated in active primary genital HSV
infection
Neonatal infection:
Diagnosis is made by detection of the viral
by PCR

Manifested by:
Chorioretinitis
Treated by intravenous acyclovir
Microcephaly
Prophylactic acyclovir ( 400mg BD)
Mental
for women with recurrent
retardation infections particularly near term
Seizures
Death

Breastfeeding is allowed provided the mother

avoids any contact between her lesions, her
hands and the baby.
 -Vertical transmission HI
Anti HIV-1 drugs:
(14-25%)
-Transplacental V
i) Nucleoside reverse transcriptase
inhibitor (zidovudine, Zalcitabine,
transmission occur: 20% lamivudine, stavudine)
before 36 weeks, 50% ii) Non-nucleoside reverse
before delivery and 30% transcriptase inhibitors
during labour. (Nevirapine, Delavirdine)
-Vertical transmission is iii) Protease inhibitors ( indinavir,
more cases with Saquinavir, Ritonavir)
preterm birth and with Regimen: 2 from i) + 1 from either
prolonged rupture
Diagnosis: ii), iii)
-membrane.
The enzyme In resourece poor setting Zidovudine
immunoassay 100mg 5x daily (can reduce
screening for HIV perinatalcare:
Post partum transmission)
zidovudine syrup-
antibodies. 2mg/kg given to neonate 4x daily for 6
- PCR amplifying viral weeks of life. High risk neonate should
DNA early diagnosis be treated with HAART
-Western blot test or ** the infant is tested at day 1, weeks
immunofluorescence 6,12,& 18 months of age
General Surgey
&
Acute Pain Abdomen
Nur Farahin Bt Mohd Firdaus
 General Surgery
Principles of general surgery during pregnancy:
Try to avoid major elective surgery, specially
abdominal, till delivery.
Second trimester is the safest time for surgery as the
risks of teratogenosis, miscarriage and preterm
delivery are lowest.
Diagnosis of acute abdomen is difficult in pregnant
state.
Emergency surgery has to be done at any time during
pregnancy.
Laparoscopic surgery can be performed safely during
pregnancy.
Use of non-ionizing imaging procedures, e.g. USG,
MRI is preferred to minimize fetal irradiation.
 Management of pregnant woman with trauma should always be
to stabilize the mother first, with evaluation of the fetus
thereafter.
Operation should be done preferably by a senior surgeon with an
expert anesthetist. An obstetrician should remain as a standby.
Minimal handling of the uterus should be done.
Postoperatively, the patient is to be given pain relief for 48 hours.
Use of tocolytics may be helpful.
Close observation is mandatory for evidences of abortion or
premature labor.
 acute appendicitis
Effect of appendicitis on pregnancy
may lead to abortion
premature delivery
increased perinatal mortality and maternal mortality.

Effect of pregnancy on appendicitis

late diagnosis
failure of localization due to displacement of the position
peritonitis is more common, specially, in last trimester.

Diagnosis is difficult in pregnancy due to:

(a) Nausea and vomiting common in normal pregnancy are also the
common symptoms of appendicitis
(b) Leukocytosis is common in normal pregnancy
(c) Appendix moves upwards and outwards as the uterus enlarges.
So pain and tenderness may not be located in the right iliac fossa
(d) Diagnosis is often confused with disturbed ectopic pregnancy,
pyelonephritis, twisted ovarian cyst, abruptio placenta and red
degeneration of a fibroid.
Treatment
Laparotomy at the earliest opportunity. Once the
diagnosis is suspected, it is better to operate
rather than to wait until generalized peritonitis
has developed. Muscle splitting incision should be
made at the point of maximum tenderness.
Uterine manipulation is avoided to minimize the
risk of preterm labor.
Laparoscopic appendicectomy can be done before
28 weeks of gestation. Intraoperative fetal
monitoring should be considered.

TRAUMA IN PREGNANCY
Common types of penetrating trauma in
pregnant women are due to road traffic
accidents, gunshot or stab wounds. Maternal
death rates in penetrating trauma is two-thirds
lower than in the non-gravid women. It is due to
protective effects of the uterus to other
abdominal organs. Fetal death is high (70%).
SYMPTOMATIC CHOLELITHIASIS
It is the second most common nongynecological
condition that needs surgery during pregnancy.
Initial management is conservative. Elective
endocystectomy is done in the second trimester
or puerperium. Deterioration of clinical condition
despite medical therapy needs cholecystectomy
regardless of trimester.
ACUTE PANCREATITIS:
It is difficult to diagnose during pregnancy because
of the physiological increase of amylase value during
the second and last trimester. Serum amylase is
elevated to 1000 IU/L or more, serum calcium is
usually low. Ultrasound is of diagnostic value.
Preterm labor is more common. Once the diagnosis is
made, the treatment should be conservative rather
than surgical.
PEPTIC ULCER
It is rare during pregnancy to appear for the first time.
The course of the disease is unpredictable.
Perforation and hemorrhage are uncommon during
pregnancy. Infection with Helicobacter pylori plays an
important part in the pathogenesis. TREATMENT:
Directed to inhibit acid production (H2 blocker), acid
neutralization (antacids) and eradication of H.pylori
infection (antibiotic).
LAPAROSCOPY IN PREGNANCY
Laparoscopic surgery can be performed safely during
pregnancy. Second trimester is the best time. Fetal risks
and preterm labor are less as the uterine manipulation and
the use of narcotics are less.

Guidelines of laparoscopic surgery during pregnancy

(SAGES, 1998)
1. Obstetric consultation is essential for preoperative
management.
2. Surgery should preferably be done in the second trimester
3. Gastric aspiration precaution should be taken before
surgery
4. Patient should be in the left lateral decubitus with minimum
reverse trendelenburg
5. Open technique (Hasson) for entering the abdominal cavity
to be used. Veress needle is contraindicated.
6. Antiembolic shockings should be used
 CO2 pneumoperitoneum is maintained at 1215 mm Hg, keeping
intraperitoneal pressure minimum
Maternal end tidal CO2 should be maintained at 2530 mm Hg to
minimize maternal and fetal acidosis
Fetal monitoring (TVS) is to be continued and pneumoperitoneum is
to be released if fetal distress arises
Operative time should be minimum as possible.
 Acute Abdomen
Some amount of abdominal pain is common during pregnancy.
A meticulous history coupled with systematic and thorough
examinations (general, abdominal and vaginal) are mandatory to
arrive at a diagnosis.
Laboratory tests, ultrasonography and X-ray are helpful diagnostic
parameters. However, their limitations and restrictions in
pregnancy should be borne in mind.
The physician should be conscious of the entity of disturbed tubal
pregnancy in early months and rupture of the uterus, in the later
months while dealing with acute abdomen in pregnancy.
 Obstetrical
EARLY LATE MEDICAL
Abortion Abruptio placentae Pyelitis
Disturbed ectopic Preterm labor Pyelonephritis

Hydatidiform mole Labor pains Cystitis

Acute polyhydramnios Rupture uterus
Polyhydramnios
Acute fulminating
preeclampsia
Torsion of the uterus
 Non-obstetrical
surgical gynaecological
Acute appendicitis Torsion of ovarian cyst
Intestinal or gastric perforation Red degeneration of fibroid
Intestinal obstruction Retention of urine due to retroverted
gravid uterus, impacted fibroid or
ovarian tumor
Volvulus
Rectus sheath hematoma
Cholecystitis
Renal or ureteric calculi
Malignant disease