Pregnancy With Internal Medical Diseases
This document was uploaded by user and they confirmed that they have the permission to share it. If you are author or own the copyright of this book, please report to us by using this DMCA report form. Report DMCA
Overview
Download & View Pregnancy With Internal Medical Diseases as PDF for free.
More details
- Words: 3,424
- Pages: 82
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(nonf,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 selflimited.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 2428weeks’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 2025kcal 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.Glucosecontaining 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
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(nonf,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 selflimited.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 2428weeks’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 2025kcal 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.Glucosecontaining 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
Related Documents
Pregnancy With Internal Medical Diseases
April 2020 8
Cv Diseases In Pregnancy
June 2020 5
Thyroid Diseases In Pregnancy
November 2019 14
Diseases During Pregnancy
June 2020 6
Medical Complications Of Pregnancy
December 2019 18More Documents from "MemMed Administrator"
