Unit II-

Woman with preexisting or newly acquired

illness

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 Objectives
At the end of this unit students will be able to:
List the major complications of pregnancy
To discuss different medical disorders during
pregnancy
To describe effects of medical illnesses to the fetus and
the mother
To discuss management options for different medical
illnesses during pregnancy

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 Anaemia in pregnancy

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 Anemia in pregnancy
 Anaemia is the reduced ability of the blood to carry oxygen to
the cells; in pregnancy is a hgb level of 11 g/dl (<33% hct)
normally the hgb ranges from 10.4 to 13.2g/dl, the decreased
carrying capacity might be due to:
Reduced number of blood cells
Low concentration of haemoglobin
Combination of both
 It affects approximately 5-50% of pregnant women 55-60%
in developing and 18% in developed nations.
Common -
iron def. anaemia and folic acid anaemia (nutritional) 80-95%
megaloblastic (V-B12) -3-4
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Etiologies
1. Nutritional deficiency (Fe & folate) due to:-
 Increased demand, iron requirement during pregnancy include:
450 for RBC & Uterine muscles
270 for fetal iron
170- 200 for daily loss
90- for placenta
 Increased blood volume
2. Malaria
3. Blood loss due to
 Abortion
 APH
 Ectopic pregnancy
 Hook worm infestations
4. Infections
- Hemolysis in septicemia
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 Iron deficiency Anemia
RBCs are small (microcytic) and pale (hypo chromic).
Causes include:
 reduced intake /absorption
dietary deficiency
GI disturbance / morning sickness
 Excess demand
Multiple pregnancy
Frequent pregnancy
Chronic inflammation (UTIs)
 Blood loss
 APH (Ante Partum Hemorrhage)
 Ectopic pregnancy
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 S/S

Pallor

Fatigue

Fainting

Tachycardia
 & palpitations, edema
Dyspnoea

Cardiac
 failure
Intrauterine hypoxia

Complication of Anemia /Associated risks/
Fetal
Abortion

Preterm
 delivery
LBW

IUGR

Still

 
birth
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Con...
Maternal
CHF
Pulmonary edema
PPH
Puerperal sepsis
Delayed wound healing
Increased risk of infections
Neonatal – Anemia of infancy

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Con...
Treatment
Investigate for underlying causes
Admit if Hct < 20%
Outpatient Rx
FeSo4 100mg contain 60mg elemental iron three times per
day
Anti malarial drugs if the cause is malaria
Patient seen weekly and a Hg rise of 0.5 -1g/dl is expected

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Con...
Inpatient
well balanced diets containing V-B12
Iron supplementation
Antihelminthis in the case of hook worm infestation
Folic acid 5 mg three times a day and continued as 5 mg day
for the rest of pregnancy in case of megaloblastic anemia
Indication for transfusion
presence of anemic heart failure
Hg < 5 mildly
Moderate anemia with coexisting sepsis renal failure
hemorrhage and eclamptia
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Con...
Prevention
Identify risks ,taking accurate history during antenatal visit
Prevent and treat hook worm infestation & malaria
Advice child spacing
Iron supplementation during pregnancy for risk mothers
Improve dietary intake containing iron & V-B12
Avoid taking iron with milk or antacids, because calcium
decreases its absorption.
Encourage intake of vitamin C, it enhances absorption

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 Cardiac disease in pregnancy

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Cardiac disease in pregnancy
Cardiovascular disease are the most important non obstetric
cause of disability and death of pregnant women, occurring
in 0.4-4% of pregnancy;
the most common type is rheumatic heart disease which can
be provoked by pregnancy or might become severe in
pregnant women having the history.
Manifestations
Increased levels of clotting factors
Increased risk of thrombosis
If woman’s heart cannot handle increased workload, then
congestive heart failure (CHF) results.
Fetus suffers from reduced placental blood flow
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 The risk is high during:
24 wks
labor
Immediate post partum
 Risk factors for cardiac failure during pregnancy
 Infection
 Anemia
 Obesity
 Hypertension
 Hyperthyroidism
 Multiple pregnancy
Cardiac output begins to rise in the first trimester and
continues as steady increase to peak at 32 weeks gestation by
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Con....
Causes for increased cardiac output are
1. Increases in stroke volume (early pregnancy)
2. Increase in heart rate (late pregnancy)
3. Decreased peripheral resistance
4. Decreased blood viscosity

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Con...
Cardiac output increases by 20% with uterine contraction
because 200-300ml of blood is squeezed from uterine muscles
causing extra load over the heart.
Signs of CHF during Pregnancy
Persistent cough
Moist lung sounds
Fatigue or fainting on exertion
Difficulty breathing on exertion
Orthopnea
Severe pitting edema of the lower extremities or generalized edema
Palpitations
Changes in fetal heart rate indicating hypoxia or growth restriction
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Physiological changes during labour and puerperium.
1. First stage.
Cardiac output increases by15%. Uterine contractions increases
venous return, causing increase in cardiac output & can cause
reflex bradycardia.
2. Second stage
Increase in intra abdominal pressure (valsalva’s) causes decrease
in venous return and cardiac output.

3. Third stage
Normal blood loss during delivery (around 250-350 ml).
 It leads to :
a. Decrease blood volume
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b. Decrease cardiac output.
The clinical features in a normal pregnancy which can mimic a cardiac disease are

1.    Dyspnea - due to hyperventilation, elevated diaphragm.

2.    Pedal Edema
3.    Cardiac impulse- Diffused and shifted laterally from elevated
diaphragm.
4.    Jugular veins may be distended and JVP raised.
5. Systolic ejection murmurs along the left sternal border occur
in 96% of pregnant women and are believed to be caused by
increased flow across the aortic and pulmonary valves.

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 Cont…
Criteria to diagnose cardiac disease during
pregnancy:
1. Presence of diastolic murmurs.
2. Systolic murmurs of severe intensity (grade 3).
3. Unequivocal enlargement of heart (X-ray).
4. Presence of severe arrhythmias, a trial fibrillation or
flutter

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Classification
I – No symptoms during ordinary physical activity
II – symptoms during ordinary physical; activity
III- symptoms during mild physical activity
IV – symptoms at rest  
Effects
IUGR
fetal loss
preterm labor
Congenital heart failure , etc,

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 1.Preconception care
Give advice for mothers with cardiac disease before deciding to
become pregnant; FP methods.
 Women should be advised to control obesity, cut down smoking &
choose diet which prevent anemia.
2. Antenatal
Identify risk mothers with past history
Advice bed rest
Moderate dietary restriction
Reduce & treat infection
Restrict activity & admit with severe cases
Special attention, frequent ANC
Provision of diuretic (chlorothiazides) with potassium
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Prevent anemia
3. Intra partum
1st stage
Prepare blood , cross match in case of need
Oxygen & resuscitation
V/S monitoring
monitor heart by ECG
follow fetal condition
antibiotic prophylaxis because they are at risk of
endocarditis
Avoid lithotomy position to prevent aortocaval
compression which causes fetal and maternal distress
by the gravid uterus.
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Reduce IV fluid intake, give analgesics for pain04/13/2022
relief.
 2nd stage

Should be short
Vaginal birth is preferred because it carries less risk for
infection or respiratory complications
Avoid prolonged pushing with held breath (valsalva maneuvers)
Instrumental delivery
Left lateral position is preferable
3rd stage
Avoid ergometrine (oxytocics) and give syntocinon
accompanied by IV frusemide to prevent pulmonary edema

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Postrecord
natal
temperature to detect infection
advise breast feeding if not severe
Antibiotics
Advice family planning method –progestin only is preferable or
sterilization.
Ideal contraceptive methods for women with cardiac disease
include:

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 Tuberculosis in pregnancy

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 Tuberculosis in pregnancy

Tuberculosis was one the leading causes of death in the

United States for many years until the introduction of
effective therapy in the early 1950s.
Since then, the number of reported cases declined
steadily until recently, when the number of cases has
increased.
This situation is attributed to increased immigration from
countries with a high tuberculosis prevalence and
particularly to the human immunodeficiency virus
(HIV)/acquired immunodeficiency syndrome (AIDS)
epidemic.
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 Cont…
Tuberculosis in adults is mainly (> 95%) a disease of
the pulmonary parenchyma caused by Mycobacterium
tuberculosis, a non-motile, acid-fast aerobic rod.
Transmission usually occurs by inhalation of droplets
produced by infected individuals when coughing.

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Clinical Findings

Most cases of tuberculosis can be diagnosed on the basis of a

history of cough, weight loss, positive tuberculin skin test,
and chest x-ray film.
The droplets can remain suspended in the air for prolonged
periods (several hours).
The persons most at risk for becoming infected are family
members and other close contacts, such as coworkers and
roommates (elderly residents and employees in long-term care
facilities, correctional institutions), homeless individuals, and
intravenous drug users.

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Cont...
After the initial inhalation, the bacilli multiply in the alveoli
and subsequently spread to the regional lymph nodes and to
other organs such as the upper lung regions, kidneys, bones,
central nervous system (CNS), and, rarely, during pregnancy, to
the placenta.

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Symptoms and Signs
Typical symptoms include cough, weight loss, fatigue, night
sweats, and anorexia.
However, some patients may have very few symptoms.
Laboratory Findings
The definitive diagnosis is made after positive identification of
the bacilli by Ziehl- Neelsen staining and a positive culture.
Tuberculin Skin Test
The tuberculin skin test is the most important screening test for
tuberculosis.
It should be performed early in pregnancy, especially in high-risk
populations.

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Chest X-Ray Film
With the abdomen shielded and preferably after the first trimester,
a chest x-ray film should be taken in patients in whom skin testing
is positive after an earlier negative test and in patients with a
suggestive history or physical examination even though skin
testing is negative.
Congenital Tuberculosis
Congenital tuberculosis is rare. The criteria for diagnosis include
positive bacteriologic studies, primary disease complex in the
liver, disease occurring within the first few days of life, and
exclusion of extra uterine infection.
The most common signs are non specific and include fever, failure
to thrive, lymphadenopathy, hepatomegaly, and splenomegaly.
The disease usually is miliary or disseminated.
An early diagnosis is necessary for effective treatment.
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Treatment
Medical Therapy
Untreated tuberculosis is far riskier to the mother and fetus than
any of the potential medications necessary to treat active
disease.
A preventive course of isoniazid (isonicotinic acid hydrazine
[INH]) is generally recommended for those with a positive skin
test and no evidence of active disease if they are at risk for
developing active tuberculosis.

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Con....
In those at high risk (particularly in cases of HIV/AIDS),
preventive INH treatment is initiated as soon as evidence of
tuberculosis infection (but no active disease) is documented.
The recommended dose of INH is 300 mg/d for 9 months as
well as pyridoxine (vitamin B6) to prevent INH-related
neuropathy.
 Periodic evaluation of liver function is recommended to detect
hepatotoxicity early if it occurs.
 Most studies have shown no teratogenic effects of INH.

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Con...
Active tuberculosis should be treated as soon as the diagnosis is
made.
Most treatment programs consist of a 3-drug regimen, usually
INH 5 mg/kg/d (total 300 mg/d), and ethambutol 15 mg/kg/d,
and rifampcin 10 mg/kg/d (maximum 600 mg/d) for 8 weeks and
the INH and rifampin to complete 9 months.
Pyridoxine should be given along with INH.

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Con...
These three medications cross the placenta, but no adverse fetal
side effects have been reported to date.
Pyrazinamide has been used in addition to the three medications
mentioned in areas of highly drug-resistant tuberculosis but is
not recommended during pregnancy because of limited safety
data.
Because of the risk for fetal (and maternal) ototoxicity,
streptomycin, kanamycin, and capreomycin should not be used.
.

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Con...
 Isoniazid has many therapeutic advantages (e.g., high efficacy,
patient acceptability, and low cost) and appears to be the safest
drug for use during pregnancy
The major side effects of INH are hepatitis, hypersensitivity
reactions, peripheral neuropathy, and gastrointestinal distress.
A baseline liver function test should be obtained and then
repeated periodically.
Pyridoxine 50 mg/d should be administered to prevent INH-
induced neuritis due to vitamin B6 deficiency

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 Obstetric Management
Routine ante partum obstetric management includes adequate
rest and nutrition, family support, correction of anemia if present,
and regular follow-up visits.
Immediate neonatal contact is allowed if the mother has received
treatment for inactive disease and no evidence of reactivation is
present.
 In patients with inactive disease in whom prophylactic INH was
not given or those with active disease in whom adequate
treatment was given, early neonatal contact may be allowed,
provided the mother is reliable in continuing therapy.
A mother with active disease should receive at least 3 weeks of
treatment before coming into contact with her baby, and the baby
must also receive prophylactic INH.
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Con...
There are no absolute contraindications to breastfeeding once
the mother is non-infectious.
 Although anti tuberculosis drugs are found in breast milk, the
concentrations are so low that the risk of toxicity in the infant
is minimal.
However, each case should be judged individually if the
mother wishes to breastfeed her infant.
In general, breastfeeding is not contraindicated while the
mother is taking anti tuberculosis medications.
If prompt use of INH as prophylaxis is unlikely or if the
mother has INH-resistant disease, BCG vaccination of the
infant should be considered.
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Prognosis
If the pregnant patient is adequately treated with anti
tuberculosis chemotherapy for active disease, tuberculosis
generally has no deleterious effect either during the course of
pregnancy or the puerperium or on the fetus.
Pregnant women have the same prognosis as non pregnant
women.

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