medical conditions in pregnant women .pptx

Medical conditions in pregnancy.
Pregnancy induced hypertension
Preeclampsia
Gestational diabetes mellitus
Heart diseases in pregnancy
Malaria
Anemia
Epilepsy
Hyperemesis gravidarum
Psychological disorders

Created for academic presentation purposes.
It is intended for nursing and allied health students and can also be used as a final review for medical students.

1. Hyperemesis Gravidarum (HG) Definition: Persistent vomiting in pregnancy causing: Weight loss Ketosis More severe than typical morning sickness Rare, but can be fatal if untreated Risk Factors: Multiple pregnancy Molar pregnancy History of hyperemesis gravidarum Possibly related to high hCG levels Timeline: Seldom persists after 14 weeks

2. Clinical Presentation: Inability to keep food/fluids down Weight loss (up to 5% of pre-pregnancy weight) Dehydration and hypovolemia Tachycardia Postural hypotension Electrolyte disturbances (hypokalemia, hyponatremia → shock) Vitamin B deficiency (polyneuritis) Behavioural disturbances Haematemesis (Mallory-Weiss tears) Potential liver/renal failure

3. Investigations Urinalysis: Ketones; MSU to rule out UTI CBC: Raised hematocrit (hemoconcentration) U&E: Monitor Na⁺ and K⁺ Ultrasound: Rule out molar/multiple pregnancies TFTs: Often abnormal

4. Management Hospital admission if unable to keep anything down IV fluids: 0.9% NaCl + K⁺ or Hartmann's solution Avoid glucose to prevent Wernicke’s encephalopathy Antiemetics : First-line: Promethazine, Cyclizine , Metoclopramide Second-line: Ondansetron (not licensed in pregnancy) Intractable vomiting: Consider corticosteroids Prednisolone 40–50 mg/day PO Hydrocortisone 100 mg IV q12h Vitamin supplementation: Folic acid 5 mg/day Thiamine (Pabrinex) 50 mg PO TID DVT prophylaxis: Enoxaparin 40 mg SC daily + anti-embolism stockings

5. Hypertension in Pregnancy Normal BP Changes in Pregnancy: Decrease in BP during 2nd trimester (by ~30/15 mmHg) BP returns to baseline near term

6. Pregnancy-Induced Hypertension (PIH): BP ≥140/90 mmHg after 20 weeks No proteinuria or other signs of pre-eclampsia Most common after 28 weeks Risk of progression to pre-eclampsia Management: Check for proteinuria: ≥0.3 g/24h → suspect pre-eclampsia Continue antihypertensives during labor Consider C-section if BP uncontrolled on treatment

7. Severity BP Range Management Mild 140/90–149/99 Weekly BP + urine check Moderate 150/100–159/109 Twice weekly BP + urine + oral labetalol Severe ≥160/110 Admit, BP 4x daily, urine check daily, weekly labs (FBC, U&E, LFTs)

8. Chronic (Pre-existing) Hypertension: Diagnosed before pregnancy or before 20 weeks May be primary or secondary (e.g., renal disease) Increased risk of: Superimposed pre-eclampsia (6x risk) Placental abruption Fetal growth restriction Preconception care: Stop ACEi, ARBs, thiazides → switch to labetalol or methyldopa

9. Pre-eclampsia Definition: Hypertension + Proteinuria ≥20 weeks gestation Multisystem disorder; only cure = delivery Pathophysiology: Step 1: Abnormal placental vascular remodeling → oxidative stress Step 2: Secretion of antiangiogenic factors → endothelial dysfunction ↑ sFlt-1, ↓ PlGF → vasospasm, capillary leak, clotting dysfunction Risk Factors: Nulliparity Previous severe/early pre-eclampsia Long interpregnancy interval (>10 years) Age >40, Obesity IVF/donor egg Microvascular diseases: Chronic HTN, CKD, SCD, diabetes, APS, SLE Large placental load: twins, molar pregnancy, hydrops fetalis

10. Symptoms & Signs: Often asymptomatic Headache, visual disturbances Epigastric/RUQ pain, nausea/vomiting Edema (massive, sudden) Brisk reflexes, clonus (>2 beats) Proteinuria, IUGR, stillbirth Investigations: PCR >30 mg/ mmol ↑ Uric acid, Hb , ALT, LDH ↓ Platelets (sign of HELLP) Coagulation profile Ultrasound: IUGR, oligohydramnios , abnormal Dopplers

11. Maternal Complications: Eclampsia (tonic- clonic seizures) MgSO ₄: 4g IV bolus → 1g/ hr infusion Monitor RR (>12), U/O (>20 ml/h), reflexes Calcium gluconate if Mg toxicity Deliver once stable Avoid ergometrine in 3rd stage (risk of severe HTN) Cerebral hemorrhage HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets) RUQ pain, N/V, dark urine Treat supportively + MgSO ₄ ± platelets, ICU if needed Renal failure (may require dialysis) Pulmonary edema (treat with oxygen + furosemide) Fetal Complications: Early-onset PE: IUGR, preterm delivery Late-onset PE: Fetal death risk

12. Management Severity BP Range Management Mild 140/90–149/99 Monitor BP q4h, bloods biweekly, fetal scan q2w, no Rx unless >150/100, IOL at 37w Moderate 150/100–159/109 Admit, 4h BP, labs 3x/week, fetal scans + CTG, start Rx, IOL at 37w Severe ≥160/110 Stabilize with Nifedipine 10mg x2, MgSO ₄, bloods q12–24h, deliver if >34w (or sooner if unstable)

13. Diabetes in Pregnancy Type Description Gestational Diabetes Mellitus (GDM) Glucose intolerance first recognized during pregnancy (usually in 2nd or 3rd trimester) Pregestational Diabetes Known Type 1 or Type 2 DM before pregnancy Overt Diabetes in Pregnancy Meets diagnostic criteria for diabetes in non-pregnant state, but diagnosed in early pregnancy

14. Diagnostic Criteria A. GDM Diagnosis (24–28 weeks) IADPSG/WHO 75g OGTT – one-step approach ➤ GDM is diagnosed if any ONE value is abnormal B. Overt Diabetes (early pregnancy) Diagnosed if any of the following (based on ADA/WHO): Fasting glucose ≥ 126 mg/dL (7.0 mmol /L) HbA1c ≥ 6.5% Random glucose ≥ 200 mg/dL with symptoms Time Glucose Threshold Fasting ≥ 92 mg/dL (5.1 mmol/L) 1 hour ≥ 180 mg/dL (10.0 mmol/L) 2 hours ≥ 153 mg/dL (8.5 mmol /L)

15. Pathophysiology Normal pregnancy : Increased insulin resistance due to placental hormones ( hPL , estrogen, cortisol). GDM : Pancreatic β-cells fail to compensate → hyperglycemia. Type 1 DM : Absolute insulin deficiency. Type 2 DM : Peripheral insulin resistance + relative insulin deficiency Risk Factors for GDM Age > 25 Obesity (BMI >30) Family history of DM PCOS Previous GDM or macrosomia Ethnicity: South Asian, Hispanic, African Unexplained stillbirth

16. Antenatal Intrapartum Long-term Preeclampsia Increased C/S Type 2 DM Polyhydramnios Shoulder dystocia CV disease Infections (UTI, candida) Birth trauma — Worsening retinopathy/nephropathy (in pregestational DM) — — In GDM In Pregestational DM Macrosomia Congenital anomalies (esp. neural tube, cardiac) Polyhydramnios IUGR (if vasculopathy) Shoulder dystocia IUFD Neonatal hypoglycemia Neonatal hypoglycemia Jaundice, RDS, polycythemia — Maternal Complications Fetal & Neonatal Complications

17. Investigations For Diagnosis: OGTT (75g or 100g depending on approach) Fasting/random blood sugar HbA1c (for pregestational DM) For Monitoring: FBS and postprandial glucose HbA1c (each trimester) Urine ketones (if indicated) For Fetal Surveillance: Ultrasound for fetal growth and AFI NST or BPP (from 32–34 weeks if on insulin or poorly controlled) Anomaly scan (at 18–22 weeks in pregestational DM)

18. Management 🔸 Lifestyle Modification Diet (MNT) : 3 meals + 2–3 snacks, low glycemic index Exercise : 30 mins /day unless contraindicated Medical Therapy Drug Indication Notes Insulin 1st-line in GDM if uncontrolled Does not cross placenta Metformin Alternative, esp. in low-resource settings Crosses placenta but safe Glyburide Less favored Higher neonatal hypoglycemia risk Glycemic Targets (in Pregnancy) Time Target Fasting < 95 mg/dL 1-hour postprandial < 140 mg/dL 2-hour postprandial < 120 mg/dL HbA1c < 6.0% (ideal), < 6.5% acceptable

19. Intrapartum Care Factor Management Timing of delivery GDM (controlled, diet): 39–40 wks Insulin-controlled or poor control: 38–39 wks Mode C/S if EFW > 4500 g Monitoring Keep maternal BG 70–110 mg/dL Insulin in labor May use IV insulin + dextrose drip Postpartum Care Stop insulin/metformin after delivery in GDM Reassess glucose at 6–12 weeks postpartum : 75g OGTT (diagnose persistent DM or prediabetes ) Annual screening for Type 2 DM Breastfeeding encouraged (↓ maternal glucose, infant obesity)

20. Pregestational Diabetes: Extra Points Preconception Care is vital HbA1c <6.5% before conception Review medications (stop ACE inhibitors, statins) Start Folic acid 5 mg/day 1st Trimester: Risk of congenital anomalies Perform early anomaly scan + fetal echo 3rd Trimester: Increased risk of IUGR or macrosomia Consider early delivery Key Antenatal Visit Checklist (DM) Visit Investigations/Actions 1st trimester FBS, HbA1c, creatinine, urine protein Baseline eye check (retina), BP 18–22 weeks Anomaly scan 28 weeks OGTT (if not diagnosed earlier) 32–36 weeks Growth scan, NST/BPP 37–40 weeks Plan delivery, adjust insulin

21. Cardiac Disease in Pregnancy

22. Normal Cardiovascular Changes in Pregnancy ↑ Cardiac Output: ~40% increase due to ↑ stroke volume and ↑ heart rate. ↑ Blood Volume: ~40% increase. ↓ Systemic Vascular Resistance: ~50% reduction → BP drops in 2nd trimester, returns to normal by term. Common Findings (Physiological): Ejection systolic murmur in 90–96% ↑ Pulse volume and peripheral edema Forceful apex beat (<2 cm lateral to MCL) Loud first heart sound and third heart sound in 84% Venous hums (posture-dependent), murmurs from mammary vessels ECG Changes: Left axis deviation Inverted T waves in lead III and lateral leads Ectopic beats, Q-waves QRS left shift CXR Findings: Mild cardiomegaly Increased pulmonary vascular markings and pulmonary vein distension

23. High-Risk Cardiac Conditions in Pregnancy . Pulmonary Hypertension Mortality: 25–40% Causes: Lung disease, connective tissue disease, Eisenmenger syndrome Management: Strongly advise against pregnancy; offer termination. Congenital Heart Disease Generally Safe: PDA, VSD, ASD, Mitral valve prolapse — usually no complications. Referral: Fetal echocardiography. Marfan Syndrome Genetics: Autosomal dominant Cardiac Risks: Mitral valve prolapse, regurgitation, aortic root dilatation Complications: Aortic dissection/rupture (especially if root >4 cm) Recommendations: Aortic root >4.5 cm → Elective LSCS Consider aortic root replacement pre-pregnancy

24. Mitral Stenosis Watch for: Dyspnea, orthopnea, PND Monitoring: Regular echocardiography Management: Atrial fibrillation: Digoxin, beta-blockers (safe in pregnancy) Pulmonary edema treatment Prognosis: Valve area <1 cm² → poor outcome Aortic Stenosis Severe Cases: Poor cardiac output reserve → correct before pregnancy Epidural: Contraindicated in severe cases Mechanical Valve Replacement: Anticoagulation Required:

25. . Peripartum Cardiomyopathy Definition: Heart failure without prior cardiac history; develops: 1 month before or within 6 months postpartum Diagnosis: Echocardiography Prognosis: 50% develop permanent LV dysfunction Management: Elective delivery if antenatal Anticoagulation May require LV assist device or intra-aortic balloon pump High recurrence in future pregnancies

26. Labour and Delivery in Cardiac Disease Preparation: Oxygen and medications for heart failure available Preferred Delivery: Vaginal at term Analgesia: Epidural safe (avoid hypotension) Postpartum Hemorrhage: Avoid ergometrine → use oxytocin instead

27. Epilepsy in Pregnancy I. Prevalence & Seizure Types Affects 0.5% of pregnant women . Seizure types : Primary generalized : tonic- clonic , myoclonic, absence. Partial/focal seizures : may progress to secondary generalization (e.g., complex partial seizures). II. Differential Diagnosis of Seizures in Pregnancy Other potential causes of seizures include: Eclampsia (most important to rule out) . Cerebral vein thrombosis. Intracranial mass. Stroke. Hypoglycemia. Hyponatremia.

28. Antiepileptic Drugs (AEDs) and Pregnancy Safest AEDs: Levetiracetam and Lamotrigine . Contraindicated: Sodium valproate – high teratogenicity and risk of impaired neurodevelopment. Preconception Care AED optimization: Use the lowest effective dose . Avoid polytherapy where possible (higher risk of congenital malformations). If seizure-free ≥2 years → consider stopping AEDs. Folic acid 5 mg/day : Start ≥3 months before conception and continue until delivery.

29. Antenatal Care Consultant-led obstetric care . Routine scans : NT scan, 20-week anomaly scan. Continue current AED (except valproate) if epilepsy is well controlled. Lifestyle advice : Use bath only when someone else is at home . Vitamin K prophylaxis : 10 mg PO daily during the last 4 weeks of pregnancy if on enzyme-inducing AEDs : Carbamazepine. Ethosuximide . Phenytoin. Primidone . Phenobarbital. Intrapartum Care Vaginal delivery is preferred. Do NOT perform LSCS for seizures unless in status epilepticus . Deliver in a hospital setting. Continue AEDs during labor. Epidural is safe (if not contraindicated otherwise). Seizure management during labor : Lorazepam 4 mg IV . Diazepam 10–20 mg IV if seizure does not self-terminate. Seizures are more likely: Intrapartum or postpartum (due to sleep deprivation, reduced drug absorption, hyperventilation).

30. Postnatal Care Baby should receive: Vitamin K 1 mg IM to prevent hemorrhagic disease of the newborn (especially if mother was on enzyme inducers). Parental education to prevent baby injury during maternal seizures: Change baby on the floor. Feed while sitting supported by cushions. Bathe only with supervision. Encourage breastfeeding : Most AEDs safe. Phenobarbital may cause drowsiness in baby.

31. Complications Maternal: Increased risk of 3rd trimester vaginal bleeding . 1% of women may convulse during labor . Fetal: Congenital malformations : Sodium valproate: 6.2% . Carbamazepine: 2.2% . Lamotrigine: 3.2% . Hemorrhagic disease if mother on enzyme-inducing AEDs. Reduced cognitive function : Associated with valproate use and frequent tonic- clonic seizures during pregnancy.

32. Mental Illness in the Postpartum Period 1. Baby Blues Onset: Around 3–5 days after delivery. Prevalence: Occurs in up to 70% of mothers. Clinical Features: Tearfulness, mood swings, anxiety. Course: Self-limited; resolves spontaneously within 2 weeks. Management: Reassurance only; no medical treatment required.

33. 2. Postnatal Depression (PND) Prevalence: Up to 10% of women after birth. Risk Factors: Antenatal depression. Family history of depression. Traumatic birth experience. Lack of support. Low socioeconomic status. Prior PND. Severe baby blues. Screening Tool: Edinburgh Postnatal Depression Scale (EPDS) – 10-item questionnaire. Treatment: Psychotherapy (CBT) – First-line. Antidepressants: All excreted in breast milk. TCAs and SSRIs rarely detectable except fluoxetine , which has higher levels.

34. 3. Postpartum Psychosis Onset: Peak within 2 weeks postpartum. Clinical Features: Severe mood symptoms (mania/depression). Rapid mood changes, disorientation, insomnia. Psychosis (delusions, hallucinations). Recurrence Risk: ~30% if previous episode. Risk Factors: History of postpartum psychosis or other mental illness. Single parenthood. Poor social support. Management: Mood stabilizers, antidepressants, or ECT for mood symptoms. Atypical antipsychotics, benzodiazepines for psychosis. Psychological therapy.

35. Anaemias in Pregnancy Iron Deficiency Anemia Usually asymptomatic unless Hb < 90 g/L. Lab findings: ↓ Ferritin. MCV starts normal, then ↓. Treatment: Oral iron: Ferrous sulfate 200 mg PO twice daily (can cause GI upset). Parenteral iron: If oral iron not tolerated (iron dextran or iron sucrose). Response: Hb ↑ ~8 g/L/week for 6 weeks. Severe anemia: May require blood transfusion (1 unit = Hb ↑ 7 g/L).

36. Folic Acid & B12 Deficiency Folic acid deficiency more common. Lab findings: ↑ MCV. Suspect folate deficiency if anemia without microcytosis . Treatment: Folic acid and/or B12 supplementation.

37. Malaria in Pregnancy Introduction Malaria is a life-threatening parasitic infection caused by Plasmodium species, transmitted by Anopheles mosquitoes . Pregnant women are at increased risk of severe malaria and related complications due to immune suppression and placental sequestration of parasites. Plasmodium Species Most relevant in pregnancy: Plasmodium falciparum → Most severe , common in sub-Saharan Africa. Plasmodium vivax → Common in Asia & South America, can cause relapses ( hypnozoites in liver).

38. Why Is Pregnancy a Risk Factor? Reduced immunity in pregnancy increases susceptibility. P. falciparum can sequester in the placenta , evading the immune system. First pregnancies (primigravida) are at higher risk because they lack immunity to placental-binding strains. Malaria in pregnancy is often asymptomatic , making it hard to detect early.

39. Adverse Effects of Malaria in Pregnancy A. Maternal Complications Severe anemia (due to hemolysis) Hypoglycemia Pulmonary edema Cerebral malaria Multi-organ failure Increased maternal mortality B. Fetal/Neonatal Complications Miscarriage (especially in 1st trimester) Stillbirth Intrauterine growth restriction (IUGR) Preterm labor Low birth weight Congenital malaria (rare) Neonatal death

40. Clinical Presentation Symptoms may vary with immunity level and parasite load: A. Typical Symptoms Fever, chills, rigors Headache Myalgia Nausea, vomiting Malaise B. Severe Malaria Signs (P. falciparum) Altered consciousness (cerebral malaria) Respiratory distress Jaundice Shock Seizures Hypoglycemia Severe anemia 🛑 Note: Asymptomatic infection is common in pregnancy — especially in high transmission areas.

41. Diagnosis Microscopy (Giemsa-stained blood film) : gold standard (thick and thin smears) Rapid Diagnostic Tests (RDTs) : detect antigens PCR : sensitive but expensive, not routinely used Hemoglobin : to assess for anemia Glucose : screen for hypoglycemia Ultrasound : for fetal growth, placental maturity, amniotic fluid CTG : for fetal well-being in 3rd trimester

42. Treatment (based on WHO 2024/2025 guidelines) First Trimester Quinine + Clindamycin for 7 days Artemisinin -based therapies are avoided due to limited safety data in 1st trimester Second & Third Trimester Artemisinin -based combination therapy (ACT) is safe and effective. Example: Artesunate + Lumefantrine Severe malaria (any trimester): IV Artesunate (preferred) or IV Quinine (if artesunate unavailable) Followed by full oral ACT course

43. Prevention Strategies A. Intermittent Preventive Treatment in Pregnancy ( IPTp ) Sulfadoxine-Pyrimethamine (SP) given at routine antenatal visits starting from second trimester , spaced monthly . Minimum of 3 doses recommended in high-transmission areas. B. Insecticide-Treated Nets (ITNs) Highly effective in preventing mosquito bites C. Indoor Residual Spraying Community-level prevention strategy

44. Thanks