OTHER MEDICAL DISORDER IN PREGNANCY.pptx

OTHER MEDICAL DISORDER IN PREGNANCY

1. OTHER MEDICAL DISORDER IN PREGNANCY SUPERVISOR : DR SITI ANISAH MOHAMED PRESENTER : DR NABIL DR ASYRAF

2. DIABETES IN PREGNANCY Gestational diabetes refers to any degree of abnormal glucose intolerance diagnosed in or with onset in pregnancy. Overt diabetes is diagnosed when high blood glucose(diabetic range) is detected in the first trimester, signifying a possibility of pre-existing diabetes. Pre-existing diabetes refers to either type 1 or type 2 diabetes mellitus, which has already been diagnosed before pregnancy.

3. Glu c ose m e t abolism during p r egnancy Fi r s t half of p r egnancy Se c ond half of p r egnancy • ↑ m a t er n al e s t r o g en a n d p r o g e s t e r one Stimul a t e s β- cell h yp e rpla s ia Inc r e as e d ins u lin p r od u ction ↑ in periphe r al glu c ose u t il i z a t ion in m a t er n al tissue • ↑ place n t al horm o n e s mainly human place n t al lac t o g en ( hPL) I m p e de the m o ther's ability t o u ti l i z e insulin Insulin r e s i st ance eme rg es Glu c ose is suppli e d t o the g r o wing f e tus • • • • • •

4. In d i c a tion f or per f orming t ole r ance t e s t (O G T T) an o r al glu c ose • • • • • • Body mass ind e x >27 k g / m 2 P r e vi o us h i s t o r y of G D M Fi r s t deg r ee r el a ti v e with diabe t es m e llitus Hi s t o r y of m a c r o s o m ia (bi r th w eig h t >4 k g ) Gl y c o s ur i a ≥2+ on t w o oc c asions Cu r r e n t o b s t e tr i c p r oble m s • E s s e n tial h yper t ens i on, P I H, pol y h y d r amnios and cur r e n t use of c orti c o s t e r oids Bad o b st etric hi st o r y • • • • P r e vi o us un e xplain e d i n t r a u t erine de a th P r e vi o us c on g eni t al an o m a lies R ecur r e n t mis c a r ri a g e

5. When t o d o? • W omen a t risk t o d e v elop GDM • A t b o ok i n g / as early as p o ss i ble • W omen a g e ≥25 with no other risk f a c t o r s • a t 2 4 - 28 w e e k s of g e st a ti o n

6. M e thod f or O G T T 1. F a s ti n g o v ern i g h t (usual l y st arti n g 10 p.m.) u n til n e x t morn i ng or a t l e a s t 8 ho u r s. Blood samp l e wi l l be c ol l ec t ed in the morn i ng ( f a s ti n g b l ood su g ar). Dr i nk 75g of g l u c ose in 250ml of w a t er (1 - 15 m i ns). T a k e b l ood f or af t er 2 hou r s (po s tp r and i al). I nt erp r e t the r eadi n g. 2. 3. 4. 5.

7. Interpretation of OGTT result OGTT Plasma Glucose Value (Mmol/L) Category Fasting Blood Sugar (FBS) 2 Hours Post-prandial Normal <5.1 <7.8 Impaired Fasting Glucose 5.1-6.9 Impaired Glucose Tolerance 7.8-11.0 Diabetes Mellitus ≥7.0 ≥11 . 1

8. Effect of diabetes on pregnant mother and fetus Mother Fetus Pre-eclampsia Increased risk of infection Severe hyperglycemia Diabetic ketoacidosis Increased chance of caesarean section Risk of deterioration of pre-existing retinopathy and nephropathy Increased chance to develop T2DM Polyhydramnios Macrosomia Neonatal hypoglycemia Congenital abnormality Stillbirth Hyperbilirubinemia Respiratory distress syndrome

9. Management women with pre-existing diabetes Preconception and counselling Li f e s ty l e adv i ce (di e t, p h y si c al a c ti v it i es, smoki n g o p ti m al body w eig h t) F ol i c a c id su p p l eme n t a tion App r opr i a t e c o n t r a c e p tion • cess a tion and • • • Fu l l med i ca tion r e v ie w (dis c o n ti n ue med i ca tio n s) R e ti n al and r enal sc r een i ng R el e v a n t b l ood i n v e s ti g a tio n s po t e n tia l ly t e r a t o g en i c • •

10. Gl y cemic c o n t r ol • W omen with p r e - e xi s ti n g d i ab e t es who p l an f or p r egnancy t o a im f or H b A1c <6.5% (48m m ol/ m ol) • R educt i on in HbA1c l e v el t o w a r ds the t a r g e t is li k ely t o r educe the r i sk of c on g en i t al mal f orm a tio n s in the ba b y Those with H b A1c l e v el >10% (86 mmo l /mo l ) a r e adv i sed not t o ge t p r egna n t be c ause of the asso c i at ed r i s k s. Inc r ease the f r equ e ncy of sel f - mon i t ori n g of blood glu c ose (SMBG) b y i n cl u d i ng f a s t i n g , p r e -and po s tp r and i al l e v e l s • •

11. • Gl y caemic Co n t r ol • S e lf M o ni t oring of B lo o d Glu c o s e ( SMBG) t o achie v e c o n t r ol and imp r o v e p r egnan c y ou t c ome Assi s ts in adju s tme n t of medi c a ti o ns H e l p s t o p r e v e n t h ypo/ h yp e r gl y c e mia episodes • • • H e lp r edu c e in c iden c e of p r e - e c lam p si a , sh o ulder d y st oci a , ma c r o s omia • Gl y caemic t a r ge t • • • F a s ting blo o d su g ar : ≤5.3 mmol/L 1- HPP: ≤7 . 8 mmo l /L 2- HPP: ≤6 .4-6. 7 mmol/L Antenatal management of diabetes in pregnancy

12. • Medical Nutri t ion The r ap h y • • • • F ocused on Carbo h y d r a t e c o n t r olled meal plan D e t e r mine based on their i nt a k e amou n t ( g r am) and gl y c e mic ind e x A minimum of 1 7 5g CHO daily is r e c ommended Bal a nc e d di e t f or ideal ma c r onutrie n ts di s tribution is r e c ommend e d. (6 % C H O , 2 0% p r o t ein, 20% f a t) L o w gl y c e mix ind e x is b e t t er f or r edu c ing in s ulin r equi r e m e n t. E x : in rice ca t e g o r y , barl e y has l o w er GI than ba s m a ti ric e . Whi t e rice has t h e highe s t G I of all. •

13. • O r al A n tidi a b e tic A g e n t • • M e t f ormin ( m o s t used) and Glibencl a mide M e t f ormin c an l o w er the m a t e r nal w eig h t g ain, neon at al w eig h t birth, mac r o s omia and L GA O AD is t o be o f f e r ed w hen blood glu c ose t a r g e ts a r e not m e t by modifi c a tion of di e ts and l i f e s tyles ch a n g es within 1 - 2 w ee k s (NICE guidel i nes) Co n tin u ed if al r eady on t r e a tme n t b e f o r e p r egnan c y • •

14. • Insulin • Admit p a tie n t f or r e f e r r al t o other multidisciplina r y t e a ms and closer moni t oring In s ulin is gi v en wh e n • • • • • MN T / m e t f or m in the r a p y f a i l e d t o achi e v e gl y c ae m ic c o n t r ol t a r g e t M e t f or m in is co n t r aindi c at ed FPG ≥7.0 m m o l / L a t d iag n osis FPG of 6. -6.9 mmo l / L w i th c omp l i c a tions ( mac r oso m ia or poly h y d r amn i os) • M o s t p r e f er r ed r egime is M ultiple D o se I nje c ti o n(MDI) H u m a n I n sul i n (p r e f er r ed choic e ) I n sul i n Analogue I n t e r medi a t e/long ac t ing (NPH) Long acting (b a sal) – D e t emir & Gla r gine Short acting ( r egular) Rapid acting – Lisp r o & Aspart

15. • Insulin sh o uld be initi at ed when: - B loo d glu c o s e t a r ge ts a r e not me t a f t er di e t c o n t r ol

16. • P r e – E cla m p sia P r op h yl a xis • P r egna n t mother with p r e - e xi s ting diabe t es has fi v e - f old in c r e a sed risk of p r e - e c lam p sia 7 5 mg Aspirin daily f r om 12 w e e k s of g e st a ti o n u n til deli v e r y is r e c ommended Mother with l o w c al c ium c an be gi v en c al c ium supplem e nt a tion with 1 . 5 - 2. g of el e me n t al c al c ium daily f r om 20 w e e k ’ s g e s t a tion • •

17. • Asse s s m e n t of Complic a tions of Diab e t es 1. R e ti n al assessme n t Done a t bo o king and 28 w e e k s. If diab e tic r e tin o p a t h y d e t e c t ed, r e f er t o o p h thalmo l o g i s ts R enal assessme n t Done a t bo o king R e f er t o neph r ol o gi s ts when • • 2. • • • • • Serum c r e a tinine is 1 2 μ mo l / L or mo r e Ur i na r y album i n : c r e a tinine r a tio (ACR) >30m g / m m ol T o t al p r o t e i n e x c r e tion e x ceeds 0. 5 g / d a y

18. • F e t al Su r v eillance • Babi e s of GDM w omen h a v e high risk of d e v eloping c on g eni t al mal f orm a tions • Doing U l t r asound guided mana g em e n t hel p s r edu c es risk of L GA/SGA and mac r o s omia

19. • Timing and Mode of Deli v e r y • P r e - e xi s ting diabe t es with no m a t e r nal or f e t al c ompli ca tion s , deli v er b e t w e e n 37 and 39 w e e k s P r e - e xi s ting diab e t es with m a t ernal or f e t al c omp l i ca ti o ns, deli v er b e f o r e 37 w e e k s GDM with no m a t e r nal or f e t al c ompli ca tion s , deli v er no l at er than 41 w e e k s GDM with m a t e r nal or f e t al c ompli ca tion s , deli v er b e f o r e 41 w e e k s • • • • A nt en a t al c orti c o s t e r oid is admini s t e r ed t o those who h a v e spo n t ane o us or planned p r e t erm del i v e r y t o a c c e le r a t e f e t al l u ng d e v elopme n t.

20. • Imp o r t a n t t o moni t or since m a t ernal h y p e r gl y c aemia du r i n g labour inc r e a ses ris k s of neon a t al h y p ogl y c aemia and f e t al R e c ommend a tion • mon i t or CBG e v e r y h o ur during labo u r and deli v e r y , and mai n t ained a t 4 . 0-7. mmol/L • use IV d e x t r o s e and insulin f or w omen with • T1DM f r om the o n s e t of e s t abli s hed lab ou r • CBG >7.0 mm ol /L d i s t r ess • ensu r e th a t it is Intrapartum glycaemic control for diabetes in pregnancy

21. • Glucose Moni t oring • F a s ting Plasma Glu c o s e t e s t a t 6 - 13 w e e k s a f t er deli v e r y t o e x clude (po s tn a t al f oll o w - up) diabe t es • • O r al Glu c o s e T ole r ance T e s t (O G T T) done a t 6 Annual sc r e e ning if O G T T ne g a ti v e w e e k s p o s tn at all y . • M e t f or m in • P r e v e n t n e wl y - di a gnos e d di a be t es B r ea s t f eeding • R e c ommend e d f or a t le a s t 3 mo n ths r edu c e diabe t es. • o r mo r e ( e n c ou r a g e) as it is p r o v es t o Postpartum management of diabetes in pregnancy

22. • Li f e s tyle I n t e r v e n tion • • MNT P h y si c al ac t ivity • I nt ens i v e ( addit i on of m ode r at e p h y s ic al acti v ity l i k e br i sk w a l k i n g , 5 -60 m inu t e s , f our d a y s/ w eek) B e h a vi o u r al modifi ca tion • * M a y be ef f ecti v e i n r educ i ng po s tpartum w eig h t r e t e n tio n , w ai s t ci r cum f e r enc e , insu l in r esi st an c e, LD L - chole s t e r ol and tr i gl y ceri d es.

23. ANEMIA IN PREGNANCY D i s o r d er b y w h i ch t h e b o d y i s d epl e t ed o f RBC to carry adequate oxygen to tissues D e f i n i t ion of an e m i a in p r e g n a nc y : W HO & M a l ay s i a: Hb < 11 . g / d l C D C: < 11 . g / d l i n 1st & 3rd trimester < 10 . 5 g / d l i n 2nd trimester ** Hb l e v e l n ee d s t o be c h e c k e d a t b oo k i n g and a g a i n a t 28 w ee k s

24. C a uses o f Anem i a Duri n g P r egn a n c y 1. 2. I n c r eased plasma v o l ume e xp a n s i o n. I n c r eased f e t o - place nt al dema n d f o r i r o n a n d f o li c acid. • Th u s, l ack o f i r o n a n d f o l at e → ↓ i n RBC p r o d u cti o n. 3. A n e mi a se c o n d a r y t o c h r o nic bl o o d l o ss o r hem o l y si s .

25. E FF E C T O F A NE M I A T O P R E GN A N C Y M A TE R N A L F E T A L A N TE N A T A L I N T R A PARTUM P O S T N A T A L • H y p o x i a d u e t o r e du c e o x y g en c a rri er i n m o th e r ’ s b l oo d R e d u c e f e t a l m o v e m e n t L o w b i r t h w e i g h t P r e m a tu ri t y I U G R (s e v e r e a n e m i a H b < 8 ) • • • • • P oo r w e i g h t g a i n P r e t erm l a b o u r P r e - e c l a mp s i a A b r upt i o p l a c e n t a U n a b l e t o w i th s t a n d h a e m o rr h a g e P r e m a tu r e r uptu r e o f m e m b r a n e S u s c e p t i b l e f o r i n f e c t i o n & h e a r t f a il u r e • • P u er p e r a l s e p s i s S ub - i n v o l ut i o n o f u t er u s P u lm o n a r y e m b o li s m • D y s f un c t i o n a l l a b o u r • H a e m o rr h a g e & s h o c k • • • • • • •

26. T ypes o f A n em i a i n P r egn a n c y ACQUIRED HEREDITARY N u t ri t i o n a l : o I r o n d ef ici e n c y a n e m i a o F o l a t e d ef i e n c y a n e m i a o V i t a min B 1 2 def ici en c y a ne mia • H a e m o g l o b i n o p a t h i e s o T h a l ass e m i a o S ickl e c e l l a n e m i a A n e mia du e t o b o n e m a r r o w f a il u r e : o A p l a s t i c a n e m i a o L eu k e mia o P a r o x y s m a l n o c t u r n a l h a e m o g l o b i nu ri a • Mem b r a n e d e f e c t : o H e r ed i t a r y s phe r o c y t o s i s A n e mia s e c o nd a r y t o i nf l a mm a t i on o r c h r on i c d i s e as e A n e m i a du e t o a c u t e / c h r o n i c b l oo d l o s s

27. Hi s t o r y t a k i ng • S y m p t om s : F a tig u e , f ai n ti n g , d y s pn oea, p al p i ta ti o n , p allo r , w e a kn e ss , d iz z i n e ss , h e a d a c h e . A n y h i s t o ry o f h oo k w o rm i n f e s t a t io n , G IT p r o b l e m ( ha e mor rh o i d ), h i s t o ry o f b l e e d i n g M e d i c al h i s t o r y : a n y h i s t ory of b lo o d d i s o r d e r , p r e v io u s h i s t ory of an e m ia, a d m i ss ion h i s t o r y , und e rl y i n g h e a rt o r r e n a l d i s e a s e O b s te t r i c & g y n a eco l o g y h i s t o r y : a n y h i s t o ry o f a b o rti on s , me n s tr u al h i s t o r y , APH F a m il y h i s t o r y : F a m ily h i s t o ry o f b l ee d i n g d i s o r d e r D ru g h i s t o r y : a n y h i s t ory of t a k i n g a n t aci d , c omplia n ce t o h e m a ti n i c . D iet a r y h i s t o r y • • • • • •

28. P h y s i c al e x a m i n a tion • • • • • • • • • • • P a llor T a c h y c a r d ia B r e a t h l e ss n e s s G los s iti s , an g u lar s t o m a t itis K o ilo n y c h ia Br u i s e s , p e t e c h iae S o ft s y s t o lic m u rm u r I n c r e a s e d J VP Di s p laced a p e x b e a t Bib a s a l c r e p i ta ti o n - m it r al a r e a H e p a t o m e g a l y / s p l e n o m e g a ly

29. I r on D e f i c ie n c y A nem i a (I D A ) • • C o mmo n e s t a n e m i a i n p r eg n a n c y . P h y siolo g i c al i r o n r equi r e m e n ts a r e 3 ti m es hig h er i n p r egna n c y , w i th i nc r eas i ng deman d s as p r eg n a n cy a d v a n ces. • MCV ( < 8 f L ) a n d MCH ( < 2 7 p g ) s u g g e s t t h e p o s s i b ili ty h y p o ch r o m i c m i c r o cyt i c a n aem i a. I na d equacy d i e t a r y s u p p l e m e n t. I n e f f ect i v e ab s or pti o n. I nc r eased i r o n l o s s . o f • • •

30. Di a g n o s i s i. ii. i i i . iv. v. vi. Haem og l o b i n < 11 g /dL MCV < 75 f L S e r u m i r o n < 6 µ g /dL S er u m f er r i tin < 12 µ g /dL ( 8 - 95) ( 60 -120) (1 3-27) P erip h e r al bl o o d f il m: h yp o c h r o m i c m i c r o cyt i c S e r u m f e r r i tin < 15 μ g /L i s d i a g n o s tic < 30 μ g /L p r o mpt t r e a tme n t

31. Other i n v e s ti g a tions . . • I de n tify c a u se of i r o n d e f i ci e n c y - s t oo l o c u l t b l oo d , s t o o l e x am i n a tion f o r w or m F e t al m on i t or i n g ( F K C, USG, D o pp l e r , C T G) M a t er n al m o n i t or i n g - EC G a n d E c h o c a r d i og r am • •

32. T r e a tme n t 1) O r al i r o n s upp l em e n t s (T D S ) • • • F e r r o u s s u l ph at e , F e r r o u s f u m a r at e A d v a n t a g e : c h e a p , e a s y t o t a k e D i sa d v a n t a g e : sl o w t o a c t, G I T si d e e f f e c t (n a u s e a, c o n s t i p a t i o n , d ark s t ool s) 2) P a r e n t e r al i r o n ( t a k e 4 w ee k s t o w or k) • • • I M / I V i r o n d e x t r an F o r a d v a n c e d & n o n - c om p li a n c e t o o r al S i d e e f f e c ts: a r th r a l g i a, m y a l g i a, a n a p h y l a x i s. 3) Bl o o d t r a n s f u s i o n – p a c k ed cell v o l u m e (PC V )

33. F ol a t e D e f i c ie n c y A nem i a (F D A ) • • F o l at e d e f i ci e ncy i s much l ess c o mmon t h an i r o n d e f i ci e nc y . H o w e v e r , f o l at e s u p p l e m e n t i s r e c o mm e n d ed t o all p r eg n a n t m o t h e r s t o r educe t h e r i sk o f neu r al t u be d e f ect. F o l at e & B 1 2 d e f i ci e ncies u s u a ll y c a u se m e g alo b l a s tic a n aem i a w i th MCV ( > 10 f L ) . •

34. Di a g n o s i s C o m p o n e n t s V al u es H e m og l o bi n < 11 g / d L M e an c o r pu s c ul ar v o lu m e ( M CV) > 100 f L S e r u m F o l a t e < 3 n g / d L P e ri p he r al bl oo d f il m M ac r o c y tic h y po c h r o mic, me g a l o bl a s tic neu t r o peni a, h y p e r s e g m e n t a t i o n o f neu t r o phil s

35. T r e a tme n t 1. 2. F o l at e s u p ple m e n ts – f o li c acid 5 m g /d a y . I n c r ease die t a r y i n t a k e o f f o l at e – l e a f y g r e e n s , b r o c c o li , c a u li f l o w e r , a sp a r a g u s, fr u i ts (p a p a y a, o r a n g es, a v o c a do ) , b ea n s, p eas a n d l e n ti l s.

36. Tha l ass e m i a • G r oup of i nh e r i t ed b l o o d d i s o r de r s whe r e t he H b i s a bnormal a s a r esu l t of mu t a t i ons i n g en e s t h a t c ode H b . A u t o s om a l r e c es s i v e p a tt e r n. H e a l t h y a du l t s sh o u l d h a v e > 9 5 % h a emogl o b i n A ( Hb A) , w h i ch c o nsi s t of 2 a l pha a nd 2 be t a pept i de c h a i ns. Inc i d e n c e: 1 i n 30 – 50 p r e g nanc i es. • • •

37. R i s k s o f T ha l asse mi a i n p r egn a ncy M O T H ER F E T U S Cardiac siderosis are at risk of d e c om p e n s a t i o n & d e a t h I n c r e ase t r a n s f u si o n r e qu i r e m e n t Acc e l e r a t i n g p r e - e x i s t i n g d i a be t ic r e t i n o p a t h y o r n e ph r o p a t h y W o r s en i n g o s t e o p o r o sis Hig h i n ci d e n c e o f g e s ta t i o n al d i a be t e s H i g h i n ci d e n c e o f o p e r a t i v e d e li v e ry Fetal growth restriction P r e m a t u r i t y

38. Di a g n o s i s 1. Haemo g l o bin e l ect r o ph o r esis: H B A ( r ed u ced / a b se n t ) , (inc r eased), H B A2 ( v a r i a b l e) P eriphe r al B l oo d Smea r : HBF 2. • • • • Mic r o cytic, h yp o c h r o m i c T a r g et ce l l A n i s o p o i k i l o cy t o sis N or m o bla s t n u cl e at ed RBC 3. F u l l Blo o d Co u n t ( F BC): • • • L o w MC V , l o w MCH, l o w Hb ( <7 g /dl) High R D W , WBC N o r mal p l at e l et

39. M a n a g eme n t A n t en a t al c a r e: • F oli c a ci d s u pp l e m e n t. F oli c a ci d 5 m g d a il y a n d c a lci u m a n d v i t a mi n D s u pp l e m e n ts, i f b o n e d e n si t y i s r e du c e d , s h o u l d b e t a k e n . • I f b o th p a r e n ts c a r r i e r , d o s c r ee n i n g . C h o r io n i c v i ll u s sa m p li n g f o r D N A t e s t i n g a t 1 1 - 14 w ee k s o f p r e g n a n c y Am n ioc e n t e sis t e s t e d a f t e r 15 w ee k s o f p r eg n a n c y F e t al b loo d sa m p li n g t a k e n f r o m u m b ili c al c o r d b e t w ee n 1 8 - 21 w ee k s. i. ii. iii. • C h e c k a n d o p t i mi se a n y e nd oc r i n e a n d c a r d i ac d y s f un c t i o n p r e n a t a ll y • C o n si d e r t e r m i n a t i o n o f p r e g n a n c y i n s e v e r e l y a f f e c t e d f e tu s .

40. RENAL DISEASE IN PREGNANCY A c u t e K i d n e y I n j ur y (A K I) in P r e g n a nc y • Ab r u p t de t erio r a tion o f r enal f u n ction se c o n d a r y disease o r p r eg n a n c y - r e l at ed d i s o r d e r s. t o p r e - e x i s ting r enal • L e ss c o mmon t h an ch r o nic k i d n e y disease • C l i ni c al f e a t u r es i nclu d e: • • • O l i g u r i a / a nu r i a I n c r e as e d s e r u m c r e a t i n i n e a n d u r e a D e c r e as e d G F R

41. A c u t e K i d n e y I n j ur y (A K I) in P r e g n a nc y • Ab r u p t de t erio r a tion o f r enal f u n ction se c o n d a r y disease o r p r eg n a n c y - r e l at ed d i s o r d e r s. t o p r e - e x i s ting r enal • L e ss c o mmon t h an ch r o nic k i d n e y disease • C l i ni c al f e a t u r es i nclu d e: • • • O l i g u r i a / a nu r i a I n c r e as e d s e r u m c r e a t i n i n e a n d u r e a D e c r e as e d G F R

42. C h r o n i c K i d n e y D i s e a s e (CK D ) in p r e g n a n cy • W o m e n w i th C K D a r e l e ss able t o ma k e t h e r enal ada p t a tio n s necess a r y f o r a healt h y p r eg n a n c y . C K D i s classi f i ed i n t o f i v e s t a g es b a sed o n t h e l e v el o f r enal f u n cti o n. 3 % o f w o man i n chi l d b ea r i ng a g e g r o up m a y h a v e s t a g e 1 a n d 2 . • • • • A bo ut 1 i n P r eg n a n cy 15 o f w o man i n chi l d b ea r i ng a g e g r o up m a y h a v e s t a g e 3 - 5 m a y u n mask p r e v i o u s l y u n de t ec t ed r enal d i sea s e.

43. S t a g e D es c r i p t i o n E s t i m a t e d G F R ( mL / m i n /1 . 73 m 2 ) 1 Ki d n e y d a m a g e wi t h n o r m a l / r a i s e d G F R > 90 2 Ki d n e y d a m a g e d wi t h mil d l y lo w G F R 60 - 89 3 M o d e r at e l y lo w G F R 30 - 59 4 Severely lo w G F R 15 - 29 5 K i dn e y f a i l u r e < 15 o r d i a l y sis Cl a ssi f i c a t io n o f C h r o n i c K i dn ey D i se a se ba sed o n r e na l fun c t io n

44. E f f e c t s o f p r e g n a nc y o n C K D S t a g e 1 a n d 2 ( m i l d r en a l d y s f un c t i o n ) • • Usual l y h a v e an u n e v e n t f ul p r eg n a n cy P r eg n a n cy w i th a n d g oo d r enal o u t c o me • • • S e r u m c r e at i n i n e < 1 10 µ mo l / L Mi n i m a l p r o t e inu r i a ( < 1 g / 2 4 h o u r s) A b se n t / w e l l - c o n t r oll ed h y p e r t e n s io n p r e - p r eg n an cy H a s li t t l e /n o ad v e r se e f f ect o n lo n g t e r m m a t e r na l r e n a l f un c t io n

45. E f f e c t s o f p r e g n a nc y o n C K D S t a g es 3- 5 (m o de r at e t o se v e r e) • A t hi g he s t r i sk o f c o mpl i ca ti o ns d ur i ng decl i ne i n r enal f u n cti o n. p r eg n a n cy & acce l e r at ed • P r e - e x i s ting h ype r t en s i o n & p r o t e i nu r i a g r e a tly i n c r ease t h e p o o r p r egna n cy o u t c o m e s r i sk o f • I f p r e - ec l amp s i a de v e l o ps – de t eri o r at es f u r t h e r . m a t er n al r enal f u n cti o n of t en

46. Effect of CKD on pregnancy outcomes F E T AL O U T C O M E S M A T E RN AL O U T C O M E S Premature birth Intra-uterine growth retardation Small-for-gestational age Low birth weight Still birth Neonatal mortality Gestational hypertension, pre-eclampsia, eclampsia Maternal death

47. M o n i t o r i n g o f p a t i e n t s wi t h C K D du r i n g p r e g n a nc y • • • • B l oo d p r essu r e R e n a l f u n c t io n • C r e a tinine U r i n e • I n f ecti o n • P r o t e i nu r i a F u ll b l o o d c o u n t • Haem og l o bin • F er r i tin R en a l u l t r a s oun d Fet a l u l t r a s oun d • • F e t al a n at o m y U t e r i n e a r t e r y w e e k s D o pp l er 2 -24 • • F e t al g r o w th •

48. D ia l y s i s in p r e g n a nc y • • I ncidence o f p r egna n cy o n dia l y sis i s i nc r eas i n g . ( s t a g e 5 C K D ) D i al y sis mu s t be ad j u s t ed t o al l o w p h y siol og i c al ch a n g es d ur i ng p r eg n a n cy ( plasma v o l ume, f l uid r e t e n ti o n, se r um e l ect r o ly t es ) . • Haemo d i al y sis i s u s u al l y m o r e ac h i e v i ng t h i s. C o mpl i ca ti o n o f dia l y sis: e f f ecti v e t h an p e r i t o n eal d i al y sis i n • • • • • P r e t e rm d e li v e ry P ol y h y d r a m n io s ( 3 0- 60%) P r e - e cl a m p sia ( 4 - 80%) Ca e sa r e an d e li v e ry ( 50 % )

49. P r i nc i p l e s o f m a n a ge m e n t o f C K D in p r e g n a nc y • All p r egna n t w o m e n w i th C K D s h o uld be c o - man a g ed by a mult i discipl i n a r y t eam c o n s i s ts o f nep h r o l og i s t/p h y sic i an a n d o b s t et r i cian. • All w o m e n w i th C K D w ho i n t end t o g et c o u n se l li ng. p r eg n a n t s h o uld i n f o r m t h e i r d o c t o r s f o r p r ep r eg n a n cy

50. P r e p r eg n a n cy c o u n s e lli n g f o r C K D p a t i e n t s The d i sc u s s i o n s ho uld i n c l u d e: • • • • • S a f e c o n t r aception u n til p r egna n cy adv i sed F er t ili ty i s s ues i f i n d i c a t ed. G en e tic c o u n se l li ng i f i n h eri t ed d i s o r der R i s k s t o mo t her and f etus d ur i ng p r egna n cy A v o i d kn ow n t e r a t o g ens and c o n t r aindi c a t ed d r u g s

51. • • • T r e a tme n t o f bl oo d p r ess u r e a n d a d j u s tme n t o f a n ti h y pe r t ensi v es Low d o se a s pi r i n Ne e d f o r a n ti c o a g ula n t o nce p r eg n a n t i n w o man w i th si g ni f i c a n t p r o t e i n ur i a • • • • Need f o r c o mpl i a n ce w i th s t r i ct s u r v e i ll a n ce L i k e l i h oo d o f p r o l o n g ed a d m i s s i o n o r ea r l y d e l i v e r y P o s s i b ili ty o f ac c e l e r at ed d ec l i n e Need f o r p o s t p a r t u m f o ll o w - up i n m at e r n al r en a l f un c t i o n