PREGESTATIONAL CONDITIONS CARDIAC CONDITIONS INCIDENCE: 1% or 1 in every 100 pregnancies. Over 75% of heart disease in pregnancy isvalv lar!

often "he #atic $ever or "%D. Effects of pregnancy on heart disease:1. 1. Increased &lood vol #e and cardiac o tp t

Cardiac o tp t and &lood vol #e increase a&o t 50% #ore d ring

pregnancy 'increase (or)load to the heart*

D ring la&or and delivery! cardiac (or)load increases even #ore 'every ti#e the ter s contracts a&o t 1 or + nits of &lood are a totransf sed fro# tero, placental to #aternal circ lation. -hen contraction stops! this vol #eret rns to teroplacental and the heart #ay not &e a&le to co#pensate (ith s ch rapidshifting.

.fter delivery! the teroplacental &lood ret rns to #aternal circ lation
increasingonce again &lood vol #e.

. (o#an (ho receives epid ral or spinal anesthesia! her &lood vessels
dilate and&lood press re decreases that res lts to decreased veno s ret rn (hich pro#ptsthe heart to co#pensate to #eet &ody/s needs &y p #ping harder

E0cessive &lood loss d ring second stage of la&or.+.

+. 1yste#ic vasc lar resistance drops &y +5% d ring pregnancy lo(ering &lood press re.2. 2. 3ravid ter s can dra#atically affect veno s ret rn in so#e positions co#pressing I4Cand can lead to hypotension. $5NC6ION.7 C7.11I$IC.6ION1 O$ %E."6 DI1E.1E: C7.11 I8 nco#pro#ised9 :atient is asy#pto#atic (ith no li#itation of physical activity! noangina pain or disco#fort (ith ordinary activity. :erinatal #ortality is 5% C7.11 II8 slightly co#pro#ised 9 patient (ith slight li#itation of physical activity! ordinaryactivities ca se dyspnea! fatig e! chest pain and palpitations. :erinatal #ortality is 10,15%

C7.11 III8#ar)edly co#pro#ised 9 (ith #ar)ed li#itation &eca se ordinary activities ca see0cessive fatig e! palpitations! chest pain! and dyspnea! only co#forta&le at rest. :erinatal#ortality is 25%. C7.11 I48severely co#pro#ised 9 e0perienced sy#pto#s even at rest! na&le to perfor# anyactivity (itho t disco#fort! perinatal #ortality is #ore than 50%. Condition sho ld &e corrected&y s rgery. .&ortion co ld &e considered if gestation is less than 1; (ee)s and cannot &ecorrected &y s rgery and also sterili<ation. 1I3N1 .ND 1=>:6O>1:

Diffic lty of &reathing li)e dyspnea and orthopnea+. :alpitations lasting several #in tes associated (ith lightheadedness2. .rrhyth#ias8 dysrhyth#ias;. Chest pain5. %e#optysis?. 1yncope (ith e0ertion7. Cyanosis@. Cl &&ing of fingersA. Nec) vein distention10. 1ystolic and diastolic # r# rs

>.N.3E>EN6: :renatal Care:1. .ssess#ent 9 #anage#ent depends on the f nctional capacity of the heart deter#ined&efore the 2rd #onth pregnancy and at 7,@th #onths. Diagnostic tests

EC38EB3 9 electrocardiogra# records the electrical activity of the heart andsho(s a&nor#al rhyth#s and detects heart # scle da#age Echocardiography8 heart ltraso nd 9 eval ates heart str ct res and f nctions of heart &y sing so nd (aves recorded on electronic sensor that prod ce a #ovingpict re of heart and heart valaves.+.

:ro#otion of rest 9 @,10 ho rs of sleep at night and freC ent rest periods d ring the day!lie do(n for 20 #in tes after each #eal! allo(ed only light (or)sD consider ho se(or)assistance s ch as cleaning! la ndry and #ar)eting! severely affected patients #ay need to&e confined in the hospital as early as #id,second tri#ester to ens re rest and#anage#ent.2. Diet

%igh in iron! protein! #inerals and vita#ins 7i#it sodi # inta)e after @,1+ (ee)s to avoid fl id retention -eight gain of no #ore than +; l& to prevent f rther increase of cardiac(or)load;. .void high altit des! s#o)ing! npress ri<ed planes! and alcoholic inta)e5. :revent infection .void people (ith infection Early treat#ent of infection?. Instr ct on danger signs of heart fail re Co gh (ith rales Increasing dyspnea! rales and ede#a

DIABETES MELLITUS . hereditary endocrine disorder characteri<ed &y inadeC ate ins lin prod ction thatres lts to i#paired gl cose a&sorption and #eta&olis# res lting to hyperglyce#ia 1I3N1 .ND 1=>:6O>1:1. %yperglyce#ia+. 3lycos ria2. :oly ria;. :olydipsia5. -eight loss?. Betoacidosis d e to &rea)do(n of fats and proteins E$$EC61 O$ :"E3N.NC= ON 375CO1E CON6"O7 ,pregnancy is )no(n to &e a dia&etogenicstate d e to effects of placental hor#ones especially %:7 (hich increases cells/ resistance toins lin INCIDENCE: ,Dia&etes is #ost co##on endocrine disorder affecting pregnancy co#plicating a&o t ;% ,3estational dia&etes 9 @@%! 6ype II ,@%! 6ype I ,;% >.N.3E>EN6: :renatal:1. :regnancy planning 9 a dia&etic (o#an sho ld have a sta&le disease state &eforeconception and # st &e evidenced &y: Nor#al fasting &lood gl cose level1 Nor#al glycosylated he#oglo&in levels of 7 9 10% 'reflects the average#eas re#ent of the gl cose levels over past 100,1+0 days*+. :renatal clinic visits: every + (ee)s pto 2? (ee)s .O3 then (ee)ly2. Dia&etic diet Caloric inta)e sho ld &e eno gh to #eet pregnancy needs '1!@00,

+!;00cal8day* +0,+5% caloric inta)e sho ld co#e fro# protein rich foods ;0,50% fro# C%O 20,;0% fro# poly nsat rated fats -eight gain sho ld &e a&o t +; l&s Instr ct to: red ce sat rated fats and cholesterol and concentrated s gars!increase dietary fi&er! avoid feasting and fasting %ave (o#an &eco#e fa#iliar (ith food e0change list and caloric val es of foods;.

E0ercise 9 &efore! instr ct #other to eat co#ple0 C%O to prevent hypoglyce#ia5. Ins lin therapy ,3D s ally responds (ell to diet and e0ercise therapy ho(ever if &lood gl cosecannot &e controlled or #aintained! ins lin therapy #ay &e needed ,% # lin is safest to se for pregnant (o#en ,sched le is t(ice a day! &efore &rea)fast and 20 #in tes &efore dinner. Often! a fastand inter#ediate acting ins lin are co#&ined. ,hypoglyce#ia co ld occ r d ring the pea) ti#e of action 1hort acting8reg lar Ins lin 9 onset occ rs 1 ho r (ith pea) action in + 9 ;ho rs Inter#ediate8 7ente 9 onset is +,; ho rs (ith pea) at @,1+ ho rs 7ong acting8 5ltralente 9 onset is ;,@ ho rs (ith pea) of 1?,1@ ho rs , instr ct on signs of hypoglyce#ia ca sed &y e0cessive ins lin! e0ercise andins fficient dietary inta)e: :allor! (ea)ness! n #&ness! headache! perspiration! conf sion! irrita&ility!&l rred vision! h nger! conv lsion! co#a Instr ct C%O foods that can correct it li)e fr it E ices! cola! s gar candy?. 1elf #onitoring of &lood gl cose '1>F3* ,6ype I patients are reco##ended to test at least 20 a day. Deserved val esare:1. Fefore #eal 9A5 #g8d7+. One ho r after , G1;0 #g8d72. 6(o ho r after , G1+0 #g8d7 ,1he can decrease testing to 20 a (ee) if she has good nderstanding on dietand gl cose val es are of desired range7. $etal (ell &eing #onitoring@. Contin o s eval ation of dia&etic co#plications ANEMIAS OF PREGNANCY Is a condition of fe( "FC or a lo(ered a&ility of the "FC. In pregnancy! it is defined ashe#oglo&in level less than 11 g8d7 in the 1st and 2rd tri#ester and 10.5 g8d7 in the +nd.

6=:E1

Iron Deficiency .ne#ia 'ID.* 9 +. 4ita#in F1+ deficiency2. .ne#ia d e to Flood loss;. $olate Deficiency .ne#ia

"I1B $.C6O"1: 1.:oor n trition +.E0cess alcohol cons #ption 2.>edical history of any disorder that red ces a&sorption of n trients ;.5se of anticonv lsant dr gs 5%istory of se of oral contraceptives ?.3?:D deficiency co##on in >editerranean! .frican .#ericans and He(ishD 1ic)le celldisease co##on in .frican .#ericans! Italians and #iddle eastern and east Indians. IRON DEFICIENCY ANEMIA ,Is the #ost co##on type d ring pregnancy. %o(ever! the ne(&orn is not affected for the irons pply to the fet s is sa#e (ith that of the non,ane#ic #other. :redisposing $actors:1.

:oor diet8n trition+. %eavy #enses2. :regnancies at close intervals or s ccessive pregnancies

1igns and sy#pto#s:1. Easy fatiga&ility+. 1ensitivity to cold2. :roneness to infection;. Di<<iness5. 7a&oratory $indings li)e in CFC Effects on :regnancy:1.

Decreased resistance to infection+. :re#at rity and lo( &irth (eight infants2. :redispose to heavy &leeding d ring la&or and delivery;. %igh digestive disco#fort of pregnancy

>anage#ent:1. Oral iron s pple#entation +00 #g of ele#ental iron daily $erro s s lfate is the #ost a&sor&a&le! ferro s f #arate and ferro sgl conate

gastrointestinaldisco#fort Never ta)e (ith #il) and calci # s pple#ents 6a)e (ith citr s E ice to enhance a&sorption If given in liC id for#! se stra( or rinse #o th after If given parenterally! I,trac) is sed and do not #assage Oral iron is contin ed pto 2 #onths after ane#ia is corrected to & ild#other/s iron reserves+. Increase inta)e of vita#in C2. Increase inta)e of iron rich foods: lean #eat! liver! dar) green leafy vegeta&les. 3oodfood so rces of iron incl de the follo(ing: >eats 9 &eef! por)! la#&! liver! and other organ #eats :o ltry 9 chic)en! d c)! t r)ey! liver 'especially dar) #eat* $ish 9 shellfish incl ding cla#s! # ssels! oysters! sardines and anchovies 7eafy greens of the ca&&age fa#ily! s ch as &roccoli! )ale! t rnip greens andcollards 7eg #es s ch as li#a &eans and green peas =east 9 leavened (hole,(heat &read and rolls Iron 9 enriched (hite &read! pasta! rice! and cereals

1ide effects of these dr gs are tarry stools! constipation and

ANEMIA FROM ACUTE BLOOD LOSS .ne#ia fro# ac te &lood loss is d e to &leeding disorders of pregnancy. 6hese incl de: ectopicpregnancy! a&ortion! placenta previa! h,#ole! and placenta previa and a&r ption placenta. >.N.3E>EN61.

If the he#oglo&in level is #ore than 7# g8dl! iron replace#ent therapy ntil three#onths after ane#ia has &een corrected.+. $or #assive he#orrhage: &lood transf sion of the (hole &lood. :ac)ed red &loodcells and plas#a e0panders to restore nor#al &lood vol #e.>E3.7OF7.16IC .NE>I.>egalo&lastic ane#ia is a gro p of he#atologic diseases ca sed &y i#paired DN. synthesisres lting in &lood and &one #arro( a&nor#alities.

6=:E1 O$ >E3.7OF7.16IC .NE>I.1.

$olic .cid Deficiency8:ernicio s .ne#ia+. 4ita#in F1+ Deficiency8.ddison :ernicio s .ne#ia

$O7IC .CID DE$ICIENC=: $olic acid is necessary for the nor#al for#ation and n trition of red&lood cells. Deficiency in folic acid leads to the for#ation of large and i##at re &lood cells thathave shorter life span than nor#al red &lood cells.

Effects on :regnancy: .&r ptio :lacenta! .&ortion! Ne ral 6 &e defects :redisposing factors long ter# se of pills poor n trition # ltiple pregnancies s ccessive pregnancies signs and sy#pto#s na sea vo#iting anore0ia >anage#ent:1.

treat#ent: $olic acid s pple#ent 1 #g8day acco#panied &y iron+. prevention &y vita#in of ;00 #cg of folic acid daily and inta)e of: leafy! dar) greenveggies! dried &eans and peas! citr s fr its and E ices8&erries! fortified &rea)fast cereals!enriched grain prod cts

4I6.>IN F1+ DE$ICIENC=: .ddison :ernicio s .ne#ia is rare! there is a toi## ne disorderca sed &y fail re to a&sor& 4ita#in F1+ d e to lac) of intrinsic factor. Ca ses: total gastrecto#y 'treated (ith lifeti#e #onthly ad#inistration of 1000 #cgcyanoco&ala#ine I>* Crohn/s Disease Ilial resection Facterial overgro(th in large intestine

HEMOLYTIC DISORDERS IN PREGNANCY,he#olytic disease of the ne(&orn is ca sed either &y "h inco#pati&ility or .FO inco#pati&ility.6he #other prod ces anti&odies that destroy "FC of the fet s (hich res lts to fetal death andhyper&ilir &ine#ia. RH INCOMPATIBILITY Rh factor 9 a distinct protein antigen genetically deter#ined that is fo nd on the covering of "FC. If this is present in the cells! the person is "h positive! if not! "h negative. :resence of thisantigen in &lood #a)es it inco#pati&le for &lood that does not have it. 6he "h is considered as an antigen8foreign &y the "h negative &lood pro#pting the person (ho is "h negative to prod ceanti&odies to destroy this antigen. ,a&o t @5% are "h positive and 15% are "h negative

6he "h positive gene is stronger8 #ore do#inant that the "h negative gene! even if co#&ined(ith an "h negative gene! the "h positive gene prevailsD Foth parents are "h J K fet s is "h J If one parent has "hJ K fet s is "h J If &oth are "h 9 K fet s "h 9 "h sensiti<ation or isoi## ni<ation 9 e0pos re of "h negative &lood to an "h positive &loodthat res lts to prod ction of anti&odies against "h antigens. It can occ r &y: 1ensiti<ation fro# a previo s pregnancy (hich occ rs if a (o#an (ho is "h negativeconceives an "h positive fet s. 6he fetal &lood entered #aternal circ lation d ringdelivery of placenta. InadeC ate response to prophyla0is Inco#pati&le &lood transf sion 0.5 #7 of fetal "h positive &lood that enters #aternal circ lation of "h negative &loodcan sti# late #assive prod ction of anti&odies (hich is detri#ental to a f t reconception of "h positive fet s. ,these anti&odies do not disappear in #aternal &lood strea# once present. If fet s is "h positive!the anti&odies (ill attac) the fetal &lood ca sing erythro&lastosis fetalis d ring pregnancy orhe#olytic disease in ne(&orns '%DN* Effects of Erythro&lastocis $etalis: ane#ia spleno#egaly hepato#egaly hyper&ilir &ine#ia hydrops fetalis still&irth 1igns and sy#pto#s, >other is asy#pto#atic nless &a&y dies in tero and not &orn right a(ay! cessation of pregnancy signs and sy#pto#s! no fetal #ove#ents! not affected &y erythro&lastocis fetalis

>.N.3E>EN6: $etal s rveillance: 6his is instit ted if #other titer is positive. -hen the titer rises to 1:1? or #ore: .#niocentesis every + (ee)s &eginning +? (ee)s gestation for e0a#ination of &ilir &in level :erc taneo s #&ilical &lood sa#pling #ay &e done if severe he#olysis isdetected in a#niocentesis! can &e started at 1@,+0 (ee)s gestation 5ltraso nd to assess co#plications s ch as hydrops fetalis!

polyhydra#nios! andenlarge#ent of the heart Intra terine &lood fetal transf sion: to directly i#prove fetal tiss e o0ygenation prevents8reverses hydrops fetalis ,can &e given at 10,day to + (ee)s intervals generally ntil 2;,2? (ee)s gestation! (hen fet s is#at re eno gh to &e delivered 7a&or and delivery: the goal is to #ini#i<e opport nity for #aternal,fetal &leeds

do not re#ove placenta #an ally cla#p cord i##ediately after &irth ens re that a &lood sa#ple is dra(n fro# the #other for &lood test shortly after &irth totest for presence and C antity of fetal &lood that entered #aternal circ lation.