ENDOCRINE DISORDERS

Diabetes mellitus-most common endocrine disorders in pregnancy

Increase in maternal blood glucose-increase in fetal glucose---stimulates fetal

pancreas to produce insulin---fetal beta cell hyperplasia and hyperinsulemia---
infant morbidity and mortality

Types: f . iDDM ( insulin dependent diabetes mellitus)

Genetic predisposition, immune dependent( destruction of pancreatic

cells leading to low insulin )

2. NIDDM ( Non-insulin dependent diabetes mellitus)

Adult onset, familial, abnormal insulin secretion, obese

Pregnancy is diabetogenic, reversible( insulin secretion is impaired by placental

lactogens and to a lesser degree by estrogen and progesterone )

Gestational diabetes-disorder induced by pregnancy related to exaggeration of the

physiological changes in glusose metabolism, commonly in obese women

Maternal effects of Diabetes during pregnancy: increase incidence of

preeclam psia/eclam psia, increase bacterial
infection,macrosomia,polyhydramios,increase maternal mortality(hypertension, C-
section, infection )

Fetal effects of Diabetes: increase peranatal death,increase fetal anomalies, preterm

labor,neonatal morbidity due to macrosomia,hereditary predisposition to
dia betes, neonata I cardiomyopathy

Macrosomia-results when an increase in fetal glucose---- increase insulin secretion-

promotes growth factor by increase glycogen synthesis,lipogenesis and protein
synthesis

SCREENING for high risk ( more than 30yo,(+) family history of DM,previous
macrosomia or deformed baby,obese, hypertension,glucosuria)

Performed al 24-28 weeks on pregnant women with no known glucose intolerance

ONE-STEP: Fasting sample, ingest 75g glucose,extrac blood after 2 hrs -Value: FBS
> 105mgo/o/ L4Omgo/o
TWO-STEP APPROACH: OGCT-509 glucose load (non fasting )- a value of
> 140mgo7o--Oroceed to OGTT

HgbAlc-glycosylated marker, long term picture of blood glucose

MANAGEMENT:

Glycemic control with insulin and oral hypoglycemics,C-section for large baby,
Induction of labor, Contraception( POP, IUD, barrier method, sterilization )

THYROID DISEASE

Hyperthyroidism-characterized by tachycardia, thyromegaly,exopthalmos,failoure to

gain weight, increase T4

Treatment: PTU(propylthiouracil), methimazole(cross placenta causing

hypothyroidism and goiter)

Surgical

Hypothyroidism-usually related to infertility

RENAL DISEASE

Changes during pregnancy-increase renal and interstitial vascularity which leads to

increase renal size and weight

Hydroureter and hydronephrosis( due to dextrorotation and "cushion effect"of the

sigmoid colon )

Assymptomatic Bacteriuria( ASB)

-due to Escherichia coli, patient is asymptomatic, if unrteated wil lead to UTI

Urinary tract infection (UTi)- caused by E. Coli

Pyelonephritis- ascending infection from untreated bacteriuria

- Associated with preterm labor, growth retardation, feta I death

- SSX: costovertebral angle tenderness, chills, myalgia, nausea and
vom iting
- Tx: hospitalization, antibiotic and hydration
GASTROINTESTINAL DISEASES

Change in motility during pregnanc casusing -prolonged transit time

Nausea and Vomitting

- usually early morning,, due to HCG hormone

Usually at 1't trimester and resolves at 20th week

Hyperemesis gravidarum-severe form of vomiting

- Requires hospitalization for electyrolyte replacement and nutritional

support
- Presence of ammonia in urinalysis( signifies protein breakdown )

GERD( Gastro-esophageal Reflux D iseases) -'pyrosis/hea rtburn "

 -usually end of 2nd trimester to term
-due to relaxed esophageal sphincter, stomach compression,and increase
intraabdominal pressure

Tx]head-of-bed" elevation, small meals,Limit fat in the diet, so smoking, antacids

medications

PUD( Peptic Ulcer Dioseases )- uncommon in pregnancy

Appendicitis ( AP)-most common non-obstetrical exploratory laparotomy in
pregnancy, difficult to diagnosis because of changing location of the appendix in
relation to the pregnancy progression
 PULMONARY DISEASES
Pregnancy change-" dyspnea in pregnancy" due to high progesterone that stimulate respiratory center

ASTHMA - chronic inflammatory disorder of airway

Caused by stimuli-> allergy resulting in limitation of airflow
a. contraction of smooth muscle
b. mucosal edema
c. secretion
Diagnosis: Spirometry
Tx: Safe to treat rather than episode of hypoxia( benefit vs. risk)
Ex. Salbutamol

PNEUMONIA
a Bacterial - Streptococcus pneumonia/Mycoplasma pneumoniae

SSx: cough, phlegm, nasal congestion, shortness of breath

Cough fever with dyspnea
X-ray: sign of con solid ation
Sputum: gram positive lancet shape diplococcus

Treatment: Antibiotic

b. Aspiration- due to increase intragastric pressure, relaxed GE sphincter delayed gastric emptying

TUBERCULOSIS- caused by mycobacterium tuberculi

High incidence of pre-eclampsia, vaginal bleeding with fetal death
with Apgar score
LBW
Congenital tuberculosis- maternal transfer thru umbilical vein & aspiration
SSx:
chronic cough, weight loss, chills, sweat, fever, body malaise

Diagnostic- sputums exam (3 samples early morning)

TB culture and Chest X ray
Tx:
First line -
lsoniazid, Rifampicin, Ethambutol with PZA (safe)
6 months treatment with 2 months intensive phase (quadruple)
4 months maintenance phase (2/3 drugs)

PULMONARY EMBOLISM

Venous thromboembolic disease (VTE) pregnant > non pregnant

Risk Factor: age >35
>G3
obese (>L65lbs)
family History due to hypercoagulable state
SSx: leg swelling, pain, dyspnea, tachypnea
Tx: Heparin

Amniotic Fluid Embolism (AFE)

Amniotic fluid, fetal cells, hair enter maternal circulation causing respiratory collapse
SSx: Dyspnea -) hypotension +cardiac arrest +DlC
Tx: Supportive

TOBACCO
Drug dependence
Cigarette 6,000 chemical (carcinogenic)
Tx: Nicotine replacement

CARDIAC DISEASES

I ncidence1,1 L00 pregnancies

Effects of pregnancy on heart

-increase blood volume with cardiac output
-increase workload in labor with delivery (volume shift with auto transfusion)
-Effect of anesthesia
-blood loss in delivery
- lower vascular resistance

Fu nctional Classification
Class I - uncompromised -no limitation of activity, asymptomatic
-continue and do well in pregnancy

Class II - slightly cornpromised -slight liniitation of activity close medical supervision. risk forcardiac
Decompensation

Class III - markedly compromised -marked limitation of activities

-excessive fatigue with ordinar,v activity
-bed rest w'ith medication
-special rronitoring witli anesthetic management during labor and delivery

Class IV- severely compromised -symptomatic even at rest

-close monitoring
-sterilization to prevent future pregnancy

*Class III and IV- against pregnancy 1-7% mortality

SSx
l. Difficulty of breathing - dyspnea. orthopnea. nocturnal dyspnea
2. Arrhythmia
3. Palpitation
4. Chest Pain
5. Syncope
6. Cyanosis
7 .
Clubbing of fingers
8. Neck vein distention
9. Murmurs
10. Cardiomegaly

Management
l. Pre-natal - team care (OB/cardiologist or IM/ Midwifb/Anesthesiologist)
2. Rest - 8- 10 hrs sleep /day
Light work
3.
Diet - high in iron. protein and minerals
Prevent Infection
Avoid high altitude, smoking areas
Watch for danger sign of heart f-ailure
Medication: Rest
Cardiac drugs
Antibiotics

Mode of Deliveries
Vaginal vs. Cesarean
Early hospitalization
Semi- fowler position
Forceps with painless delivery
Watch out 4tl' stage of labor for cardiac decompensation
Post-parlum - promote rest
Cleared cardiac status prior to discharge
Gradual ambulation
Breastfeed (Class I-ll)
Sterilization to prevent future pregnancy
 INFECTIOUS

Female genitaltract with normal vaginalflora( Gram (+) and cram (-) both aerobes and an aerobes),
fungal and non=pathologic protozoal

lnfections are POLYMICROCIAL

lntraamnionic lnfecion (lAl )

---infection of the amniotic sac, its contents ( fetus,placenta, fluid and membranes)

-*-predisposing factor : PROM

Dx: fever,uterine irritability causing preterm labor, maternal and fetal tachycardia, passage of turbid,
foul smelling fluid/vagina

Tx: a ntibiotics

Puerperal Sepsis

----fever during the 1" 10 days postpartum excluding the first 24hrs

---main focus: endometrium

Dx: fever,hypogastric pain, foul smelling lochia, uterus boggy and tender, cervix open and tender

Tx: a ntibiotics

lnfection of the IOWER GENITAL TRACT

Fungal vaginitis- caused by Candida specie( albicans)

- Characterized by "curd-like" "cheesy" vaginal discharge with " beefy red" itchy vulva
- lnfections during delivery can cause neonatal oral moniliasis

Bacterial vaginosis - caused by Gardnerella vaginalis

- With fishy odor, grayish vaginbaldischarge and presence of " clue cells"

SEXUATLY TRANSMITTED DISEASES ( STD )

Trichomoniasis - caused by Trichomonas vaginalis

- Frothy, greenish vaginal discharge, vulvovagibalsoreness,dyspareunia and dysuria

' Dx; wet mount (presence offlagellates/parasites)
- Tx: Metron idazole

Gonorrhea (GC)- caused by Neisseria gonorrhoea

--*infection during delivery can caused Gonococcal opthalmia neonatorum which can be prevented by
neonatal prophylaxis : 1% silver nitrate, 1% tetracycline, 0.5% erythromycin eye ointment

Chlamydia-caused by Chlamydia trachomatis, which can cause infertility

Dx: wrights or Giemsa stain

Tx: Erythromycin

Syphilis (SY )- caused by TReponema pallidum

Crosses the placenta to cause premature birth, growth retardation and fetal death
Dx: presence of spirochetes on darkfield microscopy
Screening: RPR/VDRL ( Rapid plasma Reagin ), confirmatory FTA_ ABS
Tx: Penicillin

VIRAL INFECTIONS

Genital warts( Condyloma acuminata )

-- caused by HPV( human papiloma virus ), which flourishes during pregnancy with spontaneous
resolution puerperium

-'*- aim: to achieve a lesion-free stated at term/ delivery

Genital herpes- caused by HSV( herpes simplex virus type 2)

'-characterized by vesicles that are tender and ulcerates

--- facilitate HIV tra nsm ission

HIV ( human immunodeficiency virus )

----transmitted thru blood and body fluids, delivery by C-section to minimize transmission

Tx: Antiretrovira I

Hepatitis- caused by Hepatitis virus

---Types :A- infectious, B- serum hepatitis, C- parenteral hepatitis, D- delta, E- enteric

Hepatitis B- diagnosed by HbsAg

- Neonates of infected mother be given HepB lg and HepB vaccine after birth

Rubella- causes multisystem abnormalities ( microcephaly, hearing deficit,cataract, retinopathy,

blueberry -muffin syndrome )
---vaccination should be done before pregnancy, infection during early pregncny results in death of the
embryo or varyinB degrees of congenital abnormalities

-----infection in later stage do not result in such outcome

----many infections are either symptomatic with mild non-specific symptoms ( fever and rash )

lnfluenza ( Flu )- influenza A and B

- Vaccinatron du ring pregnancy

PARASITIC INFECTIONS

Malaria-caused by Plasmodium specie( ovale, vivax, falcifarum. Malariae), transmitted by Anopheles

mosq uitoes

----effects during pregnancy abortion, stillbirths, transplacentaltransfer leading to congenital malaria is

rare.

Tx: benefits outweighs the risk-- Chloroquine

Amoebiasis E ntamoeba hist o lyt ica

No transplacental tra nsfer

Dx; presence of Entamoeba histolytica on stool exam
Tx; Mte ronidazole

Toxoplasmosis- caused by Toxoplasma gondii

Thru ingestion, can cause abortion, or liveborn with evidence of the diseases( LBW,
icterus, hepatosplenomega ly, anemia, neurologic deficit, m icrocephaly,
hyd rocepha lus)
Dx; Serologic
Tx; Spiromycin

INFECTIONS OF FETUS and NEONATES

Clostridial infection- caused by Closridium tetani, due to poor aseptic technique in delivery and cord
cutting

-:-- causes Tetanus neonatorum( trim us/lockjaw,seizu res) symptoms may not be apparent at birth,
incubation period from 24hrs- 30 days post natal

----prevented by immunization of pregnant women with Tetanus toxoid

Group B Streptococcus- most common cause of neonatalsepticaemia, treated with Ampicillin

 HEMATOTOGICAL DISORDERS

in plasma
Anemia- in pregnancy is haemoglobin level < 11g/dl( due to hemodilution, a 50% increase
volume vs.20-30% increase in red cell mass)

lron deficiency anemia

placenta, expanding
lncrease in iron demand during pregnancy due to : demand of growin8 fetus and
maternal blood volume and blood loss during delivery

--risk for preterm delivery and low birth welght

--screenlng be done during first

prenatalvisit

meet the demands of pregnancy, an addltional 500mg iron to increase maternal volume,3oomg
for
--to
fetal erythropoiesis, 200mg for blood loss

Daily dose of iron for pregnant women -27mg elemental iron and 60-120 mg elemental iron if with
IDA

Folate Deficiency

--- usually dietary deficiency, can cause Neural tube defect spina bifida, anencephaly)

-'-daily dose of 600ug folate