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Medical conditions in pregnancy

Sep 25, 202510 min read

Medical Disorders in Pregnancy

Table

Sickle Cell Anemia

Definition and Pathophysiology

Sickle cell anemia is an autosomal recessive disorder characterized by abnormal hemoglobin S (HbS). The mutation leads to the destruction of red blood cells.

Prepregnancy Counselling

  • Multidisciplinary team involvement (obstetrician and hematologist)
  • Partner screening
  • Stop iron-chelating agents before pregnancy
  • Folic acid supplementation (5mg/day) and penicillin prophylaxis for hyposplenism
  • Monitoring of Hb and HbS percentage, with transfusion if necessary

Clinical Features

  • Hemolytic anemia
  • Painful crises
  • Hyposplenism
  • Increased risk of infections (UTI, pyelonephritis, pneumonia, puerperal sepsis)
  • Avascular necrosis of bone
  • Increased risk of thromboembolic disease (pulmonary embolism, stroke)
  • ACUTE CHEST SYNDROME (FEVER, CHEST PAIN, TACHYPNEA, INCREASE)
  • WCC, pulmonary infiltrates
  • iron overload leads to cardiomyopathy

Antenatal Care

  • Screening for urine infection at each visit
  • Treatment of crisis (analgesia, oxygen, rehydration, antibiotics if infection suspected)
  • Regular assessment of fetal growth (ultrasound, Doppler)
  • Aim for vaginal delivery with adequate hydration, avoiding hypoxia, and continuous fetal monitoringZ - UNLESS CS is indicated
  • Consider antenatal and postnatal thromboprophylaxis
  • the use of prophylactic antibiotics

Fetal Complications

  • Miscarriage
  • IUGR
  • Prematurity
  • Stillbirth

Thyroid Disease and Pregnancy

Thyrotoxicosis:

  • 95% of women have graves disease.
  • For first time in pregnancy occur in the late first or early second trimester.Z

Clinical features:

  • Palpitation.
  • Vomiting.
  • Goitre.
  • Palmer erythema.
  • Emotional liabilities.
  • Tremors.
  • Lid lag.
  • Lid retraction.

Diagnosis:

  • TFT

Complications

  • Maternal complications: hypertension, preeclampsia, heart failure
  • Fetal risks:
    • Miscarriage.
    • IUGR.
    • Preterm birth.
    • Fetal hypothyroidism(drug induced).Z
    • Thyrotoxicosis (in autoimmune cases due to transplacental TSI)
    • IUFD.

Management

  • Propylthiouracil is better than carbimazole (less teratogenisity).
  • Do serial US to monitor the baby.
  • Do TFT in each semester.
  • Close monitoring during labour”+ continuous CTG”.
  • Do cord blood sampling for TFT.
  • Delivery is by VD unless CS is indicated

Asthma in Pregnancy

Course of disease

  • Approximately one-third of patients worsen during pregnancy, one-third improve, and one-third remain unchanged (pregnancy has no effect).Z
  • Most exacerbations occur in the third trimester, but most pregnancies pass uneventfully.

Symptoms

  • Cough, wheeze, dyspnoea, chest tightness.
  • Avoid known trigger factors.

Common trigger factors

  • Pollen, animal dander, dust
  • Chest infection, cold weather, emotional stress

Signs of exacerbation

  • Tachycardia, increased respiratory rate, audible wheeze, use of accessory respiratory muscles.

Maternal risks

  • Increased risk of preeclampsia, higher maternal mortality, and greater need for hospitalization.

Fetal/neonatal risks

  • Low birth weight, preterm delivery, and risk of neonatal asphyxia.

#Z

Management

  • O2.
  • Bronchodilator(Salbutamol).(inhaler or oral ).
  • Steroids.(oral , inhaler).
  • Antibiotics if there is infection.
  • Avoid PGs in induction(exacerbate asthma).
  • Delivery

VD Unless C/S is indicated.

Iron Deficiency Anemia

Definition

  • Anaemia in pregnancy: haemoglobin or haematocrit below trimester-specific cut-offs
    • 1st trimester: Hb < 11 g/dL, Hct < 33%
    • 2nd trimester: Hb < 10.5 g/dL, Hct < 32%
    • 3rd trimester: Hb < 11 g/dL, Hct < 33%

Classification (by MCV / mechanism)

  • By size (MCV):
    • Microcytic (< 80 fL): iron deficiency, thalassaemia (commonly)
    • Normocytic (80–100 fL): anaemia of chronic disease, acute blood loss
    • Macrocytic (> 100 fL): folate or vitamin B12 deficiency
  • By mechanism (often overlapping):
    • ↓ Production: iron, folate, B12 deficiency, bone marrow disease
    • ↑ Destruction: haemolysis (sickle cell, thalassaemia)
    • Blood loss: acute or chronic (menstrual, obstetric, GI)

Risk factors

  • Poor dietary intake (low iron/protein/folate)
  • Short interpregnancy interval, teenage pregnancy, multiparity
  • Heavy menses or prior delivery blood loss
  • GI malabsorption, chronic illness
  • Hemoglobinopathies (suspect with relevant family history or ethnicity)

Diagnosis

  • CBC with indices: Hb, Hct, MCV
  • Ferritin: < 30 ”g/L confirms iron deficiency
  • Peripheral blood smear
  • Hemoglobin electrophoresis if hemoglobinopathy suspected

Management

  • Lifestyle / nutrition:
    • Eat iron-rich foods (red meat, poultry, legumes, leafy greens)
    • Vitamin C enhances iron absorption; avoid tea/coffee with meals
  • Pharmacological:
    • Routine supplementation in pregnancy: ~27 mg/day elemental iron (prenatal vitamins)
    • Treatment (oral): ferrous sulfate / ferrous fumarate / ferrous gluconate (dosing depends on elemental iron goal)
    • Parenteral iron: for severe anaemia, oral intolerance, or poor response
    • Transfusion: reserved for severe cases (e.g., Hb < 6 g/dL with maternal or fetal compromise)
  • Practical choices and considerations:
    • Ferrous sulfate — first-line: effective, widely available, affordable
    • Ferrous gluconate — lower elemental iron, better tolerated (less GI upset) but requires more tablets
    • Ferrous fumarate — highest elemental iron per tablet → fewer tablets needed, but may cause more GI side effects

Elemental iron content (approximate per tablet)

  • Ferrous fumarate (325 mg): ~106 mg elemental iron
  • Ferrous sulfate (325 mg): ~65 mg elemental iron
  • Ferrous gluconate (300 mg): ~34 mg elemental iron

Treatment approach (summary)

  • Start with ferrous sulfate unless not tolerated.
  • If intolerance → switch to ferrous gluconate (gentler).
  • If higher elemental dose with fewer pills needed and tolerated → consider ferrous fumarate.
  • Use parenteral iron or transfusion for severe / refractory cases or urgent maternal/fetal compromise.

Prevention & screening

  • Universal low‑dose iron supplementation from 1st trimester (prenatal vitamins with folate)
  • Early screening: CBC at booking and again at 24–28 weeks

Maternal and fetal complications (with emphasis on severe anaemia)

  • Maternal: fatigue, reduced work capacity, increased infection risk, higher likelihood of transfusion in obstetric haemorrhage
  • Severe anaemia (Hb < 6 g/dL) associated with: abnormal fetal oxygenation, non‑reassuring fetal heart patterns, fetal cerebral vasodilatation, fetal death — may prompt maternal transfusion for fetal indications
  • Postpartum: increased risk of postpartum depression, poorer maternal–infant interaction and potential negative effects on infant development

Urinary Tract Infections (UTI)Z

  • Asymptomatic bacteriuria: ~4–8% prevalence; if untreated, ~40% may progress to symptomatic infection.

  • Acute cystitis: ~1% (incidence).

  • Acute pyelonephritis: ~1–2% (incidence).

  • Risk factors

    • Female sex, especially with diabetes mellitus
    • Sickle cell trait or disease
    • Immunosuppression
    • Urinary tract stones
    • Polycystic kidney disease
    • Congenital renal anomalies

  • Typical symptoms

    • Pyelonephritis: nausea, vomiting, loin (flank) pain, fever
    • Cystitis: suprapubic pain, dysuria

  • Investigations

    • Positive urine dipstick should always be followed by a midstream urine (MSU) culture.

  • Management

    • All bacteriuria should be treated to prevent pyelonephritis and reduce risk of preterm labor — typically with 3–7 days of a broad-spectrum antibiotic.
    • Acute cystitis: treat for 7 days with an appropriate antibiotic.
    • Pyelonephritis: treat for 10–14 days with an appropriate antibiotic.

Epilepsy in pregnancy — key points

  • Common causes of seizures in pregnancy: epilepsy, eclampsia, encephalitis/meningitis, space‑occupying lesions (tumour, tuberculoma), cerebrovascular accident, cerebral malaria or toxoplasmosis, thrombotic thrombocytopenic purpura, drug/alcohol withdrawal, toxic overdose, metabolic abnormalities (e.g. hypoglycaemia).
  • Most mothers have healthy babies. Risk of congenital abnormalities depends on the type, number and dose of antiepileptic drugs (AEDs). Sodium valproate should be avoided in pregnancy because it has a high risk of congenital malformations and adverse neurodevelopmental effects in the child.

Definition, diagnosis and seizure types

  • Definition: Epilepsy = recurrent unprovoked seizures, normally diagnosed by a neurologist.
  • Common seizure types: tonic–clonic, absence, focal.
  • Pregnancy differential diagnosis: eclampsia, metabolic causes, cardiac syncope, psychogenic non‑epileptic seizures, and epilepsy.

Cardiovascular diseases pre-pregnancy counselling

  • Lifestyle
  • Multidisciplinary with cardiologist 5 mg
  • IUGR
  • Small for gestational age
  • Preterm

Labor

  • 1 stage (Cervical diltation + pain) - we give pain killer
  • 2 stage (Delivery of baby) - Prophylactic Forceps
  • 3 stage (Placental delivery) - Avoid angometr
?

Pre‑pregnancy counselling

  • Folic acid: 5 mg/day before conception to reduce neural tube defects.
  • AED choice: use the lowest effective dose and avoid valproate and polytherapy where possible.
  • Counselling topics: risks of congenital malformations and long‑term neurodevelopmental effects (particularly with valproate). Women who have been seizure‑free for ≄1 year have the best prognosis in pregnancy.

Antenatal management

  • Joint obstetrics–neurology care is recommended.
  • Screening: detailed anomaly scan at 18–20 weeks; consider serial growth scans if on AEDs.
  • AED monitoring: routine serum levels usually not required (exceptions such as lamotrigine in selected cases).
  • Obstetric risks: increased risk of miscarriage, hypertensive disorders, haemorrhage and preterm birth.
  • Maternal mental health: screen for depression, anxiety and cognitive effects.
  • Manage pregnant women with significant heart disease in a joint obstetric/cardiac clinic.
  • Continuity of care makes the detection of subtle changes in maternal wellbeing more likely.
  • Routine physical examination should include:
  • pulse rate.
  • blood pressure.
  • jugular venous pressure.
  • heart sounds.
  • ankle and sacral oedema
  • and presence of basal crepitations.
  • Most women will remain well during the antenatal period.
  • Echocardiography is useful in assess function and valves,
  • and an echocardiogram at the booking visit and at around 28
  • weeks’ gestation is usual.
  • Any signs of deteriorating cardiac status should be carefully investigated and treated.
  • Anticoagulation is essential in patients with:
  • congenital heart disease with pulmonary hypertension (PH).
  • or artificial valve replacements.
  • and in those at risk of atrial fibrillation.
  • Low molecular-weight heparin is often used as an alternative to
  • warfarin, especially in the first and third trimester.

Intrapartum care

  • Seizure risk in labour is low (~1–2%). Continue AEDs (oral or parenteral as needed).
  • Seizure treatment: benzodiazepines are first‑line — treat promptly.
  • Analgesia: epidural, Entonox and TENS are safe. Avoid pethidine (can be epileptogenic).
  • Delivery: epilepsy alone is not an indication for caesarean section unless there is poor seizure control. Continuous fetal monitoring if seizures occur.

Postpartum management

  • Seizure risk ↑ in the first 72 hours postpartum (stress, sleep deprivation, missed doses).
  • Review AED dose within ~10 days postpartum to avoid toxicity (physiological changes can alter levels).
  • Breastfeeding: encouraged — most AED exposure via milk is compatible with breastfeeding. Lamotrigine and levetiracetam transfer more into milk, but definitive adverse outcomes have not been proven.
  • Safety advice: take practical precautions (e.g. baby baths on the floor, don’t bathe alone, general seizure‑safety measures).
  • Postpartum depression: more common in women with epilepsy (≈29% vs 11%) — screen all.

Contraception & future pregnancy

  • With enzyme‑inducing AEDs, effective options include copper IUD, levonorgestrel IUS and depot injection; enzyme inducers reduce the efficacy of combined pills, patches, rings and implants.

  • Note: lamotrigine levels can be affected by estrogen contraceptives (dose interactions may increase seizure risk).

  • Emergency contraception: copper IUD preferred when on enzyme‑inducing AEDs.

Management of labour and delivery

  • In most cases the aim of management is to await the onset of spontaneous labour.
  • Anaesthesia is often recommended to reduces the pain related stress.
  • Prophylactic antibiotics should be given to any woman with a structural
  • heart defect to reduce the risk of bacterial endocarditis.
  • VD is the mode of delivery unless C-section is indicated.
  • Caesarean delivery is associated with:
  • Risk of haemorrhage, thrombosis and infection, conditions that are likely to be much less
  • well tolerated in women with cardiac disease
  • the maternal condition is considered too unstable to tolerate the physiological
  • demands of labour.. Postpartum haemorrhage in
  • particular can lead to major cardiovascular instability. Ergometrine may be
  • associated with intense vasoconstriction, hypertension and heart failure, and
  • therefore active management of the third stage is usually with Syntocinonℱ
  • (synthetic oxytocin) alone. Syntocinon is a vasodilator and therefore should be
  • given slowly to patients with significant heart disease, with low-dose infusions
  • preferable. High-level maternal surveillance is required until the main
  • haemodynamic changes following delivery have passed

Prepregnancy counselling

  • Women with heart disease: will be aware of their condition prior pregnancy
  • They should be fully assessed by an obstetrician and cardiologist.
  • fetal risks carefully explained.
  • A plan to optimize medication & health state.

Issues in pre-pregnancy counselling of women with heart disease

  • Risk of maternal death.
  • Possible reduction of maternal life expectancy.
  • Effects of pregnancy on cardiac disease.
  • Mortality associated with high-risk conditions.
  • Risk of fetus developing congenital heart disease.
  • Risk of preterm labour and FGR.
  • Need for frequent hospital attendance and possible admission.
  • Intensive maternal and fetal monitoring during labour.
  • Other options – contraception, adoption, surrogacy.
  • Timing of pregnancy

Fetal risk of maternal cardiac disease

  • Recurrence (congenital heart disease).
  • Maternal cyanosis (fetal hypoxia).
  • Iatrogenic prematurity.
  • FGR.
  • Effects of maternal drugs (teratogenesis, growth restriction, fetal loss).

Risk factors for development of heart failure in pregnancy

  • Respiratory or urinary infections.
  • Anaemia.
  • Obesity.
  • Corticosteroids.
  • Tocolytics.
  • Multiple gestation.
  • Hypertension.
  • Arrhythmias.
  • Pain-related stress.
  • Fluid overload
  • Management of labour in women with heart disease
  • Avoid induction of labour if possible.
  • Use prophylactic antibiotics.
  • Ensure fluid balance.
  • Avoid the supine position.
  • Discuss regional/epidural anaesthesia/analgesia with senior anaesthetist.
  • Keep the second stage short.
  • Use Syntocinon judiciously.

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