ZHEENA JADE B.

NADELA
DM-2

ASSignment # 7 ( MEDICAL CONDITIONS OF SIGNIFICANCE TO MIDWIFERY PRACTICE )

REFERENCE : CHAPTER 13- MYLES TEXTBOOK OF MIDWIFERY/VIDEOS POSTED

1. Give the pathophysiology of Obesity.

● Obesity is an exaggeration of normal adiposity and is a central player in the
pathophysiology of diabetes mellitus, insulin resistance, dyslipidemia,
hypertension, and atherosclerosis, largely because of its secretion of excessive
adipokines.
2. During antenatal care, the BMI( Body mass index) is measured to diagnose Obesity .
What are the risks associated with obesity in pregnancy? ( Maternal/Fetal)
● Risk Associated with obesity in pregnancy.
(Maternal)
- Miscarriage and stillbirth.
- Gestational diabetes:
- Hypertension
- Venous thromboembolism
- Prolonged pregnancy
- Presence of pre - existing medical conditions
- Poorer mental health

● (Fetal)
- Neural tube defects ( NTDs)
- Macrosomia
- Preterm labour
- Lower apgar scores
- Late stillbirth
- Neonatal mortality

What are intrapartum risks associated with obesity?

● Prolonged pregnancy and induction of labour
● Prolonged labour
● Complication, e.g. shoulder dystocia
● Emergency caesarean birth
● Primary postpartum haemorrhage.
What are risks associated with obesity on the postnatal/postpartum
period(Maternal/neonatal)
(Maternal)
- Venous thromboembolism
- Longer postoperative recovery
 - Increased postoperative complication
- Tendency to retain pregnancy weight gain
- Lowered rates of breastfeeding duration
- Reduced contraception choices

(Neonatal)

- Increased risk of congenital abnormality

- Macrosomia
- Low birth weight

3. a) Define Diabetes mellitus.

● It is a metaboloc disordee due to deficiency or diminished effectiveness of
endogenous insulin.

b) Classic presentation especially in Type I

● Is a weight loss and the occurrence of the three polys: polydipsia ( excess thirst),
polyuria ( excessive dilute urine production) and polyphagia ( excessive hunger).
There may also be lethargy, prolonged infection, boils and pruritis vulvae.
c) Types of Diabetes and differentiate them /treatment
● Type 1 Diabetes ( formally insulin-dependent or juvenile onset diabetes)
develops as a result of progressive auto-immune destruction of the pancreatic
beta cells, most probably initiated by infection, with the result that no, or an
inadequate amount of insulin is produced.
● Treatment is the lifelong administration of insulin, which has to be given by
subcutaneous injections 2-5 times a day.
● Type 2 Diabetes ( formally non - insulin - dependant or maturity onset diabetes),
there is a gradual resistance to the action of insulin in the liver and muscle.
● Initial treatment is by strict diet to reduce weight and increased physical activity to
improve glucose tolerance and control the diabetes.
d) Define Gestational diabetes mellitus ( GDM).What are the factors associated with
GDM
● GDM is a form of diabetes that arises in the second or third trimester of
pregnancy and resolves after birth of the baby.
● It associated with:
● Increasing maternal age
● Previous or family history of diabetes or GDM
● Previous unexplained stillbirth
● Previous macrosomia infant
● Obesity
e) What are complications associated with Diabetes in pregnancy
● Pre eclampsia
● Macrosomic baby
● IUGR
 ● Polyhydramnios
● Exacerbation of diabetic complications in the woman.
f) Give the steps to consider in the antenal care of woemn presenting with/developing
diabetes.
● A supplement of 5 mg folic acid should be taken daily for the first 12 week of
prenancy to reduce the risk of congenital malformations in the fetus.
● Urinalysis should be undertaken at each visit to test for glocuse, ketones as well
as the protein.
● Women with type 1 diabetes should be offered ketone testing strips ang be
advised to test for ketonuria if they have symptoms of hyperglycaemia or become
unwell,
● Blood pressure should be recorded at each visit with the midwife being alert for
signs of pre eclampsia, especially with GDM.
● Women should be discouraged from fasting, especially for long periods.
● Women should test their blood glucose level on walking and 1 hour postprandial
after every meal during pregnancy.
● In taking insulin, women should also test their blood glucose level before going to
bed.
● Women with type 2 diabetes are likely to be started on insulin: if taking metformin
pre- pregnancy, some centres may decide to continue its use until 32 weeks due
to emerging evidence of its safety.
● An ultrasound scan is undertaken at 7-9 weeks gestation to confirm viability and
gestational age, followed by a further scan at 18-20 weeks to assess the four
chambers of the fetal heart for any anomalities, estimate liquor volume and to
ascertain fetal growth.
● Monthly scans from 28-36 weeks are undertaken and their amniotic fluid volume
and their results recorded, observing for signs of macrosomia.
● Weekly test of fetal wellbeing, including CTG or biophysical profiles, are offered
from 38 weeks until labour commences.

g) Intrapartum management of diabetes.

● NICE recommends offering induction of labour or caesarean section between 37
and 39 weeks for women with type 1 or 2 diabetes.
● If the labour is pre term, steroids are given to the woman to improve fetal lung
maturation and additional insulin may be required to control blood glucose level l;
betamimetic medicines to slow or stop preterm labour are not recommended.
● If the fetus is macrosomic, the woman should be informed of the risk and benefits
of viginal birth, induction of labour and caesarean section.
● Capillary plasma glucose level should be monitored hourly through labour and
birth, aiming to maintain them.between 4 and 7 mmol/L.
● For women with type 1 diabetes, an IVI of insulin and dextrose should be started
from the onset of established labour
 ● For women with type 2 and GDM, an IVI of insulin and dextrose should be
started if capillary plasma blood glucose levels cannot be maintained between 4
and 7 mmol/L.
● The neonatal team should be alerted that the women is in labour, should their
assistance be required when the baby is born.
h) Care of baby at birth
● • A neonatologist should be present at the birth if the woman is receiving
insulin.
● • The midwife should be alert for signs of respiratory distress,
hypoglycemia, hypothermia, cardiac decompensation and neonatal
encephalopathy.
● • A baby should be admitted to a neonatal intensive care unit (NICU) only if
a significant is apparent.
● • The woman should hold her baby as soon as is practical after the birth
and prior to any transfer to the NICU.
● • And so on.
h) Postnatal care of the woman with diabetes
● • Women with insulin treated pre-existing diabetes
● • The women should be observed for signs of hypoglycaemia
● • As placental hormones level falls, the insulin sensitivity improves, such
that insulin infusion rate is likely to need reducing in early postnatal period.
● • The woman usually return to her pre-pregnancy insulin levels, unless she
is breastfeeding, when the insulin required are reduced by 30%.
● • And so on.
4. Thyroid disease.What are the most common thyroid disorders in pregnancy?
● Thyroid gland is a highly vascular organ that is shaped like a butterfly and is
situated at the front of the neck.
● Thyroid disorders are common in pregnancy and the most common disorder is
subclinical hypothyroidism. Due to the complex hormonal changes during
pregnancy, it is important to remember that thyroxine requirements are higher in
pregnancy.
a) Define Hypothyroidism and its common causes, symptoms, and its serious
complication/
● This is underactivity of the thyroid gland with absent or low levels of
thyroid hormones T3 and T4 due to malfunctioning thyroid tissue, or
secondary to pituitary or hypothalamic disease.
● The most common cause in pregnancy is autoimmune thyroiditis and
goiter may or may not be present.
● Pregnancy complication of hypothyroidism are hypertension and low birth
weight and psychomotor retardation in the fetus.
b) What laboratory levels are monitored during pregnancy?Postnatally,what are the
symptoms to be observed in the woman.
● AFP screening. Also called maternal serum AFP, this blood test
measures the level of AFP in your blood during pregnancy.
 ● Estriol. This is a hormone produced by the placenta.
● Inhibin. This is a hormone produced by the placenta.
● Human chorionic gonadotropin.
● Most new moms experience postpartum "baby blues" after childbirth,
which commonly include mood swings, crying spells, anxiety and difficulty
sleeping. Baby blues typically begin within the first two to three days after
delivery, and may last for up to two weeks.
c) Hyperthyroidism- define,signs and symptoms,main complication and its features
● Hyperthyroidism is an over activity of the thyroid gland that affect 0.2% of
pregnancy women.
● It usually manifests as a clinical syndrome called 'thyrotoxicosis with signs
and symptoms that include weight loss, despite having a good appetite,
intolerance to heat, sweating, tachycardia with bouncing pulse, insomnia,
agitation, tremor, exophthalmos, diarrhea and menstrual irregularities.
● The main complication is the medical emergency of thyroid crisis (or
thyroid storm), where there are exaggerated features of thyrotoxicosis
with additional hyperpyrexia, cardiac dysrhythmias, congestive cardiac,
altered mental state and ultimately coma. Goitre may also be presented.
5. Cardiac disease
a) Give the diagnostic laboratory work-ups for diagnosis of cardiac disease in pregnancy
● Diagnostic imaging procedures that may be used in pregnancy include chest
radiography, fluoroscopy, echocardiography, invasive angiography,
cardiovascular computed tomography, computed tomographic pulmonary
angiography, cardiovascular magnetic resonance (CMR) and nuclear techniques.
b) Give the pre-conception care
● • Women with pre-existing cardiac problem should receive pre conception
counselling, this include a visit with maternal fetal specialist particularly for
women at high possibility of complications during pregnancy or birth, to inform
them of any potential risks that a pregnancy may have on their health and that
their unborn baby in terms of inheriting any congenital malformations.
c) Give the antenatal care steps/plan
● • A care plan using a shared decision model should be developed by the
multidisciplinary team and the woman for pregnancy, labour and the early
postnatal period should be informed by the individual woman’s situation,
reflecting and acknowledging the woman’s own understanding of her condition,
with a view to optimizing outcomes for her and her baby.
d) Why is anti-thrombotic being given to women with cardiac diseases in pregnancy?
● The use of anticoagulants and thrombolytics in pregnancy is an important
consideration, because pregnancy is associated with a 4-fold increase in the risk
of venous thromboembolism (VTE), with the risk rising to 14-fold during
puerperium. The risk further increases if an underlying thrombophilia is present.
e) Enumerate the intrapartum care in the 1st stage, 2nd stage,3rd stage and postnatal
care.
(first stage)
 ● Intrapartum care involves monitoring the maternal condition using the modified
early obstetric warning scoring (MEOWS) system that triggers any deviation in
order to prompt timely intervention and maximize maternal and fetal well being.
● Continuing ECG is recommended in nearly all cases and pulse oximetry
● Labour Induction
● Pain Relief
● Positioning
(Second stage)

● For clinically stabled women with complex heart disease a normal labour
and birth should be anticipated.
● Historically, caution has been suggested in use of prolonged pushing with
held breath ( the valsalva manoeuvre) as it can further compromise the
health of the women with cardiac disease particularly if obstructive
lesions, fragility of aorta, pulmonary hypertension venous return and
myocardial contractility is compromised.
f) What are types of Congenital heart diseasesand define each
● Atrial septal defect (ASD) - An atrial septal defect is a birth defect of the heart in
which there is a hole in the wall (septum) that divides the upper chambers (atria)
of the heart. A hole can vary in size and may close on its own or may require
surgery.
● Ventricular septal defect (VSD) - is a birth defect of the heart in which there is a
hole in the wall (septum) that separates the two lower chambers (ventricles) of
the heart. This wall also is called the ventricular septum.
● Patent duct arteriosus (PDA) - is a persistent opening between the two major
blood vessels leading from the heart. The opening (ductus arteriosus) is a normal
part of a baby's circulatory system in the womb that usually closes shortly after
birth. If it remains open, it's called a patent ductus arteriosus.
● Pulmonary stenosis - Pulmonary stenosis is the narrowing of the pulmonary
valve, which controls the flow of blood from the heart's right ventricle into the
pulmonary artery. The pulmonary artery carries blood to the lungs. Stenosis
occurs when the valve's flaps (cusps or leaflets) are thickened or fused together.
● Aortic stenosis - is a type of heart valve disease (valvular heart disease). The
valve between the lower left heart chamber and the body's main artery (aorta) is
narrowed and doesn't open fully. This reduces or blocks blood flow from the heart
to the aorta and to the rest of the body.
● Tetralogy of fallot - is a birth defect that affects normal blood flow through the
heart. It happens when a baby's heart does not form correctly as the baby grows
and develops in the mother's womb during pregnancy.
g) What are the types of Acquired heart disease and define each
● Rheumatic Heart Disease - Rheumatic heart disease is a condition in which the
heart valves have been permanently damaged by rheumatic fever. Rheumatic
fever is an inflammatory disease that can affect many connective tissues,
especially in the heart.
 ● Myocardial Infarction - heart attack or acute myocardial infarction (MI) occurs
when one of the arteries that supplies the heart muscle becomes blocked.
Blockage may be caused by spasm of the artery or by atherosclerosis with acute
clot formation.
● Ischaemic heart Disease - Ischemic means that an organ (e.g., the heart) is not
getting enough blood and oxygen. Ischemic heart disease, also called coronary
heart disease (CHD) or coronary artery disease, is the term given to heart
problems caused by narrowed heart (coronary) arteries that supply blood to the
heart muscle.
● Peripartum cardiomyopathy - Peripartum cardiomyopathy (PPCM), also known
as postpartum cardiomyopathy, is an uncommon form of heart failure that
happens during the last month of pregnancy or up to five months after giving
birth. Cardiomyopathy literally means heart muscle disease.
● Arrhythmias - An arrhythmia, or irregular heartbeat, is a problem with the rate or
rhythm of your heartbeat. Your heart may beat too quickly, too slowly, or with an
irregular rhythm. It is normal for your heart rate to speed up during physical
activity and to slow down while resting or sleeping.

6. Respiratory Disorders
a) What is Asthma and its triggers?
● Asthma, also called bronchial asthma, is a disease that affects your lungs. It's a
chronic (ongoing) condition, meaning it doesn't go away and needs ongoing
medical management.
● Asthma triggers : infections like colds and flu. allergies – such as to pollen, dust
mites, animal fur or feathers. smoke, fumes and pollution. medicines –
particularly anti-inflammatory painkillers like ibuprofen and aspirin. emotions,
including stress, or laughter.
b) Give the treatments of asthma
● Inhalers, which are devices that let you breathe in medicine, are the main
treatment. Tablets and other treatments may also be needed if your asthma is
severe.
7. Hematological Disorders
a) What are the types of anemia? Define each.
● Iron deficiency anemia -Iron deficiency anemia is a common type of anemia — a
condition in which blood lacks adequate healthy red blood cells. Red blood cells
carry oxygen to the body's tissues. As the name implies, iron deficiency anemia
is due to insufficient iron.
● Megaloblastic anaemia - Megaloblastic anemia is a type of anemia
characterized by very large red blood cells. In addition to the cells being large,
the inner contents of each cell are not completely developed. This malformation
causes the bone marrow to produce fewer cells, and sometimes the cells die
earlier than the 120-day life expectancy.
 ● Thalassaemia - Thalassemia is an inherited (i.e., passed from parents to children
through genes) blood disorder caused when the body doesn't make enough of a
protein called hemoglobin, an important part of red blood cells.
● Sickle Cell disease - Sickle cell disease (SCD) is a group of inherited red blood
cell disorders. Red blood cells contain hemoglobin, a protein that carries oxygen.
b) What is Folic acid deficiency?
● Folate-deficiency anemia is the lack of folic acid in the blood. Folic acid is a B
vitamin that helps your body make red blood cells. If you don't have enough red
blood cells, you have anemia.
c) What is Megaloblastiuc anemia
● Megaloblastic anemia is a type of anemia characterized by very large red blood
cells. In addition to the cells being large, the inner contents of each cell are not
completely developed. This malformation causes the bone marrow to produce
fewer cells, and sometimes the cells die earlier than the 120-day life expectancy.
d) Give the types of hemoglobinopathies and differentiate
● thalassemia syndromes and structural hemoglobin variants.
● Thalassemia is an inherited blood disorder that causes your body to have less
hemoglobin than normal. Hemoglobin enables red blood cells to carry oxygen.
Thalassemia can cause anemia, leaving you fatigued. If you have mild
thalassemia, you might not need treatment.
● The structural hemoglobin variants typically are based on the point mutations in
the α- or β-globin chain that results in a single-amino acid substitution in the
corresponding globin chain, whereas thalassemias are caused by quantitative
reduction in globin chain synthesis.

8. What is Epilepsy and its complications?

● Epilepsy occurs when changes in the brain cause it to be too excitable or irritable. As a
result, the brain sends out abnormal signals. This leads to repeated, unpredictable
seizures. (A single seizure that does not happen again is not epilepsy).
● Abnormalities in the brain, including brain tumors or vascular malformations such as
arteriovenous malformations (AVMs) and cavernous malformations, can cause epilepsy.
Stroke is a leading cause of epilepsy in adults older than age
a) What are the Medications used during pregnancy throughout labor and delivery
● Antiepileptic Drugs and Pregnancy
● Birth defects — including cleft palate, neural tube defects, skeletal problems, and
heart and urinary tract problems — are some of the potential side effects
associated with anti-seizure medications. The risk seems to increase with higher
doses and if you take more than one anti-seizure medication.
● review of the risks of major congenital malformations and of adverse
neurodevelopmental outcomes for antiepileptic drugs by the Commission on
Human Medicines has confirmed that lamotrigine (Lamictal) and levetiracetam
(Keppra) are the safer of the medicines reviewed during pregnancy.
9. Infections during pregnancy
● Bacterial vaginosis
 ■ Candida albicans
● Chlamydia trachomatis
● Cytomegalovirus
● Gonorrhea
● Hepatitis A,B,C
● HIV
● Human papillomavirus
● Streptococcus A and B
● Syphilis
● UTI
a) In a table, differentiate the FF infections according to :
1. Causative agent ( bacteria,fungal,virus, spirochete,
2. Signs and symptoms
3. Microscopic feature
4. Diagnostic tests
5. Treatment

Infections Causative Signs and Microscopic Diagnostic Treatment

during agent symptoms feature tests
pregnancy

Bacterial Abnormal Offensive, clue cells on Take a Metronidazol

vaginosis discharge fishy-smelling a saline sample of e, taken over
due to an diacharge. smear vaginal multiple days,
imbalance of secretions. is one of the
normal most effective
bacteria that treatments for
inhibit the BV.
vagina. Metronidazol
e is available
as an oral pill
or vaginal gel

Candida Yeast Itching, Creamy white taking a use

albicans soreness and vaginal blood sample antifungal
swelling of discharge. or sample medicine to
the genital from the treat it. Often,
area. infected body the treatment
site is an
antifungal
medicine
applied inside
the vagina or
a single dose
of fluconazole
taken by
 mouth.

Chlamydia Bacteria Dysuria, scrapings sample of Chlamydia

trachomatis vaginal from the eyes your urine is trachomatis is
discharge, or the analyzed in treated with
lower urogenital the laboratory antibiotics.
abdominal tract. for presence You might
pain, of this receive a
postcoital and infection one-time
intermenstrua dose, or you
l bleeding might need to
and etc. take the
medication
daily or
multiple times
a day for five
to 10 days. In
most cases,
the infection
resolves
within one to
two weeks.
During that
time, you
should
abstain from
sex.

Cytomegalovi Viral infection Mild flu like Owl's eye polymerase Antiviral
rus illness and chain drugs have
pregnant reaction been used to
women have (PCR) on treat CMV
an increased saliva, with
susceptibility urine usually
to infection collected and
during tested for
pregnancy. confirmation

Gonorrhea Bacterium Painful an elevated Via urine and Antibiotics

micturition, number of cervical
yellow / blood polymorphon swabs
stained uclear
vaginal leucocytes
discharge (PMNLs) and
and postcoital the presence
bleeding. of
intracellular
Gram-
negative
diplococci
 (IGND).

Hepatitis Viruses Sexual Blood borne Routine rest and

A,B,C activity, screening for hydration or
sharing hepatitis B antiviral
injecting medication to
equipment treat viral
and via the hepatitis
placenta to
the fetus
during
delivery.

HIV Virus Weakens an Retro virus Through An HIV treatment

individual HIV test, (antiretroviral
immune where blood therapy or
sysytem is examine. ART)
involves
taking
medicine as
prescribed by
a health care
provider.

Human Genital warts Small, fleshy Warts An HPV test Weekly

papillomaviru painless is usually cryotherapy
s growths and done at the and
single or or in same time as consideration
cluster. a Pap test — of excision or
a test that deferred
collects cells treatment
from your
cervix to
check for
abnormalities
or the
presence of
cancer

Streptococcu Bacteria Cause no like a twisted a urine test or Antibiotics

s A and B cause a harm, but if a bunch of vaginal swab. are effective
variety of woman is round berries. treatment for
infections colonized at group B strep
the time of infection in
labour around adults.
36% will
transmit the
bacteria to
their new
born.
Syphilis Spirochete Prematurity, Sore or nontreponem A single
bacterium low birth chancre al tests that injection of
weight, use a long-acting
neonatal nonspecific Benzathine
death and cardiolipin penicillin G
infections in antigen and can cure the
newborn. confirmatory early stages
tests that use of syphilis.
specific T. This includes
pallidum primary,
antigens secondary, or
early latent
syphilis. CDC
recommends
three doses
of long-acting
Benzathine
penicillin G at
weekly
intervals for
late latent
syphilis or
latent syphilis
of unknown
duration

UTI Bacteria Dysuria, Escherichia Urine sample Trimethoprim

frequency, coli and
suprapubic sulfamethoxa
discomfort zole (Bactrim,
and Bactrim DS)
haematuria Fosfomycin
(Monurol)
Nitrofurantoin
(Macrodantin,
Macrobid,
Furadantin)
Cephalexin.
Ceftriaxone.