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Answers of Exam Questions

Multiple choice questions


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10.a
Long answer question
1. State the effect of diabetes on pregnancy. Explain the management of
diabetes during pregnancy, labor and postnatal period. [ 4+6= 10 ]
Answer:
Diabetes mellitus is the state of chronic hyperglycemia due to defect in
insulin secretion or its action. Gestational diabetes mellitus develops during
pregnancy in women whose pancreatic function is insufficient to overcome
the insulin resistance associated with pregnant state.
The effect of diabetes on pregnancy is given as below :
Maternal
During pregnancy:
 Recurrent spontaneous abortion may be associated with uncontrolled
diabetes.
 Miscarriage rates are 2-3 fold higher in women with pre-gestational diabetes
than among non diabetic women.
 Maternal distress due to combined effect of an oversized fetus and
polyhydraminos.
 Polyhydramnios:
o Fetal hyperglycemia leading to polyuria is one causing
polyhydramnios. Decreased fetal swallowing or an imbalance of
water movement between the maternal and fetal compartments are
other possible mechanisms.
 Urinary tract infection and vulvovaginitis.
 Preeclampsia and gestational hypertension.
 Diabetic retinopathy.
 Diabetic ketoacidosis.
During labor
 Preterm delivery
 Prolonged labor due to a big baby
 Shoulder dystocia
 Perineal injuries
 Higher chances of C/S
 Postpartum hemorrhages
Puerperium
 Puerperal sepsis
 Lactation failure
 Postpartum hemorrhages
Fetal effects
 CNS and skeletal; neural tube defects, anencephaly, microcephaly, sacral
agenesis.
 Cardiac; VSD, ASD, coarctation of the aorta, transposition of great vessels,
cardiomegaly
 Renal; renal agenesis, hydronephrosis, ureteral duplication.
 Gastrointestinal; duodenal atresia, anorectal atresia
 Single umbilical artery
 Unexplained still birth
 Increased incidence of macrosomia
 IUGR
 Respiratory distress syndrome
 Birth injuries due to macrosomia and prolong labor.

The management of diabetes during pregnancy, labor and postnatal period is


explained as below:
Pre-conceptional counseling
• Women with pre-gestational diabetes are counseled before the time of
conception to plan the optimal time of pregnancy to establish glycemic
control and diagnose vascular complication before pregnancy.
• If pre-gestational diabetes, women are kept on insulin before pregnancy or as
soon as pregnancy is diagnosed.
• Diet including weight control, folic acid supplementation and general
measures including checking rubella status, smoking cessation, need to be
discussed in addition to giving advice regarding the effect of diabetes on
pregnancy and of pregnancy on diabetes.
Antepartum management
When the diagnosis of GDM is made treatment begins immediately.
• Strict blood glucose level should be maintained.
• Fasting blood glucose level should be less than 105 mg/dl and two hours
post prandial blood level should be less than 120 mg/dl.
Diet:
• GDM woman should be placed on a standard diabetic diet; 30-35 kcal/kg of
present pregnancy weight, which translates into 2500kcal/day for most
woman.
Exercise:
• Exercise in GDM is safe. It helps to low blood glucose levels and may
instrumental in eliminating the need for insulin.
• Woman with GDM who already have an active lifestyle should be
encouraged to continue exercise program.
• An exercise that use the upper body is ideal for most woman because they
are not associate with increased uterine contractions.
• A sedentary women may also encouraged to increase their physical activity.
• 15-30 min walking 4-6 times a week is satisfactory for most pregnant
women.
Monitoring blood glucose level:
• Blood glucose levels are routinely measured at various times throughout the
day such as before breakfast, lunch and dinner, 2 hrs after each meal ,at
bedtime and in the middle of the night.
• Woman with good glycemic control and who do not require insulin may wait
for spontaneous onset of labor.

Insulin therapy:
• Many women with GDM will require insulin during pregnancy to maintain
adequate blood glucose levels despite compliance with the prescribed diet.
• Glibenclamide and metformin have been found to be effective and safe.
They crosses placenta but does not have any teratogenic effects.
• Insulin therapy is accepted medical management of pregnant women with
GDM not controlled on medical nutrition therapy in 2 weeks.
• Insulin to be administered subcutaneously using insulin syringe (40 IU) on
the lateral aspect of the thigh, anterior abdominal wall
• Elective delivery (induction or cesarean section ) is considered in patients
requiring insulin or with complications (macrosomia) at around 38 weeks.

Intra-partum management
• During the labor and birth process, blood glucose levels are monitored at
least every 2 hours to maintain the level at 100 mg/dl or less.
• IV fluids containing glucose are not given as a bolus.
• Blood glucose level and hydration must be carefully controlled during
labour.
• An IV line is inserted for infusion and maintenance of fluid such as R/L or
5% dextrose.
• Insulin may be administered by continous infusion or intermittent
subcutaneous injection.
• During 2nd stage of labor, shoulder dystocia may occur if delivery of
macrosomia infant is attempted.
• If C/S is planned it should be schedule in the early morning to facilitate
glycemic control.
• The morning dose of insulin should be with hold and the women is given
nothing by mouth.
• Epidural anesthesia is recommended because hypoglycemia can be detected
earlier if the women is awake.
• After surgery glucose level should be closely monitored at least every 2hrs.

Post-partum care
• More than 90% of the women with GDM will return to normal glucose
levels after child birth.
• Assessment for carbohydrate intolerance can be initiated 4-6 weeks
postpartum or after breast feeding has stopped.
• Mothers are encouraged to breastfeed as breastfeeding has an anti-diabetic
effect.
• Women who breastfeed should have additional 500 kcal daily in diet.
• In lactating women insulin dose is lower.
Care of the baby
• A neonatologist should be present at the time of delivery.
• The baby should be kept in intensive neonatal unit and to remain vigilant for
at least 48 hrs.
• All babies should have blood glucose to be checked within 2 hours of birth
to avoid problems of hyperglycemia.
• All babies should receive 1mg vitamin k intramuscularly.
• Early breastfeeding within half to 1 hour is initiated and repeated at 3-4
hours interval to minimize hypoglycemia and hyperbilirubinemia.

Write short notes on:


a. Anemia in pregnancy
b. PMTCT
c. Polyhydramnios

1. Anemia in pregnancy
Definition
Center for Disease Control (1990) has defined anemia as less than 11gm/dl
in the first and third trimesters and less than 10.5gm/dl in the second
trimester.
The qualitative definition of anemia is decreased oxygen carrying capacity
of the blood due to decrease in number of RBCs or hemoglobin or both.

A. Nutritional anemia
-Iron deficiency anemia
Iron is an essential constituent of the body, being necessary for formation of
hemoglobin
Signs and symptoms:
-Fatigue
-Anorexia and indigestion
-Lassitude
-Dyspnea
-Nausea and vomiting
-Pallor of mucous membrane
Investigation
-History taking
- Physical examination
-Blood investigations(CBC,RBC, ESR,PCB)
-Liver function test
-Renal function test
Treatment
-It includes:
a. Oral iron therapy
b. Parenteral iron therapy
c. Blood transfusion
a. Oral iron therapy
Preparation: ferrous form gluconate, fumarate, succinate but best absorbed in
ferrous form and ferrous sulphate 200 mg is given.
b.Parenteral Iron Therapy

-Intravenous route: Total Dose Infusion (TDI)


The compound used is iron dextran compound, 1ml of which contains 50mg
element iron and 1 ampoule contains 2ml.
-Intramuscular route:
IM iron is given in the form of imferon, which contains 50mg of elemental iron
in 1 ml and 1 ampoule contain 2ml. The injection should be given deep into the
muscle to prevent attaining of the skin, formation of abscess and fat necrosis
a. Blood transfusion: Packed cells
Indications:
 Severe anemia diagnosed in late pregnancy (oral or parenteral iron
rises is 0.8gm/dl a week)
 To correct anemia due to blood loss.
 To correct hemolytic anemias.
 Cardiac failure due to severe anemia.
 Precaution to be taken for blood transfusion:
• The blood to be transfused must be fresh (collected within 24 hours) and
properly grouped
• Only packed cells are transfused, and the quantity should be between 80-100
ml at a time.
• The drip should be about 10 drops per minute and transfusion should not be
repeated within 24 hours
• Precaution is to be taken to minimize reaction and over loading of the heart.
• Antihistamine (Phenergan 25mg) is given intramuscularly.
• Frusemide 20mg is given intramuscularly at least 2 hours prior to transfusion
to produce negative fluid balance.
 Management during labor

First stage of labor


• The patient should lie in a uncomfortable position.
• Light analgesics are preferred for pain relief.
• Arrangement of oxygen inhalation are to be kept ready to increase
oxygenation of maternal blood.
• -Strict asepsis to minimize the risk of puerperal infection.
Second stage of labor
-Prophylactic low forceps or vacuum delivery may be done to shorten the duration
-Intravenous methergine 0.2mg should be given following delivery of anterior
shoulder.

Third stage of labor


• Significant amount of blood loss should be replenished by fresh packed cell
transfusion.
• Consider active management.
Puerperium
• Prophylactic antibiotics given to prevent infection.
• Iron therapy continued at least up to 3 months post -partum.
• Warning of recurrence in subsequent pregnancy.

2. Polyhydramnios

Definition
Polyhydramnios is defined as a state where liqor amnii exceeds 2000 ml.
• Sonographic diagnosis is made when amniotic fluid index (AFI) is more than
24cm (more than 95 percentile for gestational age) and a deepest vertical
pocket(DVP) is more than 8cm.

Etiology
Fetal Anomalies
• Anencephaly
• Open spinal bifida
• Esophageal or duodenal atresia
• Facial Clefts and neck masses
Maternal
• Diabetes
• Cardiac or renal disease
• Multiple pregnancy
• Idiopathic (50-60%)

Clinical types
Depending upon the rapidity of onset, it may be :
a. Acute (very rare types)
b. Chronic(common)

Chronic polyhydramnios
In majority of cases, the accumulation of liquor is gradual and the patient is not
very much inconvenienced.
Symptoms
• Respiratory: The patient may suffer from dyspnea or even remain in the
sitting positon for easier breath.

• Palpitation: Edema of the legs, varicosities in the legs or vulva and


hemorrhoids.
Sign
• The patient may be in dyspneic state in the lying down position.

• Evidence of preeclampsia (edema, hypertension and proteinuria) may be


present.

Investigation
• Sonography
• Blood
• Amniotic fluid is assessed to detect polyhydramnios.
Treatment
A. Mild degree hydramnios

Most commonly found in mid-trimester and usually requires no treatment except


extra bed rest for few days.
B. Severe degree hydramnios
The patient should be admitted to a hospital equipped to deal with high risk
patients.
-Supportive Treatment
• Bed rest if necessary with back rest for dyspnea.
• Analgesics and sedatives when required and treatment of the associated
conditions like pre-eclampsia or diabetes the usual line.
• Give indomethacin orally to the mother (25 mg every 6 hours) which has
been shown to reduce the baby’s urine output, reduce lung liquid production,
high absorption fluid movement across fetal membranes.

• Amniocentesis
This procedure may need to be repeated.
If the pregnancy is less than 37weeks
• Done to relieve maternal mechanical distress.
• Amniotic fluid can be tested for fetal lungs, maturity.
• Slow decompression is done at the rate of about 500ml per hour.
If pregnancy more than 37 weeks
Induction of labor is done.

3.PMTCT (Prevention of mother to child transmission )


Definition
It is a term used to describe a package of services comprehensive care intended to
reduce the risk of mother to child transmission of HIV in inter uterine, labor,
postpartum and breastfeeding.
Risk Factor
 During Pregnancy

• High maternal viral load


• Viral, bacterial or parasitic placental injections such as malaria
• Low CD4 count
• STIs
 Labor and Delivery
• High maternal viral load
• Prolonged ruptured of membrane>24 hours
• Vaginal delivery
• Invasive delivery procedure (episiotomy, artificial rupture of membrane)
 Breast Feeding
• Long duration of breast feeding
• Mixed feeding
• Breast abscess, nipple fissures and mastitis.

 Current National PMTCT Strategies


-Reduced transmission of HIV infection to the newborn.
- Increased decentralized coverage and access to PMTCT at the districts level
in collaboration with private sector, communities and NGOs.
- Increased health seeking behaviors among pregnant women Increased
knowledge, acceptance and demands for the PMTCT program among
community, families.
- The strengthened linkage between PMTCT services and HIV services to ensure
that ART program fast tracks women in PMTCT Program into ARV treatment
plans, followed by care and support services.
- Increased capacity of health service providers for effective management and
delivery of PMTCT service.

Intervention
• Provision of ARV drugs to mother infant

• Pregnant or breastfeeding women :TDF+3TC(FTC)


+EFVAZT+3TC+EFV(NVP)+TDP+3TC(FTC)+NVP

*TDF=Tenofovir
3TC=Lamivudine
FTC=Emtricitabine
EFVAZT=Efavirenz and Zidovudine
NVP=Nevirapine
• Modified safer obstetric practice i.e Elective Cesarean section

• Infant feeding information, counselling and support.

• Referral to comprehensive treatment care and social support for mother and
families with HIV infection.

 PMTCT packages for mother infant and partner

1. HIV counselling and Testing

2. Antiretroviral prophylaxis for HIV infant-mother and infant

3. Infant feeding counselling and support

4. Safe obstetrical care

5. Family planning counselling and referral service


6. Referral care and support of HIV infected mother and infant.

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