High Risk Pregnancy

Pregnancy related hypertension 

Hypertensive disorders are the most common medical complications of pregnancy.

Classification of hypertensive disorders during pregnancy: 

1. Gestational hypertension: It is hypertension alone, without proteinuria, occurring for the first time during pregnancy usually in the second half. 

2. Preeclampsia: It is hypertension and proteinuria, with or without edema occurring mostly in the second half of pregnancy. 

3. Eclampsia: It is the occurrence of seizures, convulsions or fits. 

 4. Chronic hypertension: Is defined as hypertension that is present prior to pregnancy or is diagnosed before the 20th week gestation. 

Preeclampsia

Preeclampsia is a form of hypertension that is unique to pregnancy.

Mild PE	Severe PE
Blood pressure is greater than 140/90 mmHg.	Diastolic blood pressure which exceeds 110 mmHg.
Protienuria more than 0.3 gm/Liter of protein in urine.	Protein excretion greater than 3gm/day.

Diagnosis of PE:
A- Signs: 
1. Elevation of blood pressure: 140/90 or more, observed on at least 2 different occasions at least 6 hours apart. 
2. Proteinuria 
3. Edema and weight gain 

B- Symptoms: 

1. PE is asymptomatic in the early and mild cases. 
2. Symptoms usually occur late, and more commonly in severe or complicated cases, it includes: 

1. Persistent headache. 
2. Epigastric and right upper abdominal pain. 
3. Vomiting. 
4. Visual disturbances. 
5. Edema (lower limb, abdominal, or generalized edema).

Treatment of preeclampsia:

• The Goal of treatment is the prevention of the complications of PE. 
• The Only definitive treatment of PE is termination of pregnancy (delivery) 
• The Timing of termination depends on both Gestational age and the severity of PE.

mild preeclampsia :

• full term ( 37 weeks or more ) ; delivery by  induction of labor or cs
• preterm (<37 weeks ) ; expectant management until fetal lung maturity

Severe preeclampsia :

• introduction of labor or  cs

Physical therapy management 

1. Relaxation training in form of diaphragmatic breathing for 15 min in addition to (Methyldopa) 250mg 3 times daily.

2. Submaximal exercises program at 70% of maximal HR, in addition of (Methyldopa drug) 3 times daily

Relaxation training program: 

1. The pregnant woman is instructed to assume half lying position with supported back, and to rest for 10 min, through which measurement of arterial blood pressure and pulse rate were taken. 
2. Her hand applied on the upper abdomen, over the mid rectus abdominis area, below the anterior costal margin. 
3. Ask her to inhale slowly through the nose (keeping her shoulder relaxed), feeling the air flow in, and raising her abdomen upward. 
4. Then asked to let the air slowly out through the mouth, feeling the tension going with it. 
5. Ask her to take 3 times of deep breathing, then a period of rest equal to the period of breathing to avoid hyperventilation. 
6. Once she masters the technique, she asked to place her own hands below the anterior costal margin, and to feel the respiratory movement herself and be aware of the movements that occur underneath her hands. Then ask her to move her hands down a bit lower and feel the whole abdomen gently raising and falling in synchronization with her breath.

Exercises program 

A- Exercises for lower limb 

1. 

• Flexion and extension of the toes of right foot 
• Flexion and extension of the toes of the left foot 
• Flexion and extension of the toes of both feet. 

2. 

• Abduction and adduction of the toes of right foot Abduction and adduction of the toes of left foot 
• Abduction and adduction of the toes of both feet 

3. 

• Dorsiflexion and plantar flexion of the ankle joint of the right foot 
• Dorsiflexion and plantar flexion of the ankle joint of the left foot 
• Dorsiflexion and plantar flexion of the ankle joint of both feet. 

4. 

• Inversion and eversion of subtalar joint of the right foot 
• Inversion and eversion of subtalar joint of the left foot 
• Inversion and eversion of subtalar joint of the both feet 

5. 

• Circumduction of the right foot 
• Circumduction of the left foot 
• Circumduction of the both feet 

6. 

• Flexion and extension of the right knee joint 
• Flexion and extension of the left knee joint 
• Flexion and extension of the both knee joints 

7. 

• Abduction and adduction of the right hip joint 
• Abduction and adduction of the left hip joint 
• Abduction and adduction of the both hip joints 

B- Exercises for upper limb 

1. 

• Flexion and extension of fingers of the right hand 
• Flexion and extension of fingers of the left hand 
• Flexion and extension of fingers of the both hands 

2. 

• Abduction and adduction of fingers of right hand 
• Abduction and adduction of fingers of left hand 
• Abduction and adduction of fingers of both hands.

3. 

• Flexion and extension of the right wrist joint 
• Flexion and extension of the left wrist joint 
• Flexion and extension of the both wrist joints 

4. 

• Flexion and extension of the right elbow joint 
• Flexion and extension of the left elbow joint 
• Flexion and extension of the both elbow joints 

5. 

• Flexion and extension of the right shoulder joint 
• Flexion and extension of the left shoulder joint 
• Flexion and extension of the both shoulder joints 

6. 

• Abduction and adduction of the right shoulder joint 
• Abduction and adduction of the left shoulder joint 
• Abduction and adduction of the both shoulder joints

All movement are performed through full range of motion with repetition of ten times. 

Diabetes and pregnancy

Impact of maternal diabetes on the fetus: 

Diabetic in pregnant woman can be detrimental to her fetus for many reasons:

 A. Diabetic women have an increased spontaneous abortion rate compared with the rate in nondiabetic pregnant women 

B. Congenital anomalies have been found in the newborns of type 1 diabetic women compared with the nondiabetic pregnant women. Other negative consequences that diabetes may have on the fetus are certain neonatal morbidities such as respiratory distress syndrome, hypoglycemia and hypocalcemia.

Classification of diabetes during pregnancy: 

1. Gestational diabetes (GDM): Diabetes occurs at first time during pregnancy. 
2. Insulin dependent Diabetes Mellites (IDDM): 

• Juvenile onset in which the pancreas produce little or no insulin. 
• Occurs before pregnancy usually before 10 years old. 

3. Non-insulin dependent Diabetes Mellites (NDDM): 

• It is known as adult-onset. 
• The body resists the effects of insulin or doesn't produce enough insulin to maintain a normal glucose level. 
• It happen prior to pregnancy. 

Treatment

The GOAL of appropriate dietary management for a pregnant diabetic woman is to provide adequate nutrition for both the woman and the fetus. 

Protein: Additional protein is required for growth of the fetus, and the increased size of the maternal blood volume, uterus and breasts, Additional 10gm of protein per day is required for this purpose.

Carbohydrate: It is recommended that the CHO content of the diet in a pregnant woman is often less than in the pre-pregnant state for instance 40% to 50% instead of 50% to 60%. 

Fat: less than 1/3 should be saturated fat no more than 1/3 should be polyunsaturated fat, the remainder should be monoun saturated fat. 

Vitamins and minerals: 

• Additional calcium is necessary for calcification of fetal bones and teeth. 
• Additional iron and multivitamin (V B6, C, D and folate) 

2. Insulin:
Oral hypoglycemic agents are not recommended during pregnancy because they cross the placental barrier and may induce fetal and neonatal hypoglycemia.

There are 3 types of insulin treatment:
a. Short-acting insulin: peak action about 4 hours. 
b. Intermediate-acting insulin: peak action about 12 hours. 
c. Long-acting insulin : peak action about 14 to 20 hours .

Insulin treatment for 3 types of diabetes in pregnant women:
 1. GDM: 
There are 2 treatment options 
a- Dietary treatment 
b- Diet plus insulin

• In elevated fasting glucose level ˃ 90 mg/dl or 2h post prandial glucose levels ˃ 120mg/dl, Insulin treatment should be started. 

• Body mass index in pregnant women is different, we classify it as : Obese: BMI ˃ 27 Kg/m2 & Thin BMI ˂ 27 Kg/m2

►In normal weight GDM women 
Give them a small dose of rapid acting insulin before each meal to maintain normal glucose level with meal stimulation. 

►In obese GDM women, they have insulin resistance secondary to obesity. 
So, they respond well to reduction in caloric intake (diet) and a dose of rapid acting insulin before each meal.

2. IDDM: 
A mixture of intermediate-acting/rapid acting insulin before breakfast to maintain normal glucose level during morning and evening. 

3. NIDDM: 
►Normal BMI NIDDM women respond well to twice daily injection of short-acting insulin before meals. 
►Obese NIDDM usually ˃90 Kg require treatment before conception and were controlled by diet alone except if there are a marked degree of hyperglycemia during gestation they requires ˃ 100 u of insulin daily. 

3. Exercises: 

• It was reported that exercises could lower blood glucose levels and improve acutely the tolerance to carbohydrate load in diabetic patient. 
• A combination of exercises and insulin therapy produced a greater reduction in blood glucose levels than insulin alone

Exercises in IDDM pregnancies: 

Women who are usually sedentary and have no experience with their own tolerance and endurance for various types of exercises, pregnancy is not the time to initiate such a program but in women who are in good physical condition and metabolic control a moderate exercise program is suitable for them.

Contraindications of exercise in pregnant women with IDDM:
a. Myocardial ischemia or arrhythmias 
b. Proliferative retinopathy 
c. Twins and multiple birth 
d. Hydraminos and macrosomia 
e. Severe emotional stress 

Exercises in pregnant NIDDM women: 
In this type, moderate exercises program is an ideal therapeutic measure to reduce insulin requirement and achieve better control of plasma glucose level.

Cardiac disease in pregnancy 

The maternal risk varies according to the nature of the cardiac lesion. Heart disease in pregnancy can be divided into 2 categories: 
A.Congenital heart disease 
B. Rheumatic heart disease

The important guidelines during the prenatal period are:

• Avoidance of excessive weight gain and edema , so cardiac patient should be placed on a low-sodium diet (2gm per day) to prevent excessive expansion of blood volume. 
• Adequate rest should be encouraged 
• Avoidance of strenuous activity 
• Avoidance of anemia

Management of labour: 

• During labour, cardiac output increases when compared with pre-labor levels 
• To minimize the increase in cardiac output, sedation and epidural anesthesia are encouraged early in labor. 
• Women should be given oxygen by mask to reduce the risk of supine hypotension and increase the oxygen carrying capacity to the blood. 
• Monitoring the cardiovascular status during delivery

Asthma and pregnancy 

Asthma is the most common obstructive pulmonary disease of pregnancy.

Obstetric management: 

• In most asthmatics, no drug therapy is needed (because most of the medications the mother receives during pregnancy cross the uteroplacental barrier). 
• Women should have plenty of fresh air, keep away from people with infections such as bronchitis and influenza. 
• Cessation of smoking 
• Adequate bed rest 
• Treatment of respiratory infection 
• Avoid exposure to cold 
• Minimize stress or anxiety 
• Exercises or hyperventilation induced asthma can be prevented by exercising in a moist humid environment. 
• Management of labor and delivery