Clinical Problems

During Pregnancy
Conditions Caused
or Exacerbated by
Pregnancy
 Nausea and Vomiting
•Common name; morning sickness
•½ of the pregnant women suffer some degree
of N&V during the first trimester
•Begins within few weeks of conception and
continues through weeks 12 and 14 of gestation
•Most often in the morning
•Some women suffer during day time
Hyperemesis gravidarum; is severe N&V that
cannot be controlled and may result in dehydration
and malnutrition
If not treated: Maternal neurologic, renal, retinal
and hepatic damage may occur
Etiology;
Unknown cause
Increase levels of hormones and emotional factors
play a role
Recent research indicated that women with
hyperemesis gravidarum have a higher incidence of
Helicobacter pylori infection
Preconceptual treatment of H pylori should be
considered for women with history of a pregnancy
complicated by severe nausea and vomiting, or of
recurrent GI problems
Treatment;
2. Symptomatic
3. IV infusion of electrolytes and parenteral nutrition
is required for hyperemesis gravidarum patients
4. Enteral nutrition works some times
5. Soda crackers upon wakening, then wait 15 to 20
minutes before arising for mild cases
6. Small, dry meals, high in CHOs
7. Avoid spicy food and foods with noxious odor
Medication is considered for pts whose vomiting
persists despite dietary alterations
Doxylamine 10 mg plus pyridoxine 10 mg
(Benedectin) is the most widely used until it is
withdrawn in 1983
Pyridoxine
Cyclizine
Meclizine
All of the three are used to control N&V
Ondansetron category B is currently available
Ginger?
Pyridoxine 50 to 75 mg daily. Maximum dose 100
mg daily
Fitzgerald suggests that patients make their own
ginger or lemon aromatherapy "kit”
This is made by placing 5 ginger or lemon teabags
in an airtight plastic tub. The tub is opened and the
vapors inhaled when nausea occurs.
 Fitzgerald described a 2-day nausea management
program that she has successfully used with
pregnant patients
Day 1:
1 Stay home in bed. Take a chewable calcium
antacid tablet every 2 hours. Frequent sips of liquid
and small, bland meals are also recommended. Use
one 25-mg promethazine (Phenergan) suppository at
bedtime.
Day 2:
2 Use one 25-mg promethazine suppository in
the morning. Begin taking 25 mg of vitamin B6 twice
a day if tolerated. The patient may use 2 other 25-mg
promethazine suppositories during the day if needed.
Fitzgerald M. Sick and pregnant: treatment of common episodic illness. Program and abstracts of the National Conference for Nurse Practitioners 2001; November 7-10, 2001;
Washington, DC
 Things to do
In the morning
• Take your time getting out of bed
• If you tend to feel really sick in the morning,
eat a little as soon as you wake up and before
getting out of bed
• Ask your partner to bring the food to you, or
prepare a snack the night before and leave it
beside your bed
Throughout the day
•Eat little and often, every two or three hours - even if you're not hungry
•Drink a lot of liquid, preferably 10 to 12 glasses of water, fruit juice or
herbal tea each day
•Avoid food containing a lot of fat or spices
•Avoid alcohol and caffeine
•Eat dry crackers, toasted bread or rusks
•Ginger tea or ginger tablets can help reduce nausea
•Rest several times a day. Lie down with a pillow under your head and legs
•Move slowly and avoid sudden movements
•After eating, sit down so that gravity helps to keep the food in your
stomach
•Avoid smells that make you feel sick or throw up
•Don't brush your teeth immediately after eating because this can cause
vomiting
•Get some fresh air and exercise by going for a little walk every day
•Avoid smoking. Not only is it harmful for you and your child, it also
diminishes your appetite
At night
Before going to bed, it may help to eat a snack
such as a yogurt, bread, milk, cereal or a
sandwich
If you wake up during the night, eating a small
snack may stop you feeling sick in the morning
Sleep with the windows open to get some fresh air,
if possible
 Remedies
B-vitamins Take a high-dose B-complex vitamin with at
least 100 mg of B-6, morning and night, for both motion sickness
and morning sickness.

Cloves Chew five whole cloves.

Cola syrup The age-old standby for nausea and upset

stomach has been cola syrup. For adults take 1-2 tablespoons
every 15 minutes until the symptoms subside (no more than six
doses in a 24 hour period). For children it's 1-2 teaspoons. There is
caffeine in cola syrup, so it is best not to take it before bedtime if
you are affected by caffeine. Also, don't take cola syrup if you are
a diabetic.
Ginger Take two to four gingerroot capsules (500 mg each), 1/4
inch slice of fresh ginger or 1/2-1 teaspoon of powdered ginger in
some juice three times daily, depending on the circumstances. Best
results will probably occur when the gingerroot is taken an hour or two
before departure on your trip, with one or more capsules every four
hours while traveling; can be used as either a preventative or remedy.
Ginger has also been found to significantly reduce post-operative
vomiting for women who have undergone major gynecological
surgery, and helps alleviate chemotherapy-induced nausea. If you use
standardized extract, take 1,000 mg. This remedy has proved to be
more effective than Dramamine. Another way to get ginger is to eat
candied slices.
Ginger/honey Make a tea by mixing 1 teaspoon
fresh ginger juice and 1 teaspoon honey in a cup of
boiling water; drink as needed

Ice Research at Penn State University suggests that

applying a cold-pack to your forehead may alleviate the
symptoms

Lemon Suck on a lemon wedge.

Peppermint Put a small drop of peppermint
essential oil under your nose. It will help stop your
stomach from churning

Red raspberry leaf tea helps relieve morning

sickness
Soda crackers. Eating some crackers will help
relieve morning sickness. Remedy courtesy of Shantel
Marie from Hawaii.
Water Morning sickness is a thirst signal of both the
mother and the fetus
Be sure that you are drinking enough water. Normally,
people should drink eight 8 glasses of water a day.
Consult your doctor to discuss the proper amount for
you if you have morning sickness.
 Heartburn

2/3 of pregnant women in the later pregnancy

Due to relaxation of the esophageal sphincter and
increased pressure on the stomach caused by enlarged
uterus, allowing regurgitation of the stomach contents
into the lower esophagus
Treatment;
2. Elevating the head when sleep
3. Avoid eating 3 hrs before sleep
4. Avoid acidic food
5. Small more frequent meals
6. Antacids for whom not responding to non drug therapy
7. Mg and Al hydroxide is effective
8. Calcium carbonate is used but with Na bicarbonate has a
short duration
9. Sucralfate is poorly absorbed from GIT and used as
alternative
 Constipation
Due to decreased peristalsis
Drink plenty of fluids
Surfactants and bulk forming laxatives
Mineral oil should be avoided due to possibility of
impairment of vitamin K absorption
Stool softeners
Senna used if safer softeners are not active but there
is a possibility of uterine contraction
Avoid senna in the late stages
 Hemorrhoids “Piles”
Due to constipation and increased venous pressure
below the uterus
Correct constipation
Use stool softeners
Avoid anesthetics and corticosteroids
Taking sitz bath
 Coagulation Disorders
Uncommon
Avoid warfarin because of 30% of the development
of fetal malformation, stillbirth, and hemorrhage
SC heparin or LMWH is the drug of choice
Anticoagulation effect of heparin can be suppressed
by protamine sulfate when needed especially in
emergency labor
Heparin is considered safe for the mother and fetus
Osteoporois may reults from heparin due to effect
on vtamin D metabolism, and thrombocytopnia
LMWH is better than heparin because of the low
thrombocytopenia,
thrombocytopenia once daily,
daily no monitoring,
monitoring and
less risk of osteoporosis
 Headache and Backache
Common
Due to intracranial vascular changes mediated by
progesterone and estrogen
Migraine attacks often improves during pregnancy
due to the lack of estrogen
Worse during 2nd trimester and 3rd trimester
Backache caused by strain on the muscle of the back
as the uterus enlarges and grows forward
In the 3rd trimester, the hormone relaxin softens the
muscles and ligaments in readiness for labor,
making them more able to stretch but this can make
them ache
Weight gain can cause backache
Paracetamol is the safest analgesic
Aspirin and ibuprofen should be avoided
Teratogenisity of codeine with paracetamol is not
evident but they depress respiration in the newborn
babies if taken near birth
Massage is helpful
 Vaginal Thrush
(Candidiasis)
10 times more common in pregnant than non
pregnant women
Vagina rich in glycogen which promotes candida
Imidazole OTC can be given by doctor
Candida does not harm babies but can be passed to
baby when the baby pass through the birth canal
Varicose Vein and Muscle
Cramps
>80% of pregnant women suffer from leg edema
1/3 of pregnant women suffer from calf muscle
cramps in the lat pregnancy
Support hosiery is usually recommended for varicose
vein
Rest is the treatment of edema with their legs
elevated
Wearing tight clothes should be avoided
Increase intake of calcium and potassium is
recommended to decrease muscle cramps
Avoid high heeled shoes
Put a pillow at the foot of the bed to prevent
stretching the foot forward from the ankle while
lying on the back, which often triggers cramps
Massage and stretching the affected muscle is
helpful
 Pruritis
Pruritus gravidarum; the most common during
pregnancy
It is a generalized mild itching without rash that
affects up to 20% of pregnant women
It occurs from the 3rd month upwards
Due to estrogen induced cholestasis
Oily calamine lotion is effective
Sometime papular rash happens and it needs
investigation
 Stretch Marks &
Hyperpigmentation
Hyperpigmentation is due to increased level of
MSH, while estrogen makes veins more noticeable
Melasma; brown, clearly defined patches on the
face
Darkening of the nipples
All these fade after delivery
Stretch marks are caused by the overstretching of the
elastic tissue in the skin as the abdomen and breasts
enlarge and the replacement of collagen by scar
tissue
They appear as a red bands or lines during
pregnancy
Usually fade afterwards to white or silvery colour
They may never disappear completely
Exercise during pregnancy may help prevent the
development of stretch marks
Vitamin E topical products, cocoa butter, collagen
and elastin products can be used
After pregnancy, tretinoin can be used in severe
cases to remove scarring
 Coughs and Cold
Lozenges are helpful but without artificial
sweeteners
Honey and lemon
Steam inhalations
Decongestants should be avoided
Menthol nasal is helpful
 Acute Bacterial
Rhinosinusitis
Acute bacterial rhinosinusitis (ABRS) is a
significant problem in pregnancy due to the chronic
nasal congestion frequently experienced by pregnant
women
The causative pathogens are similar to those seen
frequently in acute otitis media (Streptococcus
pneumoniae, Haemophilus influenzae, and Moraxella
catarrhalis)
In order to decrease the incidence of ABRS among
pregnant women, prevention of upper respiratory
infection is critical
Topical therapies commonly used in pregnancy to
treat ABRS include nasal saline and over-the counter
medications such as Vicks VapoRub
Herbal teas offer relief as well
Antibiotics and Decongestants
Decongestants and antibiotics
Oral forms of decongestants can cause systemic
vasoconstriction
Use of a low-dose topical preparation is probably
safer in pregnancy
Rhinitis medicamentosa, also referred to as rebound,
is common, so short-course (less than 3 days)
treatment is preferable
Antibiotics in the lowest-risk category should be
selected to minimize potential adverse fetal effects.
 Urinary Tract Infection
Asymptomatic bacteriuria occurs in approximately
6% of pregnant women, and up to 30% of them will
go on to develop symptomatic urinary tract infection
(UTI)
40% of UTIs experienced during pregnancy
progress to pyelonephritis
 Because of the increased risk for the development
of pyelonephritis, the first symptom of UTI may be
fever
Any woman presenting with unexplained fever in
pregnancy should be screened for UTI
Two subgroups of women, those with sickle cell
trait and diabetes, are at increased risk for
asymptomatic bacteriuria and should be screened
frequently for UTI during pregnancy
Pathogens causing UTIs are unchanged in
pregnancy; 80% of infections involve Escherichia
coli

Normal UTI avoidance measures;

•adequate fluids
•voiding after intercourse
•limited tub-baths
Treatment should continue for 7-10 days because of
the mild immunosuppression associated with
pregnancy
In an uncomplicated UTI, Fitzgerald recommended
considering treatment with nitrofurantoin
(category B)
For treatment of pyelonephritis, treatment with
third-generation cephalosporins or amoxicillin with
clavulanate (Augmentin) was recommended
because of their coverage of gram-negative
organisms
 Migraine Headache
Among women with a migraine history, many
experience improvement during pregnancy, while
some will have worsening headaches
 Migraine prophylaxis should be discussed with all
migraine sufferers
Treatment with 400 mg of vitamin B2 (riboflavin)
daily can reduce the number and length of migraine
headaches by up to 60% after 2 months of use
Lipton RB, Stewart WF, Ryan RE, Saper J, Silberstein S, Sheftell F. Efficacy and safety of acetaminophen and caffeine in alleviating migraine headache pain -- three
double-blind, randomized, placebo-controlled trials. Arch Neurol. 1998;55:210-217
Other nonprescription relief measures include
caffeine (particularly helpful with awakening
headache), lidocaine nasal spray (not FDA-
approved, but according to Fitzgerald, limited trials
indicate that 50% of users will have 50% reduction
in pain), and migraine ice gel pad
Triptans
Cause vasoconstriction
All 4 triptan drugs (naratriptan [Amerge], sumatriptan
[Imitrex], zolmitriptan [Zomig], and rizatriptan [Maxalt]) are
in the risk categories CM, L3

The route of triptan administration may be important

because vasoconstriction is associated with the speed of
drug delivery
Subcutaneous delivery, the most rapid route, confers the
highest vasoconstriction risk, followed by nasal spray, and
then oral preparations
Analgesics
Acetaminophen, a risk category B drug, is not typically
effective in managing migraine
Nonsteroidal anti-inflammatory drugs (NSAIDs) are in risk
category B/D
High doses are generally not recommended, particularly at
term, because of associated antiplatelet activity
An examination of 3 double-blind, placebo-controlled studies of Excedrin
Migraine/Extra Strength use in individuals with migraine showed that 20.8% of the
drug-treated patients had complete headache relief at 2 hours compared with 7.1% of
placebo-treated patients. At 6 hours, 50.8% of the drug-treated patients had complete
relief compared with efficacy at 6 hours compared with 23.5% of the subjects given
placebo. However, bleeding risk (particularly near term) should be considered,
because Excedrin contains acetaminophen, caffeine, and acetylsalicylic acid, which is
considered a category C/D medication in pregnancy. Pregnant women should avoid
the aspirin-containing product and use the nonaspirin version.
 Depression
•Up to 20% of women experience a major depression at some
point during their lifetime
•women are twice as likely to be depressed as men
•many pregnant women will either enter pregnancy in a depressed
state or develop depression during the course of the pregnancy
•Therapy frequently requires a combination of lifestyle changes,
counseling, and drug therapy.
•Pharmacologic management of depression can involve several
classes of medications
•The more common drugs used to treat depression include
serotonin and dopamine receptor modulators, tricyclic
antidepressants, monoamine oxidase inhibitors (MAOIs) and, less
frequently, benzodiazepines
 Serotonin and Dopamine Receptor
Modulators
The SSRIs act to modulate serotonin receptors, and are all in risk category C. They are
currently the most commonly prescribed class of antidepressant and are frequently used by
reproductive-age women. Bupropion (Wellbutrin), a dopamine receptor modulator, is in
category B, a "better" risk category than the SSRIs. While it would seem reasonable to
switch a pregnant woman from a higher-risk category C SSRI to bupropion, doing so may
actually worsen depression because the drugs act through different mechanisms.
If a decision is made to discontinue antidepressants during pregnancy, a slow tapering of
approximately 25% per week will be required in order to avoid SSRI withdrawal syndrome.[1]
Gradual tapering is particularly important for SSRIs with longer half-lives. Paroxetine (Paxil)
has the shortest half-life (26 hours), while fluoxetine (Prozac) has a 24- to 72-hour half-life
with a metabolite that lingers for up to 16 days, making it the most difficult SSRI from which
to withdraw. Sertraline (Zoloft) and citalopram (Celexa) have intermediate half-lives of
between 24 and 65 hours. While abrupt withdrawal is not life-threatening, women often
experience significant CNS side effects such as jitteriness or nightmares.
If SSRIs are used late in the third trimester, fetal withdrawal can also occur and effects may
last for as long as 30 days. Fetal effects are similar to maternal withdrawal and include
irritability, constant crying, shivering, and increased muscle tone. Long-term epidemiologic
data are now becoming available, and no apparent adverse maternal or fetal affects have
been identified with prenatal exposure to the serotonin or dopamine receptor modulators
Tricyclic Antidepressants and MAOIs
The older tricyclic and MAOI antidepressants are known to have more adverse side
effects and higher toxicities than the newer receptor modulator agents. These drugs
have largely been replaced by the receptor modulator agents and are not often used
for treatment of depression in pregnant patients. If a patient is considering pregnancy
and is taking a tricyclic antidepressant (category D) or MAOI (category C), serious
consideration should be given to tapering the patients off of these drugs. Treatment
with either a serotonin or dopamine receptor modulator would then be initiated
Benzodiazepines
Benzodiazepines, in risk category D, are rarely used in the management of depression
and they are not frequently used during pregnancy. If a reproductive-age woman is
prescribed a benzodiazepine, she should be instructed to use effective contraception
to avoid pregnancy while taking the drug. These drugs are highly lipophilic and cross
the placenta very easily. Fetal serum levels of benzodiazepines can be 1-3 times
higher than maternal levels. When discontinuing benzodiazepines, it is critical to taper
doses gradually (25% per week) in order to avoid a withdrawal syndrome

Edmunds MW, Mayhew MS. Pharmacology for the Primary Care Provider. Baltimore, Md: Mosby; 2000;115.
Pins and needles
Pins and needles, especially in the hands, can be accompanied by some pain or numbness and occasionally weakness in the fingers. Usually
this is caused by fluid build-up around the wrists, which compresses the nerves that run to the hand muscles and skin. This is known as carpal
tunnel syndrome and tends to occur when there is also swelling in the ankles

If finger pain or numbness is an ongoing problem, it may be wise

to wear a moulded wrist splint, especially at night
Pregnancy Specific
Conditions
 Pregnancy Induced
Hypertension
So called gestational hypertension
Diagnosed when the BP exceeds 140/90 mmHg in
the absence of proteinuria or pathologic edema
Pre-eclampsia (or toxemia, as it was historically
called) is the hypertensive disease that occurs only in
pregnancy
 Hypertension during pregnancy divided into
four categories:
*Chronic hypertension
*Preeclampsia-eclampsia
*Preeclampsia superimposed on chronic
hypertension
*Transient Hypertension

This classification is done to differentiate between women with chronic hypertension from those with pregnancy induced or
pregnancy specific hypertension
Transient hypertension is the increase in blood
pressure during pregnancy with out signs and
symptoms of Preeclampsia woman who did not
have pre-existing hypertension
Preeclampsia is the presence of hypertension with
proteinuria, edema or both occur after week 20 of
pregnancy (proteinuria of 100mg/dl in two random
urine selection 6 hrs apart)

If Preeclampsia happened in women with chronic

hypertension, it may be termed Preeclampsia
superimposed on chronic hypertension

Preeclampsia ranged from mild to severe

Considered severe when proteinuria exceeds 4
g/24hrs plus BP >160/110mmHg, severe headache,
visual disturbances, and epigastric pain
Preeclampsia can lead to the development
of:
B.Preeclampsia variant in which a women exhibits;
• Hemolytic anemia
• Elevated liver enzymes
• Decreased platelet count

• Eclampsia which may be defined as convulsions

or seizures that occur in a patient with
Preeclampsia
All these cases required hospitalization,
antihypertensive therapy, may be anticonvulsant
therapy
Pre-eclampsia occurs more often among some
groups of women those;
•Are under 20 years old, with a first pregnancy
•Are over 35 years old, with a first pregnancy
•Have chronic, or "essential" hypertension
•Had hypertension in a previous pregnancy, other
than the first pregnancy
•Have multiple gestation (twins)
•Have diabetes
 Signs & Symptoms

Pre-eclampsia has been called the great

imitator ( because its symptoms are (
often much like many other diseases

Characteristic signs and symptoms occur

after the 20th week of pregnancy and include:
1.High Blood Pressure
2. BP of at least 140 over 90 is considered
hypertension (160 over 110 is "severe")
3. If the woman's normal (pre-pregnant or very early
pregnancy) blood pressure is not known, it's very
hard to distinguish pre-eclampsia from chronic
hypertension
4. Pre-eclampsia is more dangerous to the mother
and baby
5. About 20 percent of women with chronic
hypertension will develop pre-eclampsia too
2.Swelling, or "edema"
2. A common sign and may go along with a rapid
weight gain
3. Swelling is a confusing symptom
4. It is normal to have some swelling of the feet or
ankles, especially late in pregnancy and some
women with pre-eclampsia will have no edema
5. Swelling is not a reliable symptom of pre-
eclampsia
3.Protein in the urine
2. The presence of protein in the urine is considered to
be an important factor for making the diagnosis of
pre-eclampsia
3. The disease causes damage to the filtering function of
the kidneys (repairs itself after delivery), which allows
protein to "spill" into the urine
4. It is a reliable sign of pre-eclampsia
5. Protein in the urine very often does not occur until the
disease has progressed to a later stage
6. The majority of women with pre-eclampsia feel
perfectly well
7. It can only be detected by the routine screening tests
carried out at ante-natal visits
Other symptoms which may arise
include upper abdominal pain and
vomiting, severe headache and visual
disturbances
These symptoms can indicate the
disease has reached an advanced stage
 Pre-eclampsia differs from a normal
pregnancy in the following:
1.In a normal pregnancy the fluid part of the mother's blood increases dramatically, resulting in a 35-50% increase in the
total volume. This helps serve the added needs of the uterus and placenta, among other functions. In the woman with pre-
eclampsia, the blood volume increases only a small amount or not at all

2.The "resistance", or stiffness of the blood vessels throughout the mother's body normally decreases, allowing free flow of
blood to the placenta and uterus. Pregnancy hormones and changes in the blood vessel regulating mechanisms "relax" the
vessel walls. With pre-eclampsia, instead of relaxing, the blood vessels spasm

5.In the normal pregnancy, blood clotting is affected very slightly. With severe pre-eclampsia, platelets (clotting factors in
the blood) can be very low, and the blood does not clot normally. This results in a life threatening risk of internal bleeding

4.With the increase in blood volume and relaxed vessels, the normal pregnant woman gets extra blood flow to the uterus,
kidneys, liver and other organs. In the woman with pre-eclampsia, the vessels are in spasm, and this blood flow is decreased
instead. The spasm in the small vessels of the body is believed to cause the organ damage that happens with the disease.
Kidney damage is one example - protein in the urine is what results from the damage. Other organs, especially the liver can
also be damaged. Except in the most severe cases, organ damage heals by itself after delivery of the baby

3.Normally, the pregnant woman's blood pressure drops a little in mid-pregnancy, partly because of the increase in volume
of blood, and partly due to the relaxing of the blood vessels. With pre-eclampsia, the blood pressure does not drop in mid-
pregnancy, and the blood pressure increases in the last weeks
 Etiology of Pre-eclampsia
Genetic factors are probably involved since women whose mothers and sisters have suffered pre-eclampsia are more likely
to get it themselves.

What is known is that pre-eclampsia originates in the placenta. The placenta needs a large and efficient blood supply from
the mother to sustain the growing baby. In pre-eclampsia the placenta runs short of blood either because its demands are
unusually high - as with twins - or because the arteries in the womb (‫الرحم‬did not enlarge as they should have done when the (
placenta was being formed in the first half of pregnancy. This shortage of blood has serious consequences for mother and
baby.

Increased Vasoconstrictor Tone

Women with Preeclampsia appear to have markedly increased vasoconstrictor tone and this increase in
the response to vasoconstrictors can be detected before the clinical development of prteeclampsia; thus,
Preeclampsia may be a chronic problem during pregnancy that persist when the fetus is delivered.

Prostaglandin imbalance
The development of Preeclampsia may reflect a deficiency of certain prostaglandins that can occur as a
result of prostaglandin precursor deficiency, defective prostaglandin activity, or lowered prostaglandin
synthetase enzyme action.
The imbalance in the process of enoperoxides conversion to prostaglandins E2 and F2, prostacycline,
thromboxane occurs in woman with Preeclampsia. The reduction in the vasodilator prostaglandins induce
blood vessel constriction. Also prostacycline is a potent vasodilator and oppose platelet aggregation process
in the pregnant woman.
 Complication of Preeclampsia in the
mother and her baby

1. Damage to the kidney and liver

2. Swelling or fluid in the lungs
3. These problems are caused by the decreased flow
of blood and vessels in spasm
4. Since the uterus also gets less blood flow, often the
placenta is damaged
5. The baby may not grow well
6. May be overly stressed during labor
Many women with pre-eclampsia will deliver
an essentially healthy baby

Some women will experience only an anxious

nurse-midwife or doctor, and maybe delivery a
week or so earlier

Some women, however, progress rapidly to

more severe forms of the disease
Two very serious consequences are:
1.Eclampsia is when the mother has convulsions. Serious complications
such as brain injury as a result of the convulsion are uncommon but occur
The fetus is deprived (‫يستنفذ‬of oxygen during the convulsion, and damage or (
separation of the placenta can occur. Preventing eclampsia is one of the major goals
of treating pre-eclampsia.

2.HELLP Syndrome stands for hemolysis (destruction of red blood cells),

elevated liver enzymes (indicating liver damage), and low platelets (internal
bleeding risk). HELLP Syndrome is a life threatening condition for both mother
and fetus
Prevention of Preeclampsia
Calcium intake appears to play some role
in reducing pre-eclampsia. Adequate
amounts of calcium (1,200 - 1,500 mg per
day) can be obtained from a balanced diet
which includes 3 to 4 servings of milk or
dairy products daily. If the diet is not
adequate, a supplement may be
recommended
Low dose aspirin therapy is being studied
as one possible way to prevent the
chemical imbalances at the placenta,
which are believed to be a cause of pre-
eclampsia
Studies recommend that aspirin be used
only in women at very high risk for pre-
eclampsia
Dose; 60 mg/day begins from 24 – 24 of
gestation until delivery
 Have regular antenatal check-ups,
which can detect the earliest signs of pre-
eclampsia and other complications.
Take an active interest in your ante-
natal checks, never miss an appointment,
and make sure you have your blood
pressure and urine checked regularly
Research suggests that vitamin C and
possibly vitamin E and betacarotene
may be instrumental in preventing
Preeclampsia

The body relies on vitamin C to fend off the free radicals that
injure blood vessels in the uterus and placenta and trigger the
high blood pressure and swollen tissues that accompany the
disease. Antioxidants may be more important in prevention than
in treatment; adequate levels going into pregnancy could keep
free radicals a way
 Treatment of Preeclampsia
1. Delivery of the placenta and baby is the only
known treatment
2. When the disease occurs in the last weeks of
pregnancy, bed rest and observation for
worsening of pre-eclampsia may be attempted, but
often labor must be induced, or in severe cases,
cesarean birth performed
3. Diet therapy (calcium)
4. Restricted activity and bed rest
 Pharmacological agents
• Parenteral magnesium sulfate to prevent seizures
IV dose: LD 4g then infusion 1-3 g /h
Or
4 g IV LD with simultaneous IM 10 g (5g in each
buttock)
Disadvantages of IM; the large volume of injection
and the pain
Lidocaine may be used to minimize pain
Monitoring parameters

1. Optimal Serum Conc. 4-7 mEq/L

2. At 9-10 mEq/L, the patellar reflexes becomes
hypoactive and may disappear
3. Reflexes should be checked every hour
4. Urine Output should be greater than 25 ml/hr
because Mg excreted only in urine
5. Respiration should be greater than 10/min
6. Respiratory depression and cardiac conduction
abnormality may occur at conc. 13-15 mEq/L
7. IV 1g calcium gluconate 910ml of 10% solution)
reverses mild Mg toxicity
1. Calcium ampoule should be kept at the bedside of
the pt receiving Mg
2. Calcium has no effect of hypermagnesemia in the
fetus
3. Mg is not an antihypertension and used to prvent
seizure complications with some hypotensive
effect
4. Monitor BP

1. Seizures not responding to magnesium may

respond to diazepam or phenytoin
• Systolic BP > 160-180 and diastolic > 110 mmHg
should be treated with hydralazine to prevent
intracranial hemorrhage
Dose; 5-10 mg initially, followed by 10 mg every 20
minutes PRN to decrease diastolic BP to below
100 mmHg
BP must not be reduced qickly to prevent the
incidence of shock
SEs; tachycardia, headache, palpitations, flushing
Propranolol may be used to oppose the side effects
but not to control BP alone
• IV labetalol an alpha and beta blocker is an
alternative to hydralazine in acute attacks
Dose; IV 10-20, double the dose every 10 minutes
until BP is controlled or cumulative dose of 300
mg is reached
IV infusion 1-2 mg/min to maintain BP, then
decrease to 0.5mg/min to maintain control
It is faster in onset than hydralazine with less
tachycardia
Hydralazine is more effective in overall
If hydralazine is not available, use labetalol
• Calcium channel blockers are used “nefidipine”

• Diazoxide is not used because of the serious

adverse effects like sodium and water retention,
hyperglycemia, in both mother and neonate and
irreversible hypotension, it inhibits labor
• Diuretics are not recommended because of the
decreased placental perfusion following
intravenous fluid depletion
• Nitropruside is not used due to lack of experience
 Management of
Pneumonia in Pregnancy
Pneumonia is the leading cause of death during
pregnancy from nonobstetric causes
With the advent of antibiotic therapy, maternal
mortality had been decreasing, but recently there has
been an increase in cases due to:
•HIV;
•Drug use; and
•Increase in maternal age during pregnancy
When symptoms indicate the possibility of pneumonia, a
thorough history and physical examination must be done to
rule out other causes of respiratory complaints such as:
•Pulmonary emboli;
•Congestive heart failure;
•Tuberculosis; and
•Pneumothorax
Causes of pneumonia include;
1. Streptococcus pneumoniae,
2. Haemophilus pneumoniae
3. Klebsiella pneumoniae
4. Atypical organisms to consider include
Mycoplasma, Legionella, and Chlamydia
5. Viral causes may include varicella, influenza
6. Pneumocystis carinii secondary to HIV
The diagnostic evaluation may include:
•Complete blood cell count
•Sputum Gram stain/culture
•Blood cultures
•Serum cold agglutinins
•Titers for suspected pathogens
•X-ray has a hazardous consequences
Choice of therapy for pneumonia will be guided by
the clinical diagnosis
If antibiotic therapy is necessary, safe choices in
pregnancy include:
•Penicillin
•Cephalosporins
•Erythromycin
•Azithromycin
•Clindamycin
Drugs that should be avoided in pregnancy include;

• Clarithromycin,
Clarithromycin which has been associated with
teratogenetic effects in animal studies
• Quinolone family, which have been associated
with adverse effects on bone development in
animal studies
The only drug available to treat patients who are
diagnosed with Pneumocystis carinii pneumonia, an
opportunistic AIDS-related infection, is
trimethoprim-sulfamethoxazole (Bactrim, Septra)
It is a folic acid antagonist, so folate supplementation
must be given
Additional supportive measures may include:
•Oxygen therapy
•Beta agonists
•Postural drainage
•Fluids/electrolytes
Pregnant women have a 20% increase in oxygen
consumption during pregnancy, and, along with a
decrease in functional residual capacity seen with
pneumonia, a woman's ability to tolerate even limited
periods of hypoxia is limited
It is critical that clinicians diagnose pneumonia
and its causes early and treat with the appropriate
therapy in order to limit risks to the mother and the
fetus
 Group B Streptococcus
(GBS)
Between 10% and 30% of pregnant women are
colonized with GBS
GBS is an organism that may be present in the
mouth, lower gastrointestinal tract, urinary
tract, and reproductive tracts
During delivery, GBS can be passed from
mother to infant and is a leading cause of
serious neonatal infection
Only a small percentage of exposed
infants develop GBS sepsis, but those
that do have higher incidence of
morbidity and mortality
Quidelines for treatment and screening for
GBS include:
•Universal prenatal screening for vaginal and rectal GBS
colonization at 35 to 37 weeks of pregnancy
•Recommendations based upon large retrospective cohort
study
•Risk-based approach for women whose culture status is
unknown at time of delivery
•Women who have previously had a baby affected by
GBS or have had GBS infection documented in their
urine should automatically be treated in labor
Penicillin remains the first-line choice for treatment;
ampicillin is an acceptable alternative
For patients who are allergic to penicillin,
For patients who are at high risk for anaphylaxis, the
it is recommended to perform clindamycin and
erythromycin susceptibility testing in order to
determine the appropriate antibiotic with which to
treat the patient
If this testing is not available or not done by time of
delivery, then patients should receive vancomycin
Rubella is a major cause of congenital anomalies,
particularly of the cardiovascular system and inner
ear
Cytomegalovirus infection can cross the placenta
and damage the fetal liver
Toxoplasmosis can affect the fetal brain, so pregnant
women should avoid contact with cats unless the cats
are strictly confined to the house and are not exposed
to outdoor cats
Chlamydial infection during pregnancy may be
associated with premature rupture of the membranes
and preterm labor
Bacterial vaginosis may be a more important factor

The presence of mucopurulent cervicitis or recurrent

culture-negative urethritis mandates testing for
chlamydiae, including DNA probes
 Preterm Labor
It is the beginning of uterine contractions with
cervical changes before week 37 of gestation
Labor occurring before week 20 of amenorrhea
usually results in expulsion of nonviable fetus
Inhibition of labor is not usually attempted before
week 20
Many women respond to bedrest, hydration and
sedation
Pharmacological intervention is successful when the
cervix is dilated less than 4 cm and membranes is
intact (not ruptured)
Tocolytic agents are the choice; drugs that inhibit
contraction
Premature rupture of membranes is considered a
contraindication to tocolysis
Tocolytics used to;
• Prolong gestation while an effective regimen
of corticosteroids can be administered to
enhance fetal lung development
• Decrease perinatal mortality
• to prolong pregnancy to term or long enough
for substantial increases in gestational age
and infant birth weight
Tocolytic drugs are;
A. Magnesium
B. Beta-mimetic drugs
C. Calcium channel blockers
D. Nonsteroidal anti-inflammatory agents
(nsaids)
 Beta agonists
The most widely used
Ritodrine is the best drug
Terbutaline is used also and less expensive than
retodrine
Isoxsuprine was used in the past but it is associated
with significant tachycardia and hypotension
Ritodrine is available as IV only
Terbutaline available as IV, SC, oral
Beta agonists

Both have similar SEs

SEs; hypotension, tachycardia, hyopkalemia.
Resolve after discontinuation of the drug
Hyperglycemia is a side effect but not clinically
important
If hyperglycemia happens, treated as for gestational
diabetes
To avoid pulmonary edema, 5% dextrose in water is the best
solution for infusion
Limit the fluid intake by 2500 ml/24hrs to decrease the
occurrence of pulmonary edema
Beta agonists

Concentrated solution of ritodrine (300mg in 500 ml

D5W) will help minimize fluid intake
IV continued for 12 hrs after contraction cease
Oral medication is initiated 30 minutes before the
infusion is stopped
Terbutaline SC pump is used
To prevent tachyphylaxis (beta receptor down
regulation with results in less response) use
terbutaline in low doses continuously
 Magnesium
Magnesium sulfate is effective
It antagonizes calcium to prevent the actin-myosin
interaction, thus reducing uterine activity
Serum magnesium level of 6-8 mEq/L is enough
Monitoring is required as mentioned before
It crosses the placenta
No specific harm to the fetus
 Prostaglandin Inhibitors
Prostaglandins induce labor
NSAIDs are useful in stopping labor
Have serious SEs in the fetus; ductus arteriosus, poor
cardiopulmonary adaptation after delivery
Calcium Channel Blockers
Verapamil and nifedipine relax myometrium in vitro
Nifedipine is clinically effective in decreasing severe
uterine contractions in dysmenorrhea
Used as tocolytic agents
 Oxytocin Antagonists
Atosiban is recently introduced
Lack cardiopulmonary, CNS side effects and also
nausea
It seems to have a great promise for preterm labor
 Induction of Labor

It should not be attempted unless an operative

delivery would be indicated if the induction fails
Appropriate indications;
1. Severe maternal infection
2. Uterine bleeding due to abruptio placeta
3. Preeclapmsia/eclampsia
4. Chronic hypertension
5. DM
6. Maternal renal insufficiency
7. Macrosomia
8. Premature rupture of membranes after week 36
9. Oligohydramnios
10. Polyhydramnios
11. Evidence of placental insufficiency
12. Intrauterine growth retardation
13. Isoimmunization
14. Postdate pregnancy
3 classes of drugs that stimulate uterine
contraction;
1. Oxytocin
2. Ergot alkaloids
3. Prostaglandins
Ergot alkaloids are not used to induce labor at
term or in late pregnancy because of the possibility
of violent, sustained contractions that could
compromise the fetus or rupture the uterus
They are used to terminate early pregnancies and to
stimulate contractions to decrease postpartum or
post abortion bleeding
Administered orally or parenterally
Prostaglandin dinoprostone available as gel
in a prefilled applicator and an extended release
vaginal insert
For labor induction
They are applied with electronic monitoring to the
fetus and uterus due to possibility of
hyperstimualtion
These agents used to soften the uterus for
contraction and then oxytocin given after several hrs
Vaginal suppositories are only used to terminate
early pregnancy
Misoprostol has been used for labor induction by both
vaginal and oral routes
25-50 microgram vaginal tablets
Misoprostol advantages over dinoprostone;
1. Less expensive
2. Can be stored at room temperature
3. Effective
4. No need for oxytocin
But it has no large studies to support its use
Any hyperstimulation can be reversed by beta agonists
Oxytocin
Most commonly used
It augments inadequate labor
IV infusion; solusion of 10 U oxytocin in 1L fluid
Dose; 1mU/20-30 min
Maximum dose; 20mU/min
The goal of therapy is contractions that last 45 to 60
seconds at intervals of 2 to 3 minutes
IV is the best bec of better absorption
IM is not recommended bec of inconsistent
absorption and drug given IM cannot be discontinued
when necessary
If higher doses is required, internal monitoring of the
uterus is needed to avoid uterine rupture
No side effects if the drug is perfectly monitored
Does not cross the placenta
Decreases uteroplacental blood flow which results in
decrease fetus heart rate
Fluid retention may happen
Contraindications;
1. Abnormal fetal positions
2. Cephalopelvic disproportion
3. Previous classical cesarean section
4. Other uterine surgeries
5. Pts with class III or IV heart disease
6. Grand multiparas (greater than 7 previous
deliveries) have a significant increased risk of
uterine rupture with oxytocin
Chronic Medical
Disorders in
Pregnancy
 Diabetes Mellitus
Gestational diabetes mellitus is carbohydrate
intolerance of variable severity with onset or first
recognition during the current pregnancy
It is associated with increased fetal and neonatal loss
and neonatal and maternal morbidity
Poor glucose control before conception and during
organogenesis places the fetus at high risk of
congenital malformations, especially cardiac and
neural tube defects
Diabetes mellitus (DM) can occur during
pregnancy in 2 forms:
• Pregestational diabetes is defined as Type I or
Type II DM that existed before conception

• Gestational diabetes (GDM) is defined as

glucose intolerance that is first detected during
the pregnancy and is associated with a probable
resolution after the end of the pregnancy
 Etiology of Gestational Diabetes

HCG = human chorionic gonadotropin; HCS (HPL) = human placental lactogen

Human placental lactogen;
2. Plays a pivotal role in triggering the changes that
can lead to glucose intolerance
3. It has strong anti-insulin and lipolytic effects
4. Peripheral insulin sensitivity during the third
trimester decreases to 50% of that seen in the first
trimester
5. Basal hepatic glucose output is 30% higher
despite higher insulin levels
 Increased Decreased
mobilization sensitivity to
of glucose PLUS insulin

GESTATIONAL DIABETES
 There is evidence that women who develop
GDM secrete less insulin in response to a
glucose load than women who do not
develop the disease
Bowes SB, Hennessy TR, Umpleby AM, et al. Measurement of glucose metabolism and insulin secretion during normal pregnancy and pregnancy complicated by gestational
diabetes. Diabetologia. 1996;39:976-983.
 Screening and Diagnosis

The American College of Obstetrics and Gynecology (ACOG) recommends universal screening between 24
and 28 weeks gestation for women of average risk (ACOG does not define what constitutes average risk; for
low-risk women, such as teens, selective screening may be considered an alternative.[1] Recently, the Expert
Committee on the Diagnosis and Classification of Diabetes Mellitus of the American Diabetes Association
(ADA) advocated selective screening. They recommend that women younger than 25 years of age whose
body weight is normal and who do not have a family history of diabetes, and who are not included in
racial/ethnic groups considered to be at high risk, need not be screened for GDM.[15,16] The ADA
recommendations are made on the basis of data collected since the 1994 ACOG guideline was written, but
ACOG has not yet endorsed these screening recommendations or made revisions to their 1994 guideline
The Australasian Diabetes in Pregnancy Society
(ADIPS) recommends that screening for GDM
should be considered in all pregnant women
If resources are limited, screening may be reserved
for those at highest risk
Risk factors include:
•Glycosuria
•Age over 30 years
•Obesity
•Family history of diabetes
•Past history of GDM or glucose intolerance
•Previous adverse pregnancy outcome
•Belonging to an ethnic group with a high risk for GDM
The recommended screening test for
GDM is performed at 26-28 weeks'
gestation and positive results are: 1
hour venous plasma glucose level more
than 7.8 mmol/L after a 50 g glucose
load (morning, non-fasting); or 1 hour
venous plasma glucose level more than
8.0 mmol/L after a 75 g glucose load
(morning, non-fasting)
Confirmation of diagnosis after a positive
screening test: a 75 g oral glucose
tolerance test (fasting) with a venous
plasma glucose level at 0 hours of more
than 5.5 mmol/L and/or at 2 hours of more
than 8.0 mmol/L
If the clinical suspicion of GDM is high, a
diagnostic OGTT is indicated, irrespective of the
stage of pregnancy
If an OGTT gives normal results early in pregnancy
the test should be repeated between 26 and 30 weeks'
gestation
A 75 g OGTT should use 75 g of anhydrous
glucose or the equivalent, and preferably should also
be performed after a high carbohydrate diet of at least
150 g of carbohydrate for three days
 Complications
1.Infections
2.Preterm labor
3.pregnancy-induced hypertension
• Retinopathy
• Nephropathy
• Neuropathy
• Congenital malformations of major organs have been
positively correlated with elevated Hb A1c concentrations
at conception and during embryogenesis (the first 8 wk)
• Oral hypoglycemic drugs in the 1st trimester has been
associated with cardiac defects, ear malformations, and
the VATER (Vertebral, Anal, TracheoEsophageal, Renal)
anomaly
In pregnancies complicated by type I or II diabetes,
the major cause of neonatal mortality is congenital
malformation incompatible with life. Therefore,
maternal serum -fetoprotein should be determined at
16 to 18 wk gestation, and a thorough ultrasound
examination should be performed at 18 to 22 wk; if
the maternal serum level is abnormal, the
-fetoprotein level in amniotic fluid should be
measured. Abnormal maternal serum and amniotic
fluid levels or abnormal ultrasound results suggest
neural tube or other developmental defects. Fetal
echocardiography should be performed if the Hb A1c
value is abnormally high at the first prenatal visit or in
the 1st trimester.
The minimum goals for glycaemic control
are:
•a fasting capillary (venous plasma) blood
glucose level <5.5 mmol/L
•a 1 hour postprandial capillary (venous plasma)
blood glucose level <8.0 mmol/L
•a 2 hour postprandial capillary (venous plasma)
blood glucose level <7.0 mmol/L
 Labor and Delivery

During the 3rd trimester, care of diabetic women

consists of;
1. Controlling maternal plasma glucose
levels
2. Assessing fetal well-being
3. Determining fetal pulmonary
maturation
For most women with gestational diabetes, labor begins
spontaneously at term, and delivery is vaginal
If these pregnancies go beyond 42 wk, the fetus is at risk of death in
utero, so labor should be induced
Many obstetricians suggest induction at 40 wk
Even when maternal glucose levels have been normal or nearly so
throughout pregnancy, macrosomia is a risk
Thus, cesarean section may be necessary in cases of dysfunctional
labor or cephalopelvic disproportion or to avoid shoulder dystocia and
injury to the newborn and to the birth canal
The obstetrician should assess fetal well-being at 32 wk by external
fetal heart rate monitoring (with nonstress tests) and biophysical
profiles
The patient should be instructed to count fetal movements during a
30-min period daily; A sudden decrease should be reported
immediately to the obstetrician
Nonstress tests may begin earlier in women with such complications
as hypertension, hydramnios, premature rupture of membranes,
intrauterine growth retardation, preterm labor, infection, or
developmental defects
Most diabetologists and perinatologists do not measure maternal
serum or urinary estriol levels, because these expensive assays are not
the most practical or useful tests for assessing fetal well-being
Amniocentesis to assess fetal lung maturity is not routinely
performed in women whose diabetes is well controlled and who have
documented dating criteria; However, it is often necessary in women
with obstetric complications, inadequate prenatal care, or poor diabetic
control
 Insulin therapy
Should be considered if the blood glucose goals are
exceeded on two or more occasions within a 1 to 2 week
interval, particularly in association with clinical or
investigational suspicion of macrosomia
The benefit of instituting insulin therapy after 38
weeks' gestation is unproven
Human insulin should be used
No insulin preparations have a pregnancy category
listing, except for the new, rapidly acting insulin
analogue lispro, which is category B2

Two cases of congenital malformations were recently

noted in women with insulin-dependent diabetes treated
in pregnancy with lispro

Insulin preparations and dosage schedules should be

tailored to the abnormalities present in the glycaemic
profile (eg, postprandial and/or fasting hyperglycaemia)
and patient acceptability
No causative relationship between lispro and
teratogenicity has been documented

The doses may be higher than those required in non-

pregnant subjects and should be reviewed frequently so
that adequate glycaemic control is achieved rapidly

Care should be taken to minimise the risk of

hypoglycaemia, especially nocturnal episodes.

Oral hypoglycaemic agents have no place in treatment

of gdm under normal circumstances
 General Guidelines
a. Control of plasma glucose levels during labor and
delivery is easier when insulin is administered as
a continuous low-dose infusion for women with
type I or II diabetes
b. The patient is hospitalized 1 day before induction
of labor and given her usual diet and insulin dose
c. The next morning, breakfast and insulin are
withheld, baseline fasting blood glucose is
measured, and an IV infusion of 5% dextrose in
0.5% sodium chloride is started at 125 mL/h,
using an infusion pump
a. If the capillary glucose level is < 80 mg/dl (< 4.4
mmol/l), the initial insulin dose is 0
b. If the glucose level is 80 to 100 mg/dl (4.4 to 5.5
mmol/l), the dose is 0.5 u/h. Thereafter, the dose is
increased by 0.5 u/h for each 40-mg/dl increase in
glucose level up to 2.5 u/h for levels > 220 mg/dl (>
12.2 mmol/l)
c. Adjustments should be made for each patient as needed
d. During labor, plasma glucose levels are checked
hourly with a meter at bedside, and the insulin dose is
adjusted hourly, if needed, by doubling or halving the
insulin concentration so that normal glucose levels (70
to 120 mg/dl [3.8 to 6.6 mmol/l]) are maintained
a. If the glucose level is > 110 mg/dl (> 6.1 mmol/l), 10
U regular insulin is added to 1000 ml of the IV
infusion; The infusion rate is kept constant
b. For spontaneous labor, the same procedure is
followed
c. The insulin requirement is less if the patient has taken
intermediate-acting insulin in the previous 12 h
d. Patients with fever, infection, or other complications
require higher doses, as do obese patients with type II
diabetes who have required > 100 U of insulin/day
prepartum
 Monitoring
Self monitoring of blood glucose level is the optimal
method and is well tolerated by most women
On commencement of self monitoring, at least one
fasting and one 1 or 2 hour postprandial glucose level
should be obtained daily
The frequency may be decreased or increased
depending on the results of the blood glucose
monitoring and the progress of the pregnancy
If self monitoring is not possible, fasting and 1 or 2
hour postprandial laboratory capillary blood or
venous plasma glucose levels should be performed
regularly (at 1 to 2 weekly intervals)
 Postpartum Care
The immediate decrease in insulin requirement
after delivery is related to the abrupt loss of the
placenta, which has synthesized high levels of
peptide and steroid hormones throughout pregnancy
In the immediate postpartum period, women with
gestational diabetes and many of those with type II
diabetes require no insulin
For women with type I diabetes, insulin
requirements decrease dramatically but gradually
increase after about 72 h
During the first 6 wk postpartum, the insulin regimens of women with
type I or II diabetes must be carefully readjusted to obtain tight
control. These women should check blood glucose levels before meals
and at bedtime. Breastfeeding is not contraindicated but may be
associated with hypoglycemia in women with type I. For women with
type II, continuing insulin rather than taking oral hypoglycemic drugs
is recommended while breastfeeding.
Women who have had gestational diabetes should have a 2-h oral
glucose tolerance test with 75 g of glucose at 6 to 12 wk
postpartum to determine whether they are normal, clearly
diabetic, or have impaired glucose tolerance (based on WHO
criteria)
Newborns of diabetic mothers must be thoroughly assessed. They
are at risk of respiratory distress, hypoglycemia, hypocalcemia,
hyperbilirubinemia, polycythemia, and hyperviscosity
 Renal Disease
A patient with significant renal dysfunction (serum
creatinine > 3 mg/dL [> 270 µmol/L] or BUN > 30
mg/dL [> 10.5 mmol urea/L]) before pregnancy
cannot carry to term

The incidence of preeclampsia is high