Complications in Pregnancy

1
Complications in Pregnancy

• Objectives for learning
• Review some of the physiological changes in
  pregnancy
• Review case presentations for some medical and
  surgical conditions that occur during pregnancy

2
Physiological Adaptations to Pregnancy

• Numerous normal changes in response to pregnancy
• It is important to have an awareness of what is
  considered normal in pregnancy
• Such awareness allows an obstetrician to diagnose
  and manage common problems such as
• Hypertension
• Hyperthyroidism
• Anemia
• Asthma
• Diabetes
• Seizure disorders
• Urinary Tract Infections/ Acute Pyelonephritis

3
Weight Gain in Pregnancy

• Normal weight gain can be 30-35 lbs in average
  patient and 50-70 lbs. in twin pregnancy
• Daily requirements of 2000-2500 calories
• Associated with good outcome, ie delivery of
  normal sized baby
• Excess weight gain associated with variety of
  complications
• GDM, pre-eclampsia, macrosomia
• Total pregnancy expenditure is 75,000kcalories
• Recommendations for appropriate weight gain in
  pregnancy based on initial weight, BMI

4
Weight Gain in Pregnancy
5
Gastrointestinal Changes

• Key Changes
• Appetite Usually increased, with
  cravings
• Gastric Reflux Sphincter relaxation
• GI Motility Decreased
• GI Transit Time Slower
• Liver Functionally unchanged
• Gallbladder Dilated

6
Common GI Changes in Pregnancy

• Nausea and vomiting of pregnancy or morning
  sickness
• Exact etiology is unknown
• Supportive therapy usually helpful
• On rare occasion, TPN and hyperalimentation
  necessary
• Dietary cravings commonplace
• Pica
• Ptyalism
• Increased tendency for gallbladder dysfunction
  with possible need for surgery, or laporoscopic
  cholecystectomy

7
Hepatic Function Laboratory Studies
8
Hematological Changes in Pregnancy

• Plasma volume increases early in pregnancy with a
  50 increase (and higher in higher order multiple
  pregnancies) and a delayed increase in RBC mass
  and volume but less than the plasma volume
• Normal pregnancy associated with a demand of
  1000 milligrams of additional iron
• 500 mg. to increase maternal RBC volume
• 300 mg. tranpsorted to fetus
• 200 mg. for normal iron loss
• 60 mg. of elemental iron required daily, provided
  in 300 mg. of ferrous sulfate
• Serum iron decreased
• Transferrin and TIBC are increased

9
Iron Metabolism in Pregnancy
10
More Hematological Changes Occurring During
Pregnancy

• Pregnancy considered a hypercoagulable state
• Fibrinogen increases to 450-600 mg/dl
• Factors VII, VIII, IX and X increase
• Prothrombin, Factor V, and XII are unchanged
• Bleeding time does not change
• Platelet count may increase to 450,000 to 600,000
  
• WBC count may increase to as high as 20,000 due
  to an increase in granulocytes

11
Pulmonary Adaptations

• Anatomical
• Increased chest diameter, subcostal angle
  changes, increased diaphragmatic excursion with
  diaphragm elevated as well
• Physiological
• Hyperventilation, Increased IC,VC and Minute
  Volume, Residual volume decreased, Expiratory
  Reserve Volume decreased, Tidal volume increased
  by 40, pO2 increased, pCO2 decreased, arterial
  pH unchanged, and serum bicarbonate reduced

12
Pulmonary Changes in Pregnancy
13
Respiratory Changes in Pregnancy
14
Cardiac Changes in Pregnancy

• Cardiac output increases around 50 from an
  increase in HR and SV (3L/min to 6.2L/min)
• There is an additional 40 increase above that
  level during active labor
• Immediately following delivery, cardiac output
  may be increased by an additional 10-20
• Cardiac exam is different during pregnancy
• Many patients will have an S3 after midpregnancy
• Diastolic murmurs are usually considered serious
• Systolic murmurs (flow murmurs) common
• Displacment of heart is to right and upwards
• EKG shows left axis deviation and low voltage QRS
  complexes

15
Key Cardiovascular Changes During Pregnancy
16
Circulatory Changes in Pregnancy
17
Hemodynamic Changes During Labor
18
More Hemodynamic Changes
19
Renal Changes in Pregnancy

• Minimal renal enlargement, bilaterally
• Both renal pelvises and ureters are dilated
  (hydronephrosis of pregnancy)
• Greater urinary stasis, ureteral compression,
  leading to urinary stasis and possilbe urinary
  tract infections, pyelonephritis
• Loss of urinary control
• Bladder capacity diminished
• RPF increases to 75 of non-pregnant value

20
More Renal Changes in Pregnancy

• GFR increases 50 over non-pregnant state
• Creatinine clearance increases to 150-200 ml/min
• Plasma osmolality decreases
• Urine output is unchanged
• There is an increased sensitivity to renin and
  angiotensin
• Renal glycosuria common
• Proteinuria up to 300 mg/24 hours normal

21
Endocrine Changes with Pregnancy

• Carbohydrate Metabolism
• Overall effect is that pregnancy is diabetogenic
• First half tendency to hypoglycemia
• Second half tendency to hyperglycemia
• Progressive insulin resistance as pregnancy
  progresses
• Progesterone
• Estrogen
• HPL
• Typical FBS less than in non-pregnant state
• Blunting response to meals, eating as pregnancy
  progresses
• Hypertrophy of beta cells as well

22
Diurnal Glucose and Insulin Changes in Late
Pregnancy
23
Endocrine Changes in Pregnancy

• Thyroid Function in Pregnancy
• The normal pregnant woman remains euthyroid while
  pregnant despite/ with hormonal changes which
  occur
• Estrogen production increases
• Increased TBG
• Increased total thyroxine, and T3
• Free T4 and T3 remain unchanged
• BMR increases 15-20 above normal
• There is lowered T3 uptake during pregnancy
• TSH does not cross the placenta

24
Thyroid Changes in Pregnancy, Both Mother and
Infant
25
Gestational Diabetes

• A patient has a abnormal 1 hour glucola value of
  165mg at 28 weeks. Her 3 hour test is also
  abnormal and she is labeled as having gestational
  diabetes.
• Can you outline how she should be managed?
• What is she at risk for when in labor?
• What problems may happen in this infant?
• What implications does this diagnosis have?

26
Diabetes and Pregnancy

• A 22 year old female with type I Diabetes poorly
  controlled presents at 10 weeks for pregnancy
  care.
• Can you outline her pregnancy risks?
• What are the potential fetal complications?
• What labs or other evaluations would you order?

27
Hypertension and Pregnancy

• A 28 year old female with known chronic
  hypertension presents as a NOB and has a BP of
  160/100.
• What laboratory studies are indicated?
• Which antihypertensive agents can be used during
  pregnancy? Are any contraindicated?
• Potential pregnancy complications?
• Can you outline a management plan?

28
Viral Illnesses in Pregnancy

• A patient calls and tells you she has been
  exposed to chicken pox at 10 weeks gestation.
• How would you treat this patient?
• What is she were 34 weeks pregnant?
• What if the patient was rubella non-immune and
  she had exposure to that virus instead?
• How do you counsel patients about the flu
  vaccine?

29
GI Problems in Pregnancy

• A new OB patient at 8 weeks gestation has
  severe nausea and vomitting with weight loss of
  10 lbs.
• What is the likely diagnosis?
• Associations?
• Workup/treatment?
• A patient complains of severe RUQ pain after
  eating and is diagnosed with acute cholecystitis.
• How is this treated medically?
• Are there any issues related to surgery?

30
Anemias in Pregnancy

• A 27 year old female is found to be anemic on
  initial NOB testing with a hemoglobin of 9 grams.
• What is the most common anemia in pregnancy?
• How is the diagnosis made?
• Treatment?
• What are the recommendations for doing hemoglobin
  electrophoresis in pregnancy?
• Management plan?

31
Renal Problems in Pregnancy

• A patient is diagnosed with pyelonephritis in the
  first trimester.
• What are the signs and symptoms?
• Treatment?
• What if she has recurrent symptoms?
• How might she present in the third trimester?
• Differential diagnosis?
• Potential complications?

32
Thyroid Disease in Pregnancy

• A woman has a goiter, is hyperthyroid and is 12
  weeks pregnant.
• What are the signs and symptoms, physical
  findings, and lab results you would have for her?
• How would you treat her during pregnancy?
• Monitor her?
• Infant issues?
• If she were not pregnant, would your treatment be
  different?

33
Infectious Diseases and Pregnancy

• A NOB has a test positive for chlamydia.
• Treatment?
• Other studies?
• What are the recommendations for managing a HIV
  patient during pregnancy (labs) and at the time
  of delivery (method of delivery)?
• What do you do if she refuses HIV testing?
• Do you know how the infant is treated?

34
DVT/Pulmonary Emboli in Pregnancy

• A patient has a history of a DVT in a previous
  pregnancy, now she is 10 weeks pregnant.
• What are potential risk factors for this? Lab
  tests?
• How would you treat?
• If this patient had cardiorespiratory arrest in
  labor, what would also be your on differential
  diagnosis?
• What are the factors that contribute to DVTs and
  PEs occurring in pregnancy?
• When are the most likely to occur?

35
Seizure Disorders in Pregnancy

• A patient has a tonic-clonic seizure at 10 weeks
  
• What is the most likely diagnosis? Others?
• How do you treat a patient with seizures?
• Any medications contraindicated?
• If the patient is 37 weeks gestation and has a
  tonic-clonic seizure, what is the most likely
  diagnosis and management? What are other
  possibilities?

36
Surgical Problems in Pregnancy

• A normal OB at 8 weeks complains of RLQ pain?
• What is your differential diagnosis?
• If it is not an ectopic pregnancy or ovarian
  cyst, how would you treat this?
• If this is an ovarian mass, when/why would you
  recommend surgery?
• If this problem occurred at gt28 weeks, what might
  be on the differential diagnosis?

37
Drug Problems in Pregnancy

• A 26 year old pregnant patient presents to the
  ER, with cramping, bleeding and is combative.
• What is a likely diagnosis and how would you
  manage this patient?
• What other tests would you order/do?
• A NOB tells you that she has a history of alcohol
  abuse and is now pregnant.
• How can you screen for alcoholism in pregnancy?
• If she had binged at the start what would you
  say?
• What are the stigma of fetal alcohol syndrome?

38
Pulmonary Problems in Pregnancy

• A 30 year old woman is pregnant and is a severe
  asthmatic.
• What historical factors would you ask?
• What is the best way to evaluate her status?
• What are the recs for any of the agents for
  treatment in pregnancy?
• A RN now pregnant wants to be tested for TB.
• Your recommendations?
• A undelivered severe pre-eclamptic has pulmonary
  edema.
• What is your treatment?

39
Depression and Pregnancy

• A patient presents as a NOB and has a history of
  depression, currently on no therapy
• How can she be screened during pregnancy?
• What are your recommendations for treatment?
• Risk factors for depression in pregnancy?
• How do you counsel about the post partum blues
  vs. depression?
• How common is Post Partum Depression?

40
Cardiac Problems in Pregnancy

• A patient presents with several questions
  concerning such issues
• What murmurs are normal in pregnancy?
• Is it safe to become pregnant if there is a
  small VSD or ASD, repaired? A PDA closure?
• How about if there is MR? Mitral Stenosis?
• What if there is a corrected Tetrology of Fallot?
  
• If a patient had a peripartum cardiomyopathy, at
  what time should her cardiac function be
  evaluated to provide prognosis?