Medical and Surgical Complications during Pregnancy

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Medical and Surgical Complications during
Pregnancy

• Heart Deseases in Pregnancy

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• Incidence
• Heart disease complicates about 1 percent of
  pregnancies.
• Component
• congenital heart disease
• rheumatic heart disease
• hypertensive heart disease
• other varieties (inclued pregnancy-induced
  hypertension,
• thyroid, coronary, syphilitic, and
  kyphoscoliotic cardiac
• disease)
• idiopathic cardiomyopathy (perinatal
  cardiomyopathy)
• isolated myocarditis
• various forms of heart block

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Maternal mortality

• 0.3 per 10,000 live births
• Heart disease still significantly
  contributes to
• maternal mortality.
• 5.6-8.5 percent of maternal deaths

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Effect of pregnancy on heart disease

• The pregnant period
• Cardiac output is increased by as much as
  30-50 percent
• almost half of the total increase has occurred
  by 8
• weeks, and it is maximized by mid pregnancy.
• Total blood volume is increased about 35.
• from 6th week to 32nd week
• Stroke volume is increased by 20-40.
• Resting pulse is increased (by 10-17)
• The changes of anatomic positions
• heart, diaphragm, uterus.
• formation of utero-placental circulation

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• Labor and delivery
• Consumption of energy and oxygen is further
  increased.
• Labor is increased maternal cardiac burdens.
• Expulsion of the fetus and placenta produce a
  drematic
• hemodynamic changes .

• The puerperium
• After delivery of the fetus and placenta,
  during 1-2 days,
• great amont of blood return into the systemic
  circulation,
• and great amont of fluid from intertissue
  space return to
• the systemic circulation, increase cardiac
  burdens again. 
• 32-34 gestational weeks, during the labor and
  delivery,
• and early postpartum period (1-3 days) are
  the most
• danger time for pregnant women with heart
  disease. It
• is easy development heart failure.

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Clinical Classification (By the New York Heart
Association)
Class I Uncompromised Patients with cardiac
disease and no limitation of physical activity.
They do not have symptoms of cardiac
insufficiency, nor do they experience anginal
pain. Class II Slightly compromised Patients
with cardiac disease and slight limitation of
physical activity. These women are comfortable at
rest, but if ordinary physical activity is
undertaken, discomfort results in the form of
excessive fatigue, palpitation, dyspnea, or
anginal pain.
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Clinical Classification (cont)
Class III Markedly compromised Patients with
cardiac disease and marked limitation of physical
activity. They are comfortable at rest, but less
than ordinary physical activity causes discomfort
by excessive fatigue, palpitation, dyspnea, or
anginal pain. Class IV Severely compromised
Patients with cardiac disease and inability to
perform any physical activity without discomfort.
Symptoms of cardiac insufficiency or angina may
development at rest, and if any physical activity
is undertaken, discomfort is increased.
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Diagnosis of heart disease
Many of the physiological changes of normal
pregnancy tend to make the diagnosis of heart
disease more difficult.
Disease history, Symptoms and Clinical Findings
Listed in here symptoms and clinical findings
may indicate heart disease
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Symptoms

• Severe or progressive dyspnea
• Progressive orthopnea
• Paroxysmal nocturnal dyspnea
• Hemoptysis
• Syncope with exertion
• Chast pain related to effort or emotion
• Clinical Findings
• Cyanosis
• Clubing of fingers

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Symptoms (cont)

• Persistent neck vein distension
• Systolic murmur greater than grade 3/6
• Diastolic murmur
• Cardiomegaly
• Sustained arrhythmia
• Persistent split second sound
• Criteria for pulmonary hypertension
• Left parasternal lift
• Loud P2

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• Conventional tests
• Electrocardiography
• Ecocardiography
• Chast X-ray
• Diagnosis of early heart failure during pregnancy
  
• Dyspnea, palpitation at slight physical
  activity.
• Resting pulse larger than 110 beats per minute.
• Paroxysmal nocturnal dyspnea.
• Rale in lower lungs

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Prognosis
The likelihood of a favorable outcome for the
mother with heart disease depends upon the (1)
functional cardiac capacity (2) other
complications that further increase cardiac load
(3) quality of medical care provided.
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Management

• General management

Counseling (Preconceptional counceling). (to
decide the pregnancy should be continued) Intensiv
e pregnatal care. Active prevent factors
increasing cardiac functional load. (such as
respiratory tract infection, anemia and
pregnancy-induced hypertension)
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• Management during labor and delivery

Monitoring the vital signs Sedatives and
analgesic Shortening the second stage of labor
(by forceps)(Classes I and II) Indications of CS
(cesarean section) (Class III or more, obstetric
indications,)
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• Management or early puerperium

Bring pressure to bear on the upper abdomen Bed
rest Monitoring the vital signs Breast feeding
(Classes I and II) and artificial feeding
(Classes III or IV)
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Medical and Surgical Complications during
Pregnancy

• Acute Viral Hepatitis

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• Hepatitis is the most common serious liver
  disease
• encountered in pregnant women.
• There are at least five distinct types of viral
  hepatitis
• hepatitis A hepatitis B hepatitis C(non-A
  and non-B
• hepatitis) hepatitis D and hepatitis E.
• In pregnancy complicate hepatitis ,
  hepatitis B is
• common.
• The incidence of acute viral hepatitis during
  pregnancy
• is about 6fold increased than non-pregnancy,
  and the
• fulminant hepatitis is 66 times increased than
  non-
• pregnancy.
• Hepatitis B is transmitted by infected blood,
  blood
• products, and in saliva, vaginal secretions,
  and semen. It
• is a sexually transmitted disease.

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• Delta hepatitis ( hepatitis D) is a defective
  RNA virus
• that is a hybrid particle with a hepatitis B
  surface
• antigen coat and a delta core. The virus must
  co-infect
• with hepatitis B and cannot persist in serum
  longer
• than hepatitis B virus. It transmission is
  similar to
• hepatitis B viral infection.
• Transmission of hepatitis C infection appears to
  be
• identical to hepatitis B.
• Hepatitis E is a waterborne RNA virus that is
  enterically
• transmitted.
• Hepatitis A is transmitted by the fecal-oral
  route.

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Effect of pregnancy on hepatitis

• The course of hepatitis B infection in the
  mother
• does not seem to be altered by
  pregnancy.However,
• at least in some underprivileged populations,
  both
• perinatal and maternal deaths are
  substantively
• increased for hepatitis A and B.

• Tend to become chronic hepatitis. (hepatitis B
  and C)

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Effect on pregnancy

• Mother
• Increasing nausea and vomiting early in
  pregnancy.
• Increasin the incidence of pregnancy-induced
• hypertension in late pregnancy.
• Increasing the incidence of postpartum
  hemorrhage.
• Fetus ans Infants
• Abortion
• Preterm delivery
• Fetal deaths
• Increasing the antenatal mortality rate
• Affected the fetus and infants (maternal-fetal
• transmission)

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Diagnosis

• History
• contect with hepatitis patients, used blood and
• blood products,..
• Clinical symptoms and findings
• Serological tests
• liver function, identifying of viris antigen and
  
• antibodies)

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Diagnosis of severe acute hepatitis

• Jaundice is deeper rapidly. Serous
  bilirubingt171umol/L
• (10mg/dL)
• The size of liver is diminished quickly .
• Ascites, anorexia, severe vomiting.
• Hepatic encephalopathy.
• Hepatic-renal syndrome ( acute renal failure)
• Severe liver function impairment.

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Defferential diagnosis

• Hyperemesis gravidarum
• Preeclampsia (HELLP)
• Intrahepatic cholestasis of pregnancy (ICP)
• Acute fatty liver of pregnancy
• Liver impairment from drugs overdose.

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Management

• Supportive medical measures as for the
  nonpregnant
• patient.
• rest, adequate nutrition, vitamins, sufficient
  protein,
• carbohydrate, low fatty diet.
• Obstetric management
• Early stage of pregnancy active treatment
  the disease,
• then artificial abortion should be performed.
• During midpregnancy and late pregnancy,
  vitamin K
• and C should be admited, and active prevent
  pregnancy-
• induced hypertension.

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• Obstetric management (cont)
• During labor and delivery vitamin K is
  admited,
• prepairing frash blood avoid operative
  obstetric
• intervention shortening the second stage of
  labor(by a
• vacuum) preventing the laceration of the
  birth canal
• preventin retained placental fragmants or
  membranes
• using of oxytocin.
• Postpartum period Antibiotic drugs,
  artificial feeding,
• lactifuge infant isolation
• Prevented by the administration of
  hepatitis B immune
• globulin after birth, followed promptly by
  hepatitis B
• vaccine in newborn infant.
• Treatment of severe hepatitis properly.

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• Intrahepatic cholestasis
• of pregnancy (ICP)
• ?????????

• Pruritus occurring in pregnancy ,in the absence
  of
• dermatologic abnormalities,is usually due to
  ICP
• Symptoms(pruritus)usually commence between 28
• and 34 weeks
• Incidence 1-2/1000 pregnancies.

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Diagnosis
ICP should be suspected when widespread
pruritus occurs in the third trimester.
without skin rash. High levels of bile
acids(5-100 times normal) Bilirubin appears in
the urine. (in most ),alkaline phosphatase and
bilirubin be elevated. transaminases is
elevated (in many) for differential diagnosis
,hepatitis serology ,hepatobiliary tract
ultrasonoguaphy and autoantibodies screan should
be performed in all cases.(ultrasonography is
very important to exclude abstruction of the
biliary tree.)
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Maternal/Fetal Risks

• For the mother,it carries a 10-22 risk of
• obstetric Hemorrhage,and preterm labor.
• For the fetal prognosis,stillbirth(up to 15),
• Preterm delivery (up to 30),
• fetal distress(up to 25),
• and meconium staining of the amniotic fluid
• (30-40),
• The mechanism of fetal compromise is uncertain.

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Management

• Prenatal monitoring of fetal well being
• timing of delivary
• maternal symptom control
• vitamin K supplementation.
• intramuscular Vit.K 10mg weekly should be given
  from 36 weeks.
• Intrapartum Vitamin K 10mg is given to mother
• The newborn body should receive Vitamin K
• (there is evidence of a
  bleeding tendency).
• Postnatal Biliary tract ultrasonography (for
  stones),
• (if pruritus does not disapear gt7-10
  days after delivery.)
• In occasional case where abnormalities do
  not resolve
• after delivery ,liver biopsy may
  need consideration.

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Medical and Surgical Complications during
Pregnancy

• Chronic Glomerulonephritis And
• Pyelonephritis

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Urinary Tract Changes during Pregnancy

• Urinary tract dilation(It involves dilatation
  of the renal
• calyces and pelves,as well as the
  ureters)These changes
• are more promiment on the right side.
• The size of kidney increases 1cm.
• The glomerular filtration rate increases about
  50.
• The renal plasma flow increases about 35.
• These changes create urinary stasis,and may lead
  to serious upper urinary infections.

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Assessment of Renal Disease During Preg1ancy

• Urinalysis is essential.
• Most degree that proteinuria must exceed
  500mg/day to be
• considered abnormal for pregnancy.
• If the serum creatinine persistently exceeds
  0.9mg/dl
• (75umol/L), then intrinsic renal disease
  should be suspected.
• Ultrasonogaphy provides imaging of renal size
  and relative
• consistency,as well as elements of obstruction.
• If necessary,cystoscop, intravenous pyelography,
  or renal
• biopsy may be considered.

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Acute Pyelonephritis

• Incidence
• About 1-2 of pregnancies.
• Acute Pyelonephritis is the most common serious
• medical complication of pregnancy.
• Pyelonephritis is more common after
  midpregnancy.It is
• unilateral and right-sided in more than half of
  cases,and
• bilateral in one fourth.
• In most women, renal parenchymal infection is
  caused by
• bacteria that ascend from the lower tract.

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• Effect on pregnancy
• The high fever can creates abortion, preterm
  labor.
• In the first trimester, malformations are
  increase.
• (such as spinal defects)
• Toxic shock.(by bacteria toxin)

• Clinical findings
• General symptoms
• The onset of pyelonephritis is usually rather
  abrupt.
• High fever (as well as 40degree C),
• Shaking chills.(thermoregulatory instability)
• Nausea and vomiting
• Headache

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• Clinical findings(cont)
• Urinary systemic symptoms
• Aching pain in one or both lumbar regions.
• Tenderness in one or both costovertebral angles
• (by percussion)
• Dysuria,urgency,and frequency.

• Asymptomatic bacteriuria
• The reported prevalence of asymptomatic bacteria
• during pregnancy varies from 2-7.

• About 15 of women with acute pyelonephritis
  also
• have bacteremia.

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• Clinical findings(cont)
• Transient renal dysfunction
• Elevated serum creatinine
• Decreased creatinine clearance

• Hematological dysfunction
• Hemolysis
• Anemia
• Thrombocytopenia

• Pulmonary dysfunction
• Adult respiratory distress syndrome

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• Diagnosis
• Clinical findings
• Urine specimen examination is anomaly.
• A clean-voided specimen containing more than
  100,000
• organisms of a single uropathogen per mL.
• Positive urine culture.

• Management
• Hospitalization
• Urine and blood cultures
• Complete blood count, serum crsatinine, and
  electrolytes
• Monitor vital signs frequently,including
  urinary output
• (place indwelling bladder catheter if
  necessary)

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• Management(cont)
• Intravenous crystalloid to establish urinary
  output to at
• least 30mL/hr
• Intravenous antimicrobial therapy
• Chest X-ray if there is dyspnea or tachypnea
• Repeat hematology and chemistry studies in 48
  hours
• Change to oral antimicrobils when afebrile
• Discharge after afebrile 24 hours,consider
  antimicrobial
• therapy for 7-10 days
• Urine culture 1-2weeks after antimicrobial
  therapy completed
• Treatment of complications

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Chronic GlomeruIonephritis

• This is characterized by progressive renal
  destruction over a period of yean or decades,
  eventually producing the end-stage kidney.
  Usually persistent proteinuria and hematuria
  accompany a gradual decline in renal function.
• Effect of glomerullonephritis on pregnancy
• Delivered preterm,(as high as 25)
• Fetuses intrauterine growth retadatio(IUGR,gt15)
• Perinatal mortality rate 8(after 28 gestational
  weeks)
• Factors that portended the worst perinatal
  prognosis included
• impaired renal function, early or severe
  hypertension,and
• nephrotic-range proteinuria.

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• kaplan's Typing
• Type I Have only proteinuria and edema without
• hypertension and renal function
  impairment.
• Type II Have proteinuria and hypertension and
  without
• renal function impairment.
• Type III All proteinuria,hypertension and renal
  function
• impairment exist.
• Lindheimer categories
• Mild impairment of renal functionserum
  creatinine
• lt1.5mg/dL and minimal hypertension
• Moderate impairment of renal function serum
  creatinine
• of 1.5-3.0mg/dL
• Severe renal insufficiencyserum creatinine gt3.
  0mg/dL

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• Common Complications
• (in moderate and severe renal insufficiency)
• chronic hypertemion(70)
• anemia (75)
• preeclampsia (60)
• preterm delivery (35)
• fetal growth restriction (30)
• fetal death

• Management
• Dietlower phosphorus,lower protein(high
  quality)
• Control hypertension
• Prevention of infection
• Intensive prenatal care
• Termination of pregnancy timely

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