medical-surgical problems in pregnancy lectures 7, 8 petrenko n.v., md, phd

Medical-SurgicalMedical-SurgicalProblems in PregnancyProblems in Pregnancy

Lectures 7, 8Lectures 7, 8Petrenko N.V., MD, PhDPetrenko N.V., MD, PhD

about 1% of pregnancies complicated by heart diseasesleading cause of maternal mortalityMortality rate 50% in case pulmonary hypertension

CARDIOVASCULAR CARDIOVASCULAR DISORDERSDISORDERS

Physiologic adaptation to pregnancy Physiologic adaptation to pregnancy Increase blood volume on 40-50 %Increase blood volume on 40-50 % Increase cardiac output 30-50%Increase cardiac output 30-50% Decreased systemic vascular resistance Decreased systemic vascular resistance The heart elevated upward and rotated forward to the leftThe heart elevated upward and rotated forward to the left Pulse increase about 10-15 beat/min after 14-20 weeks, palpitationPulse increase about 10-15 beat/min after 14-20 weeks, palpitation Disturbed rhythm: sinus arrhythmia, premature atrial contractions, Disturbed rhythm: sinus arrhythmia, premature atrial contractions,

premature ventricalar systolepremature ventricalar systole BP: BP:

■ I trim as prepregnancy levelI trim as prepregnancy level■ II trim decrease 10-15 mm hHgII trim decrease 10-15 mm hHg■ After 20 weeks turn to prepregnancy levelAfter 20 weeks turn to prepregnancy level

Increase clot factors (VII, VIII, IX, X, fibrinogen)Increase clot factors (VII, VIII, IX, X, fibrinogen)

Cardiac output changes during labor and birthCardiac output changes during labor and birth Intravascular volume changes just after childbirthIntravascular volume changes just after childbirth

Cardiac hypertrophyCardiac hypertrophy

Physiologic adaptation to pregnancyPhysiologic adaptation to pregnancy

If cardiac changes are not well tolerated If cardiac changes are not well tolerated cardiac failure can develop during pregnancy, cardiac failure can develop during pregnancy, labour, postpartumlabour, postpartum

If myocardial disease develops, valvular If myocardial disease develops, valvular disease exists or congenital heart defect is disease exists or congenital heart defect is present, cardial decompensation is present, cardial decompensation is anticipated anticipated

Pregnancy result in case of Pregnancy result in case of Cardiovascular Disorders Cardiovascular Disorders

miscarriagesmiscarriages Preterm labor and birthPreterm labor and birth IUGRIUGR Congenital heart lesions (4-16%)Congenital heart lesions (4-16%) Maternal mortality Maternal mortality

Maternal cardiac disease risk groupMaternal cardiac disease risk group Group I (mortality rate 1%)Group I (mortality rate 1%)

■ Corrected tetralogy FallotCorrected tetralogy Fallot■ Pulmonic/tricuspid diseasePulmonic/tricuspid disease■ Mitral stenosis (classes I, II)Mitral stenosis (classes I, II)■ Patern ductus arteriosusPatern ductus arteriosus■ Ventricular septal defectVentricular septal defect■ Atrial septal defectAtrial septal defect

Group II (mortality rate 5-15%)Group II (mortality rate 5-15%)■ Mitral stenosis with atrial fibrillationMitral stenosis with atrial fibrillation■ Uncorrected tetralogy FallotUncorrected tetralogy Fallot■ Aortic coarctation (uncomplicated)Aortic coarctation (uncomplicated)■ Marfan syndrome with normal aortaMarfan syndrome with normal aorta

Group III (mortality rate 20-50%)Group III (mortality rate 20-50%)■ Aortic coarctation (complicated)Aortic coarctation (complicated)■ Myocardial infarctionMyocardial infarction■ Marfan syndrome with aortic involvementMarfan syndrome with aortic involvement■ Pulmonary hypertensionPulmonary hypertension

Functional classification of organic heart diseaseFunctional classification of organic heart disease

(New York Heart Association, NYHA)(New York Heart Association, NYHA) Class I:Class I: Asymptomatic at normal levels of Asymptomatic at normal levels of

activityactivity Class II:Class II: Symptomatic at increased activity Symptomatic at increased activity Class III:Class III: Symptomatic with ordinary activity Symptomatic with ordinary activity Class IV:Class IV: Symptomatic at rest Symptomatic at rest

DeterminationDetermination■ 3 month3 month■ 7 or 8 month7 or 8 month

Contraindications to pregnancyContraindications to pregnancy

Pulmonary hypertensionPulmonary hypertension Shunt lesions associated with Eisenmenger Shunt lesions associated with Eisenmenger

syndromesyndrome Complex cyanotic congenital heart diseaseComplex cyanotic congenital heart disease Aortic coarctation complicated by artic Aortic coarctation complicated by artic

dissectiondissection Poor ventricular functionPoor ventricular function Marfan syndrome with marked aortic Marfan syndrome with marked aortic

dilatationdilatation

Associated Cardiovascular Disorders Associated Cardiovascular Disorders

I Congenital cardiac diseaseI Congenital cardiac disease■ Septal defectsSeptal defects

Atrial septal defect (ASD)Atrial septal defect (ASD) Ventricular septal defect (VSD)Ventricular septal defect (VSD) Patent ductus arteriosus (PDA)Patent ductus arteriosus (PDA)

■ Acyanotic lesionsAcyanotic lesions Coarctation of aortaCoarctation of aorta

■ Cyanotic lesionsCyanotic lesions Tetralogy of FallotTetralogy of Fallot

Associated Cardiovascular Disorders cont Associated Cardiovascular Disorders cont

II Acquired cardiac diseaseII Acquired cardiac disease■ Mitral valve stenosisMitral valve stenosis■ Aortic stenosisAortic stenosis■ Ischemic heart diseaseIschemic heart disease

Myocardial infarction (MI) Myocardial infarction (MI)

■ Other cardiac diseasesOther cardiac diseases (PPCM) Pulmonary hypertension(PPCM) Pulmonary hypertension Marfan syndromeMarfan syndrome Infective endocarditisInfective endocarditis Eisenmenger syndromeEisenmenger syndrome Valve replacementValve replacement Peripartum cardiomyopathyPeripartum cardiomyopathy

Associated Cardiovascular DisordersAssociated Cardiovascular Disorders

Increased number of successfully completed Increased number of successfully completed pregnancies pregnancies

Postpone conception 1 year after Postpone conception 1 year after transplantationtransplantation

Vaginal birth is desired, yet there is an Vaginal birth is desired, yet there is an increased rate of cesarean birthincreased rate of cesarean birth

Breastfeeding not advised when taking Breastfeeding not advised when taking cyclosporinecyclosporine

Congenital Cardiac DiseaseCongenital Cardiac Disease Septal Defects Septal Defects

Arial septal defectArial septal defect

Left-to-right shuntLeft-to-right shunt Undetected because Undetected because

woman is asymptomaticwoman is asymptomatic Uncomplicated pregnancyUncomplicated pregnancy Right-side heart failure or Right-side heart failure or

arrhythmia as a result of arrhythmia as a result of increased blood volumeincreased blood volume

Ventricular septal defectVentricular septal defect Left-to-right shuntLeft-to-right shunt Diagnosed and corrected during Diagnosed and corrected during

infancy and childhood, not infancy and childhood, not common in pregnancycommon in pregnancy

Not complicated pregnancyNot complicated pregnancy Risk for: arrhythmias, heart failure, Risk for: arrhythmias, heart failure,

pulmonary hypertensionpulmonary hypertension

ManagementManagement■ Rest Rest ■ decrease of decrease of

physical physical activityactivity

■ anticoagulantsanticoagulants

Patent ductus arteriosusPatent ductus arteriosus Left-to-right shuntLeft-to-right shunt Diagnosed and corrected during Diagnosed and corrected during

infancyinfancy Possible complicationsPossible complications

■ arrhythmias, arrhythmias, ■ heart failure, heart failure, ■ pulmonary hypertensionpulmonary hypertension■ EndocarditisEndocarditis■ Pulmonary emboliPulmonary emboli

ManagementManagement■ Rest Rest ■ decrease of physical activitydecrease of physical activity■ anticoagulantsanticoagulants

Congenital Heart DiseaseCongenital Heart Disease

Acyanotic LesionsAcyanotic Lesions

Coarctation of the aortaCoarctation of the aorta Pregnancy safe for mother with Pregnancy safe for mother with

uncomplicated coarctationuncomplicated coarctation ComplicationsComplications

■ HypertensionHypertension■ Congestive heart failureCongestive heart failure■ Aortic ruptureAortic rupture

ManagementManagement■ RestRest■ Antihypertensive medications (beta-blockers)Antihypertensive medications (beta-blockers)■ Vaginal birth with epidural anesthesia and Vaginal birth with epidural anesthesia and

shortening of the II stage (vacuum- or shortening of the II stage (vacuum- or forceps assisted)forceps assisted)

■ Antibiotic prophylaxisAntibiotic prophylaxis

Congenital Heart DiseaseCongenital Heart Disease

Cyanotic LesionsCyanotic Lesions

Tetralogy of FallotTetralogy of Fallot 1. Ventricular septal defect1. Ventricular septal defect.. 2. 2. overriding aortaoverriding aorta 3. 3. right ventricular hypertrophyright ventricular hypertrophy 4. pulmonary 4. pulmonary stenosisstenosis Right-to-left shuntRight-to-left shunt Corrected at childhoodCorrected at childhood Management Management

■ AnticoagulantAnticoagulant■ OxygenOxygen■ hemodinamic monitoringhemodinamic monitoring

Acquired Heart DiseasesAcquired Heart Diseases

Mitral StenosisMitral Stenosis

The pressure gradient across the narrow valve The pressure gradient across the narrow valve increases secondary to the increases secondary to the increased heart rateincreased heart rate and and blood volumeblood volume

Left atrial pressure increases, back pressure into the Left atrial pressure increases, back pressure into the lungs causes lungs causes breathlessnessbreathlessness, , swelling in theswelling in the legslegs and may lead to and may lead to atrial arrhythmiasatrial arrhythmias. .

Stretching of the atrium can also occur causing Stretching of the atrium can also occur causing palpitations and arrhythmiapalpitations and arrhythmia..


Maternal mortality rate in classes III and IV Maternal mortality rate in classes III and IV ■ 5 %without arterial fibrillation5 %without arterial fibrillation■ 15% with arterial fibrillation15% with arterial fibrillation

There is marked increase in the following There is marked increase in the following issues regarding the fetus issues regarding the fetus ■ Rate of prematurityRate of prematurity■ Fetal growth retardationFetal growth retardation■ Low neonatal birth weightLow neonatal birth weight

Mitral StenosisMitral Stenosis Therapeutic approach is:Therapeutic approach is:

■ to reduce the heart rate to reduce the heart rate ■ and decrease left atrial pressureand decrease left atrial pressure

Restrict physical activityRestrict physical activity Restrict salt intake Restrict salt intake diureticsdiuretics Beta blockersBeta blockers Digoxin (if patient is in a. fib)Digoxin (if patient is in a. fib) Calcium channel blockersCalcium channel blockers

if medical therapy is ineffective surgery if medical therapy is ineffective surgery may be necessary after 20 weeksmay be necessary after 20 weeks

■ Balloon valvuloplastyBalloon valvuloplasty■ Surgery (repair/replacement)Surgery (repair/replacement)


Vaginal delivery can be permitted in most Vaginal delivery can be permitted in most patientspatients

Hemodynamic monitoring is recommended Hemodynamic monitoring is recommended (Swan) and should be continued several (Swan) and should be continued several hours following delivery hours following delivery

Aortic StenosisAortic Stenosis AS lead to obstruction to AS lead to obstruction to

left ventricular ejectionleft ventricular ejection Mild AS is usually tolerated Mild AS is usually tolerated Moderate to severe AS is Moderate to severe AS is

likely to be associated with likely to be associated with symptomatic deterioration symptomatic deterioration during pregnancyduring pregnancy

Women with valve area Women with valve area <1.0 should consider valve <1.0 should consider valve replacement prior to replacement prior to pregnancypregnancy

Aortic StenosisAortic Stenosis

Symptoms often develop in the 2nd and 3rd trimesterSymptoms often develop in the 2nd and 3rd trimester■ Exertional dyspneaExertional dyspnea■ Chest painChest pain■ SyncopeSyncope

Fetal effects includedFetal effects included■ Intrauterine growth retardationIntrauterine growth retardation■ Premature deliveryPremature delivery■ Reduced birth weightReduced birth weight■ Increase in cardiac defectsIncrease in cardiac defects

Ischemic Heart DiseaseIschemic Heart Disease MI is rare in childbearing womanMI is rare in childbearing woman Risk factors increaseRisk factors increase

■ AgeAge■ SmokingSmoking■ StressStress■ Cocaine useCocaine use■ HyperbilirubinemiaHyperbilirubinemia■ DMDM■ Family history of IHDFamily history of IHD■ HypertensionHypertension■ Oral contraceptivesOral contraceptives

Ischemic Heart DiseaseIschemic Heart Disease

MangementMangement■ OxygenOxygen■ AspirinAspirin■ Beta-blockersBeta-blockers■ NitratesNitrates■ HeparinHeparin■ Side-lying positionSide-lying position■ Vaginal birth is preferable with avoiding of maternal Vaginal birth is preferable with avoiding of maternal

pushing (vacuum- or forceps-assisted)pushing (vacuum- or forceps-assisted)■ Diuretic postpartumDiuretic postpartum

Other Heart DiseasesOther Heart Diseases

Primary Pulmonary HypertensionPrimary Pulmonary Hypertension Constriction of the arteriolar vessels in the Constriction of the arteriolar vessels in the

lung, leads to increase in the pulmonary lung, leads to increase in the pulmonary artery pressure right ventricular artery pressure right ventricular hypertension, hypertrophy, dilatation, right hypertension, hypertrophy, dilatation, right ventricular failure with tricuspid ventricular failure with tricuspid regurgitationregurgitation

Associated with high maternal mortality Associated with high maternal mortality estimated to be 50%, half of them occurs estimated to be 50%, half of them occurs a few hours to several days post partum a few hours to several days post partum usually related to sudden death or usually related to sudden death or progressive RV failure, although the exact progressive RV failure, although the exact cause of death is not clearcause of death is not clear

Deterioration usually occurs in the Deterioration usually occurs in the second/third trimestersecond/third trimester

Primary Pulmonary HypertensionPrimary Pulmonary Hypertension Symptoms may includeSymptoms may include

■ FatigueFatigue■ DyspneaDyspnea■ Chest painChest pain■ Edema and ascitesEdema and ascites■ SyncopeSyncope

Diagnostic testDiagnostic test■ Chest radiogramChest radiogram■ ECGECG■ EchoCGEchoCG■ Dopler studiesDopler studies

Primary Pulmonary HypertensionPrimary Pulmonary Hypertension

Fetal effects includeFetal effects include■ High incidence of prematurityHigh incidence of prematurity■ Fetal growth retardationFetal growth retardation■ Fetal lossFetal loss

Pregnancy should be discouraged in all Pregnancy should be discouraged in all patients with primary pulmonary HTNpatients with primary pulmonary HTN

Primary Pulmonary HypertensionPrimary Pulmonary Hypertension

For patients who chose to continue pregnancyFor patients who chose to continue pregnancy■ Nifedipin or prostacycline (for pulmonary Nifedipin or prostacycline (for pulmonary

vasodilatation)vasodilatation)■ AnticoagulantAnticoagulant■ Continuous hemodynamic monitoring during labor Continuous hemodynamic monitoring during labor

and delivery and delivery Antiembolic strockingAntiembolic strocking Side-lying positionSide-lying position Oxygen therapy Oxygen therapy Epidural analgesiaEpidural analgesia

Marfan SyndromeMarfan Syndrome Autosomal dominant genetic disorder Autosomal dominant genetic disorder

characterizedcharacterized■ weakness of the connective tissue, weakness of the connective tissue, ■ resulting in joint deformities, resulting in joint deformities, ■ ocular lens dislocation, ocular lens dislocation, ■ weakness of aortic wall and rootweakness of aortic wall and root

Mitral valve prolapse (90%)Mitral valve prolapse (90%) Aortic insufficiency (25%) risk of Aortic insufficiency (25%) risk of

aortic dissection and rupturingaortic dissection and rupturing

Pregnancy in patients with Marfan poses 2 Pregnancy in patients with Marfan poses 2 problemsproblems

■ Cardiovascular complications of the motherCardiovascular complications of the mother■ Risk of having a child who inherits Marfan’s Risk of having a child who inherits Marfan’s

syndromesyndrome

Cardiovascular problemsCardiovascular problems■ Dilation of the ascending aorta, may lead to Dilation of the ascending aorta, may lead to

development of aortic regurgitation and heart development of aortic regurgitation and heart failurefailure

■ Proximal and distal dissections of the aorta with Proximal and distal dissections of the aorta with possible involvement of the coronariespossible involvement of the coronaries

Marfan’s SyndromeMarfan’s Syndrome Obstetrical complications Obstetrical complications

■ Cervical incompetenceCervical incompetence■ Abnormal placental location (previa)Abnormal placental location (previa)■ Postpartum hemorrhagePostpartum hemorrhage

Preconception counselingPreconception counseling■ Patients with more than mild dilation of the aorta, or history of Patients with more than mild dilation of the aorta, or history of

aortic dissection should be advised against pregnancyaortic dissection should be advised against pregnancy■ Progressive dilation of the aorta during gestation may occur Progressive dilation of the aorta during gestation may occur

even with a normal-sized aortaeven with a normal-sized aorta Preconception echo evaluation allows for evaluation of the Preconception echo evaluation allows for evaluation of the

aortic root, CT, MRI.aortic root, CT, MRI. Periodic echocardiographic follow-up is recommendedPeriodic echocardiographic follow-up is recommended

Marfan’s SyndromeMarfan’s Syndrome

ManagementManagement■ Vigorous physical activity should be avoidedVigorous physical activity should be avoided■ Beta blockers (reduces the rate of aortic dilation)Beta blockers (reduces the rate of aortic dilation)■ If substantial dilation/dissection should occur, If substantial dilation/dissection should occur,

depending on the stage of pregnancydepending on the stage of pregnancy therapeutic abortion, therapeutic abortion, early delivery or early delivery or surgical intervention should be consideredsurgical intervention should be considered

Infective endocarditisInfective endocarditis

Inflammation of endocardiumInflammation of endocardium Cause: microorganismsCause: microorganisms Clinical manifestation: Clinical manifestation:

■ incompetence of heart valvesincompetence of heart valves■ Congestive heart failureCongestive heart failure■ Cerebral emboliCerebral emboli

TreatmentTreatment■ AntibioticsAntibiotics

Eisenmenger SyndromeEisenmenger Syndrome

Right-to-left or bidirectional shunting at Right-to-left or bidirectional shunting at atrial or ventricular level and combined atrial or ventricular level and combined with elevated pulmonary vascular with elevated pulmonary vascular resistanceresistance

High risk of maternal (30-50%) and fetal High risk of maternal (30-50%) and fetal (50%) morbidity and mortality(50%) morbidity and mortality

Pregnancy is contraindicated Pregnancy is contraindicated (contraception or termination of (contraception or termination of pregnancy)pregnancy)

Death usually (75%) occurs between the Death usually (75%) occurs between the first few days and weeks after delivery, first few days and weeks after delivery, but the cause is unclearbut the cause is unclear

Eisenmenger SyndromeEisenmenger Syndrome

Patients should be monitored closely for any signs of Patients should be monitored closely for any signs of deteriorationdeterioration

Early elective hospitalization is recommendedEarly elective hospitalization is recommended Activity is strictly limitedActivity is strictly limited Hemodynamic monitoring is requiredHemodynamic monitoring is required Anticoagulant???Anticoagulant??? Prophylaxis of hypovolemiaProphylaxis of hypovolemia OxygenOxygen Epidural analgesiaEpidural analgesia

Hypertrophic CardiomyopathyHypertrophic Cardiomyopathy Most cases have favorable outcomesMost cases have favorable outcomes Symptoms may worsen, especially in patients who Symptoms may worsen, especially in patients who

were already symptomaticwere already symptomatic■ Increased SOBIncreased SOB■ FatigueFatigue■ Chest painChest pain■ SyncopeSyncope

The risk of the fetus of inheriting the disease is as The risk of the fetus of inheriting the disease is as high as 50%high as 50%

Valve replacementValve replacement Risk of thromboembolismRisk of thromboembolism Anticoagulant???Anticoagulant???

■ + hypercoagulability+ hypercoagulability■ - maternal, fetal hemorrhage- maternal, fetal hemorrhage■ - risk of fetal abnomalities- risk of fetal abnomalities

Porcine heterograft valvesPorcine heterograft valves■ + do not require of anticoagulants+ do not require of anticoagulants■ - premature valve failure- premature valve failure

Heparin (beside coumadin)Heparin (beside coumadin)■ Before conception or as soon as possibleBefore conception or as soon as possible■ 2-3 times a day, activated partial thromboplastin 2-3 times a day, activated partial thromboplastin

time 1.5-2.0time 1.5-2.0■ Dicontinued at the time of active labourDicontinued at the time of active labour■ Reactivate within 6 h of VB or 12-24 h after CSReactivate within 6 h of VB or 12-24 h after CS

Low-molecular weight heparin Low-molecular weight heparin

Peripartum CardiomyopathyPeripartum Cardiomyopathy A form of dilated CMP with LV systolic dysfunction that results A form of dilated CMP with LV systolic dysfunction that results

in the signs and symptoms of heart failurein the signs and symptoms of heart failure CriteriaCriteria

■ Development in last month of pregnancy or the first 5 months after Development in last month of pregnancy or the first 5 months after deliverydelivery

■ Absence of heart disease prior to last month of pregnancyAbsence of heart disease prior to last month of pregnancy■ Absence of identifiable cause of heart failureAbsence of identifiable cause of heart failure■ LV systolic dysfunctionLV systolic dysfunction

Etiology is unknownEtiology is unknown TheoriesTheories

■ Genetic predispositionGenetic predisposition■ AutoimmunityAutoimmunity■ Viral infectionViral infection

Peripartum CardiomyopathyPeripartum Cardiomyopathy

Associated risk factors:Associated risk factors:■ Age - over 35Age - over 35■ twin pregnancytwin pregnancy■ gestational hypertensiongestational hypertension■ MultiparityMultiparity■ African-american raceAfrican-american race■ use of tocolytic therapyuse of tocolytic therapy

Motality rate 25-50%Motality rate 25-50%


Clinical findingsClinical findings■ Left ventricular failureLeft ventricular failure

DyspneaDyspnea FatigueFatigue EdemaEdema Enlarged heartEnlarged heart S3, murmurs of MR and TRS3, murmurs of MR and TR TachycardiaTachycardia ST-T wave abnormalitiesST-T wave abnormalities arrhythmiasarrhythmias


clinical course varies clinical course varies ■ 50-60% of patients demonstrate complete recovery 50-60% of patients demonstrate complete recovery

within the first 6 monthswithin the first 6 months■ The rest of the patients demonstrate either further clinical The rest of the patients demonstrate either further clinical

deterioration, leading to cardiac transplant or premature deterioration, leading to cardiac transplant or premature death, or persistent LV dysfunction and chronic heart death, or persistent LV dysfunction and chronic heart failurefailure

■ No agreement on recommendation for future No agreement on recommendation for future pregnanciespregnancies

■ Pregnancy contraindicated Pregnancy contraindicated Persistent cardiomegalyPersistent cardiomegaly Cardiac dysfunctionCardiac dysfunction


ManagementManagement■ Acute heart failure treatment with O2, Acute heart failure treatment with O2,

diuretics, digoxin and vasodilators diuretics, digoxin and vasodilators (hydralazine is safe)(hydralazine is safe)

■ Because of the increased incidence of Because of the increased incidence of thromboembolic events, anticoagulation thromboembolic events, anticoagulation therapy is recommendedtherapy is recommended

Care managementCare management

Preconceptual councellingPreconceptual councelling■ Peripartum riskPeripartum risk

PregnancyPregnancy■ Decisions after evaluation riskDecisions after evaluation risk

If possible – multidisciplinary approch If possible – multidisciplinary approch (cardiologist, perinsatologist, (cardiologist, perinsatologist, anesthesiologist, ginecologist)anesthesiologist, ginecologist)

AssessmentAssessment

InterviewInterview■ Personal medical historyPersonal medical history■ Heart disease (congenital, streptococcal infections, rheumatic Heart disease (congenital, streptococcal infections, rheumatic

fever, valvular disease, endocarditis, angina, MI)fever, valvular disease, endocarditis, angina, MI)■ Factors increase stress of the heart (anemia, infection, edema)Factors increase stress of the heart (anemia, infection, edema)■ Review cardiovascular and pulmonary systemReview cardiovascular and pulmonary system

Chest pain, edema on face, hand, feet, hypertension, heart Chest pain, edema on face, hand, feet, hypertension, heart murmur, palpitation,dyspnea, diaphoesis, pallor, syncopemurmur, palpitation,dyspnea, diaphoesis, pallor, syncope

Cough, hemoptysis, shortness of breath, Cough, hemoptysis, shortness of breath, ■ MedicationMedication■ Emotional status (depression, anxiety, fear of morbidity and Emotional status (depression, anxiety, fear of morbidity and

mortality for herself and featus) mortality for herself and featus)

Assessment Assessment ExaminationExamination

■ Vital signVital sign■ Oxygen saturation levelOxygen saturation level■ Pattern of edemaPattern of edema■ Discomphort of pregnancyDiscomphort of pregnancy■ Weight gainWeight gain■ Sign of potential cardiac decompensationSign of potential cardiac decompensation

Sign of potential cardiac Sign of potential cardiac decompensationdecompensation

Subjective symptomsSubjective symptoms■ Increasing fatigue or difficulty of breathing or both with usual activitiesIncreasing fatigue or difficulty of breathing or both with usual activities■ Feeling of smotheringFeeling of smothering■ Frequent coughFrequent cough■ Palpitations; feeling that her heart is racingPalpitations; feeling that her heart is racing■ Swelling of face, feet, legs, fingersSwelling of face, feet, legs, fingers

Objective signsObjective signs■ Irregular weak, rapid pulse (more 100b/m)Irregular weak, rapid pulse (more 100b/m)■ Progressive generalised edemaProgressive generalised edema■ Cracles at the base of lungsafter 2 inspirations and exhalationsCracles at the base of lungsafter 2 inspirations and exhalations■ Orthopnea; increasing dyspneaOrthopnea; increasing dyspnea■ Rapid respirations (more 25 b/m)Rapid respirations (more 25 b/m)■ Moist, frequent coughMoist, frequent cough■ Increasing fatiqueIncreasing fatique■ Cyanosis of lips and nail bedsCyanosis of lips and nail beds

AssessmentAssessment

LabLab■ UrinalisisUrinalisis■ CBCCBC■ Blood chemistryBlood chemistry■ ECGECG■ EchoCGEchoCG■ Pulse oximetryPulse oximetry■ Chest filmChest film■ Fetal ultrasoundFetal ultrasound■ DFMCDFMC■ NST NST

Antepartum careAntepartum care Critical period 28-32 weeks – hemodinamic changes Critical period 28-32 weeks – hemodinamic changes

reach their maximumreach their maximum Reduce emotional stress, hypertension, anemia, Reduce emotional stress, hypertension, anemia,

hyperthyroidism, obesityhyperthyroidism, obesity Class I and II Class I and II

■ 8-10 h of sleeping + 30 min naps after eating8-10 h of sleeping + 30 min naps after eating■ Activities: housework, shopping, exercise limitedActivities: housework, shopping, exercise limited

Class IIClass II■ Avoid any activities that causes even minor signs of Avoid any activities that causes even minor signs of

cardiac decompensationcardiac decompensation■ Admit to the hospital near termAdmit to the hospital near term

Class III, IVClass III, IV■ Bed rest at the hospital Bed rest at the hospital

Antepartum careAntepartum care Treatment of infections of GI, UT, RespiratoryTreatment of infections of GI, UT, Respiratory Adequate nutrition (folic acid, protein, fluid, fiber)Adequate nutrition (folic acid, protein, fluid, fiber) Medication:Medication:

■ anticoagulant – anticoagulant – heparin (large molecule does not cross the placenta)heparin (large molecule does not cross the placenta)

● Recurrent vein thrombosisRecurrent vein thrombosis● Pulmonary embolusPulmonary embolus● rheumatic heart diseaserheumatic heart disease● Prostetic valvesProstetic valves● Cyanotic congenital heart defectsCyanotic congenital heart defects

Monitiring clotting factors (blood test)Monitiring clotting factors (blood test) Avoid food high in vit K (raw, dark green and leafy Avoid food high in vit K (raw, dark green and leafy

vegetablesvegetables Folic acidFolic acid

Antepartum careAntepartum care Digoxin: crosses placentaDigoxin: crosses placenta Procainamide: crosses placenta, no known teratogenic effectsProcainamide: crosses placenta, no known teratogenic effects Verapamil: crosses placenta, can produce maternal hypotensionVerapamil: crosses placenta, can produce maternal hypotension Propranolol: crosses placenta, no known teratogenic effects, Propranolol: crosses placenta, no known teratogenic effects,

associated with fetak bradicardia, IUGR, preterm labour, neonatal associated with fetak bradicardia, IUGR, preterm labour, neonatal respiratory depressionrespiratory depression

Warfarin: crosses placenta, fetal anomalies, and hemorrhage, Warfarin: crosses placenta, fetal anomalies, and hemorrhage, congenital malformation, preterm birth, stillbirthcongenital malformation, preterm birth, stillbirth

Furosemide: crosses placenta, no known teratogenic effects, thiazides: Furosemide: crosses placenta, no known teratogenic effects, thiazides: crosses placenta, neonatal jaudice, thrombocitopenia, anemiacrosses placenta, neonatal jaudice, thrombocitopenia, anemia

Lidocaine: crosses placenta, safe as long as toxic leves avoidedLidocaine: crosses placenta, safe as long as toxic leves avoided Quinidine: crosses placenta, no known teratogenic effects, neonatal Quinidine: crosses placenta, no known teratogenic effects, neonatal

thrombocytopeniathrombocytopenia Nifedipine: crosses placenta, maternal hypotensionNifedipine: crosses placenta, maternal hypotension Diazoxide: crosses placenta, hyperglycemia, potential relaxant of Diazoxide: crosses placenta, hyperglycemia, potential relaxant of

uterine smooth muscleuterine smooth muscle Sodium nitroprusside: crosses placenta, only in critical care unitSodium nitroprusside: crosses placenta, only in critical care unit

Antepartum careAntepartum care

Heart surgeryHeart surgery■ Ideal scenario – before pregnancyIdeal scenario – before pregnancy■ If need present – early at the second trimIf need present – early at the second trim

Closed cardiac surgery – low riskClosed cardiac surgery – low risk Open heart surgery – high risk r/t with Open heart surgery – high risk r/t with

artificial circulation an temporary hypoxiaartificial circulation an temporary hypoxia

Intrapartum Care Intrapartum Care Routine assessment of laboring womanRoutine assessment of laboring woman Assessment of cardiac decompensationAssessment of cardiac decompensation Arterial blood gasesArterial blood gases ECGECG BP, Ps, OxymetryBP, Ps, Oxymetry Position: elevated upper part of body or side-lyingPosition: elevated upper part of body or side-lying Management of discomfort: supportive care, epidural analgesiaManagement of discomfort: supportive care, epidural analgesia Preterm laboue: betaadrenergic agonist (ritodrine, terbutaline)Preterm laboue: betaadrenergic agonist (ritodrine, terbutaline) Labour induction (syntocinon)Labour induction (syntocinon) Cervical rippening (prostaglandins)Cervical rippening (prostaglandins) Vaginal birth Vaginal birth

■ in side-lying positionin side-lying position■ Oxygen maskOxygen mask■ EpisiotomyEpisiotomy■ vacuum extractionvacuum extraction■ ForcepsForceps

CS: risk r/t with dramatic fluid shifts, sustained hemodinamic changes and increased CS: risk r/t with dramatic fluid shifts, sustained hemodinamic changes and increased blood loss blood loss

Dilute oxytocin is indicated, ergot products are contraindicated Dilute oxytocin is indicated, ergot products are contraindicated

Postpartum CarePostpartum Care First 24-48 h are the most hemodinamically difficultFirst 24-48 h are the most hemodinamically difficult AssessmentAssessment

■ Vital signVital sign■ Oxygen saturation levelsOxygen saturation levels■ Lung and heart auscultationLung and heart auscultation■ EdemaEdema■ Character of bleeding, uterine toneCharacter of bleeding, uterine tone■ Fundal heightFundal height■ Urinary outputUrinary output■ PainPain

Activity rest patternActivity rest pattern Elevated the head of the bedElevated the head of the bed Family member helpFamily member help Brestfeeding is not contraindicatedBrestfeeding is not contraindicated

AnemiaAnemia

AnemiaAnemia

Most common medical disorder of pregnancy Most common medical disorder of pregnancy Iron deficiency anemia (90%)Iron deficiency anemia (90%) Folic acid deficiency anemiaFolic acid deficiency anemia Sickle cell hemoglobinopathySickle cell hemoglobinopathy ThalassemiaThalassemia

AnemiaAnemia Anemia is the reduced ability of the blood to carry Anemia is the reduced ability of the blood to carry

oxygen to the cells and the heart tries to compensate oxygen to the cells and the heart tries to compensate by increasing cardiac output increase workload by increasing cardiac output increase workload of the heart and stresses ventricular functionof the heart and stresses ventricular function

Therefore anemia with complication (preeclampsia) Therefore anemia with complication (preeclampsia) may result un congestive heart failuremay result un congestive heart failure

Increased risk of infectionIncreased risk of infection

Definition of Anemia Definition of Anemia

Hemoglobin below 11gm/dl in 1Hemoglobin below 11gm/dl in 1stst and 3 and 3rdrd trimester and below 10.5gm/dl in second trimester and below 10.5gm/dl in second trimester.trimester.

WHOWHO 11gm/dl or less11gm/dl or less By this standard, 50% of women not on By this standard, 50% of women not on

hematinics become anemic.hematinics become anemic.

Ht nonpregnant 38-45%Ht nonpregnant 38-45% pregnant 34% (result of hydratation)pregnant 34% (result of hydratation)

Criteria for Physiologic AnemiaCriteria for Physiologic Anemia

Hb: 10gm%Hb: 10gm% RBC: 3.2 million/mm3RBC: 3.2 million/mm3 Peripheral smear showing normal Peripheral smear showing normal

morphology of RBC with central pallormorphology of RBC with central pallor

Iron Deficiency AnaemiaIron Deficiency Anaemia

Symptoms: lassitude, weakness, anorexia, Symptoms: lassitude, weakness, anorexia, palpitation, dyspneapalpitation, dyspnea

Signs: Pallor, glossitis, soft systolic murmur in Signs: Pallor, glossitis, soft systolic murmur in mitral area due to physiologic mitral mitral area due to physiologic mitral incompetenceincompetence

Degree: Mild: 8-10gm%Degree: Mild: 8-10gm% Moderate: 7-8gm% Moderate: 7-8gm%

Severe: <7gm% Severe: <7gm%

Iron Deficiency AnemiaIron Deficiency Anemia

PreventionPrevention

■ Iron supplementsIron supplements■ Vitamin C may enhance absorptionVitamin C may enhance absorption■ Do not take iron with milk or antacidsDo not take iron with milk or antacids

Calcium impairs absorptionCalcium impairs absorption

Iron Deficiency AnemiaIron Deficiency Anemia (continued) (continued)

TreatmentTreatment Oral doses of elemental iron (60-80 mg/day)Oral doses of elemental iron (60-80 mg/day) Continue therapy for about 3 months after anemia Continue therapy for about 3 months after anemia

has been correctedhas been corrected GI side effectGI side effect

■ ConstipationConstipation■ nauseanausea■ vomitingvomiting

Folic Acid Deficiency AnemiaFolic Acid Deficiency Anemia Large, immature RBCs (megaloblastic anemia)Large, immature RBCs (megaloblastic anemia) Anticonvulsants, oral contraceptives, sulfa drugs, and Anticonvulsants, oral contraceptives, sulfa drugs, and

alcohol can decrease absorption of folate from mealsalcohol can decrease absorption of folate from meals Nutritional riskNutritional risk

■ Poor dietPoor diet■ Cooking with large amount of waterCooking with large amount of water■ malabsorbtionmalabsorbtion

Folate is essential for normal growth and development.Folate is essential for normal growth and development. Deficit leads to neural tube defects, cleft lip, cleft Deficit leads to neural tube defects, cleft lip, cleft

palate.palate.

PreventionPrevention■ Before pregnancy - Daily supplement of 400 Before pregnancy - Daily supplement of 400

mcmcg (0.4 mg)g (0.4 mg)■ During pregnancy - Daily supplement of 600 During pregnancy - Daily supplement of 600

mcmcg (0.6 mg)g (0.6 mg)■ Risk group (NTD) - Daily supplement of 800 Risk group (NTD) - Daily supplement of 800

mcmcg (0.8 mg)g (0.8 mg)

Sickle Cell DiseaseSickle Cell Disease Autosomal recessive disorderAutosomal recessive disorder Abnormal hemoglobin Abnormal hemoglobin Causes erythrocytes to become distorted Causes erythrocytes to become distorted

and sickle (crescent) shaped during and sickle (crescent) shaped during hypoxic or acidotic episodeshypoxic or acidotic episodes

Abnormally shaped blood cells do not flow Abnormally shaped blood cells do not flow smoothlysmoothly

Can clog small blood vesselsCan clog small blood vessels Recurrent crises: fever, pain in abdomen Recurrent crises: fever, pain in abdomen

or extremities as rsult of vascular or extremities as rsult of vascular obstruction, tissue hypoxia,edema, RBS obstruction, tissue hypoxia,edema, RBS destruction, associated with anemia, destruction, associated with anemia, jaundice, reticulocytosisjaundice, reticulocytosis

Sickle Cell Disease (continued)Sickle Cell Disease (continued) Pregnancy can cause a crisisPregnancy can cause a crisis Massive erythrocyte destruction and vessel occlusionMassive erythrocyte destruction and vessel occlusion

■ Risk to fetus if occlusion occurs in vessels that supply the placentaRisk to fetus if occlusion occurs in vessels that supply the placenta Can lead to Can lead to

■ FetusFetus preterm birthpreterm birth IUGRIUGR skeletal changesskeletal changes small for gestational agesmall for gestational age fetal demisefetal demise

■ MotherMother UTIUTI Leg ulcersLeg ulcers Bone abnormalitiesBone abnormalities StrokeStroke CardiopathyCardiopathy Congestive heart failureCongestive heart failure Preeclampsia Preeclampsia postpartum hemorrhage postpartum hemorrhage

Oxygen and fluids are given continuously throughout laborOxygen and fluids are given continuously throughout labor Perinatal mortality is high.Perinatal mortality is high.

ThalassemiaThalassemia is an inherited is an inherited autosomalautosomal recessiverecessive bloodblood diseasedisease. In . In

thalassemia the genetic defect, which could be either thalassemia the genetic defect, which could be either mutation or deletion, results in reduced rate of mutation or deletion, results in reduced rate of synthesis or no synthesis of one of the globin chains synthesis or no synthesis of one of the globin chains that make up that make up hemoglobinhemoglobin. This can cause the . This can cause the formation of abnormal hemoglobin molecules, thus formation of abnormal hemoglobin molecules, thus causing causing anemiaanemia, the characteristic presenting , the characteristic presenting symptom of the thalassemias.symptom of the thalassemias.

Manifestation: severe bone deformation caused by Manifestation: severe bone deformation caused by massive marrow tissue explanationmassive marrow tissue explanation

ββ chain seen most often in United States chain seen most often in United States■ Can inherit abnormal gene from each parent, causing Can inherit abnormal gene from each parent, causing ββ--

thalassemia major (homozygous)thalassemia major (homozygous)■ If only one abnormal gene is inherited, then infant will If only one abnormal gene is inherited, then infant will

have have ββ-thalassemia minor (heterozygous)-thalassemia minor (heterozygous)

http://en.wikipedia.org/wiki/Autosomal_recessive



http://en.wikipedia.org/wiki/Blood_disease



http://en.wikipedia.org/wiki/Hemoglobin

http://en.wikipedia.org/wiki/Anemia

ThalassemiaThalassemia

Infertility problemInfertility problem Complications of pregnancyComplications of pregnancy

■ StillbirthStillbirth■ IUGRIUGR■ PreeclampsiaPreeclampsia■ Preterm labourPreterm labour

TreatmentTreatment■ Hemotransfusion Hemotransfusion

ThalassemiaThalassemia

Woman with Woman with ββ-thalassemia minor has few problems, -thalassemia minor has few problems, other than mild anemiaother than mild anemia

Iron supplements may cause iron overloadIron supplements may cause iron overload

■ Body absorbs and stores iron in amounts that Body absorbs and stores iron in amounts that are higher than usualare higher than usual

Nursing CareNursing Care Teach woman which foods are high in iron and folic acidTeach woman which foods are high in iron and folic acid Teach woman how to take supplementsTeach woman how to take supplements

■ Do not take iron supplements at the same time when Do not take iron supplements at the same time when drinking milkdrinking milk

■ Do not take antacids with ironDo not take antacids with iron■ When taking iron, stools will be dark green to blackWhen taking iron, stools will be dark green to black

Nursing CareNursing Care

The woman with sickle cell disease requires close The woman with sickle cell disease requires close medical and nursing caremedical and nursing care■ Teach her to prevent dehydration and Teach her to prevent dehydration and

activities that cause hypoxiaactivities that cause hypoxia■ Teach her to avoid situations where exposure Teach her to avoid situations where exposure

to infections are more likelyto infections are more likely■ Teach her to promptly report any signs of Teach her to promptly report any signs of

infectionsinfections

Pulmonary DisordersPulmonary Disorders

Pulmonary disordersPulmonary disorders

AsthmaAsthma Cystic fibrosisCystic fibrosis Adult respiratory distress syndrome (ARDS)Adult respiratory distress syndrome (ARDS)

AsthmaAsthma Acute respiratory illness caused by alergens, marked Acute respiratory illness caused by alergens, marked

changes in ambient temperature or emotional tensionchanges in ambient temperature or emotional tension In response to stimuli reversible narrowing of the In response to stimuli reversible narrowing of the

hyperactive airways makes difficult to breathhyperactive airways makes difficult to breath ManifestationManifestation

■ Expiratory wheezingExpiratory wheezing■ Productive coughProductive cough■ Thick sputumThick sputum■ DyspneaDyspnea

Effect of pregnancyEffect of pregnancy■ Improve (50%)Improve (50%)■ Stay same (25%)Stay same (25%)■ Worsen (25%)Worsen (25%)

Peak of symptoms: 29-36 weeks Peak of symptoms: 29-36 weeks

AsthmaAsthma TreatmentTreatment

■ Relief of acute attackRelief of acute attack■ Prevention or limitation of later attacksPrevention or limitation of later attacks■ Adequate maternal and fetal oxygenationAdequate maternal and fetal oxygenation

These goals can be achieved in pregnancy byThese goals can be achieved in pregnancy by● eliminating environmental triggers (e.g., dust mites, animal eliminating environmental triggers (e.g., dust mites, animal

dander, pollen), dander, pollen), ● drug therapy (e.g., bronchodilators, antiinflammatory drug therapy (e.g., bronchodilators, antiinflammatory

agents),agents),● patient educationpatient education

■ Respiratory infections should be treated and mist or steam Respiratory infections should be treated and mist or steam inhalation employed to aid expectoration of mucus. inhalation employed to aid expectoration of mucus.

■ Acute episodes may require albuterol, steroids, Acute episodes may require albuterol, steroids, aminophylline, beta-adrenergic agents, and oxygen.aminophylline, beta-adrenergic agents, and oxygen.

AsthmaAsthma LabourLabour

■ medications for asthma are continued in labor and medications for asthma are continued in labor and postpartum. postpartum.

■ Pulse oximetry Pulse oximetry ■ Pain relief – epidural analgesiaPain relief – epidural analgesia■ Morphine and meperidine are histamine-releasing Morphine and meperidine are histamine-releasing

narcotics and should be avoidednarcotics and should be avoided PostpartumPostpartum

■ Risk for hemorrhage, management with oxitocinRisk for hemorrhage, management with oxitocin■ Medication cont. during postpartum period and Medication cont. during postpartum period and

lactationlactation■ Return to pre-pregnancy status within 3 month after Return to pre-pregnancy status within 3 month after

deliverydelivery

Cystic FibrosisCystic Fibrosis autosomal recessive genetic disorder in which the exocrine glands produce excessive autosomal recessive genetic disorder in which the exocrine glands produce excessive

viscous secretions causing problems with both respiratory and digestive functions.viscous secretions causing problems with both respiratory and digestive functions. Respiratory failure and early death (early twenties) may occur.Respiratory failure and early death (early twenties) may occur. Genetic counseling is encouraged to identify carriers of the disease.Genetic counseling is encouraged to identify carriers of the disease. In women with good nutrition, mild obstructive lung disease, and good chest x-rays, In women with good nutrition, mild obstructive lung disease, and good chest x-rays,

pregnancy is tolerated wellpregnancy is tolerated well Increased risk of maternal and perinatal mortality is related to severe pulmonary Increased risk of maternal and perinatal mortality is related to severe pulmonary

infection.infection. ComplicationComplication

■ chronic hypoxia chronic hypoxia ■ frequent pulmonary infections. frequent pulmonary infections.

Women with cystic fibrosis show a decrease in their residual volume during pregnancy, Women with cystic fibrosis show a decrease in their residual volume during pregnancy, as do normal pregnant women, and are unable to maintain vital capacity. as do normal pregnant women, and are unable to maintain vital capacity.

Presumably the pulmonary vasculature cannot accommodate the increased cardiac Presumably the pulmonary vasculature cannot accommodate the increased cardiac output of pregnancy. The results are output of pregnancy. The results are

■ decreased oxygen to the myocardium, decreased oxygen to the myocardium, ■ decreased cardiac output,decreased cardiac output,■ increased hypoxemia.increased hypoxemia.

A pregnant woman with less than 50% of expected vital capacity usually has a difficult A pregnant woman with less than 50% of expected vital capacity usually has a difficult pregnancy. pregnancy.

Cystic FibrosisCystic Fibrosis Fetal effectsFetal effects

■ Preterm birthPreterm birth■ IUGRIUGR■ Neonatal dethNeonatal deth

Mothers effectsMothers effects■ GDMGDM■ Liver diseaseLiver disease■ Pancreatic insuficiencyPancreatic insuficiency

MalnutritionMalnutrition TreatmentTreatment

■ Pancreatic enzymePancreatic enzyme■ Parental nutritionParental nutrition■ AntibioticsAntibiotics

LabourLabour■ monitoring for fluid and electrolyte balance. Because sodium lost through sweat can be monitoring for fluid and electrolyte balance. Because sodium lost through sweat can be

significant, and hypovolemia can occur.significant, and hypovolemia can occur.■ Oxygen by face mask, monitoring by pulse oximetryOxygen by face mask, monitoring by pulse oximetry■ Epidural or local analgesiaEpidural or local analgesia

PostpartumPostpartum■ Breastfeeding appears to be safe as long as the sodium content of the milk is not abnormalBreastfeeding appears to be safe as long as the sodium content of the milk is not abnormal■ Pumping and discarding the milk is done until the sodium content has been determined.Pumping and discarding the milk is done until the sodium content has been determined.

Adult respiratory distress syndromeAdult respiratory distress syndrome

Lungs are unable to maintain levels of oxygen and Lungs are unable to maintain levels of oxygen and carbon dioxide within normal limits (shock of lung)carbon dioxide within normal limits (shock of lung)

Severe hypoxemia, in spite levels of inspired oxygen, Severe hypoxemia, in spite levels of inspired oxygen, is accompanied by an increase in pulmonary is accompanied by an increase in pulmonary permeability, decrease in lung, and shunting of bloodpermeability, decrease in lung, and shunting of blood

As result of chest trauma, drug ingestion, pneumonia, As result of chest trauma, drug ingestion, pneumonia, inhalation of gastric contents during anestesia, DIC, inhalation of gastric contents during anestesia, DIC, preclampsia, eclampsia, abruptio placentae. Dead preclampsia, eclampsia, abruptio placentae. Dead fetus syndrome. Amniotic fluid embolismfetus syndrome. Amniotic fluid embolism

Adult respiratory distress syndromeAdult respiratory distress syndrome

ManagementManagement■ Find and correct underlying causeFind and correct underlying cause■ Early intubation and mechanical ventilation? Early intubation and mechanical ventilation?

With positive end-expiratory pressureWith positive end-expiratory pressure■ Vasoactive, inotropic agentsVasoactive, inotropic agents■ CorticosteroidsCorticosteroids■ Maintaining offluid balanceMaintaining offluid balance

Result depends of causeResult depends of cause

Дякую за увагу!Дякую за увагу!

Other Medical Disorders in Pregnancy Other Medical Disorders in Pregnancy

Neurologic disordersNeurologic disorders■ EpilepsyEpilepsy■ Multiple sclerosis (MS)Multiple sclerosis (MS)■ Bell’s palsyBell’s palsy

Autoimmune disordersAutoimmune disorders■ Systemic lupus erythematosus (SLE)Systemic lupus erythematosus (SLE)■ Myasthenia gravis (MG)Myasthenia gravis (MG)

Effect Of Epilepsy On PregnancyEffect Of Epilepsy On Pregnancy

Data on 1Data on 1stst trimester losses, PROM, ante-partum hemorrhage, trimester losses, PROM, ante-partum hemorrhage, operative vaginal delivery and CS are inconclusive.operative vaginal delivery and CS are inconclusive.

Increased incidence of IUGR, cognitive dysfunction, Increased incidence of IUGR, cognitive dysfunction, microcephaly and perinatal mortality (1.2 - 3 times microcephaly and perinatal mortality (1.2 - 3 times normal). normal).

Increased incidence of congenital malformations.Increased incidence of congenital malformations.

Effect Of Epilepsy On LactationEffect Of Epilepsy On Lactation

No studies on the effects of AED on either quantity or quality of breast No studies on the effects of AED on either quantity or quality of breast milk.milk.

Breast feeding should be stopped if obvious sedation develops in an Breast feeding should be stopped if obvious sedation develops in an infant and is likely to relate to the presence of AED in breast milk.infant and is likely to relate to the presence of AED in breast milk.

Effects Of Epilepsy On Fetus And NeonateEffects Of Epilepsy On Fetus And Neonate

1-There is increased risk for infants of epileptic mothers to have epilepsy. 1-There is increased risk for infants of epileptic mothers to have epilepsy. The risk of neonatal susceptibility depends on:The risk of neonatal susceptibility depends on:

Nature of the mother’s seizure disorder.Nature of the mother’s seizure disorder. Genetic factors.Genetic factors. Seizures arises during pregnancy.Seizures arises during pregnancy. Metabolic & toxic consequences of seizures and AEDs.Metabolic & toxic consequences of seizures and AEDs.

2-Increase perinatal morbidity.2-Increase perinatal morbidity.

Other Medical Disorders in Pregnancy Other Medical Disorders in Pregnancy

Gastrointestinal disordersGastrointestinal disorders■ Cholelithiasis and cholecystitisCholelithiasis and cholecystitis■ Inflammatory bowel diseaseInflammatory bowel disease

Surgery during pregnancySurgery during pregnancy■ AppendicitisAppendicitis

Chapter 33: Medical-Surgical Problems in Pregnancy

Lowdermilk and Perry: Maternity and Women’s Health Care93 of 18

Key Points Key Points

Stress of normal maternal adaptations to Stress of normal maternal adaptations to pregnancy on a heart whose function is pregnancy on a heart whose function is already taxed may cause cardiac already taxed may cause cardiac decompensationdecompensation

Cardiac arrest in pregnant women requires Cardiac arrest in pregnant women requires that standard advanced cardiac life support that standard advanced cardiac life support guidelines be implemented with modificationsguidelines be implemented with modifications■ Uterus must be displaced laterallyUterus must be displaced laterally■ Defibrillation paddles should be placed one rib Defibrillation paddles should be placed one rib

interspace higherinterspace higher




Maternal morbidity and mortality is significant Maternal morbidity and mortality is significant risk complicated by mitral stenosisrisk complicated by mitral stenosis

Normal hemodynamic values are significantly Normal hemodynamic values are significantly altered as a result of pregnancyaltered as a result of pregnancy

Anemia, the most common medical disorder Anemia, the most common medical disorder of pregnancy, affects 20% of pregnanciesof pregnancy, affects 20% of pregnancies

Asthma is most common respiratory crisis Asthma is most common respiratory crisis complicating pregnancycomplicating pregnancy




Pruritus is common symptom in pregnancy-Pruritus is common symptom in pregnancy-specific inflammatory skin diseasesspecific inflammatory skin diseases

Epilepsy is most common neurologic disorder Epilepsy is most common neurologic disorder of pregnancy and can be confused with of pregnancy and can be confused with eclampsiaeclampsia■ History of seizures and no signs of History of seizures and no signs of

preeclampsia point to epilepsypreeclampsia point to epilepsy Cholecystitis and cholelithiasis are common Cholecystitis and cholelithiasis are common

gastrointestinal problems in pregnancygastrointestinal problems in pregnancy




Autoimmune disorders (e.g., SLE, MG) show Autoimmune disorders (e.g., SLE, MG) show predilection for women in reproductive years; predilection for women in reproductive years; associations with pregnancy not uncommonassociations with pregnancy not uncommon

Enlarged uterus, displaced internal organs, Enlarged uterus, displaced internal organs, and altered laboratory values may confound and altered laboratory values may confound differential diagnosis when the need for differential diagnosis when the need for immediate abdominal surgery occursimmediate abdominal surgery occurs




Preoperative care for pregnant woman differs Preoperative care for pregnant woman differs from that for nonpregnant woman in one from that for nonpregnant woman in one significant aspect: significant aspect: ■ Presence of at least one other person, the Presence of at least one other person, the

fetusfetus


Lowdermilk and Perry: Maternity and Women’s Health Care98 of 18Slide 98

Signs of CHF During Signs of CHF During PregnancyPregnancy

Persistent coughPersistent cough Moist lung soundsMoist lung sounds Fatigue or fainting on Fatigue or fainting on

exertionexertion Difficulty breathing on Difficulty breathing on

exertionexertion Orthopnea Orthopnea

Severe pitting edema of Severe pitting edema of the lower extremities or the lower extremities or generalized edemageneralized edema

PalpitationsPalpitations Changes in fetal heart Changes in fetal heart

raterate

■ Indicating hypoxia Indicating hypoxia or growth or growth restrictionrestriction



TreatmentTreatment

Under care of both obstetrician and cardiologistUnder care of both obstetrician and cardiologist Priority care is limiting physical activityPriority care is limiting physical activity

Drug therapyDrug therapyMay include beta-adrenergic blockers, May include beta-adrenergic blockers,

anticoagulants, diureticsanticoagulants, diuretics Vaginal birth is preferred because it carries less risk Vaginal birth is preferred because it carries less risk

for infection or respiratory complicationsfor infection or respiratory complications



Physical ExamPhysical Exam

Normal pregnancy is often accompanied by Normal pregnancy is often accompanied by symptoms of:symptoms of:■ fatiguefatigue■ decreased exercise capacitydecreased exercise capacity■ hyperventilationhyperventilation■ dyspneadyspnea■ palpitationspalpitations■ lightheadnesslightheadness■ syncopesyncope




LE edema is commonLE edema is common RV heave is usually present in the second RV heave is usually present in the second

and third trimestersand third trimesters Pulmonary trunk and pulmonic valve closure Pulmonary trunk and pulmonic valve closure

are often palpableare often palpable




The S1 is increased with exaggerated The S1 is increased with exaggerated splitting that may mimic S4splitting that may mimic S4

Innocent systolic murmurs may be heard as a Innocent systolic murmurs may be heard as a result of the hyperkinetic circulation of result of the hyperkinetic circulation of pregnancypregnancy■ They are midsystolic and softThey are midsystolic and soft■ Heard best over the pulmonic area and radiate Heard best over the pulmonic area and radiate

to the suprasternal notchto the suprasternal notch




Continuous murmursContinuous murmurs■ Venous hum, heard over the right Venous hum, heard over the right

supraclavicular fossasupraclavicular fossa■ Mammary souffle heard over the breast late in Mammary souffle heard over the breast late in

gestation and decreases when pressure is gestation and decreases when pressure is applied with the stethoscopeapplied with the stethoscope



HypertensionHypertension Defined in pregnancy as >140/90Defined in pregnancy as >140/90 Complicates 8-10% of pregnanciesComplicates 8-10% of pregnancies May effect maternal morbidity/mortality:May effect maternal morbidity/mortality:

■ abruptio placentaabruptio placenta■ pulmonary edemapulmonary edema■ respiratory failurerespiratory failure■ DICDIC■ Cerebral hemorrhageCerebral hemorrhage■ Hepatic failureHepatic failure■ Acute renal failureAcute renal failure



HypertensionHypertension

Chronic HTNChronic HTN■ HTN that preceded pregnancy or is detected prior to the HTN that preceded pregnancy or is detected prior to the

20th week20th week■ Occurs 1 in 5 pregnanciesOccurs 1 in 5 pregnancies■ Drug therapy is recommended for high risk characteristics of Drug therapy is recommended for high risk characteristics of

preeclampsia (poor obstetric history, renal insufficiency, preeclampsia (poor obstetric history, renal insufficiency, diabetes, severe HTN with evidence of end-organ diabetes, severe HTN with evidence of end-organ involvement)involvement)

■ Low risk patients (SBP140-160) and normal exam, normal Low risk patients (SBP140-160) and normal exam, normal ekg and echo, antihypertensive therapy has not been shown ekg and echo, antihypertensive therapy has not been shown to prevent the development of preeclampsia or affect fetal to prevent the development of preeclampsia or affect fetal outcomeoutcome




Gestational HTNGestational HTN■ Begins after 20 weeks and resolves by the 6 Begins after 20 weeks and resolves by the 6

postpartum weekpostpartum weekTransient (without proteinuria)Transient (without proteinuria)Preeclampsia (proteinuria)Preeclampsia (proteinuria)

■ Preeclampsia should be considered and Preeclampsia should be considered and seizure prophylaxis should be instituted seizure prophylaxis should be instituted empirically in patients with BP >160/110 empirically in patients with BP >160/110




Preeclampsia-EclampsiaPreeclampsia-Eclampsia■ Usually occurs after 20 weeksUsually occurs after 20 weeks■ SBP>140/ DBP>90 and proteinuriaSBP>140/ DBP>90 and proteinuria■ The disease is highly suspect even in the The disease is highly suspect even in the

absence of proteinuria if symptoms of absence of proteinuria if symptoms of headache, blurred vision, pulmonary edema, headache, blurred vision, pulmonary edema, elevated LFT, low plateletselevated LFT, low platelets

■ Usually reversible within 24-48 hours after Usually reversible within 24-48 hours after deliverydelivery




The majority of patients with SBP>140-160 The majority of patients with SBP>140-160 and DBP <110 are at low risk of and DBP <110 are at low risk of cardiovascular complications and are cardiovascular complications and are candidates for nondrug therapycandidates for nondrug therapy

Indications for drug therapy includeIndications for drug therapy include■ SBP>160, DBP>110SBP>160, DBP>110■ End-organ damage (LVH, renal insufficiency)End-organ damage (LVH, renal insufficiency)



HypertensionHypertension ManagementManagement

■ Methlydopa is the preferred therapy but may also use Methlydopa is the preferred therapy but may also use labetalol and nefedipine. labetalol and nefedipine.

■ An effective prepregnancy regimen can often be An effective prepregnancy regimen can often be continued with the exception of ACE inhibitors or ARBscontinued with the exception of ACE inhibitors or ARBs

■ ACEI/ARB may cause significant fetal risks including ACEI/ARB may cause significant fetal risks including damage to the cardiovascular, renal and central damage to the cardiovascular, renal and central nervous systemsnervous systems

■ Delivery is the only definitive treatment of preeclampsiaDelivery is the only definitive treatment of preeclampsia



Prosthetic Heart ValvesProsthetic Heart Valves

Increased thromboembolic events have been Increased thromboembolic events have been reported during pregnancy in women with reported during pregnancy in women with prosthetic valves, incidence as high as 10-prosthetic valves, incidence as high as 10-15%15%

2/3rds of these patients presented with valve 2/3rds of these patients presented with valve thrombosis which led to death in 40% thrombosis which led to death in 40%



Prosthetic Heart ValvesProsthetic Heart Valves Oral anticoagulants can cross the placenta and be Oral anticoagulants can cross the placenta and be

harmful to the fetusharmful to the fetus Exposure during the first 8-12 weeks can be Exposure during the first 8-12 weeks can be

associated with a teratogenic effect leading to associated with a teratogenic effect leading to warfarin embryopathy (nasal deformity) as well as warfarin embryopathy (nasal deformity) as well as other complicationsother complications■ intracranial bleedingintracranial bleeding■ Congenital anomaliesCongenital anomalies■ Fetal wastageFetal wastage■ Spontaneous abortion/fetal lossSpontaneous abortion/fetal loss



Prosthetic Heart ValvesProsthetic Heart Valves ACCP recommendations for anticoagulation in ACCP recommendations for anticoagulation in

pregnant patients with porsthetic heart valvespregnant patients with porsthetic heart valves■ Unfractionated heparin(UFH) SQ q12 hours throughout Unfractionated heparin(UFH) SQ q12 hours throughout

pregnancy following PTT levelspregnancy following PTT levels■ LMWH (Lovenox) throughout pregnancy following anti-LMWH (Lovenox) throughout pregnancy following anti-

Xa levelsXa levels■ LMWH or UFH until week 13, then coumadin until LMWH or UFH until week 13, then coumadin until

middle of third trimester, then restart UFH/LMWH until middle of third trimester, then restart UFH/LMWH until deliverydelivery



ImagingImaging CXR - radiation exposure is minimalCXR - radiation exposure is minimal Echo - safeEcho - safe Stress testing - use low level exercise protocol to Stress testing - use low level exercise protocol to

obtain 70% maximal heart rate, use with fetal monitorobtain 70% maximal heart rate, use with fetal monitor CT scan - radiation may varyCT scan - radiation may vary MRI- no known risk to the fetusMRI- no known risk to the fetus Cardiac cath - relatively high doses of radiation, Cardiac cath - relatively high doses of radiation,

obtain access via the brachial artery rather than obtain access via the brachial artery rather than femoral to limit fetal radiationfemoral to limit fetal radiation



ImagingImaging

Radiation exposureRadiation exposure■ 5 rads - low risk5 rads - low risk■ 5-10 rads - provide counseling regarding the 5-10 rads - provide counseling regarding the

low risk of problemslow risk of problems■ 10-15 rads - during the first 6 weeks, individual 10-15 rads - during the first 6 weeks, individual

consideration for terminationconsideration for termination■ >15 rads - termination recommended>15 rads - termination recommended



CaseCase

34 year old female presents to the emergency 34 year old female presents to the emergency room 2 weeks after giving birth to twins. Her room 2 weeks after giving birth to twins. Her pregnancy and delivery were uneventful. She pregnancy and delivery were uneventful. She now is feeling short of breath. She notes that now is feeling short of breath. She notes that she can not sleep flat at night anymore. she can not sleep flat at night anymore.



On physical exam she has bibasilar rales and On physical exam she has bibasilar rales and is tachycardic with an S3 present. is tachycardic with an S3 present. ■ What disease state do you suspect?What disease state do you suspect?■ What testing would you like to order?What testing would you like to order?



EKG: ST with non-specific ST-T wave EKG: ST with non-specific ST-T wave abnormalities abnormalities

CXR: pulmonary edema with cardiomegalyCXR: pulmonary edema with cardiomegaly Echo: dilated LV with depressed ejection Echo: dilated LV with depressed ejection

fraction at 30%fraction at 30%



How would you treat this patient?How would you treat this patient? What does the diagnosis of peripartum What does the diagnosis of peripartum

cardiomyopathy mean for her long term cardiomyopathy mean for her long term prognosis?prognosis?



Treatment is similar to other forms of heart Treatment is similar to other forms of heart failure failure ■ DiureticsDiuretics■ VasodilatorsVasodilators■ DigoxinDigoxin

50-60% of patients make a full recovery 50-60% of patients make a full recovery within 6 months. within 6 months.



Nutritional AnemiasNutritional Anemias

SymptomsSymptoms

■ Easily fatiguedEasily fatigued■ Skin and mucous membranes are paleSkin and mucous membranes are pale■ Shortness of breathShortness of breath■ Pounding heartPounding heart■ Rapid pulse (with severe anemia)Rapid pulse (with severe anemia)

medical-surgical problems in pregnancy lectures 7, 8 petrenko n.v., md, phd

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