Upload
2012
View
469
Download
3
Embed Size (px)
DESCRIPTION
neonatal trans
Citation preview
Medical and Surgical Complications of Pregnancy
Non-obstetric reasons for admission of a pregnant woman
Common Medical reasons Renal GI Pulmonary Infections
Surgical Causes Appendicitis Gall bladder disease Pancreatitis Bowel Obstruction Trauma
These require multi-specialty team
OB working knowledge of medical and
surgical conditions in women Non-OB specialists familiar with effects of these diseases on
pregnant women and vice versa pregnancy induced physiological changes
Surgical Conditions and Pregnancy
Surgical conditions in pregnancy: Abdominal pain
often during pregnancy etiology may be pregnancy-specific or non-
pregnancy related dynamic changes of pregnancy complicate
diagnosis, especially when abdominal complaints persist
1 in 500 pregnancies complicated by a non-obstetric surgical condition
most common non-obstetric abdominal surgical conditions seen in pregnancy
Appendicitis, Cholecystitis, Pancreatitis, Bowel obstruction
Surgical conditions during pregnancy
Concerns:Can surgery induce malformations if done 1st
trimester? Effect of anesthetic drugs
Can surgery precipitate labor and delivery? Uncomplicated operations do not increase risk of
adverse pregnancy outcomes with precautions Complications: appendicitis with perforation/peritonitis
maternal / fetal morbidity and even mortality increase
Surgery during pregnancy
Concerns: Technical problems
Gravid uterus poses a technical problem in 3rd trim Procedure related complications:
e.g aspiration of gastric contents during extubation in a pregnant woman
Complications arise from: Hesitation to operate on a pregnant women delays
treatment Difficulty in diagnosis: Physiologic changes in
pregnancy itself may mimic a pathological condition
Surgical Management Principle
Never forego a surgical procedure when maternal health and welfare ordinarily mandates that the procedure be completed if the mother were not pregnant.
Best Treatment Electives – early second trimester Emergency – prompt operation if compromised
mother regardless of gestational age
Effect of anesthesia on pregnancy outcome
Mazze and Källen (1989) 5405 non-OB surgery in 720,000 pregnant women 1973-1981: 1st trim 41%, 2nd trim 35%, 3rd trim 24%>50% underwent general anesthesia using
nitrous oxide Inc incidence of low birth weight and
preterm birth
Effect of anesthesia on pregnancy outcome
No difference in rates of stillbirth and congenital malformations
Those that had preterm delivery 1st trim surgery, peritonitis, long operations, surgery >24 wks
(Stepp and assoc, 2002)
Anesthetic agents not generally teratogenic except in Surgery done 4-5 wks AOG Significant increase in neural tube defects
(Källen and Mazze,1990) Hydrocephaly + eye defects in those exposed
to general anesthesia( Sylvester et al 1994)
Appendicitis
1 in 10,000 to 1 in 300 with an average rate of 1 in 550 pregnancies.
Adolescents have a higher risk of appendicitis
in pregnancy than other age groups.
Other commonly seen conditions that mimic appendicitis include pyelonephritis, pancreatitis, cholecystitis, and gastroenteritis, among others
Appendicitis: Signs and symptoms in pregnancy
Long-held view that as pregnancy advances and the uterus enlarges, the appendix moves upward toward the right flank, reaching the level of the iliac crest after the fourth month of pregnancy, and thus severe appendicitis pain would be noted higher in the pregnant abdomen.
Pain Location by Gestational Age in
Histologically Proven Appendicitis Cases Estimated Gestation
al Age (wks)
No. of Patients
Right Upper
Quadrant
Right
Lower Quadrant
Others
0-12 14 0 12 2
12-24 18 1 15 2
>24 13 2 11 0
Total 48 3 38 4
Mourad J, Elliott J, Erickson L, Lisboa L. Appendicitis in pregnancy: new information that contradicts long held clinical beliefs. Am J Obstet Gynecol, 2000, 182;1027-
1029
Signs and Symptoms
In addition, the point of severe abdominal tenderness can change with movement.
Anorexia, nausea, and new onset nausea and vomiting vary. Although rebound tenderness and guarding may be elicited, they are not specific for the diagnosis of appendicitis.
Diagnosis in Pregnancy
High-resolution ultrasound with graded compression technique has been used to aid in the diagnosis of appendicitis in pregnancy. Sonographic findings of a normal appendix include an appendix that is both compressible and less than 6 mm in diameter.
Sonographic accuracy similar in the non-pregnant woman, especially in the first and second trimesters.
Normal ultrasound, does not always rule out appendicitis in pregnancy.
Llimitations: operator skill level and difficulty in obese women
Diagnosis in Pregnancy
Currently, computed tomography scan is being used in non-pregnant women with symptoms suggestive of appendicitis and may be warranted in extreme cases in pregnancy.
No studies have been published to date on use of computed tomography scanning in pregnant women with appendicitis.
Fever and elevated white count are not clear indicators of appendicitis.
Serial white blood cell (WBC) counts may be helpful primarily to see if it is trending upward and can be a useful indicator of appendicitis when observing a woman over an extended period of time.
A left shift (WBC with an increased number of immature forms) has been noted in acute appendicitis in pregnancy.
Two studies have documented an increase in left shift in patients with acute appendicitis
Surgery
Surgical techniques depend on which trimester of pregnancy acute appendicitis occurs.
Laparoscopy is often performed prior to 20 weeks' gestation.
However, laparotomy is still used frequently during all trimesters.
The incidence of ruptured appendix is highest in the third trimester of pregnancy primarily due to the difficulty of determining a diagnosis prior to surgery.
Complications from appendicitis during pregnancy
preterm labor risk range 10% to 15%[3] to 15% to 43%.[ increased risk of delivery the week following surgery
when performed after 23 weeks' gestation. the use of tocolytics prior to surgery is not
recommended for prophylactic use due to the potential risk of fluid overload that can result in pulmonary edema and adult respiratory distress syndrome with use of tocolytics.
A perforated appendix often leads to uterine contractions and premature labor.
Complications from appendicitis during pregnancy
An increase in medical complications is noted when 1) symptomatology > 24 hours or greater prior to
surgery, 2) rising white count with left shift is noted, 3) when peritonitis or a perforated appendix is
noted at time of surgery
Increased maternal morbidityEarly fetal delivery or fetal loss.
Fetal loss varies between 3% and 5% without perforation and can be as high as 36% when perforation occurs.
Gallbladder Disease
A common non-obstetric abdominal complaint. The incidence of gallbladder disease in pregnancy is 0.05% to 0.3%.
Cholelithiasis or calculi/gallstones in the gallbladder or common duct occurs more frequently in pregnant women.
Gallstones can present as an obstructive disease or as cholecystitis, which is an inflammation of the gallbladder secondary to gallstone obstruction of the cystic duct.
Gallbladder Disease
The gallbladder functions as a storage reservoir for bile produced by the liver. There is a high concentration of bile salts, pigments, and cholesterol within the bile storage pool
Following the intake of foods high in lipid content, the gallbladder contracts, ejecting the bile salts into the intestine. Within the intestinal tract, bile acid aids the absorption of lipids.
Sign and symptoms
Gallstones and biliary sludge cause the most gallbladder-related pain.
Sludge a precursor to the formation and buildup of gallstones, which are formed from crystallization of cholesterol, calcium, or bile salts.
Multiparity a risk factor for gallstone development
However, gallstones are also noted to increase with age, and their formation may be mediated by changes in estrogen and progesterone.
Sign and symptoms
Asymptomatic gallstones are seen in 3.5% to 10% of pregnancies
Ultrasound findings of the gallbladder in pregnant women show a decrease in the emptying rate and an increase in residual volume after emptying. Eventually, this can lead to stasis and gallstone formation.
An decrease in gallbladder motility and the larger amounts of circulating bile salt add to more sluggish gallbladder functioning during pregnancy.
Signs and symptoms
Right upper quadrant colicky or stabbing pain Generalized epigastric pain, which can radiate to the
right scapula and flank area due to CBD obstruction of a stone
Murphy's sign, Other symptoms: anorexia, nausea, vomiting, dyspepsia,
low-grade fever, tachycardia, and fatty food intolerance. Abdominal guarding is not usually seen.
Pregnant women usually present with acute epigastric pain.
Signs and symptoms
Laboratory testing: WBC for elevation elevated liver function tests,
Ultrasound: imaging method of choice 95% effective in diagnosing gallstones and has
no radiation exposure gallstones appear as mobile echogenic
structures with shadowing Acute cholecystitis dx distention of the
gallbladder, pericholecystic fluid, and thickening of the gallbladder wall.
Management of Gallbladder disease
Depends on gestational age and severity of symptoms Conservative medical management : first consideration
in the first and third trimesters use of intravenous fluids, correction of electrolyte
imbalance, bowel rest, narcotics, antispasmodics, broad spectrum antibiotics, and a fat-restricted diet.
Fetal assessment and uterine monitoring indicated, depending on trimester.
Unless symptoms acute, surgical options delayed into the second trimester to avoid the risk of spontaneous abortion in first trimester.
Management of Gallbladder disease
1st trim 2nd trim 3rd trim
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Relapse rate in gallbladder disease after medical treatment
RelapseRate
Other surgical techniques
1) endoscopic retrograde cholangiopancreatography,
2) open cholecystectomy,
3) laparoscopic cholecystectomy.
Other surgical techniques
1) The choice of technique varies by institution, access, operator availability and skill, severity of symptoms, and gestational age.
Most of these surgical procedures are used in patients with acute biliary colic, acute cholecystitis, and those with relapsing symptoms.
Swisher et al. propose that elective second trimester cholecystectomy is safe and minimizes relapse time.
Gallstones are present in 12% of all pregnancies, more than one-third of patients fail medical treatment
and therefore require surgical endoscopy or laparoscopy.
Gallstone pancreatitis and jaundice during pregnancy is associated with a high recurrence rate, exposing both fetus and mother to an increased risk of morbidity and mortality.
Endoscopic retrograde cholangiopancreatography
Recently used for pregnant women with severe gallbladder symptoms and also for persons with gallstone-related pancreatic symptoms. performed by a gastroenterologist The woman is placed on an x-ray table after sedation, and drugs
are administrated to induce duodenal hypotonia
Contrast material is injected under fluoroscopy. In pregnant women, fetal shielding is used, and fluoroscopy time
is held to a minimum. Visualization of the common bile duct is seen as well as the
whole biliary tract, including the gallbladder.
endoscopic sphincterotomy
With, an actual incision is made through which removal of stones and the placement of stents can be performed. Small stones can be removed easily or may be pulled out with a balloon catheter or basket. Larger stones will need to be fragmented initially.
Laparoscopic Chole
For persons with gallbladder complaints undergoing endoscopic retrograde cholangiopancreatography, cholecystectomy can be delayed or may be avoided entirely.
Laparoscopic cholecystectomy is another surgical option for gallstones. Graham et al.1998, in a literature review and reported on 105 cases of laparoscopic cholecystectomy performed in pregnancy.
Ninety of these cases noted gestational age at time of surgery; 12 cases (13%) were performed in the first trimester; 64 cases (71%) in the second trimester, 14 cases (16%) in the third trimester.
There were no spontaneous abortions in the women who underwent surgery during the first trimester.
Laparoscopic Chole
Graham et al. 1998. noted one case of fetal demise, 7 weeks after laparoscopic cholecystectomy, and noted that there have been anecdotal reports of stillbirths, correlating with the timing of laparoscopic surgery.
They suggest using the Hasson open approach during laparoscopy to prevent inadvertent puncture of the gravid uterus and maintaining pressure between 10 and 12 mmHg.
Transvaginal ultrasound for fetal assessment is ideal during laparoscopy.
Compared to laparotomy, laparoscopy is associated with a shorter recovery time, less uterine manipulation, and earlier ambulation.
Complications:
Cosenza et al. reviewed the surgical management of biliary gallstones in pregnancy.
They reported on a total of 32 cholecystectomies, 7 open common bile duct explorations, and 12 laparoscopic cholecystectomies.
One spontaneous abortion was noted in the laparoscopy group.
One woman in the cholecystectomy group had a preterm delivery.
Monitoring for preterm labor is critical although laparoscopy has been noted to have a lower incidence of preterm labor than the incidence noted in women who undergo laparotomy.
Pancreatitis
Incidence: ranges from 1 in 1,066 live births to 1 in 3,333 pregnancies.
Predisposing factor during pregnancy: most common, secondary to cholelithiasis hypertriglyceride-induced pancreatitis.
results from the increased estrogen effect of pregnancy and the familial tendency for some women toward high triglyceride levels.
Drugs, specifically tetracycline and thiazides (not commonly used in pregnancy), as well as increased alcohol consumption, can also cause pancreatitis.
Recently, pancreatitis has been linked to more than 800 mutations of the cystic fibrosis transmembrane conductance regular gene.
Symptoms and signs midepigastric pain, left upper quadrant pain radiating to the left flank, anorexia, nausea, vomiting, decreased bowel sounds, low-grade fever, and associated pulmonary findings 10% of the time (unknown cause). A pulse
oximeter reading should be obtained. Pulmonary signs often include hypoxemia, which can lead to full-blown adult respiratory distress syndrome.
Other symptoms may include jaundice, abdominal tenderness, muscle rigidity, and hypocalcemia.
The most common misdiagnosis of pancreatitis in the first trimester is hyperemesis. Given this constellation of symptoms, it is critical to distinguish between hyperemesis gravidarum and pancreatitis when evaluating a woman in the first trimester of pregnancy. In women presenting with severe nausea and vomiting in the first trimester, consider obtaining amylase, lipase levels, and liver function tests, which when elevated are diagnostic for pancreatitis. In one study of 25 cases of pancreatitis, 11 cases were diagnosed in the first trimester.[33]
Symptoms and signs
midepigastric pain, left upper quadrant pain radiating to the left flank, anorexia, nausea, vomiting, decreased bowel sounds, low-grade fever, and associated pulmonary findings 10% of the time (unknown
cause). A pulse oximeter reading should be obtained. Pulmonary signs often include hypoxemia, which can lead to full-blown adult respiratory distress syndrome.
Other symptoms may include jaundice, abdominal tenderness, muscle rigidity, and hypocalcemia.
Symptoms and signs
The most common misdiagnosis of pancreatitis in the first trimester is hyperemesis.
Distinguish between hyperemesis gravidarum and pancreatitis when evaluating a woman in the first trimester of pregnancy.
in the first trimester, consider obtaining amylase, lipase levels, and liver function tests, which when elevated are diagnostic for pancreatitis. In one study of 25 cases of pancreatitis, 11 cases were diagnosed in the first trimester
Complications
Pancreatitis in pregnancy had been associated in the past with a high maternal death rate and fetal loss rate. More recent studies have found declining rates due to
earlier diagnosis and greater treatment options and improved management of pancreatic symptoms that can cause preterm labor.
The relapse rate for gallstone-related pancreatitis is higher than for other causes—up to 70% with conservative treatment only.
ComplicationsHyperlipidemia during pregnancy (2nd most common cause)
Lipids and lipoprotein levels increase during pregnancy, triglycerides increase threefold peaking in the third trimester
The level of triglycerides required to induce acute pancreatitis is between 750 and 1,000 mg/dL . The total serum triglyceride level during pregnancy is usually less than 300 mg/dL. After delivery, triglyceride levels usually fall
An increase in cholesterol of 25% to 50% occurs primarily as a result of higher blood levels of estrogen.
Fifty percent of women with pancreatitis develop hypocalcemia secondary to diminished calcium in pregnancy, which worsens with pancreatitis.
Diagnosis
Ultrasound is the imaging technique of choice for pregnant women because it can distinguish a normal appearing pancreas from one that is enlarged, and it can also identify gallstones.
Diagnostic blood tests serum amylase (10 to 130 in some labs to 30 to 110 in
others or even up to 150 to 160 in pregnancy) increased also in bowel obstruction, cholecystitis, ruptured ectopic In another study, the mean amylase levels in a selected group of persons presenting with pancreatitis was 1,400 IU/L.
Diagnosis Lipase, another enzyme produced by the pancreas, has
norms ranging from 4 to 57 and from 23 to 208 (these also vary depending on laboratory).
triglyceride levels calcium levels complete blood count. In one study, an elevated amylase level had a
diagnostic sensitivity of 81%, and adding lipase increased the sensitivity to 94%.[31] Amylase levels do not correlate with disease severity. Elevated serum lipase levels remain elevated longer than amylase following an episode of pancreatitis.
Diagnosis Ultrasound is the imaging technique of choice for pregnant women
because it can distinguish a normal appearing pancreas from one that is enlarged, and it can also identify gallstones.
Diagnostic blood tests serum amylase (10 to 130 in some labs to 30 to 110 in others
or even up to 150 to 160 in pregnancy) increased also in bowel obstruction, cholecystitis, ruptured ectopic In another study, the mean amylase levels in a selected group of persons presenting with pancreatitis was 1,400 IU/L.
Lipase, another enzyme produced by the pancreas, has norms ranging from 4 to 57 and from 23 to 208 (these also vary depending on laboratory).
triglyceride levels calcium levels complete blood count.
Diagnosis
In one study, an elevated amylase level had a diagnostic sensitivity of 81%, and adding lipase increased the sensitivity to 94%.
Amylase levels do not correlate with disease severity. Elevated serum lipase levels remain elevated longer than amylase following an episode of pancreatitis.
Treatment Ranson developed criteria for classification of severity of acute pancreatitis based on non-pregnant
persons. One set of criteria is used at the time of admission and another after the initial 48 hours
Classification of Severity of Acute Pancreatitis
3 or greater at time of admission Age >55 years White blood cell count >16,000/mm Blood glucose >200 mg/dL Serum lactate dehydrogenase more than twice normal Serum glutamic-oxaloacetic transaminas more than six times normal
3 or greater after initial 48 hours Decrease in hematocrit of >10% Serum calcium < 8 mg/dL Increase in blood urea nitrogen of >5 mg/dL Arterial pO2 < 60 mm Hg Base deficit >4 mEq/L Estimated fluid sequestration 6,000 mL
Treatment
In persons with fewer than three prognostic signs, the risk of death or major complications is small. These criteria are often used as a guide when treating gravid women with pancreatitis as well.
Conservative medical management of pancreatitis includes intravenous fluids, nasogastric suctioning, total parenteral nutrition, use of analgesics and antispasmodics, fat restriction with total parenteral nutrition, and antibiotics. Lipoprotein apheresis and plasmapheresis are therapies known to lower serum triglyceride levels.
Treatment
Endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy are techniques used to treat gallstone-related pancreatitis
Again, fluoroscopy time during pregnancy is limited or omitted. Fetal shielding can be used in which a lead apron is placed over the maternal abdomen, and fluoroscopy is limited to less than one minute. Increased serum amylase levels are often elevated transiently following this procedure.
Endoscopic retrograde cholangiopancreatography in pregnancy
Jamidar et al.details 23 pregnant women with pancreatic-biliary disease, treated at several different medical centers, who underwent diagnostic and therapeutic endoscopic retrograde cholangiopancreatography.
Prophylactic antibiotics were administered, Abdomen was shielded with a lead apron. Fluoroscopy time was kept under 1 minute.
Common bile stones were found in 14 of the 23 women. There was one spontaneous abortion in the second trimester, occurring
3 months after endoscopic retrograde cholangiopancreatography and a spontaneous abortion after a third stent replacement occurred in
another woman. Second trimester is thought to be the ideal time for endoscopic
retrograde cholangiopancreatography to avoid any possible teratogenic effects of radiation.
Bowel Obstruction
The most common cause in pregnancy is adhesions secondary to prior surgery or illness
77% of the 66 cases presented with known obstruction due to adhesions from previous abdominal surgery, pelvic surgery, or pelvic inflammatory conditions or previous cesarean birth
The incidence of intestinal obstruction in pregnancy varies from 1 in 1,500 to 1 in 66,500 pregnancies.
Although adhesions is the most common cause the ff contribute , volvulus (25%), intussusception (5%) malignancies, Hernias worsening diverticulitis/diverticulosis The differential diagnosis includes appendicitis and perforated ulcer.
Bowel Obstruction
Occurs during the fourth to fifth months of pregnancy when the uterus rises into the abdomen but most often occurs in the third trimester or postpartum.
Significant risk for severe morbidity or mortality for both mother and fetus
treatment is urgent Delays due to errors in diagnosis, or reluctance to
operate during pregnancy all add to increased risk. The maternal mortality rate in one study was 4 deaths in
66 women diagnosed with obstruction
Definition
Partial or complete, small or large intestine-related, acute or chronic, high or low. Simple intestinal obstruction refers to an
obstructed portion of lumen without vascular or neurological involvement.
Strangulated obstruction is the most serious because it involves occlusion of the blood supply.
Definition
Simple obstruction changes the normal secretory and absorptive functions of the bowel.
Absorption is decreased, and the wall of the bowel becomes congested and swollen.
Motility of intestinal contents changes, and food and intestinal secretions accumulate proximal to the blockage.
The more distal portion of the intestine collapses, and a bowel movement is not uncommon at this point.
Peristalsis increases in an attempt to push past the obstruction but can add to edema and inflammation.
Intestinal gas also accumulates and adds to abdominal distention. There are waves of peristalsis, with both motility and hypoactivity adding to the colicky pain.
Fluid and electrolyte losses can be significant, leading to hypovolemia, renal problems, shock, and death.
Signs and symptoms
Obstipation (extreme constipation often secondary to an obstruction) 30%
abdominal tenderness 71% vomiting are commonly noted symptoms of bowel obstruction 82% Intestinal, colicky, crampy pain radiating to the back, along with
abdominal distention, may be noted in persons with obstruction. One study of 66 cases of bowel obstruction during pregnancy and
the puerperium revealed 98% of women complained of abrupt onset pain,
In women with more complicated, infracted, or strangulated bowel obstruction, abdominal guarding and rebound tenderness can be noted.
Over time, vomitus and stools become more foul smelling secondary to bacteria being absorbed into the peritoneum.
Signs and symptoms
Early findings of intestinal obstruction can seem fairly normal, or more vividly affected persons may present with pain out of proportion to what might be expected.
Serial assessments of increasing WBC count Mild to moderate dehydration can become evident with
noted hemoconcentration and decreased urinary output Serum electrolytes and renal function studies can be
altered. Fever, tachycardia, marked elevation in WBC, and
localized abdominal pain signify more intensive bowel sequelae.
Diagnostics
upright and flat plate x-ray of the abdomen. 82% sensitive in detecting either air fluid levels and/or bowel dilatation.
magnetic resonance imaging (MRI) Early imaging and diagnosis are warranted because
bowel necrosis can occur rapidly. Minimal delay in treatment is key, and early surgical consultation is necessary to evaluate bowel viability
Treatment
Fluid and electrolyte replacement must be aggressive Use of nasogastric tube and antibiotics are often
necessary. Fetal monitoring and maternal oxygen saturation levels
need to be closely evaluated. In one literature review of 66 pregnant and postpartum women, 15 required resection of nonviable bowel at laparotomy. Fetal death rates following maternal intestinal obstruction are
between 20% and 26%. Maternal mortality can range from 6% to 20%.[4, 38]
Trauma in Pregnancy
Types: Physical Abuse : usually no prenatal care,high
risk for LBW, preterm delivery, chorioamnionitis Sexual Assault: usually < 20 wks, STD Vehicular Accidents Penetrating Injuries Burns: Maternal/ fetal survival parallel to
percentage of burned surface area, prognosis worse for survival when burn 50%
Obstetric Complications in Trauma in Pregnancy
Abruptio Placenta: minor trauma 1% risk, major trauma 50%, more likely in accidents > 30 mph
Uterine Rupture: uncommon, <1% of severe cases
Feto-Maternal Hemorrhage: blunt injury to pregnant woman’s abdomen causing placental
fractures or tears caused by stretching. 30% of pregnant trauma cases. Fetus bleeds to maternal circulation
Obstetric Complications in Trauma in Pregnancy
Fetal Injury : only in direct feto-placental injury, maternal shock pelvic fractures, maternal head injury or hypoxia.
Commonly fetal skull and brain injuries
Management
Resuscitate and stabilize Deflect large uterus away from large vessels to
improve cardiac output Evaluate for fractures, internal injuries, bleeders
and uterine as well as fetal injuries. Surgical exploration if indicated like gunshot
wounds Fetal heart rate monitoring: 20% of women with
frequent contractions have an associated placental abruption
Diagnostic Tests
Are they safe?
Diagnostic Techniques
X-ray Ultrasound Magnetic Resonance Imaging
The use of X-ray prior to recognition of pregnancy …. Cause for concern?
Fetal Effects of Radiation
Cell death Growth restriction Congenital malformations Carcinogenesis Microcephaly and mental retardation Sterility
Effects of Ionizing radiationHuman data
Radiation > 100 rad caused Microcephaly hydrocephaly, mental retardation, abnormal genitalia, growth restriction, micropthalmia and cataracts
(From women with malignancies (Goldstein and Murphy 1929; Dekaban 1968; Brent 1999)
Effects of Ionizing radiationHuman data
2. Increased risk of mental retardation exposure at 8 to 15 wks greatest risk of MR
4% for 10 rad 60% for 150 rad
larger exposure dose needed at 16 to 25 wks. No mental retardation with exposures < 8wks and >
25 weeks even with doses of >50 rad(Nagasaki and Hiroshima atomic bomb survivors exposure to
fallout Greskovich Macklis, 2000; otake et al, 1987):
Dose to Uterus of Common Radiological Procedures of Concern in OB
Study View Films/study Dose/study (mrad)
Skull AP,PA, Lat 4.1 <0.05
Chest AP,PA, Lat 1.5 0.02 –0.07
Mammogram CC, Lat 4.0 7-20
Lumbosacral spine AP,PA, Lat 3.4 168-359
Abdomen AP,PA, Lat 1.7 122-245
Intravenous pyelogram
AP,PA, Lat 5.5 686-1398
Hip (single) AP,Lat 2.0 103-213
Diagnostic Imaging Xray – most diagnostic procedures do not reach
exposure of 1 rad except for an IVP Fluroscopy and Angiography –variable dose but
farther from fetus, less radiation CT- 2-5 rads Ultrasound – proven to be harmless MRI – contrast not recommended otherwise
useful and safe
Diagnostic Radiation
No singe diagnostic procedure results in a radiation dose significant enough to threaten the well-being of the developing embryo and fetus
American College of Radiology,1991
Guidelines for Diagnostic Imaging During Pregnancy (ACOG, 1995)
Counsel Women that x-ray exposure from a single diagnostic procedure does not result in harmful fetal effects.
Specifically exposure less than 5 rad has not been associated with an increase in fetal anomalies or pregnancy loss
Concern about possible effects of high dose ionizing radiation exposure should not prevent x-ray medically indicated diagnostic procedure in pregnant women.
During pregnancy, As much as possible procedures w/o ionizing radiation like ultrasound and MRI should be used
Ultrasound and MRI are not associated with known adverse fetal effects.However until more info available,MRI not recommended in the first trimester
Consult with a radiologist to help estimate radiation dose in multiple diagnostic x-rays
Radioactive isotopes of iodine contraindicated for therapy in pregnancy
Heart Disease
Philippine General Hospital Incidence: 2.8% in the year 2007
Causes: Rheumatic Heart Disease – 60.1% Congenital Heart Disease – 32.7% Mitral Valve Prolapse – 2.9% Others (IHD, Cardiomyopathy, Arrhythmia) –
4.3%
Hemodynamics during Pregnancy Peripheral Resistance Uterine blood flow Cardiac Blood volume 40-45% output
30% Heart rate 10-20% Blood pressure or Pulmonary vascular resistance Venous pressure in lower extremities
Hemodynamics during Pregnancy Cause problems for the mother with
cardiac disease
Added volume load compromise a patient who has impaired ventricular function and limited cardiac reserve
Stenotic valvular lesions are less well tolerated than regurgitant lesions, because the decrease in peripheral resistance exaggerates the gradient across the aortic valve.
Hemodynamics during Pregnancy
Tachycardia of pregnancy reduces the time for diastolic filling in a patient with mitral stenosis, with resultant increase in left atrial pressure
With a lesion such as mitral regurgitation, the afterload reduction helps offset the volume load on the left ventricle that gestation imposes
Hemodynamics during labor and delivery
Each uterine contraction
500ml of blood is released into the circulation
Rapid increase in CO and BP
Hemodynamics during labor and delivery
Cardiac output is 50% above baseline during the 2nd stage of labor and may be even higher at the time of delivery
Normal vaginal delivery: 400ml of blood is lost
Cesarean section: 800ml of blood is lost more significant hemodynamic burden to the parturient
Hemodynamics during labor and delivery
Following delivery of the baby
Abrupt increase in venous return(autotransfusion & baby no longer compresses the inferior vena cava)
Autotransfusion of blood in the 24 to 72 hours after delivery
(pulmonary edema may occur)
High risk patient with cardiac disease
Multidisciplinary approach Cardiologist and obstetrician should work with
the anesthesiologist to determine the safest mode of delivery
Vaginal delivery – feasible and preferable Cesarean section – only indicated for
obstetric reasons Exceptions:
Patient anticoagulated with warfarin Dilated unstable aorta (e.g. Marfan Syndrome) Severe pulmonary hypertension Severe obstructive lesion, such as aortic stenosis
Severe heart failure – may worsen before mid pregnancy
Some fail in 3rd trimester during maximal blood volume
Majority heart failure peripartum when there are rapid change in cardiac output
Clinical Indicators of Heart Disease during Pregnancy
Symptoms Progressive dyspnea/
orthopnea Nocturnal cough Hemoptysis Syncope Chest pain
Clinical findings Cyanosis Clubbing of fingers Persistent neck vein
distnetion Systolic murmur grade 3/6
or greater Diastolic murmur Cardiomegaly Persistent arrythmia Persistent split S2
Diagnostic Tests
Electrocardiography: frequent findings in pregnancy
Diaphragm elevation caused 15° LAD producing mild ST changes in inferior leads
PACs and PVCs frequent
Echocardiography: normal findings Tricuspid regurgitation Increased left atrial size Left ventricular outflow x-sectional area increased
Chest X-ray To exclude cardiomegaly
New York Heart Association
Classification Scheme
Class I: Uncompromised – no limitation of physical activity
Class II: Slight limitation of physical activity – comfortable at rest, fatigue, palpitations, dyspnea, angina with regular activity
Class III: Marked limitation of physical activity – comfortable at rest,fatigue with less than regular activity
Class IV: Severely Compromised- inability to perform any physical activity without discomfort
Class I and II usually without morbidity and mortality is rare Observe for early signs of heart failure, avoid
infections, avoid smoking Vaginal delivery Watch out for pulmo edema, hypoxia, hypotension
intrapartum Semirecumbent with lateral tilt, vital signs monitoring
(maintain PR<100 bpm, RR <24 Pain relief, epidural anesthesia
Class III to IV Counsel regarding risk of getting pregnant If pregnant explain need for prolonged
hospitalization and bed rest Operations /CS tolerated poorly
Risks of Maternal Mortality caused by various
Types of Heart Disease (ACOG, 1992)
Group 1:
Minimal Risk
0-1% Mortality
Group 2:
Moderate Risk
5-15% Mortality
Group 3:
Major Risk
25-50% Mortality
ASD MS NYHA Class III and IV Pulmonary Hypertension
VSD Aortic Stenosis Aortic coarctation with valve involvement
PDA Aortic coarctation w/o valve involvement
Marfan with aortic involvement
Pulmonic or tricuspid disease
Uncorrected TOF
Previous MI
Tetralogy Fallot, corrected Marfan S w/ normal aorta
Bioprosthetic valve MS with AF
Mitral Stenosis NYHA Class I and II
Artificial Valve
Pulmonary hypertension
Primary – idiopathic Acquired – secondary to an underlying cardiac or pulmonary
disease
Cardiac disease with L to R shunting Pulmo hypertension develops when pulmo
vascular resistance > systemic vascular resistance also called Eisenmenger Syndrome Poor prognosis for mother and pregnancy Mx of labor and delivery problematic Greatest risk when there is diminished venous return
and right ventricular filling
Subacute Bacterial Endocarditis
Infection involving cardiac endothelium producing vegetations in the valves
Refers to a low virulence bacterial infection superimposed on an underlying heart lesion, usually organisms that cause indolent bacterial endocarditis like streptococci or enterococci
Estimates of risk for infective endocarditis with various types of cardiac lesions
High Risk Moderate Risk Not recommended
Prosthetic heart valves Most congenital HD not in low or high risk
category
ASD
Previous endocarditis Acquired valvular dis (RHD)
Surgically corrected lesions w/o prosthesis
( ASD,VSD, PDA)
Complex congenital cyanotic heart dis
Hypertrophic cardiomopathy
Coronary artery dis with previous bypass
Surgically constructed systemic pulmo shunts
MVP w/ valve regurgitation and/ or
thick leaflets
MVP w/o regurgitation
Physiologic murmurs
Previous Rheumatic fever w/o valve dysfunction
Pacemakers
Endocarditis Prophylaxis for Genitourinary and Gastrointestinal Procedures
High Risk patients Ampicillin + Gentamicin
Penicillin -allergic Vancomycin + Gentamicin
Moderate risk patients
(dental procedures)
Amoxicillin or Ampicillin
Pneumonia
Pneumonia –inflammation of lung parenchyma beyond large airways … bronchioles and alveolar units Pneumonitis cause loss of ventilatory capacity and
poorly tolerated by pregnant women Hypoxia and acidosis poorly tolerated by fetus May lead to preterm labor Any pregnant woman suspected of having pneumonia
should undergo Chest AP and Lat x-ray
Bacterial Pneumonia
Common Pathogens Streptococcus pneumoniae Mycoplasma pneumoniae Haemophilus influenzae Chlamydia pneumoniae
Presentation: productive cough, fever, chest pain and dypnea.
Mild leukocytosis, sputum Gram stain, Sputum culture and sensitivity ( poor predictability, only 50% organism identified)
Bacterial pneumonia: Management
Hospitalization Erythromycin in uncomplicated cases, IV intially If Haemophilus pneumonia, Cefotaxime,
cefuroxime, ceftizoxime Since 25% penicillin resistant pneumococcal
pneumonica, Levofloxacin drug of choice in strains resistant to penicillin
Prevention: Pneumococcal vaccine protective against 23 vaccine-related serotypes, 60-70% protective
Viral Pneumonia: Influenza
Influenza – Orthomyxoviridae family, spread by aerosolized droplet Outbreaks every year with global pandemics every
10-15 yrs Influenza A more serious than type B Primary pneumonitis most severe form with scanty
sputum and x-ray picture of interstitial infiltrates Secondary bacterial infection with strep or staph
Viral Pneumonia: Influenza Management
Prevention: VACCINATION after the 1st trimester recommended in all pregnant women
If high risk with underlying heart disease, diabetes, asthma, vaccinate anytime. No evidence for teratogenicity
Management: Supportive rest and anitpyretics Amantidine or Rimantidine to reduce severity of
infection, prevents infection in high risk non-immunized women with exposure
Viral Pneumonia: Varicella-Zoster
Primary infection “chicken pox” attack rate of 90% Fetal Effects: Infection of pregnant woman <20 wks
infects fetus with permanent sequelae: chorioretinitis, cerebral cortical atrophy, hydronephrosis, skin and bony leg defects and scarring
Complications: varicella pneumonia (5-10%) tachypnea, dry cough, dyspnea, fever, chest pain
Chest PA characteristic nodular infiltrates and interstitial pneumonitis
Viral Pneumonia: Varicella management
PROPHYLAXIS: Varicella-zoster immunoglobulin to prevent infection after exposure in susceptible
individuals within 96 hours Because of severity of varicella during pregnancy
immunoglobulin recommended by some Treatment: Varicella pneumonia with IV acyclovir Prevention: Attenuated live varicella vaccine not
recommended in pregnancy
Asthma in Pregnancy
Reversible airway obstruction from bronchial smooth muscle contraction, mucus hypersecretion and mucosal edema
Airway inflammation and responsiveness to stimuli like irritants, viral infections, cold air and exercise
Chronic inflammatory airway problem with a major hereditary component
Spectrum of illness from mild wheezing to severe bronchocenstriction, respiratory failure and death
Asthma: Mangement
Assess pulmonary function Avoid/ control environmental precipitants Patient education Drug therapy:
Beta-agonist Inhaled steroids Cromlyn Sodium Theophylline Leukotriene modifiers
Asthma in Pregnancy
Treatment same as in non-pregnant Continue treatment regimen for asthma during
labor and delivery Non histamine-releasing narcotic for pain
relief Conduction analgesia preferred since tracheal
intubation can trigger severe bronchospasm
Antiphospholipid Antibody Syndrome
Is an immune disorder characterized by production of moderate to high levels of antiphospholipid antibodies and special clinical features:
– Recurrent venous / arterial thrombosis– Cerebral and nervous system disorders– Pregnancy complications
Asheron et al eds. The Antiphospholipid Syndrome, 1996
CRITERIA
CLINICAL CRITERIAVascular thrombosis
Confirmed by imaging, doppler or histopathology
1 unexplained death 10th week AOG
1 premature birth 34th AOG because of:• Severe
preeclampsia or eclampsia
• Severe placental insufficiency
3 consecutive spontaneous abortions 10th week AOG excluding the following as causes:• Maternal anatomic or
hormonal abnormalities
• Maternal and paternal chromosomal abnormalities
Pregnancy Morbidity
NONCRITERIA FEATURES OF APAS
CLINICAL– Livedo reticularis– Cardiac valvulopathy– Seizures, TIA– Thrombocytopenia– AIHA– Pulmonary hypertension
Asherson, 1996
Pregnancy complications
Early and late abortions
Blighted ova
IUGR (30%)
Pre-eclampsia (11-17%)
HELLP syndrome
Asherson et al eds. The antiphospholipid Syndrome, 1996
Subchorionic Hemorrhage
(Abruption)
Oligohydramnios in 1st Trimester
Placental Infarcts
Intervillous Thrombosis
Premature Aging of the Placenta
LABORATORY CRITERIAAnticardiolipin antibodies
– Medium or high titers of ACL on at least 2 occasions 6 wks apart
– IgG, IgM, IgA (?)– ELISA
Lupus anticoagulants (KCT, DRVVT, aPTT)
– Prolonged coagulation– Failure to correct with normal plasma– Corrected with excess phospholipid
– Anti ß2 Glycoprotein-1 IgG and IgM
Treatment of APS
Best treatment: Low dose aspirin ( 60-80mg OD) to block conversion
of arachidonic acid to thromboxane A2 that aggregates platelets and causes vasoconstriction
Low dose heparin (7500 u to 10,000 u SC bid) to prevent thrombotic episodes
Other treatment: Steroids (Prednisone) not widely used for treatment due to
adverse effects Intravenous Immunoglobulins – used when first-line
therapies have failed. Very costly and given monthly
ACOG Proposed Management for Women with APLAs, 1998
Features Pregnant
APS with FDU/RPL UFH prophylactic 15,000 – 20,000 u/day + LD ASA daily +Calcium+Vit D
APS w/ previous VTE or Stroke
UFH full anticoag. Or as prophylactic as above + LD ASA
APS w/o VTE nor RPL No tx, or daily LD ASA, or prophylactic UFH + LD ASA
APLAs w/0 APS or low level antibodies
Uncertain. Same as APS w/o VTE nor RPL
Outcome of Treatment for APAS
• Without treatment: 40-50% births
• With treatment 70-80% live births
• However fetal growth restriction and preeclampsia are still common despite treatment
Systemic Lupus Erythematosus and Pregnancy
SLE, a disease of unknown etiology Tissues and cells of different organ
systems are damaged by autoantibodies and immune complexes
Maternal and Perinatal Effects of SLE
Outcome Description
Maternal
Lupus flare 1/3 of women experience flare during pregnancy
Preeclampsia Controversial if incidence increased
Flare can be life-threatening
Flares associated with worst outcome
Increased incidence with nephritis
Worse with APAs
Preterm labor Increased
Perinatal
Preterm labor Increases with preeclampsia
Growth restriction Increased
Stillbirth Increased with APS
Neonatal lupus About 10%, transient except for heart block
Outcome of pregnancy with SLE
Better if:
1. Lupus quiescent for 6 months
2. No active renal involvement
3. Superimposed preeclampsia does not develop
4. No evidence of antiphospholipid activity
Neonatal LUPUS
Syndrome characterized by: Skin lesions – lupus dermatitis Hematologic: thrombocytopenia, autoimmune
hemolysis Diffuse fetal myocarditis and fibrosis in the
region between AV node and bundle of His causing congenital heart block ( associated with Anti-SS-A (Ro) and anti-SS-B (La) antibodies)
Cardiac lesions permanent if affected and require pacemakers
Urinary Tract Infections
Most common infection in pregnant women BACTERIURIA 2-8%
Coitus is the most important contributing factor UTI can affect any part of the urinary tract
Urethritis Cystitis Pyelonephritis
caused by complex interaction between virulence of pathogen and host defense
Asymptomatic Bacteriuria
Persistent, actively multiplying bacteria in the urinary tract w/o symptoms
Incidence: routine urinalysis on first consult 2-7% will be positive
Bacteriuria seen at initial consult If culture negative, symptomatic UTI <1% If culture positive and persists after delivery, will have
pyelographic evidence of chronic infection
Asymptomatic Bacteriuria
Evidence shows it is unlikely that it can cause low birth weight or prematurity
Controvesial whether it causes maternal hypertension, preeclampsia or anemia
If untreated, 25% develop clinical infection
How Much BACTERIURIA?
Clean voided urine specimen( midstream urine sample after washing external genitalia 2-3x with a cleansing agent before collecting specimen, with 100,000 organisms of a single uropathogen
Lesser number from 20,000 to 50,000 organisms should be treated if symptomatic
If cultures not possible, presence of >10 WBC/hpf Eradication of bacteriuria prevents most of clinical
infections. Recurrences, persistenc of infection treates with
suppressive therapy for remainder of pregnancy e.g Nitrofurantoin 100 mg OD throughout pregnancy
Single Dose Therapy Amoxicillin 3g
Ampicillin 2g
Cephalosporin 2g
Nitrofurantoin 200mg
Sulfonamide 2g
Trimethoprim-sulfamethoxazole 320/1600mg
Three day Therapy Amoxicillin 500 mg TID
Ampicillin 250mg QID
Cephalosporin 250mg QID
Ntrofurantoin 50-100mg QID or 100 mg BID
Sulfonamide 500mg QID
Other Regimens Nitrofurantoin 100mg QID x 10days
Nitrofurantoin 100mg OD at bedtime x 10 days
Treatment Failures Nitrofurantoin 100 mg QID x 21 days
Suppression fro Bacterial persistence or recurrence Nitrofurantoin 100mg OD at bedtime remainder of pregnancy
Seizures in Pregnancy
Seizure –a paroxysmal disorder of the CNS characterized by abnormal neuronal discharge with or without loss of consciousness
Epilepsy is a condition characterized by a tendency to have two or more recurrent seizures unprovoked by any known proximate insult
Partial – originate in one localized area of the brain, usually no loss of consiousness
Generalized – involve both hemispheres of brain simultaneously, preceded by an aura before an abrupt loss of conscousness
Effect of Pregnancy on Epilepsy
Seizure control is unpredictable and variable. Frequency can increase by 30%
1. Nausea and vomiting leading to skipped doses
2. Decreased GI motility and the use of antacids reducing drug absorption
3. Expanded intravascular volume lowering serum drug levels
4. Induction of hepatic, plasma and placental enzymes that increase drug metabolism
Effect of Pregnancy on Epilepsy
5. Increased GFR, increases drug clearance6. Lowering of seizure threshold affected by
sleep deprivation and hyperventilation7. Protein binding of drug is decreased
increasing free drug levels8. fear of fetal effects
Effects of Maternal Epilepsy on Pregnancy
Various reports: Increased vaginal bleeding 2x risk of toxemia Preterm labor Stillbirths due to hypoxia and acidosis
during maternal convulsions
Effects of Maternal Epilepsy on Pregnancy
Risk of fetus inheriting epilepsy depends on nature of mothers seizure disorder.
Risk is higher ( about 2-3%) with idiopathic than acquired causes.
Increased risk of certain congenital malformations caused by the epilepsy itself, the anticonvulsant medication or combination of both
Increased risk of neonatal bleeding due to decreased factors II, VII, IX, X similar to that produced by vitamin K deficiency
The Women with Epilepsy Guidelines Development Group: Best Practice Guidelines for the Management of Women with Epilepsy (1999)
Systematic review of literature (1966-1998) adopted as UK clinical guidelines
Preconception counseling offered to all women of childbearing potential
Change antiepileptic medication should be completed before conception and monotherapy is preferred.
Crawford P, Appleton R, Betts T et al Seizure 1999: 8, 201-217
Consensus Guidelines: Preconception Counseling, Management and Care of the Pregnant Woman with Epilepsy
Antiepileptic drugs are associated with a 2-3 fold increased risk of congenital anomalies; preconceptional counseling is advised.
A detailed ultrasound scan for fetal anomalies at 20 weeks should be performed.
Delgado-Escueta AV, Janz D (1992) Neurology 42, 149-160 (multi-national workshop symposium)
Consensus Guidelines: Preconception Counseling, Management and Care of the Pregnant Woman with Epilepsy
Folic Acid supplements are recommended. If treatment needed monotherapy is preferred
at the lowest effective dose Monitoring unbound or free plasma drug levels
regularly
Delgado-Escueta AV, Janz D (1992) Neurology 42, 149-160 (multi-national workshop symposium)
Prenatal Management
Short acting benzodiazepine may be given in the acute stage if seizures recur
Avoid hypertension Search for the cause of the seizure Some advocate maternal administration
of Vitamin K during the last 4 weeks of pregnancy
Treatment of Status Epilepticus during Pregnancy
Same as in non-pregnant Accurate diagnosis and rapid treatment were
more important than initial choice of anticonvulsant ( Duley L, Guimezoglu AM, Henderson-Smart DG et al (2000) Anticonvulsants for women with preeclampsia. In: Cochrane database of systematic reviews, issue 2. Oxford: Update Software)
Ventilate while maintaining anticonvulsants if anticonvulsants alone fail to control seizures
Labor and delivery
Must be delivered in a hospital setting Continue anticonvulsant medication Seizures may occur during
hyperventilation and sleep deprivation
Postnatal Period
Examine newborn to confirm normality Vitamin K to newborn, or FFP if bleeding
excessive Monitor seizure control and serum levels
dose adjustment may be necessary Breastfeeding is not contraindicated if
anti-epileptics are given
Overall pregnancy need not be discouraged in patients with epilepsy
Risk for fetal congenital anomalies, 2-3x more than the general population, there is still a>90% chance of having a normal baby
Risk of epilepsy in the newborn is more common in idiopathic causes than acquired causes
Patient compliance is paramount in successful management.