Medical and Surgical Complications during Pregnancy Heart Deseases in Pregnancy Heart Deseases in...

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  • Medical and Surgical Complications during Pregnancy

    Heart Deseases in Pregnancy

  • Incidence Heart disease complicates about 1 percent of pregnancies.

    Component congenital heart disease rheumatic heart disease hypertensive heart disease other varieties (inclued: pregnancy-induced hypertension, thyroid, coronary, syphilitic, and kyphoscoliotic cardiac disease) idiopathic cardiomyopathy (perinatal cardiomyopathy) isolated myocarditis various forms of heart block

  • 0.3 per 10,000 live births Heart disease still significantly contributes to maternal mortality.

    5.6-8.5 percent of maternal deaths Maternal mortality

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

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

  • Clinical Classification (By the New York Heart Association) Class I Uncompromised: Patients with cardiac disease and no limitation of physical activity. They do not have symptoms of cardiac insufficiency, nor do they experience anginal pain.

    Class II Slightly compromised: Patients with cardiac disease and slight limitation of physical activity. These women are comfortable at rest, but if ordinary physical activity is undertaken, discomfort results in the form of excessive fatigue, palpitation, dyspnea, or anginal pain.

  • Clinical Classification (cont)Class III Markedly compromised: Patients with cardiac disease and marked limitation of physical activity. They are comfortable at rest, but less than ordinary physical activity causes discomfort by excessive fatigue, palpitation, dyspnea, or anginal pain.

    Class IV Severely compromised: Patients with cardiac disease and inability to perform any physical activity without discomfort. Symptoms of cardiac insufficiency or angina may development at rest, and if any physical activity is undertaken, discomfort is increased.

  • Diagnosis of heart disease Many of the physiological changes of normal pregnancy tend to make the diagnosis of heart disease more difficult.Disease history, Symptoms and Clinical Findings Listed in here symptoms and clinical findings may indicate heart disease:

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

  • Persistent neck vein distension Systolic murmur greater than grade 3/6 Diastolic murmur Cardiomegaly Sustained arrhythmia Persistent split second sound Criteria for pulmonary hypertension Left parasternal lift Loud P2Symptoms (cont)

  • Conventional tests Electrocardiography Ecocardiography Chast X-ray

    Diagnosis of early heart failure during pregnancy Dyspnea, palpitation at slight physical activity. Resting pulse larger than 110 beats per minute. Paroxysmal nocturnal dyspnea. Rale in lower lungs

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

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

  • Monitoring the vital signsSedatives and analgesicShortening the second stage of labor (by forceps)(Classes I and II)Indications of CS (cesarean section)(Class III or more, obstetric indications,) Management during labor and delivery

  • Bring pressure to bear on the upper abdomenBed rest Monitoring the vital signsBreast feeding (Classes I and II) and artificial feeding (Classes III or IV) Management or early puerperium

  • Medical and Surgical Complications during Pregnancy

    Acute Viral Hepatitis

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

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

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

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

  • Diagnosis History contect with hepatitis patients, used blood and blood products,..

    Clinical symptoms and findings

    Serological tests liver function, identifying of viris antigen and antibodies)

  • Diagnosis of severe acute hepatitis Jaundice is deeper rapidly. Serous bilirubin>171umol/L (10mg/dL)

    The size of liver is diminished quickly .

    Ascites, anorexia, severe vomiting.

    Hepatic encephalopathy.

    Hepatic-renal syndrome ( acute renal failure)

    Severe liver function impairment.

  • Defferential diagnosis Hyperemesis gravidarum

    Preeclampsia (HELLP)

    Intrahepatic cholestasis of pregnancy (ICP)

    Acute fatty liver of pregnancy

    Liver impairment from drugs overdose.

  • Management Supportive medical measures as for the nonpregnant, adequate nutrition, vitamins, sufficient protein, carbohydrate, low fatty diet.

    Obstetric management Early stage of pregnancy: active treatment the disease, then artificial abortion should be performed. During midpregnancy and late pregnancy, vitamin K and C should be admited, and active prevent pregnancy- induced hypertension.

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

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

  • ICP should be suspected when widespread pruritus occurs in the third trimester. without skin rash. High levels of bile acids(5-100 times normal) Bilirubin appears in the urine. (in most ),alkaline phosphatase and bilirubin be elevated. transaminases is elevated (in many)

    for differential diagnosis ,hepatitis serology ,hepatobiliary tract ultrasonoguaphy and autoantibodies screan should be performed in all cases.(ultrasonography is very important to exclude abstruction of the biliary tree.)Diagnosis

  • For the mother,it carries a 10-22% risk of obstetric Hemorrhage,and preterm labor.

    For the fetal prognosis,stillbirth(up to 15%), Preterm delivery (up to 30%), fetal distress(up to 25%), and meconium staining of the amniotic fluid (30-40%),The mechanism of fetal compromise is uncertain.Maternal/Fetal Risks

  • Prenatal monitoring of fetal well being; timing of delivary; maternal symptom control; vitamin K supplementation. intramuscular Vit.K 10mg weekly should be given from 36 weeks. Intrapartum Vitamin K 10mg is given to mother;The newborn body should receive Vitamin K (there is evidence of a bleeding tendency).Postnatal Biliary tract ultrasonography (for stones), (if pruritus does not disapear >7-10 days after delivery.) In occasional case where abnormalities do not resolve after delivery ,liver biopsy may need consideration.Management

  • Medical and Surgical Complications during Pregnancy

    Chronic Glomerulonephritis And Pyelonephritis

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

    These changes create urinary stasis,and may lead to serious upper urinary infections.Urinary Tract Changes during Pregnancy

  • Urinalysis is essential. Most degree that proteinuria must exceed 500mg/day to be considered abnormal for pregnancy. If the serum creatinine persistently exceeds 0.9mg/dl (75umol/L), then intrinsic renal disease should be suspected. Ultrasonogaphy provides imaging of renal size and relative consistency,as well as elements of obstruction. If necessary,cystoscop, intravenous pyelography, or renal biopsy may be considered.Assessment of Renal Disease During Preg1ancy

  • Incidence About 1-2% of pregnancies. Acute Pyelonephritis is the most common serious medical complication of pregnancy.

    Pyelonephritis is more common after midpregnancy.It is unilateral and right-sided in more than half of cases,and bilateral in one fourth.

    In most women, renal parenchymal infection is caused by bacteria that ascend from the lower tract.Acute Pyelonephritis

  • Effect on pregnancy The high fever can creates abortion, preterm labor. In the first trimester, malformations are increase. (such as spinal defects) Toxic shock.(by bacteria toxin) Clinical findings General symptoms: The onset of pyelonephritis is usually rather abrupt. High fever (as well as 40degree C), Shaking chills.(thermoregulatory instability) Nausea and vomiting Headache

  • Clinical findings(cont) Urinary systemic symptoms: Aching pain in one or both lumbar regions. Tenderness in one or both costovertebral angles (by percussion) Dysuria,urgency,and frequency. Asymptomatic bacteriuriaThe reported prevalence of asymptomatic bacteria during pregnancy varies from 2-7%. About 15% of women with acute pyelonephritis also have bacteremia.

  • Clinical findings(cont)

    Transient renal dysfunction: Elevated serum creatinine Decreased creatinine clearance Hematological dysfunction: Hemolysis Anemia Thrombocytopenia Pulmonary dysfunction Adult respiratory distress syndrome

  • Diagnosis Clinical findings Urine specimen examination is anomaly. A clean-voided specimen containing more than 100,000 organisms of a single uropathogen per mL. Positive urine culture. Management Hospitalization Urine and blood cultures Complete blood count, serum crsatinine, and electrolytes Monitor vital signs frequently,including urinary output (place indwelling bladder catheter if necessary)

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

  • This is characterized by progressive renal destruction over a period of yean or decades, eventually producing the end-stage kidney. Usually persistent proteinuria and hematuria accompany a gradual decline in renal function. Effect of glomerullonephritis on pregnancy Delivered preterm,(as high as 25%) Fetuses intrauterine growth retadatio(IUGR,>15%) Perinatal mortality rate 8%(after 28 gestational weeks) Factors that portended the worst perinatal prognosis included impaired renal function, early or severe hypertension,and nephrotic-range proteinuria.Chronic GlomeruIonephritis

  • kaplan's TypingType I Have only proteinuria and edema without hypertension and renal function impairment.Type II Have proteinuria and hypertension and without renal function impairment.Type III All proteinuria,hypertension and renal function impairment exist.Lindheimer categories: Mild impairment of renal function:serum creatinine 3. 0mg/dL

  • Common Complications (in moderate and severe renal insufficiency) chronic hypertemion(70%) anemia (75%) preeclampsia (60%) preterm delivery (35%) fetal growth restriction (30%) fetal deathManagement Diet:lower phosphorus,lower protein(high quality) Control hypertension Prevention of infection Intensive prenatal care Termination of pregnancy timely