Medical and Surgical Medical and Surgical Complications during Complications during

Pregnancy Pregnancy

Heart Deseases in PregnancyHeart Deseases in Pregnancy

Incidence Incidence • Heart disease complicates about 1 percent of pregnancies. Heart disease complicates about 1 percent of pregnancies.

ComponentComponent • congenital heart diseasecongenital heart disease

• rheumatic heart diseaserheumatic heart disease

• hypertensive heart diseasehypertensive heart disease

• other varieties (inclued: pregnancy-induced hypertension, other varieties (inclued: pregnancy-induced hypertension,

thyroid, coronary, syphilitic, and kyphoscoliotic cardiac thyroid, coronary, syphilitic, and kyphoscoliotic cardiac

disease)disease)

• idiopathic cardiomyopathy (perinatal cardiomyopathy)idiopathic cardiomyopathy (perinatal cardiomyopathy)

• isolated myocarditis isolated myocarditis

• various forms of heart blockvarious forms of heart block

• 0.3 per 10,000 live births 0.3 per 10,000 live births

Heart disease still significantly contributes to Heart disease still significantly contributes to

maternal mortality.maternal mortality.

• 5.6-8.5 percent of maternal deaths 5.6-8.5 percent of maternal deaths

Maternal mortalityMaternal mortality

Effect of pregnancy on heart diseaseEffect of pregnancy on heart disease The pregnant period The pregnant period • Cardiac output is increased by as much as 30-50 percentCardiac output is increased by as much as 30-50 percent

almost half of the total increase has occurred by 8 almost half of the total increase has occurred by 8

weeks, and it is maximized by mid pregnancy.weeks, and it is maximized by mid pregnancy.

• Total blood volume is increased about 35%.Total blood volume is increased about 35%. from 6th week to 32nd weekfrom 6th week to 32nd week

• Stroke volume is increased by 20-40%.Stroke volume is increased by 20-40%.

• Resting pulse is increased (by 10-17%)Resting pulse is increased (by 10-17%)

• The changes of anatomic positionsThe changes of anatomic positions heart, diaphragm, uterus.heart, diaphragm, uterus.

formation of utero-placental circulationformation of utero-placental circulation

Labor and delivery Labor and delivery • Consumption of energy and oxygen is further increased.Consumption of energy and oxygen is further increased.

• Labor is increased maternal cardiac burdens.Labor is increased maternal cardiac burdens.

• Expulsion of the fetus and placenta produce a drematicExpulsion of the fetus and placenta produce a drematic

hemodynamic changes . hemodynamic changes . The puerperium The puerperium • After delivery of the fetus and placenta, during 1-2 days,After delivery of the fetus and placenta, during 1-2 days,

great amont of blood return into the systemic circulation,great amont of blood return into the systemic circulation,

and great amont of fluid from intertissue space return toand great amont of fluid from intertissue space return to

the systemic circulation, increase cardiac burdens again. the systemic circulation, increase cardiac burdens again. 

• 32-34 gestational weeks, during the labor and delivery,32-34 gestational weeks, during the labor and delivery,

and early postpartum period (1-3 days) are the mostand early postpartum period (1-3 days) are the most

danger time for pregnant women with heart disease. It danger time for pregnant women with heart disease. It

is easy development heart failure.is easy development heart failure.

Clinical ClassificationClinical Classification ((By the New York Heart Association)By the New York Heart Association)

Class IClass I Uncompromised: Uncompromised:

Patients with cardiac disease and no limitation of Patients with cardiac disease and no limitation of physical activity. They do not have symptoms of cardiac physical activity. They do not have symptoms of cardiac insufficiency, nor do they experience anginal pain.insufficiency, nor do they experience anginal pain.

Class IIClass II Slightly compromised: Slightly compromised: Patients with cardiac disease and slight limitation Patients with cardiac disease and slight limitation

of physical activity. These women are comfortable at of physical activity. These women are comfortable at rest, but if ordinary physical activity is undertaken, rest, but if ordinary physical activity is undertaken, discomfort results in the form of excessive fatigue, discomfort results in the form of excessive fatigue, palpitation, dyspnea, or anginal pain. palpitation, dyspnea, or anginal pain.

Class IIIClass III Markedly compromised: Markedly compromised:

Patients with cardiac disease and marked Patients with cardiac disease and marked limitation of physical activity. They are comfortable limitation of physical activity. They are comfortable at rest, but less than ordinary physical activity causes at rest, but less than ordinary physical activity causes discomfort by excessive fatigue, palpitation, dyspnea, discomfort by excessive fatigue, palpitation, dyspnea, or anginal pain.or anginal pain.

Class IVClass IV Severely compromised: Severely compromised: Patients with cardiac disease and inability to Patients with cardiac disease and inability to

perform any physical activity without discomfort. perform any physical activity without discomfort. Symptoms of cardiac insufficiency or angina may Symptoms of cardiac insufficiency or angina may development at rest, and if any physical activity is development at rest, and if any physical activity is undertaken, discomfort is increased.undertaken, discomfort is increased.

Clinical Classification Clinical Classification (con’t)(con’t)

Diagnosis of heart disease Diagnosis of heart disease

Many of the physiological changes of normal Many of the physiological changes of normal pregnancy tend to make the diagnosis of heart pregnancy tend to make the diagnosis of heart disease more difficult.disease more difficult.

Disease history, SymptomsDisease history, Symptoms andand Clinical FindingsClinical Findings

Listed in here symptoms and clinical findings Listed in here symptoms and clinical findings may indicate heart disease: may indicate heart disease:

• Severe or progressive dyspneaSevere or progressive dyspnea

• Progressive orthopneaProgressive orthopnea

• Paroxysmal nocturnal dyspneaParoxysmal nocturnal dyspnea

• HemoptysisHemoptysis

• Syncope with exertionSyncope with exertion

• Chast pain related to effort or emotionChast pain related to effort or emotion

• Clinical FindingsClinical Findings

• CyanosisCyanosis

• Clubing of fingersClubing of fingers

SymptomsSymptoms

• Persistent neck vein distensionPersistent neck vein distension

• Systolic murmur greater than grade 3/6Systolic murmur greater than grade 3/6

• Diastolic murmurDiastolic murmur

• CardiomegalyCardiomegaly

• Sustained arrhythmiaSustained arrhythmia

• Persistent split second soundPersistent split second sound

• Criteria for pulmonary hypertensionCriteria for pulmonary hypertension

• Left parasternal liftLeft parasternal lift

• Loud P2Loud P2

Symptoms Symptoms (con’t)(con’t)

Conventional testsConventional tests • ElectrocardiographyElectrocardiography

• Ecocardiography Ecocardiography

• Chast X-rayChast X-ray

Diagnosis of early heart failure during pregnancyDiagnosis of early heart failure during pregnancy • Dyspnea, palpitation at slight physical activity.Dyspnea, palpitation at slight physical activity.

• Resting pulse larger than 110 beats per minute.Resting pulse larger than 110 beats per minute.

• Paroxysmal nocturnal dyspnea.Paroxysmal nocturnal dyspnea.

• Rale in lower lungsRale in lower lungs

Prognosis Prognosis

The likelihood of a favorable outcome for the mother The likelihood of a favorable outcome for the mother

with heart disease depends upon the with heart disease depends upon the

(1) functional cardiac capacity(1) functional cardiac capacity

(2) other complications that further increase cardiac load (2) other complications that further increase cardiac load

(3) quality of medical care provided.(3) quality of medical care provided.

Counseling (Preconceptional counceling).Counseling (Preconceptional counceling).

(to decide the pregnancy should be continued)(to decide the pregnancy should be continued)

Intensive pregnatal care.Intensive pregnatal care.

Active prevent factors increasing cardiac Active prevent factors increasing cardiac

functional load.functional load.

(such as respiratory tract infection, anemia and (such as respiratory tract infection, anemia and pregnancy-induced hypertension) pregnancy-induced hypertension)

ManagementManagement

General managementGeneral management

Monitoring the vital signsMonitoring the vital signs

Sedatives and analgesicSedatives and analgesic

Shortening the second stage of labor Shortening the second stage of labor

(by forceps)(Classes I and II)(by forceps)(Classes I and II)

Indications of CS (cesarean section)Indications of CS (cesarean section)

(Class III or more, obstetric indications,)(Class III or more, obstetric indications,)

Management during labor and deliveryManagement during labor and delivery

Bring pressure to bear on the upper abdomenBring pressure to bear on the upper abdomen

Bed rest Bed rest

Monitoring the vital signsMonitoring the vital signs

Breast feeding (Classes I and II) and Breast feeding (Classes I and II) and

artificial feeding (Classes III or IV) artificial feeding (Classes III or IV)

Management or early puerperiumManagement or early puerperium

Medical and Surgical Medical and Surgical Complications during Complications during

Pregnancy Pregnancy

Acute Viral HepatitisAcute Viral Hepatitis

Hepatitis is the most common serious liver diseaseHepatitis is the most common serious liver disease

encountered in pregnant women.encountered in pregnant women. There are at least five distinct types of viral hepatitis:There are at least five distinct types of viral hepatitis:

hepatitis A; hepatitis B; hepatitis C(non-A and non-Bhepatitis A; hepatitis B; hepatitis C(non-A and non-B

hepatitis); hepatitis D; and hepatitis E. hepatitis); hepatitis D; and hepatitis E. In pregnancy complicate hepatitis , hepatitis B isIn pregnancy complicate hepatitis , hepatitis B is

common. common. The incidence of acute viral hepatitis during pregnancy The incidence of acute viral hepatitis during pregnancy

is about 6fold increased than non-pregnancy, and theis about 6fold increased than non-pregnancy, and the

fulminant hepatitis is 66 times increased than non-fulminant hepatitis is 66 times increased than non-

pregnancy.pregnancy. Hepatitis B is transmitted by infected blood, blood Hepatitis B is transmitted by infected blood, blood

products, and in saliva, vaginal secretions, and semen. It products, and in saliva, vaginal secretions, and semen. It

is a sexually transmitted disease.is a sexually transmitted disease.

Delta hepatitis ( hepatitis D) is a defective RNA virusDelta hepatitis ( hepatitis D) is a defective RNA virus

that is a hybrid particle with a hepatitis B surfacethat is a hybrid particle with a hepatitis B surface

antigen coat and a delta core. The virus must co-infectantigen coat and a delta core. The virus must co-infect

with hepatitis B and cannot persist in serum longerwith hepatitis B and cannot persist in serum longer

than hepatitis B virus. It transmission is similar tothan hepatitis B virus. It transmission is similar to

hepatitis B viral infection.hepatitis B viral infection. Transmission of hepatitis C infection appears to beTransmission of hepatitis C infection appears to be

identical to hepatitis B.identical to hepatitis B. Hepatitis E is a waterborne RNA virus that is entericallyHepatitis E is a waterborne RNA virus that is enterically

transmitted. transmitted. Hepatitis A is transmitted by the fecal-oral route. Hepatitis A is transmitted by the fecal-oral route.

Effect of pregnancy on hepatitisEffect of pregnancy on hepatitis

The course of hepatitis B infection in the mother The course of hepatitis B infection in the mother

does not seem to be altered by pregnancy.However,does not seem to be altered by pregnancy.However,

at least in some underprivileged populations, both at least in some underprivileged populations, both

perinatal and maternal deaths are substantively perinatal and maternal deaths are substantively

increased for hepatitis A and B. increased for hepatitis A and B.

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

Effect on pregnancyEffect on pregnancy Mother:Mother:

• Increasing nausea and vomiting early in pregnancy.Increasing nausea and vomiting early in pregnancy.

• Increasin the incidence of pregnancy-inducedIncreasin the incidence of pregnancy-induced

hypertension in late pregnancy.hypertension in late pregnancy.

• Increasing the incidence of postpartum hemorrhage.Increasing the incidence of postpartum hemorrhage. Fetus ans Infants:Fetus ans Infants:

• AbortionAbortion

• Preterm deliveryPreterm delivery

• Fetal deathsFetal deaths

• Increasing the antenatal mortality rateIncreasing the antenatal mortality rate

• Affected the fetus and infants (maternal-fetalAffected the fetus and infants (maternal-fetal

transmission)transmission)

Diagnosis Diagnosis

• History History contect with hepatitis patients, used blood and contect with hepatitis patients, used blood and

blood products,…..blood products,…..

• Clinical symptoms and findingsClinical symptoms and findings

• Serological tests Serological tests liver function, identifying of viris antigen and liver function, identifying of viris antigen and

antibodies)antibodies)

• Jaundice is deeper rapidly. Serous bilirubin>171umol/L Jaundice is deeper rapidly. Serous bilirubin>171umol/L

(10mg/dL)(10mg/dL)

• The size of liver is diminished quickly .The size of liver is diminished quickly .

• Ascites, anorexia, severe vomiting.Ascites, anorexia, severe vomiting.

• Hepatic encephalopathy.Hepatic encephalopathy.

• Hepatic-renal syndrome ( acute renal failure)Hepatic-renal syndrome ( acute renal failure)

• Severe liver function impairment. Severe liver function impairment.

Diagnosis of severe acute hepatitisDiagnosis of severe acute hepatitis

• Hyperemesis gravidarumHyperemesis gravidarum

• Preeclampsia (HELLP)Preeclampsia (HELLP)

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

• Acute fatty liver of pregnancyAcute fatty liver of pregnancy

• Liver impairment from drugs overdose.Liver impairment from drugs overdose.

Defferential diagnosis Defferential diagnosis

Management Management

• Supportive medical measures as for the nonpregnantSupportive medical measures as for the nonpregnant

patient.patient.rest, adequate nutrition, vitamins, sufficient protein,rest, adequate nutrition, vitamins, sufficient protein,

carbohydrate, low fatty diet.carbohydrate, low fatty diet.

• Obstetric managementObstetric management

Early stage of pregnancy:Early stage of pregnancy: active treatment the disease, active treatment the disease,

then artificial abortion should be performed.then artificial abortion should be performed.

During midpregnancy and late pregnancy,During midpregnancy and late pregnancy, vitamin K vitamin K

and C should be admited, and active prevent pregnancy-and C should be admited, and active prevent pregnancy-

induced hypertension. induced hypertension.

• Obstetric management (con’t)Obstetric management (con’t) During labor and delivery:During labor and delivery: vitamin K is admited, vitamin K is admited,

prepairing frash blood ; avoid operative obstetricprepairing frash blood ; avoid operative obstetric

intervention; shortening the second stage of labor(by aintervention; shortening the second stage of labor(by a

vacuum); preventing the laceration of the birth canal;vacuum); preventing the laceration of the birth canal;

preventin retained placental fragmants or membranes;preventin retained placental fragmants or membranes;

using of oxytocin.using of oxytocin.

Postpartum period:Postpartum period: Antibiotic drugs, artificial feeding, Antibiotic drugs, artificial feeding,

lactifuge; infant isolationlactifuge; infant isolation

Prevented by the administration of hepatitis B immunePrevented by the administration of hepatitis B immune

globulin after birth, followed promptly by hepatitis B globulin after birth, followed promptly by hepatitis B

vaccine in newborn infant.vaccine in newborn infant.

• Treatment of severe hepatitis properly.Treatment of severe hepatitis properly.

Intrahepatic cholestasis Intrahepatic cholestasis of pregnancy of pregnancy （（ ICPICP ））妊娠肝内胆汁郁积症妊娠肝内胆汁郁积症

Pruritus occurring in pregnancy ,in the absence ofPruritus occurring in pregnancy ,in the absence of

dermatologic abnormalities,is usually due to ICPdermatologic abnormalities,is usually due to ICP Symptoms(pruritus)usually commence between 28 Symptoms(pruritus)usually commence between 28

and 34 weeksand 34 weeks

Incidence: 1-2/1000 pregnancies.Incidence: 1-2/1000 pregnancies.

ICP should be suspected when widespread pruritus occurs ICP should be suspected when widespread pruritus occurs

in the third trimester.in the third trimester.

without skin rash.without skin rash.

High levels of bile acids(5-100 times normal)High levels of bile acids(5-100 times normal)

Bilirubin appears in the urine.Bilirubin appears in the urine.

(in most ),alkaline phosphatase and bilirubin be elevated.(in most ),alkaline phosphatase and bilirubin be elevated.

transaminases is elevated (in many)transaminases is elevated (in many)

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

DiagnosisDiagnosis

For the mother,it carries a 10-22% risk of For the mother,it carries a 10-22% risk of

obstetric Hemorrhage,and preterm labor.obstetric Hemorrhage,and preterm labor.

For the fetal prognosis,stillbirth(up to 15%),For the fetal prognosis,stillbirth(up to 15%),

Preterm delivery (up to 30%),Preterm delivery (up to 30%),

fetal distress(up to 25%),fetal distress(up to 25%),

and meconium staining of the amniotic fluidand meconium staining of the amniotic fluid

(30-40%),(30-40%),

The mechanism of fetal compromise is uncertain.The mechanism of fetal compromise is uncertain.

Maternal/Fetal RisksMaternal/Fetal Risks

Prenatal Prenatal monitoring of fetal well being;monitoring of fetal well being;

timing of delivary;timing of delivary;

maternal symptom control;maternal symptom control;

vitamin K supplementation.vitamin K supplementation.

intramuscular Vit.K 10mg weekly should be given from 36 weeks. intramuscular Vit.K 10mg weekly should be given from 36 weeks.

IntrapartumIntrapartum Vitamin K 10mg is given to mother; Vitamin K 10mg is given to mother;

The newborn body should receive Vitamin KThe newborn body should receive Vitamin K

(there is evidence of a bleeding tendency).(there is evidence of a bleeding tendency).

PostnatalPostnatal Biliary tract ultrasonography (for stones), Biliary tract ultrasonography (for stones),

(if pruritus does not disapear >7-10 days after delivery.)(if pruritus does not disapear >7-10 days after delivery.)

In occasional case where abnormalities do not resolve In occasional case where abnormalities do not resolve

after delivery ,liver biopsy may need consideration.after delivery ,liver biopsy may need consideration.

ManagementManagement

Medical and Surgical Medical and Surgical Complications during Complications during

Pregnancy Pregnancy

Chronic Glomerulonephritis And Chronic Glomerulonephritis And PyelonephritisPyelonephritis

• Urinary tract dilation(It involves dilatation of the renalUrinary tract dilation(It involves dilatation of the renal

calyces and pelves,as well as the ureters)These changes calyces and pelves,as well as the ureters)These changes

are more promiment on the right side.are more promiment on the right side.

• The size of kidney increases 1cm.The size of kidney increases 1cm.

• The glomerular filtration rate increases about 50%.The glomerular filtration rate increases about 50%.

• The renal plasma flow increases about 35%.The renal plasma flow increases about 35%.

These changes create urinary stasis,and may lead to serious These changes create urinary stasis,and may lead to serious upper urinary infections.upper urinary infections.

Urinary Tract Changes during PregnancyUrinary Tract Changes during Pregnancy

• Urinalysis is essential.Urinalysis is essential.

• Most degree that proteinuria must exceed 500mg/day to beMost degree that proteinuria must exceed 500mg/day to be

considered abnormal for pregnancy.considered abnormal for pregnancy.

• If the serum creatinine persistently exceeds 0.9mg/dl If the serum creatinine persistently exceeds 0.9mg/dl

(75umol/L), then intrinsic renal disease should be (75umol/L), then intrinsic renal disease should be suspected.suspected.

• Ultrasonogaphy provides imaging of renal size and relativeUltrasonogaphy provides imaging of renal size and relative

consistency,as well as elements of obstruction.consistency,as well as elements of obstruction.

• If necessary,cystoscop, intravenous pyelography, or renal If necessary,cystoscop, intravenous pyelography, or renal

biopsy may be considered.biopsy may be considered.

Assessment of Renal Disease During Assessment of Renal Disease During Preg1ancyPreg1ancy

IncidenceIncidence• About 1-2% of pregnancies.About 1-2% of pregnancies.

Acute Pyelonephritis is the most common seriousAcute Pyelonephritis is the most common serious

medical complication of pregnancy.medical complication of pregnancy.

• Pyelonephritis is more common after midpregnancy.It is Pyelonephritis is more common after midpregnancy.It is

unilateral and right-sided in more than half of cases,andunilateral and right-sided in more than half of cases,and

bilateral in one fourth.bilateral in one fourth.

• In most women, renal parenchymal infection is caused byIn most women, renal parenchymal infection is caused by

bacteria that ascend from the lower tract.bacteria that ascend from the lower tract.

Acute PyelonephritisAcute Pyelonephritis

Effect on pregnancyEffect on pregnancy

• The high fever can creates abortion, preterm labor.The high fever can creates abortion, preterm labor.

• In the first trimester, malformations are increase.In the first trimester, malformations are increase.

(such as spinal defects)(such as spinal defects)

• Toxic shock.(by bacteria toxin) Toxic shock.(by bacteria toxin)

Clinical findingsClinical findings• General symptoms:General symptoms:

o The onset of pyelonephritis is usually rather abrupt.The onset of pyelonephritis is usually rather abrupt.

o High fever (as well as 40degree C),High fever (as well as 40degree C),

Shaking chills.(thermoregulatory instability)Shaking chills.(thermoregulatory instability)

o Nausea and vomitingNausea and vomiting

o HeadacheHeadache

Clinical findings(con’t)Clinical findings(con’t)• Urinary systemic symptoms:Urinary systemic symptoms:

o Aching pain in one or both lumbar regions.Aching pain in one or both lumbar regions.

o Tenderness in one or both costovertebral angles Tenderness in one or both costovertebral angles

(by percussion)(by percussion)

o Dysuria,urgency,and frequency.Dysuria,urgency,and frequency.

• Asymptomatic bacteriuriaAsymptomatic bacteriuria

The reported prevalence of asymptomatic bacteria The reported prevalence of asymptomatic bacteria

during pregnancy varies from 2-7%.during pregnancy varies from 2-7%.

• About 15% of women with acute pyelonephritis alsoAbout 15% of women with acute pyelonephritis also

have bacteremia.have bacteremia.

Clinical findings(con’t)Clinical findings(con’t)

• Transient renal dysfunction:Transient renal dysfunction:

o Elevated serum creatinineElevated serum creatinine

o Decreased creatinine clearanceDecreased creatinine clearance

• Hematological dysfunction:Hematological dysfunction:

o HemolysisHemolysis

o AnemiaAnemia

o ThrombocytopeniaThrombocytopenia

• Pulmonary dysfunctionPulmonary dysfunction

Adult respiratory distress syndromeAdult respiratory distress syndrome

DiagnosisDiagnosis• Clinical findingsClinical findings

• Urine specimen examination is anomaly.Urine specimen examination is anomaly.

• A clean-voided specimen containing more than 100,000 A clean-voided specimen containing more than 100,000

organisms of a single uropathogen per mL.organisms of a single uropathogen per mL.

• Positive urine culture.Positive urine culture.

ManagementManagement

• HospitalizationHospitalization

• Urine and blood culturesUrine and blood cultures

• Complete blood count, serum crsatinine, and electrolytesComplete blood count, serum crsatinine, and electrolytes

• Monitor vital signs frequently,including urinary output Monitor vital signs frequently,including urinary output

(place indwelling bladder catheter if necessary)(place indwelling bladder catheter if necessary)

Management(con’t)Management(con’t)

• Intravenous crystalloid to establish urinary output to at Intravenous crystalloid to establish urinary output to at

least 30mL/hrleast 30mL/hr

• Intravenous antimicrobial therapyIntravenous antimicrobial therapy

• Chest X-ray if there is dyspnea or tachypneaChest X-ray if there is dyspnea or tachypnea

• Repeat hematology and chemistry studies in 48 hoursRepeat hematology and chemistry studies in 48 hours

• Change to oral antimicrobils when afebrileChange to oral antimicrobils when afebrile

• Discharge after afebrile 24 hours,consider antimicrobialDischarge after afebrile 24 hours,consider antimicrobial

therapy for 7-10 daystherapy for 7-10 days

• Urine culture 1-2weeks after antimicrobial therapy completedUrine culture 1-2weeks after antimicrobial therapy completed

• Treatment of complicationsTreatment of complications

This is characterized by progressive renal destruction over a This is characterized by progressive renal destruction over a period of yean or decades, eventually producing the end-stage period of yean or decades, eventually producing the end-stage kidney. Usually persistent proteinuria and hematuria kidney. Usually persistent proteinuria and hematuria accompany a gradual decline in renal function. accompany a gradual decline in renal function.

Effect of glomerullonephritis on pregnancyEffect of glomerullonephritis on pregnancy• Delivered preterm,(as high as 25%)Delivered preterm,(as high as 25%)

• Fetuses intrauterine growth retadatio(IUGR,>15%)Fetuses intrauterine growth retadatio(IUGR,>15%)

• Perinatal mortality rate 8%(after 28 gestational weeks)Perinatal mortality rate 8%(after 28 gestational weeks)

• Factors that portended the worst perinatal prognosis includedFactors that portended the worst perinatal prognosis included

impaired renal function, early or severe hypertension,and impaired renal function, early or severe hypertension,and

nephrotic-range proteinuria.nephrotic-range proteinuria.

Chronic GlomeruIonephritisChronic GlomeruIonephritis

kaplan's Typingkaplan's TypingType IType I Have only proteinuria and edema without Have only proteinuria and edema without

hypertension and renal function impairment.hypertension and renal function impairment.

Type IIType II Have proteinuria and hypertension and without Have proteinuria and hypertension and without

renal function impairment.renal function impairment.

Type IIIType III All proteinuria,hypertension and renal function All proteinuria,hypertension and renal function

impairment exist.impairment exist.

Lindheimer categories:Lindheimer categories:• Mild impairment of renal function:serum creatinine Mild impairment of renal function:serum creatinine

<1.5mg/dL and minimal hypertension;<1.5mg/dL and minimal hypertension;

• Moderate impairment of renal function: serum creatinine Moderate impairment of renal function: serum creatinine

of 1.5-3.0mg/dLof 1.5-3.0mg/dL

• Severe renal insufficiency:serum creatinine >3. 0mg/dLSevere renal insufficiency:serum creatinine >3. 0mg/dL

Common ComplicationsCommon Complications (in moderate and severe renal insufficiency)(in moderate and severe renal insufficiency)

• chronic hypertemion(70%)chronic hypertemion(70%)

• anemia (75%)anemia (75%)

• preeclampsia (60%)preeclampsia (60%)

• preterm delivery (35%)preterm delivery (35%)

• fetal growth restriction (30%)fetal growth restriction (30%)

• fetal deathfetal deathManagementManagement• Diet:lower phosphorus,lower protein(high quality)Diet:lower phosphorus,lower protein(high quality)

• Control hypertensionControl hypertension

• Prevention of infectionPrevention of infection

• Intensive prenatal careIntensive prenatal care

• Termination of pregnancy timelyTermination of pregnancy timely