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.