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Medical disorders associated with pregnancy • Care for women with pre-existing medical disorders (PEMD) should ideally take place before conception in multidisciplinary pre-pregnancy clinics. • This process should begin during adolescence with discussions about family planning, contraception and pregnancy. • A complete medical history and assessment of health at this time, including obtaining up-to-date investigations, enables a risk assessment for pregnancy to be made. • These risks should be discussed with the woman and her family so that appropriate choices can be made. • - Women with PEMD have high-risk pregnancies and a collaborative multidisciplinary approach is recommended to ensure careful monitoring of both the woman and her fetus. • - Equally midwives and doctors need to be aware and recognize the clinical signs and symptoms of deteriorating maternal health • -Labour and birth in women with PEMD can be a time of additional challenges • Timing and mode of birth should be carefully planned and should take place in a hospital with neonatal facilities. • -disease will put an effect on the physical, psychological, sexual and social aspects of women's lives. • - Involvement of the woman and her family should participate in decisions regarding her care • . *Midwives have a role in supporting women and their families, ensuring that their needs are met and that the pregnancy is treated as normal, as possible Cardiac disease • In most pregnancies, heart disease is diagnosed before pregnancy. • - There is, however, a small but significant group of women who will present at an antenatal clinic with an undiagnosed heart condition. • -Although heart disease complicates <1% of maternities • -it continues to contribute significantly to maternal morbidity and mortality and is the leading cause of maternal death • Heart disease can be broadly classified into ‘congenital’ and ‘acquired’. Congenital heart disease • The most common congenital heart diseases (CHD) -atrial septal defect (ASD) • ventricular septal defect (VSD) • patent ductus arteriosus (PDA), • pulmonary stenosis, • aortic stenosis • tetralogy of Fallot (TOF). • • • • • • • All of them need surgical intervention. -Uncorrected lesions may cause : pulmonary hypertension, cyanosis and severe left ventricular failure and are therefore high risk for pregnancy. CHD is also associated with increased fetal complications : • • • • • These include fetal loss, intrauterine growth restriction, pre-term birth and an increased risk of fetal CHD -high risk cardiac conditions for pregnancy include: Eisenmenger's syndrome • VSD, ASD or PDA • -fibrosis and the development of pulmonary hypertension and cyanosis • - Women with this condition are advised against pregnancy as maternal mortality 30– 50%. The greatest risk to the fetus is prematurity which contributes to the high perinatal mortality rate Marfan's syndrome: • -an autosomal dominant • - defect on chromosome 15. • - It is a connective tissue disease that affects the musculoskeletal system, the cardiovascular system and the eyes. • -The cardiovascular abnormalities are the most life-threatening condition. • -there is a 50% chance of a child inheriting Marfan's syndrome if one parent is affected. • -Women and their partners should be counseled carefully • - Careful monitoring is required throughout pregnancy including the use of serial echocardiography to identify progressive aortic root dilatation. • -Prophylactic antihypertensive therapy using beta-blockers is recommended Acquired heart disease: • -Rheumatic heart disease • -the most common cardiac problem. • - RHD causes inflammation and scarring of the heart valves and results in valve stenosis, plus or minus regurgitation. • The mitral valve is most often affected with stenosis, • c\p: • -severe breathlessness and tiredness for the first time during pregnancy • -Most women with valvular heart disease can be managed medically which aims to reduce the work rate of the heart. • • During pregnancy, this involves bed rest, oxygen therapy and the use of cardiac drugs e.g. diuretics, digoxin and heparin (reduces risk of thromboembolic disease). • Women with more severe symptomatic disease may require surgical intervention such as balloon valvoplasty or valve replacement • Antibiotic prophylaxis is recommended for all women with valvular lesions during labour. Myocardial infarction and ischemic heart disease • • • • • • • • • • • Myocardial infarction (MI) and ischaemic heart disease (IHD) -uncommon cardiac complications -May lead to maternal death. - risk factors include : increasing maternal age obesity diabetes pre-existing hypertension smoking family history inequalities in health • A myocardial infarction is most likely to occur in the third trimester and periperium period due to the hypercoagulability induced by hormonal changes. • - women present with ischemic chest pain in the presence of an abnormal ECG and elevated cardiac enzymes although these signs and symptoms may be masked during labour and birth as • abdominal or epigastric pain and vomiting. • - Primary percutaneous transluminal coronary angioplasty (PTCA) which improves the patency of blocked arteries is first line therapy for this condition Aortic dissection (acute) • -may occur in pregnancy in association with severe hypertension (systolic >160 mmHg) due to: • 1- pre-eclampsia • 2- coarctation of the aorta • 3-connective tissue disease such as Marfan's syndrome. • The woman presents with • severe chest • intrascapular pain. • Early diagnosis using computed tomography chest scan or MRI or as maternal mortality is high . Endocarditis • -Endocarditis is an inflammation of the heart involving the heart valves. • -Although rare in pregnancy, it is one of the most serious complications of heart disease. • Risk group: • Women with valvular heart disease • prosthetic valves • a previous history of endocarditis • periodontal disease • and intravenous substance misusers • - Streptococcal organisms are the most common cause • -Acute endocarditis is due to a Staphylococcus aurous, Streptococcus pneumonia and Neisseria gonorrhea. • -Primary prevention includes recognition of risk factors and • -e.g. good dental hygiene • - avoidance of drug misuse • -early treatment of sepsis • - administration of antibiotic prophylaxis to women with high risk cardiac conditions Peripartum cardiomyopathy: • rare but fatal disease. • - mortality rates range from 25% to 50% . • - occurring between the last month of pregnancy and the first 5 months postpartum • - women have no previous history of heart disease. Risk group: • -older and • - multiparous women, • hypertension, • pre-eclampsia, • • • • • • • obesity diabetes. myocarditis viral infection long-term oral tocolytic therapy and cocaine misuse. • Pathology : • Inflammation and enlargement of the myocardium (cardiomegaly) • left ventricular heart failure • and thromboembolic complications • Treatment : • -use of medication (oxygen, diuretics, vasodilators) to decrease pulmonary congestion and fluid overload, • - inotropic agents to improve myometrial contractility • - and anticoagulation therapy. • • As the cardiomegaly resolves may take up to 6 months and there is a risk of recurrence in a subsequent pregnancy. • -a heart transplant is performed • mortality will be high