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Medical-Surgical
PROBLEMS
in Pregnancy
Lectures 7
Prepared by MD, PhD Kuziv I.
Heart Diseases 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
Maternal mortality
• 0.3 per 10,000 live
births
Heart disease still
significantly contributes
to
• 5.6-8.5 percent of
maternal deaths
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
Symptoms
• Severe or progressive dyspnea
• Progressive orthopnea
• Paroxysmal nocturnal dyspnea
• Hemoptysis
• Syncope with exertion
• Chest pain related to effort or
emotion
• Clinical Findings
• Cyanosis
• Clubing of fingers
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.
What is preeclampsia?
Triad of criteria

 BP of 30 mmHg systolic or  15 mmHg diastolic as
compared to BP prior to 20 weeks gestation. (The  BP
must be present on 2 occasions taken 6 hours apart; if
previous BP is unknown, 140/90 after 20 weeks
gestation is considered diagnostic)
-WITH-
Edema resulting in wt gain
of 5 pounds in 1 week.
-AND/ORProteinuria 0.1 g/L (1-2+ on
urine dip) in at least 2
random specimens collected
6 hours apart or 300 mg/L
in a 24-hour urine collection.
Clinical Manifestations of
Preeclampsia:
CNS Changes




 cerebrovascular resistance
Vision changes: scotomata (spots), diplopia
(blurry), retinal detachment (usually unilateral;
rare)
HA that is unrelieved by medication
Hyperreflexia / clonus


Clonus is involuntary, rapid, rhythmical CTXs and
relaxations of a muscle when it is sharply stretched and
maintained
Seizure activity with eclampsia which can occur
antepartally, intrapartally, or postpartally
Clinical Manifestations of
Preeclampsia:
Pulmonary Changes

Colloid oncotic
pressure decreases
even further than what
is normal in pregnancy
due to damaged
vessels and
proteinuria, potentially,
resulting in generalized
and/or pulmonary
edema
Non-Pharmacologic Care of the
Preeclamptic Patient
Depends on Severity of Preeclampsia, Maternal and
Fetal Status at time of evaluation, Gestational
Age, Bishop Cervical Score, and wishes of the
Parents
 If mild to moderate HTN, bedrest with BP and
urine protein checks (1+ proteinuria), in addition
to regular office visits including fetal evaluation
(i.e., NSTs, BPP)
 If fetal evaluation indicates compromise (IUGR,
non-reactive NST) or maternal condition worsens
( BP,  proteinuria), hospitalization is usually
required for constant observation and therapy;
continuous fetal monitoring is indicated
Normal Fetal Heart Pattern
tracing at term

Reassuring pattern. Baseline fetal heart
rate is 130 to 140 bpm, preserved beat-tobeat and long-term variability.
Accelerations last for 15 sec and peak at
15 bpm above baseline.
Late Decelerations
Late Decelerations
Management
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 during labor and delivery
Monitoring the vital signs
Sedatives and analgesic
Shortening the second stage of labor
(by forceps)(Classes I and II)
Indications of CS (cesarean section)
(Class III or more, obstetric indications,)

•
•
•
•
•
Management or early puerperium
Bring pressure to bear on the upper abdomen
Bed rest
Monitoring the vital signs
Breast feeding (Classes I and II) and
Artificial feeding (Classes III or IV)
Non-Obstetric Causes for Surgery






Appendicitis
Biliary disease
Ovarian disorders
Breast disease
Cervical disease
Bowel obstruction
Rate of non-obstetric surgery
45
40
35
30
25
20
% Cases
15
10
5
0
Adnexal
Mass
Appendicitis Gallstones
Other
Rate – 1:527 pregnancies, 77 surgeries total
Appendicitis

1:2000 to 1:6000
pregnancies

Incidence 0.05%

Difficult diagnosis??

Immediate intervention a
must
Appendix Location

1932 Baer
described
location of
appendix during
pregnancy.

Since, most
agree there is a
shift in location.
Psoas and Obturator signs. Sensitivity/specificity??
Can we do better than 50%?


CT Scan
Numerous reports in
surgical literature
suggesting accuracy of
>97% in non-pregnant
patients.
Ultrasound





90 % suspected Appendicitis
Diagnosis missed in 7% of
cases due to gravid uterus
(all in 3rd trimester)
100% sensitivity
96% specificity
98% accuracy
Laparoscopy

Safe – especially in
the first 20 weeks

Risks:
Low birth weight
infants
 Preterm labor
 Fetal growth restriction
(no diff. Vs. laparotomy)

General anesthesia
considered safe
Other Risks

Pneumoperitoneum


Animal studies indicate
decreased
unteroplacental blood
flow with CO2
pressures >15mmHg
Also, some infants
developed acidemia
Gall Bladder

Biliary Disease




Increased biliary sludge in
pregnancy

Increased bile
viscosity

Increased micelles

Gall bladder relaxation
Increased risk of gallstone
formation
Cholelithiasis cause of
90% cases of cystitis
0.2-0.5/1000 pregnancies
require surgery
(Landers eta ak 1987)
Symptoms

May be asymptomatic

2.5-10% of pregnant
patients


RUQ Pain – most reliable
symptom



(Maringhini et al 1987)
(pain may radiate to
back)
Vomiting approx 50%
Can mimic appendicitis in
3rd trimester
Workup

Ultrasound



Effective rate 90%
Liver enzymes
Amylase, Lipase
Pancreatitis




1:3000 – 1:4000
pregnancies
High incidence of
Gallstones
Elevated Amylase, Lipase
Medical management

NG tube

NPO

IVF, Pain control
The Adnexa







Estimated 1:200 deliveries
(adnexal masses)
Est. 1:1300 adnexal masses
require surgery
5% malignant rate
½ Serous Carcinomas of
low malignant potential
30% cystic teratomas
28% serous/mucinous
cystadenomas

13% corpus luteal

7% benign
Complications

Whitecar study cont..

Ovarian Torsion



most common and
serious sequelae
5% occurrence
rupture most common
in 1st trimester
MRI?
Correctly
identified 17 of 17
adnexal masses
with MRI vs. 12
out of 17 with
ultrasound
Axial SSFSE T2W image
Breast Disease

“Any suspicious breast
mass found during
pregnancy should
prompt an aggressive
plan to determine its
cause, whether by FNA
or open biopsy.”

Williams 21st
Edition