Download Medical and Surgical Complications of Pregnancy

Medical and
Surgical
Complications of
Pregnancy
ROBAB DAVAR M.D.
Obstetrician and Gynecologist,
Fellowship of Infertility
Shahid sadoughi university of
medical sciences
Hematologic Disease
Anemias
 Hb <12 g/dL in nonpregnant.
 pregnancy Hb<10.
 either acquired or inherited.
Iron Deficiency Anemia
 acquired
anemia
 most common cause in gravid women
 15% to 25% of all pregnancies
 transported actively across the placenta, fetal
iron and ferritin levels are three times higher
than maternal levels.
 severe anemia (Hb <8 g/dL) is associated with
IUGR.
 The
total iron requirement is 1,000 mg: 500 mg
increases the maternal red blood cell mass, 300
mg is transported to the fetus and placenta, and
200 mg compensates for blood loss at delivery.
 for nonanemic gravidas is 300 mg of ferrous
sulfate per day, which contains 60 mg of
elemental iron.
 Anemic gravidas (Hb of 8 or 9 g/dL) 300 mg
ferrous sulfate two or three times per day.
Hb
<8 g/dL may require
intramuscular or intravenous
iron dextran.
Megaloblastic Anemia
 1%
and caused by folate or rarely vitamin B12
deficiency.
 Malnutrition (e.g., alcoholism), malabsorption,
anticonvulsant, oral contraceptive, or
pregnancy cause folate deficiency
 nonpregnant is 50 to 100 mg; a pregnant 300 to
400 mg/d
 0.4 mg per day if no family history of neural
tube defects; 4.0 mg per day if there is.
beginning before conception and continue in
first trimester.
Folate
deficiency 0.5 to 1.0 mg
orally per day.
B12 deficiency vitamin B12, 1
mg IM, weekly for 6 wks.
Thalassemias
ß-thalassemia
minor tolerates pregnancy
well.
 should receive folic acid but not iron
unless iron deficiency is diagnosed.
Sickle Cell Disease
 Pregnancy
cause an increase in sickle
crises and associated complications (e.g.,
pneumonia, pyelonephritis, pulmonary
emboli, congestive heart failure) and
pregnancy complications (e.g., IUGR,
preterm birth, preeclampsia).
should
ingest 1 mg of folate per
day and polyvalent
pneumococcal vaccine.
 Iron should not be given
prophylactically but if there is
iron-deficiency anemia.
funduscopic
examination, with
laser therapy as needed.
Asymptomatic bacteriuria
(ASB) and other infections
treated aggressively.
Platelet Disorders
Thrombocytopenia
<150,000
occurs in 7% to 8% of all
pregnancies.
 The diagnosis of benign or
essential gestational
thrombocytopenia is one of
exclusion.
Thrombotic Thrombocytopenic
Purpura
 thrombocytopenia,
hemolytic anemia, fever,
neurologic abnormalities, and renal failure.
 rare and unknown etiology. affects all ages,
most commonly young women. The untreated
mortality rate exceeds 90%.
 has bleeding (uterine, gastrointestinal, or other)
with Coombs-negative hemolytic anemia,
thrombocytopenia, and mild jaundice.
Hypertension and renal failure occur later.
in
the third trimester DDx:
preeclampsia or HELLP
syndrome.
PT, PTT, fibrinogen, fibrin
dimers are normal.
Plasmapheresis
as soon
as the diagnosis is made.
Cesarean for obstetric
indications only.
Von Willebrand Disease
tolerate
pregnancy well.
therapy is 15 to 20 U of
cryoprecipitate twice daily just
prior to delivery and for 2 to 3
days afterward. Factor VIII
concentrate can be administered
instead.
Hemophilias A and B
Carrier
females should offer genetic
counseling. Female offspring will be
carriers, and one half of their sons
will have hemophilia.
 Prenatal diagnosis is available.
Gastrointestinal Disease
Nausea and Vomiting
Mild occur in 60% to 80% of women.
 Chronic nausea and vomiting, or hyperemesis
gravidarum, complicates 1 in 200 to 300
pregnancies.
 dehydration, electrolyte imbalance.
 Etiology is unclear. Theories human chorionic
gonadotropin, the pituitary adrenal axis,
transient hyperthyroidism, psychogenic factors.
Gastrointestinal Reflux Disease
Occur in one half , known as heartburn.
 Treatment lifestyle modifications and
antacids. In severe refractory cases,
cimetidine and metoclopramide.

Peptic Ulcer Disease
Gastric
secretion and motility
reduced and mucus secretion is
increased during gestation.
 As a result, peptic ulcer disease is
uncommon in pregnancy, often
improvement in pregnancy.
Upper Gastrointestinal Bleeding
most
women with hematemesis
have Mallory-Weiss tears.
Cholelithiasis and Biliary Disease

the risk is increased, 2% to 10%.

acute cholecystitis about 1 in 1,000 to 1,600 gestations.
postprandial pain in the right upper quadrant or
epigastric area, with radiation to the back or shoulder.

Management same as nonpregnant. Medical therapy:
bowel rest, nasogastric suction, intravenous hydration,
antibiotics, and analgesics. The remainder require
surgical intervention.
Pancreatitis



incidence of 1 in 1,500 to
4,000.
majority due to
cholelithiasis. Other less
common etiologies ethanol
abuse, certain medications,
trauma, and
hypertriglyceridemia.
Symptoms include
midepigastric pain with
back radiation, anorexia,
nausea, and emesis.
Hepatitis B




transmitted by parenteral and sexual contact.
incubation period is 40 to 100 days recovered from
all body fluids , blood, breast milk, and amniotic
fluid.
HBsAg and anti-HBc IgM are seen in early clinical
phase. They indicate infectivity .
HBeAg indicates acute infection, its persistence
correlates both with the chronic carrier state and
with the development of hepatocellular carcinoma.
The risk of transmission to 90% when acute infection
occurs in the third trimester or in the presence of both
HBsAg and HBeAg positivity and is a consequence of
intrapartum exposure to blood and genital secretions.
 If mother develops HBV infection remote from delivery
and has anti-HB antibodies, the risk of fetal or neonatal
infection is less.
 The neonate's risk of active or chronic disease is reduced
by HB immune globulin and the HBV vaccine; should be
given at delivery.
 Breast-feeding does not increase the risk of infection in
these infants.

Acute Fatty Liver
 incidence
of 1 in 13,000 deliveries. mortality of up to 25%.
 Primiparity, male sex, and multiple gestation higher risk.
 The etiology is unknown
 Symptoms in late third trimester, include malaise,
persistent nausea, and vomiting. Right upper quadrant or
epigastric pain is noted in 50% to 80%.
 elevated liver function tests, increased ammonia and uric
acid , hemolysis, hypoglycemia, and coagulopathy.
 if untreated, progresses to multiorgan system failure and
death.
Cardiovascular Disease
Physiologic Changes in Pregnancy
 Plasma volume↑ 45% by 30 to 34 weeks. Red blood cell
volume↑ about 25%, resulting in a physiologic anemia.
 Cardiac output↑ by 30% to 50% in first half of pregnancy
, by a further 30% in active labor, and by 45% during
pushing.
 Systemic vascular resistance ↓ during pregnancy, systolic
and diastolic blood pressures falling in second trimester
and then returning to prepregnancy in third trimester.
 During labor, each uterine contraction results in
autotransfusion of 300 to 500 mL of blood.
 Class
I: patients are asymptomatic in all
situations.
 Class II: patients are symptomatic with greaterthan-normal exertion.
 Class III: patients are symptomatic with
normal activities.
 Class IV: patients are symptomatic at rest.
Mitral Stenosis
most common form of rheumatic heart disease in
women.
 occurs between ages 6 to 15 years. The mean age
for the initiation of symptoms is thus 31.
 Initial symptoms ,fatigue and dyspnea on
exertion, progress to dyspnea at rest and
hemoptysis.
 complications are atrial fibrillation and
pulmonary edema, with maternal death.

 ß-Blockers
with a heart rate above 90 .
Digoxin and heparin required with
atrial fibrillation.
 Rarely, surgery becomes necessary.
 Epidural anesthesia can be used .
 Fluid management must be meticulous,
extra attention in immediate postpartum
period.
 SBE
prophylaxis ampicillin 2 g and gentamicin
1.5 mg/kg intravenously 30 minutes before
delivery and ampicillin 1 g intravenously or
amoxicillin 1 g orally 6 hours after delivery.
Penicillin-allergic, vancomycin.
Mitral Insufficiency
 During
labor, pain should be treated.
 SBE prophylaxis should be given.
 Occasionally, surgical valve replacement
is necessary.
Aortic Stenosis
 can
occur in reproductive-age women,
and those who are symptomatic ( angina,
syncope, shortness of breath) have a risk
of sudden death .
 epidural anesthesia is controversial ,
and the patient could managed with
parenteral narcotics and pudendal block.
 Fluid management must be meticulous.
Congenital Heart Disease
 should
receive genetic counseling regarding
etiology and risks to her fetus.
 MVP is most common congenital valvular
lesion, incidence of 5% to 10% in the
general population.
 The majority are asymptomatic and
tolerate pregnancy, labor, and delivery well.
 no special therapy other than SBE
prophylaxis, although this is controversial.
Tetralogy of Fallot
Pregnancy is discouraged in those with
uncorrected tetralogy.
 Pregnancy management includes bed rest,
oxygen therapy, and isotopic support as
necessary.
 epidural or spinal anesthesia should be
avoided. Intravenous medication and
pudendal block can be used, and the second
stage of labor should be shortened.

Peripartum Cardiomyopathy
 arises
in last month of pregnancy or in first 5
months postpartum.
 may complain of orthopnea, dyspnea, edema,
weakness, and palpitations.
 Management of heart failure with digitalis,
diuretics, and vasodilators as necessary; strict
bed rest; and full anticoagulation.
 prognosis is poor. If heart size and function do
not return to normal within 6 months, the
mortality rate is high (up to 85%).
Myocardial Infarction
 The
risk in a reproductive-age is low (1 in
10,000). The risk of death is highest at the time
of the MI and is gestational-age dependent.
 maternal morality is approximately 23% in the
first and second trimesters but 50% in the
third. The risk of death is high if delivery
occurs within 2 weeks of infarction.
Thromboembolic Disease
 Venous
thromboembolism occurs in 1 in 1,000
to 2,000 pregnancies and is a leading cause of
maternal mortality in the United States.
Superficial Thrombophlebitis
 involves
only superficial saphenous veins
and is a relatively benign condition, often
associated with varicosities. treated with
analgesia, rest, and elastic support.
Deep Venous Thrombosis


risk in pregnancy is 0.5 to 3.0 per 1,000 women.
Most commonly in the iliofemoral region or in the veins
of the calf .




characterized by edema and lower extremity aching and
limb discoloration.
Most occurs on left side .
Impedance plethysmography is highly sensitive and
specific for identifying obstruction of the proximal veins
(iliac, femoral, and popliteal). Real-time sonography and
duplex Doppler sonography detect proximal vein
thrombosis.
If these studies are equivocal or negative and suspicion is
high, venography can be performed.
Pulmonary Thromboembolism




Dyspnea, tachypnea, tachycardia, pleuritic chest pain,
cough, and anxiety.
In pregnancy, is caused by emboli from a DVT and more
frequently in postpartum period.
Arterial blood gases :hypoxemia and hypocapnia, the
ECG: tachycardia with right heart strain, and the chest
radiograph :subsegmental atelectasis.
If there is a strong clinical suspicion of PTE, I.V. heparin
immediately.





Risk factors : history of DVT, a mechanical heart valve, atrial
fibrillation, trauma, prolonged immobilization, major surgery,
antiphospholipid antibody syndrome, and several hereditary
thrombophilias.
Heterozygous for protein C or S deficiency 3% to 10% risk of
antepartum thromboembolism and 7% to 19% risk
postpartum.
antithrombin III deficiency is 12% to 60% during pregnancy
and 11% to 33% during the puerperium.
A mutation in factor V Leiden 28% incidence of pregnancyassociated thromboembolism.
all inherited in an autosomal dominant fashion .
 Treatment:
unfractionated heparin I.V.
for 5 to 10 days, followed by
subcutaneous every 12 hours or three
times a day for the remainder of the
pregnancy.
 does not cross the placenta.
 The dosage should be titrated to
midinterval (aPTT) 1.5 to 2.5 times
normal.
 Unfractionated
heparin has a short half-life (60
to 90 min.) reversed with protamine sulfate.
 Because the half-life of low-molecular-weight
heparin is much longer, most practitioners
convert to unfractionated heparin in last
month of pregnancy.
 When delivery is planned or patient enters
labor, heparin should be discontinued and
aPTT checked.
 Fractionated
or low-molecular-weight
heparin longer half-life than ordinary
heparin.
 Once daily
 Reduced bleeding, osteoporosis, and
thrombocytopenia that can complicate
standard heparin .
 Does not cross placenta.
 Warfarin sodium can be used after second
trimester, first-trimester exposure resultant
warfarin embryopathy.
 epidural
anesthesia or cesarean section
within 4 to 6 hours of last unfractionated
heparin, and protamine if reversal of
anticoagulation is required sooner.
 Heparin should be resumed 6 to 12 hours
postpartum, depending on the type of
delivery , with warfarin sodium
simultaneously.
 Once a therapeutic level is reached,
warfarin alone should be continued for at
least 6 weeks.
 The
recurrence risk in subsequent pregnancy
4% to 15%.
 Prophylactic heparin in subsequent
pregnancies, although the ideal heparin dosage
and duration of treatment remains
controversial.
Mechanical Heart Valves







require anticoagulation during pregnancy.
coumarin should be avoided during embryogenesis.
Can be switched to subcutaneous heparin before conception or
immediately after conception (1 to 2 weeks after the first
missed period).
The optimal agent from 14 to 39 weeks is controversial.
The advantages of heparin inability to cross the placenta and
rapid reversibility.
Disadvantages difficulty in maintaining a therapeutic dosage
and failure to prevent all valve thromboses.
warfarin provide more consistent anticoagulation, its effects
cannot be readily reversed and may extend to fetus.
Pulmonary Disease
Asthma
 May
improve, worsen, or remain unchanged
during pregnancy.
 Peak of exacerbations is 24 to 36 weeks , with
relative improvement in last month .
 Severe or uncontrolled asthma, increased risk
of preeclampsia and maternal mortality, IUGR,
preterm delivery, and perinatal mortality.
Treatment of Acute Asthma Attack









Arterial blood gas, complete blood cell count, electrolytes, peak
flow meter, chest radiograph
Call respiratory therapy
Intravenous hydration, supplemental oxygen therapy to
maintain Po2 >70 mm Hg; monitor urine output
Albuterol, nebulized, three doses in initial 60-90 min
Methylprednisolone 1 mg/kg i.v. q6h
Aminophylline 6 mg/kg i.v. loading dose, then 0.5 mg/kg/h
maintenance
Antibiotic i.v.
Terbutaline 0.25 mg s.c.
Transfer to intensive care for respiratory support and
or/ventilation in absence of improvement.
Tuberculosis



Pregnancy does not worsen the course of TB, and TB
does not alter outcome of pregnancy.
TB screening consists of (PPD) test or Mantoux test.
Forty-eight to 72 hours following intradermal injection,
the presence or absence of induration at the injection site
is determined.
Induration 5 mm is considered positive in an HIVpositive patient, in anyone in recent contact with an
active TB case, or in anyone with clinical or radiologic
evidence of TB. Induration 10 mm is considered positive
in health care workers, chronic alcoholics, or
institutionalized individuals. induration15 mm is
considered positive in all low-risk patients.
 When
a skin test is positive, a chest radiograph
should be done; with shielding. If the chest
radiograph is normal, or abnormal but inconsistent
with TB, treatment : (INH) 300 mg every day for 6
months. Pyridoxine (vitamin B6) at 50 mg daily is
recommended to decrease the incidence of
peripheral neuropathy and to protect the fetus from
the neurotoxic effects of INH.
 If the chest radiograph is consistent with old TB and
further evaluation fails to reveal active TB, the
patient should receive INH 300 mg every day for 12
months after delivery.
 If
the chest radiograph findings are consistent
with TB, further workup to confirm the
diagnosis is necessary. Treatment for 6 to 9
months with two or more drugs is required, as in
nonpregnant patients.
 Maternal treatment does not treat the infant.
 Treatment in infants is similar to that in adults.
Isolation of the uninfected infant is
recommended until effective treatment is under
way, although the infant may breast-feed.