Medical and Surgical Complications of Pregnancy

ROBAB DAVAR M.D.Obstetrician and Gynecologist, Fellowship of InfertilityShahid sadoughi university of medical sciences

Hematologic Disease

AnemiasHb <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 Diseasetolerate 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 VomitingMild 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 DiseaseGastric 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 PregnancyPlasma 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 greater-than-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 pregnancy-associated 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.

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.

Mechanical Heart Valves

Pulmonary Disease

AsthmaMay 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 HIV-positive 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.