MedicalandSurgicalComplicationsduringPregnancy

HeartDeseasesinPregnancy

IncidenceHeartdiseasecomplicatesabout1percentofpregnancies.Component

congenitalheartdiseaserheumaticheartdiseasehypertensiveheartdiseaseothervarieties(inclued:pregnancy-inducedhypertension,thyroid,coronary,syphilitic,andkyphoscolioticcardiacdisease)idiopathiccardiomyopathy(perinatalcardiomyopathy)isolatedmyocarditisvariousformsofheartblock

0.3per10,000livebirthsHeartdiseasestillsignificantlycontributestomaternalmortality.5.6-8.5percentofmaternaldeathsMaternalmortalityEffectofpregnancyonheartdisease

ThepregnantperiodCardiacoutputisincreasedbyasmuchas30-50percentalmosthalfofthetotalincreasehasoccurredby8 weeks,anditismaximizedbymidpregnancy.Totalbloodvolumeisincreasedabout35%.from6thweekto32ndweekStrokevolumeisincreasedby20-40%.Restingpulseisincreased(by10-17%)Thechangesofanatomicpositionsheart,diaphragm,uterus.formationofutero-placentalcirculationLaboranddelivery

Consumptionofenergyandoxygenisfurtherincreased.Laborisincreasedmaternalcardiacburdens.Expulsionofthefetusandplacentaproduceadrematichemodynamicchanges.Thepuerperium

Afterdeliveryofthefetusandplacenta,during1-2days,greatamontofbloodreturnintothesystemiccirculation,andgreatamontoffluidfromintertissuespacereturntothesystemiccirculation,increasecardiacburdensagain.

32-34gestationalweeks,duringthelaboranddelivery,andearlypostpartumperiod(1-3days)arethemostdangertimeforpregnantwomenwithheartdisease.Itiseasydevelopmentheartfailure.ClinicalClassification

(BytheNewYorkHeartAssociation)

ClassIUncompromised:

Patientswithcardiacdiseaseandnolimitationofphysicalactivity.Theydonothavesymptomsofcardiacinsufficiency,nordotheyexperienceanginalpain.ClassIISlightlycompromised: Patientswithcardiacdiseaseandslightlimitationofphysicalactivity.Thesewomenarecomfortableatrest,butifordinaryphysicalactivityisundertaken,discomfortresultsintheformofexcessivefatigue,palpitation,dyspnea,oranginalpain.ClassIIIMarkedlycompromised:

Patientswithcardiacdiseaseandmarkedlimitationofphysicalactivity.Theyarecomfortableatrest,butlessthanordinaryphysicalactivitycausesdiscomfortbyexcessivefatigue,palpitation,dyspnea,oranginalpain.ClassIVSeverelycompromised: Patientswithcardiacdiseaseandinabilitytoperformanyphysicalactivitywithoutdiscomfort.Symptomsofcardiacinsufficiencyoranginamaydevelopmentatrest,andifanyphysicalactivityisundertaken,discomfortisincreased.ClinicalClassification(con’t)DiagnosisofheartdiseaseManyofthephysiologicalchangesofnormalpregnancytendtomakethediagnosisofheartdiseasemoredifficult.Diseasehistory,Symptoms

and

ClinicalFindings

Listedinheresymptomsandclinicalfindingsmayindicateheartdisease:SevereorprogressivedyspneaProgressiveorthopneaParoxysmalnocturnaldyspneaHemoptysisSyncopewithexertionChastpainrelatedtoeffortoremotionClinicalFindingsCyanosisClubingoffingersSymptoms

PersistentneckveindistensionSystolicmurmurgreaterthangrade3/6DiastolicmurmurCardiomegalySustainedarrhythmiaPersistentsplitsecondsoundCriteriaforpulmonaryhypertensionLeftparasternalliftLoudP2Symptoms(con’t)

Conventionaltests

ElectrocardiographyEcocardiographyChastX-rayDiagnosisofearlyheartfailureduringpregnancy

Dyspnea,palpitationatslightphysicalactivity.Restingpulselargerthan110beatsperminute.Paroxysmalnocturnaldyspnea.RaleinlowerlungsPrognosisThelikelihoodofafavorableoutcomeforthemotherwithheartdiseasedependsuponthe(1)functionalcardiaccapacity(2)othercomplicationsthatfurtherincreasecardiacload(3)qualityofmedicalcareprovided.Counseling(Preconceptionalcounceling).(todecidethepregnancyshouldbecontinued)Intensivepregnatalcare.Activepreventfactorsincreasingcardiacfunctionalload.(suchasrespiratorytractinfection,anemiaandpregnancy-inducedhypertension)ManagementGeneralmanagement

MonitoringthevitalsignsSedativesandanalgesicShorteningthesecondstageoflabor(byforceps)(ClassesIandII)IndicationsofCS(cesareansection)(ClassIIIormore,obstetricindications,)ManagementduringlaboranddeliveryBringpressuretobearontheupperabdomenBedrestMonitoringthevitalsignsBreastfeeding(ClassesIandII)andartificialfeeding(ClassesIIIorIV)ManagementorearlypuerperiumMedicalandSurgicalComplicationsduringPregnancy

AcuteViralHepatitis

Hepatitisisthemostcommonseriousliverdiseaseencounteredinpregnantwomen.Thereareatleastfivedistincttypesofviralhepatitis:hepatitisA;hepatitisB;hepatitisC(non-Aandnon-Bhepatitis);hepatitisD;andhepatitisE.Inpregnancycomplicatehepatitis,hepatitisBiscommon.Theincidenceofacuteviralhepatitisduringpregnancyisabout6foldincreasedthannon-pregnancy,andthefulminanthepatitisis66timesincreasedthannon-pregnancy.HepatitisBistransmittedbyinfectedblood,bloodproducts,andinsaliva,vaginalsecretions,andsemen.Itisasexuallytransmitteddisease.Deltahepatitis(hepatitisD)isadefectiveRNAvirusthatisahybridparticlewithahepatitisBsurfaceantigencoatandadeltacore.Thevirusmustco-infectwithhepatitisBandcannotpersistinserumlongerthanhepatitisBvirus.IttransmissionissimilartohepatitisBviralinfection.TransmissionofhepatitisCinfectionappearstobeidenticaltohepatitisB.HepatitisEisawaterborneRNAvirusthatisentericallytransmitted.HepatitisAistransmittedbythefecal-oralroute.EffectofpregnancyonhepatitisThecourseofhepatitisBinfectioninthemotherdoesnotseemtobealteredbypregnancy.However,atleastinsomeunderprivilegedpopulations,bothperinatalandmaternaldeathsaresubstantivelyincreasedforhepatitisAandB.Tendtobecomechronichepatitis.(hepatitisBandC)Effectonpregnancy

Mother:

Increasingnauseaandvomitingearlyinpregnancy.Increasintheincidenceofpregnancy-inducedhypertensioninlatepregnancy.Increasingtheincidenceofpostpartumhemorrhage.FetusansInfants:

AbortionPretermdeliveryFetaldeathsIncreasingtheantenatalmortalityrateAffectedthefetusandinfants(maternal-fetaltransmission)DiagnosisHistorycontectwithhepatitispatients,usedbloodandbloodproducts,…..ClinicalsymptomsandfindingsSerologicaltestsliverfunction,identifyingofvirisantigenandantibodies)Jaundiceisdeeperrapidly.Serousbilirubin>171umol/L(10mg/dL)Thesizeofliverisdiminishedquickly.Ascites,anorexia,severevomiting.Hepaticencephalopathy.Hepatic-renalsyndrome(acuterenalfailure)Severeliverfunctionimpairment.DiagnosisofsevereacutehepatitisHyperemesisgravidarumPreeclampsia(HELLP)Intrahepaticcholestasisofpregnancy(ICP)AcutefattyliverofpregnancyLiverimpairmentfromdrugsoverdose.DefferentialdiagnosisManagementSupportivemedicalmeasuresasforthenonpregnantpatient.rest,adequatenutrition,vitamins,sufficientprotein,carbohydrate,lowfattydiet.Obstetricmanagement

Earlystageofpregnancy:activetreatmentthedisease,thenartificialabortionshouldbeperformed.

Duringmidpregnancyandlatepregnancy,vitaminKandCshouldbeadmited,andactivepreventpregnancy-inducedhypertension.Obstetricmanagement(con’t)

Duringlaboranddelivery:vitaminKisadmited,prepairingfrashblood;avoidoperativeobstetricintervention;shorteningthesecondstageoflabor(byavacuum);preventingthelacerationofthebirthcanal;preventinretainedplacentalfragmantsormembranes;usingofoxytocin.

Postpartumperiod:Antibioticdrugs,artificialfeeding,lactifuge;infantisolationPreventedbytheadministrationofhepatitisBimmuneglobulinafterbirth,followedpromptlybyhepatitisBvaccineinnewborninfant.Treatmentofseverehepatitisproperly.

Intrahepaticcholestasisofpregnancy（ICP）妊娠肝內(nèi)膽汁郁積癥Pruritusoccurringinpregnancy,intheabsenceofdermatologicabnormalities,isusuallyduetoICPSymptoms(pruritus)usuallycommencebetween28and34weeksIncidence:1-2/1000pregnancies.ICPshouldbesuspectedwhenwidespreadpruritusoccursinthethirdtrimester.withoutskinrash.Highlevelsofbileacids(5-100timesnormal)Bilirubinappearsintheurine.(inmost),alkalinephosphataseandbilirubinbeelevated.transaminasesiselevated(inmany)fordifferentialdiagnosis,hepatitisserology,hepatobiliarytractultrasonoguaphyandautoantibodiesscreanshouldbeperformedinallcases.(ultrasonographyisveryimportanttoexcludeabstructionofthebiliarytree.)DiagnosisForthemother,itcarriesa10-22%riskofobstetricHemorrhage,andpretermlabor.Forthefetalprognosis,stillbirth(upto15%),Pretermdelivery(upto30%),fetaldistress(upto25%),andmeconiumstainingoftheamnioticfluid(30-40%),Themechanismoffetalcompromiseisuncertain.Maternal/FetalRisksPrenatalmonitoringoffetalwellbeing; timingofdelivary; maternalsymptomcontrol; vitaminKsupplementation.intramuscularVit.K10mgweeklyshouldbegivenfrom36weeks.IntrapartumVitaminK10mgisgiventomother; ThenewbornbodyshouldreceiveVitaminK(thereisevidenceofableedingtendency).PostnatalBiliarytractultrasonography(forstones),(ifpruritusdoesnotdisapear>7-10daysafterdelivery.) Inoccasionalcasewhereabnormalitiesdonotresolveafterdelivery,liverbiopsymayneedconsideration.ManagementMedicalandSurgicalComplicationsduringPregnancy

ChronicGlomerulonephritisAndPyelonephritisUrinarytractdilation(Itinvolvesdilatationoftherenalcalycesandpelves,aswellastheureters)Thesechangesaremorepromimentontherightside.Thesizeofkidneyincreases1cm.Theglomerularfiltrationrateincreasesabout50%.Therenalplasmaflowincreasesabout35%.Thesechangescreateurinarystasis,andmayleadtoseriousupperurinaryinfections.UrinaryTractChangesduringPregnancyUrinalysisisessential.Mostdegreethatproteinuriamustexceed500mg/daytobeconsideredabnormalforpregnancy.Iftheserumcreatininepersistentlyexceeds0.9mg/dl(75umol/L),thenintrinsicrenaldiseaseshouldbesuspected.Ultrasonogaphyprovidesimagingofrenalsizeandrelativeconsistency,aswellaselementsofobstruction.Ifnecessary,cystoscop,intravenouspyelography,orrenalbiopsymaybeconsidered.AssessmentofRenalDiseaseDuringPreg1ancy

IncidenceAbout1-2%ofpregnancies.AcutePyelonephritisisthemostcommonseriousmedicalcomplicationofpregnancy.Pyelonephritisismorecommonaftermidpregnancy.Itisunilateralandright-sidedinmorethanhalfofcases,andbilateralinonefourth.Inmostwomen,renalparenchymalinfectioniscausedbybacteriathatascendfromthelowertract.AcutePyelonephritis

Effectonpregnancy

Thehighfevercancreatesabortion,pretermlabor.Inthefirsttrimester,malformationsareincrease.(suchasspinaldefects)Toxicshock.(bybacteriatoxin)

ClinicalfindingsGeneralsymptoms:Theonsetofpyelonephritisisusuallyratherabrupt.Highfever(aswellas40degreeC),Shakingchills.(thermoregulatoryinstability)NauseaandvomitingHeadache

Clinicalfindings(con’t)Urinarysystemicsymptoms:Achingpaininoneorbothlumbarregions.Tendernessinoneorbothcostovertebralangles(bypercussion)Dysuria,urgency,andfrequency.AsymptomaticbacteriuriaThereportedprevalenceofasymptomaticbacteriaduringpregnancyvariesfrom2-7%.About15%ofwomenwithacutepyelonephritisalsohavebacteremia.

Clinicalfindings(con’t)Transientrenaldysfunction:ElevatedserumcreatinineDecreasedcreatinineclearanceHematologicaldysfunction:HemolysisAnemiaThrombocytopeniaPulmonarydysfunctionAdultrespiratorydistresssyndrome

DiagnosisClinicalfindingsUrinespecimenexaminationisanomaly.Aclean-voidedspecimencontainingmorethan100,000organismsofasingleuropathogenpermL.Positiveurineculture.

Management

HospitalizationUrineandbloodculturesCompletebloodcount,serumcrsatinine,andelectrolytesMonitorvitalsignsfrequently,includingurinaryoutput(placeindwellingbladdercatheterifnecessary)

Management(con’t)

Intravenouscrystalloidtoestablishurinaryoutputtoatleast30mL/hrIntravenousantimicrobialtherapyChestX-rayifthereisdyspneaortachypneaRepeathematologyandchemistrystudiesin48hoursChangetooralantimicrobilswhenafebrileDischargeafterafebrile24hours,considerantimicrobialtherapyfor7-10daysUrineculture1-2weeksafterantimicrobialtherapycompletedTreatmentofcomp