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29 - Medical and Surgical Complications during Pregnancy...

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Unformatted text preview: Medical and Surgical Complications during Pregnancy Heart Deseases in Pregnancy Heart Incidence • Heart disease complicates about 1 percent of pregnancies. Component Component • • • • congenital heart disease congenital rheumatic heart disease rheumatic hypertensive heart disease hypertensive other varieties (inclued: pregnancy-induced hypertension, thyroid, coronary, syphilitic, and kyphoscoliotic cardiac disease) disease) • idiopathic cardiomyopathy (perinatal cardiomyopathy) idiopathic • isolated myocarditis • various forms of heart block various Maternal mortality Maternal • 0.3 per 10,000 live births Heart disease still significantly contributes to maternal mortality. maternal • 5.6-8.5 percent of maternal deaths Effect of pregnancy on heart disease Effect The pregnant period The • • • • • Cardiac output is increased by as much as 30-50 percent Cardiac almost half of the total increase has occurred by 8 weeks, and it is maximized by mid pregnancy. weeks, Total blood volume is increased about 35%. Total from 6th week to 32nd week from Stroke volume is increased by 20-40%. Stroke Resting pulse is increased (by 10-17%) Resting The changes of anatomic positions The heart, diaphragm, uterus. heart, formation of utero-placental circulation formation Labor and delivery Consumption of energy and oxygen is further increased. Consumption • Labor is increased maternal cardiac burdens. Labor • Expulsion of the fetus and placenta produce a drematic Expulsion hemodynamic changes . The puerperium • After delivery of the fetus and placenta, during 1-2 days, After great amont of blood return into the systemic circulation, great and great amont of fluid from intertissue space return to and the systemic circulation, increase cardiac burdens again. • 32-34 gestational weeks, during the labor and delivery, 32-34 and early postpartum period (1-3 days) are the most and danger time for pregnant women with heart disease. It is easy development heart failure. is • Clinical Classification Clinical (By the New York Heart Association) (By Class I Uncompromised: Class Patients with cardiac disease and no limitation of physical activity. They do not have symptoms of cardiac insufficiency, nor do they experience anginal pain. insufficiency, Class II Slightly compromised: Patients with cardiac disease and slight limitation of physical activity. These women are comfortable at rest, but if ordinary physical activity is undertaken, discomfort results in the form of excessive fatigue, palpitation, dyspnea, or anginal pain. Clinical Classification (con’t) (con’t) Clinical Class III Markedly compromised: Class Patients with cardiac disease and marked limitation of physical activity. They are comfortable at rest, but less than ordinary physical activity causes discomfort by excessive fatigue, palpitation, dyspnea, or anginal pain. or Class IV Severely compromised: Patients with cardiac disease and inability to perform any physical activity without discomfort. Symptoms of cardiac insufficiency or angina may development at rest, and if any physical activity is undertaken, discomfort is increased. undertaken, Diagnosis of heart disease Many of the physiological changes of normal pregnancy tend to make the diagnosis of heart disease more difficult. disease Disease history, Symptoms and Clinical Findings and Clinical Listed in here symptoms and clinical findings may indicate heart disease: Symptoms • Severe or progressive dyspnea Severe • Progressive orthopnea Progressive • Paroxysmal nocturnal dyspnea Paroxysmal • Hemoptysis Hemoptysis • Syncope with exertion Syncope • Chast pain related to effort or emotion Chast • Clinical Findings Clinical • Cyanosis Cyanosis • Clubing of fingers Clubing Symptoms (con’t) Symptoms (con’t) • Persistent neck vein distension Persistent • Systolic murmur greater than grade 3/6 Systolic • Diastolic murmur Diastolic • Cardiomegaly Cardiomegaly • Sustained arrhythmia Sustained • Persistent split second sound Persistent • Criteria for pulmonary hypertension Criteria • Left parasternal lift Left • Loud P2 Loud Conventional tests Conventional • Electrocardiography Electrocardiography • Ecocardiography • Chast X-ray Chast Diagnosis of early heart failure during pregnancy • Dyspnea, palpitation at slight physical activity. Dyspnea, • Resting pulse larger than 110 beats per minute. Resting • Paroxysmal nocturnal dyspnea. Paroxysmal • Rale in lower lungs Rale Prognosis The likelihood of a favorable outcome for the mother with heart disease depends upon the (1) functional cardiac capacity (1) (2) other complications that further increase cardiac load (2) (3) quality of medical care provided. (3) Management Management General management General Counseling (Preconceptional counceling). Counseling (to decide the pregnancy should be continued) Intensive pregnatal care. Active prevent factors increasing cardiac Active functional load. functional (such as respiratory tract infection, anemia and (such pregnancy-induced hypertension) Management during labor and delivery Management Monitoring the vital signs Monitoring Sedatives and analgesic Shortening the second stage of labor Shortening (by forceps)(Classes I and II) (by Indications of CS (cesarean section) (Class III or more, obstetric indications,) Management or early puerperium Management Bring pressure to bear on the upper abdomen Bring Bed rest Bed Monitoring the vital signs Monitoring Breast feeding (Classes I and II) and Breast artificial feeding (Classes III or IV) Medical and Surgical Complications during Pregnancy Acute Viral Hepatitis Acute Hepatitis is the most common serious liver disease Hepatitis encountered in pregnant women. encountered There are at least five distinct types of viral hepatitis: There hepatitis A; hepatitis B; hepatitis C(non-A and non-B hepatitis hepatitis); hepatitis D; and hepatitis E. In pregnancy complicate hepatitis , hepatitis B is In common. The incidence of acute viral hepatitis during pregnancy is about 6fold increased than non-pregnancy, and the is fulminant hepatitis is 66 times increased than nonfulminant pregnancy. pregnancy. Hepatitis B is transmitted by infected blood, blood products, and in saliva, vaginal secretions, and semen. It is a sexually transmitted disease. is Delta hepatitis ( hepatitis D) is a defective RNA virus Delta that is a hybrid particle with a hepatitis B surface that antigen coat and a delta core. The virus must co-infect antigen with hepatitis B and cannot persist in serum longer with than hepatitis B virus. It transmission is similar to than hepatitis B viral infection. hepatitis Transmission of hepatitis C infection appears to be Transmission identical to hepatitis B. identical Hepatitis E is a waterborne RNA virus that is enterically Hepatitis transmitted. Hepatitis A is transmitted by the fecal-oral route. Hepatitis Effect of pregnancy on hepatitis Effect The course of hepatitis B infection in the mother does not seem to be altered by pregnancy.However, does at least in some underprivileged populations, both perinatal and maternal deaths are substantively increased for hepatitis A and B. Tend to become chronic hepatitis. (hepatitis B and C) Effect on pregnancy Effect Mother: Mother: • Increasing nausea and vomiting early in pregnancy. Increasing • Increasin the incidence of pregnancy-induced Increasin hypertension in late pregnancy. hypertension • Increasing the incidence of postpartum hemorrhage. Increasing Fetus ans Infants: Fetus • Abortion Abortion • Preterm delivery Preterm • Fetal deaths Fetal • Increasing the antenatal mortality rate Increasing • Affected the fetus and infants (maternal-fetal Affected transmission) transmission) Diagnosis • History contect with hepatitis patients, used blood and blood products,….. blood • Clinical symptoms and findings Clinical • Serological tests liver function, identifying of viris antigen and antibodies) antibodies) Diagnosis of severe acute hepatitis Diagnosis • Jaundice is deeper rapidly. Serous bilirubin>171umol/L (10mg/dL) (10mg/dL) • The size of liver is diminished quickly . The • Ascites, anorexia, severe vomiting. Ascites, • Hepatic encephalopathy. Hepatic • Hepatic-renal syndrome ( acute renal failure) Hepatic-renal • Severe liver function impairment. Defferential diagnosis Defferential • Hyperemesis gravidarum Hyperemesis • Preeclampsia (HELLP) Preeclampsia • Intrahepatic cholestasis of pregnancy (ICP) Intrahepatic • Acute fatty liver of pregnancy Acute • Liver impairment from drugs overdose. Liver Management • Supportive medical measures as for the nonpregnant Supportive patient. patient. rest, adequate nutrition, vitamins, sufficient protein, carbohydrate, low fatty diet. carbohydrate, • Obstetric management Obstetric Early stage of pregnancy: active treatment the disease, Early then artificial abortion should be performed. then During midpregnancy and late pregnancy, vitamin K During and C should be admited, and active prevent pregnancyand induced hypertension. • Obstetric management (con’t) Obstetric During labor and delivery: vitamin K is admited, During prepairing frash blood ; avoid operative obstetric prepairing intervention; shortening the second stage of labor(by a intervention; vacuum); preventing the laceration of the birth canal; vacuum); preventin retained placental fragmants or membranes; preventin using of oxytocin. using Postpartum period: Antibiotic drugs, artificial feeding, Postpartum lactifuge; infant isolation lactifuge; Prevented by the administration of hepatitis B immune Prevented globulin after birth, followed promptly by hepatitis B vaccine in newborn infant. vaccine • Treatment of severe hepatitis properly. Treatment Intrahepatic cholestasis of pregnancy ( ICP ( ((((((((( Pruritus occurring in pregnancy ,in the absence of Pruritus dermatologic abnormalities,is usually due to ICP dermatologic Symptoms(pruritus)usually commence between 28 and 34 weeks and Incidence: 1-2/1000 pregnancies. Incidence: Diagnosis ICP should be suspected when widespread pruritus occurs in the third trimester. in without skin rash. without High levels of bile acids(5-100 times normal) High Bilirubin appears in the urine. Bilirubin (in most ),alkaline phosphatase and bilirubin be elevated. (in transaminases is elevated (in many) transaminases for differential diagnosis ,hepatitis serology ,hepatobiliary differential tract ultrasonoguaphy and autoantibodies screan should be performed in all cases.(ultrasonography is very important to exclude abstruction of the biliary tree.) exclude Maternal/Fetal Risks For the mother,it carries a 10-22% risk of obstetric Hemorrhage,and preterm labor. obstetric For the fetal prognosis,stillbirth(up to 15%), For Preterm delivery (up to 30%), Preterm fetal distress(up to 25%), fetal and meconium staining of the amniotic fluid and (30-40%), (30-40%), The mechanism of fetal compromise is uncertain. Management Prenatal monitoring of fetal well being; monitoring timing of delivary; timing maternal symptom control; maternal vitamin K supplementation. vitamin intramuscular Vit.K 10mg weekly should be given from 36 weeks. Intrapartum Vitamin K 10mg is given to mother; Intrapartum The newborn body should receive Vitamin K (there is evidence of a bleeding tendency). (there Postnatal Biliary tract ultrasonography (for stones), (if pruritus does not disapear >7-10 days after delivery.) (if In occasional case where abnormalities do not resolve after delivery ,liver biopsy may need consideration. after Medical and Surgical Complications during Pregnancy Chronic Glomerulonephritis And Pyelonephritis Pyelonephritis Urinary Tract Changes during Pregnancy • Urinary tract dilation(It involves dilatation of the renal Urinary calyces and pelves,as well as the ureters)These changes are more promiment on the right side. are • The size of kidney increases 1cm. The • The glomerular filtration rate increases about 50%. The • The renal plasma flow increases about 35%. The These changes create urinary stasis,and may lead to serious These upper urinary infections. upper Assessment of Renal Disease During Assessment Preg1ancy Preg1ancy • Urinalysis is essential. Urinalysis • Most degree that proteinuria must exceed 500mg/day to be Most considered abnormal for pregnancy. considered • If the serum creatinine persistently exceeds 0.9mg/dl (75umol/L), then intrinsic renal disease should be suspected. (75umol/L), • Ultrasonogaphy provides imaging of renal size and relative Ultrasonogaphy consistency,as well as elements of obstruction. consistency,as • If necessary,cystoscop, intravenous pyelography, or renal biopsy may be considered. biopsy Acute Pyelonephritis Incidence Incidence • About 1-2% of pregnancies. About Acute Pyelonephritis is the most common serious Acute medical complication of pregnancy. medical • Pyelonephritis is more common after midpregnancy.It is unilateral and right-sided in more than half of cases,and unilateral bilateral in one fourth. bilateral • In most women, renal parenchymal infection is caused by In bacteria that ascend from the lower tract. bacteria Effect on pregnancy Effect • The high fever can creates abortion, preterm labor. The • In the first trimester, malformations are increase. In (such as spinal defects) (such • Toxic shock.(by bacteria toxin) Clinical findings Clinical • General symptoms: General o The onset of pyelonephritis is usually rather abrupt. The o High fever (as well as 40degree C), High Shaking chills.(thermoregulatory instability) Shaking o Nausea and vomiting Nausea o Headache Headache Clinical findings(con’t) Clinical • Urinary systemic symptoms: Urinary o Aching pain in one or both lumbar regions. Aching o Tenderness in one or both costovertebral angles (by percussion) (by o Dysuria,urgency,and frequency. Dysuria,urgency,and • Asymptomatic bacteriuria Asymptomatic The reported prevalence of asymptomatic bacteria The during pregnancy varies from 2-7%. during • About 15% of women with acute pyelonephritis also About have bacteremia. have Clinical findings(con’t) Clinical • Transient renal dysfunction: Transient o Elevated serum creatinine Elevated o Decreased creatinine clearance Decreased • Hematological dysfunction: Hematological o Hemolysis Hemolysis o Anemia Anemia o Thrombocytopenia Thrombocytopenia • Pulmonary dysfunction Pulmonary Adult respiratory distress syndrome Adult Diagnosis Diagnosis • • • Clinical findings Clinical Urine specimen examination is anomaly. Urine A clean-voided specimen containing more than 100,000 organisms of a single uropathogen per mL. organisms • Positive urine culture. Positive Management Management • • • • Hospitalization Hospitalization Urine and blood cultures Urine Complete blood count, serum crsatinine, and electrolytes Complete Monitor vital signs frequently,including urinary output (place indwelling bladder catheter if necessary) (place Management(con’t) Management(con’t) • Intravenous crystalloid to establish urinary output to at least 30mL/hr least • Intravenous antimicrobial therapy Intravenous • Chest X-ray if there is dyspnea or tachypnea Chest • Repeat hematology and chemistry studies in 48 hours Repeat • Change to oral antimicrobils when afebrile Change • Discharge after afebrile 24 hours,consider antimicrobial Discharge therapy for 7-10 days therapy • Urine culture 1-2weeks after antimicrobial therapy completed Urine • Treatment of complications Treatment Chronic GlomeruIonephritis This is characterized by progressive renal destruction over a period of yean or decades, eventually producing the end-stage kidney. Usually persistent proteinuria and hematuria accompany a gradual decline in renal function. Effect of glomerullonephritis on pregnancy Effect • Delivered preterm,(as high as 25%) Delivered • Fetuses intrauterine growth retadatio(IUGR,>15%) Fetuses • Perinatal mortality rate 8%(after 28 gestational weeks) Perinatal • Factors that portended the worst perinatal prognosis included Factors impaired renal function, early or severe hypertension,and nephrotic-range proteinuria. nephrotic-range kaplan's Typing kaplan's Type I Have only proteinuria and edema without hypertension and renal function impairment. hypertension Type II Have proteinuria and hypertension and without renal function impairment. renal Type III All proteinuria,hypertension and renal function impairment exist. impairment Lindheimer categories: • Mild impairment of renal function:serum creatinine <1.5mg/dL and minimal hypertension; <1.5mg/dL • Moderate impairment of renal function: serum creatinine of 1.5-3.0mg/dL of • Severe renal insufficiency:serum creatinine >3. 0mg/dL Severe Common Complications (in moderate and severe renal insufficiency) (in • chronic hypertemion(70%) chronic • anemia (75%) anemia • preeclampsia (60%) preeclampsia • preterm delivery (35%) preterm • fetal growth restriction (30%) fetal • fetal death fetal Management • Diet:lower phosphorus,lower protein(high quality) Diet:lower • Control hypertension Control • Prevention of infection Prevention • Intensive prenatal care Intensive • Termination of pregnancy timely Termination ...
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