Unformatted text preview: Medical and Surgical
Heart Deseases in Pregnancy
• 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
• idiopathic cardiomyopathy (perinatal cardiomyopathy)
• isolated myocarditis
• various forms of heart block
various Maternal mortality
• 0.3 per 10,000 live births Heart disease still significantly contributes to
maternal • 5.6-8.5 percent of maternal deaths Effect of pregnancy on heart disease
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.
Total blood volume is increased about 35%.
Total 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
The heart, diaphragm, uterus.
formation of utero-placental circulation
formation Labor and delivery Consumption of energy and oxygen is further increased.
• Labor is increased maternal cardiac burdens.
• Expulsion of the fetus and placenta produce a drematic
hemodynamic changes . The puerperium
• After delivery of the fetus and placenta, during 1-2 days,
great amont of blood return into the systemic circulation,
and great amont of fluid from intertissue space return to
the systemic circulation, increase cardiac burdens again.
• 32-34 gestational weeks, during the labor and delivery,
and early postpartum period (1-3 days) are the most
danger time for pregnant women with heart disease. It
is easy development heart failure.
• Clinical Classification
(By the New York Heart Association)
Class I Uncompromised:
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)
Class III Markedly compromised:
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 history, Symptoms and Clinical Findings
Listed in here symptoms and clinical findings
may indicate heart disease: Symptoms
• Severe or progressive dyspnea
• Progressive orthopnea
• Paroxysmal nocturnal dyspnea
• Syncope with exertion
• Chast pain related to effort or emotion
• Clinical Findings
• Clubing of fingers
Clubing Symptoms (con’t)
• Persistent neck vein distension
• Systolic murmur greater than grade 3/6
• Diastolic murmur
• Sustained arrhythmia
• Persistent split second sound
• Criteria for pulmonary hypertension
• Left parasternal lift
• Loud P2
Loud Conventional tests
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.
• Paroxysmal nocturnal dyspnea.
• Rale in lower lungs
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.
Management General management
Counseling (Preconceptional counceling).
(to decide the pregnancy should be continued)
Intensive pregnatal care.
Active prevent factors increasing cardiac
(such as respiratory tract infection, anemia and
pregnancy-induced hypertension) Management during labor and delivery
Management 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
Monitoring the vital signs
Breast feeding (Classes I and II) and
artificial feeding (Classes III or IV) Medical and Surgical
Acute Viral Hepatitis
Acute Hepatitis is the most common serious liver disease
encountered in pregnant women.
encountered There are at least five distinct types of viral hepatitis:
hepatitis A; hepatitis B; hepatitis C(non-A and non-B
hepatitis); hepatitis D; and hepatitis E. In pregnancy complicate hepatitis , hepatitis B is
common. The incidence of acute viral hepatitis during pregnancy
is about 6fold increased than non-pregnancy, and the
fulminant hepatitis is 66 times increased than nonfulminant
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
that is a hybrid particle with a hepatitis B surface
antigen coat and a delta core. The virus must co-infect
with hepatitis B and cannot persist in serum longer
than hepatitis B virus. It transmission is similar to
hepatitis B viral infection.
hepatitis Transmission of hepatitis C infection appears to be
identical to hepatitis B.
identical Hepatitis E is a waterborne RNA virus that is enterically
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,
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
• Increasing nausea and vomiting early in pregnancy.
• Increasin the incidence of pregnancy-induced
hypertension in late pregnancy.
• Increasing the incidence of postpartum hemorrhage.
Increasing Fetus ans Infants:
• Preterm delivery
• Fetal deaths
• Increasing the antenatal mortality rate
• Affected the fetus and infants (maternal-fetal
• History contect with hepatitis patients, used blood and
blood • Clinical symptoms and findings
• Serological tests liver function, identifying of viris antigen and
antibodies) Diagnosis of severe acute hepatitis
• Jaundice is deeper rapidly. Serous bilirubin>171umol/L
• The size of liver is diminished quickly .
• Ascites, anorexia, severe vomiting.
• Hepatic encephalopathy.
• Hepatic-renal syndrome ( acute renal failure)
• Severe liver function impairment. Defferential diagnosis
• Hyperemesis gravidarum
• Preeclampsia (HELLP)
• Intrahepatic cholestasis of pregnancy (ICP)
• Acute fatty liver of pregnancy
• Liver impairment from drugs overdose.
• Supportive medical measures as for the nonpregnant
rest, adequate nutrition, vitamins, sufficient protein,
carbohydrate, low fatty diet.
• Obstetric management
Early stage of pregnancy: active treatment the disease,
then artificial abortion should be performed.
During midpregnancy and late pregnancy, vitamin K
and C should be admited, and active prevent pregnancyand
induced hypertension. • Obstetric management (con’t)
During labor and delivery: vitamin K is admited,
prepairing frash blood ; avoid operative obstetric
intervention; shortening the second stage of labor(by a
vacuum); preventing the laceration of the birth canal;
preventin retained placental fragmants or membranes;
using of oxytocin.
Postpartum period: Antibiotic drugs, artificial feeding,
lactifuge; infant isolation
Prevented by the administration of hepatitis B immune
globulin after birth, followed promptly by hepatitis B
vaccine in newborn infant.
• Treatment of severe hepatitis properly.
Treatment Intrahepatic cholestasis
of pregnancy （ ICP （ （（（（（（（（（ Pruritus occurring in pregnancy ,in the absence of
dermatologic abnormalities,is usually due to ICP
dermatologic Symptoms(pruritus)usually commence between 28
and 34 weeks
Incidence: 1-2/1000 pregnancies.
ICP should be suspected when widespread pruritus occurs
in the third trimester.
without skin rash.
High levels of bile acids(5-100 times normal)
Bilirubin appears in the urine.
(in most ),alkaline phosphatase and bilirubin be elevated.
transaminases is elevated (in many)
for differential diagnosis ,hepatitis serology ,hepatobiliary
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%),
Preterm delivery (up to 30%),
fetal distress(up to 25%),
and meconium staining of the amniotic fluid
The mechanism of fetal compromise is uncertain. Management
Prenatal monitoring of fetal well being;
timing of delivary;
maternal symptom control;
vitamin K supplementation.
intramuscular Vit.K 10mg weekly should be given from 36 weeks.
Intrapartum Vitamin K 10mg is given to mother;
The newborn body should receive Vitamin K
(there is evidence of a bleeding tendency).
Postnatal Biliary tract ultrasonography (for stones),
(if pruritus does not disapear >7-10 days after delivery.)
In occasional case where abnormalities do not resolve
after delivery ,liver biopsy may need consideration.
after Medical and Surgical
Chronic Glomerulonephritis And
Pyelonephritis Urinary Tract Changes during Pregnancy
• Urinary tract dilation(It involves dilatation of the renal
calyces and pelves,as well as the ureters)These changes
are more promiment on the right side.
• The size of kidney increases 1cm.
• The glomerular filtration rate increases about 50%.
• The renal plasma flow increases about 35%.
These changes create urinary stasis,and may lead to serious
upper urinary infections.
upper Assessment of Renal Disease During
• Urinalysis is essential.
• Most degree that proteinuria must exceed 500mg/day to be
considered abnormal for pregnancy.
• If the serum creatinine persistently exceeds 0.9mg/dl
(75umol/L), then intrinsic renal disease should be suspected.
• Ultrasonogaphy provides imaging of renal size and relative
consistency,as well as elements of obstruction.
• 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
medical complication of pregnancy.
• Pyelonephritis is more common after midpregnancy.It is
unilateral and right-sided in more than half of cases,and
bilateral in one fourth.
• In most women, renal parenchymal infection is caused by
bacteria that ascend from the lower tract.
bacteria Effect on pregnancy
Effect • The high fever can creates abortion, preterm labor.
• In the first trimester, malformations are increase.
(such as spinal defects)
• Toxic shock.(by bacteria toxin) Clinical findings
Clinical • General symptoms:
o The onset of pyelonephritis is usually rather abrupt.
o High fever (as well as 40degree C),
Shaking chills.(thermoregulatory instability)
o Nausea and vomiting
Headache Clinical findings(con’t)
Clinical • Urinary systemic symptoms:
o Aching pain in one or both lumbar regions.
o Tenderness in one or both costovertebral angles
o Dysuria,urgency,and frequency.
• Asymptomatic bacteriuria
The reported prevalence of asymptomatic bacteria
during pregnancy varies from 2-7%.
• About 15% of women with acute pyelonephritis also
have Clinical findings(con’t)
Clinical • Transient renal dysfunction:
o Elevated serum creatinine
o Decreased creatinine clearance
• Hematological dysfunction:
• Pulmonary dysfunction
Adult respiratory distress syndrome
• Clinical findings
Urine specimen examination is anomaly.
A clean-voided specimen containing more than 100,000
organisms of a single uropathogen per mL.
• Positive urine culture.
Urine and blood cultures
Complete blood count, serum crsatinine, and electrolytes
Monitor vital signs frequently,including urinary output
(place indwelling bladder catheter if necessary)
Management(con’t) • Intravenous crystalloid to establish urinary output to at
• Intravenous antimicrobial therapy
• Chest X-ray if there is dyspnea or tachypnea
• Repeat hematology and chemistry studies in 48 hours
• Change to oral antimicrobils when afebrile
• Discharge after afebrile 24 hours,consider antimicrobial
therapy for 7-10 days
• Urine culture 1-2weeks after antimicrobial therapy completed
• 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%)
• Fetuses intrauterine growth retadatio(IUGR,>15%)
• Perinatal mortality rate 8%(after 28 gestational weeks)
• Factors that portended the worst perinatal prognosis included
impaired renal function, early or severe hypertension,and
nephrotic-range kaplan's Typing
Type I Have only proteinuria and edema without
hypertension and renal function impairment.
Type II Have proteinuria and hypertension and without
renal function impairment.
Type III All proteinuria,hypertension and renal function
impairment Lindheimer categories:
• Mild impairment of renal function:serum creatinine
<1.5mg/dL and minimal hypertension;
• Moderate impairment of renal function: serum creatinine
• Severe renal insufficiency:serum creatinine >3. 0mg/dL
Severe Common Complications (in moderate and severe renal insufficiency)
• chronic hypertemion(70%)
• anemia (75%)
• preeclampsia (60%)
• preterm delivery (35%)
• fetal growth restriction (30%)
• fetal death
Management • Diet:lower phosphorus,lower protein(high quality)
• Control hypertension
• Prevention of infection
• Intensive prenatal care
• Termination of pregnancy timely
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- Fall '08
- physical activity, clinical findings