Complication Of Pregnancy

Complication of pregnancy

To accommodate the development of fetus , a series of physiological adaptation occur in woman in response to physiological stimuli provided by the fetal tissues.

Medical and surgical complications •Anaemia in pregnancy •Heart disease√ •Diabetes Mellitus in pregnancy •Thyroid dysfunction with pregnancy •Tuberculosis •Jaundice in pregnancy •STD(sexually transmitted disease) in pregnancy •Urinary Tract Infection •Epilepsy in pregnancy •Viral infections in pregnancy(viral hepatitis) •Asthma in pregnancy •General surgery during pregnancy •Acute pain abdomen during pregnancy

Physiological changes of heart and circulation during pregnancy

Anatomical changes Enlarged uterus Elevation of the diaphragm The heart is pushed upwards and outwards with slight rotation to left. There is no evidence of hypertrophy or dilatation of the heart.

Physiological changes

normal clinical findings

•The apex beat is shifted to the 4 intercostal space about 2.5cm outside the mid clavicular line. •Pulse rate is slightly raised, often with extrasystoles. •There may be split in the first sound in the apical area. •A systolic murmur may be audible in the apical or pulmonary area. •X-ray shows enlarged cardiac shadow due to displacement of the heart. •ECG reveals normal pattern except evidences of th

left axis deviation.

Physiological changes

The physician should be familiar with these physiologic findings and should execute a cautious approach in diagnosis of pathological during pregnancy.

Physiological changes

Cardiac output Increased blood volume Starts to increase from 6th week of pregnancy Reaches its peak at about 32-34 weeks Rises from 4.5L in non pregnant state to 6.2L per minute in third trimester Returns to almost nonpregnant level by 6 weeks postpartum To meet the additional O2 required due to increased metabolic activity during pregnancy Physiological changes

A normal heart has got enough reserve power to cope with the increased load but a damaged heart fails to do so.

Physiological changes

Heart disease complicating pregnancy

1. Cardiovascular changes during pregnancy 2. Classification 3. diagnosis 4. Management

Incidence: 1%~4% in china It is one major reason of maternal death. •postpartum hemorrhage •PIH (pregnancy induced hypertension) •Heart disease •Amnionic fluid embolism

Interaction between cardiac disease and pregnancy

During pregnancy •The maternal circulating blood volume increases

gradually as the pregnancy progresses and peaks at 32~34weeks which increase by 30~45%.

•Especially during the last few weeks of pregnancy, hemodynamic burden has a maximum change with increased stroke volume and heart rate.

• As the uterus enlarges and the

diaphragm is elevated, the heart is elevated and rotated and shifted to the upper and left.

During labor The first stage About 500ml blood are pushed into peripheral circulation by every uterine contraction, thus backflow of blood increased which makes cardiac output increased by 20%. Every retraction also increases the right atrial pressure which make MBP increased by 10%. The increased cardiac output and MBP both aggravated the burden of left ventricle.

The second stage Participation of abdominal muscle and skeletal muscle→peripheral resistance increased Exerting out breathing Pulmonary circulation pressure increased Abdominal pressure increased Makes blood in viscera flow back to the heart. Above all, burden of the heart is the more heavy in the second stage.

The third stage The uterus contracts and becomes more smaller. Abdominal pressure drops down. Blood congests in visceral vascular beds.

Results in abruptly decreased backflow of the heart. A large amount of blood from uterus suddenly comes into circulation as contraction of empty uterus. Both of them make the hemodynamic change, increase the heart burden.

During puerperium During 24~28hs after labor, the fluid retention in tissues begins to backflow into circulation → increase blood volume. The volume returns non-pregnancy state 6 weeks later after the excess fluid passes out through kidney.

In a total, the most risk period of complicated cardiac disease pregnant women are

•During 32~34 weeks of pregnancy •During labor •Initial 3 days

Simple drawing about cardiac output Cardiac output

Nonpregnancy

34w in pregnancy

delivery

Initial 3 days of puerperium

Classification rheumatic heart disease congenital heart disease peripartum cardiomyopathy hypertension heart disease myocarditis ( become common during recent years )

1 Rheumatic heart disease in pregnancy  Rheumatic heart disease accounted for the great majority of cases(65%-80%).  However this has changed because rheumatic fever has been treated thoroughly in recent years.  It is now becoming less common..

 Mitral stenosis is the most common lesion found  and there may also be mitral regurgitation or aortic regurgitation  aortic stenosis is rarely seen.

2. Congenital heart disease  congenital heart disease in pregnancy is increasing gradually.  It includes cyanotic and acyanotic heart disease. On the whole those patients who survive to the age of childbearing are those without cyanosis or gross disability including cases of atrial septum defect,pulmonary stenosis ,patent ductus arterious ,ventricle septum defect coarctation of the aorta and so on.

3 Cardiomyopathy of pregnancy  This term refers to rare cases of myocardial disease of unknown aetiology occurring in late pregnancy or in the puerperium,  and sometimes recurring in successive pregnancies,which causes congestive cardiac failure

Effects of heart lesion on pregnancy Abortion Preterm delivery (Prematurity) IUGR (intrauterine growth retardation) Fetal congenital malformation Maternal and fetal death

Prognosis Maternal mortality is less than 1%. The causes of death are • cardiac failure • infection • pulmonary oedema • pulmonary embolism • active rheumatic carditis • subacute bacterial endocarditis • rupture of cerebral aneurysm in coarctation of aorta

Diagnosis The heart should always be examined carefully at the first antenatal visit .The diagnosis of cardiac disease during pregnancy is sometimes difficult. Dyspnoea of slight degree and oedema of the ankles may occur in normal pregnancy .A soft systolic murmur without any other evidence of cardiac disease may have no significance.

Diagnosis Presence of any one of the following criteria confirms the diagnosis of organic heart lesions 1. Presence of diastolic murmur 2. Cardiac enlargement 3. Presence of loud systolic murmur associated with a thrill 4. Presence of arrhythmia

The clinical diagnosis should be substantiated with electro-cardiography, chest X-ray, echocardiography and doppler flow studies. The ultimate clinical diagnosis should be a composite one, including aetiology, structures involved and functional grading.

Gradings Depending upon the cardiac response to physical activity Grade-I : uncompromised. Patients with cardiac disease but no limitation of physical activity. Grade-II : slightly compromised. Patients with cardiac disease with slightly limitation of physical activity.

Gradings Grade-III : markedly compromised. Patients with cardiac disease with markedly limitation of activity. The patients are comfortable at rest but discomfort occurs with less than ordinary activity. Grade-IV : severely compromised. Patients with cardiac disease with discomfort even at rest.

General management Principles

•Early diagnosis and evaluation of the functional grading of the cases

•To prevent, to detect and to institute effective therapy for cardiac failure

•To prevent and to control the additional complications

•Mandatory hospital delivery

Indications for termination of pregnancy Absolute indications: • primary pulmonary hypertension • Eisenmenger’s syndrome • pulmonary veno occlusive disease Relative indications • parous woman with grade III and IV • grade I or II with previous history of cardiac failure in early months

Special notes •To enquire about dyspnoea and cough •To note the pulse rate •To look for anaemia and the weight and Bp •Revaluation of the functional grading of the heart

•To exclude fetal congenital abnormality using sonography

Advices Adequate rest (10h in bed at night and 2h at noon) To avoid undue excitement and strain To avoid caffeine, alcohol and, high calorie or spicy diet Avoid cold and infections Adequate dental care (caries teeth)

Admission Elective: Grade-I at least two weeks prior to the expected date of delivery Grade-II at 28th week Grade-III and IV as soon as pregnancy is diagnosed. The patient should be kept in the hospital throughout pregnancy.

The early signs of heart failure dyspnea, shortness of breath palpitation after light activities HR ＞ 110times/min, R ＞ 20times/min at rest, have to get up or open the window to get fresh airs because of depressed at midnight.

Management during labor Prophylactic antibiotic should be used at the onset of labor Sedative drug Oxygen inhalation Instrumental labor such as episiotomy, forceps delivery Sands bag should be put on the abdomen Prevent postpartum hemorrhage Cesarean section

Acute viral hepatitis

The incidence of Acute viral hepatitis in pregnant woman is 6 times as high as that of nonpregnant women and violent hepatitis is 66 times also. It often cause maternal death.

There are 5 distinct types of hepatitis viruses Including : hepatitis A virus (HAV) hepatitis B virus (HBV) hepatitis C virus (HCV) hepatitis D virus (HDV) hepatitis E virus (HEV)

The influence of pregnancy to hepatitis 1. Easy to get hepatitis 2. Become severe hepatitis 3. Become chronic hepatitis

The influence of hepatitis to pregnancy 1. To mother: PIH-syndrome Postpartum hemorrhage The synthesis of coagulation factors decreased during hepatitis ,and is easy to happen postpartum hemorrhage. 2. To fetus : Fetal deformity The mortality of perinatal baby

Transmission of the virus from the mother to the infant HBV: hepatitis B many be transmitted by ways of  infection from blood perfusion and biological products  intimate everyday contaction  vertical transmission

but vertical transmission is an important road ,which include (1) trans-placental transmission in uterus (2)contaction with maternal blood or amniotic fluid at delivery (3)contact with maternal saliva ,sweat during postpartum (4)through breast feeding

Diagnosis The diagnosis of pregnancy complicating viral hepatitis is more difficult than non-pregnant period,esp in late stage of pregnancy. The abnormal hepatic function was induced by other combined factors. So we can not diagnose only depending on the raising of SGPT but also on the clinical symptoms ,signs and laboratory examinations to get a overall analysis.

Common type of hepatitis has specific symptoms that are malaise, anorexia, nausea and vomiting, abdominal distention, dull pain in hepatic area or low fever, jaundice, slight enlargement of liver, tenderness on the liver.

The diagnosis of severe hepatitis in pregnancy is: (1)The jaundice becomes deeper rapidly (2) Progressive minimization of liver. (3)Toxic distention of bowel with ascites. (4) Foul hepatic smell (5) Symptoms of hepatic encephalopathy at different degree. (6) Bleeding tendency systemically.

Prophylaxis (1) Intensify propaganda and education Every child-bearing age woman suffered viral hepatitis must take contraception measures and may be pregnant 2 years ideally,at least a half year after the hepatitis cure.

(2) Reinforce antenatal care This includes detecting hepatitis virus Ag-Ab system in early,mild,late term repeatedly to screen for all patients in pregnancy. During the delivery, strict sterilization and isolation measures should be taken for the women with positive HBsAg or HBeAg ,especially pay attention to refrain from laceration of soft tissue and neonatal delivery injury .

(3) Immunoprophylaxis of hepatitis B Infection of the newborn infant whose mother is chronic carrier of virus can be prevented by the administration of hepatitis B immune globulin very soon after birth followed promptly by hepatitis B vaccine .

Management The management of pregnancy complicating common type hepatitis. (1) Active treatment to recover and improve liver function.Treatment consists of a well balanced diet, enough bed rest and drugs such as proheparin ,inosine , and glucurone .etc.

(2)Evade usage of drugs that are harmful of liver function Some sedatives and anesthetics that are harm to liver are inhibited as possible as you can. Tetracycline which can induce acute fatty liver and fetal death is forbidden in pregnant women .

(3) Guard against infections Take precautions such as use of wide spectrum antibiotics against spread of birth tract and intestinal infection.

(4) avoid postpartum hemorrhage

Obstetrical management Pregnant period: If hepatitis B is complicated at the early pregnancy ,artificial abortion should be done .Stopping the pregnancy is not proposed if hepatitis complicated at mid or late pregnancy because operation and anesthetics can enhance the hepatic load.

Labor period: The choice of delivery way is very important to prognosis vaginal delivery is suitable to relatively small fetus ,good cervical conditions or with enough cervical dilation and delivery ending in a brief space of time successfully . Before delivery ,blood perfusion should be prepared.

To the severe hepatitis women ,the prognosis is better when the cesarean section is choice in time after protective therapy of liver in short term and correction of the coagulate function.

Postpartum period:  Antibiotics without harm to liver such as penicillin ,cloxacillin ,ampicillin,etc.is chosen routinely at delivery.  Breast feeding is forbidden for the sake of vertical transmission when HBeAg is positive.

Anamia

 Anamia in pregnancy is often defined as a hemoglobin measurement is low 100g/L or hematocrit below 30%  Plasma volume increases 50% during pregnancy, while red cell volume increases 25%, causing lower hemoglobin and hematocrit values,which are maximally changed around the 24th and 28th weeks.

 Anamia is very common in pregnancy, causing fatigue, anorexia, dyspnea, and edema.

Including  Iron deficiency anemia  Follic acid deficiency anemia  Sickle cell anemia

Many women enter pregnancy with low iron stores resulting from  Heavy menstrual periods  Previous pregnancies  Breast feeding  Poor nutrition

 It is difficult to meet the increased requirement for iron through diet,and anemia often develops unless iron supplement are given.

Inter-action  Anemia increase miscarriage, preterm birth, fetal growth restriction, low birth weight, still birth.  Pregnancy woman with anemia is easy to get PIH, placental abruption and infection, even heat disease.

treatment  Consists of a diet containing iron-rich foods  60mg of elemental iron, eg, 300mg of ferrous sulfate three times a day  Iron is best absorbed if taken with a source of vitamin C