Medical-Surgical Medical-Surgical PROBLEMS PROBLEMS in Pregnancy in Pregnancy

Prepared by MD, PhD Kuziv I.

Incidence Incidence • Heart disease complicates about 1 percent of pregnancies. Heart disease complicates about 1 percent of pregnancies.

Component Component • congenital heart diseasecongenital heart disease• rheumatic heart diseaserheumatic heart disease• hypertensive heart diseasehypertensive heart disease• other varieties (inclued: pregnancy-induced hypertension, other varieties (inclued: pregnancy-induced hypertension,

thyroid, coronary, syphilitic, and kyphoscoliotic cardiac thyroid, coronary, syphilitic, and kyphoscoliotic cardiac

disease)disease)• idiopathic cardiomyopathy (perinatal cardiomyopathy)idiopathic cardiomyopathy (perinatal cardiomyopathy)• isolated myocarditis isolated myocarditis • various forms of heart block various forms of heart block

Heart Diseases in PregnancyHeart Diseases in Pregnancy

• 0.3 per 10,000 live 0.3 per 10,000 live births births

Heart disease still Heart disease still significantly contributes significantly contributes to to

• 5.6-8.5 percent of 5.6-8.5 percent of maternal deaths maternal deaths

Maternal mortalityMaternal mortality

Effect of pregnancy on heart diseaseEffect of pregnancy on heart disease The pregnant period The pregnant period • Cardiac output is increased by as much Cardiac output is increased by as much as 30-50 percentas 30-50 percent

almost half of the total increase has almost half of the total increase has occurred by 8 weeks, and it is occurred by 8 weeks, and it is maximized by mid pregnancy.maximized by mid pregnancy.

• Total blood volume is increased about Total blood volume is increased about 35%.35%.

from 6th week to 32nd weekfrom 6th week to 32nd week• Stroke volume is increased by 20-40%.Stroke volume is increased by 20-40%.• Resting pulse is increased (by 10-17%)Resting pulse is increased (by 10-17%)• The changes of anatomic positionsThe changes of anatomic positions

heart, diaphragm, uterus.heart, diaphragm, uterus. formation of utero-placental formation of utero-placental circulationcirculation

• Severe or progressive dyspneaSevere or progressive dyspnea• Progressive orthopneaProgressive orthopnea• Paroxysmal nocturnal dyspneaParoxysmal nocturnal dyspnea• HemoptysisHemoptysis• Syncope with exertionSyncope with exertion• Chest pain related to effort or Chest pain related to effort or emotionemotion• Clinical FindingsClinical Findings• CyanosisCyanosis• Clubing of fingersClubing of fingers

Symptoms Symptoms

Conventional tests Conventional tests • ElectrocardiographyElectrocardiography• Ecocardiography Ecocardiography • Chast X-rayChast X-ray

Diagnosis of early heart failure during pregnancy Diagnosis of early heart failure during pregnancy • Dyspnea, palpitation at slight physical activity.Dyspnea, palpitation at slight physical activity.• Resting pulse larger than 110 beats per minute.Resting pulse larger than 110 beats per minute.• Paroxysmal nocturnal dyspnea.Paroxysmal nocturnal dyspnea.• Rale in lower lungsRale in lower lungs

Prognosis Prognosis The likelihood of a favorable outcome for the mother The likelihood of a favorable outcome for the mother

with heart disease depends upon the with heart disease depends upon the

(1) functional cardiac capacity(1) functional cardiac capacity

(2) other complications that further increase cardiac load (2) other complications that further increase cardiac load

(3) quality of medical care provided.(3) quality of medical care provided.

What is preeclampsia?What is preeclampsia?Triad of criteriaTriad of criteria

BP of BP of 30 mmHg systolic or 30 mmHg systolic or 15 mmHg diastolic as 15 mmHg diastolic as compared to BP prior to 20 weeks gestation. (The compared to BP prior to 20 weeks gestation. (The BP BP must be present on 2 occasions taken 6 hours apart; if must be present on 2 occasions taken 6 hours apart; if previous BP is unknown, 140/90 after 20 weeks previous BP is unknown, 140/90 after 20 weeks gestation is considered diagnostic)gestation is considered diagnostic)

-WITH--WITH-

Edema resulting in wt gain Edema resulting in wt gain of of 5 pounds in 1 week.5 pounds in 1 week.

-AND/OR--AND/OR-

Proteinuria Proteinuria 0.1 g/L (1-2+ on 0.1 g/L (1-2+ on urine dip) in at least 2 urine dip) in at least 2 random specimens collected random specimens collected 6 hours apart or 6 hours apart or 300 mg/L 300 mg/L in a 24-hour urine collection.in a 24-hour urine collection.

Clinical Manifestations of Clinical Manifestations of Preeclampsia:Preeclampsia:CNS ChangesCNS Changes

cerebrovascular resistancecerebrovascular resistance Vision changes: scotomata (spots), diplopia Vision changes: scotomata (spots), diplopia

(blurry), retinal detachment (usually unilateral; (blurry), retinal detachment (usually unilateral; rare)rare)

HA that is unrelieved by medicationHA that is unrelieved by medication Hyperreflexia / clonusHyperreflexia / clonus

Clonus is involuntary, rapid, rhythmical CTXs and Clonus is involuntary, rapid, rhythmical CTXs and relaxations of a muscle when it is sharply stretched and relaxations of a muscle when it is sharply stretched and maintainedmaintained

Seizure activity with eclampsia which can occur Seizure activity with eclampsia which can occur antepartally, intrapartally, or postpartally antepartally, intrapartally, or postpartally

Clinical Manifestations of Clinical Manifestations of Preeclampsia:Preeclampsia:Pulmonary ChangesPulmonary Changes

Colloid oncotic Colloid oncotic pressure decreases pressure decreases even further than what even further than what is normal in pregnancy is normal in pregnancy due to damaged due to damaged vessels and proteinuria, vessels and proteinuria, potentially, resulting in potentially, resulting in generalized and/or generalized and/or pulmonary edemapulmonary edema

Non-Pharmacologic Care of the Non-Pharmacologic Care of the Preeclamptic PatientPreeclamptic Patient

Depends on Severity of Preeclampsia, Maternal and Depends on Severity of Preeclampsia, Maternal and Fetal Status at time of evaluation, Gestational Fetal Status at time of evaluation, Gestational Age, Bishop Cervical Score, and wishes of the Age, Bishop Cervical Score, and wishes of the

ParentsParents If mild to moderate HTN, bedrest with BP and If mild to moderate HTN, bedrest with BP and

urine protein checks (1+ proteinuria), in addition urine protein checks (1+ proteinuria), in addition to regular office visits including fetal evaluation to regular office visits including fetal evaluation (i.e., NSTs, BPP)(i.e., NSTs, BPP)

If fetal evaluation indicates compromise (IUGR, If fetal evaluation indicates compromise (IUGR, non-reactive NST) or maternal condition worsens non-reactive NST) or maternal condition worsens (( BP, BP, proteinuria), hospitalization is usually proteinuria), hospitalization is usually required for constant observation and therapy; required for constant observation and therapy; continuous fetal monitoring is indicatedcontinuous fetal monitoring is indicated

Normal Fetal Heart Pattern Normal Fetal Heart Pattern tracing at termtracing at term

Reassuring pattern. Baseline fetal heart Reassuring pattern. Baseline fetal heart rate is 130 to 140 bpm, preserved beat-to-rate is 130 to 140 bpm, preserved beat-to-beat and long-term variability. beat and long-term variability. Accelerations last for Accelerations last for 15 sec and peak at 15 sec and peak at 15 bpm above baseline.15 bpm above baseline.

Late DecelerationsLate Decelerations

Late DecelerationsLate Decelerations

Counseling (Preconceptional Counseling (Preconceptional counceling).counceling).

(to decide the pregnancy (to decide the pregnancy should be continued)should be continued)

Intensive pregnatal care.Intensive pregnatal care.

Active prevent factors Active prevent factors increasing cardiac increasing cardiac

functional load.functional load.

(such as respiratory tract (such as respiratory tract infection, anemia and infection, anemia and pregnancy-induced pregnancy-induced hypertension) hypertension)

MManagementanagement

Monitoring the vital signsMonitoring the vital signs

Sedatives and analgesicSedatives and analgesic

Shortening the second stage Shortening the second stage of labor of labor

(by forceps)(Classes I and (by forceps)(Classes I and II)II)

Indications of CS (cesarean Indications of CS (cesarean section)section)

(Class III or more, obstetric (Class III or more, obstetric indications,)indications,)

Management during labor and deliveryManagement during labor and delivery

Management or early puerperiumManagement or early puerperium

• Bring pressure to bear on the upper abdomenBring pressure to bear on the upper abdomen• Bed rest Bed rest • Monitoring the vital signsMonitoring the vital signs• Breast feeding (Classes I and II) and Breast feeding (Classes I and II) and • Artificial feeding (Classes III or IV) Artificial feeding (Classes III or IV)

Non-Obstetric Causes for Surgery Appendicitis Biliary disease Ovarian disorders Breast disease Cervical disease Bowel obstruction

Rate of non-obstetric surgery

0

5

10

15

20

25

30

35

40

45

AdnexalMass

Appendicitis Gallstones Other

% Cases

Rate – 1:527 pregnancies, 77 surgeries total

Appendicitis

1:2000 to 1:6000 pregnancies

Incidence 0.05%

Difficult diagnosis??

Immediate intervention a must

Appendix Location

1932 Baer described location of appendix during pregnancy.

Since, most agree there is a shift in location.

Psoassign

Obturatorsign

Psoas and Obturator signs. Sensitivity/specificity??

Can we do better than 50%?

CT Scan Numerous reports in

surgical literature suggesting accuracy of >97% in non-pregnant patients.

Ultrasound

90 % suspected Appendicitis Diagnosis missed in 7% of

cases due to gravid uterus (all in 3rd trimester)

100% sensitivity 96% specificity 98% accuracy

Laparoscopy

Safe – especially in the first 20 weeks

Risks: Low birth weight

infants Preterm labor Fetal growth restriction

(no diff. Vs. laparotomy)

General anesthesia considered safe

Other Risks

Pneumoperitoneum Animal studies indicate

decreased unteroplacental blood flow with CO2 pressures >15mmHg

Also, some infants developed acidemia

Gall Bladder

Biliary Disease Increased biliary sludge in pregnancy

Increased bile viscosity Increased micelles Gall bladder relaxation

Increased risk of gallstone formation Cholelithiasis cause of 90% cases of

cystitis 0.2-0.5/1000 pregnancies require surgery

(Landers eta ak 1987)

Symptoms

May be asymptomatic 2.5-10% of pregnant patients

(Maringhini et al 1987)

RUQ Pain – most reliable symptom (pain may radiate to back)

Vomiting approx 50% Can mimic appendicitis in 3rd

trimester

Workup

Ultrasound Effective rate 90%

Liver enzymes Amylase, Lipase

Pancreatitis

1:3000 – 1:4000 pregnancies High incidence of Gallstones Elevated Amylase, Lipase

Medical management NG tube NPO IVF, Pain control

The Adnexa

Estimated 1:200 deliveries (adnexal masses)

Est. 1:1300 adnexal masses require surgery

5% malignant rate ½ Serous Carcinomas of

low malignant potential 30% cystic teratomas 28% serous/mucinous cystadenomas

13% corpus luteal 7% benign

Complications

Whitecar study cont..

Ovarian Torsion most common and serious

sequelae 5% occurrence rupture most common in 1st

trimester

MRI?Correctly

identified 17 of 17 adnexal

masses with MRI vs. 12 out of 17 with ultrasound

Axial SSFSE T2W image

Breast Disease “Any suspicious breast mass

found during pregnancy should prompt an aggressive plan to determine its cause, whether by FNA or open biopsy.”

Williams 21st Edition