medical complications of pregnancy for educational purposes only

Medical Complications of

Pregnancy

For Educational Purposes Only

Identify the following medical and surgical conditions in pregnancy and discuss the potential impact of the conditions on the gravid patient and the fetus/newborn, as well as the impact of pregnancy (if any) on each condition, and appropriate initial evaluation: Anemia Endocrine disorders (Diabetes mellitus, Thyroid disease) Cardiovascular disease Hypertension Pulmonary disease Renal disease Gastrointestinal disease Neurologic disease Autoimmune disorders Alcohol, tobacco, and substance abuse Surgical abdomen Infectious disease, including:

Syphilis, TORCH, Group B Streptococcus, Hepatitis, HIV, HPV, Parvovirus,Varicella


In pregnancy, plasma volume expands proportionally greater than that of RBC mass

Because Hct reflects proportion of blood made up primarily of RBCs, Hct demonstrates a “physiologic” decrease during pregnancy

Defined as Hct <33% for first and third trimestersHct <32% for second trimester


Iron deficiency:Pregnancy results in increased iron requirements

Standard American diet and endogenous stores of many women are not sufficient to provide for increased requirements

Recommendation: 27mg Fe daily supplementation for pregnant women


Other anemiasSickle cell diseaseThalassemias Hereditary hemolytic anemias


Fetal outcomes such as preterm labor, IUGR and LBW are more common in women with hemoglobinopathies – except those with sickle cell trait

Antenatal assessment of fetal well-being and growth is important part of managing these patients


EvaluationRoutine prenatal labs:

Hematocrit or hemoglobin to screen for anemia

Mean corpuscular volume (MCV) to screen for thalassemia (MCV <80 fL in the absence of iron deficiency suggests thalassemia and further testing with hemoglobin electrophoresis is indicated)

Further testing for thalassemias and/or other hemoglobinopathies based on parent history, family history, ethnic origin


Pathophysiology Placental hormone increases insulin

resistance Human placenta lactogen (hPL)

Disease presents like Type II diabetes, but for the first time in pregnancy

Diagnosis One hour 50gm glucose screening test

(O‘Sullivan) (nl < 140mg/dl) 3-hour GTT (fasting < 105, 1-hour <

190, 2-hour <165. 3-hour < 145mg/dl)


Gestational


Management Tight control essential Diet – 30-35 kcal/kg ideal body weight

ADA diet Glucose testing - fasting and 2-hours

following meals FBS <105mg/dl 1-hour PP <130mg/dl


HyperthyroidismMay suppress fetal and neonatal thyroid

functionHas been associated with fetal goiterThyroid storm – high risk of maternal heart

failure Hypothyroidism

Maternal thyroxine requirements increase during pregnancy

Adjust levels q4 wks and then check TSH each trimester


Pregnancy results in ~40% increase in cardiac output

The risks for mother and fetus are therefore often profound for women with pre-existing cardiac disease; ex:Rheumatic heart diseaseAcquired infectious valvular disease


Fetal complicationsFetuses of patients with functionally

significant cardiac disease are at increased risk for LBW and prematurity

Patient w/ congenital heart disease is 1-5% more likely to have a fetus with a congenital heart disease as well

High rate of fetal loss in women with rheumatic heart disease


Evaluation Ideally, women with cardiac disease

should have preconception care directed at maximizing cardiac function and counseling regarding risks that their particular disease poses in pregnancy

Serial evaluation of Maternal cardiac status Fetal well-being and growth


Cardiovascular Disease

Classification: Chronic – HTN present before 20th week of

pregnancy Gestational – HTN that develops after 20

wks gestation in the absence of proteinuria and returns to normal postpartum

Preeclampsia – HTN with proteinuria and edema after 20 wks gestation

Eclampsia – additional presence of convulsions in a woman with preeclampsia that is not explained by a neuro disease

HELLP Syndrome – presence of hemolysis, elevated liver enzymes and low platelets


Pathophysiology:Predominant pathophysiologic finding is

maternal vasospasmPotential contributors:

Endothelial damage Increased platelet activation and consumption Increased TXA2 and PGI2 Decreased NO


Maternal complications:Liver dysfunctionRenal insufficiencyCoagulopathyConvulsions


Potential Fetal Complications IUGRPTBAbruption

Studies to evaluate: UltrasoundFetal weight and growth assessmentAmniotic fluid volumeUmbilical artery dopplers


Evaluation:Routine measurement of BPCompare weight to pregravid weight and

previous weights during pregnancy to monitor for rapid or excessive gain

Note excessive, persistent edema (general peripheral edema is normal)

Labs CBC, platelets LFTs Serum Cr


Asthma – restrictive airway disease Effects of pregnancy on asthma are

variable1/3 patients improve1/3 worsen1/3 unchanged


Women with mild-moderate asthma usually have excellent maternal and fetal outcomes

Suboptimal control of asthma during pregnancy may be associated with increased risk ofLBWPrematurity


Routine evaluation of pulmonary function in pregnant women w/ persistent asthma is recommended

Consider serial ultrasounds starting at 32 weeks for women w/ moderate-severe asthma during pregnancy


UTIs Pre-existing renal disease


Common in pregnancy Aysmptomatic bacteruria is more

likely to lead to cystitis and pyelonephritis in pregnant womenPregnancy associated urine stasis Glycosuria↑ urine pH

Urine culture should be obtained at first prenatal visit


One of the most common medical complications in pregnancy requiring hospitalization

Associated with↑increased risk of preterm laborE. coli produces phospholipase A

promotes prostaglandin synthesis ↑ uterine activity

Treat with IV hydration and antibiotics


Women with significant pre-existing renal disease (chronic renal failure or transplant) should be advised of risks involved in pregnancy during preconception counseling

Patients with mild renal insufficiency generally have uneventful pregnancy


Patients with moderate-severe disease are at risk for worsening renal function, proteinuria and associated hypertensive complications of pregnancy

Women with chronic renal disease also have increased incidence of IUGR and need serial assessments of fetal well being and growth


Nausea and vomiting of pregnancy (NVP) – typically begins ~4-8 wks gestation and stops by 14-16 wksRelated to ↑ progesterone and hCG,

smooth muscle relaxation of the stomach Hyperemesis gravidarum – severe NVP

which results in weight loss, ketonemia or electrolyte imbalance

GERD – symptoms become more pronounced as pregnancy advances Due to ↑ intraabdominal pressure


Complications for mom or baby are rare Evaluation for mom with persistent

vomiting: Weight Orthostatic BPs Serum electrolytes Urine ketones Thyroid function tests Ultrasound to exclude gestational

trophoblastic disease and multiple gestation, both of which are associated with hyperemesis


Majority of women with epilepsy have normal pregnancy

Typically there is not an increased frequency of seizures during pregnancy


Small association with LBW, lower Apgar scores, preeclampsia, bleeding, placental abruption, and prematurity

Increases risk of congenital malformations in fetus exposed to phenytoin, valproic acid, phenobarbital and carbamazepine

Risks to fetus of actual seizures - hypoxia, abruption, or miscarriage due to maternal trauma sustained during a seizure; although few studies have been done to assess


Prognosis for mom and baby is best when SLE has been quiescent for at least 6 months prior to the pregnancy

Should be seen by OB who is experienced in management of high risk pregnancies

Exacerbation of disease can occur throughout all three trimesters and even in postpartum period


Women with SLE have increased risk of preeclampsia

Significant risk of fetal loss in women with hypertension, active lupus, lupus nephritis, hypocomplementemia, ↑ anti-DNA antibodies, ↑ aPL or thrombocytopenia

Mothers should be assessed for disease activity at least once per semester – more if they have active lupus


Leading preventable cause of mental retardation, developmental delay and birth defects in the fetus

Greatest risk – exposure during first trimester

No established safe level of consumption


Risks to fetus – IUGR, LBW, fetal death Safety of nicotine replacement products

in pregnancy has not been documented


Illicit drugs reach fetus via placental transfer or reach newborn through breast milk

Opiate-exposed fetus – may have withdrawal symptoms in utero or after birth

Universal specimen screening is not recommended, however all women should be questioned about and counseled if appropriate about past and present use of alcohol, nicotine and other drugs


Surgical treatment of pregnancy women should consider maternal and fetal health needs

Don’t avoid radiographic or other studies because woman is pregnant, but exercise caution

Monitor fetal heart tones during surgery to the extent possible

Avoid placing patient fully supine if possible – place in decubitus lateral tilt to prevent supine hypotensive syndrome


Infection Transmission Maternal Disease Neonatal Disease

Toxoplasma

Cat feces, undercooked meat

Usually asymptomatic, sometimes lymphadenopathy

Triad - chorioretinitis, hydrocephalus, intracranial calcifications

RubellaRespiratory droplets

Rash, lymphadenopathy, arthritis

Triad - PDA (or pulmonary artery hypoplasia), cataracts, deafness; +/- blueberry muffin rash

CMV

Sexual contact, organ transplants

Usually asymptomatic, sometimes mono-like illness

Hearing loss, seizures; most asymptomatic; some w/ same triad as toxoplasma

HIV Sexual contact Variable, depending on CD4 count Recurrent infxns, chronic diarrhea

HSV

Skin or mucous membrane contact

Usually asymptomatic; herpetic lesions

Temporal lobe encephalitis (seizures), herpetic lesions

Syphillis Sexual contact

Primary - chancre, Secondary - disseminated rash, Tertiary - cardiac/neurologic disease

Stillbirth, hydrops fetalis

If child survives - facial abnormalities (notched teeth, saddle nose, short maxilla), saber shins, snuffles (bloody nasal discharge)


Asymptomatic lower genital tract colonization is common

Without treatment, GBS sepsis can occur

Infection of newborn – septicemia, septic shock, pneumonia or meningitis

Universal screening at 35-37 wks if positive, give antibiotic prophylaxis in labor


All women exhibit absolute decline in CD4 counts in pregnancy – thought to be 2/2 hemodilution

Perinatal transmission w/o prophylaxis is ~25%

With Zidovudine monotherapy – transmission ~8%

Combination therapy and undetectable viral load – transmission ~1-2%

Universal, voluntary HIV screening should be part of standard prenatal labs


Genital wart lesions often increase in size and area during pregnancy due to relative immune suppression

If extensive – c/s delivery may be necessary

Transmission to infant is rare, but if occurs – manifests as laryngeal papillomatosis c/s delivery does not prevent transmission


Can cause devatsating fetal outcomes – SAB, fetal nonimmune hydrops fetalis, death

Maternal immune status can be determined by serologic testing – IgM recent infection, IgG past infection and immunity Routine serologic testing not recommended Exposed pregnant women should be offered

B-19 specific IgM and IgG serologic testing If IgM + confirmed – serial ultrasounds starting

at 10 wks to look for evidence of hydrops, placentomegaly and growth disturbances

If hydrops doesn’t develop, long-term outcomes good


Hepatitis AVaccination safety during pregnancy has not

been establishedHAV IG is effective for both pre and post-exposure

prophylaxis and can be used during pregnancy Hepatitis B

Routine testing for HBsAg - if neg w/ risk factors for HBV infection – offer vaccination during pregnancy

All infants receive Hep B vaccine Infants of mothers who are HBsAg pos should get

vaccine and HBIG w/in 12 hrs of birth


Hepatitis C Routine screening is not recommended Co-infection with HIV is associated with a higher risk of

vertical transmission of HCV No known preventative measures to reduce risk of mother

to child transmission Hepatitis D

Infection can only occur along with Hep B infection Vertical transmission has been documented but is rare

Hepatitis E Associated with higher rates of fulminant disease and

mortality in pregnant women Risk of vertical transmission is low


Maternal medical or surgical conditions can complicate the course of a pregnancy and/or can be affected by pregnancy

Important to understand: Effect of pregnancy on natural course of disorder

Effect of disorder on pregnancy

Change in mgmt of the pregnancy and disorder caused by their coincidence

Screening for and preventing infectious diseases is an integral part of routine prenatal care

Many infectious diseases can have devastating effects for mother, infant or both


Conclusion

medical complications of pregnancy for educational purposes only

Documents

impact of pregnancy

surgical conditions

educational purposes

potential impact

appropriate initial

group b streptococcus

physiologic decrease

rbc mass