Medical disorders associated with pregnancy

• Care for women with pre-existing medical disorders (PEMD) should ideally take place before conception in multidisciplinary pre-pregnancy clinics.

• This process should begin during adolescence with discussions about family planning, contraception and pregnancy.

• A complete medical history and assessment of health at this time, including obtaining up-to-date investigations, enables a risk assessment for pregnancy to be made.

• These risks should be discussed with the woman and her family so that appropriate choices can be made.

• - Women with PEMD have high-risk pregnancies and a collaborative multidisciplinary approach is recommended to ensure careful monitoring of both the woman and her fetus.

• - Equally midwives and doctors need to be aware and recognize the clinical signs and symptoms of deteriorating maternal health

• -Labour and birth in women with PEMD can be a time of additional challenges

• Timing and mode of birth should be carefully planned and should take place in a hospital with neonatal facilities.

• -disease will put an effect on the physical, psychological, sexual and social aspects of women's lives.

• - Involvement of the woman and her family should participate in decisions regarding her care

• . *Midwives have a role in supporting women and their families, ensuring that their needs are met and that the pregnancy is treated as normal, as possible

Cardiac disease

• In most pregnancies, heart disease is diagnosed before pregnancy.

• - There is, however, a small but significant group of women who will present at an antenatal clinic with an undiagnosed heart condition.

• -Although heart disease complicates <1% of maternities

• -it continues to contribute significantly to maternal morbidity and mortality and is the leading cause of maternal death

• Heart disease can be broadly classified into ‘congenital’ and ‘acquired’.

Congenital heart disease

• The most common congenital heart diseases (CHD) -atrial septal defect (ASD)

• ventricular septal defect (VSD)

• patent ductus arteriosus (PDA),

• pulmonary stenosis,

• aortic stenosis

• tetralogy of Fallot (TOF).

• All of them need surgical intervention. • -Uncorrected lesions may cause :• pulmonary hypertension, • cyanosis • and severe left ventricular failure• and are therefore high risk for pregnancy.• CHD is also associated with increased fetal

complications :

• These include fetal loss,

• intrauterine growth restriction,

• pre-term birth

• and an increased risk of fetal CHD

• -high risk cardiac conditions for pregnancy include:

Eisenmenger's syndrome

• VSD, ASD or PDA• -fibrosis and the development of pulmonary

hypertension and cyanosis• - Women with this condition are advised

against pregnancy as maternal mortality 30–50%. The greatest risk to the fetus is prematurity which contributes to the high perinatal mortality rate

Marfan's syndrome:

• -an autosomal dominant• - defect on chromosome 15.• - It is a connective tissue disease that affects the

musculoskeletal system, the cardiovascular system and the eyes.

• -The cardiovascular abnormalities are the most life-threatening condition.

• -there is a 50% chance of a child inheriting Marfan's syndrome if one parent is affected.

• -Women and their partners should be counseled carefully

• - Careful monitoring is required throughout pregnancy including the use of serial echocardiography to identify progressive aortic root dilatation.

• -Prophylactic antihypertensive therapy using beta-blockers is recommended

Acquired heart disease:

• -Rheumatic heart disease• -the most common cardiac problem.• - RHD causes inflammation and scarring of the heart

valves and results in valve stenosis, plus or minus regurgitation.

• The mitral valve is most often affected with stenosis, • c\p:• -severe breathlessness and tiredness for the first time

during pregnancy• -Most women with valvular heart disease can be managed

medically which aims to reduce the work rate of the heart.•

• During pregnancy, this involves bed rest, oxygen therapy and the use of cardiac drugs e.g. diuretics, digoxin and heparin (reduces risk of thromboembolic disease).

• Women with more severe symptomatic disease may require surgical intervention such as balloon valvoplasty or valve replacement

• Antibiotic prophylaxis is recommended for all women with valvular lesions during labour.

Myocardial infarction and ischemic heart disease

• Myocardial infarction (MI) and ischaemic heart disease (IHD) • -uncommon cardiac complications • -May lead to maternal death.• - risk factors include :• increasing maternal age• obesity• diabetes• pre-existing hypertension• smoking• family history• inequalities in health

• A myocardial infarction is most likely to occur in the third trimester and periperium period due to the hypercoagulability induced by hormonal changes.

• - women present with ischemic chest pain in the presence of an abnormal ECG and elevated cardiac enzymes although these signs and symptoms may be masked during labour and birth as

• abdominal or epigastric pain and vomiting.

• - Primary percutaneous transluminal coronary angioplasty (PTCA) which improves the patency of blocked arteries is first line therapy for this condition

Aortic dissection (acute)

• -may occur in pregnancy in association with severe hypertension (systolic >160 mmHg) due to:

• 1- pre-eclampsia• 2- coarctation of the aorta • 3-connective tissue disease such as Marfan's syndrome. • The woman presents with • severe chest• intrascapular pain.• Early diagnosis using computed tomography chest scan or

MRI or as maternal mortality is high .

Endocarditis

• -Endocarditis is an inflammation of the heart involving the heart valves.

• -Although rare in pregnancy, it is one of the most serious complications of heart disease.

• Risk group:• Women with valvular heart disease• prosthetic valves• a previous history of endocarditis• periodontal disease • and intravenous substance misusers

• - Streptococcal organisms are the most common cause • -Acute endocarditis is due to a Staphylococcus aurous,

Streptococcus pneumonia and Neisseria gonorrhea. • -Primary prevention includes recognition of risk factors

and • -e.g. good dental hygiene• - avoidance of drug misuse• -early treatment of sepsis • - administration of antibiotic prophylaxis to women with

high risk cardiac conditions

Peripartum cardiomyopathy:

• rare but fatal disease.• - mortality rates range from 25% to 50% . • - occurring between the last month of pregnancy and the

first 5 months postpartum • - women have no previous history of heart disease. Risk

group:• -older and• - multiparous women, • hypertension,• pre-eclampsia,•

• obesity

• diabetes.

• myocarditis

• viral infection

• long-term oral tocolytic therapy

• and cocaine misuse.

• Pathology :

• Inflammation and enlargement of the myocardium (cardiomegaly)

• left ventricular heart failure

• and thromboembolic complications

• Treatment :• -use of medication (oxygen, diuretics,

vasodilators) to decrease pulmonary congestion and fluid overload,

• - inotropic agents to improve myometrial contractility

• - and anticoagulation therapy.•

• As the cardiomegaly resolves may take up to 6 months and there is a risk of recurrence in a subsequent pregnancy.

• -a heart transplant is performed

• mortality will be high