Medical-Surgical PROBLEMS in Pregnancy

1. Medical-Surgical PROBLEMS in Pregnancy Lectures 7 Prepared by MD, PhD Kuziv I.

2. Heart Diseases in Pregnancy • Incidence • 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 • disease) • idiopathic cardiomyopathy (perinatal cardiomyopathy) • isolated myocarditis • various forms of heart block

3. Maternal mortality • 0.3 per 10,000 live births • Heart disease still significantly contributes to • 5.6-8.5 percent of maternal deaths

4. Effect of pregnancy on heart disease • The pregnant period • Cardiac output is increased by as much as 30-50 percent • 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%. • 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 • heart, diaphragm, uterus. • formation of utero-placental circulation

5. Severe or progressive dyspnea • Progressive orthopnea • Paroxysmal nocturnal dyspnea • Hemoptysis • Syncope with exertion • Chest pain related to effort or emotion • Clinical Findings • Cyanosis • Clubing of fingers Symptoms

6. Conventional tests • Electrocardiography • Ecocardiography • Chast X-ray • Diagnosis of early heart failure during pregnancy • Dyspnea, palpitation at slight physical activity. • Resting pulse larger than 110 beats per minute. • Paroxysmal nocturnal dyspnea. • Rale in lower lungs

7. Prognosis 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.

8. What is preeclampsia?Triad of criteria •  BP of 30 mmHg systolic or  15 mmHg diastolic as compared to BP prior to 20 weeks gestation. (The  BP must be present on 2 occasions taken 6 hours apart; if previous BP is unknown, 140/90 after 20 weeks gestation is considered diagnostic) -WITH- Edema resulting in wt gain of 5 pounds in 1 week. -AND/OR- Proteinuria 0.1 g/L (1-2+ on urine dip) in at least 2 random specimens collected 6 hours apart or 300 mg/L in a 24-hour urine collection.

9. Clinical Manifestations of Preeclampsia:CNS Changes •  cerebrovascular resistance • Vision changes: scotomata (spots), diplopia (blurry), retinal detachment (usually unilateral; rare) • HA that is unrelieved by medication • Hyperreflexia / clonus • Clonus is involuntary, rapid, rhythmical CTXs and relaxations of a muscle when it is sharply stretched and maintained • Seizure activity with eclampsia which can occur antepartally, intrapartally, or postpartally

10. Clinical Manifestations of Preeclampsia:Pulmonary Changes • Colloid oncotic pressure decreases even further than what is normal in pregnancy due to damaged vessels and proteinuria, potentially, resulting in generalized and/or pulmonary edema

11. Non-Pharmacologic Care of the Preeclamptic Patient Depends on Severity of Preeclampsia, Maternal and Fetal Status at time of evaluation, Gestational Age, Bishop Cervical Score, and wishes of the Parents • If mild to moderate HTN, bedrest with BP and urine protein checks (1+ proteinuria), in addition to regular office visits including fetal evaluation (i.e., NSTs, BPP) • If fetal evaluation indicates compromise (IUGR, non-reactive NST) or maternal condition worsens ( BP,  proteinuria), hospitalization is usually required for constant observation and therapy; continuous fetal monitoring is indicated

12. Normal Fetal Heart Pattern tracing at term • Reassuring pattern. Baseline fetal heart rate is 130 to 140 bpm, preserved beat-to-beat and long-term variability. Accelerations last for 15 sec and peak at 15 bpm above baseline.

13. Late Decelerations

14. Late Decelerations

15. Management Counseling (Preconceptionalcounceling). (to decide the pregnancy should be continued) Intensive pregnatal care. Active prevent factors increasing cardiac functional load. (such as respiratory tract infection, anemia and pregnancy-induced hypertension)

16. Management during labor and delivery 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,)

17. Management or early puerperium • Bring pressure to bear on the upper abdomen • Bed rest • Monitoring the vital signs • Breast feeding (Classes I and II) and • Artificial feeding (Classes III or IV)

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

19. Rate of non-obstetric surgery Rate – 1:527 pregnancies, 77 surgeries total

20. Appendicitis 1:2000 to 1:6000 pregnancies Incidence 0.05% Difficult diagnosis?? Immediate intervention a must

21. Appendix Location 1932 Baer described location of appendix during pregnancy. Since, most agree there is a shift in location.

22. Psoas and Obturator signs. Sensitivity/specificity??

23. Can we do better than 50%? CT Scan Numerous reports in surgical literature suggesting accuracy of >97% in non-pregnant patients.

24. Ultrasound 90 % suspected Appendicitis Diagnosis missed in 7% of cases due to gravid uterus (all in 3rd trimester) 100% sensitivity 96% specificity 98% accuracy

25. 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

26. Other Risks Pneumoperitoneum Animal studies indicate decreased unteroplacental blood flow with CO2 pressures >15mmHg Also, some infants developed acidemia

27. 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)

28. 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

29. Workup Ultrasound Effective rate 90% Liver enzymes Amylase, Lipase

30. Pancreatitis 1:3000 – 1:4000 pregnancies High incidence of Gallstones Elevated Amylase, Lipase Medical management NG tube NPO IVF, Pain control

31. 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

32. Complications Whitecar study cont.. Ovarian Torsion most common and serious sequelae 5% occurrence rupture most common in 1st trimester

33. MRI? Correctly identified 17 of 17 adnexal masses with MRI vs. 12 out of 17 with ultrasound

34. 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