ภาวะแทรกซ้อนทางอายุรกรรมและศัลยกรรม Medical and surgical complications

1. ภาวะแทรกซ้อนทางอายุรกรรมและศัลยกรรม Medical and surgical complications • พญ.ฐิติมา ชัยศรีสวัสดิ์สุข • กลุ่มงานสูติศาสตร์และนรีเวชกรรม • รพ.สรรพสิทธิประสงค์ อุบลราชธานี

2. Cardiac disease

3. Incidence • Complicate 1% of pregnancy • But contribute significant maternal morbidity and mortality rate • Mortality rate is about 2.7 : 1000 pregnancy

4. Why we take cardiac dz in pregnancy so serious?

5. Pregnancy induce worsen cardiac diseases during antepartum, intrapartum and postpartum period • Physiologic change in hemodinamic of pregnancy mimics clinical finding of cardiac dz.

6. Effect of pregnancy on cardiac disease • Antepartum period • Cardiac output is increase by 30-50% • Total blood volume is increase about 50% • Increase heart rate by 10-20 beats/min • Decrease in peripheral vascular resistant

7. Effect of pregnancy on cardiac disease • Intrapartum and delivery • Consumption of energy and oxygen is increase • Pain increases sympathetic tone • Uterine contractions induce wide swings in the systemic venous return

8. Effect of pregnancy on cardiac disease • Postpartum • Autotransfusion of at least 500 ml occur wiht placental separation • During first 2 days of postpartum period, great amount of fluid from interstitial tissue return into the systemic circulation

9. Physiologic change in pregnancy mimics cardiac dz • Functional systolic heart murmur • Respiratory effort • Edema in the lower extremities • Various heart sounds may suggest cardiac dz.

11. Clinical indicators of cardiac dz. in pregnancy • Progressive dyspnea or orthopnea • Nocturnal cough • Hemoptysis • Syncope • Chest pain Symptoms Clinical finding • Cyanosis • Clubbing of fingers • Persistent neck vein distension • Systolic murmur > gr.3 • Diastolic murmur • persistent split 2nd sound

12. Diagnostic study • EKG (15 degree left axis deviation, mild ST changes in inferior leads, atrial and ventricular premature contractions) • CXR • Echocardiography

13. Clinical classification of cardiac dz.(New York Heart Association; NYHA) • Class 1: Uncompromised -- no limitation of physical activity • Class 11: Slight limitation of physical activity • Class 111: Marked limitation of physical activity • Class 1v: Severely compromised -- inability to perform any physical activity without discomfort

14. Predictors of cardiac complications • Prior heart failure, transient ischemic attack, arrhythmia, or stroke • Baseline NYHA class 111 or 1v or cyanosis • Left-sided obstruction: mitral valve area <2cm2, aortic valve area less than 1.5 cm2, or peak left ventricular out flow tract gradient above 30 mm Hg • Ejection fraction less than 40%

15. Prognosis The likelihood of a favorable outcome for the mother with heart disease depends upon 1. Functional cardiac capacity 2. Other complications that further increase cardiac load 3. Quality of medical care provided

16. Valvular Heart Lesions Associated with High Maternal and/or Fetal Risk During Pregnancy • Severe AS with or without symptoms • AR with NYHA functional class III-IV symptoms • MS with NYHA functional class II-IV symptoms • MR with NYHA functional class III-IV symptoms • Aortic and/or mitral valve disease resulting in severe pulmonary hypertension • Aortic and/or mitral valve disease with significant LV disfunction (EF < 40%) • Mechanical prosthetic valve requiring anticoagulation • Marfan syndrome with or without AR

17. High-Risk Maternal Cardiovascular Disorders • Aortic valve stenosis 10-20 • Coarctation of the aorta 5 • Marfan syndrome 10-20 • Peripartum cardiomyopathy 15-60 • Severe pulmonary hypertension 50 • Tetralogy of Fallot 10 Estimated Maternal Mortality Rate (%) Disorder

18. Management in cardiac diseases

19. Preconceptional counseling • Maternal mortality rates vary directly with functional classification BUT may change as pregnancy progresses. • By corrective surgery, subsequent pregnancy is less dangerous. If mechanical valves taking warfarin, fetal risk should be consider. • Congenital heart lesions could be inherited.

20. Congenital heart disease risks in fetus with affected family members

21. Management of NYHA Class I and II Disease • Mostly deliver without morbidity • Prevention and early detection of heart failure • Prevent infection and sepsis syndrome • Prevention of bacterial endocarditis • Pneumococcal and influenza vaccination • Avoid smoking, intravenous drug use

22. Sudden limitation of normal activities • Dyspnea on exertion • Smothering with cough • Hemoptysis, Progressive edema, tachycardia Signs of congestive heart failure • Persistent basilar rales • Nocturnal cough Warning signs Serious signs

23. Labor and delivery • Vaginal delivery with short second stage unless obstetrical indication is obtained for C/S Rout of delivery Monitory • V/S : if PR > 100 bpm or RR > 24 tpm with dyspnea, may suggest impending ventricular failure Analgesia and Anesthesia • Epidural analgesia is recommended in most case • General anesthesia is preferable in case of intracardiac shunts, pulmonary hypertension and aortic stenosis

24. Labor and delivery • Proper therapeutic approach depends on the specific hemodynamic status and the underlying cardiac lesion. Intrapartum heart failure Puerperium • Woman who have no evidence of cardiac distress during pregnancy, labor, or delivery may still decompensate postpartum • Avoid : Postpartum hemorrhage, anemia, infection, and thromboembolism ( cause much more serious complication in heart disease)

25. Contraception • Sterilization : should delay until hemodynamically near normal, afebrile, not anemic and ambulates normally • Oral combine pills: should avoid because they can induce thrombosis • DMPA: can use safely, but hematoma should be monitors • Implant: safely use, less hematoma complication • IUDs: safely use, but ATB should be given for endocarditis prevention

26. Management of NYHA Class III and IV Disease • Pregnancy interruption is preferable • If the pregnancy is continued, prolonged hospitalization or bed rest is often necessary • Epidural analgesia usually recommended • vaginal delivery is preferred in most cases, and labor induction can usually be done safely • C/S is limited to obstetrical indications • Need ICU care, experienced obstetrician and anesthesiologist

27. Valve replacement before pregnancy • Mechanical valve itself doesn’t effect on pregnancy. • Thromboembolism involving the prosthesis and hemorrhage from anticoagulation are of extreme concern • Overall; maternal mortality rate = 3-4% with mechanical valves, and fetal loss is common Effects on pregnancy

28. Management • The critical issue for mechanical prosthetic valves is anticoagulation: thromboembolic issue VS bleeding , teratogenic issue

29. Anticoagulation agent • Most effective to prevent mechanical valve thrombosis • Cause teratogenic and miscarriage, still birth and fetal malformation • Highest risk is when mean daily dose exceeded 5 mg Warfarin

30. Anticoagulation agent • No teratogenic issue • Is definitely inadequate control of thromboembolism Low dose unfractionated heparin Unfractionated heparin or low-molecular-weight heparins • Report of valvular thrombosis • ACOG(2002) advised against use of LMWH during pregnancy. • American College of Chest Physicians has recommended us of UFH or LMWH given throughout pregnancy

31. American College of Chest Physicians Guidelines for Anticoagulation of pregnant women with mechanical prosthetic valves

32. Bacterial endocarditis prophylaxis • Estimate incidence of transient bacteremia at delivery is 1-5% • ATB prophylaxis is optional for uncomplicated delivery • Ampicillin 2 g. or cefazolin/ceftriaxone 1 g. IV 30-60 minutes before the procedure • For penicillin-sensitive pt. : Cefazolin/ceftriaxone 1 g., or if anaphylaxis, Clindamycin 600 mg IV 30-60 minutes before the procedure Regimen recommended

33. American Heart Association Guidelines for Endocarditis Prophylaxis with Dental Procedures

34. Thyroid Disorders

35. Thyroid physiology and pregnancy • Thyroid binding globulin • TSH in early pregnancy • Thyroxine cross placenta and is important for normal fetal brain development and fetal thyroid gland function 90

36. Hyperthyroidism • 1:1000 - 2000 pregnancies • Mild thyrotoxicosis may be difficult to Dx during pregnancy • Most common cause : Graves disease • Molar pregnancy should be considered

37. Clinical features suggestive of possibility of hyperthyroidism • Prior Hx of thyrotoxicosis/autoimmune thyroid dz in pt or in her family • Presence of typical symptoms of thyrotoxicosis : weight loss ( or failure to wt gain), palpitations, proximal muscle weakness • Symptoms suggestive of Graves disease like opthalmopathy, pretibial myxedema • Thyroid enlargement • occurrence of hyperemesis gravidarum leading to wt loss Historical

38. Clinical features suggestive of possibility of hyperthyroidism • Pulse > 100 bpm • Widened pulse pressure • Eye signs of Graves disease or pretibial myxedema • Thyroid enlargement esp. in iodine sufficient geographical area • Onycholysis Physical examination

39. Diagnosis • confirmed by laboratory tests • Serum TSH <0.1 mIU/L • Elevated Serum FT4 & FT3 levels • Thyroid autoantibodies

40. Graves disease in pregnancy • Women with active Graves dz Dx pregnancy • Women who are in remission and considered cured after primary treatment • Women who is in diagnosis of Graves dz has not been established before the onset of pregnancy but have TSHR Ab Both maternal & fetal outcome is directly related to adequate control of hyperthyroidism

41. Graves disease in pregnancy • Obstetric complication : Preeclampsia, fetal malformations, premature delivery, low birth weight • The risk of fetal and neonatal hyperthyroidism is negligible in euthyroid women not currently receiving ATD, but had received ATD previously for graves dz • For euthyroid women who has previously received radioiodine therapy or undergone thyroid surgery for graves dz, the risk of fetal & neonatal hyperthyroidism depends on level of TSHR Ab in mother • So these antibodies had to be measured early in pregnancy to evaluate the risk

42. Graves disease in pregnancy • For pregnant woman who takes ATDs for active graves dz, TSHR Ab should be checked again in 3rd trimestter • If the Ab titers have not decreased during the 2nd trimester, the possibility of fetal hyperthyroidism is to be considered

43. Graves disease in pregnancy • Hyperthyroidism due to graves tends to improve during pregnancy. ( Although exacerbations in early months of pregnancy) • Partial immunosuppression (due to pregnancy) with significant decrease in TSHR Ab titer • Marked increase serum TBG = reduce FT3 & FT4 Reasons

44. Management of hyperthyroidism • Monitor PR, wt gain, thyroid size, FT4, FT3, TSH monthly) • Use lowest dose of ATD (not > 300mg of PTU) : maintain euthyroid or mildly hyperthyroid state. • Follow fetal pulse & growth • Should Not attemp full normalization of serum TSH (Keep TSH 0.1-0.4 mU/L ) lower levels are acceptable if pt is doing well clinically

45. Management of hyperthyroidism • Propylthiouracil (PTU) is preferred to methimazole, but both can be used • Methimazole could cause embryopathy (esophageal or choanal atresia or aplasia cutis) • Iodides should not used during pregnancy unless for preparing the patient for surgery

46. Management of hyperthyroidism • Requirement for high doses of PTU/MMI with inadequate control of clinical hyperthyroidism • Poor compliance with resulting clinical hyperthyroidism • Appearance of fetal hypothyroidism at dose required to control disease in mother Indication for surgery

47. Management of hyperthyroidism • Usually the dose of ATD can be adjusted downward after 1st trimester & discontinued during 3rd trimester • ATDs often need to be reconstituted/increased after delivery

48. Thyroid storm and heart failure • Pulmonary hypertension and heart failure from cardiomyopathy caused by thyroxine is common in pregnant women • High-output state dilated cardiomyophthy • Cardiac decompensation is usually precipitated by preeclampsia, anemia, sepsis, or combination • Fortunately, thyroxine-induced cardiomyopathy and pulmonary hypertension are frequently reversible

49. Thyroid storm and heart failure • ICU is needed • 1000mg of PTU orally the 200mg every 6 hr • An hour after initial PTU, iodide is given to inhibit thyroidal release of T3 & T4 • Sodium iodide 500-10000mg of sodium iodide IV every 8 hrs. • Supersaturated solution of potassium iodide (SSKI) 5 drops or Lugol solution 10 drops orally every 8 hr Management

50. Thyroid storm and heart failure • Dexamethasone 2 mg IV every 6 hrs. for IV dose for blocking peripheral conversion of T4 to T3 • Beta-blocker drug is given to control tachycardia • Coexisting severe preeclampsia, infection, or anemia should be aggressively managed Management