Medical Complications of Pregnancy

1. Medical Complications of Pregnancy For Educational Purposes Only

2. Objectives • 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 For Educational Purposes Only

3. Anemia For Educational Purposes Only

4. Anemia • 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 trimesters • Hct <32% for second trimester For Educational Purposes Only

5. Anemia • 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 For Educational Purposes Only

6. Anemia • Other anemias • Sickle cell disease • Thalassemias • Hereditary hemolytic anemias For Educational Purposes Only

7. Anemia • 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 For Educational Purposes Only

8. Anemia • Evaluation • Routine 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 For Educational Purposes Only

9. Endocrine disorders For Educational Purposes Only

10. Gestational diabetes • 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) For Educational Purposes Only

11. Diabetes: Complications • Gestational For Educational Purposes Only

12. Gestational diabetes • 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 For Educational Purposes Only

13. Thyroid Disease • Hyperthyroidism • May suppress fetal and neonatal thyroid function • Has been associated with fetal goiter • Thyroid storm – high risk of maternal heart failure • Hypothyroidism • Maternal thyroxine requirements increase during pregnancy • Adjust levels q4 wks and then check TSH each trimester For Educational Purposes Only

14. Cardiovascular disease For Educational Purposes Only

15. Cardiovascular Disease • 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 disease • Acquired infectious valvular disease For Educational Purposes Only

16. Cardiovascular Disease • Fetal complications • Fetuses 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 For Educational Purposes Only

17. Evaluation Cardiovascular 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 For Educational Purposes Only

18. hypertension For Educational Purposes Only

19. Hypertension • 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 For Educational Purposes Only

20. Hypertension • Pathophysiology: • Predominant pathophysiologic finding is maternal vasospasm • Potential contributors: • Endothelial damage • Increased platelet activation and consumption • Increased TXA2 and PGI2 • Decreased NO For Educational Purposes Only

21. Hypertension • Maternal complications: • Liver dysfunction • Renal insufficiency • Coagulopathy • Convulsions For Educational Purposes Only

22. Hypertension • Potential Fetal Complications • IUGR • PTB • Abruption • Studies to evaluate: Ultrasound • Fetal weight and growth assessment • Amniotic fluid volume • Umbilical artery dopplers For Educational Purposes Only

23. Hypertension • Evaluation: • Routine measurement of BP • Compare 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 For Educational Purposes Only

24. Pulmonary disease For Educational Purposes Only

25. Pulmonary Disease • Asthma – restrictive airway disease • Effects of pregnancy on asthma are variable • 1/3 patients improve • 1/3 worsen • 1/3 unchanged For Educational Purposes Only

26. Pulmonary Disease • Women with mild-moderate asthma usually have excellent maternal and fetal outcomes • Suboptimal control of asthma during pregnancy may be associated with increased risk of • LBW • Prematurity For Educational Purposes Only

27. Pulmonary Disease • 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 For Educational Purposes Only

28. Renal disease For Educational Purposes Only

29. Renal Disease • UTIs • Pre-existing renal disease For Educational Purposes Only

30. UTIs • Common in pregnancy • Aysmptomatic bacteruria is more likely to lead to cystitis and pyelonephritis in pregnant women • Pregnancy associated urine stasis • Glycosuria • ↑ urine pH • Urine culture should be obtained at first prenatal visit For Educational Purposes Only

31. Pyleonephritis • One of the most common medical complications in pregnancy requiring hospitalization • Associated with↑increased risk of preterm labor • E. coli produces phospholipase A  promotes prostaglandin synthesis  ↑ uterine activity • Treat with IV hydration and antibiotics For Educational Purposes Only

32. Pre-Existing Renal Disease • 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 For Educational Purposes Only

33. Pre-Existing Renal Disease • 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 For Educational Purposes Only

34. Gastrointestinal disease For Educational Purposes Only

35. GI Disease • Nausea and vomiting of pregnancy (NVP) – typically begins ~4-8 wks gestation and stops by 14-16 wks • Related 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 For Educational Purposes Only

36. GI Disease • 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 For Educational Purposes Only

37. Neurologic disease For Educational Purposes Only

38. Epilepsy • Majority of women with epilepsy have normal pregnancy • Typically there is not an increased frequency of seizures during pregnancy For Educational Purposes Only

39. Epilepsy • 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 For Educational Purposes Only

40. Autoimmune disorders For Educational Purposes Only

41. SLE • 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 For Educational Purposes Only

42. SLE • 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 For Educational Purposes Only

43. Alcohol, tobacco and substance abuse For Educational Purposes Only

44. Alcohol Use • 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 For Educational Purposes Only

45. Tobacco Use • Risks to fetus – IUGR, LBW, fetal death • Safety of nicotine replacement products in pregnancy has not been documented For Educational Purposes Only

46. Substance Abuse • 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 For Educational Purposes Only

47. Surgical abdomen For Educational Purposes Only

48. Surgical Abdomen • 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 For Educational Purposes Only

49. Infectious diseases For Educational Purposes Only

50. ToRCHeS For Educational Purposes Only