Transcript Normal Labor and Delivery

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).
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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 :
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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.
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• 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
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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
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• 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,
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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.
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• 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