Transcript Medical diseases of pregnancy

1 May 2013
Dr Samantha Russell
The parturient with systemic disease
1. Autoimmune Disorders
2.Cardiovascular Disease
3. Endocrine Disorders
4. Hematologic and Coagulation Disorders
5. Human immunodeficiency virus
6. Hypertensive Disorders
7. Liver Disease
8. Malignant Hyperthermia
9. Musculoskeletal Disorders
10. Neurologic and Neuromuscular Disease
11. Obesity
12. Renal Disease
13. Respiratory Disease
14. Substance Abuse
15. Trauma
Autoimmune disorders
Failure of self-tolerance
Systemic lupus erythematosus
Antiphospholipid syndrome
Systemic sclerosis (scleroderma)
Polymyositis and dermatomyositis
Systemic lupus
erythematosus (SLE)
Production of autoantibodies causing an immune
complex disorder
1/700 women with peak incidence at around age 30
Diagnosis of SLE (1997)
Presence of 4 or more of criteria:Malar rash
Discoid rash
Photosensitivity
Oral ulceration
Arthritis
Serositis
Renal disorder
Neurologic disorder
Hematologic disorder
Immunologic disorder
Antinuclear antibody
often patients have increased disease activity, most often
during the 2nd, 3rd trimesters & puerperium
Maternal effects - mortality prevalence about 0.05%
Fetal effects
Loss ->
 obstetric history is a strong predictor of outcome in
subsequent pregnancies
 Pregnancy loss is increased with renal involvement
and hypertension
Increased risk of preterm delivery
Neonatal lupus erythematosus (NLE) – reversible and
irreversible manifestations
Management
Medical
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Ideally delay pregnancy until disease has been quiet for at least 6 months
Hydroxychloroquine & azathioprine should be continued
Mycophenolate mofetil should be discontinued
Low dose prednisone (<20mg daily) appears to be safe watch for gestational diabetes
Manage complications of SLE
Preeclampsia is more common (reviews quote 20-30% incidence)
Obstetric
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Should be considered high-risk
Measure Cr Cl, 24-hour urine protein level and anti-Ro/anti-La antiboides
Thromboprophylaxis if antiphospholipid syndrome
Monitor for preeclampsia
Platelet count to be repeated monthly
Antiphospholipid syndrome
is a prothrombotic disorder that results in both arterial and venous thrombosis
and is characterised by the presence of two autoantibodies, lupus
anticoagulant and anticardiolipin antibody
Lupus anticoagulant has no true anticoagulant activity in vivo but appears to
block in vitro assembly of prothrombinase ( a phospholipid complex) thus
preventing the conversion of prothrombin to thrombin
The current model for thrombotic tendency involves antiphospholipid
antibodies binding to glycoproteins on platelets, monocytes and endothelial
cells. These complexes cause platelet adhesion, expression of
prothrombotic molecules and local complement activation
Modified Sapporo classification criteria
or Sydney criteria (2006) – by the
presence of 2 major components, one
clinical and the other a laboratory
finding.
Effects
Maternal
• Thromboembolic disease
• Thrombocytopenia
• Antiphospholipid syndrome
Fetal
• placental infarction may increase risk for death in utero
Treatment
ACOG 2005:
•women with antiphospholipid syndrome
and no thrombotic history should receive
prophylactic doses of heparin and low-dose
aspirin during pregnancy and 6-8 weeks
postpartum
• if thrombotic history should receive full
anticoagulation throughout pregnancy and
postpartum period.
Anaesthetic management
Antiphospholipid antibodies can cause coagulation factor deficiencies. In
such patients neuraxial anaesthesia (NA) is relatively contra-indicated. In
the absence of an underlying coagulation deficit or anticoagulation therapy,
the prolonged aPTT does NOT suggest bleeding tendency, and NA may be
administered
Systemic sclerosis (scleroderma)
Lidar M, Langevitz P. Pregnancy issues in scleroderma. Autoimmunity reviews 2012 (11) A515-519
Chronic progressive autoimmune disease of unknown aetiology
characterised by deposition of fibrous connective tissue in the skin and other
tissues.
A heterogeneous disorder that is separated into limited cutaneous
scleroderma ( also termed CREST syndrome) and diffuse cutaneous
scleroderma.
Multidisciplinary approach required
Diagnosis
Triad of Raynaud’s phenomenon, non-pitting oedema, and hidebound skin.
Complications
Maternal
• Difficult airway
• Thrombocytopenia
• Scleroderma renal crisis
Fetal
• Miscarriages and prematurity
• small full-term infants
Cardiovascular System
Central Hemodynamics at term
gestation
Parameter
Change
Cardiac output
+50%
Stroke volume
+25%
Heart rate
+25%
Left ventricular end-diastolic volume
Increased
Left ventricular end-systolic volume
No change
Ejection fraction
Increased
Left ventricular stroke work index
No change
Pulmonary capillary wedge pressure
No change
Pulmonary artery diastolic pressure
No change
Central venous pressure
No change
Systemic vascular resistance
-20%
Cardiovascular Disease
Congenital Heart Disease
Primary pulmonary hypertension
Cardiomyopathy
• Hypertrophic obstructive cardiomyopathy
• Peripartum cardiomyopathy
Ischemic heart disease
Valvular disorders
Transplanted heart
Arrhythmias
Diseases of the Aorta
Infective endocarditis
Estimated prevalence of clinically significant cardiac disease in pregnancy is
<1%, yet is the most important cause of nonobstetric maternal morbidity
and mortality in the United States
Significant morbidity in pulmonary HTN, Eisenmenger’s syndrome, and
severe cases of Marfan’s syndrome
Maternal outcomes correlate with
• NYHA functional classification
Congenital heart disease
If complete repair and normal cardiovascular function require no special
treatment
If shunts: avoid air bubbles in IV lines, use LOR to saline in epidural rather
than air, early administration of labour analgesia, maintain balance of PVR
and SVR
Valvular heart disease and pregnancy
Trail TA. Cardiol Clin 30 (2012) 369-381
Among women with valvular heart disease, those with mitral stenosis carry
the greatest potential for problems during pregnancy. Asymptomatic
women with aortic stenosis and only mild or moderate LV outflow
obstruction generally tolerate pregnancy well, as do those with regurgitant
lesions
In Marfan ‘s syndrome, pregnancy should not be undertaken if the aortic
root dimension exceeds 4 cm. Even if the aortic root is normal, a small
increased risk of dissection is present
Women with well-functioning bioprosthetic valves and normal
hemodynamics may safely undertake a pregnancy. Bioprostheses
deteriorate rapidly in young people, and therefore preconception counseling
should be kept under frequent review.
Goals of anaesthetic management in
patients with aortic stenosis
• Preload: avoid aortocaval compression, maintain
intravascular volume and venous return
• Afterload: maintain adequate SVR
• Contractility: Avoid myocardial depression during GA
• Heart rate: maintain normal HR
Rhythm: maintain sinus rhythm
Right side of heart
~ Aortic regurgitation
• Maintain normal to slightly elevated HR
• Prevent an increase in SVR
• Avoid myocardial depression during GA
~ Mitral stenosis
• Aggressively treat acute AF
• Maintain venous return
• Maintain adequate SVR
• Right side of heart: prevent pain, hypoxemia, hypercarbia, and acidosis, which may
increase PVR
~ Mitral regurgitation
Prevent an increase in SVR
Maintain a normal to slightly elevated HR (ephedrine)
Aggressively treat AF (cardioversion/anticoagulate)
Maintain venous return
Prevent an increase in central vascular volume
Avoid myocardial depression during GA
Right side of heart: Prevent increase in PVR
Mitral valve prolapse
Most common cardiac condition
12-17% of women of childbearing age
Primary/idiopathic MVP or secondary and associated with ASD, endocarditis
or MS
Prognosis depends on coexisting CVS disease
Beta-adrenergic receptor antagonists may be necessary to treat
arrhythmias, chest pain and palpitations
Progressive MR occurs in approximately 15% of patients with MVP
Cardiac arrhythmia
Organic heart disease
Normal CVS status
Treat underlying disease
Rule out other causes
Drug therapy only if arrhythmia persists
and use smallest dosage required
Treat underlying cause, drug therapy only
if arrhythmias are symptomatic or
threatening to mother or fetus
Use drugs known as safe to fetus
Re-evaluate periodically
Paroxysmal supraventricular
tachycardia (SVT)
In women of reproductive age the commonest arrhythmia is paroxysmal SVT
Defined as any tachyarrhythmia with a HR >120bpm, requiring atrial or
atrioventricular junctional tissue for its initiation and maintenance.
Paroxysmal describes an arrhythmia that begins and ends abruptly.
Atrioventricular nodal re-entry and Wolf-Parkinson White syndrome account
for the majority of SVT
Pregnancy is a risk factor for paroxysmal SVT. Result of hemodynamic,
hormonal, autonomic, and emotional changes. An expanded circulating
volume may increase myocardial irritability and a faster sinus heart rate may
alter tissue excitability, initiating a re-entry circuit.
Peripartum oxytocin, tocolytic and anaesthetic drugs have also been
suggested as triggers for inducing SVT
Chest pain syndromes in pregnancy
Differential diagnosis includes
• acute myocardial infarction (AMI)
• aortic dissection and aortic syndromes
• pulmonary embolism
• amniotic fluid embolism
Balance between myocardial oxygen supply and demand during
pregnancy
Parameter
Effect of pregnancy
Supply
Diastolic time
Decreased
CPP
Decreased
Arterial oxygen content
Arterial oxygen tension
Increased
Haemoglobin concentration
Decreased
Coronary vessel diameter
Unchanged
Demand
Basal oxygen requirement
Increased
Heart rate
Increased
Wall tension
Preload (ventricular radius)
Increased
Afterload
Decreased
Contractility
increased
Endocrine System
Endocrine Disorders
Diabetes Mellitus
Thyroid disorders
Pheochromocytoma
Biggar MA, Lennard TWJ. Systemic review of
phaeochromocytoma in pregnancy. British Journal of
Surgery 2013; 100:182-190
Diabetes Mellitus
Major complications of diabetes mellitus
Acute
• DKA
• Hyperglycemic nonketotic state
• hypoglycemia
Chronic
• Macrovascular
• Coronary
• Cerebrovascular
• Peripheral vascular
• Microvascular
• Retinopathy
• nephropathy
• Neuropathy
• Autononic
• somatic
Thyroid disorders
Hyperthyroidism (0.2-1.9%)
• Abnormal thyroid stimulator
• Graves Disease (70-90%)
• Intrinsic thyroid autonomy
• Toxic adenoma
• Inflammatory disease
• Subacute thyroiditis
• Extrinsic hormone source
• Ectopic thyroid tissue
• Thyroid hormone ingestion
Diagnosis
Labwork
Hyperthyroid symptom scale developed on the basis of the following clinical
factors:
• Nervousness
• Sweating
• Heat intolerance
• Hyperactivity
• Tremor
• Weakness
• Hyperdynamic precordium
• Diarrhoea
• Appetite
• Level of incapacitation
Treatment of thyroid storm
General supportive measures
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Cooling blanket and ice
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Chlorpromazine (25-50mg IV) or meperidine (25-50mg IV) to diminish shivering
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Intravenous hydration
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Glucose and electrolyte replacement
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Oxygen
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Glucocorticoids: dexamethasone (2-4mg IV 8hr) or hydrocortisone (100mg IV q8hr)
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B complex vitamins
Reduction of synthesis and secretion of thyroid hormone
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Antithyroid med: PTU 200-400mg po 6-8hrly, methimazole 20-25mg po q 6hrly
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Iodine: sodium iodide (1g IV) or lugol’s solution 4-8drops orally 6-8hr) after PTU
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glucocorticoids
Reduction of peripheral conversion of T4 to T3
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Antithyroid medication
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Glucocorticoids
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Radiographic contrast agents
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propanolol
Decrease in metabolic effects of thyroid hormones: B-blockers
Other therapeutic manoeuvres: plasma exchange, dantrolene
Dx and rx of the underlying illness that precipitated the thyroid storm
Hematologic and
coagulation systems
Hematologic and coagulation disorders
Anemia
Coagulation
Thrombocytopenic coagulopathies
Congenital coagulopathies
Acquired coagulopathies
Hypercoagulable states
Anemia
Dilutional anemia of pregnancy
Thalassemia
Sickle cell disease
Autoimmune hemolytic anaemia
Thrombocytopenic coagulopathies
Autoimmune thrombocytopenic purpura
Thrombotic thrombocytopenic purpura
Drug-induced platelet disorders
Gestational thrombocytopenia
Congenital coagulopathies: bleeding
disorders
Prenatal diagnosis only considered in severe bleeding disorders such as
hemophilia
Besides fibrinogen and Factor XIII deficiencies unclear whether there is
increased pregnancy loss and APH
But all are increased risk of PPH
Von Willebrand’s disease and carriers of hemophilia account for the majority
of inherited bleeding disorders in women
Von Willebrand’s disease
1% of population
Haemophilia A & B
X-linked recessive disease
Women mainly carriers and expected to have 50% of normal clotting factor
level
Wide variation of levels have been reported though due to lyonisation and
some women may have low levels of factor
Factor 8 levels increase progressively in Haemophilia A carriers during
pregnancy reaching peak in 3 rd trimester. Most carriers of haemophilia A
have normal (>50IU/dL) F8 levels at term. In contrast, F9 levels do not
increase significantly during pregnancy..
Gender can be determined from 11 weeks gestation to avoid invasive
diagnostic tests if requested by parents
Multidisciplinary approach with early recognition
Bleeding disorder is not an indication for abdominal delivery
Neuraxial anaesthesia not a contra-indication if normal coagulation and
factor levels. Very little evidence with risk and safety
Avoid prolonged labour, mid-forceps delivery, fetal scalp monitoring or
blood sampling, vacuum extraction and intramuscular injections
Active management of 3 stage
Human
immunodeficiency virus
(HIV)
HIV
“window period”
Comorbid disease and substance abuse
Transmission of the disease in nonbreast-fed infants occurs 30% of the
time in utero and 70% during labour and delivery
Impaired cell-mediated (humoral) immunity, causes infected person to be
more susceptible to viral, bacterial, mycobacterial and malignant disease
*Peripheral neuropathy is the most frequent neurological complication in
HIV patients. Affects approximately 35% of patients with AIDS and
manifests clinically as polyneuropathy and myopathy.
Autonomic dysfunction in the HIV-infected person may appear with or
without CNS abnormalities. AIDS patients may present with uncommon
autonomic disturbances, such as orthostatic syncope, hypotension and
diarrhea.
Coagulation abnormalities include ITP
Management
Surgical interventions do not increase the postoperative risk for
complications or death.
CNS HIV infection has occurred in asymptomatic patients therefore not a
contra-indication for NA.
Regional anesthesia is often technique of choice
Take into consideration the presence of neuropathies, local infection, or
blood clotting abnormalities
Patients with AIDS are more sensitive to opioids and benzodiazepines*
Adverse reactions of HAART
No evidence that pregnancy accelerates clinical deterioration or that viral
RNA load changes significantly
PEP prophylaxis
Hypertension
JOGC Volume 30, number 3, march 2008
Diagnosis, evaluation and management of
the hypertensive disorders of pregnancy
Liver Disease
Viral hepatitis
Intrahepatic cholestasis of pregnancy
Acute fatty liver of pregnancy
Spontaneous hepatic rupture of pregnancy
Portal hypertension
Liver transplantation
Anesthetic management of the parturient with liver disease
Liver disease in
pregnancy
Mufti AR, Reau N. Clin Liver Dis
16(2012) 247-269
Musculoskeletal disorders
Scoliosis
Rheumatoid arthritis
Ankylosing spondylitis
Spina bifida
Achondroplasia
Osteogenesis imperfecta
spondylolisthesis
Spina Bifida
Spina bifida occulta is defined as failed fusion of the neural arch without
herniation of the meninges or neural elements
Spina bifida cystica is defined as failed closure of the neural arch with
herniation of the meninges (or together with neural elements) !tethered
cord syndrome (TCS)
Occult spinal dysraphism where the bony defect is associated with > 1
anomalies of the spinal cord
Management of women with known
TCS
Should avoid both the squatting position and prolonged lithotomy position
Epidural: higher incidence of dural puncture
If occult spinal dysraphism – neurological history, MRI
What type of neuraxial technique?
Neurologic and neuromuscular disease
Multiple sclerosis
Headache
Spinal cord injury
Myasthenia gravis
Epilepsy
Myotonia and myotonic dystrophy
Muscular dystrophy
Neurocutaneous syndromes
Landry-Guillain-Barre syndrome
Polio
Brain neoplasms
Idiopathic intracranial hypertension
Maternal hydrocephalus with shunt
Intracerebral hemorrhage
Cerebral vein thrombosis
Motor neuron disorders
Isolated mononeuropathies during pregnancy
Pregnancy complications in patients with epilepsy
Borthen I, Gikhus NE. Curr opin obstet gynecol 2012 24:78-83
Epilepsy is one of the most common neurological disorders in childbearing
age with a prevalence of 0.3-0.7% in pregnant women
Risk of seizures in pregnancy was reduced by 50-70% once there had been 1
year’s freedom from seizures before pregnancy.
Polytherapy gave the highest incidence of congenitial malformations.
Valproate treatment was associated with the highest incidence of
malformed infants. Lamotrigine has the lowest rate
Management
Planned pregnancy by optimizing antiepileptic drugs versus the seizure and
obstetric complication risks.
Unclear if there is an increased risk of pregnancy complications some
studies report increased risks of preeclampsia, gestational hypertension and
preterm birth in patients with epilepsy
Management of aneurysms and AVMS
?surgical repair
HD stability
NA techniques
No definite advantage of certain delivery. If vaginal reduce 2 nd stage and
attenuate blood pressure fluctuations
40% of post-partum women have headaches often within the first week
after delivery
Difference between pituitary apoplexy and Sheehan’s syndrome?
Renal Disease
Renal parenchymal disease
Acute renal failure
Renal transplant
urolithiasis
Respiratory System
Effects of pregnancy on respiratory
mechanics and physiology
Parameter
Change relative to non-pregnant
state
Diaphragm excursion
Increased
Chest wall excursion
Decreased
Pulmonary resistance
Decreased 50%
FEV1
No change
FEV1/FVC
No change
Flow-volume loop
No change
Closing capacity
No change
Parameter
Change relative to non-pregnant state
Lung volumes:
Inspiratory reserve volume
+5%
Tidal volume
+45%
Expiratory reserve volume
-25%
Residual volume
-15%
Lung capacities:
Inspiratory capacity
+15%
Functional residual capacity
-20%
Vital capacity
No change
Total lung capacity
-5%
Dead space
+45%
Respiratory rate
No change
Ventilation:
Minute ventilation
+45%
Alveolar ventilation
+45%
Respiratory disease
Asthma
Cigarette smoking
Cystic fibrosis
Respiratory failure
Asthma
McCallister JW. Asthma in pregnancy: management strategies. Curr Opin Pulm Med.
2003; 19:13-17
Most common medical conditions, 4-8% of pregnancies
1/3 of women will experience a worsening of asthma control, 1/3 will improve and
the remaining 1/3 will remain unchanged during pregnancy
Risk factors for exacerbations
Younger age
Unmarried
Lower socioeconomic status
Obesity
Smokers
Women with asthma have been shown to be more likely to have URTIs and
UTIs during pregnancy
Management
Perception of teratogenic risks of asthma medications may influence a
patients decision to continue therapy with better compliance if the
obstetrician says it will be safe to continue meds.
Spirometry and peak expiratory flow rates are useful objective tools for
monitoring PFTs as they are unaffected by gestation, and routine
measurement is recommended.
Fraction of exhaled nitric oxide has been evaluated as a tool for assessing
eosinophilic airway inflammation in asthma.
The End