Transcript Nausea and vomiting of pregnancy

Medical Complications
of
Pregnancy
For Educational Purposes Only

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:
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Anemia
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Endocrine disorders (Diabetes mellitus, Thyroid disease)
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Cardiovascular disease
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Hypertension
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Pulmonary disease
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Renal disease
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Gastrointestinal disease
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Neurologic disease
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Autoimmune disorders
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Alcohol, tobacco, and substance abuse
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Surgical abdomen
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Infectious disease, including:
 Syphilis, TORCH, Group B Streptococcus, Hepatitis, HIV, HPV, Parvovirus,Varicella
For Educational Purposes Only
For Educational Purposes Only
 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
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Hct <33% for first and third trimesters
Hct <32% for second trimester
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 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
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 Other
anemias
 Sickle cell disease
 Thalassemias
 Hereditary hemolytic anemias
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 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
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 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
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For Educational Purposes Only
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Pathophysiology
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Placental hormone increases insulin resistance
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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, 2hour <165. 3-hour < 145mg/dl)
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Pregestational
Materna
 Gestational
Gestational
Accelerated retinopathy or nephropathy
More difficult to control glucose levels
• DKA, hyperosmolar coma
• Hypoglycemia
Pregnancy induced hypertension/preeclampsia
Increased risk of infection
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Preeclampsia
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Macrosomia
Intrauterine growth restriction (IUGR)
Stillbirth (IUFD)
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Spontaneous abortion
Congenital anomalies
• Congenital heart disease (VSD, transposition of the
great arteries)
• Neural tube defects
• Caudal regression
Macrosomia
Polyhydramnios
Preterm birth
Stillbirth (IUFD)
Intrauterine growth restriction (IUGR)
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Morbidity from preterm delivery
Injury from traumatic delivery secondary to macrosomia
Hypoglycemia, hypocalcemia, hyperbilirubinemia
Management of congenital anomalies
Respiratory distress syndrome
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Fetal
Neonatal
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Injury from traumatic delivery secondary
to macrosomia
Hypoglycemia, hypocalcemia,
hyperbilirubinemia
Respiratory distress syndrome
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Management
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Tight control essential
Diet – 30-35 kcal/kg ideal body weight ADA
diet
Glucose testing - fasting and 2-hours
following meals
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FBS <105mg/dl
1-hour PP <130mg/dl
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 Hyperthyroidism
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May suppress fetal and neonatal thyroid
function
Has been associated with fetal goiter
Thyroid storm – high risk of maternal heart
failure
 Hypothyroidism
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Maternal thyroxine requirements increase
during pregnancy
Adjust levels q4 wks and then check TSH each
trimester
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For Educational Purposes Only
 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:
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Rheumatic heart disease
Acquired infectious valvular disease
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 Fetal
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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
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Cardiovascular Disease
 Evaluation
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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
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Maternal cardiac status
Fetal well-being and growth
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For Educational Purposes Only
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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
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 Pathophysiology:
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Predominant pathophysiologic finding is
maternal vasospasm
Potential contributors:
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Endothelial damage
Increased platelet activation and consumption
Increased TXA2 and PGI2
Decreased NO
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 Maternal
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complications:
Liver dysfunction
Renal insufficiency
Coagulopathy
Convulsions
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 Potential
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IUGR
PTB
Abruption
 Studies
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Fetal Complications
to evaluate: Ultrasound
Fetal weight and growth assessment
Amniotic fluid volume
Umbilical artery dopplers
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 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
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CBC, platelets
LFTs
Serum Cr
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For Educational Purposes Only
 Asthma
– restrictive airway disease
 Effects of pregnancy on asthma are variable
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1/3 patients improve
1/3 worsen
1/3 unchanged
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 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
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LBW
Prematurity
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 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
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For Educational Purposes Only
 UTIs
 Pre-existing
renal disease
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 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
 One
of the most common medical
complications in pregnancy requiring
hospitalization
 Associated with↑increased risk of preterm
labor
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E. coli produces phospholipase A  promotes
prostaglandin synthesis  ↑ uterine activity
 Treat
with IV hydration and antibiotics
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 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
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 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
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For Educational Purposes Only
 Nausea
and vomiting of pregnancy (NVP) –
typically begins ~4-8 wks gestation and
stops by 14-16 wks
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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
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Due to ↑ intraabdominal pressure
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 Complications
for mom or baby are rare
 Evaluation for mom with persistent
vomiting:
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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
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For Educational Purposes Only
 Majority
of women with epilepsy have
normal pregnancy
 Typically there is not an increased frequency
of seizures during pregnancy
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 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
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For Educational Purposes Only
 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
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 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
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For Educational Purposes Only
 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
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 Risks
to fetus – IUGR, LBW, fetal death
 Safety of nicotine replacement products in
pregnancy has not been documented
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 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
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 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
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For Educational Purposes Only
Infection
Transmission
Maternal Disease
Cat feces,
undercooked
Usually asymptomatic,
Toxoplasma meat
sometimes lymphadenopathy
Rubella
CMV
HIV
HSV
Syphillis
Respiratory
droplets
Sexual contact,
organ
transplants
Rash, lymphadenopathy,
arthritis
Usually asymptomatic,
sometimes mono-like illness
Variable, depending on CD4
count
Neonatal Disease
Triad - chorioretinitis,
hydrocephalus, intracranial
calcifications
Triad - PDA (or pulmonary artery
hypoplasia), cataracts, deafness;
+/- blueberry muffin rash
Hearing loss, seizures; most
asymptomatic; some w/ same
triad as toxoplasma
Sexual contact
Recurrent infxns, chronic diarrhea
Skin or mucous
membrane
Usually asymptomatic; herpetic Temporal lobe encephalitis
contact
lesions
(seizures), herpetic lesions
Stillbirth, hydrops fetalis
Sexual contact
If child survives - facial
abnormalities (notched teeth,
Primary - chancre, Secondary - saddle nose, short maxilla), saber
disseminated rash, Tertiary shins, snuffles (bloody nasal
cardiac/neurologic disease
discharge)
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 Asymptomatic
lower genital tract
colonization is common
 Without treatment, GBS sepsis can occur
 Infection of newborn – septicemia, septic
shock, pneumonia or meningitis
 Universal screening at 35-37 wks  if
positive, give antibiotic prophylaxis in labor
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 All
women exhibit absolute decline in CD4
counts in pregnancy – thought to be 2/2
hemodilution
 Perinatal transmission w/o prophylaxis is
~25%
 With Zidovudine monotherapy –
transmission ~8%
 Combination therapy and undetectable
viral load – transmission ~1-2%
 Universal, voluntary HIV screening should
be part of standard prenatal labs
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 Genital
wart lesions often increase in size
and area during pregnancy due to relative
immune suppression
 If extensive – c/s delivery may be
necessary
 Transmission to infant is rare, but if occurs
– manifests as laryngeal papillomatosis
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c/s delivery does not prevent transmission
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Can cause devatsating fetal outcomes – SAB, fetal
nonimmune hydrops fetalis, death
Maternal immune status can be determined by
serologic testing – IgM recent infection, IgG past
infection and immunity
 Routine serologic testing not recommended
 Exposed pregnant women should be offered B-19
specific IgM and IgG serologic testing
If IgM + confirmed – serial ultrasounds starting at 10
wks to look for evidence of hydrops,
placentomegaly and growth disturbances
If hydrops doesn’t develop, long-term outcomes
good
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Hepatitis A
 Vaccination safety during pregnancy has not been
established
 HAV IG is effective for both pre and post-exposure
prophylaxis and can be used during pregnancy
 Hepatitis B
 Routine testing for HBsAg - if neg w/ risk factors for
HBV infection – offer vaccination during pregnancy
 All infants receive Hep B vaccine
 Infants of mothers who are HBsAg pos should get
vaccine and HBIG w/in 12 hrs of birth
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Hepatitis C
Routine screening is not recommended
 Co-infection with HIV is associated with a higher risk of vertical
transmission of HCV
 No known preventative measures to reduce risk of mother to
child transmission
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Hepatitis D
Infection can only occur along with Hep B infection
 Vertical transmission has been documented but is rare
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Hepatitis E
Associated with higher rates of fulminant disease and mortality in
pregnant women
 Risk of vertical transmission is low
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Conclusion
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Maternal medical or surgical conditions can complicate the
course of a pregnancy and/or can be affected by pregnancy
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Important to understand:
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Effect of pregnancy on natural course of disorder
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Effect of disorder on pregnancy
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Change in mgmt of the pregnancy and disorder caused by their coincidence
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Screening for and preventing infectious diseases is an integral
part of routine prenatal care
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Many infectious diseases can have devastating effects for
mother, infant or both
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