Dr. A.R.Pintilie

MEDICAL AND SURGICAL COMPLICATIONS IN PREGNANCY 1.Cardiovascular Diseases 2.Urinary Tract Infections 3.Gastrointestinal Disorders 4.Diabetes 5.Infections 6.Neoplastic Diseases 7.Fibroma

MEDICAL AND SURGICAL COMPLICATIONS IN PREGNANCY 1.Cardiovascular Diseases Cardiovascular disease is one of the most important nonobstetric cause of disability and death in pregnant women occurring in about 1% of all pregnant women.The influence of pregnancy on cardiovascular diseases-minors cv incidents: palpitation, dyspnea-majors cv incidents: pulmonary edema, cardiac failure, rhythm disturbances, arterial embolism The risk for death is up to the folowing 3 groups factors:Group nr.1 ( mortality 0-1%):- atrial or ventricular septal defect- patent ductus arteriosus- mitral stenosis (class I and II)

MEDICAL AND SURGICAL COMPLICATIONS IN PREGNANCY Group nr.2 (mortality 5-15%):- mitral stenosis (class III and IV)- aortic stenosis- aortic coarctation (without valvular involvement)- Fallot tetralogy (uncorrected)- artificial valveGroup 3 (mortality 25-50%):- pulmonary hypertension- aortic coarctation with valvular involvement - Marfan's syndrome - Eisenmenger's syndrome

MEDICAL AND SURGICAL COMPLICATIONS IN PREGNANCY The lesions are classified according to the functional grading of the New York Heart Association as follows: => class I = patients with cardiac disease and no limitation of physical activity; these patients do not have symptoms of cardiac insufficiency nor anginal pain (uncompromised patients); => class II = slightly compromised: patients with cardiac disease and slight limitation of physical activity; they are free from symptoms while at rest, but ordinary activity is accompanied by undue fatigue, palpitation, dyspnea or anginal pain;

MEDICAL AND SURGICAL COMPLICATIONS IN PREGNANCY => class III = markedly compromised: patients with cardiac disease and marked limitation of physical activity; less than ordinary activity causes discomfort in the form of excessive fatigue, palpitation, dyspnea or anginal pain; => class IV = severely compromised: patients with cardiac disease and inability to perform any physical activity without discomfort ; symptoms of cardiac insufficiency or of the anginal syndrome may develop even at rest and any activity increases them.

MEDICAL AND SURGICAL COMPLICATIONS IN PREGNANCY The influence of cardiovascular disease on pregnancy - increased incidence of spontaneous abortion , - increased incidence of prematurity and low-birth-weight

With satisfactory surgical correction prior to pregnancy maternal risks are decreased dramatically and fetal environment is improved. Operations to correct heart lesions are seldom necessary during pregnancy as it is indicated by the excellent results that can be obtained by medical treatment alone.

MEDICAL AND SURGICAL COMPLICATIONS IN PREGNANCY Delivery should be accomplished vaginally unless there are obstetrical indications for cesarean delivery. In spite of the physical effort inherent in labor and vaginal delivery, less morbidity and mortality are associated with it. Induction of labor for heart disease alone is contraindicated During labor, the patient should be kept in a semirecumbent position. Prophylactic antibiotics are recomended in all cases of congenital or acquired heart disease to prevent subacute bacterial endocarditis in uncomplicated vaginal deliveries.

MEDICAL AND SURGICAL COMPLICATIONS IN PREGNANCY 2.Urinary Tract Infections Asymptomatic bacteriuria Asymptomatic (covert) bacteriuria refers to persistent actively multiplying bacteria within the urinary tract without symptoms. A clean-voided specimen containing more than 100,000 colonies/ml is considered evidence for infection. Bacteriuria has been linked to an increased incidence of preterm births, pregnancy-induced hypertension and anemia. A 10 to 14 day course of one of these agents (ampicillin, nitrofurantoin, cephalosporin) will effectively eradicate bacteriuria in about 70% of pregnant patients.

MEDICAL AND SURGICAL COMPLICATIONS IN PREGNANCY Cystitis and urethritis The principal symptoms are frequency, dysuria and suprapubic pain and tenderness. Although cystitis is usually uncomplicated it is presumed that the upper urinary tract may become involved by ascending infection. Bacterial cystitis responds readily to any of several regimens (Ampicillin 500mg every 6 hours, Nitrofurantoin lOOmg once a day, Sulfisoxazole lg, four times daily). Treatment should be continued for 10 days. Single-dose therapy (as described for asymptomatic bacteriuria) has been shown effective.

MEDICAL AND SURGICAL COMPLICATIONS IN PREGNANCY Acute pyelonephritis Acute upper urinary tract infections usually develop late in the second trimester, early in the third or after delivery. Approximately two thirds occur in women who have asymptomatic bacteriuria. The usual symptoms are : chills, fever, flank pain, dysuria, nausea and vomiting. The temperature may have high levels (40-41C). Palpation of the kidney area produces severe pain and there may be tenderness along the course of the ureter and over the bladder. The right kidney is most often involved, but the infection frequently occurs bilaterally.

MEDICAL AND SURGICAL COMPLICATIONS IN PREGNANCY The diagnosis is confirmed by examination of a catheterized specimen of urine which will contain many pus cells and bacteria (E. coli, Klebsiella, Enterobacter, Proteus). About 15% of women also have bacteriemia. The white blood cell count may be as high as 20,000 to 30,000. Undelivered patients are best treated in the hospitalThe medication should be continued for at least 14 days. Antimicrobial resistance of E.coli to ampicillin has often been encountered. For these reasons, many prefer to give gentamicin or tobramycin along with ampicillin or a cephalosporin or extended spectrum penicillin. Intravenous hydration to insure adequate urinary output is essential.

MEDICAL AND SURGICAL COMPLICATIONS IN PREGNANCY 3.Gastrointestinal Disorders Appendicitis Acute appendicitis occurs with the same frequency in pregnant as in nonpregnant women, but the diagnosis is more difficult and delay in treatment is hazardous. The difficulty in diagnosis and delay in operative intervention increase with gestational age, as does maternal and fetal mortality. The enlarged uterus may obscure the appendix which tends to be displaced upward and laterally, containment of infection by the omentum becomes increasingly unlikely and appendiceal rupture causes generalized peritonitis.

MEDICAL AND SURGICAL COMPLICATIONS IN PREGNANCY Effects on pregnancy outcome Abortion or premature labor may occur if the infection involves the uterine serosa. Uterine contractions stimulated by the infection are frequently tetanic and predispose to fetal hypoxia and intrauterine fetal death. Diagnosis Nausea and vomiting, epigastric pain localizing in the right side of the abdomen and tenderness anywhere from McBurney's point to the right flank- during the first trimester, the pain localizes in the right lower quadrant; at 6 months, the point of maximal thickness is above the iliac crest and at 8 months, it rises to the level of the right costal margin.

MEDICAL AND SURGICAL COMPLICATIONS IN PREGNANCY All these simptoms are suggestive but the diagnosis is reputed to be more difficult because the clinical picture tends to be masked by the symptoms and physical changes of pregnancy: => nausea, vomiting and abdominal discomfort of early pregnancy; => upward displacement of the appendix by the expanding uterus; => round ligament spasm, physiologic leukocytosis and elevated sedimentation rate.

MEDICAL AND SURGICAL COMPLICATIONS IN PREGNANCY Changes in position of the appendix as pregnancy advances

MEDICAL AND SURGICAL COMPLICATIONS IN PREGNANCY If appendicitis is suspected, treatement is immediate surgical exploration. In most reports, the diagnosis is verified in about half of women who undergo surgical exploration. Intravenous antimicrobial are given.If generalized peritonitis does not develop, then the prognosis is quite good. Undiagnosed appendicitis often stimulates labor. In these cases , an acute surgical abdomen is encountered within a few postpartum hours. When generalized peritonitis develops , cesarian delivery is indicated at the time of appendectomy.

MEDICAL AND SURGICAL COMPLICATIONS IN PREGNANCY Hepatitis A and pregnancy In developed countries the effects of HA on pregnancy are not dramatic. However, at least in some underprivileged populations, both perinatal and maternal death are substantialy increased. Treatment consists of a well-balanced diet and diminished activity. Women with less severe illness may be managed as outpatients. There is no evidence that HA virus is teratogenic. Risk of transmission to the fetus is negligible and to the newborn infant it is quite small. The risk of preterm birth appears to be increased.

MEDICAL AND SURGICAL COMPLICATIONS IN PREGNANCY Hepatitis B and pregnancy HB infection is a major cause of acute hepatitis as well as its serious sequelae, namely chronic hepatitis, cirrhosis and hepatocellular carcinoma. The course of HB infection in the mother does not seem to be altered by pregnancy. The likelihood of preterm delivery is increased Transplacental viral transfer from the mother to the fetus is rare. Instead, infection of the fetus or infant is by ingestion of infected material during delivery or exposure subsequent to birth. Some infected infants are asymptomatic but others develop fulminant disease and succomb. The majority (85%) become chronic carriers who can infect others.

MEDICAL AND SURGICAL COMPLICATIONS IN PREGNANCY Mothers with AgHBs and AgHBe are very likely to transmit the disease to their infants, whereas those who are negative for AgHBe but positive for AcHBe do not appear to transmit the infection. Infection of the newborn whose mother chronically carries the virus can usually be prevented by the administration of HB immune globulin very soon after birth, followed promptly by HB vaccine. For these reasons HB serological screening for all prenatal patients is recommended. If positive, and especially if e antigen is identified in the mother, the offspring should be given HB immune globulin and recombinant vaccine.

MEDICAL AND SURGICAL COMPLICATIONS IN PREGNANCY4.Diabetes

P. White classification (1978) was designed originally to prognosticate pregnancy outcome, because infant survival decreased with increasing severity of diabetes. The classification suggested by the American College of Obstetricians and Gynecologists (1986) relates the duration of diabetes to the severity of end- organ derangement, especially the eyes, kidneys, cardiovascular system.

MEDICAL AND SURGICAL COMPLICATIONS IN PREGNANCY

MEDICAL AND SURGICAL COMPLICATIONS IN PREGNANCY

MEDICAL AND SURGICAL COMPLICATIONS IN PREGNANCY Pregestational diabetes Diagnosis during pregnancy High plasma glucose levels, glucosuria and ketoacidosis are elements of diagnosis. Women with only minimal metabolic derangement may be difficult to identify. In these cases diagnosis is based on: => strong familial history of diabetes; => large infants or unexplained fetal losses; => persistent glucosuria.

MEDICAL AND SURGICAL COMPLICATIONS IN PREGNANCY Effect of pregnancy on diabetes During pregnancy, control of diabetes is usually made more difficult due to a variety of complications: - nausea and vomiting may lead on the one hand to hypoglycemic shock -infection during pregnancy commonly results in insulin resistance and ketoacidosis -the exertion of labor may also result in troublesome hypoglicemia unless the amount of insulin given is reduced accordingly, or glucose is provided by intravenous infusion. -after delivery, the need of exogenous insulin most often decreases .Hypoglycemic shock occurs more often in the immediate period following delivery than at any other time in pregnancy.

MEDICAL AND SURGICAL COMPLICATIONS IN PREGNANCY Effects of diabetes on pregnancy Maternal effects of diabetes include the following : The likelihood of preeclampsia-eclampsia is increased about four times. This incidence is increased even in the absence of demonstrated preexisting vascular or renal disease; Some bacterial infections are more common in diabetic pregnancy;

MEDICAL AND SURGICAL COMPLICATIONS IN PREGNANCY Water balance is readily disturbed. Both fetal and maternal edema are common complications. Hydramnios occurs in 5 to 50% of diabetic mothers; Excessive size of the infant (macrosomia) is so common a finding that unrecognized maternal diabetes should be suspected in patients who deliver babies weighing more than 4320g (9 pounds); The rate of cesarean delivery is increased; Maternal mortality is increased because of the complications of diabetes as well as an increased risk for hypertension, infection and operative delivery.

MEDICAL AND SURGICAL COMPLICATIONS IN PREGNANCY Fetal and neonatal effects : Stillbirth and neonatal death rates are increased even with mild maternal diabetes. The risk of intrauterine fetal death rises sharply after the 36th week; The incidence of preterm delivery in many cases induced because of hypertension, is increased two to three times. Neonatal morbidity is common. Major congenital anomalies occur in 4% to 12% of infants and include: anencephaly, spina bifida and hydrocephalus, cardiac anomalies (transposition of the great vessels, atrial and ventricular septal defects), situs inversus, renal anomalies. They occur primarily as a result of the influence of hyperglicemia on the developing embryo during the fifth to eighth week after conception.

MEDICAL AND SURGICAL COMPLICATIONS IN PREGNANCY