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Maternal Illnesses in Pregnancy

Maternal Illnesses in Pregnancy

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02/01/2013

Obstetrics Maternal Illnesses in Pregnancy Dr. Teh 2nd shifting/11.08.

08 Juday and forever friends
CARDIOVASCULAR DISEASES I. Physiologic Changes During Pregnancy 1. Increase in cardiac output (30-50%) 2. Increase in blood volume (20-50%) secondary to an increase in aldosterone (Na retention) 3. Decrease in peripheral vascular resistance 4. Increase in resting pulse rate (10-15bpm) *do not expect increase blood pressure due to decrease peripheral vascular resistance II. Normal ECG Findings 1. Slight left axial deviation 2. Mild ST changes in inferior leads 3. frequent sinus tachycardia 4. higher incidence of arrythmias III. Normal PE of the Heart 1. Exaggerated splitting of the first heart sound 2. Systolic murmur in 90% IV. Normal CXR Findings 1. Straightening of the upper left border of the heart 2. Horizontal position of the heart 3. Increase lung markings 4. Small pleural effusion early postpartum V. Normal 2-D Echo Findings 1. Slight increase in systolic and diastolic LV dimensions 2. Unchanged or slightly improved LV systolic function Clinical Indicators of Heart Disease During Pregnancy I. Symptoms  Progressive dyspnea (secondary to increase progesterone) or orthopnea  Nocturnal cough  Hemoptysis  Syncope  Chest pain II. Clinical findings  Cyanosis  Clubbing of fingers  Persistent neck veins  Systolic murmurs grade 3/6 (<3/6 is still normal)  Presence of diastolic murmurs  Persistent arrythmia (transient is still considered normal)  Persistent split second heart sound  Arterial or pulmonary hypertension  Cardiomegaly NYHA (New York Heart Association) Clinical Classification of Heart Disease 1. 2. 3. 4. Class 1 – Uncompromised - no limitation of phyicals activity Class 2 – Slightly compromised - (+) symptoms only exists after ordinary physical activity Classs 3 – Markedly compromised - (+) symptoms occur even with less than ordinary activty Class 4 – Severely compromised - (+) symptoms even at rest

Classification of Heart Disease: 1. Valvular Heart Disease - MS, MR, AS, AR 2. Congenital Heart Disease - Volume overload (L-R shunt) - VSD, ASD, PDA - Pressure Overload – PS, coarctation of the aorta - Cyanotic lesion (R-L shunt) – TOF, Eisenmenger Syndrome 3. Ischemic Heart Disease 4. Arrythmias Risk for Maternal Mortality Caused by Various Heart Diseases Group 1 – Minimal Risk (0-1%) Eg. VSD, ASD, PDA, PS, corrected TOF, bioprosthetic valves, Class 1 & 2 MS Group 2 – Moderate Risk (5-15%) 2A- Class 3 & 4 MS, AS, aortic coarctation w/o valvar involvement, uncorrected TOF, Marfan Syndrome w/ normal aorta, previous MI 2B- MS w/ artificial valve Group 3 – Major Risk (25-50%) pulmonary hpn, Eisenmengerization, aortic coarctation w/ valvar involvement, Marfan Syndrome w/ aortic involvement MITRAL STENOSIS - ¾ is caused by rheumatic enocarditis - contracted mitral valves (stiff mitral valves) impedes blood flow from LA to LVLA dilatation (secondary to increased LA pressure)pulmonary hpn - MR is well tolerated compared to MS MITRAL REGURGITATION or INSUFFICIENCY - due to decreased systemic vascular resistance - heart failure rarely occurs - occasional tachyarrythmias nedd to be treated Types of Valve Replacements 1. Mechanical Valve Prosthesis - may lead to fetal loss, abortion, and embryopathy - disadvantages: risk of thromboembolism - need for use of anticoagulant=increased risk of hemorrhage

MARY YVETTE ALLAIN TINA RALPH SHERYL BART HEINRICH PIPOY TLE JAM CECILLE DENESE VINCE HOOPS CES XTIAN LAINEY RIZ KIX EZRA GOLDIE BUFF MONA AM MAAN ADI KC PENG KARLA ALPHE AARON KYTH ANNE EISA KRING CANDY ISAY MARCO JOSHUA FARS RAIN JASSIE MIKA SHAR ERIKA MACKY VIKI JOAN PREI KATE BAM AMS HANNAH MEMAY PAU RACHE ESTHER JOEL GLENN TONI

Obstetrics Maternal Illnesses in Pregnancy Dr. Teh 2nd shifting/11.08.08 Juday and forever friends
- MMR: 3-4% 2. Porcine Tissue Valve - safer during pregnancy - less thrombogenic - doesn’t need anticoagulant *stop heparin 6 hrs. before delivery Effect of Cardiac Disease on Mother/Fetus Increase MMR IUGR Miscarriage Preterm delivery Fetal Death Malformed fetus (due to medications) Effect of Pregnancy in Gravidocardia Patient - increased workload to the heart – worsening of symptoms 4 Critical Periods of Gravidocardic Patient 1. at 28-32 weeks AOG – max increase in blood volume occurs, increase preload 2. During labor – increase in CO during contration of the uterus i. Pain & anxiety – 5-60% increase in CO due to increase sympathetic stimulation ii. Squeezing of blood from the uterus 3. Delivery – increase CO (60-80%) 4. one week post partum Labor and Delivery - Vaginal delivery is the preferred route (assisted vaginal delivery either by forceps or vacuum) - CS delivery is limited to OB indications - Hypotension should be avoided Epidural Anesthesia is the anesthesia of choice AHA (1997) Guidelines for Bacterial Endocarditis Prophylaixs  High risk patients - IV or IM ampicillin 2g + gentamicin 1.5mg/kg w/in 30 mins or before the procedure, then ampicillin 1g q6 - if allergic to penicillin, IV vancomycin 1g over 1-2 hrs + gentamicin  Moderate risk patients - oral amoxicillin 2g p.o. 1 hr before the procedure or IV ampicillin 2g w/in 30 minutes prior to procedure Management 1. Antepartum – before labor  limit physical activity  fluid restriction  correct anemia

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beta-blocker, digoxin anticoagulant (valve replacement)

2. Intrapartum – during labor  avoid excessive pain  FHR monitoring  Avoid hypotension  Minimize blood loss MI During Pregnancy - overall MMR 30-50% - women who sustain an infarction <2weeks prior to labor are at especially high risk of death - lidocaine to suppress malignant arrythmias Peripartum Cardiomyopathy  Development of cardiac failure in the last month of pregnancy or w/in 5 months after delivery  Absence of an identifiable cause for the cardiac failure  Absence of recognizable heart disease prior to the last month of pregnancy  LV systolic dysfunction demonstrated by classic Echo criteria such as depressd shortening fraction or ejection fraction RESPIRATORY DISEASES IN PREGNANCY I. Physiologic Changes 1. diaphragm rises about 4 cm 2. subcostal angle widens 3. transverse diameter of thoracic cage increases by about 2cm 4. thoracic circumference increases about 6cm 5. changes in pulmonary function II. Changes in Pulmonary Function 1. ↑ Vital capacity by 100-200cc 2. ↑ Inspiratory capacity by 300cc 3. ↑ Tidal volume 4. ↑ Minute ventilation rate by 40% from 7-10.5% 5. ↓ Expiratory reserve volume from 1,300 to 1,100cc 6. ↓ Residual Volume from 1500-1200cc 7. ↓ Functional residual capacity results to increase ventilation due to deeper but more frequent breathing induced by increased basal O2 consumption (20-40 ml/min) in the 2nd half of pregnancyfall in arterial pO2 to 28mmHg slightly alkalotic plasma pH at 7.45 decrease in HCO3 to 20 mEq/L Dyspnea During Pregnancy  Due to alveolar hyperventilation  A response to substantially low pCO2 due to anatomical changes in the thorax Pneumonia

MARY YVETTE ALLAIN TINA RALPH SHERYL BART HEINRICH PIPOY TLE JAM CECILLE DENESE VINCE HOOPS CES XTIAN LAINEY RIZ KIX EZRA GOLDIE BUFF MONA AM MAAN ADI KC PENG KARLA ALPHE AARON KYTH ANNE EISA KRING CANDY ISAY MARCO JOSHUA FARS RAIN JASSIE MIKA SHAR ERIKA MACKY VIKI JOAN PREI KATE BAM AMS HANNAH MEMAY PAU RACHE ESTHER JOEL GLENN TONI

Obstetrics Maternal Illnesses in Pregnancy Dr. Teh 2nd shifting/11.08.08 Juday and forever friends
BACTERIAL PNEUMONIA  Secondary to aspiration of nasopharyngeal secretions  Organisms: S. pneumoniae, H. influenzae, mycoplasma  Symptoms: fever, productive cough, chest pain, dyspnea, pleuritic chest pain  Laboratory: (+) mild leukocytosis, Gram stain of sputum  Mangaement: antimicrobial treatment is empirical Erythormycin (pneumococci, mycoplasma, chlamydia) Cefotaxime or ceftriaxone (staph, haemophlius)  Clinical improvement evident in 48-72 hrs, reduction of fever I 2-4 days  Effect on pregnancy: MMR=1.6%, PMR=2.2% Factors that Increase the Risk of Death or Complication with CAP 1. Coexisting chronic condition 2. Clinical findings  RR: 30/min  Hypotension  PR > 125 bpm  Hypothermia <30OC  Altered mental status  Extrapulmonary disease 3. Laboratory findings  Leucopenia (<4000/υL) or leukocytosis (>20,000/ υL)  pCO2 (60mmHg) or CO2 retention  Increase serum urea  Evidence of sepsis or organ dysfunction 4. CXR findings  1 lobe involvement cavitation or pleural effusion VIRAL PNEUMONIA (INFLUENZA, VARICELLA)  Effect to baby a. 3x risk of NTD (neural tube defects like anencephaly, spina bifida) of women with influenza early in pregnancy due to hyperthermia b. serious infection with varisella in asso with preterm delivery. if infection occurs before 20th AOG, fetus can be infected and permanent sequelae results  Treatment Influenza – amantadine or rimantidine 200mg OD - prevent with vaccination after the 1st trimester Varicella – acyclovir 10mg/kg - VZIG 125 units/10kg IM should be given w/in 96 hrs from infection (max dose 625 units) - vaccine is contraindicated in pregnancy Bronchial Asthma Pathophysiology: Bronchial smooth muscle contraction, mucus hypersecretion, mucosal edema Effects of Pregnancy on Asthma  1/3 improved, 1/3 unchanged, 1/3 worsen

 

with severe asthma at start of pregnancy more likely to experience worsening disease 18x ↑ exacerbation following CS delivery compared with vaginal (choice of delivery)

Effects on Pregnancy  risk of preeclampsia, PTL, LBW and perinatal mortality  maternal deaths from status asthmaticus  life threatening complications: pneumothorax, cardiac arrythmia, muscle fatigue with respiratory arrest  maternal alkalosis leading to fetal hypoxemia Diagnosis of Asthma  ABGs  FEV1 (1 sec from max expiration) – single best measure to reflect severity of disease Management of Acute Asthma  IV hydration  Supplementation O2 by mask after ABG extraction  Baseline FEV1 or PEFR  Continuous O2 pulse oximetry and ext. fetal monitoring  Pharmacologic treatment (B-agonist, EPI)  Corticosteroid be given early to all patients (hydrocortisone) *if initial treatment with B-agonist results to PEFR>70% of baseline=DISCHARGE!! Status Asthmaticus  Managed in ICU  Early intubation is considered when maternal respiratory status continues to decline despite aggressive treatment Indication for intubation  Fatigue  CO retention  Hypoxemia Management of Labor and Delivery  Stress-dose corticosteroids are given to any patient given systemic steroid treatment w/in preceding 4 weeks  Fentanyl is preferred analgesic than meperidine and morphine  Epidural anesthesia for labor is ideal  For CS, continuous conduction analgesia  PGE2 instead of PGF2 for refractory post partum hemorrhage Tuberculosis in Pregnancy Effects on pregnancy  Incidence of pretem labor, LBW, IUGR  6x increase in perinatal mortality rate Treatment

MARY YVETTE ALLAIN TINA RALPH SHERYL BART HEINRICH PIPOY TLE JAM CECILLE DENESE VINCE HOOPS CES XTIAN LAINEY RIZ KIX EZRA GOLDIE BUFF MONA AM MAAN ADI KC PENG KARLA ALPHE AARON KYTH ANNE EISA KRING CANDY ISAY MARCO JOSHUA FARS RAIN JASSIE MIKA SHAR ERIKA MACKY VIKI JOAN PREI KATE BAM AMS HANNAH MEMAY PAU RACHE ESTHER JOEL GLENN TONI

Obstetrics Maternal Illnesses in Pregnancy Dr. Teh 2nd shifting/11.08.08 Juday and forever friends

  

INH 5mg/kg/day (not>300mg) + vit B6 50mg OD Rifampicin 10 mg/kg/day (not>2.5g OD) Ethambutol 5-25mg/kg/day (not>2.5g OD)

Neonatal TB is Fatal Aquired thru:  Infected placenta  Hematogenously  Aspiration of infected secretions at delivery 50% occur if mother with active infection is not treated When to suspect TB A. Physical Exam B. Diagnostic Exam 1. sputum exam smear – more specific than CXR 2. CXR 3. culture – definitve diagnosis a. culture media – identification in 4-6 weeks b. BACTEC 460 method – identification in 2-3 weeks Indications for the Various Microbiological Tests: 1. AFB smear – for all suspected TB cases 2. Mtb culture – for smear (-) patients w/symptoms highly suggestive of PTB and suggestive CXR 3. Mtb culture and drug sensitivity a. smear (+) or (-) patients suspected of MDRTB (multidrug-resistant TB) b. smear (+) patients w/ fall or rise phenomenon c. all cases of relapse d. all active cases previously treated for >3 months e. all cases of treatment failure THYROID PHYSIOLOGY DURING PREGNANCY 1. Anatomically (+) moderate thyroid enlargement (glandular hyperplasia and increase vascularity) 2. Histologically (+) active formation and secretion of thyroid hormones 3. Increase radioactive iodine by thyroid gland 4. Start of 2nd month: total serum T3 and T4 concentration increase sharply 5. Daily T4 secretion is increased 6. TBG (thyroid binding globulin) – due to estrogen effect 7. NO effect on TRH level 8. TSH unchanged – doe not cross placenta 9. Normal FT3 and FT4 levels Signs and Symptoms of Hyperthyroidism  Tachycardia  Abnormally high sleeping pulse rate  Thyromegaly  Exophthalmos  Failure to gain weight Diagnosis Elevated free T4 and low TSH

Thyrotoxicosis in Pregnancy occur in about 2 out of 1000 pregnancies most common causes: • Grave’s disease (90-95%) • Gestational trophoblastic neoplasia • Toxic multinodular goiter • Toxic adenoma • Hyperenuresis gravidarum Therapy  Limited to anti-thyroid drugs or surgery  Radioactive iodine is an absolute contraindication Cause destruction of fetal thyroid Caution against pregnancy = 1year after treatment  Therapeutic gain is to achieve a euthyroid or a slightly hyperthyroid mother to prevent hypo- or hyperthyroidism Anti-thyroid Drugs A. Thionamide (PTU and methimazole) Synthesis of T4 to T3 in peripheral tissues Crosses the placenta 4x less and breastmilk 10x less than methimazole B. Iodides Decrease serum T3 and T4 by 30-50% in 10 days by enabling the release of stored thyroid hormones Readily crosses the placenta and breastmilk Dosage: 5-10g BID C. Beta blockers Control of adrenergic symptoms of thyrotoxicosis Propranolo 20-40mg BID or Atenolol 50-100mg daily Side effects: IUGR, decrese in placental size, fetal bradycardia & hypoglycemia Effects on Pregnancy  Depend on whether metabolic control is achieved  Increse incidence of pre-eclampsa and heart failure  Adverse perinatal outcomes for untreated women  Perinatal Mortality Rate = 8%  Fetal Mortality Rate = 12% Effect on Neonate  Transient thyrotoxicosis  With long-standing in utero exposure to treatment  Neonatal hypothyroidism  Goiter  No adverse effect in subsequent growth and development Thyroid Storm/Heart Failure  PTU 1g PO or crushed thru NGT; after 1 hr give iodide q8  SSKI 5g or Lugol’s sol’n 10g  Dexamethasone 2mg IV q6 for 4 doses  IV beta-blocker if without heart failure

MARY YVETTE ALLAIN TINA RALPH SHERYL BART HEINRICH PIPOY TLE JAM CECILLE DENESE VINCE HOOPS CES XTIAN LAINEY RIZ KIX EZRA GOLDIE BUFF MONA AM MAAN ADI KC PENG KARLA ALPHE AARON KYTH ANNE EISA KRING CANDY ISAY MARCO JOSHUA FARS RAIN JASSIE MIKA SHAR ERIKA MACKY VIKI JOAN PREI KATE BAM AMS HANNAH MEMAY PAU RACHE ESTHER JOEL GLENN TONI

Obstetrics Maternal Illnesses in Pregnancy Dr. Teh 2nd shifting/11.08.08 Juday and forever friends
Hypothyroidism  Uncommon in pregnancy  May cause mental retardation, low IQ, cretinism DIABETES MELLITUS Glucose Metabolism During Pregnancy 3rd trimester = increase insulin resistance (skeletal and liver) due to:  Human Chorionic Somatomammotropin (hCS)  Human placental growth factor  Cortisol  Progesterone  Estrogen These hormones stimulate beta cells of pancreas to secrete insulin (cause hypertrophy and hyperplasia of beta cells) Increase plasma glucose, free fatty acids, insulin secretion, amino acids *Accelerated starvation in pregnancy is due to continuous withdrawal of nutrients by the fetus; occurs within 14-18 hrs in pregnancy (N=2-3 days) GDM (Gestational Diabetes Mellitus)  Carbohydrate intolerance of variable severity w/onset or first recognized during pregnancy  Implies: induced by pregnancy, DMII unmasked or discovered during pregnancy Screening Test  50 g OGCT (oral glucose challenge test)  done between 24-28 weeks AOG (Carpenter and Coustan) highest sensitivity within this period  >140 mg/dl (identifies 80%) Diagnostic/Confirmatory Test 100 g OGTT (oral glucose tolerance test) with 2 abnormal values to confirm OGTT 75 g OGTT Carpenter O’Sullivan NDDG mmol/L WHO/ASGO and and (1979) (mg/dl) DIP Coustan Mahan FBS 5.8 (98) 5.3 (95) 5 (90) 5.8 (105) 1 hr 10.6 (190) 10 (180) 9.2 (90) 10.6 (190) 2 hr 7.8 (140) 8.6 (155) 8.1 (145) 9.2 (165) 3 hr 7.8 (140) 6.9 (125) 8.1 (145) 4th International Workshop conference on GDM Recommendation A. Low risk  Member of ethnic group with low prevalence  No known 1st degree relative with DM  <25 y/o  normal weight before pregnancy  no history of abnormal glucose metabolism  no history of poor OB outcome B. Average risk  Hispanic, African, Asian, Native Americans

 

Women with marked obesity Strong family history

Classification of Pregnant Diabetic Class A1 GDM FBS 2OPP <120 mg/dl <105 mg/dl A2 GDM FBS 2OPP >120 mg/dl >105 mg/dl B >20 y/o <10 yrs duration C 10-19 y/o 10-19 yrs duration >20 yrs duration

diet insulin <10 years duration 10-19 yrs duration >20 yrs duration

D <10 y/o Effects of GDM GDM class A2 is associated with unexplained stillbirth ADA (1999): FBS > 105 mg/dl during last 4-8 weeks; AOG is associated with increase risk of fetal death Maternal Effects  Increase frequency of hypertension and need for CS delivery  >1/2 ultimately develop overt DM in 20 years Fetal Effects  Increased risk of macrosomia/excessive growth  Risk of shoulder dystocia  Increase chance of obesity and DM

Management  FBS>105 mg/dl or 2-hr PP glucose >120 mg/dl – insulin  FBS should be kept < or equal to 95 mg/dl  6-12 weeks after delivery: 75g OGTT • if FBS >140 mg/dl or 2-hr PPG >200 md/dl  (+) DM • if FBS <140 mg/dl or 2-hr PPG 140-200 mg/dl  impaired glucose tolerance • if normal 75g OGTT reassess at a min of 3 yr interval elevated FBS during pregnancy DM more likely to persist post partum Overt DM – random BS >200 mg/dl; FBS >126 mg/dl + 3 P’s w/unexplained weight loss Fetal Effects 1. Abortion especially in HbA1c >12% or preprandial >120 mg/dl 2. Preterm 3. Malformation (muskuloskeletal-10%, cardiac anomalies 38%) 4. Unexplained stillbirth 5. Hydrmnios (AFI >24 cm or vertical pocket 8cm) Neonatal Effects

MARY YVETTE ALLAIN TINA RALPH SHERYL BART HEINRICH PIPOY TLE JAM CECILLE DENESE VINCE HOOPS CES XTIAN LAINEY RIZ KIX EZRA GOLDIE BUFF MONA AM MAAN ADI KC PENG KARLA ALPHE AARON KYTH ANNE EISA KRING CANDY ISAY MARCO JOSHUA FARS RAIN JASSIE MIKA SHAR ERIKA MACKY VIKI JOAN PREI KATE BAM AMS HANNAH MEMAY PAU RACHE ESTHER JOEL GLENN TONI

Obstetrics Maternal Illnesses in Pregnancy Dr. Teh 2nd shifting/11.08.08 Juday and forever friends
1. 2. 3. 4. 5. 6. 7. RDS hypoglycemia Hypocalcemia <7mg/dl Hyperbilirubinemia Cardiac hypertrophy Inheritance of DM Altered fetal growth

Hi classmates!! Para maiba, maliit na space lagyan ng filler!! Hehehe..pacheck po kung tama un diagnostic/confirmatory test(100gOGTT) kasi hindi ko nakuha lahat eh..galing po yan iba’t ibang sources..hehehe..;p Salamat!!=)

MARY YVETTE ALLAIN TINA RALPH SHERYL BART HEINRICH PIPOY TLE JAM CECILLE DENESE VINCE HOOPS CES XTIAN LAINEY RIZ KIX EZRA GOLDIE BUFF MONA AM MAAN ADI KC PENG KARLA ALPHE AARON KYTH ANNE EISA KRING CANDY ISAY MARCO JOSHUA FARS RAIN JASSIE MIKA SHAR ERIKA MACKY VIKI JOAN PREI KATE BAM AMS HANNAH MEMAY PAU RACHE ESTHER JOEL GLENN TONI

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