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medicalandsurgicalcomplicationsduringpregnancy

heartdeseasesinpregnancy

incidenceheartdiseasecomplicatesabout1percentofpregnancies.component

congenitalheartdiseaserheumaticheartdiseasehypertensiveheartdiseaseothervarieties(inclued:pregnancy-inducedhypertension,thyroid,coronary,syphilitic,andkyphoscolioticcardiacdisease)idiopathiccardiomyopathy(perinatalcardiomyopathy)isolatedmyocarditisvariousformsofheartblock

0.3per10,000livebirthsheartdiseasestillsignificantlycontributestomaternalmortality.5.6-8.5percentofmaternaldeathsmaternalmortalityeffectofpregnancyonheartdisease

thepregnantperiodcardiacoutputisincreasedbyasmuchas30-50percentalmosthalfofthetotalincreasehasoccurredby8 weeks,anditismaximizedbymidpregnancy.totalbloodvolumeisincreasedabout35%.from6thweekto32ndweekstrokevolumeisincreasedby20-40%.restingpulseisincreased(by10-17%)thechangesofanatomicpositionsheart,diaphragm,uterus.formationofutero-placentalcirculationlaboranddelivery

consumptionofenergyandoxygenisfurtherincreased.laborisincreasedmaternalcardiacburdens.expulsionofthefetusandplacentaproduceadrematichemodynamicchanges.thepuerperium

afterdeliveryofthefetusandplacenta,during1-2days,greatamontofbloodreturnintothesystemiccirculation,andgreatamontoffluidfromintertissuespacereturntothesystemiccirculation,increasecardiacburdensagain.

32-34gestationalweeks,duringthelaboranddelivery,andearlypostpartumperiod(1-3days)arethemostdangertimeforpregnantwomenwithheartdisease.itiseasydevelopmentheartfailure.clinicalclassification

(bythenewyorkheartassociation)

classiuncompromised:

patientswithcardiacdiseaseandnolimitationofphysicalactivity.theydonothavesymptomsofcardiacinsufficiency,nordotheyexperienceanginalpain.classiislightlycompromised: patientswithcardiacdiseaseandslightlimitationofphysicalactivity.thesewomenarecomfortableatrest,butifordinaryphysicalactivityisundertaken,discomfortresultsintheformofexcessivefatigue,palpitation,dyspnea,oranginalpain.classiiimarkedlycompromised:

patientswithcardiacdiseaseandmarkedlimitationofphysicalactivity.theyarecomfortableatrest,butlessthanordinaryphysicalactivitycausesdiscomfortbyexcessivefatigue,palpitation,dyspnea,oranginalpain.classivseverelycompromised: patientswithcardiacdiseaseandinabilitytoperformanyphysicalactivitywithoutdiscomfort.symptomsofcardiacinsufficiencyoranginamaydevelopmentatrest,andifanyphysicalactivityisundertaken,discomfortisincreased.clinicalclassification(con’t)diagnosisofheartdiseasemanyofthephysiologicalchangesofnormalpregnancytendtomakethediagnosisofheartdiseasemoredifficult.diseasehistory,symptoms

and

clinicalfindings

listedinheresymptomsandclinicalfindingsmayindicateheartdisease:severeorprogressivedyspneaprogressiveorthopneaparoxysmalnocturnaldyspneahemoptysissyncopewithexertionchastpainrelatedtoeffortoremotionclinicalfindingscyanosisclubingoffingerssymptoms

persistentneckveindistensionsystolicmurmurgreaterthangrade3/6diastolicmurmurcardiomegalysustainedarrhythmiapersistentsplitsecondsoundcriteriaforpulmonaryhypertensionleftparasternalliftloudp2symptoms(con’t)

conventionaltests

electrocardiographyecocardiographychastx-raydiagnosisofearlyheartfailureduringpregnancy

dyspnea,palpitationatslightphysicalactivity.restingpulselargerthan110beatsperminute.paroxysmalnocturnaldyspnea.raleinlowerlungsprognosisthelikelihoodofafavorableoutcomeforthemotherwithheartdiseasedependsuponthe(1)functionalcardiaccapacity(2)othercomplicationsthatfurtherincreasecardiacload(3)qualityofmedicalcareprovided.counseling(preconceptionalcounceling).(todecidethepregnancyshouldbecontinued)intensivepregnatalcare.activepreventfactorsincreasingcardiacfunctionalload.(suchasrespiratorytractinfection,anemiaandpregnancy-inducedhypertension)managementgeneralmanagement

monitoringthevitalsignssedativesandanalgesicshorteningthesecondstageoflabor(byforceps)(classesiandii)indicationsofcs(cesareansection)(classiiiormore,obstetricindications,)managementduringlaboranddeliverybringpressuretobearontheupperabdomenbedrestmonitoringthevitalsignsbreastfeeding(classesiandii)andartificialfeeding(classesiiioriv)managementorearlypuerperiummedicalandsurgicalcomplicationsduringpregnancy

acuteviralhepatitis

hepatitisisthemostcommonseriousliverdiseaseencounteredinpregnantwomen.thereareatleastfivedistincttypesofviralhepatitis:hepatitisa;hepatitisb;hepatitisc(non-aandnon-bhepatitis);hepatitisd;andhepatitise.inpregnancycomplicatehepatitis,hepatitisbiscommon.theincidenceofacuteviralhepatitisduringpregnancyisabout6foldincreasedthannon-pregnancy,andthefulminanthepatitisis66timesincreasedthannon-pregnancy.hepatitisbistransmittedbyinfectedblood,bloodproducts,andinsaliva,vaginalsecretions,andsemen.itisasexuallytransmitteddisease.deltahepatitis(hepatitisd)isadefectivernavirusthatisahybridparticlewithahepatitisbsurfaceantigencoatandadeltacore.thevirusmustco-infectwithhepatitisbandcannotpersistinserumlongerthanhepatitisbvirus.ittransmissionissimilartohepatitisbviralinfection.transmissionofhepatitiscinfectionappearstobeidenticaltohepatitisb.hepatitiseisawaterbornernavirusthatisentericallytransmitted.hepatitisaistransmittedbythefecal-oralroute.effectofpregnancyonhepatitisthecourseofhepatitisbinfectioninthemotherdoesnotseemtobealteredbypregnancy.however,atleastinsomeunderprivilegedpopulations,bothperinatalandmaternaldeathsaresubstantivelyincreasedforhepatitisaandb.tendtobecomechronichepatitis.(hepatitisbandc)effectonpregnancy

mother:

increasingnauseaandvomitingearlyinpregnancy.increasintheincidenceofpregnancy-inducedhypertensioninlatepregnancy.increasingtheincidenceofpostpartumhemorrhage.fetusansinfants:

abortionpretermdeliveryfetaldeathsincreasingtheantenatalmortalityrateaffectedthefetusandinfants(maternal-fetaltransmission)diagnosishistorycontectwithhepatitispatients,usedbloodandbloodproducts,…..clinicalsymptomsandfindingsserologicaltestsliverfunction,identifyingofvirisantigenandantibodies)jaundiceisdeeperrapidly.serousbilirubin>171umol/l(10mg/dl)thesizeofliverisdiminishedquickly.ascites,anorexia,severevomiting.hepaticencephalopathy.hepatic-renalsyndrome(acuterenalfailure)severeliverfunctionimpairment.diagnosisofsevereacutehepatitishyperemesisgravidarumpreeclampsia(hellp)intrahepaticcholestasisofpregnancy(icp)acutefattyliverofpregnancyliverimpairmentfromdrugsoverdose.defferentialdiagnosismanagementsupportivemedicalmeasuresasforthenonpregnantpatient.rest,adequatenutrition,vitamins,sufficientprotein,carbohydrate,lowfattydiet.obstetricmanagement

earlystageofpregnancy:activetreatmentthedisease,thenartificialabortionshouldbeperformed.

duringmidpregnancyandlatepregnancy,vitaminkandcshouldbeadmited,andactivepreventpregnancy-inducedhypertension.obstetricmanagement(con’t)

duringlaboranddelivery:vitaminkisadmited,prepairingfrashblood;avoidoperativeobstetricintervention;shorteningthesecondstageoflabor(byavacuum);preventingthelacerationofthebirthcanal;preventinretainedplacentalfragmantsormembranes;usingofoxytocin.

postpartumperiod:antibioticdrugs,artificialfeeding,lactifuge;infantisolationpreventedbytheadministrationofhepatitisbimmuneglobulinafterbirth,followedpromptlybyhepatitisbvaccineinnewborninfant.treatmentofseverehepatitisproperly.

intrahepaticcholestasisofpregnancy（icp）妊娠肝内胆汁郁积症pruritusoccurringinpregnancy,intheabsenceofdermatologicabnormalities,isusuallyduetoicpsymptoms(pruritus)usuallycommencebetween28and34weeksincidence:1-2/1000pregnancies.icpshouldbesuspectedwhenwidespreadpruritusoccursinthethirdtrimester.withoutskinrash.highlevelsofbileacids(5-100timesnormal)bilirubinappearsintheurine.(inmost),alkalinephosphataseandbilirubinbeelevated.transaminasesiselevated(inmany)fordifferentialdiagnosis,hepatitisserology,hepatobiliarytractultrasonoguaphyandautoantibodiesscreanshouldbeperformedinallcases.(ultrasonographyisveryimportanttoexcludeabstructionofthebiliarytree.)diagnosisforthemother,itcarriesa10-22%riskofobstetrichemorrhage,andpretermlabor.forthefetalprognosis,stillbirth(upto15%),pretermdelivery(upto30%),fetaldistress(upto25%),andmeconiumstainingoftheamnioticfluid(30-40%),themechanismoffetalcompromiseisuncertain.maternal/fetalrisksprenatalmonitoringoffetalwellbeing; timingofdelivary; maternalsymptomcontrol; vitaminkramuscularvit.k10mgweeklyshouldbegivenfrom36weeks.intrapartumvitamink10mgisgiventomother; thenewbornbodyshouldreceivevitamink(thereisevidenceofableedingtendency).postnatalbiliarytractultrasonography(forstones),(ifpruritusdoesnotdisapear>7-10daysafterdelivery.) inoccasionalcasewhereabnormalitiesdonotresolveafterdelivery,liverbiopsymayneedconsideration.managementmedicalandsurgicalcomplicationsduringpregnancy

chronicglomerulonephritisandpyelonephritisurinarytractdilation(itinvolvesdilatationoftherenalcalycesandpelves,aswellastheureters)thesechangesaremorepromimentontherightside.thesizeofkidneyincreases1cm.theglomerularfiltrationrateincreasesabout50%.therenalplasmaflowincreasesabout35%.thesechangescreateurinarystasis,andmayleadtoseriousupperurinaryinfections.urinarytractchangesduringpregnancyurinalysisisessential.mostdegreethatproteinuriamustexceed500mg/daytobeconsideredabnormalforpregnancy.iftheserumcreatininepersistentlyexceeds0.9mg/dl(75umol/l),thenintrinsicrenaldiseaseshouldbesuspected.ultrasonogaphyprovidesimagingofrenalsizeandrelativeconsistency,aswellaselementsofobstruction.ifnecessary,cystoscop,intravenouspyelography,orrenalbiopsymaybeconsidered.assessmentofrenaldiseaseduringpreg1ancy

incidenceabout1-2%ofpregnancies.acutepyelonephritisisthemostcommonseriousmedicalcomplicationofpregnancy.pyelonephritisismorecommonaftermidpregnancy.itisunilateralandright-sidedinmorethanhalfofcases,andbilateralinonefourth.inmostwomen,renalparenchymalinfectioniscausedbybacteriathatascendfromthelowertract.acutepyelonephritis

effectonpregnancy

thehighfevercancreatesabortion,pretermlabor.inthefirsttrimester,malformationsareincrease.(suchasspinaldefects)toxicshock.(bybacteriatoxin)

clinicalfindingsgeneralsymptoms:theonsetofpyelonephritisisusuallyratherabrupt.highfever(aswellas40degreec),shakingchills.(thermoregulatoryinstability)nauseaandvomitingheadache

clinicalfindings(con’t)urinarysystemicsymptoms:achingpaininoneorbothlumbarregions.tendernessinoneorbothcostovertebralangles(bypercussion)dysuria,urgency,andfrequency.asymptomaticbacteriuriathereportedprevalenceofasymptomaticbacteriaduringpregnancyvariesfrom2-7%.about15%ofwomenwithacutepyelonephritisalsohavebacteremia.

clinicalfindings(con’t)transientrenaldysfunction:elevatedserumcreatininedecreasedcreatinineclearancehematologicaldysfunction:hemolysisanemiathrombocytopeniapulmonarydysfunctionadultrespiratorydistresssyndrome

diagnosisclinicalfindingsurinespecimenexaminationisanomaly.aclean-voidedspecimencontainingmorethan100,000organismsofasingleuropathogenperml.positiveurineculture.

management

hospitalizationurineandbloodculturescompletebloodcount,serumcrsatinine,andelectrolytesmonitorvitalsignsfrequently,includingurinaryoutput(placeindwellingbladdercatheterifnecessary)

management(con’t)

intravenouscrystalloidtoestablishurinaryoutputtoatleast30ml/hrintravenousantimicrobialtherapychestx-rayifthereisdyspneaortachypnearepeathematologyandchemistrystudiesin48hourschangetooralantimicrobilswhenafebriledischargeafterafebrile24hours,considerantimicrobialtherapyfor7-10daysurineculture1-2weeksafterantimicrobialtherapycompletedtreatmentofcomplicationsthisischaracterizedbyprogressiverenaldestructionoveraperiodofyeanordecades,eventuallyproducingtheend-stagekidney.usuallypersistentproteinuriaandhematuriaaccompanyagradualdeclineinrenalfunction.

effectofglomerullonephritisonpregnancydeliveredpreterm,(ashighas25%)fetusesintrauterinegrowthretadatio(iugr,>15%)perinatalmortalityrate8%(after28gestationalweeks)factorsthatportendedtheworstperinatalprognosisincludedimpairedrenalfunction,earlyorseverehypertension,andnephrotic-rangeproteinuria.chronicglomeruionephritiskaplan'stypingtypeihaveonlyproteinuriaandedemawithouthypertensionandrenalfunctionimpairment.typeiihaveproteinuriaandhypertensionandwithoutrenalfunctionimpairment.typeiiiallproteinuria,hypertensionandrenalfunctionimpairmentexist.lindheimercategories:mildimpairmentofrenalfunction:serumcreatinine<1.5mg/dlandminimalhypertension;moderateimpairmentofrenalfunction:serumcreatinineof1.5-3.0mg/dlsevererenalinsufficiency:serumcreatinine>3.0mg/dlcommoncomplications(inmoderateandsevererenalinsufficiency)chronichypertemion(70%)anemia(75%)preeclampsia(60%)pretermdelivery(35%)fetalgrowthrestriction(30%)fetaldeathmanagementdiet:lowerphosphorus,lowerprotein(highquality)controlhypertensionpreventionofinfectionintensiveprenatalcareterminationofpregnancytimelyquestionzf%i(m=2<6:a 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