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Medical and surgical Medical and surgical complicationscomplications

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Cardiac diseaseCardiac disease

IncidenceIncidence

Complicate 1% of pregnancy

But contribute significant maternal morbidity and mortality rate

Mortality rate is about 2.7 : 1000 pregnancy

Why we take cardiac Why we take cardiac dz in pregnancy so dz in pregnancy so

serious?serious?

Pregnancy induce worsen cardiac diseases during antepartum, intrapartum and postpartum period

Physiologic change in hemodinamic of pregnancy mimics clinical finding of cardiac dz.

Antepartum period

Cardiac output is increase by 30-50%

Total blood volume is increase about 50%

Increase heart rate by 10-20 beats/min

Decrease in peripheral vascular resistant

Effect of pregnancy on Effect of pregnancy on cardiac diseasecardiac disease


Intrapartum and delivery

Consumption of energy and oxygen is increase

Pain increases sympathetic tone

Uterine contractions induce wide swings in the systemic venous return


Postpartum

Autotransfusion of at least 500 ml occur wiht placental separation

During first 2 days of postpartum period, great amount of fluid from interstitial tissue return into the systemic circulation

Physiologic change in Physiologic change in pregnancy mimics pregnancy mimics

cardiac dzcardiac dz

Functional systolic heart murmur

Respiratory effort

Edema in the lower extremities

Various heart sounds may suggest cardiac dz.

Clinical indicators of Clinical indicators of cardiac dz. in cardiac dz. in

pregnancypregnancyProgressive dyspnea or orthopnea

Nocturnal cough

Hemoptysis

Syncope

Chest pain

Cyanosis

Clubbing of fingers

Persistent neck vein distension

Systolic murmur > gr.3

Diastolic murmur

persistent split 2nd sound

Symptoms Clinical finding

Diagnostic studyDiagnostic study

EKG (15 degree left axis deviation, mild ST changes in inferior leads, atrial and ventricular premature contractions)

CXR

Echocardiography

Clinical classification Clinical classification of cardiac dz.of cardiac dz.(New York Heart (New York Heart

Association; NYHA)Association; NYHA)Class 1: Uncompromised -- no limitation of physical activity

Class 11: Slight limitation of physical activity

Class 111: Marked limitation of physical activity

Class 1v: Severely compromised -- inability to perform any physical activity without discomfort

Predictors of cardiac Predictors of cardiac complicationscomplications

Prior heart failure, transient ischemic attack, arrhythmia, or stroke

Baseline NYHA class 111 or 1v or cyanosis

Left-sided obstruction: mitral valve area <2cm2, aortic valve area less than 1.5 cm2, or peak left ventricular out flow tract gradient above 30 mm Hg

Ejection fraction less than 40%

PrognosisPrognosis

The likelihood of a favorable outcome for the mother with heart disease depends upon

1. Functional cardiac capacity

2. Other complications that further increase cardiac load

3. Quality of medical care provided

Valvular Heart Lesions Associated with High Maternal and/or Fetal Risk During Pregnancy

Severe AS with or without symptoms

AR with NYHA functional class III-IV symptoms

MS with NYHA functional class II-IV symptoms

MR with NYHA functional class III-IV symptoms

Aortic and/or mitral valve disease resulting in severe pulmonary hypertension

Aortic and/or mitral valve disease with significant LV disfunction (EF < 40%)

Mechanical prosthetic valve requiring anticoagulation

Marfan syndrome with or without AR

High-Risk Maternal Cardiovascular Disorders

• Aortic valve stenosis 10-20 • Coarctation of the aorta 5• Marfan syndrome 10-20• Peripartum cardiomyopathy 15-60• Severe pulmonary hypertension 50• Tetralogy of Fallot 10

DisorderEstimated MaternalMortality Rate (%)

Management in Management in cardiac diseasescardiac diseases

Preconceptional Preconceptional counselingcounseling

Maternal mortality rates vary directly with functional classification BUT may change as pregnancy progresses.

By corrective surgery, subsequent pregnancy is less dangerous. If mechanical valves taking warfarin, fetal risk should be consider.

Congenital heart lesions could be inherited.

Congenital heart disease risks in fetus with affected family members

Congenital heart disease risks in fetus with affected family members

Management of NYHA Management of NYHA Class I and II DiseaseClass I and II DiseaseMostly deliver without morbidity

Prevention and early detection of heart failure

Prevent infection and sepsis syndrome

Prevention of bacterial endocarditis

Pneumococcal and influenza vaccination

Avoid smoking, intravenous drug use

Signs of congestive heart Signs of congestive heart failurefailure

Persistent basilar rales

Nocturnal cough

Sudden limitation of normal activities

Dyspnea on exertion

Smothering with cough

Hemoptysis, Progressive edema, tachycardia

Warning signsSerious signs

Vaginal delivery with short second stage unless obstetrical indication is obtained for C/S

Labor and delivery

Rout of delivery

MonitoryV/S : if PR > 100 bpm or RR > 24 tpm with dyspnea, may suggest impending ventricular failure

Analgesia and AnesthesiaEpidural analgesia is recommended in most

case

General anesthesia is preferable in case of intracardiac shunts, pulmonary hypertension and aortic stenosis

Proper therapeutic approach depends on the specific hemodynamic status and the underlying cardiac lesion.

Labor and delivery

Intrapartum heart failure

Puerperium

Woman who have no evidence of cardiac distress during pregnancy, labor, or delivery may still decompensate postpartum

Avoid : Postpartum hemorrhage, anemia, infection, and thromboembolism ( cause much more serious complication in heart disease)

Sterilization : should delay until hemodynamically near normal, afebrile, not anemic and ambulates normally

Oral combine pills: should avoid because they can induce thrombosis

DMPA: can use safely, but hematoma should be monitors

Implant: safely use, less hematoma complication

IUDs: safely use, but ATB should be given for endocarditis prevention

Contraception

Pregnancy interruption is preferable

If the pregnancy is continued, prolonged hospitalization or bed rest is often necessary

Epidural analgesia usually recommended

vaginal delivery is preferred in most cases, and labor induction can usually be done safely

C/S is limited to obstetrical indications

Need ICU care, experienced obstetrician and anesthesiologist

Management of NYHA Management of NYHA Class III and IV Class III and IV

DiseaseDisease

Valve replacement Valve replacement before pregnancybefore pregnancy

Mechanical valve itself doesn’t effect on pregnancy.

Thromboembolism involving the prosthesis and hemorrhage from anticoagulation are of extreme concern

Overall; maternal mortality rate = 3-4% with mechanical valves, and fetal loss is common

Effects on pregnancy

Management

The critical issue for mechanical prosthetic valves is anticoagulation: thromboembolic issue VS bleeding , teratogenic issue

Most effective to prevent mechanical valve thrombosis

Cause teratogenic and miscarriage, still birth and fetal malformation

Highest risk is when mean daily dose exceeded 5 mg

Anticoagulation agent

Warfarin

No teratogenic issue

Is definitely inadequate control of thromboembolism

Anticoagulation agent

Low dose unfractionated heparin

Unfractionated heparin or low-molecular-weight heparins

Report of valvular thrombosis

ACOG(2002) advised against use of LMWH during pregnancy.

American College of Chest Physicians has recommended us of UFH or LMWH given throughout pregnancy

American College of Chest Physicians Guidelines for Anticoagulation of pregnant women with mechanical

prosthetic valves

American College of Chest Physicians Guidelines for Anticoagulation of pregnant women with mechanical

prosthetic valves

Bacterial endocarditis Bacterial endocarditis prophylaxisprophylaxis

Estimate incidence of transient bacteremia at delivery is 1-5%

ATB prophylaxis is optional for uncomplicated delivery

Ampicillin 2 g. or cefazolin/ceftriaxone 1 g. IV 30-60 minutes before the procedure

For penicillin-sensitive pt. : Cefazolin/ceftriaxone 1 g., or if anaphylaxis, Clindamycin 600 mg IV 30-60 minutes before the procedure

Regimen recommended

American Heart Association Guidelines for Endocarditis Prophylaxis with Dental Procedures

American Heart Association Guidelines for Endocarditis Prophylaxis with Dental Procedures

Thyroid DisordersThyroid Disorders

Thyroid physiology Thyroid physiology and pregnancyand pregnancy

Thyroid binding globulin

TSH in early pregnancy

Thyroxine cross placenta and is important for normal fetal brain development and fetal thyroid gland function

90

HyperthyroidismHyperthyroidism

1:1000 - 2000 pregnancies

Mild thyrotoxicosis may be difficult to Dx during pregnancy

Most common cause : Graves disease

Molar pregnancy should be considered

Prior Hx of thyrotoxicosis/autoimmune thyroid dz in pt or in her family

Presence of typical symptoms of thyrotoxicosis : weight loss ( or failure to wt gain), palpitations, proximal muscle weakness

Symptoms suggestive of Graves disease like opthalmopathy, pretibial myxedema

Thyroid enlargement

occurrence of hyperemesis gravidarum leading to wt loss

Clinical features suggestive of possibility of hyperthyroidism

Historical

Pulse > 100 bpm

Widened pulse pressure

Eye signs of Graves disease or pretibial myxedema

Thyroid enlargement esp. in iodine sufficient geographical area

Onycholysis

Clinical features suggestive of possibility of hyperthyroidism

Physical examination

confirmed by laboratory tests

Serum TSH <0.1 mIU/L

Elevated Serum FT4 & FT3 levels

Thyroid autoantibodies

Diagnosis

Women with active Graves dz Dx pregnancy

Women who are in remission and considered cured after primary treatment

Women who is in diagnosis of Graves dz has not been established before the onset of pregnancy but have TSHR Ab

Graves disease in pregnancy

Both maternal & fetal outcome is directly related to adequate control of hyperthyroidism

Obstetric complication : Preeclampsia, fetal malformations, premature delivery, low birth weight

The risk of fetal and neonatal hyperthyroidism is negligible in euthyroid women not currently receiving ATD, but had received ATD previously for graves dz

For euthyroid women who has previously received radioiodine therapy or undergone thyroid surgery for graves dz, the risk of fetal & neonatal hyperthyroidism depends on level of TSHR Ab in mother

So these antibodies had to be measured early in pregnancy to evaluate the risk


For pregnant woman who takes ATDs for active graves dz, TSHR Ab should be checked again in 3rd trimestter

If the Ab titers have not decreased during the 2nd trimester, the possibility of fetal hyperthyroidism is to be considered


Hyperthyroidism due to graves tends to improve during pregnancy. ( Although exacerbations in early months of pregnancy)

Partial immunosuppression (due to pregnancy) with significant decrease in TSHR Ab titer

Marked increase serum TBG = reduce FT3 & FT4


Reasons

Monitor PR, wt gain, thyroid size, FT4, FT3, TSH monthly)

Use lowest dose of ATD (not > 300mg of PTU) : maintain euthyroid or mildly hyperthyroid state.

Follow fetal pulse & growth

Should Not attemp full normalization of serum TSH (Keep TSH 0.1-0.4 mU/L ) lower levels are acceptable if pt is doing well clinically

Management of hyperthyroidism

Propylthiouracil (PTU) is preferred to methimazole, but both can be used

Methimazole could cause embryopathy (esophageal or choanal atresia or aplasia cutis)

Iodides should not used during pregnancy unless for preparing the patient for surgery


Requirement for high doses of PTU/MMI with inadequate control of clinical hyperthyroidism

Poor compliance with resulting clinical hyperthyroidism

Appearance of fetal hypothyroidism at dose required to control disease in mother


Indication for surgery

Usually the dose of ATD can be adjusted downward after 1st trimester & discontinued during 3rd trimester

ATDs often need to be reconstituted/increased after delivery


Pulmonary hypertension and heart failure from cardiomyopathy caused by thyroxine is common in pregnant women

High-output state dilated cardiomyophthy

Cardiac decompensation is usually precipitated by preeclampsia, anemia, sepsis, or combination

Fortunately, thyroxine-induced cardiomyopathy and pulmonary hypertension are frequently reversible

Thyroid storm and heart failure

ICU is needed

1000mg of PTU orally the 200mg every 6 hr

An hour after initial PTU, iodide is given to inhibit thyroidal release of T3 & T4

Sodium iodide 500-10000mg of sodium iodide IV every 8 hrs.

Supersaturated solution of potassium iodide (SSKI) 5 drops or Lugol solution 10 drops orally every 8 hr


Management

Dexamethasone 2 mg IV every 6 hrs. for IV dose for blocking peripheral conversion of T4 to T3

Beta-blocker drug is given to control tachycardia

Coexisting severe preeclampsia, infection, or anemia should be aggressively managed


Management

Cannot be diagnosed based on clinical features

Usually diagnosed using biochemical tests

Characterised by raised TSH level

Affects 2.5% of all pregnancies

In iodine sufficient areas, most common cause is Hashimoto’s thyroiditis

Diagnosis of maternal hypothyroidism is important as has implication on both maternal and fetal outcomes

HypothyroidismHypothyroidism

Adverse outcomes of maternal hypothyroidism

Abortion

Gestational hypertension

Increased C/S

Anemia

Placental abruption

Preterm labour

Postpartum hemorrhage

Preterm birth

Fetal and perinatal death

Disorders of brain development

Low IQ scores

Fetal respiratory distress

Low birth weight

Cretinism

Maternal disorders

Fetal disorders

Difficult to detect hypothyroidism during pregnancy base on symptoms & signs alone

Diagnosis is made by Serum TSH

Serum TSH that is more than upper limit of normal should alert the clinician to diagnosis

Total or FT4 must be checked during screening

As low T4 even with normal TSH is considered abnormal (especially in iodine deficient zone)

Diagnosis

Levothyroxine is treatment of choice

Dosage: 2ug/kg/day

Subclinical hypothyroid OR TSH < 10 mU/L starting dose is 50-100 ug/day

Pregestational hypothyroidism require a 25-47% increase in dosage

Hypothyroid woman taking levothyroxine becomes pregnant, the dose is increased by 25-50 ug as soon as pregnancy is diagnosed

Management

Iron and calcium tablets should not take simultaneously with levothyroxine, may be taken 4 hrs after taking levothyroxine

First half of pregnancy - monitor Ft4, TSH every 4 wks

Later on every 6 wk

Target TSH in 1st trimester <2.5 mU/L

Target TSH in 2nd 3rd trimester <3 mU/L

Management

Monitor

Post delivery dose should reduced to pre-pregnancy dose

Thyroid function should be re-checked 6 wks after delivery

Management

Surgical complication Surgical complication in pregnancyin pregnancy

AppendicitisAppendicitis

1:2000 to 1:6000 pregnancies

Difficult diagnosis

Intermediate intervention is a must

Some time difficult in pregnancy

Displacement

Distorted lab values

Mimic symptoms

Mimic other conditions

Diagnosis

Leukocytosis

N/V, Tachycardia

Cholecystitis

Preterm labor

Pyelonephritis

Renal colic

Placental abruption

Degenerative myoma

Diagnosis

Mimic conditions

1975 Study Parkland: 34 pts over 15 year

Direct abdominal tenderness is rarely absent

Rebound tenderness 55-75%

Rectal tenderness: especially 1st trimester

Anorexia is only 1/3-2/3 pts, VS almost 100% in non pregnancy

Symptoms & Signs

(Cunningham 1975)

Ultrasound

CT scan

MRI

Diagnostic test

Difficult: cecal displacement and uterine imposition

Ultrasound

Numerous report in surgical literature suggesting accuracy of > 97% in non-pregnant patient

2008 study reported

Negative appendectomy rate was 54% with clinical Dx alone

8% if U/S +CT scan

CT scan

CT scan

* NO evidence of any increased risk of teratogenicity with exposure of up to 5 Rads

CT scan and teratogenicity

Maximal risk at 1 rad is 0.003%

15% embryos naturally abort

2.7-3.0% have genetic malformations

4% IUGR

-8-10% late onset genetic abnormalities

(Brent RL. 1989)

Preterm contractions/ labor

Rupture leading to peritonitis

Sepsis

Fetal tachycardia

Maternal/fetal death

Risks if untreated

Increased GA = Increased complication

Uterine contraction - as high as 80% of pts > 24 wks GA

Appendiceal perforation

4-19% non- pregnant pts

57% pregnant pts (inability to isolate infection by omentum)

Incidence of perforation = 8, 12, 20 percent in successive trimesters

Risks if untreated

Am Sur 2000

“ The mortality of appendicitis complicating pregnancy is the

mortality of delay”

Babler 1908

Suspicion:

Immediate surgery (Laparotomy VS Laparoscopy)

Delay:

Generalized peritonitis

Antibiotics

Perioperative 2nd cephalosporin/ 3rd penicillin, may be discontinued post-op,

Management

Safe - esp. in first 20 wks

Risk

Low birth weight

Preterm labor

Fetal growth restriction (no diff. VS laparotomy)

Fetal acidemia (CO2 Pneumoperitoneum)

Laparoscopy

General anesthesia considered safe

May increase risk of neural tube defects and hydrocephaly when general anesthesia is used in first trimester

General anesthesia

Increased biliary sludge in pregnancy

Increase bile viscosity

Increased micelles

Gall bladder relaxation

Increased risk of gallstone formation

Cholelithiasis cause of 90% of cystitis

0.2-0.5/1000 pregnancies require surgery

Gall bladderGall bladder

May be asymptomatic

2.5-10% of pregnant patient

RUQ pain- most reliable symptom

pain may radiate to back

Vomiting approx 50%

Can mimic appendicitis in 3rd trimester

Symptoms

Ultrasound

Effective rate 90%

Liver enzymes

Amylase, Lipase

CBC

Workup

Several studies - Conservative vs. Surgical

Current management favour surgical management

Conservative treatment trend to be high recurrence rate during the same pregnancy and if in later gestation : Incidence of preterm labor is higher

Management

Laparoscopic approach is safe, generally to 3rd

trimester

Slight increase of low birth weight

Slight increase of infant death within 7 day

Increase in contractions esp. > 24 wk

Surgical Management

Est. 1:200 deliveries (adnexal masses)

Est.1:1300 adnexal mass require surgery

Ovarian cystOvarian cyst

1990 Study

Whitecar 1990

130 pregnancies

5% malignant rate: >1/2 serous carcinoma of LMP

30% cystic teratomas

28% serous/mucinous cystadenoma

13% corpus luteal

7% benign

Adnexal Masses

Ovarian torsion

Most common and serious sequelae

5% occurrence

most common at 10-14 wks GA and immediate postpartum

Rupture ovarian cyst

Most common in 1st trimester

Complications

Best approach:

<5 cm : expectant management

5-10 cm: watch unless complex on sonography

if > 6 cm after 16 wks GA : surgery is required

Managements

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