1、to Complications in Pregnancy Hugh E. Mighty, MD, FACOG, MBA Associate Professor and Chair, Department of Obstetrics, Gynecology & Reproductive Sciences,Introduction,Pregnancy is not in itself a disease.However many medical disorders, as well as surgical complications can occur during pregnancy, chi
2、ldbirth, and in the post delivery time. These events are generally unexpected in what is usually a young, healthy population.In the time allowed, this mini med school topic will be explored. The participants will gain an understanding of the multiple medical and surgical complications that surround
3、pregnancy, and also learn about the basis for treatment, the likely outcomes and prevention strategies. The role of healthy lifestyles, and education of the pregnant woman will be integrated into the session.,Introduction,Hypertensive disorders complicate 6-8% of pregnancies NIH classification syste
4、m provides clinical guidance for diagnosis and management,Classification of Hypertension in Pregnancy Preeclampsia/Eclampsia,BP 140 mmHg systolic or 90 mmHg diastolic with proteinuria (300mg/24 h) after 20 weeks gestation Can progress to eclampsia (seizures),New onset proteinuria after 20 weeks in a
5、 woman with hypertension Or Sudden, 2-3 fold increase in proteinuria, sudden increase in BP, thrombocytopenia, and/or elevated AST or ALT in a woman with hypertension and proteinuria prior to 20 weeks gestation,Classification of Hypertension in Pregnancy Chronic Hypertension with Superimposed Preecl
6、ampsia,Hypertension without proteinuria occurring after 20 weeks gestation May represent preproteinuric phase of preeclampsia or recurrence of chronic HTN May evolve to preeclampsia If severe, may result in higher rates of premature delivery and IUGR than mild preeclampsia,Classification of Hyperten
7、sion in Pregnancy Gestational Hypertension,Retrospective diagnosis BP return to normal by 12 weeks postpartum May recur in subsequent pregnancies Predictive of future primary HTN,Classification of Hypertension in Pregnancy Transient Hypertension,Preeclampsia Introduction and Statistics,Microvascular
8、, vasospastic, hypertensive disorder of the second half of pregnancy Consistently one of the top three causes of maternal mortality in U.S. Affects approximately 5%-8% of pregnancies,Preeclampsia Risk Factors,Nulliparity Multiple gestation Chronic HTN 4 years duration Family history of preeclampsia
9、Preeclampsia or HTN in a previous pregnancy Renal disease Extremes of age Antiphospholipid syndrome,Preeclampsia Pathophysiology,Abnormal placentation (that may be related to immunologic factors) Development of trophoblasitc prostacyclin deficiency Relative decrease in prostacylin-thromboxane ratio
10、Endothelial cell damage/Platelet aggregation Thrombin activation and fibrin deposition in systemic vascular beds Thrombosis and vasospasm (there may be an increased vascular reactivity to vasopressors) Arterial HTN and multiorgan involvement These vascular changes and the local hypoxia that results
11、leads to hemorrhage, necrosis and other end organ disturbances associated with severe preeclampsia,Preeclampsia Diagnostic Criteria for Severe Preeclampsia,BP 160-180 mmHg systolic or 110 mmHg diastolic Proteinuria 5 g/24 hours Oliguria (500 ml/24 hours) Cerebral or visual disturbances (headache, di
12、zziness, tinnitus, drowsiness, change in respiratory rate, tachycardia, fever),Pulmonary edema Epigastric or right upper quadrant pain Impaired liver function of unclear etiology Thrombocytopenia IUGR or oligohydramnios Elevated serum creatinine Grand mal seizures (eclampsia),Preeclampsia MgSO4 Ther
13、apy,4-6 gm IV loading dose over 15-20 minutes 2-3 g/hr IV infusion maintenance dose4-7 mEq/L therapeutic plasma mag level Platellar reflexes lost at 8-10 mEq/L Respiratory arrest at 13 mEq/LMonitor urine output, patellar reflexes, respiratory rate and magnesium level Have calcium gluconate available
14、 1-g dose (10mL of a 10% solution) IV over 2 minutes as antidote Remember that magnesium sulfate is not an antihypertensive agent; goal of mag therapy is to prevent seizures,HELLP Introduction and Statistics,Variant of severe preeclampsia Affects approximately 12% of patients with preeclampsia Chara
15、cterized by: Hemolysis Elevated liver enzymes Low platelets Not primarily a disease or primigravidas May not meet BP criteria for severe preeclampsia Known as the “great masquerader” because clinical presentation and lab findings may suggest many diseases,HELLP Signs and Symptoms,BP mildly elevated
16、Proteinuria +/- Malaise almost 100% Gastrointestinal symptoms Frequently referred Frequently misdiagnosed,HELLP Diagnosis,Hemolysis Abnormal peripheral smear Elevated Bilirubin (1.2 mg/dl) Increased Lactic Dehyrogenase ( 600 U/L) Elevated Liver Enzymes SGOT ( 70 U/L) LDH ( 600 U/L) Low Platelets 100
17、,000,HELLP Complications,Abruption (7-20%) Acute renal failure Hepatic hematoma Liver rupture Ascites Hemorrhage Fetal death Maternal death,HELLP Management,Deliver,Eclampsia Introduction and Statistics,Preeclampsia + seizures 80% seizures occur prior to delivery Remainder occur postpartum (have bee
18、n reported up to 23 days following delivery) Intrapartum and postpartum seizures more likely at term while most antepartum seizures occur preterm 2% maternal mortality rate 7-16% perinatal mortality rate,Eclampsia Complications,Placental abruption Perinatal asphyxia Maternal hemorrhage Cerebrovascua
19、lr damage Severe respiratory insufficiency Disseminated intravascular coagulopathy (DIC) Perinatal death Maternal death,Eclampsia Management,If antepartum or intrapartum: Magnesium sulfate and deliver regardless of gestational age If postpartum: Magnesium sulfate Again, remember magnesium sulfate no
20、t antihypertensive so patient will need antihypertensive therapy to control BP,Pulmonary Edema Acute Renal Failure,Arterial Blood Gases, attention to oxygenation Ventilation if needed Strict maintenance of fluid status Swan-Ganz catheter,Definition Blood loss in excess of what is considered normal i
21、n the intrapartum/postpartum periodNormal Blood Loss:,Complicates approximately 4% of vaginal deliveries and 6-7% of cesarean sectionsUsing a strict definition of postpartum hemorrhage (hematocrit decrease of 10 points or more or need for transfusion) One large U.S. study found a 3.9% incidence of p
22、ostpartum hemorrhage after vaginal deliveryLife-threatening hemorrhage occurs in 1 of 1,000 deliveries Third largest cause of maternal death in the US Largest single cause of maternal death in the world (leading to 30% of the approximate 600,000 yearly maternal deaths worldwide),Categorization of He
23、morrhage:,Pregnant Woman Progressive increase in blood volume starting at 6-8 weeks gestation Reaches maximum at 32-34 weeks gestationIncrease in plasma volume of 40-50%Increase in red blood cell mass of 20-30%,Example Pregnant woman who was 60kg (132lbs) non-pregnant will have 4.68-5.12L of whole b
24、lood of which 3.08-3.3L will be plasma and 1.68-1.82 will be erythrocytes,Causes of Obstetric Hemorrhage,Obstetric Placenta previa Placental abruption Uterine rupture Uterine inversion Primary Postpartum hemorrhage Retained placenta Uterine atony Vaginal/Cervical lacerations Hematomas Placenta acret
25、a/increta/percreta,Placental Abruption (Abruptio Placentae),Definition Premature separation of the normally implanted placenta.Can be partial or complete Bleeding may be revealed (vaginal bleeding) or occult Can occur from mid-trimester (second) onward Incidence 0.45-1.3% of deliveries,Associated fa
26、ctors: Maternal hypertensive disorders (present in 50% of women with placental abruption) Advanced maternal age Advanced maternal parity Abdominal trauma Cocaine use Maternal smoking Chorioamnionitis Sudden uterine decompression (rupture of membranes in polyhdramnios or between deliveries of multipl
27、e gestations) External cephalic version Placental abruption in a previous pregnancy (10% recurrence rate),Signs Hallmark sign is painful vaginal bleeding Colicky abdominal/back pain Non-reassuring fetal heart rate tracing Intrauterine fetal death Uterine tenderness/uterine irritability Contractions
28、Uterine enlargement Couvelaire uterus in a major abruption blood extravasates into myometrium causing uterus to become “woody hard” and fetal parts will no longer be palpable” DIC Maternal shock,Management Delivery (with preparations for massive postpartum hemorrhage) If mother symptomatic/deteriora
29、ting, urgent delivery irregardless of fetal maturity If fetus very immature and maternal and fetal vital signs are stable, tocolytics for uterine quiescence may be considered If fetus alive and viable urgent delivery by cesarean section unless vaginal delivery imminent (vaginal delivery preferred un
30、less contraindications) Resuscitation/correction of hypovolemia Correction of coagulopathy,Placenta Previa Definition Malposition of the placenta in the lower uterine segment Complete body of placenta overlaps the entirety of the cervical os Partial placental edge covers (totally or partially) Margi
31、nal Edge of placenta near, but not over the cervical os,Associated Factors Multiparity Maternal age 35 Previous placenta previa Previous uterine surgery (including c/s) Multiple gestation Smoking,Signs Hallmark sign is painless vaginal bleeding with sudden onset Bleeding usually occurs in third trim
32、ester (but can start second trimester) Malpresentation,Management Ultrasound to try to determine placental placement Avoid digital exams Expectant management if no symptoms/no active bleeding If active bleeding, management will be determined by gestational age, severity of bleeding, and fetal status
33、. If active bleeding and mother and/or baby symptomatic for blood loss delivery is indicated usually via c/s,Definition Complete separation of the walls of the pregnant uterus, often at a site of previous uterine surgery, with or without expulsion of the fetusRate of 2-8 per 10,000 deliveries Has a
34、5% maternal mortality and 50% fetal mortality rates,Associated with: Previous surgery to the fundus or corpus of the uterus (such as classical cesarean section) Previous removal of intrauterine myomata that invaded the myometrium Induction or cervical ripening with prostaglandins (PGE1 and PGE2) in
35、a scarred uterus Abnormal presentation Previous uterine rupture/previous uterine scar dehiscence,Signs Changes in fetal heart rate/non-reassuring fetal heart rate Sharp and shooting abdominal pain in lower abdomen at the height of a contraction Maternal statement of “something tore”, “something brok
36、e”, “something just happened” Vaginal bleeding Sudden cessation of uterine contractions (this does not always happen) Sudden loss of fetal station Sudden loss of fetal heart rate tracing Sudden increased ease in palpation of fetal parts Maternal shock,Management Immediate cesarean delivery with prep
37、aration for massive hemorrhage Uterine repair vs. hysterectomy,Uterine AtonyFailure of the uterus to contract after delivery of the placenta.Most common cause of primary postpartum hemorrhage.,Causes/Risk factors Retained placental fragments High parity Choriomanionitis Uterine fibroids Overdistensi
38、on of the uterus (polyhydramnios, multiple gestation, fetal macrosmia) Precipitate labor Prolonged labor Use of oxytocin,Signs Bleeding following delivery of the placenta “Boggy” fundus Missing part of placenta on inspection,Management Fundal massage Bi-manual compression Administration of uterotonics Urinary catheter Uterine tamponade Uterine brace (B-Lynch suture) Uterine devascualrization Bilateral uterine artery ligation Bilateral internal iliac artery ligation Arterial embolization Hysterectomy,
