Maternal diseases

associated with

pregnancy

Division of Reproduction

Pulmonary disease

Physiologic changes
• Respiratory rate

~

• Vital capacity

~

• Inspiratory capacity

↑

5%

• Tidal volume

↑

0.1-0.2 L

• Expiratory reserve volume (ERV)

↓

15%

• Residual volume

↓

• Functional reserve capacity

↓

18%

• Minute volume

↑

40%

Pulmonary disease

ASTHMA

Pulmonary disease

Asthma

Asthma is one of the most common

(1%)

coexisting

medical conditions affecting reproductive-aged

woman.

The course of asthma during pregnancy is variable;

one

third

of patients improve (26-69%),

one third

remain

stable (22-49%), and

one third

worsen (9-23%).

In patients with symptomatic asthma, gestational weeks

24-36

tend to be the most difficult.

Only

10%

of women experience asthma

exacerbation

during labor and delivery

(high cortisol level due to

stress), and the severity tends to revert to that of

pregnancy by 3 months’ postpartum.

Pulmonary disease

Asthma

Main fetal problem:
- IUGR due to high doses of

steroids

Pulmonary disease

Asthma

• In outpatient asthma management, beta-2 agonists are

used for symptomatic benefit(or anticholonergic-

ipratropium bromide)\.

• Inhaled corticosteroids remain the mainstay of therapy

for asthma control. Initiate treatment with the lowest

possible dose of inhaled steroids; the dose can be

increased further as required by symptomatic and

objective asthma assessment.

• Long-acting adrenergic agonists, such as salmeterol or

formoterol, might be used in symptomatic patients on

adequate corticosteroid therapy.

• Theophylline might be used as a third-line agent after

beta-agonist therapy and inhaled steroids

Pulmonary disease

Asthma – exacerbation

- Hydrocortisone - 100mg iv q8h
- Methylprednisolone - 125mg iv q6h
- 30 - 40% of humidified oxygen
- Pulse oximetry
- Intubate if pCO

2

>40 mmHg

Influenza vaccine and aggressive

treatment of URTI – antibiotics for

suspected bacterial cause

No PGF

2

for induction of labour

Pulmonary disease

PNEUMONIA

Pulmonary disease

Pneumonia

Pneumonia is an infrequent, yet

serious, complication of pregnancy
and is the third most frequent cause
of indirect obstetric death.

The incidence of pneumonia varies,

with 1 episode occurring in every
1287 deliveries

Pulmonary disease

Pneumonia

Streptococcus pneumoniae

is the

most common pathogen.

Other agents are Mycoplasma

pneumoniae, Haemophilus
influenza, and Legionella species.

Influenza and other viruses also

cause pneumonia

Pulmonary disease

Pneumonia

Complications during pregnancy
- Preterm labour – 44%
- Preterm delivery – 36%

Pulmonary disease

Pneumonia

The antibiotics that are safe in a

pregnant patient are penicillins,
cephalosporins, and macrolides.

Clindamycin probably also is a safe

agent.

Pulmonary disease

TB

Prevalence – 20/100000
Diagnosis
- PPD
- Sputum samples – Mycobacterium

tuberculosis (3 days collection)

- Chest radiography with abdominal

shielding

Pulmonary disease

TB

Problems in pregnancy if untreated
- IUGR
- IUFD
- Hydrops
- Congenital TB (50%)

Pulmonary disease

TB

Treatment:
- Isolation (2 wks after Rx)
- No active disease – INH prophylaxis

for 6-9 months (after I trimester; not
in puerperium)

- INH 300mg/d + ethambutol

15mg/kg/d + pyridoxine 20-50mg/d

- Avoid streptomycin and rifampin

Thyroid disease

• Thyroid disorders are the second most common

endocrinopathies found in pregnancy. Thyroid

disorders are estimated to affect

0.2%

of all

pregnancies.

• Graves disease

accounts for more than

85%

of

hyperthyroid cases

• Hashimoto thyroiditis

- the most common cause

of hypothyroidism.

• In the postpartum period, postpartum thyroiditis

(PPT) is reported to affect

4-10%

of women.

Thyroid disease

• Hyperthyroidism

- symptoms

– loss of concentration, nervousness,

emotional lability.

– tremor, heat intolerance, excessive

sweating, palpitation, and
hyperdefecation

– difficulty climbing stairs, a sign of

proximal muscle weakness.

– „neck is getting bigger” - caused by

the enlarged thyroid gland

Thyroid disease

Hyperthyroidism

- examination

• restless, anxious

• skin is warm and moist, with a velvety texture

• hairs are fine and silky

• eyes - widened palpebral fissure, infrequent blinking.

proptosis, ophthalmoplegia, conjunctivitis, periorbital

swelling, corneal ulceration, optic neuritis, and optic

dystrophy

• a goiter - the gland is diffusely enlarged, usually 2-4

times the normal size. The gland can be soft or firm and

seldom is tender to palpation. A thrill or bruit may be

present. The presence of a nodule requires further

workup during pregnancy to rule out malignancy

• cardiac examination : wide pulse pressure (increased

systolic pressure and decreased diastolic pressure),

sinus tachycardia

• fetal tachycardia (fetal heart rate >160 bpm) is

suggestive of fetal thyrotoxicosis

Thyroid disease

Hypothyroidism

- symptoms

• untreated patients with moderate-to-

severe hypothyroidism have impaired

fertility

• symptoms of mild hypothyroidism can

mimic those of normal pregnancy,

making it difficult to diagnose.

• lethargy and constipation
• cold intolerance, stiffness, muscle

cramping, carpal tunnel syndrome, dry

hair and skin, and a deeper voice

Thyroid disease

Hypothyroidism - examination

• slow speech and movement

• skin usually is dry, pale, and yellowish in color, hairs are

thin, brittle, and sparse.

• eye - periorbital puffiness.

• a goiter associated with Hashimoto thyroiditis is firm,

diffusely enlarged, and usually painless to palpation. In

patients with atrophic chronic thyroiditis, the thyroid

gland may be normal or not palpable.

• a low-normal heart rate is common. The heart can be

enlarged if dilated. Pericardial effusion is present in

severe cases.

• bowel sounds may be decreased or absent. Paralytic ileus

has been reported in severe cases of hypothyroidism.

• extremity examination may reveal nonpitting edema and

hyporeflexia with prolongation of the relaxation phase of

the reflex response.

• fetal examination findings usually are normal in mild case

Thyroid disease

• Postpartum thyroiditis

– PPT has 3 phases,

• (1) the hyperthyroid phase (when thyroid

hormones are being released due to thyroid
destruction),

• (2) the hypothyroid phase,
• (3) the resolution or euthyroid phase.

– The most common time for patients to

present with PPT is 1-8 months
postpartum, with the peak incidence at
6 months

Thyroid disease

• Problems in pregnancy –

hypothyroidism

– Infertility
– Abortion
– Stilbirth
– Abruption
– Preterm birth
– IUGR
– Cretinism

Thyroid disease

• Problems in pregnancy –

hyperthyroidism

– Infertility
– Abortion
– Cardiac failure
– Abruption
– Preterm birth
– IUGR

Thyroid disease

• Hyperthyroidism - treatment

– Thioamide drugs are the first-line treatment in

pregnancy. PTU-drug of choice

– Beta-blockers (eg, atenolol, nadolol,

propranolol)

– Iodide decreases serum T4 and T3 by 30-50%

in 10 days. Iodide also can be used in the

medical treatment of patients with thyroid

storm.

– Fetal hypothyroidism caused by placental

passage is reported with prolonged use of

iodide products; therefore, iodide use should

be limited to less than 2 weeks.

– Radioactive iodine is contraindicated in

pregnancy

Thyroid disease

Hypothyroidism - treatment

– Thyroid hormone replacement is the

treatment for patients with
hypothyroidism. A full replacement dose
should be instituted at the time of
diagnosis.

– In general, thyroid hormone

requirement increases approximately
30-50% during pregnancy; therefore, the
TSH level should be monitored closely

Thyroid disease

Surgery should be used as a second line of

treatment in patients who are pregnant.

– Surgery is reserved for those cases meeting

one of the following criteria:

• Patient requires high doses of PTU >300 mg, MMI

>20 mg

• Inability to control clinical hyperthyroidism
• Fetal hypothyroidism at dose needed for maternal

control

• Inability to tolerate PTU, MMI
• Noncompliance
• Suspected malignancy

– When surgery is needed, it should be

performed during the second trimester

Blood disease

Physiological changes

• Blood volume

↑

by 40%

• Red cell mass

↑

by 20% and

plasma volume

↑

by 50%

Anemia

• In normal pregnancy-hemodilution.

• Anemia in a patient who is

pregnant - Hb value less than 10.5
g/dL

• Reference range of 14 g/dL in a

patient who is not pregnant

Anemia

Iron deficiency anemia

• A woman who is pregnant often has insufficient iron

stores to meet the demands of pregnancy

Elemental iron absorbed from a normal diet

1,3-2,6 mg

Elemental iron needed per day

4,0 mg

Iron supplementation during pregnancy is necessary

• An MCV < 80 fL and hypochromia of the RBCs should

prompt further studies, including total iron-binding

capacity, ferritin levels, and Hb electrophoresis if iron

deficiency is excluded (thalassemias).

• Clinical symptoms of iron deficiency anemia include

fatigue, headache, and pica (in extreme situations).

• Treatment is additional supplementation with oral iron

(320 mg, 1-3 times daily).

Hematological

disorders

• Iron deficiency anemia

Iron deficiency anemia:

Serum ferritin levels <20 ng/ml

Serum iron levels < 50 g/dl

Transferrin saturation rates < 20%

Hematological disorders

Hemoglobin <6 g/dl is associated with

an increased incidence of stillborn

premature infants

Anemia

Folate and vitamin B-12 deficiency

• Folate deficiency is much less common than iron

deficiency; however, taking

0.4 mg/d

to reduce the risk of

neural tube defects is recommended to all women

contemplating pregnancy.

• Patients with a history of neural tube defect should take

4

mg/d

.

• An increased MCV can be suggestive of folate deficiency;

in this case, determine serum levels of vitamin B-12 and

folate. If the levels are low, the patient may require oral

folate at a dose of 1 mg 3 times daily.

• Treatment of vitamin B-12 deficiency includes 100 g/d for

1 week, followed by 6 weeks of continued therapy to reach

a total administration of 2 mg.

Thrombocytopenia

Platelets-reduction in number

<150x10

9

/l

Symptoms

Petechiae

Easy bruising

Epistaxis

Gingival bleeding

Hematuria

(<20000)

Thrombocytopenia

• Getstational 73% (4-8%)
• PIH & HELLP 21% (10%)
• Immunologic 3,8% (idiopathic

thrombocytopenic purpura)

• Other (DIC, drugs, hemolitic-uremic

syndrome, bone marrow aplasia,
malignant infiltration)

Thrombocytopenia

• May complicate

– Placental ablation
– Amniotic fluid embolism
– Prolonged retention of a dead fetus

Management options

Prenatal

• Check platelet antibodies
• Check cord blood
• Serial platelet counts
• Steroids if <50x10

9

/l (prednisone)

• Platelet transfusion if <50x10

9

/l and bleeding

• IgG at 36 weeks and delivery within 2-3 weeks

if < <50x10

9

/l and steroids have been

unsuccesful

• No specific management indicated if >

100x10

9

/l

Management options

Splenectomy and platelet transfusion

only if ill patient and all else fails

Manegement options

• Labor and delivery

– platelets available if <50x10

9

/l

– prompt suturing
– avoid traumatic delivery
– elective cesarean section not

beneficiary

– Epidural ? Check bleeding time if below

100000

Management options

• Postnatal

– Check cord blood platelets (ITP.-10-15%

in fetus)

– Pediatricians for delivery and ongoing

neonatal care

Renal diseases

Physiologic changes
• Renal plasma flow

↑

by 50%

• Glomerular filtration rate

↑

by 50%

• Serum creatinine levels

↓

(<0,8

mg/dl)

• Blood urea nitrogen levels

↓

(5-12

mg/dl)

Urinary tract infections

during pregnancy

• The physiologic changes of pregnancy may

predispose patients to bacteriuria

• These include

– urinary retention from the weight of the

enlarging uterus

– urinary stasis due to ureteral smooth

muscle relaxation (caused by increases in
progesterone)

– glucosuria and aminoaciduria of

pregnancy provide culture medium for
bacteria in areas of urine stasis

Urinary tract infections

during pregnancy

• Urinary tract infection (UTI) is defined

– as more than 100 organisms per milliliter of urine in

a symptomatic patient

– or >100,000 organisms per mL of urine in an

asymptomatic patient with accompanying pyuria (>7

WBCs/mL)

• When a symptomatic UTI is present, 2 clinical

forms are recognized:

– lower UTI (ie, cystitis)
– upper UTI (ie, pyelonephritis)

• Pregnant patients are considered

immunocompromised UTI hosts because of the

physiologic changes associated with pregnancy

Urinary tract infections

during pregnancy

• Asymptomatic bacteriuria (ASB) is

defined as more than 100,000

organisms per milliliter in 2

consecutive urine samples in the

absence of declared symptoms

• Untreated ASB is a risk factor for

acute cystitis (40%) and pyelonephritis

(25-30%) in pregnancy

• These cases account for 70% of all

cases of symptomatic UTI in pregnancy

in the unscreened population

Urinary tract infections

during pregnancy

• Acute cystitis involves only the lower urinary tract; it is an

inflammation of the bladder due to bacterial or

nonbacterial causes (ie, radiation, viral)

– It occurs in approximately 1% of pregnant patients, of

whom 60% have a negative result on initial screening

– Signs/symptoms include hematuria, dysuria, suprapubic

discomfort, frequency, urgency, and nocturia. These

symptoms often are difficult to distinguish from those

due to pregnancy itself

• Acute cystitis is complicated by upper urinary tract

disease (ie, pyelonephritis) 15-50% of the time

– Pyelonephritis is the most common urinary tract

complication of pregnancy, occurring in approximately

2%

of all pregnancies. Acute pyelonephritis is the

presence of fever, flank pain, and tenderness in addition

to significant bacteriuria

– Other symptoms may include nausea, vomiting,

frequency, urgency, and dysuria

Urinary tract infections

during pregnancy

• The prevalence of ASB in pregnant

women is 2.5-11.0% (versus 3-8% in

other women)

• Prevalence increases with age, low

socioeconomic status, sexual activity,

multiparity, and untreated pathologies

• The frequency of UTI in pregnancy is not

higher than the nonpregnant rate of 0.3-

1.3%

Urinary tract infections

during pregnancy

• Infections result from ascending colonization of

the urinary tract. The primary source of

organisms is existing vaginal, perineal, and fecal

flora

• The most common uropathogen in the pregnant

patient is E coli. This organism is isolated in 80-

85% of cultures

• Other pathogens

– Klebsiella pneumoniae (5%)

– Proteus mirabilis (5%)

– Enterobacter species (3%)

– Staphylococcus saprophyticus (2%)

– Group B beta-hemolytic Streptococcus (1%)

Urinary tract infections

during pregnancy

• Urine specimen collection

– Obtain a midstream, clean-catch urine specimen from

all patients with urinary tract symptoms

• Urine culture

– This is the criterion standard for evaluation of UTI in

pregnancy

– A colony count of 100,000 colony-forming units (CFUs)

per milliliter historically has been used to define a

positive culture result

– Culture results can be used to identify specific

organisms and antibiotic sensitivities

• Urinalysis

– Positive results for nitrites, leukocyte esterase, WBCs,

RBCs, and protein are suggestive of a UTI. Bacteria

found in the specimen can help with the diagnosis

• Urine dip

– Use of urine dip for nitrites and leukocyte esterase in

the evaluation of ASB

Urinary tract infections

during pregnancy

Some antibiotics should not be used during

pregnancy due to their effects on the

fetus. These include:

– tetracyclines (adverse effects on fetal teeth

and bones, congenital defects)

– quinolones (various congenital defects)
– trimethoprim in the first trimester (facial

defects, cardiac abnormalities)

– chloramphenicol and sulfonamides in the last

trimester (Gray syndrome; hemolytic anemia

in mothers with glucose-6-phosphate

dehydrogenase [G-6-PD] deficiency, jaundice,

and kernicterus, respectively)

Urinary tract infections

during pregnancy

• Patients with acute pyelonephritis should be systemically

treated with cephalosporins or gentamicin

• Patients who are not symptomatic do not need long

courses of antibiotics but still should have at least a 7- to

10-day regimen

• Appropriate oral regimens include

– cephalexin 500 mg qid

– ampicillin 500 mg qid

– nitrofurantoin 100 mg bid

– sulfisoxazole 1 g qid

• Studies with cephalexin, co-trimazole, and amoxicillin

have indicated that a single dose is as effective as a 3- to

7-day course of therapy, but the cure rate is only 70%

• Persistent bacteriuria or development of symptoms : 10-

to 14-day course of a different antibiotic. Then

prophylactic antibiotics (ie, nitrofurantoin 50 mg every

night) for the rest of the pregnancy

Heart disease

Physiological changes

• Blood volume

↑

by 40%

• Red cell mass

↑

by 20% and plasma

volume by 50%

• Systolic blood pressure

↓

4-6 mm Hg

• Diastolic blood pressure

↓

8-15 mm Hg

• Mean blood pressure

↓

6-10 mm Hg

• Heart rate

↑

12-18 beats per minute

• Stroke volume

↑

10-30%

• Cardiac output

↑

33-45%

Heart disease

Physiological changes

• Systemic vascular resistance decreases
• More blood to kidneys, uterus (500ml/min) and

skin

Heart disease

Cardiac disease complicates 1% of all pregnancies

Signs and symptoms
• Fatigue
• Shortness of breath
• Orthopnoe
• Palpitations
• Systolic flow murmur
• Syncope
• Cyanosis
• Cardiomegaly

Maternal mortality rates

• Group I <1%

• ASD
• VSD
• PDA
• Mild MS
• Corrected

Fallot

• Bioprosthetic

valve

• Group II <5-

15%

• Severe MS
• MS+afib
• Aortic stenosis
• Uncomplicated

coarctaction

• Artificial valve
• Previous MI

• Group III <25-

50%

• Pulmonary

HTN

• Eisenmenger

syndrome

• Cardiomiopathy
• Acute MI
• Marfan

syndrome

Heart disease – valve heart

disease

Mitral valve prolapse

Most common heart defect in young

women

No effect on pregnancy or the fetus

Signs: midsystolic click or occasional

palpitations

Heart disease – valve heart

disease

Mitral stenosis
Most common: rheumatic disease
Decreased and fixed cardiac output, left atrial

obstruction→increased atrial pressure→pulmonary hypertension

Management:

• Limiting of daily activities

• Careful diuresis

• Atrial fibrillation – decreased filling time

• Tachycardia – decreased filling time
Labor

• CC only for obstetrical indications

• Oxygen

• Pain control

• Shortening of second phase of labor

• Antibiotic, anticoagulation ?

Heart disease – valve heart

disease

Mitral regurgitation

Most common: mitral valve prolapse

Well tolerated during pregnancy

Severe cases: atrial enlargement, fibrillation,

ventricular enlargement and dysfunction→inotropic

agents

Labor

• Pain management (incr in BP leading to pulmonary

vascular congestion) – epidural anesthesia

Heart disease – valve heart

disease

Aortic stenosis

Most common: rheumatic disease

Symptoms: later in life include syncope and angina

During pregnancy

• Adequate hydration

• Left lateral position

Labor

• Hydration

• Avoidance of blood loss

• Avoidance of hypotension

• Antibiotics

Heart disease – valve heart

disease

Aortic regurgitation

Most common: rheumatic disease, bifid aortic valve

Symptoms: later in life include

During pregnancy there is decreased systemic

resistance – regurgitation decreases

Labor

• Epidural anesthesia

• Normal HR (80-100/min)

Heart disease – congenital

lesions

ASD

Most common congenital lesion in adults

Symptoms: pulmonary ejection murmur and second

heart sound split in inspiratory and expiratory

phase

Without pulmonary HTN – no problem

Labor

• Correction of arrhythmias and tachycardia

Heart disease – congenital

lesions

VSD

May close spontaneously, large defects repaired during

childhood.

Symptoms:

Without pulmonary HTN – no problem

Labor

• Correction of arrhythmias and tachycardia

• Decrease of systemic vascular resistance – epidural

anesthesia

Heart disease – congenital

lesions

PDA

Large defects repaired during

childhood.

Symptoms:

Without pulmonary HTN – no problem

Heart disease – congenital

lesions

Tetralogy of Fallot

• Right ventricular outflow obstruction

• Ventricular septal defect

• Right ventricular hypertrophy

• Overriding aorta

Symptoms: right to left shunt and cyanosis

Pregnancy

• Monitoring the fetus for IUGR

Labor

• Adequate venous return at all time

Heart disease – congenital

lesions

Coarctation of the aorta

Symptoms – fixed cardiac output

Labor
• Adequate venous return at all

time