Complication of pregnancy

To accommodate the
development of fetus , a series of
physiological adaptation occur in
woman in response to physiological
stimuli provided by the fetal tissues.
Medical and surgical complications
•Anaemia in pregnancy
•Heart disease√
•Diabetes Mellitus in pregnancy
•Thyroid dysfunction with pregnancy
•Tuberculosis
•Jaundice in pregnancy
•STD(sexually transmitted disease) in pregnancy
•Urinary Tract Infection
•Epilepsy in pregnancy
•Viral infections in pregnancy(viral hepatitis)
•Asthma in pregnancy
•General surgery during pregnancy
•Acute pain abdomen during pregnancy
 Physiological changes
of heart and circulation
during pregnancy
 Anatomical changes
Enlarged uterus

Elevation of the diaphragm

The heart is pushed upwards and

outwards with slight rotation to left.
There is no evidence of hypertrophy
or dilatation of the heart.

Physiological changes
 normal clinical findings
•The apex beat is shifted to the 4 intercostal
th

space about 2.5cm outside the mid clavicular line.

•Pulse rate is slightly raised, often with
extrasystoles.
•There may be split in the first sound in the
apical area.
•A systolic murmur may be audible in the apical
or pulmonary area.
•X-ray shows enlarged cardiac shadow due to
displacement of the heart.
•ECG reveals normal pattern except evidences of
left axis deviation.
Physiological changes
 The physician should be familiar
with these physiologic findings and
should execute a cautious approach
in diagnosis of pathological during
pregnancy.

Physiological changes
 Cardiac output
Increased blood volume

Starts to increase from 6th week of pregnancy

Reaches its peak at about 32-34 weeks
Rises from 4.5L in non pregnant state to 6.2L per
minute in third trimester
Returns to almost nonpregnant level by 6 weeks
postpartum

To meet the additional O2 required due to

increased metabolic activity during pregnancy

Physiological changes
 A normal heart has got enough
reserve power to cope with the
increased load but a damaged heart
fails to do so.

Physiological changes
Heart disease complicating
pregnancy
1. Cardiovascular changes during
pregnancy
2. Classification

3. diagnosis

4. Management
Incidence: 1%~4% in china

It is one major reason of maternal

death.
•postpartum hemorrhage
•PIH (pregnancy induced hypertension)
•Heart disease
•Amnionic fluid embolism
 Interaction between
cardiac disease and pregnancy
 During pregnancy
•The maternal circulating blood volume increases
gradually as the pregnancy progresses and peaks at
32~34weeks which increase by 30~45%.

•Especially during the last few weeks of pregnancy,

hemodynamic burden has a maximum change with
increased stroke volume and heart rate.
• As the uterus enlarges and the
diaphragm is elevated, the heart is
elevated and rotated and shifted to the
upper and left.
During labor
The first stage
About 500ml blood are pushed into peripheral
circulation by every uterine contraction, thus
backflow of blood increased which makes
cardiac output increased by 20%.
Every retraction also increases the right atrial
pressure which make MBP increased by 10%.
The increased cardiac output and MBP both
aggravated the burden of left ventricle.
The second stage
Participation of abdominal muscle and skeletal
muscle→peripheral resistance increased
Exerting out breathing
Pulmonary circulation pressure increased
Abdominal pressure increased
Makes blood in viscera flow back to the heart.
Above all, burden of the heart is the more
heavy in the second stage.
The third stage
The uterus contracts and becomes more smaller.
Abdominal pressure drops down.
Blood congests in visceral vascular beds.

Results in abruptly decreased backflow of the

heart.
A large amount of blood from uterus suddenly
comes into circulation as contraction of empty
uterus.
Both of them make the hemodynamic change,
increase the heart burden.
During puerperium
During 24~28hs after labor, the fluid
retention in tissues begins to backflow into
circulation → increase blood volume.

The volume returns non-pregnancy state 6

weeks later after the excess fluid passes out
through kidney.
In a total, the most risk period of complicated
cardiac disease pregnant women are

•During 32~34 weeks of pregnancy

•During labor
•Initial 3 days
 Simple drawing about cardiac output

Cardiac
output

Non- 34w in delivery Initial 3 days

pregnancy pregnancy of puerperium
Classification
rheumatic heart disease
congenital heart disease
peripartum cardiomyopathy
hypertension heart disease
myocarditis ( become common
during recent years )
1 Rheumatic heart disease in pregnancy

 Rheumatic heart disease accounted for the

great majority of cases(65%-80%).
 However this has changed because rheumatic
fever has been treated thoroughly in recent
years.
 It is now becoming less common..
 Mitral stenosis is the most common lesion
found
 and there may also be mitral
regurgitation or aortic regurgitation
 aortic stenosis is rarely seen.
 2. Congenital heart disease
 congenital heart disease in pregnancy is
increasing gradually.
 It includes cyanotic and acyanotic heart disease.
On the whole those patients who survive to the
age of childbearing are those without cyanosis or
gross disability including cases of atrial septum
defect,pulmonary stenosis ,patent ductus
arterious ,ventricle septum defect coarctation of
the aorta and so on.
3 Cardiomyopathy of pregnancy
 This term refers to rare cases of
myocardial disease of unknown aetiology
occurring in late pregnancy or in the
puerperium,

 and sometimes recurring in successive

pregnancies,which causes congestive
cardiac failure
 Effects of heart lesion on
pregnancy
Abortion
Preterm delivery (Prematurity)
IUGR (intrauterine growth
retardation)
Fetal congenital malformation
Maternal and fetal death
 Prognosis
Maternal mortality is less than 1%.
The causes of death are
• cardiac failure
• infection
• pulmonary oedema
• pulmonary embolism
• active rheumatic carditis
• subacute bacterial endocarditis
• rupture of cerebral aneurysm in coarctation
of aorta
 Diagnosis
The heart should always be examined carefully at the first antenatal
visit .The diagnosis of cardiac disease during pregnancy is sometimes
difficult.

Dyspnoea of slight degree and oedema of the ankles may occur in

normal pregnancy .A soft systolic murmur without any other
evidence of cardiac disease may have no significance.
 Diagnosis
Presence of any one of the following criteria
confirms the diagnosis of organic heart lesions
1. Presence of diastolic murmur
2. Cardiac enlargement
3. Presence of loud systolic murmur associated
with a thrill
4. Presence of arrhythmia
 The clinical diagnosis should be
substantiated with electro-cardiography,
chest X-ray, echocardiography and
doppler flow studies.

The ultimate clinical diagnosis should

be a composite one, including aetiology,
structures involved and functional grading.
 Gradings
Depending upon the cardiac response to
physical activity
Grade-I : uncompromised. Patients with
cardiac disease but no limitation of
physical activity.
Grade-II : slightly compromised. Patients
with cardiac disease with slightly limitation
of physical activity.
 Gradings
Grade-III : markedly compromised.
Patients with cardiac disease with
markedly limitation of activity. The
patients are comfortable at rest but
discomfort occurs with less than
ordinary activity.
Grade-IV : severely compromised.
Patients with cardiac disease with
discomfort even at rest.
 General management
Principles
•Early diagnosis and evaluation of the
functional grading of the cases
•To prevent, to detect and to institute
effective therapy for cardiac failure
•To prevent and to control the additional
complications
•Mandatory hospital delivery
Indications for termination of
pregnancy
Absolute indications:
• primary pulmonary hypertension
• Eisenmenger’s syndrome
• pulmonary veno occlusive disease
Relative indications
• parous woman with grade III and IV
• grade I or II with previous history of
cardiac failure in early months
 Special notes
•To enquire about dyspnoea and cough
•To note the pulse rate
•To look for anaemia and the weight and Bp
•Revaluation of the functional grading of the
heart
•To exclude fetal congenital abnormality using
sonography
 Advices
Adequate rest (10h in bed at night and 2h at
noon)
To avoid undue excitement and strain
To avoid caffeine, alcohol and, high calorie
or spicy diet
Avoid cold and infections
Adequate dental care (caries teeth)
 Admission
Elective:
Grade-I at least two weeks prior to the expected
date of delivery
Grade-II at 28th week
Grade-III and IV as soon as pregnancy is
diagnosed.
The patient should be kept in the
hospital throughout pregnancy.
The early signs of heart failure
dyspnea, shortness of breath
palpitation after light activities
HR ＞ 110times/min, R ＞ 20times/min at
rest,
have to get up or open the window to get
fresh airs because of depressed at
midnight.
 Management during labor
Prophylactic antibiotic should be used at
the onset of labor
Sedative drug
Oxygen inhalation
Instrumental labor such as episiotomy,
forceps delivery
Sands bag should be put on the abdomen
Prevent postpartum hemorrhage
Cesarean section
Acute viral hepatitis
The incidence of Acute viral hepatitis in
pregnant woman is 6 times as high as that
of nonpregnant women

and violent hepatitis is 66 times also. It

often cause maternal death.
 There are 5 distinct types of hepatitis
viruses
Including :
hepatitis A virus (HAV)
hepatitis B virus (HBV)
hepatitis C virus (HCV)
hepatitis D virus (HDV)
hepatitis E virus (HEV)
 The influence of pregnancy to
hepatitis
1. Easy to get hepatitis

2. Become severe hepatitis

3. Become chronic hepatitis

 The influence of hepatitis to
pregnancy
1. To mother: PIH-syndrome
Postpartum hemorrhage
The synthesis of coagulation factors decreased during hepatitis ,and is easy to happen postpartum
hemorrhage.
2. To fetus : Fetal deformity
The mortality of perinatal baby
 Transmission of the virus from
the mother to the infant

HBV: hepatitis B many be transmitted by

ways of
 infection from blood perfusion and
biological products
 intimate everyday contaction
 vertical transmission
but vertical transmission is an important road ,which include
(1) trans-placental transmission in uterus
(2)contaction with maternal blood or amniotic fluid at delivery
(3)contact with maternal saliva ,sweat during postpartum
(4)through breast feeding
Diagnosis
The diagnosis of pregnancy complicating viral
hepatitis is more difficult than non-pregnant
period,esp in late stage of pregnancy.

The abnormal hepatic function was induced by

other combined factors. So we can not diagnose
only depending on the raising of SGPT but also
on the clinical symptoms ,signs and laboratory
examinations to get a overall analysis.
Common type of hepatitis has specific
symptoms that are

malaise,
anorexia,
nausea and vomiting,
abdominal distention,
dull pain in hepatic area or low fever,
jaundice,
slight enlargement of liver, tenderness on
the liver.
The diagnosis of severe hepatitis in
pregnancy is:
(1)The jaundice becomes deeper rapidly
(2) Progressive minimization of liver.
(3)Toxic distention of bowel with ascites.
(4) Foul hepatic smell
(5) Symptoms of hepatic encephalopathy
at different degree.
(6) Bleeding tendency systemically.
 Prophylaxis
(1) Intensify propaganda and education
Every child-bearing age woman suffered viral hepatitis must take
contraception measures and may be pregnant 2 years ideally,at least a
half year after the hepatitis cure.
(2) Reinforce antenatal care
This includes detecting hepatitis virus Ag-Ab
system in early,mild,late term repeatedly to
screen for all patients in pregnancy.

During the delivery, strict sterilization and

isolation measures should be taken for the
women with positive HBsAg or HBeAg
,especially pay attention to refrain from
laceration of soft tissue and neonatal delivery
injury .
(3) Immunoprophylaxis of hepatitis B

Infection of the newborn infant whose mother

is chronic carrier of virus can be prevented by
the administration of hepatitis B immune
globulin very soon after birth followed
promptly by hepatitis B vaccine .
 Management
The management of pregnancy complicating
common type hepatitis.

(1) Active treatment to recover and improve liver

function.Treatment consists of a well balanced
diet, enough bed rest and drugs such as
proheparin ,inosine , and glucurone .etc.
(2)Evade usage of drugs that are harmful of liver
function
Some sedatives and anesthetics that are harm to liver
are inhibited as possible as you can.

Tetracycline which can induce acute fatty liver and

fetal death is forbidden in pregnant women .
(3) Guard against infections
Take precautions such as use of wide spectrum antibiotics
against spread of birth tract and intestinal infection.
(4) avoid postpartum hemorrhage
 Obstetrical management
Pregnant period:
If hepatitis B is complicated at the early pregnancy
,artificial abortion should be done .Stopping the
pregnancy is not proposed if hepatitis complicated
at mid or late pregnancy because operation and
anesthetics can enhance the hepatic load.
Labor period:
The choice of delivery way is very important
to prognosis
vaginal delivery is suitable to relatively small
fetus ,good cervical conditions or with
enough cervical dilation and delivery ending
in a brief space of time successfully .

Before delivery ,blood perfusion should be

prepared.
To the severe hepatitis women ,the
prognosis is better when the cesarean
section is choice in time after protective
therapy of liver in short term and
correction of the coagulate function.
Postpartum period:
 Antibiotics without harm to liver such
as penicillin ,cloxacillin
,ampicillin,etc.is chosen routinely at
delivery.
 Breast feeding is forbidden for the
sake of vertical transmission when
HBeAg is positive.
Anamia
 Anamia in pregnancy is often defined as
a hemoglobin measurement is low
100g/L or hematocrit below 30%
 Plasma volume increases 50% during
pregnancy, while red cell volume
increases 25%, causing lower
hemoglobin and hematocrit values,which
are maximally changed around the 24th
and 28th weeks.
 Anamia is very common in pregnancy,
causing fatigue, anorexia, dyspnea, and
edema.
Including
 Iron deficiency anemia
 Follic acid deficiency anemia
 Sickle cell anemia
Many women enter pregnancy with low
iron stores resulting from
 Heavy menstrual periods
 Previous pregnancies
 Breast feeding
 Poor nutrition
 It is difficult to meet the increased
requirement for iron through diet,and
anemia often develops unless iron
supplement are given.
 Inter-action
 Anemia increase miscarriage, preterm
birth, fetal growth restriction, low birth
weight, still birth.
 Pregnancy woman with anemia is easy to
get PIH, placental abruption and infection,
even heat disease.
 treatment
 Consists of a diet containing iron-rich foods
 60mg of elemental iron, eg, 300mg of ferrous
sulfate three times a day
 Iron is best absorbed if taken with a source of
vitamin C