MEDICAL COMPLICATIONS WITH

PREGNANCY
 MEDICAL COMPLICATIONS WITH
PREGNANCY
OUTLINE:
• Maternal and fetal implications of different
medical disorders
• Role of preconceptional counselling
• Optimizing feto-maternal care.
• Importance of multi-disciplinary approach
• High risk management
 DIABETES
Pregestational diabetes
• Congenital malformations:
– Two- to three-fold higher than nondibetic
– Correlation with hemoglobin A1c (Hb A1c):
• ˂ 7 %: No congenital malformations
• ˃ 11%: 25% congenital malformations
• Spontaneous abortions: tow-fold increase
• Abnormal fetal growth
• Still-birth
• Traumatic delivery
• Increased C-section rate
 DIABETES
– The risks for spontaneous abortion and major malformation
depend on the degree of control in the first trimester
– Risks for macrosomia and stillbirth are related to control in the
second and third trimesters.
– Hypertension ( PE 20-40%; up to 60% among women with
diabetic nephropathy)
– Prematurity (two fold increase; due mostly to the development
of hypertension, polyhydramnios and pyelonephritis)
– Macrosomia ( 25-40% ˃ 4000 g): higher rate of operative
delivery and an increased risk for birth trauma.
– Late fetal demise (Hb A1c carries less oxygen, binds oxygen
more avidly and releases it less readily; fetal hyperinsulinemia
causes an increased demand for oxygen in fetal tissues,
potentially beyond placental supply, with possible lethal degree
of hypoxemia)
 DIABETES
Gestational diabetes
• Maternal complications:
– Preeclampsia
– Preterm labor
– Pyelonephritis
– Polyhydramnios
– cesarean section
– Later development of type II diabetes and associated complications,
especially cardiovascular.

• Fetal complications:
– Increased perinatal morbidity and mortality
– Increased incidence of fetal macrosomia, shoulder dystocia, operative
delivery, stillbirth
– Metabolic problems (similar to that in infants of an insulin-dependent
diabetic mother )
– Increased incidence of childhood obesity, early adulthood type II
diabetes mellitus, and intellectual-motor impairment
 DIABETES
Neonatal risks:
• RDS
• Hypoglycemia
• Transient cardiac hypertrophy
• Polycythaemia and jaundice
• Hypocalcaemia and hypomagnesaemia
 DIABETES
Timing of delivery:
– Risk for respiratory distress syndrome (RDS):
commoner among infants of diabetic mothers due
to delayed lung maturity if delivered before 39
weeks
– Favorability of the cervix for labor
– The size of the fetus
– Ongoing exposure to the risk of stillbirth:
• Poorly controlled diabetes and macrosomic fetuses are
at greater risk for still-birth: delivery by 37-38 weeks
• Well-controlled diabetes and normal-size fetuses at 39-
40 weeks
 HYPERTENSION
PRE-ECLAMPSIA
Maternal risks:
• CNS: Blurring of vision, seizures and stroke
• Pulmonary edema (Lt. heart failure)
• Renal failure
• Hepatic failure or rupture
• Increased C-section rate
• DIC
• Death

Fetal risks:
• Growth restriction
• Oligohydramnios
• Placental infarction
• Placental abruption
• Prematurity and consequences
• Uteroplacental insufficiency
• Perinatal death
 HYPERTENSION
Hypertension before 20 weeks' gestation
– Hydatidiform mole (gestational trophoblastic
disease)
– Chromosomal abnormalities in the fetus (triploidy)
– Chronic hypertension: undiagnosed essential
hypertension after excluding secondary causes (
renal disease, pheochromocytoma, Cushing
syndrome, or coarctation of the aorta)
– Drug use (Cocaine use; heroin withdrawal)
 THYROID
Graves' disease:
– Tendency for aggravation of hyperthyroidism symptoms during the
first half, followed by amelioration during the second half of
pregnancy and postpartum recurrence.
– Untreated patients: increased risk of pre-eclampsia and congestive
heart failure.
– Fetal complications include IUFD, prematurity, intrauterine growth
restriction, lymphatic hypertrophy and thrombocytopenia, fetal goiter,
and fetal exophthalmos (the thyroid-stimulating antibodies can cross
the placenta readily to stimulate the fetal thyroid)
– Neonatal complications (affected newborns can be expected to have a
transient course over 1-5 months as the maternal autoantibodies are
slowly cleared from their systems)
– Iatrogenic fetal hypothyroidism with possible delayed bone age and
central nervous system effects in exposed infants [as a result of
propylthiouracil (PTU) crossing the placenta]
 THYROID
• Hypothyroidism:
– Maternal complications:
• Anemia
• Preeclampsia
• Abruption
• Postpartum hemorrhage
• Cardiac dysfunction
– fetal complications:
• Low birth weight
• Perinatal mortality
• Untreated hypothyroidism may be associated with pregnancy loss
and prolonged gestation.
• Women with subclinical disease (increased TSH but normal T4) and
women receiving adequate replacement therapy have better
outcomes
 SEIZURES
• The most common neurological problem in pregnancy.
• Between 25% and 50% of women with idiopathic epilepsy have an
increase in seizure frequency during pregnancy, usually during the
first trimester.
• Patients with frequent seizures before pregnancy are likely to
experience worsening of seizure control during pregnancy.
• Good seizure control before pregnancy usually correlates with a
lower risk of exacerbation during pregnancy.
• Possible causes increased seizure frequency:
– little or no prepregnancy counseling
– poor seizure control before conception
– poor compliance
– lower serum levels of anticonvulsants during pregnancy
– Folic acid can decrease plasma levels of phenytoin:
• serum anticonvulsant levels should be closely monitored throughout the
pregnancy in women concurrently taking both folic acid and phenytoin.
 SEIZURES
Maternal complications:
– Preeclampsia
– Preterm labor
– Stillbirth.
– Vaginal bleeding is more common in epileptics
(probably secondary to anticonvulsant therapy-
induced vitamin K deficiency)
• Fetal complications:
– Congenital anomalies: 2-3 higher rate in patient on
anticonvulsants.
– lower risk with monotherapy
 SEIZURES

• Fetal hydantoin (phenytoin) syndrome (30%):

– Craniofacial abnormalities
– Congenital heart disease
– Prenatal and postnatal growth restriction
– Mental retardation
– Nail and digital hypoplasia
 SEIZURES
Neonatal complications:
• Hemorrhagic disease of the newborn related to
vitamin K deficiency, due to anticonvulsant
treatment with either phenytoin, phenobarbital
or primidone.
• Prophylactic vitamin K immediately after
delivery and close observation for signs of
neonatal bleeding.
 CARDIOVASCULAR
Mitral stenosis:
• Leading cause: Rheumatic fever (Congenital mitral stenosis: Lutembacher
syndrome, is very rare.)
• Main features:
– Blood from the left atrium to the left ventricle during diastole is jeopardized.
– Fixed cardiac output.
– As stenosis worsens, there can be dilation of the left atrium and pulmonary congestion
– Normal mitral valve area: 4-5 cm2
• With valve area ≤ 2.5 cm2 : symptoms with exertion
• With valve area ≤ 1.5 cm2 : symptoms at rest
– The physiological increased preload of pregnancy (increased blood volume and venous
return) causes pulmonary congestion instead of increased cardiac output.
– The tachycardia of pregnancy shortens diastole and decreases left ventricular filling (cardiac
output)
• Management during pregnancy, labor, and delivery:
– Antenatal period: maintaining cardiac output while decreasing pulmonary congestion
(diuretics and beta-blocker therapy)
– During labor and delivery: good pain control to reduce the maternal heart rate and increase
diastole
– Antibiotic prophylaxis for bacterial endocarditis.
– Instrumental vaginal delivery to shorten the second stage (diminished tolerance due to a
decreased preload with pushing)
– Diuretics in the immediate postpartum, to avoid pulmonary edema due to auto-transfusion
 CARDIOVASCULAR
AORTIC STENOSIS.
• The majority of aortic stenosis is a combination of congenital lesions and
rheumatic fever.
• Normal aortic valve area: 3-4 cm2.
Significant stenosis: area ≤ I cm2.
As stenosis progresses, the left ventricle initially hypertrophies in response
to the increased pressure gradient. Eventually the left ventricle dilates.
• Clinical manifestation: angina, near- syncope/syncope, and congestive
heart failure.
• Management during pregnancy, labor, and delivery:
– Due to the fixed cardiac output, it is essential to maintain the preload during
pregnancy, labor, and delivery.
– Any hypotension can cause sudden death
– During labor and delivery:
• Severe disease: central hemodynamic monitoring.
• Regional anesthesia with caution due to the risks for hypotension.
• Instrumental delivery( intolerance to second stage due to a decreased preload with
pushing)
• Postpartum blood loss can also significantly reduce preload, and volume replacement
with fluid or blood may be necessary
• Antibiotic prophylaxis for bacterial endocarditis.
 CARDIOVASCULAR
EISENMENGER'S SYNDROME
• A congenital communication between the pulmonary and systemic circulation
– increased pulmonary vascular resistance (PVR) either to the systemic level or greater than the
systemic level.
– Once the PVR becomes greater than the systemic vascular resistance a right-to-left shunt
develops along with significant pulmonary hypertension.
– Most common cause: large ventricular septal defect
• Pregnancy risks with Eisenmenger's syndrome:
– Maternal mortality rate of 50%,
– Fetal mortality rate of 50%
– Preterm delivery rate of 85%
– Sudden death can occur at any time.
Greatest risk during labor and delivery and the early postpartum period
• Management during pregnancy and delivery:
– Maintaining pulmonary blood flow
– limitation of physical activity, oxygen therapy, and possibly pulmonary vasodilators
– Planned delivery with central hemodynamic monitoring
– It is crucial to maintain preload (assisted second stage)
– Cesarean section is reserved for obstetric indications

• Despite rigorous care, the mortality rate remains high (50%)

 CARDIOVASCULAR
MARFAN SYNDROME
– Autosomal dominant (abnormal fibrillin gene on chromosome 15)
– Prevalence of 4-6/10,000.
– Abnormal fibrillin causes connective tissue abnormalities all over the body
• Aortic root dilation (most significant)
• Optic lens dislocation
• long limbs
• Scoliosis, and joint laxity
• Increased mortality from aortic dissection or rupture
• Risk with pregnancy:
– Modest risk with an aortic root < 4 cm
– Women with an aortic root > 5.5 cm should have aortic graft and aortic valve replacement
prior to attempting pregnancy.
– Highest risk with an aortic root 4.0-5.5 cm during pregnancy because cardiac surgery is
premature.
• Antenatal management :
– Beta blockade protect the aortic root from the increased hemodynamic forces of pregnancy
– The goal is to maintain a resting pulse of 70 bpm
– Follow the aortic root with serial echocardiograms.
• Intrapartum management:
– Vaginal delivery with prevention of tachycardia with an aortic root < 4 cm
– Cesarean section is recommended with dilated aortic roots
 CARDIOVASCULAR
PERIPARTUM CARDIOMYOPATHY
• Diagnostic criteria:
– Heart failure within the last month of pregnancy or 5 months postpartum
– Absence of prior heart disease
– No determinable cause (viral infection, pre-eclampsia)
– Echocardiographic findings of left ventricular dysfunction:
• Ejection fraction < 45%
• Fractional shortening < 30%
• left ventricular end-diastolic dimension > 2.7cm/m2
• Treatment:
– Diuretics and afterload reduction
– Hydralazine: as the afterload-reducing medication with prgnancy
– ACE inhibitor: postpartum
• Prognosis:
– 5-year mortality of 50-85% with persistent abnormal left ventricular (LV) size
and function for more than 6 months after delivery (counselling subsequent
pregnancies).
– 25% recurrence rate during a subsequent pregnancy for those with
normalization within six month postpartum
 PULMONARY DISEASES
ASTHMA
• Most common obstructive disease during
pregnancy (1 % of all pregnancies):
– 70% of patients show improvement
– 20% show no change
– 10% have exacerbations
– Asthma flares:
• Noncompliance with treatment
• Respiratory tract infections
 PULMONARY DISEASES
PULMONARY EMBOLISM
• Leading cause of maternal mortality
• 5 fold increased risk of thromboembolism in pregnancy (hypercoagulable state of
pregnancy due to increase in coagulation factors)
– 0.5 -3 per 1000 pregnancies develop symptomatic venous thrombosis
– If untreated: Up to 25% develop a pulmonary embolism (15% mortality)
– Up to 50% of women who develop a thrombosis have an acquired or congenital
thrombophilia
• Diagnosis of thromboembolic disease:
– Symptoms & signs: tachypnea, tachycardia, shortness of breath, chest pain, pleural rub, with
or without swollen lower limbs
– ECG abnormalities
– Decrease in P02 on an arterial blood gas (usually ).
– DVT: Impedence plethysmography; Duplex ultrasound
– Pulmonary embolism: a ventilation-perfusion (V/Q) scan (radiation dose to the fetus of less
than .05 rads) can be used if the chest x-ray is normal (which is often unremarkable)
– Selective pulmonary angiography (Spiral angiography with abdominal shielding; the radiation
exposure to the fetus is less than that of a V /Q scan)
• Treatment:
– Heparin throughout the pregnancy and for up to 3 months post partum.
 AUTOIMMUNE
AUTOIMMUNE DISEASES
• Autoantibodies:
– Organ-specific: antithyroid and antismooth-muscle
antibodies
– Non-organ specific: phospholipid antibodies (ACA, LA),
antinuclear antibodies, and antihistone antibodies
• Autoimmune diseases:
– Systemic lupus erythematosus (SLE)
– Antiphospholipid syndrome
– Rheumatoid arthritis
– Myasthenia gravis
– Idiopathic thrombocytopenic purpura (ITP).
 AUTOIMMUNE
SLE
• Ninety percent of SLE occurs in women of childbearing age
• Mild disease generally has a good prognosis
• Active disease-especially active renal disease and maternal
hypertension-have been associated with fetal loss, premature
birth, and intrauterine growth restriction.
• Flares may increase during pregnancy and the puerperium.

Neonatal lupus
• Diagnostic criteria:
– the presence of maternal antibodies, anti-SSA(Ro) and anti-SSB(La)
– the presence of heart block or a transient skin rash
• The development of heart block is permanent and results in
significant morbidity and mortality.
• Treatment oral corticosteroids and postnatal pacemaker
placement.
 AUTOIMMUNE
• Primary antiphospholipid syndrome (APS):
isolated presence of aPL
• Secondary APS: aPL associated with other
diseases (SLE, collagen vascular)

• APS diagnostic criteria:

– At least one clinical and one laboratory criteria
 AUTOIMMUNE
Antiphospholipid antibodies in pregnancy
Clinical implications:
– Arterial and venous thrombosis
– Recurrent pregnancy loss
– Thrombocytopenia
– Fetal growth restriction
– Preterm birth
– Preeclampsia
– Intrauterine fetal death
 APS DIAGNOSTIC CRITERIA
Clinical Criteria:
• 1. Vascular thrombosis: One or more clinical episodes of
arterial, venous or small vessel thrombosis, in any tissue or
organ.
• 2. Pregnancy complications:
– (a) ≥ 1 unexplained fetal deaths ≥ 10 weeks , or
– (b) ≥ 1 premature births ≤ 34 weeks because of severe
preeclampsia or eclampsia, or severe placental insufficiency
– (c) ≥ 3 unexplained consecutive spontaneous abortions ˂ 10
weeks, with no other etiological factors

Laboratory Criteria:
• 1. ACA of IgG and/or IgM (medium or high titer) on two or
more occasions, at least 6 weeks apart
• 2. LA on two or more occasions at least 6 weeks apart
 AUTOIMMUNE
Treatment of APS during pregnancy:
– H/O fetal death or recurrent pregnancy loss:
Prophylactic heparin with low-dose aspirin daily.

– H/O thrombosis or stroke: therapeutic dose of

heparin may be considered
 AUTOIMMUNE DISORDERS
Rheumatoid arthritis (RA):
• Generally improves during pregnancy ( higher
cortisol)
• Treatment (if required):
– Steroids and analgesics
– Gold, chloroquine, sulfasalazine, penicillamine,
and azathioprine.
 AUTOIMMUNE DISORDERS
Myasthenia gravis
• Variable relapses and remissions during pregnancy and the puerperium
• Treatment as in nonpregnant:
– Anticholinesterase medications
– Immunosuppressive agents (glucocorticoids, azathioprine)
– Thymectomy
– plasmapheresis

• Intrapartum management:
– Regional anesthesia (to avoid muscle relaxant use with general anesthesia)
– Avoidance of magnesium sulfate(may precipitate crisis)
– Instrumental delivery may be required

Neonatal myasthenia
– 10-15% of newborns (transient )
– Signs may appear in the first 72 hrs of life (a weak cry, respiratory difficulties,
and weak movements)
– Treatment with anticholinesterase drugs.
 AUTOIMMUNE DISORDERS
Idiopathic thrombocytopenic purpura (ITP)
• Risk of postparum hemorrhage
• Risk of fetal thrombocytopenia (due to placental transfer of IgG
antibodies)
• Differential diagnosis:
– SLE, APS
– HIV infection
– Drug-induced thrombocytopenia
– Thrombotic thrombocytopenic purpura (TTP)
– DIC
– Preeclampsia
– Gestational thrombocytopenia (5% of pregnancies, no maternal or
fetal affects)
– laboratory error (automated)

• Most women with ITP have a history of easy bruising and

menorrhagia.
• Bone marrow biopsy may be required for diagnosis
 AUTOIMMUNE DISORDERS
Treatment(ITP):
• Platelet ˃ 50,000/µL: No treatment
• Platelet ˂ 50,000/µL:
– Prednisone
– IV Ig: If no response to prednisone
– Platelet transfusions: If bleeding or C-section
• Splenectomy:
– If no response to steroids or IV Ig
– 80% remission
Fetal risk:
• Intracranial hemorrhage: 1% of cases, consequent to
transplacental maternal Abs. and fetal thrombocytopenia
• No correlation between maternal and fetal platelet counts
• Mode of delivery:
– Cesarean section v vaginal delivery (avoiding instrumental
delivery)
PRECONCEPTIONAL COUNSELLING
Diabetes
• Congenital malformation:
– Planned pregnancy while in good metabolic
control is the only known effective measure in
preventing malformations(A1c <6.5, FBS 4-6.1
mmol/L, PPBS <8.6 mmol/L)
• Meticulous glucose control during pregnancy:
– Reduction in risks of IUFD, macrosomia, shoulder
dystocia, and delayed fetal lung maturation.
PRECONCEPTIONAL COUNSELLING
• Recurrent pre-eclampsia:
women who have had severe second
trimester pre-eclampsia or the HELLP
syndrome should be informed about an
extremely high risk of similar complications in
subsequent pregnancies and advised for early
booking and close follow-up.
PRECONCEPTIONAL COUNSELLING
SLE:
• Planned pregnancy while free of flares for at least six
months
APS:
• Early use of heparin during pregnancy
• Therapeutic long-term postpartum anticoagulation if H/O
thrombosis or stroke due to the high risk of venous or
arterial thrombosis.
Seizures:
• Drug of choice: Carbemazepine (Tegretol) , phenobarbital
• If a free period for at least 2 years a trial off anticonvulsants
prior to pregnancy. Once successful, antenatal expectant
management can be considered.
PRECONCEPTIONAL COUNSELLING
• Eisenmerger’s syndrome: the patients should be
counselled against conceiving due to the high
mortality rate.
• Marfan's syndrome:
– If the aortic root diameter is ≥4 cm: advise against
conception considering the increased risk of aortic
dissection and rupture during pregnancy.
– If aortic root> 5.5 cm: aortic graft and aortic valve
replacement prior to attempting pregnancy.

• Obstructive valvular disease:

Evaluation for corrective surgery before conception.
 MEDICAL COMPLICATIONS WITH
PREGNANCY
Management issues:
 Cooperation and communication between different
disciplines
Obstetricians: limited familiarity with the complexity
of a given medical problem
Internists: insufficient understanding of the obstetric
considerations
 Optimizing patient care: increasing familiarity and
mutual understanding of the concerns of each other
would help reach an agreeable plan of management
 OBSTETRIC MEDICINE
 MEDICAL COMPLICATIONS WITH
PREGNANCY
Risk management:
• Pregnancies complicated with medical disorders are high risk
pregnancies: ALL pregnancies should be evaluated to determine
present or potential risk factors
• Most pregnancies are unplanned: many women will present for
their first prenatal visit well beyond the first trimester, with medical
disorders or on medications that may have deleterious effects on
the fetus
• Emphasis should always be made on pregestational assessment of
risks, to plan for pregnancy in the most favorable circumstances for
a successful outcome
• Preconceptional counseling is an appropriate form of preventive
medicine for women planning a pregnancy; apart from having the
parent fully informed about any specific concerns.
 MEDICAL COMPLICATIONS WITH
PREGNANCY
• Clinical risk management provides a mechanism for
modifying exposure to risk by recognizing events that
may result in morbidity and mortality
• Consideration is given to identification of risks and
how these may be minimized by taking action to
reduce the occurrence of risk events.
• This course of action should improve quality of care,
enhance patient safety and result in the possibility of
reducing legal claims
• These elements constitute a proactive approach and
involve review of day-to-day practice management.