Maternal Mortality and Medical problems (Medical disorders in pregnancy)

Question 1

Causes of maternal deaths - the three groups and examples?

Answer 1

DIRECT, INDIRECT, INCIDENTAL

Direct: amniotic fluid embolism, pre-eclampsia (liver rupture), Thromboembolism (PE day 3 post C section), Obstetric haemorrhage (uterine rupture), Cardiac conditions, Infection, Anaesthesia

Indirect: Cardiac conditions (MS), non-obstetric haemorrhage, Infection, Hypertension, other (diabetes/epilepsy)

Incidental: Homicide (domestic violence), accidents, malignancy

Major players –> cardiac disease and thromboembolic disease

Question 2

Physiological changes in normal pregnancy?

Cardiac, Resp, Renal, GI, Metabolic, Hematologic

Answer 2

CARDIAC: CO up 50% by 32 wks + TPR falls by 7-8wks [cardiomyopathy/valvular disorders]

RESP: hyperventilate & up tidal volume, FRC down b.c gravid uterus (up O2 requirement - HF/CF/Pulm Fibrosis)

RENAL: GFR up 55% [chronic renal impairment]

GI: Progesterone down = LOS tone & up GI motility [reflux, constipation]

METABOLIC: up liver metabolism (placental steroids is diabetogenic = gestational diabetes)

HEMATOLOGIC: anemia, thrombogenic (dilutional anaemia RBC mass up but not as much as CO; thrombogenic as up fibrinogen 8 9 10, down thrombolysis)

Question 3

Resuscitation in a pregnant woman, things to consider?

Management?

Answer 3

CONSIDERATIONS

• L tilt to decrease aorto-caval compression and supine hypotension
• increase blood volume so give more drugs
• increase risk aspiration so cuffed endotracheal tube NO laryngeal mask
• down FRC + up BMR (hypoxia is rapid need to ventilate)
• alpha adrenergic agenets + alpha beta agonists down uteroplacental perfusion (adrenaline constricts uteroplacental circulation but mom needs to survive)

MX
Consider the above
Defibrillation ok for fetus
PERIMORTEM CS at 4’; delivery by 5 (down aortocaval compression to improve venous return and CO; 50% more blood volume; chest compressions more effective, FRC up improve oxygenation)

Question 4

Cardiac disease in pregnancy

- during pregnancy

Answer 4

Fall in pulmonary vascular resistance (TPR down is systemic AND pulmonary)

• Pulmonary HT (cyanotic)
• Eisenmenger’s Disease (L to R shunt reverse body gets deoxygenated blood)

CO up

• LV dysfunction (IHD, severe valvular, peripartum cardiomyopathy up to 5 months)
• Disease fixed output (AS, MS)
• Aneurysm formation (DRA, SAH)

HR up: MS needs diastolic filling or will get Pulm. oedema

ANTICOAG: Prosthetic valves (warfarin switch to heparin for 1st trimester - warfarin 2nd and 3rd trimester - heparin at 36 weeks)

Risk of thromboembolism greatest in patients with pre existing cardiac disease

Question 5

Cardiac disease in pregnancy

- in labour

Answer 5

Rapid volume changes

• LV dysfunction
• CO dependent on good preload (Pulm HT)
• CO fixed (sudden up is Acute PO = MS)(sudden down is down coronary perfusion = AS)

Tachycardia = down diastolic filling time
- MV down area

Question 6

Cardiac disease in pregnancy

- postpartum

Answer 6

Rapid increase in preload post-delivery

• fixed output lesions
• poor LV function
• pulmonary hypertension

GIVE DIURETIC SOON AS BABY HEAD APPEARS

Question 7

Worst cardiac lesions to have in pregnancy?

Answer 7

STENOTIC worse than REGURGITANT (regurge ok b/c TPR down = regurge down) Unless dilated aortic root in Marfan’s

Pulmonary HT/ Cyanotic HD/ NYHA III and IV/ Severe AS/MS/ Severe AR/ Coronary artery disease/ peripartum cardiomyopathy/arrhythmia/valve requiring anticoag

Question 8

Pre-pregnancy counselling session for woman with cardiac disease

Answer 8

Plans of kids/contraception?

• determine lesion (echo, ECG)
• NYHA cardiac status (I asymptomatic, II slight limitation, III ok at rest activity hurts, IV symptoms at rest)
• prognosis for pregnancy advise
• lesion risk to offspring e.g. Marfan’s
• anticoagulaton issues
• SBE prophylaxis e.g. bacterial endocarditis
• Mx arrhythmia or cardiac failure

Question 9

Cardiac: Mx in pregnancy

Answer 9

Maternal:

• symptoms (SOB/palpitation/pain)
• rest L lateral, admission?
• rx (digoxin, diruetics, antiarrhythmics, anticoag)

Fetal

• echo for congenital heart disease
• surviellance for growth

Question 10

Cardiac: Mx in labour

Answer 10

vaginal delivery better: more blood loss in C section

least uterine work: spontaneous better than induction
Haemodynamic stable: minimise blood loss (slow syntocin); L lateral; no push; watch fluid; slow onset epidural if epidural used

Monitor

Abx for SBE prophylaxis

Syntocinon for stage 3 (avoid spike in venous return)

Question 11

Cardiac: Mx in post-natal

Answer 11

• Observe for APO (b/c massive AV shunt will up blood volume)
• Slow oxytocin infusion (no PPH)
• early ambulation
• contraception

Question 12

Thromboembolism in pregnancy

• incidence
• risk factors
• risk delivery/post-natal

Answer 12

• 1:1200, mortality 1-2%
• age, obesity etc….Ovarian Hyperstimulation Syndrome (IVF complication - massive 3rd space loss, must be anticoagulated)
• risk factors (delivery: long labour dehydration)(post natal: immobilization, inadequate hydration 6wks)

Question 13

Thromboembolism in pregnancy

• detection
• treatment

Answer 13

Detection: 85% in L leg, Duplex U/S, if US -ve try V/Q scan or CTPA or CXR

Treatment: anticoagulation, long enough (heparin in peripartum then back to warfarin, ok in breastfeeding)

Question 14

Imaging in pregnancy - risks? recommendations?

Answer 14

Effect depends on radiation dose and gestation at exposure

- risk at W3-W11 post conception (ok

Question 15

Cardiac messages to remember

Answer 15

Pregnancy is a stress test for life
Impact of disease on pregnancy and vice versa
Be on contraception (if cardiac disease, diabetes, epilepsy)
Imaging and resuscitation = do what’s best for mother