Medical Complications Flashcards
Thrombophilias
inherited
3 deficiency-antithrombin 3, protein c or s
2 mutations-FVL or prothrombin hetero or homo, compound hetero
Start anticoagulation as soon as confirmed pregnancy
DVT in pregnancy due therapeutic for 3-6 months and can decrease to intermediate or prophylaxis until 6 wks PP
Anti Xa levels
Prophylactic 0.2-0.5
Therapeutic 0.6-1.0 (for thrombophilias), 0.7-1.2 (mechanic heart valves)
Most common site of DVT
Left lower extremity, proximal
Iliac or iliofemoral due to right iliac vein crossing over worsened with compression from gravid uterus
Contraindications to valsalva
Assisted delivery Pulm HTN Fixed stenotic lesions Ventricular dysfunction (cardiomyopathy) or Single ventricles Moderate degrees of aortic dilation
Need CS-may be others but case specific Eisenmengers Marfan's with dilated aorta (>45) Severe AS CHF
Contraindications to epidural
Absolute: uncorrected hypovolemia, coagulopathy (clinical), infection at site.
Severe aortic stenosis- cannot tolerate preload reduction
Eisenmengers- cannot tolerate afterload reduction
Relative: spinal cord/LE disease, spinal deformity/instrumentation, back problems, coagulopathy (lab), stenotic cardiac lesions, pulm HTN, bacteremia, potential for hypovolemia (active bleeding)
Hypoxemia
diff dx
Workup
Asthma-CXR, ABG
Pneumonia-CXR, ABG
Pulmonary edema-CXR, ABG, echo
Pulmonary embolism-CT angio, ABG, ?LE Doppers
Hypoxemia treatment
Asthma -oxygen, bronchodilator
Pneumonia- oxygen, antibiotics
PE-O2, anticoag
Cardiogenic pulm edema-O2, diuretics, improve cardiac function, reduce afterload
Non cardiogenic pulm edema-O2, diuretic, address cause
Aortic aneurysm diff dx
Marfan’s
Loeys-Diet
Vascular EDS
Turner’s
Physiologic cardiac changes of pregnancy
Plasma increase 45-50% RBC volume increase 32% Renal and Na retention cause fluid retention shifted extravascular (P cause increased mineralocorticoid) BP down 10% HR up 20%, SV up 30%, CO up 30-50% PA pressure doesn't change Renal blood flow up 30%
Up:HR SV, CO
Down: SVR, pulm VR, osmotic and oncotic pressure, PCWP
May lose 30% blood volume with minimal PP hct change due to diuresis
Cardiac medication classes
Inotrope-increase contractility (dig)
Chronotrope-increase HR (beta agonists, atropine)
Neg inotrope/neg chronotrope-beta or CCB
Pressors
Norepi(levophed)- alpha/beta 1 agonist, strong vasoconstriction, best in septic, cardiogenic or hypovolemic shock
Phenylephrine-alpha-strong vasoconstriction, post anesthesia hypotension or tachyarrhryrymiasa
Epinephrine-alpha 1, beta 1/2, anaphylaxis
Dobutamime-inotrope, beta1/2, good in septic.shock. low dose up CO, down SVR, med dose both up, high dose only SVR up
Respiratory changes in pregnancy
If PaO2 is normal 60-100 then SaO2 is also normal. Any additional FiO2 increases PaO2 unless lungs abnormal
Down: TLC, functional residual capacity, ERV RV, inspiratory volume
No change: vital capacity, RR
Up: ventilatory drive, minute ventilation, TV, dead space
Minute volume=TVxRR
Pregnancy ABG
pH 7.4-7.45 (alkalosis) PaO2 101-105 (up) PaCO2 27-34 (down) HCO3 18-21 (down) If mom normal pH or acidotic then baby is always acidotic as.fetus cannot offload CO2 to mom
Indications for intubation
Unable to protect airway
Unable to ventilate (high CO2, usually asthma)
Unable to oxygenate
Prevent respiratory fatigue
Coagulation factor changes
Pro-coagulant:
Up: 7,8,10, vWF, fibrinogen, plasminogen activator inhibitor
No change: 2, 5, 9
Anticoagulant:
no change: protein C, AT
Down: protein S
Immune changes
Shift from cellular (Th1) to humoral (Th2)
Asthma
Complications
Meds
Severe or poor control then PTD, CS, PEC, FGR, maternal morbidity and mortality
Controller: inhaled steroids, Cromolyn, long acting beta agonists, theophylline (requires serum monitoring)
First line in pregnancy budesonide low dose then higher and add long acting beta (salmeterol)
Rescue: short acting beta agonists
Beta blocker, methergine and hemabate can cause exacerbation
Asthma stepwise
Severity. Symptoms. Night. FEV
Intermittent
-well controlled. <2/wk. <2/mon. >80%
Mild persistent
-not well controlled. >2/wk. >2/mo. >80%
13% exacerbation
Mod persistent
-not well controlled. Daily. >1/wk. 60-80%
26% exacerbation
Severe persistent
-very poorly control multiple in day >4/wk. <60%
52% exacerbation
Peak expiratory flow should be >330
Asthma exacerbation
Treat rescue and continue if FEV >70%
If FEV 50-70% individualize, O2, short acting beta agonists, continuous nebulizer, IV steroids
If FEV <50% admit, need ICU if severe symptoms, drowsy, confusion, PCO2>42
Oral steroids 3-10 days (40-60mg)
Need SDS and third trimester
CAP
No severe symptoms can treat outpatient
Ceftriaxine or augmentin with azithro
Pulm Edema
Cardiogenic- volume overload and/or poor heart function
-CHF, MI, cardiomyopathy, PEV, valve problems
Echo shows increase in IVC, low Ears, dilated LV, ?valve abnormalities
non-cardiogenic-imcreased permeability causing fluid leakage, not volume overloaded, normal heart, normal BNP
-sepsis, ARDS, PEC, TRALI
Crackles a late finding
In sepsis neg CXR until lungs 30% full of fluid
Dx: hypoxemia, tachypnea, tachycardia, crackles, chest pain, cough, SOB
TX: O2, diuresis, decrease afterload, may need to intubate, BiPAP or CPAP great for pulm edema
ARDS
Decrease lung compliance and intrapulmonary shunting (blood leaves lungs without oxygen)
Pregnant causes: pneumonia, sepsis, AFE, PEC, aspiration
Dx: diffuse bilateral infiltrate (pulm Edema) visible after 24 hrs, resp failure not due to cardiogenic factors
PaO2/FiO2 determines severity.
Mild 200-300
Mod 100-200
Sev <100
TX: supportive, correct cause. PEEP, prone and neuromuscular blockade if <150 and maybe need ECMO if <80
Delivery may cause temporary improvement but no change to long term outcomes
Influenza
TX
Prophylactic
Supportive
Zanamavir or oseltamivir (BID x 5 days)
Tamiflu daily x 10 days
Ventilation
Settings and goals
SIMV Rate 14-16 TV 6-10 mL/kg PEEP 5 FiO2 100% then wean Must have higher TV than non pregnant to main resp alkalosis
PaO2 > 60 mm
SaO2 >95%
PaCO2 27-34
FiO2 <50%
Sepsis
SoFA score >2 with infection , 10%>mortality
Tocolysis in sepsis may cause pulm edema, ARDS, hypotension.
Septic shock 40% mortality
1 hr bundle for sepsis-lactate, blood cultures, antibiotics, fluid resuscitation, correct hypotension
For each hour delay increase mortality 5-7%
Amp/gent/clinda covers 90% sepsis including strep a and aneorobes or vanc/zosyn (1.5mg/kg and 4
T q6)
Group a sepsis
20x MC in OB, 85% PP, 7-10% mortality
Risk factors upper resp infection prior to delivery or exp to carrier
MC in 24 hr PP with fever, abdominal pain out of proportion to exam, may have hypothermia from low tissue perfusion
Rapid spread.due to toxins
Typical signs: erythema, increase pain resistant to meds, extreme anxiety
Late sign: purple discoloration of skin.with bullae, edema,.crepitus, black necrotic plaques, muktisystem organ failure
Indications for delivery in sepsis
Maternal
Intrauterine infection, DIC, hepatic or renal failure, cardiac arrest, failed response to therapy, severe ARDS. Condition expected to improve with delivery
Fetal
Demise, advanced gestational age with min risk of delivery
If delivering for sepsis always give steroids, no reason to not give.
Always abnormal in pregnancy
Severe dyspnea Exertional syncope and chest pain Paroxysmal nocturnal dyspnea S4 gallop ( blood hitting stiff ventricles in diastole) Cyanosis Clubbing Diastolic murmur Sustained arrhythmias Loud, harsh systolic murmur
Conditions that need repaired prior to pregnancy
ASD or VSD with shunting and any pulm HTN PDS with an pulm HTN severe AS or MS or mitral regurg Severe coarc TOF
Highest risk conditions: anything with Pulm HTN, Eisenmengers, Marfan’s, dilated CM EF <40%
Maternal mortality rates by cardiac disease
AS 10-20% Coarc 5% Marfan's (aorta >40) 10-20% Peripartum CM 15-60% Severe pulm.HTN 50% TOF 10%
Maternal ASD
Often undetected before pregnancy
If no pulm HTN preg likely uncomplicated
May cause systolic ejection murmur, RBBB, enlarged RA
Contraindications to pregnancy: large ASD, chronic a-fib, RV dysfunction, pulm HTN
IE prophylaxis not indicated
Maternal VSD
If no pulm HTN well tolerates
Pan systolic murmur
Contraindications to pregnancy if SVR =PVR
IE prophylaxis only needed if recent repair
Maternal PDA
Continuous machinery murmur
Should be repaired pre-pregnancy
IE prophylaxis is unrepaired
If no pulm HTN then tolerated
Eisenmengers
RV heave
Palpable Pulm valve closure
Can have bidirectional shunting depending on hemodynamic status
MCC large VSD then PDA
Pulm HTN irreversible so surgical repair of defect worsens condition unless concomitant lung transplant
Pulmonary hypertension
Need right heart Cath if peak tricuspid regurg velocity >2.9 with signs of pHTN or >3.4
Tx with IV vasodilators, inhaled NO, diuretics, dig, anticoag
If responds to IV prostacyclins (epoprostenol, sildenafil) than good prognostic factor, may respond to oral nifed.
Main treatment to correct cause then symptoms
Mitral stenosis
Diastolic murmur
Usually rheumatic fever (multiple valves, 10-20 yrs) rarely congenital
Pulm congestion/edema, atrial arrhythmias, 25% CHF
Symptoms present if valve <2 cm2, critical 1.5. worsen with tachycardia
If AFib need anti-coag
Gentle Regional anesthesia without bolus to minimize tachycardia with assisted second stage (IV esmolol gtt if needed).
Gentle diuresis PP as proud dependent. Need euvolemia.
Pulm Edema occurs with tocolysis, PEC, or fluid overload
Percutaneous balloon valvuloplasty can be done in pregnancy under echo
Phenylephrine pressor of choice as no tachycardia
Aortic stenosis
Systolic ejection murmur. Symptoms do not always correlate with severity.
Congenital, bicuspid or rheumatic fever
Medical management is class 1 or 2, surgery with balloon valvuloplasty of replacement if needed. 20% fetal loss with bypass needed for replacement.
May cause post valve aorta dialtion, if >45mm recommend cesarean.
If severe (area <1 or gradient >40) replace prior to pregnancy, highest risk CHF mean at 27 wks. Must be wet.
moderate (area 1-1.5 or gradient 24-40) should complete child bearing then repair.
Critical area <0.5 or gradient >100
If LV failure sure dig and diuresis
Bicuspid associated with coarc.
Assisted second stage with local or regional combined, want to avoid preload reduction.
IE prophylaxis only if history of IE
AS labor management
Avoid aortocaval compression
Avoid bradycardia
Avoid SVR
Maintain venous return and LV filling
Single shot spinal absolute contaidincation due to fixed cardiac output and inability to compensate for decrease in afterload
Caution with oxytocin as could cause hypotension
Pulmonary stenosis
Preload dependent
Usually repaired in childhood
Generally well tolerated
20% offspring with CHD and 50% are PS
Maternal TOF
MC cyanotic heart disease in pregnancy
2-13% recurrence in offspring
RV and LV pressure equal but normal PA pressure
If complete repair well tolerated
If.residual PS at risk for regurg and RV failure
Uncorrected requires IE prophylaxis and 4-15% maternal mortality and 30% fetal mortality
Risk factors for death
-SaO2 <85%, RV pressure >120, h/o syncope+CHF or cardiomegaly, Hg>20
Anesthesia
Avoid drop SVR, ensure venous return, phenylephrine to maintain SVR if needed, echo to monitor volume status. CSE best choice
Preload dependent lesions
Left sided obstructions-AS, MS, coarc
Lesions that require afterload reduction
Regurg tx with hydralazine and diuretics
Must maintain euvolemia to avoid pulm edema
Maternal coarc
Uncorrected 3% mortality
Balloon dilation in pregnancy
10% aortic root aneurysm may rupture in labor, risk death 15%. Offer termination. All patients need MRA thoracic aorta and head and neck vessels at least once in lifetime to assess risk of aneurysm
May need multiple.repairs through out life
May cause distal hypotension and uteroplacental insifficiency
Increased risk PEC with worse morbidity and mortality
MV regurg not prolapse
Young women-comgential or rheumatic
Older women-HTN, ischemia, idiopathic, myocardial disease, IE
If greatly enlarged and hypokinetic ventricle than pregnancy contraindicated. 50% risk FGR, IUFD, fetal hypoxia
If mild to mod pregnancy safely managed with decreased activity, salt restriction, low dose diuretic, if a fib then low dose dig
Aortic regurgitation
MCC rheumatic then bicuspid, Marfan’s, IE, SLE
Causes volume not pressure overload
Usually well tolerated in pregnancy
Blowing diastolic murmur
Stable for long time. Once progresses to HF then rapid decompensation
Peripartum cardiomyopathy
1 mo pre-delivery to 5 mo PP
EF<45%
No other identifiable causes
Echo:
EF<45%
Decreased shortening fraction <30%
LV end diastolic volume >2.5
High BNP
Peripartum cardiomyopathy
Risk factors
Prognosis
Recurrence
Treatment
Increased age, HTN, AA multiples
20% progressive decline, need transplant
30-50% partial recovery
30-50% near complete recovery
No further recovery after 2-3 months
If normal EF, 20% recurrence, low mortality
If abnormal EF, 40% recur, 20% mortality
Vasodilation to decrease afterload-hydral then Amlodipine then nitro
Beta blocker to decrease O2 consumption
Dig for increased contractility
Marfan’s
AD, high penetrance, variable expressivity
Decreased fibrillin leading to aortic dissection, deficiency of elastic tissue causes myxomatous breakdown of aortic and mitral valves. Cystic medial necrosis of aorta
90% MVP, 60% aortic root dilation
Risk dissection 1% if <40mm and 10% >40mm and recommend CS
If >50mm recommend repair prior to pregnancy. 50% will need repeat repair.
TX: limit.physical activity, avoid HTN, beta blocker.to keep <130/70
Labor concern due to rupture avoid volume overload, HTN, tachycardia
Artificial valves
Risk clotting increased 2x with lovenox compared to warfarin, 12-24%
Warfarin to heparin not before 6 wks, if 5mg or less no transition
4-10% risk embryopathy with warfarin >5mg, 2-3% lower dose. INR
Lovenox 4hr postdose.anti Xa 0.7-1.2, check weekly
IE prophylaxis if dental but not uncomplicated VD
40% if valve infected
IV heparin 36 hrs pre delivery and 4-6 hrs PP
Highest risk thrombosis MV esp if older type valve AFib H/o embolic event EF<30% Multiple valves
SBE prophylaxis
Prosthetic valve or other prosthetic repair
H/o IE
Unrepaired cyanotic CHD (shunts or conduits)
CHD repaired less than 6 months
Repaired CHD with residual defect (high flow impairs endotheliatization
