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ЗмістStudents' independent study program
Key words and phrases
Heart disease complicates
Management of Chronic Asthma.
Acute fatty liver failure.
Assignments for Self - assessment.
Approved on Session of
Department of Obstetrics and Gynecology
with the course of Infant and Adolescent Gynecology
“__” _____________ 200___ protocol No_________
The Head of Department: ___________S.P. Polyova
Methodological instruction for practical class for foreign students
Medical illnesses and extragenital pathology during pregnancy
Subject – Obstetrics
Continuance of the class –
4 academic hours
Methodological instruction developed by assist.prof. Berbets A.
Chernivtsi – 2009
Aim: to learn how to diagnose and to prescribe special therapy for miant women with different medical illnesses.
Professional motivation: for most systemic illnesses, the physiologic and anatomic changes inherent in normal pregnancy influence the symptoms, cjgns and laboratory values to a considerable degree. Physicians providing obstetric care must have a thorough understanding of the effect of pregnancy on the natural course of a disorder on a pregnancy and the change in management of the pregnancy and /or disorder caused by their coincidence.
1. Medical conditions of pregnancy.
2. What specialist do consult pregnant women?
3. How often do medical conditions can complicate the course of a pregnancy.
I. Objectives for Students' Independent Studies
You should prepare for the practical class using the existing textbooks and lectures. Special attention should be paid to the following:
1- Pregnancy related changes of cardiovascular system during Pregnancy.
2- Classification of cardiovascular diseases in pregnant women.
3- Examination and urgency aid of pregnant cardiac patients.
4. Blood diseases in pregnancy.
5- Renal diseases in pregnancy.
6- Diabetes mellitus in pregnancy.
7- Indications to therapeutic abortion in extragenital disorders of pregnancy.
^ : medical conditions of pregnancy.
Medical and surgical illnesses complicating pregnancy require interaction between obstetrician, internist, surgeon, anesthesiologist, and frequently other subspecialists. Because pregnancy does not make a woman immune to any disease, obstetricians must have a working knowledge of common medical and surgical diseases that may befall women during childbearing years.
Importantly, normal pregnancy-induced physiological changes of pregnancy must be interpreted in relation to their effects on underlying nonobstetrical disorders. Changes induced by pregnancy on many laboratory tests should also be considered.
Physiologic adaptation to pregnancy involves the cardiovascular, pulmonary, endocrine, hematologic, neurologic, renal and gastrointestinal systems. In a normal, healthy pregnant women, the adaptive responses a appropriate and well tolerated. When underlying pathology is present th responses of the different organ systems are less well tolerated, and organic failure may occur.
^ about 1 percent of pregnancies. Heart disease in pregnancy can be divided into two categories-rheumatic and congenital. The most common lesion associated with rheumatic heart disease is mitral stenosis. Regardless of the specific valvular lesion, patients are at higher risk of developing heart failure, subacute bacterial endocarditis, and thrornboembolic disease. Asymptomatic patients may develop symptoms of cardiac decompensation or pulmonary edema as pregnancy progresses.
As a general principle,all pregnant cardiac patients should be managed with the help of a cardiologist. During every prenatal visit, the patient should be carefully examined to exclude infection, cardiac decompensation, pulmonary congestion, and cardiac arrhythmia.
To minimize the increase in cardiac output, reassurance, sedation and epidural anesthesia are encouraged early in labor. Prophylactic antibiotics (arnpkiilin and gentamicin) against subacute bacterial endocarditis are started once labor is established, and they are continued for 48 hours postpartum.Rheumatic heart disease formerly accounted for the majority of cases. The marked hemodynamic changes stimulated by pregnancy have a profound effect on underlying heart disease in the pregnant woman. The most important consideration is that during pregnancy cardiac output is increased by as much as 30 to 50 percent.
Because significant hemodynamic alterations are apparent early in pregnancy, the woman with clinically significant cardiac dysfunction may experience worsening of heart failure before midpregnancy. Additional hemodynamic burdens are placed upon the heart in the immediate peripartum period when the physiological capability for rapid changes in cardiac output may be overwhelmed in the presence of structural cardiac disease.
The likelihood of a favorable outcome for the mother with heart disease depends upon the (1) functional cardiac capacity, (2) other complications that further increase cardiac load, and (3) quality of medical care provided.
Many of the physiological changes of normal pregnancy tend to make the diagnosis of heart disease more difficult (Chap. 8 ). For example, in normal pregnancy, functional systolic heart murmurs are quite common. Respiratory effort in normal pregnancy is accentuated, at times suggesting dyspnea. Edema is generally present in the lower extremities during the latter half of pregnancy.
General management. Although a number of generalizations regarding management may be drawn, in clinical practice few women actually fit any “classic” pattern of structural cardiac disease. For this reason, individualization is essential in assuring optimal outcome. In most instances, management is with a team approach, involving the cardiologist, the obstetrician, and other specialties such as anesthesiology. Cardiovascular changes likely to be poorly tolerated by an individual woman are identified, and a plan is formulated to minimize such changes.
Management of Class I – II. With rare exceptions, women in class I and most in class II go through pregnancy without morbidity. Throughout pregnancy and the puerperium, however, special attention should be directed toward both prevention and early recognition of heart failure.
Infection has proved to be an important factor in precipitating cardiac failure. Each woman should receive instructions to avoid contact with persons who have respiratory infections, including the common cold, and to report at once any evidence for infection.
Labor and Delivery. In general, delivery should be accomplished vaginally unless there are obstetrical indications for cesarean delivery. In spite of the physical effort inherent in labor and vaginal delivery, less morbidity and mortality are associated with this route.
Relief from pain and apprehension without undue depression is especially important. For many multiparous women, intravenous analgesics provide satisfactory pain relief. For others, especially nulliparas, continuous epidural analgesia often proves valuable. The major danger of conduction analgesia is maternal hypotension.
For vaginal delivery in women with only mild cardiovascular compromise, pudendal analgesia given along with intravenous sedation often suffices. However, when low- or mid-forceps use is contemplated, or in women with cardiac conditions who are unable to accommodate the marked changes in cardiac output often seen during labor and delivery, epidural analgesia is preferable.
Management of Class III-IV. Maternal mortality for classes III and IV has been reported to be 4 to 7 percent (McFaul and colleagues, 1988; Sullivan and Ramanathan, 1985). The important question is whether pregnancy should be undertaken or continued. If women choose to become pregnant, they must understand the risks and cooperate fully with planned care. If seen early enough, women with some types of severe cardiac disease should consider pregnancy interruption. If the pregnancy is continued, prolonged hospitalization or bed rest will often be necessary.
During pregnancy, there are a number of important adaptations of the respiratory system and changes in pulmonary function. Physiologically these changes are necessary so that the increased oxygen demands of the hyperdynamic circulation and the fetus can be satisfied.
Although the effect of pregnancy on bronchial asthma is variable, severe asthma is associated with an increased abortion rate and an increased incidence of intrauterine fetal death and fetal growth restriction, most probably as a result of intrauterine hypoxia. Pregnant asthmatics should be followed closely during pregnancy to ensure adequate maternal and fetal assessment. For outpatient treatment of occasional mild asthma attacks, inhaled b-agonists should be started on a regimen of inhaled corticosteroids or cromolyn.
If the patients has been taking oral steroids during pregnancy, the intravenous administration of glucorticoids is recommended during labor delivery and postpartum period. Vaginal delivery should be anticipated-Cesarean section is indicated only for obstetric reasons.
^ According to Clark and associates (1993), effective management of asthma during pregnancy includes (1) objective assessment of pulmonary function and fetal well-being, (2) avoidance or control of environmental precipitating factors, (3) pharmacological therapy, and (4) patient education. Theophylline derivatives are considered useful by some for oral maintenance therapy of outpatients who do not respond optimally to inhaled b-agonists and corticosteroids. Treatment of acute asthma during pregnancy is similar to that for the nonpregnant asthmatic. First-line pharmacological therapy of acute asthma includes use of a b-adrenergic agonist, either epinephrine, isoproterenol, terbutaline, albuterol, isoetharine, or metaproterenol.
Renal diseases. Although some diseases of the kidney and urinary tract may be associated with pregnancy by chance, pregnancy often predisposes to the development of urinary tract disorders, an example being acute pyelonephritis. Infections of the urinary tract are the most common bacterial infections encountered during pregnancy. Although asymptomatic bacteriuria is more common, symptomatic infection may involve the lower tract to cause cystitis, or it may involve the renal calyces, pelvis, and parenchyma to cause pyelonephritis. Organisms that cause urinary infections are those from the normal perineal flora. There is now evidence that some strains of Escherichia coli have pili that enhance their virulence. In the early puerperium, bladder sensitivity to intravesical fluid tension is often decreased as the consequence of the trauma of labor as well as analgesia, especially epidural or spinal blockade. Sensations of bladder distension are also likely diminished by discomfort caused by a large episiotomy, periurethral lacerations, or vaginal wall hematomas. Asymptomatic bacteriuria refers to persistent actively multiplying bacteria within the urinary tract without symptoms and associated with preterm delivery and low-birthweight infants. Women with asymptomatic bacteriuria may be given treatment with any of several antimicrobial regimens. Selection can be chosen on the basis of in vitro susceptibilities, but most often is empirical. For example, treatment for 10 days with nitrofurantoin macrocrystals, 100 mg daily, has proved effective in most women. Other regimens include ampicillin, amoxicillin, a cephalosporin, nitrofurantoin, or a sulfonamide given four times daily for 3 day.
Acute pyelonephritis is the most common serious medical complication of pregnancy, occurring in 1 to 2 percent of pregnant women. The onset of pyelonephritis is usually rather abrupt. Symptoms include fever, shaking chills, and aching pain in one or both lumbar regions. There may be anorexia, nausea, and vomiting. The course of the disease may vary remarkably with fever to as high as 40°C or more and hypothermia to as low as 34°C. Tenderness usually can be elicited by percussion in one or both costovertebral angles. The urinary sediment frequently contains many leukocytes, frequently in clumps, and numerous bacteria. These serious urinary infections usually respond quickly to intravenous hydration and antimicrobial therapy. The choice of drug is empirical, and ampicillin, a cephalosporin, or an extended-spectrum penicillin is satisfactory. These serious urinary infections usually respond quickly to intravenous hydration and antimicrobial therapy. The choice of drug is empirical, and ampicillin, a cephalosporin, or an extended-spectrum penicillin is satisfactory.
^ Acute liver failure may be caused by fulminant viral hepatitis, drug-induced hepatic toxicity, or acute fatty liver of pregnancy. The latter is also called acute fatty metamorphosis or acute yellow atrophy, and fortunately it is a rare complication of pregnancy that often has proved fatal for both mother and fetus. Typically, there is onset over several days to weeks of malaise, anorexia, nausea and vomiting, epigastric pain, and progressive jaundice. In many women, vomiting is the major symptom. In perhaps half of these women, there is hypertension, proteinuria, and edema—signs suggestive of preeclampsia. Laboratory abnormalities include hypofibrinogenemia and prolonged clotting studies, hyperbilirubinemia of usually less than 10 mg/dL, and serum transaminase levels of 300 to 500 U/L. Peripheral blood shows hemoconcentration and leukocytosis, frequently mild thrombocytopenia, and evidence for hemolysis. In many woman, the syndrome worsens after diagnosis. Marked hypoglycemia is common, and obvious hepatic coma develops in 60 percent, severe coagulopathy in 55 percent, and there is evidence for renal failure in about half. Fetal death is common at this severe stage. Fortunately, either the disease is self-limited, or as generally accepted, delivery arrests rapid deterioration of liver function. During recovery, evidence for acute pancreatitis is common and ascites is almost universal. Recovery usually is complete and recurrence is rare.
Gestational diabetes. Gestational diabetes mellitus is defined as carbohydrate intolerance of variable severity with onset or first recognition during pregnancy. This definition applies regardless of whether or not insulin is used for treatment. Undoubtedly, some women with gestational diabetes have previously unrecognized overt diabetes. Because gestational diabetes is typically a disorder of late gestation, hyperglycemia during the first trimester usually means overt diabetes. The most important perinatal concern was excessive fetal growth, which may result in birth trauma. Importantly, more than half of women with gestational diabetes ultimately develop overt diabetes in the ensuing 20 years, and there is mounting evidence for long-range complications that include obesity and diabetes in their offspring. Except for the brain, most fetal organs are affected by macrosomia that commonly (but not always) characterizes the fetus of a diabetic woman. fat infants of diabetic women more often required cesarean delivery for cephalopelvic disproportion. Advances in the management of the diabetic patient, such as tig"' metabolic control, availability of the fetal lung profile, and fetal biophysics profile determination, have obviated the need for early delivery. If ™e maternal state is stable, blood glucose is in the euglycemic range, and indicate continued growth of a healthy baby, delivery may be delayed to terrn and spontaneous onset of labor awaited.
Infections. Rubella, or German measles, a disease usually of minor import in the absence of pregnancy, has been directly responsible for inestimable pregnancy wastage, and even more importantly, for severe congenital malformations. Confirmation of rubella infection is often difficult. Not only are the clinical features of other illnesses quite similar, but about one fourth of rubella infections are subclinical despite viremia and infection of the embryo and fetus. Antibody signifies an immune response to rubella viremia. If maternal rubella antibody is demonstrated at the time of exposure to rubella or before, it is exceedingly unlikely that the fetus will be affected.
Congenital cytomegalovirus infection, termed cytomegalic inclusion disease, causes a syndrome that includes low birthweight, microcephaly, intracranial calcifications, chorioretinitis, mental and motor retardation, sensorineural deficits, hepatosplenomegaly, jaundice, hemolytic anemia, and thrombocytopenic purpura.
II. Multiple Choice.
Choose the correct answer / statement:
1 The most frequent type of anemia in pregnancy is:
A - Iron-deficiency anemia;
g - Folate-deficiency anemia;
C - Vitamin B12-deficiency anemia,
2. Which of the following is Not characteristic of Willebrand's disease? A — Decreased factor VII;
B - Decreased factor VIII;
C - Family history of the disease;
D ~ Prolonged bleeding time.
3. The appropriate management for a pregnant patient with asymptomatic bacteriuria is:
A - No treatment;
B - Antibioti.es ;
C - Dietary alterations;
D - Changes of sexual behavior.
4. Infants born to mothers with insulin-dependent diabetes are at higher risk for:
A - Neonatal hyperbilirubinemia; B - Neonatal hypoglycemia; C - Hypocalcemia; D - Polycythemia; E - All of the above.
5- In the well-controlled diabetic with no complications, induction of is often undertaken at how many weeks' gestation? A - 40-42; B - 38-40: C - 36-38: D ~ 34-36; E - 32-34.
III. Answers to the Self- Assessment.
A. 2. B. 3. B. 4. E. 5.
Students must know:
1.Management during pregnancy and delivery in different medical illnesses.
2.Postpartum care in different medical illnesses.
3.Indications to medical abortion.
Students should be able to make:
l.Plan of management of the pregnant patients with different medical
2.Plan the treatment of the pregnant patients with different medical
3.Plan the delivery of the pregnant patients with different medicai
4.Plan the postpartum care of the pregnant patients with different
1. Danforth's Obstetrics and gynaecology. - Seventh edition.- 1994. - P. 351-
2. Obstetrics and gynaecology. Williams & Wilkins Waverly Company. - Third
Edition.- 1998. - P." 196 - 236.
3. Basic Gynecology and Obstetrics. - Norman F. Gant, F. Gary Cunningham. |
1993. - P. 444-456.
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