Maternal Mortality and Medical problems (Medical disorders in pregnancy) Flashcards Preview

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Flashcards in Maternal Mortality and Medical problems (Medical disorders in pregnancy) Deck (15):

Causes of maternal deaths - the three groups and examples?


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


Physiological changes in normal pregnancy?
(Cardiac, Resp, Renal, GI, Metabolic, Hematologic)

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)


Resuscitation in a pregnant woman, things to consider?

- 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)

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)


Cardiac disease in pregnancy
- during pregnancy

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


Cardiac disease in pregnancy
- in labour

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


Cardiac disease in pregnancy
- postpartum

Rapid increase in preload post-delivery
- fixed output lesions
-poor LV function
- pulmonary hypertension



Worst cardiac lesions to have in pregnancy?

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


Pre-pregnancy counselling session for woman with cardiac disease

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


Cardiac: Mx in pregnancy

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

- echo for congenital heart disease
- surviellance for growth


Cardiac: Mx in labour

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


Abx for SBE prophylaxis

Syntocinon for stage 3 (avoid spike in venous return)


Cardiac: Mx in post-natal

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


Thromboembolism in pregnancy
- incidence
- risk factors
- risk delivery/post-natal

- 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)


Thromboembolism in pregnancy
- detection
- treatment

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)


Imaging in pregnancy - risks? recommendations?

Effect depends on radiation dose and gestation at exposure
- risk at W3-W11 post conception (ok


Cardiac messages to remember

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