By The Name Of Allah MEDICAL
DISEASES
COMPLICATING
PREGNANCY
Maysam Hamarsheh
Both pregnancy specific and pre-existing medical *
conditions may in some circumstances be associated with
significant maternal and fetal morbidity and, more rarely,
.mortality
What the pregnant woman with medical
:disease/s wants to know
Will I have a normal healthy baby? •
• Will pregnancy make my disease worse?
• Will my disease be worse after pregnancy?
• Is there a risk of my children inheriting my
condition?
• What treatment is safe during pregnancy?
• Can I have an epidural?
• Should I be delivered by Caesarean section?
?• Is breastfeeding advisable
:Medical diseases complicating pregnancy includes
.Haematological abnormalities .1
.Neurological disorders .2
.Respiratory diseases .3
.Heart disease .4
.Hypertensive disorders .5
. Renal disease .6
.Gastroenterology .7
.Psychiatric disorders .8
.Liver disease .9
.Connective tissue disease .10
.Endocrinology .11
.Skin disease .12
Medical diseases
complicating
pregnancy
HAEMATOLOGICAL
ABNORMALITIES
Physiological changes in Pregnancy
RBC mass increase by 30% -
- WBC count increases progressively
- ESR increases because of increased gamma globulins
- Plt count unchanged
- Factors 5,7,8,9,12 and vWF increase leading to a hypercoagulable
.state
Haematological abnormalities
Anemia
Thrombocytopenia
Bleeding disorders
Thrombophilias
Thrombophilias
• It is an abnormality of blood coagulation that increases the risk of
thrombosis .
• Pregnancy is a state that conveys 4-5 times the risk of venous
thromboembolism(VTE).
• Thrombophilias are a common and important risk factor for VTE in
pregnancy ( second most common cause).
• Evidence is conflicting whether thrombophilias convey additional
risk of other adverse pregnancy outcomes such as recurrent
pregnancy loss (RPL), stillbirths, abruption, or preeclampsia
Thrombophilias
Inherited thrombophilia
Acquired thrombophilia
Inherited Thrombophilias
Factor V Leiden mutation
Protein C deficiency
Protein S deficiency
Anti-thrombin deficiency
Prothrombin gene mutation
Inherited Thrombophilias
High risk
Homozygous Factor V mutation
Homozygous PGM
All Anti-thrombin deficiency
Low risk
Heterozygous Factor V
Heterozygous PGM
Protein S and protein C deficiency
General rules for management
Anticoagulation options
UFH ( unfractionated heparin): can be use antepartum
and postpartum
Advantages : Inexpensive and can be reversed with
protamine sulfate
Disadvantages : can’t used orally, needs monitoring with
PTT levels, HIT( heparin induced thrombocytopenia
General rules for management
LMWH ( Low Molecular Weight Heparin): can be use
antepartum and postpartum
Advantages : less needs for monitoring
Disadvantages : can’t used orally, expensive and can’t be
reversed easily
General rules for management
Warfarin : can be used only postpartum
Advantages : oral, long half-life, inexpensive and OK for
breastfeeding
Disadvantages : crosses placenta and needs monitoring
w/ INR
General rules for management
Antepartum :
No prophylactic : low risk thrombophilia without
Vascular thrombotic episodes ( VTE)
Prophylactic or intermediate dose:
• Low risk thrombophilia with single VTE
• High risk thrombophilia
Therapeutic dose :
• High risk thrombophilia with single VTE
• Any thrombophilia with VTE in current pregnancy
General rules for management
intrapartum : Discontinue Anti-coagulation.
>> to decrease risk oh hemorrhage and permit anasthesia
>> protamine sulfate cn be used
Postpartum :
VTE risk increased 20 fold in the first week
postpartum
All patient should receive anticoagulation even if they
didn’t receive it antepartum
6 hours after vaginal delivery and 12 hours after
cesarean section
Acquired Thrombophilias
Anti-phospholipid syndrome
Anti-phospholipid syndrome
ITis an autoimmune hypercoagulable disorder
defined by both the presence of characteristic clinical
features and circulating anti-phospholipid antibodies
Canbe primary or secondary-associated with other
autoimmune diseases
Anti-phospholipid syndrome
IT provokes thrombosis in both arteries and veins
Can cause recurrent miscarriages, stillbirth, preterm
delivery and severe preeclampsia
Diagnosis require at least one clinical and one
laboratory criteria met
Anti-phospholipid syndrome
Clinical Criteria for diagnosis
Vascular thrombosis: one or more clinical thrombotic
episodes ( Arterial, venous or small vessels.
Pregnancy morbidity (unexplained): fetal death, one
or more at >10 weeks, or consecutive miscarriages, 3
or more <10 weeks
Anti-phospholipid syndrome
Laboratory Criteria for diagnosis :
one or more of the anti-phospholipid antibodies should be positive
on at least two occasions at least 12 weeks apart.
Lupus anti-coagulant
Anti-cardiolipin antibodies (IgG and IgM)
Anti-β-2-glycoprotein ( IgG and IgM)
Management
Antepartum :
Assessment of fetal growth monthly
Prophylactic heparin
Intrapartum : Stop Anti-coagulant
Management
Postpartum:
Resume anti-coagulant in 6h after vaginal delivery
and in 12h after cesarean section for six weeks, using
either heparin or warfarin.
Connective
tissue disease
SLE
Rheumatoid arthritis
scleroderma
Autoimmune disease > more in women
Incidence : 1 per 1000 women
more in blacks and Asian
It may cause disease in any system, but principally
it affects the joints (90 %), skin (80 %), lungs,
nervous system, kidneys and heart.
Diagnosis
finding of a positive assay for antinuclear
antibodies
presence of antibodies to double-stranded DNA
(most specific for SLE)
By ACR criteria , If 4 of the 11 criteria are present
serially or simultaneously, a person is said to have
SLE.
American College of Rheumatology (ACR)
criteria for classification of SLE
Pregnants w/ SLE are in risk for :
APS
Kidney problems
pre-eclampsia
repeated pregnancy loss
anti-Ro/LA antibodies, which cross the placenta
causing immune damage in the fetus ( neonatal
lupus , cong. Heart block)
: Treatment
Antenataly : SLE, steroids, azathioprine,
sulphasalazine and hydroxycloroquine may be given
safely
NSAIDs : should be avoided in the third trimester
because of adverse effects on the fetus
In women w/ APS : combined use of low dose
aspirin and low-molecular-weight heparin .
Liver diseases
: Intra hepatic cholestasis in pregnancy
Increased estrogen levels lead to increased
cholesterol secretion and supersaturation of bile,
and increased progesterone levels cause a decrease
in small intestinal motility.
Risk is increased with twins.
high recurrence rate with subsequent pregnancies.
:Diagnosis
symptoms : intractable pruritus on the palms and
soles of the feet, worse at night, without specific
skin findings (most significant)
Laboratory tests show a mild elevation of bilirubin
serum bile acids increased (10-100) fold.
: Management
intravenous fluids
correction of electrolytes
bowel rest
pain management
broad-spectrum antibiotics.
Oral antihistamines (mild cases)
Cholestyramine has been used to decrease
enterohepatic circulation
Ursodeoxycholic acid(ursodiol) is the treatment
of choice.
Induce labor at 38 weeks gestation.
>> However, relapse rates (40–90%) are high
during pregnancy.. surgical intervention may be
warranted, preferentially performed in the 2nd
trimester.
: Acute liver injuries
Acute viral hepatitis :
commonest cause of jaundice in pregnancy
worldwide
in the first trimester of pregnancy is associated
with a higher rate of spontaneous miscarriage
Hepatitis E is more likely to lead to fulminant
hepatic failure in pregnancy, and is more common
in primagravida and in the third trimester.
acyclovir have dramatically improved outcomes.
Incidence :
hepatitis A : around 1 in 1000 ,, fetal transmission is
extremely rare
hepatitis B : 1–2 per 1000 p (1.5% of pregnant women
are chronic carriers.)
hepatitis C : 1–2 per 100 (associated with several
adverse pregnancy outcomes , as :
preterm rupture of membranes
gestational diabetes
low birthweight
neonatal unit admission.)
Acute fatty liver :
rare life-threatening complication of pregnancy
that usually occurs in the third trimester
Prevalence :1 in 15,000
Maternal mortality rate is 20%
caused by : disordered metabolism of fatty acids
by mitochondria , caused by deficiency in the
long-chain 3-hydroxyacyl-coenzyme A
dehydrogenase (LCHAD) enzyme.
Symptoms are gradual :
- nonspecific flulike symptoms including nausea,
vomiting, anorexia, and epigastric pain.
- Jaundice and fever in (70% of patients.)
- Hypertension, proteinuria, and edema
- may progress to involvement of additional
systems (acute renal failure, pancreatitis, hepatic
encephalopathy, and coma)
Laboratory findings :
moderate elevation of liver enzymes (e.g., ALT,
AST, GGT), hyperbilirubinemia, DIC !.
Hypoglycemia and increased serum ammonia
unique laboratory abnormalities
Management :
Intensive care unit stabilization with acute IV
hydration and monitoring is essential.
• Prompt delivery is indicated.
• Resolution follows delivery if mother survives
