ภาวะแทรกซ้อนทางอายุรกรรม
และศัลยกรรม
Medical and surgical complications
พญ.ฐิตม
ิ า ชัยศรีสวัสดิสุ์ ข
กลุมงานสู
ตศ
ิ าสตรและนรี
เวชกรรม
่
์
รพ.สรรพสิ ทธิประสงค ์ อุบลราชธานี
Cardiac disease
Incidence
Complicate 1% of pregnancy
But contribute significant maternal morbidity and
mortality rate
Mortality rate is about 2.7 : 1000 pregnancy
Why we take cardiac dz
in pregnancy so serious?
Pregnancy induce worsen cardiac diseases during
antepartum, intrapartum and postpartum period
Physiologic change in hemodinamic of pregnancy
mimics clinical finding of cardiac dz.
Effect of pregnancy on
cardiac disease
Antepartum period
Cardiac output is increase by 30-50%
Total blood volume is increase about 50%
Increase heart rate by 10-20 beats/min
Decrease in peripheral vascular resistant
Effect of pregnancy on
cardiac disease
Intrapartum and delivery
Consumption of energy and oxygen is increase
Pain increases sympathetic tone
Uterine contractions induce wide swings in the
systemic venous return
Effect of pregnancy on
cardiac disease
Postpartum
Autotransfusion of at least 500 ml occur wiht
placental separation
During first 2 days of postpartum period, great
amount of fluid from interstitial tissue return into
the systemic circulation
Physiologic change in
pregnancy mimics cardiac
dz
Functional systolic heart murmur
Respiratory effort
Edema in the lower extremities
Various heart sounds may suggest cardiac dz.
Clinical indicators of
cardiac dz. in pregnancy
Symptoms
Progressive dyspnea
or orthopnea
Nocturnal cough
Clinical finding
Cyanosis
Clubbing of fingers
Hemoptysis
Persistent neck vein
distension
Syncope
Systolic murmur > gr.3
Chest pain
Diastolic murmur
persistent split 2nd
sound
Diagnostic study
EKG (15 degree left axis deviation, mild ST changes
in inferior leads, atrial and ventricular premature
contractions)
CXR
Echocardiography
Clinical classification of
cardiac dz.(New York Heart Association;
NYHA)
Class 1: Uncompromised -- no limitation of physical
activity
Class 11: Slight limitation of physical activity
Class 111: Marked limitation of physical activity
Class 1v: Severely compromised -- inability to
perform any physical activity without discomfort
Predictors of cardiac
complications
Prior heart failure, transient ischemic attack,
arrhythmia, or stroke
Baseline NYHA class 111 or 1v or cyanosis
Left-sided obstruction: mitral valve area <2cm2,
aortic valve area less than 1.5 cm2, or peak left
ventricular out flow tract gradient above 30 mm Hg
Ejection fraction less than 40%
Prognosis
The likelihood of a favorable outcome for the mother
with heart disease depends upon
1. Functional cardiac capacity
2. Other complications that further increase cardiac load
3. Quality of medical care provided
Valvular Heart Lesions Associated with High Maternal
and/or Fetal Risk During Pregnancy
Severe AS with or without symptoms
AR with NYHA functional class III-IV symptoms
MS with NYHA functional class II-IV symptoms
MR with NYHA functional class III-IV symptoms
Aortic and/or mitral valve disease resulting in
severe pulmonary hypertension
Aortic and/or mitral valve disease with significant LV
disfunction (EF < 40%)
Mechanical prosthetic valve requiring
anticoagulation
Marfan syndrome with or without AR
High-Risk Maternal Cardiovascular Disorders
Disorder
Estimated Maternal
Mortality Rate (%)
•
Aortic valve stenosis
10-20
•
Coarctation of the aorta
•
Marfan syndrome
10-20
•
Peripartum cardiomyopathy
15-60
•
Severe pulmonary hypertension
50
•
Tetralogy of Fallot
10
5
Management in cardiac
diseases
Preconceptional
counseling
Maternal mortality rates vary directly with functional
classification BUT may change as pregnancy
progresses.
By corrective surgery, subsequent pregnancy is less
dangerous. If mechanical valves taking warfarin, fetal
risk should be consider.
Congenital heart lesions could be inherited.
Congenital heart disease risks in fetus
with affected family members
Management of NYHA
Class I and II Disease
Mostly deliver without morbidity
Prevention and early detection of heart failure
Prevent infection and sepsis syndrome
Prevention of bacterial endocarditis
Pneumococcal and influenza vaccination
Avoid smoking, intravenous drug use
Signs of congestive heart
failure
Warning signs
Serious signs
Persistent basilar
rales
Sudden limitation of
normal activities
Nocturnal cough
Dyspnea on exertion
Smothering with cough
Hemoptysis,
Progressive edema,
tachycardia
Labor and delivery
Rout of delivery
Vaginal delivery with short second stage unless
obstetrical indication is obtained for C/S
Monitory
V/S : if PR > 100 bpm or RR > 24 tpm with dyspnea,
may suggest impending ventricular failure
Analgesia and
Anesthesia
Epidural analgesia is recommended in most case
General anesthesia is preferable in case of
intracardiac shunts, pulmonary hypertension and
aortic stenosis
Labor and delivery
Intrapartum heart failure
Proper therapeutic approach depends on the specific
hemodynamic status and the underlying cardiac
lesion.
Puerperium
Woman who have no evidence of cardiac distress
during pregnancy, labor, or delivery may still
decompensate postpartum
Avoid : Postpartum hemorrhage, anemia, infection,
and thromboembolism ( cause much more serious
complication in heart disease)
Contraception
Sterilization : should delay until hemodynamically
near normal, afebrile, not anemic and ambulates
normally
Oral combine pills: should avoid because they can
induce thrombosis
DMPA: can use safely, but hematoma should be
monitors
Implant: safely use, less hematoma complication
IUDs: safely use, but ATB should be given for
endocarditis prevention
Management of NYHA
Class III and IV Disease
Pregnancy interruption is preferable
If the pregnancy is continued, prolonged
hospitalization or bed rest is often necessary
Epidural analgesia usually recommended
vaginal delivery is preferred in most cases, and labor
induction can usually be done safely
C/S is limited to obstetrical indications
Need ICU care, experienced obstetrician and
anesthesiologist
Valve replacement before
pregnancy
Effects on pregnancy
Mechanical valve itself doesn’t effect on pregnancy.
Thromboembolism involving the prosthesis and
hemorrhage from anticoagulation are of extreme
concern
Overall; maternal mortality rate = 3-4% with
mechanical valves, and fetal loss is common
Management
The critical issue for mechanical prosthetic valves is
anticoagulation: thromboembolic issue VS bleeding ,
teratogenic issue
Anticoagulation agent
Warfarin
Most effective to prevent mechanical valve
thrombosis
Cause teratogenic and miscarriage, still birth and
fetal malformation
Highest risk is when mean daily dose exceeded 5
mg
Anticoagulation agent
Low dose unfractionated heparin
No teratogenic issue
Is definitely inadequate control of thromboembolism
Unfractionated heparin or low-molecular-weight
heparins
Report of valvular thrombosis
ACOG(2002) advised against use of LMWH during
pregnancy.
American College of Chest Physicians has
recommended us of UFH or LMWH given throughout
American College of Chest Physicians Guidelines for Anticoagulation
of pregnant women with mechanical prosthetic valves
Bacterial endocarditis
prophylaxis
Estimate incidence of transient bacteremia at
delivery is 1-5%
ATB prophylaxis is optional for uncomplicated
delivery
Regimen recommended
Ampicillin 2 g. or cefazolin/ceftriaxone 1 g. IV 30-60
minutes before the procedure
For penicillin-sensitive pt. : Cefazolin/ceftriaxone 1
g., or if anaphylaxis, Clindamycin 600 mg IV 30-60
minutes before the procedure
American Heart Association Guidelines for Endocarditis Prophylaxis
with Dental Procedures
Thyroid Disorders
Thyroid physiology and
pregnancy
Thyroid binding globulin
90
TSH
in early pregnancy
Thyroxine cross placenta
and is important for normal
fetal brain development
and fetal thyroid gland
function
Hyperthyroidism
1:1000 - 2000 pregnancies
Mild thyrotoxicosis may be difficult to Dx during
pregnancy
Most common cause : Graves disease
Molar pregnancy should be considered
Clinical features suggestive of possibility of
hyperthyroidism
Historical
Prior Hx of thyrotoxicosis/autoimmune thyroid dz in pt
or in her family
Presence of typical symptoms of thyrotoxicosis : weight
loss ( or failure to wt gain), palpitations, proximal
muscle weakness
Symptoms suggestive of Graves disease like
opthalmopathy, pretibial myxedema
Thyroid enlargement
occurrence of hyperemesis gravidarum leading to wt
Clinical features suggestive of possibility of
hyperthyroidism
Physical examination
Pulse > 100 bpm
Widened pulse pressure
Eye signs of Graves disease or pretibial myxedema
Thyroid enlargement esp. in iodine sufficient
geographical area
Onycholysis
Diagnosis
confirmed by laboratory tests
Serum TSH <0.1 mIU/L
Elevated Serum FT4 & FT3 levels
Thyroid autoantibodies
Graves disease in pregnancy
Women with active Graves dz Dx pregnancy
Women who are in remission and considered cured
after primary treatment
Women who is in diagnosis of Graves dz has not
been established before the onset of pregnancy but
have TSHR Ab
Both maternal & fetal outcome is directly related to
adequate control of hyperthyroidism
Graves disease in pregnancy
Obstetric complication : Preeclampsia, fetal
malformations, premature delivery, low birth weight
The risk of fetal and neonatal hyperthyroidism is
negligible in euthyroid women not currently receiving
ATD, but had received ATD previously for graves dz
For euthyroid women who has previously received
radioiodine therapy or undergone thyroid surgery for
graves dz, the risk of fetal & neonatal
hyperthyroidism depends on level of TSHR Ab in
mother
So these antibodies had to be measured early in
pregnancy to evaluate the risk
Graves disease in pregnancy
For pregnant woman who takes ATDs for active
graves dz, TSHR Ab should be checked again in 3rd
trimestter
If the Ab titers have not decreased during the 2nd
trimester, the possibility of fetal hyperthyroidism is to
be considered
Graves disease in pregnancy
Hyperthyroidism due to graves tends to improve
during pregnancy. ( Although exacerbations in early
months of pregnancy)
Reasons
Partial immunosuppression (due to pregnancy) with
significant decrease in TSHR Ab titer
Marked increase serum TBG = reduce FT3 & FT4
Management of
hyperthyroidism
Monitor PR, wt gain, thyroid size, FT4, FT3, TSH
monthly)
Use lowest dose of ATD (not > 300mg of PTU) :
maintain euthyroid or mildly hyperthyroid state.
Follow fetal pulse & growth
Should Not attemp full normalization of serum TSH
(Keep TSH 0.1-0.4 mU/L ) lower levels are
acceptable if pt is doing well clinically
Management of
hyperthyroidism
Propylthiouracil (PTU) is preferred to methimazole,
but both can be used
Methimazole could cause embryopathy (esophageal
or choanal atresia or aplasia cutis)
Iodides should not used during pregnancy unless for
preparing the patient for surgery
Management of
hyperthyroidism
Indication for surgery
Requirement for high doses of PTU/MMI with
inadequate control of clinical hyperthyroidism
Poor compliance with resulting clinical
hyperthyroidism
Appearance of fetal hypothyroidism at dose required
to control disease in mother
Management of
hyperthyroidism
Usually the dose of ATD can be adjusted downward
after 1st trimester & discontinued during 3rd trimester
ATDs often need to be reconstituted/increased after
delivery
Thyroid storm and heart failure
Pulmonary hypertension and heart failure from
cardiomyopathy caused by thyroxine is common in
pregnant women
High-output state
dilated cardiomyophthy
Cardiac decompensation is usually precipitated by
preeclampsia, anemia, sepsis, or combination
Fortunately, thyroxine-induced cardiomyopathy and
pulmonary hypertension are frequently reversible
Thyroid storm and heart failure
Management
ICU is needed
1000mg of PTU orally the 200mg every 6 hr
An hour after initial PTU, iodide is given to inhibit
thyroidal release of T3 & T4
Sodium iodide 500-10000mg of sodium iodide IV
every 8 hrs.
Supersaturated solution of potassium iodide
(SSKI) 5 drops or Lugol solution 10 drops orally
every 8 hr
Thyroid storm and heart failure
Management
Dexamethasone 2 mg IV every 6 hrs. for IV dose for
blocking peripheral conversion of T4 to T3
Beta-blocker drug is given to control tachycardia
Coexisting severe preeclampsia, infection, or anemia
should be aggressively managed
Hypothyroidism
Cannot be diagnosed based on clinical features
Usually diagnosed using biochemical tests
Characterised by raised TSH level
Affects 2.5% of all pregnancies
In iodine sufficient areas, most common cause is
Hashimoto’s thyroiditis
Diagnosis of maternal hypothyroidism is important as
has implication on both maternal and fetal outcomes
Adverse outcomes of maternal hypothyroidism
Maternal disorders
Fetal disorders
Abortion
Preterm birth
Gestational
hypertension
Fetal and perinatal death
Increased C/S
Disorders of brain
development
Anemia
Low IQ scores
Placental abruption
Fetal respiratory distress
Preterm labour
Low birth weight
Postpartum hemorrhage
Cretinism
Diagnosis
Difficult to detect hypothyroidism during pregnancy
base on symptoms & signs alone
Diagnosis is made by Serum TSH
Serum TSH that is more than upper limit of normal
should alert the clinician to diagnosis
Total or FT4 must be checked during screening
As low T4 even with normal TSH is considered
abnormal (especially in iodine deficient zone)
Management
Levothyroxine is treatment of choice
Dosage: 2ug/kg/day
Subclinical hypothyroid OR TSH < 10 mU/L starting
dose is 50-100 ug/day
Pregestational hypothyroidism require a 25-47%
increase in dosage
Hypothyroid woman taking levothyroxine becomes
pregnant, the dose is increased by 25-50 ug as soon
as pregnancy is diagnosed
Management
Iron and calcium tablets should not take
simultaneously with levothyroxine, may be taken 4
hrs after taking levothyroxine
Monitor
First half of pregnancy - monitor Ft4, TSH every 4
wks
Later on every 6 wk
Target TSH in 1st trimester <2.5 mU/L
Target TSH in 2nd 3rd trimester <3 mU/L
Management
Post delivery dose should reduced to pre-pregnancy
dose
Thyroid function should be re-checked 6 wks after
delivery
Surgical complication in
pregnancy
Appendicitis
1:2000 to 1:6000
pregnancies
Difficult diagnosis
Intermediate
intervention is a must
Diagnosis
Some time difficult in pregnancy
Displacement
Distorted lab values
Mimic symptoms
Mimic other conditions
Leukocytosis
N/V, Tachycardia
Diagnosis
Mimic conditions
Cholecystitis
Preterm labor
Pyelonephritis
Renal colic
Placental abruption
Degenerative myoma
Symptoms & Signs
1975 Study Parkland: 34 pts over 15 year
Direct abdominal tenderness is rarely absent
Rebound tenderness 55-75%
Rectal tenderness: especially 1st trimester
Anorexia is only 1/3-2/3 pts, VS almost 100% in
non pregnancy
(Cunningham 1975)
Diagnostic test
Ultrasound
CT scan
MRI
Ultrasound
Difficult: cecal displacement and uterine imposition
CT scan
Numerous report in
surgical literature
suggesting accuracy of >
97% in non-pregnant
patient
2008 study reported
Negative
appendectomy rate
was 54% with clinical
Dx alone
8% if U/S +CT scan
CT scan
* NO evidence of any increased risk of teratogenicity with
exposure of up to 5 Rads
CT scan and teratogenicity
Maximal risk at 1 rad is 0.003%
15% embryos naturally abort
2.7-3.0% have genetic malformations
4% IUGR
-8-10% late onset genetic abnormalities
(Brent RL. 1989)
Risks if untreated
Preterm contractions/ labor
Rupture leading to peritonitis
Sepsis
Fetal tachycardia
Maternal/fetal death
Risks if untreated
Increased GA = Increased complication
Uterine contraction - as high as 80% of pts > 24 wks
GA
Appendiceal perforation
4-19% non- pregnant pts
57% pregnant pts (inability to isolate infection by
omentum)
Am Sur 2000
Incidence of perforation = 8, 12, 20 percent in
successive trimesters
“ The mortality of appendicitis
complicating pregnancy is the
mortality of delay”
Babler 1908
Management
Suspicion:
Immediate surgery (Laparotomy VS Laparoscopy)
Delay:
Generalized peritonitis
Antibiotics
Perioperative 2nd cephalosporin/ 3rd penicillin, may
be discontinued post-op,
Laparoscopy
Safe - esp. in first 20 wks
Risk
Low birth weight
Preterm labor
Fetal growth restriction (no diff. VS laparotomy)
Fetal acidemia (CO2 Pneumoperitoneum)
General anesthesia
General anesthesia considered safe
May increase risk of neural tube defects and
hydrocephaly when general anesthesia is used in
first trimester
Gall bladder
Increased biliary sludge
in pregnancy
Increase bile viscosity
Increased micelles
Gall bladder relaxation
Increased risk of
gallstone formation
Cholelithiasis cause of
90% of cystitis
0.2-0.5/1000 pregnancies
require surgery
Symptoms
May be asymptomatic
2.5-10% of pregnant patient
RUQ pain- most reliable symptom
pain may radiate to back
Vomiting approx 50%
Can mimic appendicitis in 3rd trimester
Workup
Ultrasound
Effective rate 90%
Liver enzymes
Amylase, Lipase
CBC
Management
Several studies - Conservative vs. Surgical
Current management favour surgical management
Conservative treatment trend to be high
recurrence rate during the same pregnancy and if
in later gestation : Incidence of preterm labor is
higher
Surgical Management
Laparoscopic approach is safe, generally to 3rd
trimester
Slight increase of low birth weight
Slight increase of infant death within 7 day
Increase in contractions esp. > 24 wk
Ovarian cyst
Est. 1:200 deliveries
(adnexal masses)
Est.1:1300 adnexal
mass require surgery
Adnexal Masses
1990 Study
Whitecar 1990
130 pregnancies
5% malignant rate: >1/2
serous carcinoma of LMP
30% cystic teratomas
28% serous/mucinous
cystadenoma
13% corpus luteal
7% benign
Complications
Ovarian torsion
Most common and serious
sequelae
5% occurrence
most common at 10-14 wks
GA and immediate postpartum
Rupture ovarian cyst
Most common in 1st trimester
Managements
Best approach:
<5 cm : expectant management
5-10 cm: watch unless complex on sonography
if > 6 cm after 16 wks GA : surgery is required