MINISTRY OF PUBLIC HEALTH OF UKRAINE
NATIONAL PIROGOV MEMORIAL MEDICAL UNIVERSITY, VINNYTSYA
CHAIR OF OBSTETRICS AND GYNECOLOGY №1
Methodological instruction for practical class for foreign students
Medical illnesses and extragenital pathology during pregnancy
MODULE 2: Obstetrics and gynecology
CONTEXT MODULE 9: Pathology of pregnancy, labor and puerperium
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.
Basic level:
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.
STUDENTS' INDEPENDENT STUDY PROGRAM
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.
Key words and phrases: medical conditions of pregnancy.
Summary
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.
Heart disease complicates 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.
Clinincal classification

Class I. Uncompromised: Patients with cardiac disease and no limitation of
physical activity. They do not have symptoms of cardiac insufficiency, nor do they
experience anginal pain.

·
Class II. Slightly compromised: Patients with cardiac disease and slight
limitation of physical activity. These women are comfortable at rest, but if ordinary
physical activity is undertaken, discomfort results in the form of excessive fatigue,
palpitation, dyspnea, or anginal pain.

·
Class III. Markedly compromised: Patients with cardiac disease and
marked limitation of physical activity. They are comfortable at rest, but less than
ordinary activity causes discomfort by excessive fatigue, palpitation, dyspnea, or
anginal pain.

·
Class IV. Severely compromised: Patients with cardiac disease and
inability to perform any physical activity without discomfort. Symptoms of cardiac
insufficiency or angina may develop even at rest, and if any physical activity is
undertaken, discomfort is increased.
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.
Management of Chronic Asthma.
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 bagonists 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 fatty liver failure. 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.

Management. There is no effective therapy for maternal infection Primary
infection is diagnosed by fourfold increased IgG titers in paired acute and
convalescent sera measured simultaneously, or preferentially by detecting IgM
cytomegalovirus antibody in maternal serum. Recurrent infection usually is not
accompanied by IgM antibody production. Unfortunately, neither of these methods
is totally accurate to confirm maternal infection.

Counseling regarding fetal outcome depends on the stage of gestation during
which primary infection is documented. Even with a high infection rate with
primary infection in the first half of pregnancy, the majority of infants develop
normally.
Assignments for Self - assessment.
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 illnesses.
2.Plan the treatment of the pregnant patients with different medical illnesses.
3.Plan the delivery of the pregnant patients with different medical illnesses.
4.Plan the postpartum care of the pregnant patients with different medical illnesses.
References:
1. Danforth's Obstetrics and gynaecology. - Seventh edition.- 1994. - P. 351464.
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.