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If no history – then may be diagnosed by finding a significant arrhythmia, cardiac
enlargement on X-ray; cyanosis or clubbing, persistent jugular venous distention or adiastolic or presystolic murmur. Systolic murmurs may be functional.
Blood volume increases 5O% by 30th week of gestationSystemic vascular resistance decreasesRisk of both hypercoagulability and hemorrhage
Counsel regarding: maternal morbidity and mortality; fetal morbidity; inheritance ofcardiac defect; teratogenic effects of anticoagulant therapyBed restAntibiotic prophylaxis (not needed with porcine grafts)Antenatal fetal surveillance - assure adequate maternal and fetal oxygenationCautious fluid infusionIntrapartum invasive cardiac monitoring (C.O. fluctuates intrapartum and post-
Epidural anesthesia; operative vaginal delivery
New York Heart Association Classification:
Class I — No limitation of physical activity (asymptomatic)Class II —Slight limitation of physical activityClass III —Marked limitation of physical activityClass IV —Complete limitation of activity (symptomatic at rest)
Other adverse prognosticators include: PaO2 < 60mmHg; hematocrit >65%; EKG changes;cardiomegaly; CHF.
Ideally the pt should be evaluated by a cardiologist prior to conception so that all possiblesteps can be taken to ensure adequate cardiac reserve.
EISENMENGER SYNDROME AND OTHER CONDITIONS WITH PULMONARY HTN.
---Low SVR -> right to left shunting -> pulmonary hypoperfusion -> hypoxemia—The maternal risk of death may be as high as 50%--- Thromboembolism accounts for nearly half of deaths--- Death commonly occurs in the postpartum period--- Avoid hypotension
—Significant risk of aortic dissection during pregnancy.
—Pts with dilated aortic root in echocardiography are at greatest risk
—Most common form of heart disease seen by obstetricians—Most pts with MVP will have a systolic click, and no other abnormality on clinical
exam, echocardiography will image the prolapse.
Such pt will have a safe and unaffected pregnancy
---Most common Rheumatic Heart disease found in pregnancy.
—The Inc in CO, (HR and Blood volume) impose a tremendous stress
—Dyspnea is often present by 20 weeks gestation
— Tachycardia causes decreased filling time and hypotension results
—Rare complication in pregnancy.
—Mortality rates as high as 17% have been reported---Avoid tachycardia, hypotension and fluid overload.
--- Need high PCWP--- Risk of coronary and cerebral hypoperfusion--- Frequently have ischemic heart disease
--- Difficult to compensate in pregnancy--- Nitrates safe in pregnancy--- If MI; better if deliver after 2 weeks elapsed
--- Tachycardia of pregnancy reduces opportunity for regurgitation and therefore iswell tolerated--- Preeclampsia may exacerbate
--- Pre-coarctation aneurysms may rupture--- Check for intercostal dilation
—Surgical Correction of these lesions is often performed in childhood.
—Small defects are usually associated with a good pregnancy outcome.
-In pts who develop pulmonary HTN, mortality of 50% has been reported.
—The most common obstructive pulmonary disease in pregnancy.
— 18-28% improve--- 35-42% exacerbate— 33-40% no change
Course of asthma in each pregnancy is often similar
Chronic Asthma: mild - <2 brief attacks / week
Treated with inhaled β2-agonist – bronchodilates within 5 minutes
Treated with inhaled corticosteroid (may cause oral candida, purpura, cataracts anddermal thinning) or cromolyn continuously (theophylline if nocturnal symptoms arepresent) and with β2-agonists intermittently
Treatment as above; may need oral corticosteroid; may cause hypothalamic-pituitary-axis suppression; need to administer IV hydrocortisone 100mg q80 x 240when in labor.
- No increase in rate of fetal malformations in the asthmatic patient- Antenatal fetal surveillance - assure adequate maternal and fetal oxygenation- Encourage trigger avoidance- CDC recommends yearly administration of influenza vaccine to all pts with chronic
asthma. Killed vaccine that can be administered during pregnancy
- Incidence of preeclampsia is slightly higher- PGE2 not PGF2α
- Acute asthma attacks are unusual during labor- In labor epidural anesthesia is preferred for labor and cesarean section
General anesthesia carries a risk of atelectasis and subsequent chest infection
Acute Asthma: Exacerbations of the disease are associated with respiratory tract infections
Differential Diagnosis includes: pulmonary edema; pulmonary embolism; bronchitis;pneumonia; mechanical obstruction; cystic fibrosis
Evaluation: jugular venous distention; cyanosis; accessory muscle use; ambulation; sputum
temperature; respiratory rate; FEV1 ; PEFR; ABG; leukocytosis
Therapy:--- Oxygen--- Beta sympathomimetic
—may be administered as inhaled; oral; or subcutaneous preparations
— Albuterol (aerosolized) and Terbutaline (oral and subQ) are commonly used.
—Epinephrine ( alpha and beta agonist) can decrease uterine blood flow and thusdecrease fetal oxygenation
--- If no improvement, FEV1 or PEFR <40% of predicted by 10 or <70% by 40 or patient
already on oral steroids consider hospitalization for corticosteroids
— IV until improvement; then oral. Fetal adrenal suppression may occur (rare).
—The most common acute surgical condition in pregnancy.
—Incidence of 1 in 2000 births.
—Same frequency in all trimester as well as the puerperium.
— Dx is delayed because clinical pictures masked by symptoms of pregnancy.
—Factors that confuse the dx:- N&V,— abdominal discomfort of early pregnancy,— upward displacement of the appendix by the enlarging uterus,— laxity of the abdominal wall,— round ligament spasm,— physiologic leukocytosis,— . and elevated sed rate.
—S&S similar to those in the nonpregnant patient.
—Initial pain colicky , referred to the epigastrium or paraumbilical.
—First .trimester pain localized in RLQ.
—After the 4th month of gestation , the appendix is displaced
-Anorexia, N&V begins 1 to 2 hours after the onset of pain.
—Temp may be normal or moderately elevated, up to 1010F.
-leucocytosis and an increasing left shift.
-Xrays not helpful in making the dx.
-Pyelonephritis-Round ligament pain—torsion of ovarian cyst-Degenerating myomata—Pancreatitis
-Appendectomy—If unruptured appendix: no antibiotics , drainage or tocolytics necessary.
—If ruptured: multiple antibiotic therapy , drainage to prevent an abscess or
-More common in pregnancy—Incidence is 1 in 4,000 pregnancies
DX: —Clinical picture no different from that in nonpregnant.
---Biliary colic, N&V, Fever, leucocytosis.
—Ultrasound will detect stones or dilatation of the common
bile duct. If stones and a positive Murphy’s : Cholecystitis.
-Medical management suffices in most cases.
—Antibiotics, IV fluid, N suctioning, antispasmodic1, analgesics with the expectationof recovery in 48 hrs or less.
If common duct obstruction or pancreatitis develops, a cholecystectomy will benecessary and should not be delayed. There is considerable risk of preterm laborfollowing the operative procedures.
--- 1.8/1000; 5-20% mortality--- Fetal infection incarries: 4% if risk factors; 0.5% without--- With routine cultures, 26.7% of women will be treated; 86% prevention--- With treatment based on risks; 18.3% treated; 68.8% prevention
--- Highly contagious; incubation 11-21 days (mean 15)
--- Secondary viremia present 48 hrs prior to rash – infectious
--- Limb hypoplasia; scars; chorioretinitis; cataracts; cortical atrophy; and microcephaly--- Infection only between 6-20 weeks and risk is low--- Neonatal infection if baby born between two days prior to or 5 days after maternal rash--- Need quarantine; placenta infectious as well--- 10-30% develop pneumonia with a 40% mortality rate--- Antiviral drugs within 72hours
RUBELLA— A moderately contagious, mild exanthematous illness caused by an RNA virus.
— Spread via nasopharyngeal secretions.
--- Characterized by fever, lymphadenopathy , and a transient erythematous rash.
— The virus can be isolated from the bloodstream and throat 7 to 10 days after exposure.
The rash starts on the face 16 to 18 days after exposure—Serologic tests confirm the dx. Antibody level (IgG) is themost commonly used type of screening test.
--- 90% of population is seropositive--- 80% of infections are prior to reaching reproductive age.
Primary maternal infection during early pregnancy may involve the embryo or fetus.
Pregnant women w.ith confirmed rubella infections should be counseled regarding thetypes and risks of congenital anomalies.
Risk of anomalies from rubella :
50% in the first month of gestation10% by the third month of gestation
**CATARACTS, PATENT DUCTUS ARTERIOSUS AND DEAFNESSThe most common abnormalities associated with congenital rubella syndrome.
Deafness is common even after 2nd trimester exposure prior to 20 weeks
—The clinical dx of rubella is often difficult because it resembles other exanthems.
Rubella vaccines contain live attenuated virus. After vaccination, about 95% of susceptibleindividuals develops antibodies , which provide long term protection.
Rubella susceptible women of child bearing age should be vaccinated and it isrecommended that they avoid pregnancy for 90 days after immunization.
The postpartum period is an excellent time for immunization susceptible women. Newlyvaccinated women may breastfeed without fear of adverse effect to the newborn.
—The most commonly isolated virus of the female genital tract.
—It is found in approximately 4-13% of pregnant women.
—90% of reproductive age adults have serologic evidence of CMV. Most of theinfections are subclinical;
—CMV may be transmitted in utero to the fetus and is recognized as the mostcommon congenital infection in the U.S., occurring in .2 to 2% of neonates.
—5 to 10% of those affected develop neurologic sequelae.
CONGENITAL CMV INFECTION—May follow either maternal primary or recurrent infections.
Primary infection more dangerous to the fetus than recurrent infection.
Following Primary maternal infection---40% of newborns are infected.
Recurrent infection---<1O% of infected newborns.
FEATURES ARE: HEPATOSPLENOMEGALY THROMBOCYTOPENIA, MICROCEPHALYDEAFNESS, CHORIORETINITIS, OPTIC ATROPHY, AND PERIVENTRICULARCALCIFICATIONS
DX: By serologic tests such as ELISA of indirect hemagg1utination
No satisfactory treatment for CMV infection.
Protozoan infection--- 1/3 of women are seropositive--- Complicates 0.1-0.5% of pregnancies--- Acquired by eating infected meat or by inhaling oocysts from cats--- chorioretinitis, hydrocephaly, microcephaly, intracerebral calcifications--- _ asymptomatic at birth--- More transmittable later in pregnancy 59% in 3rd vs. 9% in 1st trimester--- Infection is more serious earlier (2/3 severe sequlae)--- PCR on amniotic fluid can diagnosis infection--- pyrimethamine and sulfonamides may ameliorate sequelae
--- Erythema infectiosum – fifth disease--- Respiratory secretions and hand-to-mouth transmission--- Of exposed - 5% infected -> 20% fetal infection -> <10% death
--- Prevalence of 10-20%. Associated risk of malnutrition and STD’s
Signs include: sedation, inebriation, euphoria, agitation, disorientation, dilated or constrictedpupils, track marks, inflamed mucosa, increased pulse and blood pressure, nystagmus,hallucinations, unusual infections (atypical pneumonia, endocarditis, HIV), malnutrition
ALCOHOLFetal alcohol syndrome is the most common identified cause of mental retardation ~1/1000.
--- Growth retardation, CNS abnormalities, and abnormal facies--- May see cardiac anomalies, i.e. VSD--- 1-2 oz alcohol – 10% risk; >3oz – 30-50% risk--- Neonatal jitters
--- Spontaneous abortions, abruptio placentae, PPROM, preterm delivery, IUGR--- Quit before 16 wks gest
--- Blocks reuptake of norepinephrine and dopamine--- Vasoconstriction -> hypertension -> ischemia -> infarction--- Microcephaly, limb reduction, neurobehavioral abnormalities, SIDS, as well as the
--- Neonatal withdrawal--- High rate of HIV and hepatitis
malaria among international travellers. Can Comm Dis Rep 1995;probably a change in living conditions. Even in the poorest 21, S3: 1–18. US communities, most people now live and work in air-Krogstad DJ. Plasmodium species (malaria). In: Mandell, Douglas,conditioned buildings, or are at least protected by insectand Bennett’s principles and practice of infectious diseases. 4th ed. scree
Compassionate Bob Leibowitz, M.D. Onclogy Medical Group DIPLOMATE AMERICAN BOARDS OF INTERNATIONAL MEDICINE ANTIANGIOGENER COCKTAIL (AAC) Wir haben eine sehr effektive Behandlungsoption, die weder eine Chemotherapie ist, auch keine Hormonblockade darstellt und dabei das Immunsystem stärkt. Ist es nicht genau das, was Sie immer gesucht haben? Der Name dieser Form der Behandlung