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ภาวะแทรกซ้อนทางอายุรกรรมและศัลยกรรม Medical and surgical complications. พญ.ฐิติมา ชัยศรีสวัสดิ์สุข กลุ่มงานสูติศาสตร์และนรีเวชกรรม รพ.สรรพสิทธิประสงค์ อุบลราชธานี. Cardiac disease. Incidence. Complicate 1% of pregnancy But contribute significant maternal morbidity and mortality rate

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medical and surgical complications
ภาวะแทรกซ้อนทางอายุรกรรมและศัลยกรรม Medical and surgical complications
  • พญ.ฐิติมา ชัยศรีสวัสดิ์สุข
  • กลุ่มงานสูติศาสตร์และนรีเวชกรรม
  • รพ.สรรพสิทธิประสงค์ อุบลราชธานี
  • Complicate 1% of pregnancy
  • But contribute significant maternal morbidity and mortality rate
  • Mortality rate is about 2.7 : 1000 pregnancy
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
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 disease1
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 disease2
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
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
Clinical indicators of cardiac dz. in pregnancy
  • Progressive dyspnea or orthopnea
  • Nocturnal cough
  • Hemoptysis
  • Syncope
  • Chest pain


Clinical finding

  • Cyanosis
  • Clubbing of fingers
  • Persistent neck vein distension
  • Systolic murmur > gr.3
  • Diastolic murmur
  • persistent split 2nd sound
diagnostic study
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
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
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%

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

  • Aortic valve stenosis 10-20
  • Coarctation of the aorta 5
  • Marfan syndrome 10-20
  • Peripartum cardiomyopathy 15-60
  • Severe pulmonary hypertension 50
  • Tetralogy of Fallot 10

Estimated Maternal

Mortality Rate (%)


preconceptional counseling
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.
management of nyha class i and ii disease
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

Sudden limitation of normal activities

  • Dyspnea on exertion
  • Smothering with cough
  • Hemoptysis, Progressive edema, tachycardia
Signs of congestive heart failure
  • Persistent basilar rales
  • Nocturnal cough

Warning signs

Serious signs


Labor and delivery

  • Vaginal delivery with short second stage unless obstetrical indication is obtained for C/S

Rout of delivery


  • 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

  • Proper therapeutic approach depends on the specific hemodynamic status and the underlying cardiac lesion.

Intrapartum heart failure


  • 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)


  • 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
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
Valve replacement before 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

Effects on pregnancy



  • The critical issue for mechanical prosthetic valves is anticoagulation: thromboembolic issue VS bleeding , teratogenic issue

Anticoagulation agent

  • 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

  • No teratogenic issue
  • Is definitely inadequate control of thromboembolism

Low dose unfractionated heparin

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 pregnancy

American College of Chest Physicians Guidelines for Anticoagulation of pregnant women with mechanical prosthetic valves

bacterial endocarditis prophylaxis
Bacterial endocarditis prophylaxis
  • Estimate incidence of transient bacteremia at delivery is 1-5%
  • ATB prophylaxis is optional for uncomplicated delivery
  • 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

Regimen recommended

thyroid physiology and pregnancy
Thyroid physiology and pregnancy
  • Thyroid binding globulin
  • TSH in early pregnancy
  • Thyroxine cross placenta and is important for normal fetal brain development and fetal thyroid gland function


  • 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

  • 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 loss



Clinical features suggestive of possibility of hyperthyroidism

  • Pulse > 100 bpm
  • Widened pulse pressure
  • Eye signs of Graves disease or pretibial myxedema
  • Thyroid enlargement esp. in iodine sufficient geographical area
  • Onycholysis

Physical examination



  • 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)
  • 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

  • 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

Indication for surgery


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

  • 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

  • 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


  • 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
  • Gestational hypertension
  • Increased C/S
  • Anemia
  • Placental abruption
  • Preterm labour
  • Postpartum hemorrhage
  • Preterm birth
  • Fetal and perinatal death
  • Disorders of brain development
  • Low IQ scores
  • Fetal respiratory distress
  • Low birth weight
  • Cretinism


  • 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)


  • 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


  • Iron and calcium tablets should not take simultaneously with levothyroxine, may be taken 4 hrs after taking levothyroxine
  • 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




  • Post delivery dose should reduced to pre-pregnancy dose
  • Thyroid function should be re-checked 6 wks after delivery
  • 1:2000 to 1:6000 pregnancies
  • Difficult diagnosis
  • Intermediate intervention is a must


  • Some time difficult in pregnancy
    • Displacement
    • Distorted lab values
    • Mimic symptoms
    • Mimic other conditions


N/V, Tachycardia



  • Cholecystitis
  • Preterm labor
  • Pyelonephritis
  • Renal colic
  • Placental abruption
  • Degenerative myoma

Mimic conditions


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


  • 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)
    • Incidence of perforation = 8, 12, 20 percent in successive trimesters

Am Sur 2000



  • Suspicion:
    • Immediate surgery (Laparotomy VS Laparoscopy)
  • Delay:
    • Generalized peritonitis
  • Antibiotics
    • Perioperative 2nd cephalosporin/ 3rd penicillin, may be discontinued post-op,


  • 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
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


  • 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


  • Ultrasound
      • Effective rate 90%
  • Liver enzymes
  • Amylase, Lipase
  • CBC


  • 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
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


  • 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


  • Best approach:
    • <5 cm : expectant management
    • 5-10 cm: watch unless complex on sonography
    • if > 6 cm after 16 wks GA : surgery is required