Considerations in Maternal Evaluation:

Effects of disease on pregnant women and

diseases

effect of pregnancy on these

Normal pregnancy induced physiological changes that may affect

interpretation of physical and laboratory tests.

Guidelines for Diagnostic Imaging During Pregnancy:

1. Women should be counseled that x-ray exposure from a single diagnostic
procedure does not result in harmful fetal effects. Specifically, exposure to
less than 5 rad has not been associated with an increase in fetal anomalies or
pregnancy loss.
2. Concern about possible effects of high dose ionizing radiation exposure
should not prevent medically indicated diagnostic x-ray procedures from
being performed on the mother. During pregnancy, other imaging procedures
not associated with ionizing radiation, such as ultrasonography and magnetic
resonance imaging, should be considered instead of x-rays when possible.
3. Ultrasonography and magnetic resonance imaging are not associated with
known adverse fetal effects. However, until more information is available,
magnetic resonance imaging is not recommended for use in the first
trimester.
4. 4. Consultation with a radiologist may be helpful in calculating estimated fetal
dose when multiple diagnostic x-rays are performed on pregnant women.
5. 5. The use of radioactive isotopes of iodine is contraindicated for therapeutic
use during pregnancy.
6. (American College of Obstetricians and Gynecologists 1995)
Cardiovascular System:
Physiologic considerations:

Cardiac output increased by 30-50 % half of increase by 8 weeks, maximal at

about 20 weeks

Blood volume increased by 40-45% at or near term

Cardiovascular Diseases:

Congenital heart disease

Rheumatic heart disease

Peripartum Cardiomyopathy

Infective endocarditis

Ishemic heart disease

Kyphoscoliotic heart disease

Rheumatic heart disease most common valvular heart disease in the

Philippines.

Some Clinical Indicators of Heart disease during pregnancy:

Symptoms:

Severe or progressive dyspnea

Progressive orthopnea

Paroxysmal nocturnal dyspnea

Syncope with exertion

Chest pain related to effort or emotion

Some Clinical Indicators of Heart disease during pregnancy:

Clinical Findings:

Cyanosis

Clubbing of fingers

Persistent neck vein distention

Systolic murmur >3/6

Diastolic murmur

Cardiomegaly

Sustained arrhythmia

Persistent second sound split

Criteria for pulmonary hypertension

Left parasternal lift

Loud P2

Clinical classification of Heart Disease:

CLASS I. Uncompromised:

Patients with heart disease and no limitation of physical activity.

No symptoms of insufficiency. No anginal pain.

CLASS II. Slightly compromised:

Patients with cardiac disease and slight limitationof physical

activity. Comfortable at rest, but if ordinary physical activity is
undertaken, discomfort results-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 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 or cardiac
insufficiency or angina may develop even at rest, and if any
physical activity is undertaken, discomfort is increased. (New
York Heart Association 1979)

Risks for Maternal Mortality Caused by Various heart Disease:

Cardiac Disorder

Mortality (%)

Group II

5 15

2A:
Mitral stenosis, NYHA Class III & IV
Aortic stenosis
Coarctation of aorta w/o valvular involvement
Tetrallogy of Fallot, uncorrected
Previous myocardial infarction
Marfan syndrome, normal aorta

2B:
Mitral stenosis w/ atrial fibrillation
Artificial valve
Group III

25 50

Pulmonary hypertension
Coarctation of aorta w/ valvular involvement
Marfan syndrome w/ aortic involvement

Respiratory System:
Pulmonary Physiology:

Vital capacity= increases by 100-200ml

Inspiratory capacity=increases by 300ml by late pregnancy

Expiratory reserve volume= decreases from 1300 ml to about 1100 ml

Residual volume = decreases from 1500 ml to 1200 ml

Functinal residual capacity= sum of exp reserve and residual volumes

reduced by about 500 ml

Tidal volume= increases from 500 ml to 700 ml

Minute ventilation = increases 40 % from 7.5 L to 10.5 L/min.

Pulmonary Disorders:

Bacterial Pneumonia

Viral Pneumonia

Tuberculosis

Asthma

Pulmonary Embolism

Asthma:

Reversible airway obstruction from bronchial smooth muscle contraction,

mucus hypersecretion, and mucosal edema

Airway inflammation and responsiveness to stimuli viral infections, aspirin,

cold air, exercise, inhaled allergens

Primary chemical mediator = histamines

Secondary chemical mediator = prostaglandins, thromboxane, leukotrienes

= F-series prostaglandins and ergonovine
can exacerbate asthma

Effects of Pregnancy on Asthma = one-third expect worsening of disease

during pregnancy

Effects of Asthma on Pregnancy Outcome = increases preterm labor

higher chance -low-birthweight
preeclampsia (2.5 x)

Status Asthmaticus = severe asthma not responding to 30-60 min intensive

therapy

Pulmonary Embolism:

Diagnosis: chest discomfort, shortness of breath, air hunger, tachypnea,

apprehension,

Occurs postpartum but may also develop antepartum

Diagnostic work-up: ventilation-perfusion scintigraphy

pulmonary angiography

Underling cause: thromboembolic disease of the deep

veins of the leg, thigh or pelvis
Treatment : anticoagulation with heparin

Tuberculosis:

Bacterial infection with Mycobacterium tuberculosis

Symptoms include cough w/ minimal sputum production, low-grade fever,

hemoptysis, and weight loss

Diagnosis includes chest x-ray w/ a variety of infiltrative patterns in some

cases cavitation and lymphadenopathy, acid fast bacilli in repeated stained
smears of sputum (in 2/3 of culture positive), sputum culture

Treatment: (CDC) IHH, Rifampicin, Ethambutol for 9 months

Pyrazinamide is added if there is resistance to these drugs.

Urinary Tract :
Pregnancy Changes:

Dilatation of renal calyces, pelvis and ureters

More prominent on the right side

These changes promote urinary stasis

Renal and Urinary Tract Disorders:

Urinary tract infection- most common infection in pregnancy
1. Asymptomatic bacteriuria= 2-7 % prevalence defined as 100,000
organisms/ml
organisms include bacterial flora of the perineum and E. coli
=if untreated may progress to symptomatic infection or
pyelonephritis

even

2. Cystitis and Urethritis: dysuria, urgency, and frequency urinalysis shows pyuria,
bacteriuria and commonly microscopic hematuria.
3. Acute Pyelonephritis: most common serious medical complication of pregnancy,
involves renal infection, seen after midpregnancy.
Symptoms include abrupt fever, shaking chills, aching pain in one or both lumbar
regions. Signs may include tenderness over one or both costovertebral angles. 15 %
have bacteremia. Urine shows leukocytes in clumps and numerous bacteria.
Culture reveal E. coli commonly followed by Klebsiella pneumonia followed by
Enterobacter or proteus.
Chronic renal disease:

Includes glumerulonephritis, post-infectious, multisystem disease like

SLE,and primary glumerular diseases

May eventually end with renal failure

Poor perinatal outcome with hypertension, nephrotic range proteinuria,

impaired renal function (perinatal mortality rate about 80/1000)

Gastrointestinal System:
Pregnancy changes:

Nausea and vomiting in early pregnancy

Prolonged gastric emptying time

Gastrointestinal symptoms and physical findings obscured by uterus in

advanced pregnancy

Gastrointestinal Disorders:
Hyperemesis gravidarum:

Persistent vomiting enough to produce dehydration, weight loss, acidosis

from starvation, alkalosis from HCl in vomitus and hypokalemia.

Intrahepatic Cholestasis of Pregnancy:

Or recurrent jaundice of pregnancy or cholestatic hepatosis and icterus

gravidarum

Symptoms include pruritus, icterus or both

Centrilobular bile staining. The cause is unknown but estrogen is implicated

Adverse perinatal outcome include meconium stained amniotic fluid

(25 vs 16 Rioseco 1994), preterm delivery (12 vs 4)

Acute Fatty Liver of Pregnancy:

Caused by fulminant viral hepatitis, drug induced hepatic toxicity or acute

fatty liver of pregnancy

Manifests as malaise, anorexia, nausea & vomiting, epigastric pain &

progressive jaundice. Half of those afflicted has hypertension, proteinuria
and edema

Microscopically there are swollen hepatocytes. The cytoplasm of which is

filled with microvesicular fat

Fatal for mother (mortality 75%) and fetus (mortality 90%Usta 1994)

Viral Hepatitis:
1. Hepatitis A
transmitted through fecal- oral route, risk of transmission to baby negligible
2.

Hepatitis B

3.

Delta Hepatitis
hybrid partical-defective RNA particle w/ HBsAg coat

4. Hepatitis C
formerly non-A non B hepatitis, transmission identical to Hep B
5. Hepatitis E
waterborne, enterically transmitted, w/ transplacental crossing
Hepatitis B:

Serum hepatitis

Caused by DNA hepadnavirus type 1

Responsible for chronic hepatitis, cirrhosis, hepatocellular carcinoma

Serological markers have been identified for the following:

Hepatitis B virus (dane particle), core antigen (HBcAg), surface antigen

(HBsAg), e antigen (HBeAg) and their corresponding antibodies
Hepatitis B:
HBsAg = present in the serum after infection
HBeAg= if persistent, means chronic infection
Transplacental transmission is rare
Transmission to fetus possible thru exposure to infected secretions & blood during
delivery.
Prevention of neonatal infection

Hepatitis screening for all prenatal patient (ACOG 1992)

Infants of Hep B mothers are given Hepatitis B immune globulin and

recombinant vaccine at birth

Hematological Disorders:
Anemia:

Hgb < than 11 gm/dl in 1st % 3rd trimester

Hgb < 10.5 gm/dl in second trimester

Iron deficiency is the most common cause together with acute blood loss

Hematological Disorders:
Thalassemias:
Genetically determined hemoglobinopathy with impaired production of globin
peptide chains
Alpha thalassemia

homozygous alpha thalassemia responsible for nonimmune hydrops fetalis

Hemoglobin H disease-compatible with extrauterine life but causes hemolytic

disease

Alpha thalassemia minor- minimal to mod hypochromic anemia

Common in Asians

Beta thalassemia

Impaired production of beta globin chains

Elevated hemoglobin A2 level

Thalassemia major-neonate is healthy at birth but later develops anemia and

fails to thrive

Surgical Complications of Pregnancy:

Acute Appendicitis

Most common surgical complication in pregnancy

After the first trimester the point of maximal tenderness shifts to a more
lateral and superior position

Cholelithiasis:

non-intervention if asymptomatic during pregnancy

Acute Cholecystitis:

acute obstruction of cystic duct, bacterial infection in 50-85% of cases.

Pain, anorexia, nausea, vomiting, low-grade fever, mild leucocytosis

Diagnosis: physical examination and ultrasound

Treatment: medical and surgical

SUMMARY:

PHYSIOLOGIC CHANGES IN PREGNANCY alters physical and laboratory normal

parameters

MOST COMMON GI AILMENT is NAUSEA AND VOMITING

MOST COMMON MEDICAL INFECTION in pregnancy is UTI, mostly

asymptomatic bactiuria

MOST COMMON SURGICAL COMPLICATION in pregnancy is ACUTE

APPENDICITIS

MOST COMMON HEART DISEASE in pregnancy is VALVULAR HEART DISEASE

(Rheumatic heart disease Phils)

MOST COMMON HEMATOLOGIC DISEASE in pregnancy is IRON DEFICIENCY

ANEMIA

MOST COMMON CAUSE OF NON-IMMUNE HYDROPS FETALIS is HOMOZYGOUS

ALPHA THALASSEMIA

Most dreaded thrombotic complication of pregnancy is PULMONARY

EMBOLISM

Universal Viral Screening for HEPATITIS B.