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Medical disorders associated with pregnancy
• Care for women with pre-existing medical disorders (PEMD) should ideally take place before conception in multidisciplinary pre-pregnancy clinics.
• This process should begin during adolescence with discussions about family planning, contraception and pregnancy.
• A complete medical history and assessment of health at this time, including obtaining up-to-date investigations, enables a risk assessment for pregnancy to be made.
• These risks should be discussed with the woman and her family so that appropriate choices can be made.
• - Women with PEMD have high-risk pregnancies and a collaborative multidisciplinary approach is recommended to ensure careful monitoring of both the woman and her fetus.
• - Equally midwives and doctors need to be aware and recognize the clinical signs and symptoms of deteriorating maternal health
• -Labour and birth in women with PEMD can be a time of additional challenges
• Timing and mode of birth should be carefully planned and should take place in a hospital with neonatal facilities.
• -disease will put an effect on the physical, psychological, sexual and social aspects of women's lives.
• - Involvement of the woman and her family should participate in decisions regarding her care
• . *Midwives have a role in supporting women and their families, ensuring that their needs are met and that the pregnancy is treated as normal, as possible
Cardiac disease
• In most pregnancies, heart disease is diagnosed before pregnancy.
• - There is, however, a small but significant group of women who will present at an antenatal clinic with an undiagnosed heart condition.
• -Although heart disease complicates <1% of maternities
• -it continues to contribute significantly to maternal morbidity and mortality and is the leading cause of maternal death
• Heart disease can be broadly classified into ‘congenital’ and ‘acquired’.
Congenital heart disease
• The most common congenital heart diseases (CHD) -atrial septal defect (ASD)
• ventricular septal defect (VSD)
• patent ductus arteriosus (PDA),
• pulmonary stenosis,
• aortic stenosis
• tetralogy of Fallot (TOF).
• All of them need surgical intervention. • -Uncorrected lesions may cause :• pulmonary hypertension, • cyanosis • and severe left ventricular failure• and are therefore high risk for pregnancy.• CHD is also associated with increased fetal
complications :
• These include fetal loss,
• intrauterine growth restriction,
• pre-term birth
• and an increased risk of fetal CHD
• -high risk cardiac conditions for pregnancy include:
Eisenmenger's syndrome
• VSD, ASD or PDA• -fibrosis and the development of pulmonary
hypertension and cyanosis• - Women with this condition are advised
against pregnancy as maternal mortality 30–50%. The greatest risk to the fetus is prematurity which contributes to the high perinatal mortality rate
Marfan's syndrome:
• -an autosomal dominant• - defect on chromosome 15.• - It is a connective tissue disease that affects the
musculoskeletal system, the cardiovascular system and the eyes.
• -The cardiovascular abnormalities are the most life-threatening condition.
• -there is a 50% chance of a child inheriting Marfan's syndrome if one parent is affected.
• -Women and their partners should be counseled carefully
• - Careful monitoring is required throughout pregnancy including the use of serial echocardiography to identify progressive aortic root dilatation.
• -Prophylactic antihypertensive therapy using beta-blockers is recommended
Acquired heart disease:
• -Rheumatic heart disease• -the most common cardiac problem.• - RHD causes inflammation and scarring of the heart
valves and results in valve stenosis, plus or minus regurgitation.
• The mitral valve is most often affected with stenosis, • c\p:• -severe breathlessness and tiredness for the first time
during pregnancy• -Most women with valvular heart disease can be managed
medically which aims to reduce the work rate of the heart.•
• During pregnancy, this involves bed rest, oxygen therapy and the use of cardiac drugs e.g. diuretics, digoxin and heparin (reduces risk of thromboembolic disease).
• Women with more severe symptomatic disease may require surgical intervention such as balloon valvoplasty or valve replacement
• Antibiotic prophylaxis is recommended for all women with valvular lesions during labour.
Myocardial infarction and ischemic heart disease
• Myocardial infarction (MI) and ischaemic heart disease (IHD) • -uncommon cardiac complications • -May lead to maternal death.• - risk factors include :• increasing maternal age• obesity• diabetes• pre-existing hypertension• smoking• family history• inequalities in health
• A myocardial infarction is most likely to occur in the third trimester and periperium period due to the hypercoagulability induced by hormonal changes.
• - women present with ischemic chest pain in the presence of an abnormal ECG and elevated cardiac enzymes although these signs and symptoms may be masked during labour and birth as
• abdominal or epigastric pain and vomiting.
• - Primary percutaneous transluminal coronary angioplasty (PTCA) which improves the patency of blocked arteries is first line therapy for this condition
Aortic dissection (acute)
• -may occur in pregnancy in association with severe hypertension (systolic >160 mmHg) due to:
• 1- pre-eclampsia• 2- coarctation of the aorta • 3-connective tissue disease such as Marfan's syndrome. • The woman presents with • severe chest• intrascapular pain.• Early diagnosis using computed tomography chest scan or
MRI or as maternal mortality is high .
Endocarditis
• -Endocarditis is an inflammation of the heart involving the heart valves.
• -Although rare in pregnancy, it is one of the most serious complications of heart disease.
• Risk group:• Women with valvular heart disease• prosthetic valves• a previous history of endocarditis• periodontal disease • and intravenous substance misusers
• - Streptococcal organisms are the most common cause • -Acute endocarditis is due to a Staphylococcus aurous,
Streptococcus pneumonia and Neisseria gonorrhea. • -Primary prevention includes recognition of risk factors
and • -e.g. good dental hygiene• - avoidance of drug misuse• -early treatment of sepsis • - administration of antibiotic prophylaxis to women with
high risk cardiac conditions
Peripartum cardiomyopathy:
• rare but fatal disease.• - mortality rates range from 25% to 50% . • - occurring between the last month of pregnancy and the
first 5 months postpartum • - women have no previous history of heart disease. Risk
group:• -older and• - multiparous women, • hypertension,• pre-eclampsia,•
• obesity
• diabetes.
• myocarditis
• viral infection
• long-term oral tocolytic therapy
• and cocaine misuse.
• Pathology :
• Inflammation and enlargement of the myocardium (cardiomegaly)
• left ventricular heart failure
• and thromboembolic complications
• Treatment :• -use of medication (oxygen, diuretics,
vasodilators) to decrease pulmonary congestion and fluid overload,
• - inotropic agents to improve myometrial contractility
• - and anticoagulation therapy.•
• As the cardiomegaly resolves may take up to 6 months and there is a risk of recurrence in a subsequent pregnancy.
• -a heart transplant is performed
• mortality will be high