Other Medical Complications of Pregnancy

• Hyperemesis gravidarum


  Persistent vomiting, weight loss of greater than 5% of prepregnancy body weight, and ketonuria
• Treatment of hyperemesis gravidarum


  1. First-line antiemetic therapy with Phenergan

  2. Addition of Reglan, Compazine, and Tigan

  3. Use of droperidol and Zofran if other antiemetics fail

  4. Vitamin B6 and doxylamine (Unisom)

  5. Ginger and vitamin B12 supplementation

  6. Rehydration and electrolyte correction

  7. Intravenous, intramuscular, or suppository antiemetics
• Long-term management of hyperemesis

  • Maintaining hydration
  • Adequate nutrition
  • Symptomatic relief from nausea and vomiting
  • Antiemetics and IV hydration
  • Frequent small meals to maintain blood glucose and decrease nausea
• Alternative treatments for hyperemesis

  • Corticosteroids
  • Acupuncture
  • Acupressure
  • Hypnotherapy
  • Nerve stimulation
• Pregnancy outcomes are usually good as long as hydration and adequate nutrition are maintained in hyperemesis
• Seizure disorders in pregnancy

  Concerns include risk of fetal malformations, miscarriage, perinatal death, and increased seizure frequency
• Factors contributing to increased seizure frequency in pregnancy

  • Increased volume of distribution
  • Increased hepatic metabolism of antiepileptic drugs
  • Hormonal changes
  • Added stress
  • Decreased sleep
  • Decreased compliance with antiepileptic drugs
• Effects of estrogen and progesterone on seizure activity

  • Estrogen is epileptogenic, decreasing seizure threshold
  • Progesterone has an antiepileptic effect
• Fetal congenital abnormalities associated with antiepileptic drugs

  • Neural tube defects
  • Intrauterine growth restriction
  • Microcephaly
  • Low IQ
  • Distal digital hypoplasia
  • Low-set ears
  • Epicanthal fold
  • Short nose
  • Long philtrum
  • Lip abnormalities
  • Hypertelorism
  • Developmental delay
  • Ptosis
  • Hirsutism
  • Hypoplastic nails
  • Cardiac anomalies
• Mechanisms of teratogenicity of antiepileptic drugs

  • Act as folate antagonists
  • Genetic predilection for generation of epoxides
• Clinical management of epilepsy in pregnancy

  1. Switch to single antiepileptic drug prior to conception

  2. Taper to lowest possible dose

  3. Attempt complete withdrawal if seizure-free for 2-5 years

  4. Dose valproic acid 3-4 times per day

  5. Supplement with folate prior to conception

  6. Perform level II fetal ultrasound at 19-20 weeks

  7. Offer maternal serum alpha-fetoprotein screening

  8. Consider amniocentesis for neural tube defects

  9. Monitor antiepileptic drug levels monthly
• Management of epileptic patient in labor and delivery

  • Preparation and close monitoring
  • Inform all care providers
  • Check antiepileptic drug levels on admission
  • Treat seizures promptly to avoid trauma and hypoxia
  • Consider vitamin K supplementation starting at 37 weeks
• Maternal cardiac disease in pregnancy requires consideration of the dramatic cardiovascular changes that occur
• There have been reports of increased risk of spontaneous hemorrhage in newborns because of the inhibition of vitamin K-dependent clotting factors (i.e., II, VII, IX, X) secondary to increased vitamin K metabolism and inhibition of placental transport of vitamin K by AEDs
• The risk of spontaneous hemorrhage in newborns is small, but conservative management is to overcome this theoretical vitamin K deficiency by aggressive supplementation with vitamin K toward the end of pregnancy
• The benefit of vitamin K supplementation is theoretical as it is not clear if vitamin K actually crosses the placenta
• Upon delivery, clotting studies can be performed on the cord blood and vitamin K administered to the infant


  If the cord blood is deficient in clotting factors, fresh frozen plasma may be required to protect the newborn
• Cardiac disease


  • Cardiac disease is leading to an increasing proportion of maternal mortality in the United States
  • Patients with primary pulmonary hypertension, Eisenmenger physiology, severe mitral or aortic stenosis, and Marfan syndrome are at a high risk of maternal mortality in pregnancy (reportedly ranging from 15% to 70% in small case series)
• Termination of pregnancy


  The option to terminate the pregnancy should always be offered and discussed at length with the patient in high-risk cardiac cases
• Unfortunately, since such women often may not be able to adopt because of their illness, they may think of their own pregnancy as the only way to have children
• Principles of management for cardiac diseases

  • Many of the diseases are stable prior to pregnancy with medical management, but during pregnancy can become quite unstable in response to the physiologic changes
  • Medications used during pregnancy may be different from those used outside of pregnancy
• ACE inhibitors, diuretics, and warfarin (Coumadin) have all been associated with congenital anomalies and other fetal effects and are usually discontinued in pregnancy
• The 2007 American Heart Association Guidelines state that routine vaginal delivery and cesarean section are not indications for subacute bacterial endocarditis (SBE) prophylaxis
• SBE prophylaxis may be considered for women with high-risk lesions (mechanical or prosthetic valves, unrepaired cyanotic lesions, etc.) and an infection that could cause bacteremia (chorioamnionitis or pyelonephritis)
• Management and early intervention during labor and delivery for cardiac patients

  1. Early epidural analgesia to control pain

  2. Assisted vaginal delivery (using forceps or vacuum) to diminish the potential detrimental cardiac effect of Valsalva while pushing

  3. Careful fluid monitoring, possibly with a central venous pressure monitor and arterial line
• After delivery, massive fluid shifts make the immediate postpartum period a particularly dangerous transition for women with congenital heart disease
• Rising average maternal age in pregnancy means there will be an increasing number of patients with a history of a myocardial infarction (MI) who become pregnant
• Management of patients with history of myocardial infarction

  1. Baseline ECG and adjustment of medications, if necessary, should be performed at the initial visit

  2. Minimize increased demand on the heart throughout pregnancy and during labor and delivery
• Eisenmenger syndrome and pulmonary hypertension


  • Patients with right-to-left shunts and pulmonary hypertension (PH) are among the sickest pregnant women, with mortality rates estimated at 50% and higher
  • In Eisenmenger syndrome, an initial left-to-right shunt overfills the right heart, leading to increased flow through the pulmonary vasculature, pulmonary capillary damage, and the formation of scar tissue
• Patients with Eisenmenger syndrome are chronically hypoxic secondary to the mixing of deoxygenated blood and are encouraged to terminate their pregnancies
• Management of patients with Eisenmenger syndrome who elect to continue pregnancy

  1. Followed with serial echocardiograms to measure the pulmonary pressures and cardiac function

  2. Labor and assisted vaginal delivery are preferable to elective cesarean delivery
• The greatest concentrated risk of morbidity and mortality for patients with Eisenmenger syndrome is in the postpartum period for approximately 2 to 4 weeks after delivery
• Attempts to counter the postpartum hormonal changes with progesterone and estrogen supplementation have had little success in patients with Eisenmenger syndrome
• Valvular disease


  • Surgical treatment or repair prior to becoming pregnant is preferred for moderate or severe disease carrying increased risk of maternal mortality
  • Patients with aortic stenosis and aortic insufficiency require a decreased afterload to maintain cardiac output
  • Patients with mitral stenosis may be unable to meet the increased demands of pregnancy and experience a backup into the pulmonary system leading to congestive heart failure (CHF)
  • Patients with pulmonary stenosis who elect to continue their pregnancy may actually undergo valvuloplasty during the pregnancy if they have severe disease
• Marfan syndrome


  • Patients have a deficiency in their elastin that can lead to a number of valvular cardiac complications as well as dilation of the aortic root
  • During pregnancy, the hyperdynamic state can increase the risk of aortic dissection and/or rupture, particularly in those patients with an aortic root diameter greater than 4 cm
  • Patients are advised to maintain a sedentary lifestyle and are often placed on beta-blockers to decrease cardiac output
• Peripartum cardiomyopathy (PPCM)


  A small percentage of patients will be found to have heart failure secondary to a dilated cardiomyopathy immediately before, during, or after delivery
• Management of peripartum cardiomyopathy

  1. Beyond 34 weeks' GA, the risks to the mother of remaining pregnant are usually greater than those of premature delivery of the fetus

  2. At earlier GAs, betamethasone should be administered to promote fetal lung maturity, and the patient delivered accordingly

  3. The patient's heart failure is managed similarly to other patients with heart failure using diuretics, digoxin, and vasodilators
• Well over half of the patients with PPCM have excellent return to baseline of their cardiac activity within several months of delivery
• Chronic renal disease


  • Renal blood flow and creatinine clearance increase during pregnancy in patients without renal disease, and this is also true initially in patients with renal disease
  • Moderate and severe patients, however, may experience decreasing renal function in the latter half of pregnancy that may persist postpartum in as many as half of pregnancies
• Patients with chronic renal disease have increased risk of preeclampsia, preterm delivery, and intrauterine growth restriction (IUGR) in addition to worsening renal disease