DEANNE SAZAIEKA PUTRI BINTI SALLAHUDDIN

082014100018
• DEEP VEINS THROMBOSIS
• PULMONARY EMBOLISM
 DEEP VEINS THROMBOSIS
RISK FACTORS FOR THROMBOEMBOLISM IN
PREGNANCY
SPECIFIC TO PREGNANCY NON SPECIFIC TO
PREGNANCY CLINICAL FEATURES

• Hypercoagulable • Obesity (BMI • Left leg in 90% cases

state >30kg/m2) • Sudden onset
• Venous stasis • Maternal age >35yrs unilateral painful
• Endothelial injury • Severe proteinuria ,pale,swelling of entire
• Multifetal pregnancy • Prolonged bed rest lower limb
• Cesarean delivery • Antiphospholipid • Cold lower limbs
syndrome • Reduced arterial
pulsations
• Inherited
• Calf muscle
thrombophilias tenderness
• Anaemia
• Hemorrhage
• Genetic factors
Test used for the diagnosis of DVT

1. Duplex ultrasonography/compression
ultrasonography
2. Magnetic resonance venography
3. Ascending contrast venography
4. D- dimer

MANAGEMENT

 Bed rest
 Therapeutic anticoagulation
 Ambulate once symptom better
 Elastic compression stockings
 PULMONARY EMBOLISM
CLINICAL FEATURES
DIAGNOSIS
 Unexplained tachycardia NON SPECIFIC TESTS
 Dyspnea -chest x ray
 Hypoxemia -ECG
 Pleuritic pain -Arterial blood gases
 Hemoptysis -ECHO
 Sudden severe hypotension
SPECIFIC TESTS
-Ventilation-perfusion test
MANAGEMENT -CT pulmonary angiography
-Magnetic resonance pulmonary
 Therapeutic angiography
anticoagulation -Pulmonary angiography
 Venacaval filters
 Thrombolytic therapy EVALUATION OF LOWER LIMBS FOR DVT
with t-PA -Duplex/compression ultrasonography
ANTICOAGULATION IN PREGNANCY
a) May be prophylactic , to prevent
thromboembolism in high risk women
b) Therapeutic for DVT and PE treatment
THERAPEUTIC USE OF LMW HEPARIN
INDICATIONS DRUG OF CHOICE
Established DVT or PE
 Better bioavailability
 Longer plasma half life
 Predictable dose response
No lab  More reduction in thrombus
monitoring size
 Lower risk in major bleeding
Must be  Lower recurrence
swithed to thromboembolism
 Low risk of osteoporosis and
UFH at 36 wks
thrombocytopenia
 Less frequent dosing
 THERAPEUTIC USE UNFRACTIONED
HEPARIN

INDICATIONS
Immediate treatment of PE • Initially admisnisted
When delivery or/c section as IV
anticipated
After 36wks in all women with • Switch to SC
therapeutic LMW Heparin 12hourly after 7 to
10 days

Can be reversed with • Monitored aptt

Protamine Sulphate
 INTRAPARTUM POSTPARTUM
MANAGEMENT MANAGEMENT

• AC should be stopped • AC continued for 6

24-36hrs before months postpartum
planned delivery • LMW heparin started 6
• Reduce the maternal hours after vaginal
bleeding and delivery or 12 hours
haematoma formation after c section along
with spinal or epidural with 5mg Warfarin daily
anaesthesia
 THERAPEUTIC DOSES OF LMWH AND UFH
LMWH
• Enoxaparin- 1mg/kg,12 hourly (SC)
• Dalteparin- 200 units/kg ,once daily (SC)
• Tinzaparin -175 units/kg once daily (SC)

UFH
70-100 units/kg IV Bolus
(5000-10000units)
15-20 units/kg Infusion
(1000units)/hour
Followed 7-10days later SC
By 10000 units 12 hourly
 Acute Fatty Liver of Pregnancy
 Intrahepatic Cholestasis
 Viral Hepatitis
 Gallstones
 Constipation
 Diarrhea
 Hemorrhoids
 GERD
 Appendicitis
 Acute Fatty Liver of Pregnancy
 Rare complication of An excessive fetal fatty acid
pregnancy but can lead to accumulation released into
fulminant hepatic failure. maternal circulation
 Often develops in second half
of pregnancy, closer to term.
 May only be diagnosed after
delivery.
Increased load of long-chain fatty
 Associated with autosomal acids in maternal liver tissue
recessive genetic error :
 Maternal genetic mutation
 Fetal LCHAD deficiency
(Long-chain 3-hydroxyacyl-
coenzyme A Impaired hepatic function
dehydrogenase)
 SYMPTOMS RISK FACTORS

 Nausea and vomiting  Older maternal age

 Progressive jaundice  Primiparity
 Anorexia  Multiple Gestation
 Lethargy  Preeclampsia
 Abdominal pain  Male fetus
 Ascites  Being underweight
 Transient polyuria
 Previous history of
and polydipsia due
AFLP
to transient
diabetes insipidus
 DIAGNOSIS MANAGEMENT

Intravenous fluids for correction of

 All symptoms above.
Hypovolemia
 Laboratory findings: Hypoglycemia
Serum aminotransferase moderately
elevated (300-500 U/L) Blood products as needed

Bilirubin elevated (5mg/dL or higher)

Delivery (definite treatment)
Stops overload of fatty acids on
Leukocytosis
mother’s liver
Hypoglycemia
Induction of labor or CS (regional anaes
Elevated ammonia levels not recommended due to risk
Thrombocytopenia of hematoma because of coagulopathy)
Neutrophilia Recovery within 48-72 hours after
Coagulopathy delivery
Renal Dysfunction
Management of
Renal failure
Hepatic failure
 COMPLICATIONS
 Acute renal failure – 60%
 Fulminant hepatic failure
 Hepatic encephalopathy –
60%
 Hypertension,
proteinuria, edema –
50%
 Other maternal complications
 PPH
 Hypoglycemia
 DIC
 Pancreatitis
 Pulmonary edema
PROGNOSIS
• Maternal mortality
 Up to 10%
 Due to hepatic failure lead to
 Hepatic encephalopathy
 Renal failure
 Coagulopathy
• Perinatal mortality
 Can be high as 85%
 Due to preterm birth due to
urgent need for delivery
 INTRAHEPATIC CHOLESTASIS
SYMPTOMS
• Most common liver disorder
unique to pregnancy. 1) PRURITUS
• Usually manifest in the third • Starts in second or third
trimester. trimester
• Characterized by : • Generalized
 Severe pruritus • Worse on palms and soles
• Worse at night
 Increase in direct bilirubin
– Sleep disruption
• Increased risk of preterm – Emotional disturbance
delivery and sudden intrauterine • Scratch marks on extremities and
death. abdomen
• Symptoms resolve after delivery 2) JAUNDICE
10%-15% of women
Starts 1-4 weeks after itching
Recurrence risk in next
pregnancy : 45%-70%
3) VITAMIN K DEFICIENCY
LABORATORY VALUES

1. Urine bile salts –

• positive
2. Serum Total Bile Acid
• (TBA) >10 mmol/L
3. ALT and AST elevated
4. Bilirubin elevated but <5mg/dL

MANAGEMENT
1. Symptomatic treatment of the patient

• Ursodeoxycholic acid (UDCA) – 500 mg twice daily

• Cholestyramine – 8-16 g/day
• Dexamethasone

2. Close monitoring and decision for early delivery of the fetus :

 Delivery recommended before 37 weeks .
 Since mother may have vit K deficiency, the newborn should receive an
injection of vitamin K on delivery.
 Mother Fetal
 Good prognosis  Bad prognosis

 Following delivery :  Associated with :

 Pruritus disappears  Prematurity
 LFT normalize  Meconium-stained amniotic

 No hepatic sequelae fluid

 Intrauterine demise
 Increased risk of gallstones
 Increased risk for respiratory
 Estrogen-containing OCPs
distress syndrome
 Can result in cholestatic
hepatitis
 VIRAL HEPATITIS
 Most commonly occurring infections in
pregnant woman.

 Incidence of hepatitis E is much higher

than hepatitis A, B, and C

 Hepatitis A and B can be prevented

efficiently through vaccination.
 SYMPTOMS
HEPATITIS A
• Malaise
A virus infection • Fever
occurs due to • Fatigue
• Anorexia
person-to-person • Nausea
transmission • Right upper quadrant or epigastric pain
through fecal-oral
SIGNS
contamination
• Jaundice of varying degrees
• Tender hepatomegaly
• High colored urine
• Stool chalky white or acholic
FULMINANT
HEPATITIS
• Coagulopathy
• Encephalopathy
Laboratory Findings :

Serum aminotransferase
Elevated > 1000-2000 U/L MANAGEMENT IN
ALT > AST PREGNANCY :
Serum total and direct bilirubin
Peak after elevation in ALT and AST  Usually self limited.
Usually elevated > 10mg/dL  Rest and balanced diet.
Serology :  Avoid handling food for
Serum IgM for anti-hepatitis A virus (HAV) is the other family members.
gold standard for detection of acute illness  Breastfeeding
Remains positive for 4-6 permissible with hygienic
months precautions.
 Patients with fulminant
COURSE IN PREGNANCY : infectionequires :
• More severe with increasing gestational -Aggressive support
age. therapy
• Pregnancy complications :
-Transferred to a tertiary
• Preterm labor
• Placental abruption
care center
• PROM
• Perinatal transmission for the virus does
not occur!
POSTEXPOSURE PROPHYLAXIS
• Woman with close personal contact with someone
known to
• have acute hepatitis A infection should receive :
• Single 0.02 mL/kg IM dose of immunoglobin
• Should be given within 2 weeks exposure
• Provides protection for up to 3 months
• 80%-90% effective

• If patient infected in the third trimester :

• Newborn should be given passive immunoprophylaxis
with
• hepatitis A immunoglobulin within 48 hours of delivery
 HEPATITIS B
Acquired through : Risk Factors For Hep B
Infection :
Mucosal
Parenteral
All pregnant woman should be
Sexual screened for hepatitis B by –
Mother-to-child
transmission
Testing for HBsAg in the first
trimester
Hepatitis B in pregnancy affected
Their immunization status for
both maternal and fetal health. hepatitis B should be checked.
 Transaminase levels
increased (>1000 U/L)
Clinical presentations
are same to Hep A. Serum bilirubin raised
(>10mg/dL)

Diagnosis of HBV is
made with detection of :
HBsAG
IgM antibodies to
HBcAG
Transmission to husband :
Her husband should be tested for HBsAG
If negative, he should receive the rapid immunization course with
hepatitis B vaccine (0,1, and 2 months)
Until vaccination completed, they should be advised to use
condom.

Effects on pregnancy :
Usually not severe.
Not associated with increased mortality or teratogenicity.
No indication for termination of pregnancy.
There is an increased risk of low birth weight and preterm birth.
MANAGEMENT :

1. Treat HBV during pregnancy

 Mainly supportive
 Monitoring liver function test and prothrombin time (PT)
 Antiviral therapy unnecessary except have acute liver failure or
protracted severe hepatitis

2. Prevention of perinatal transmission

 Postexposure prophylaxis with hepatitis B immunoglobulin and
HBV vaccine can help prevent 85% - 95% of cases of perinatal
transmission.
 HBeAG should be tested at 34-36 weeks. If positive
transmission risk will be high if not given prophylaxis.
 Breastfeeding is not contraindicated for
women who are HBsAg- positive at the
time of delivery.

Risk Of Perinatal Transmission Of Hepatitis B Virus

 Infection in the first trimester : 10%
 Infection in the second trimester : 10%
 Infection in the third trimester : 60%
 Without neonatal prophylaxis : 10%-20%
 Presence of HBeAg,without neonatal prophylaxis,
risk of infection : 90%
 HEPATITIS C
MANAGEMENT :
ROUTES OF
TRANSMISSION : CLINICAL General supportive
FEATURES : measures
Needle stick injuries
70% asymptomatic, Route of delivery
Intravenous drug use
30% symptomatic does not affect
Transfusion of unscreened
blood products Symptoms similar to transmission
Sexual contact Hepatitis A and B No neonatal
Perinatal transmission (<5%)
vaccination
 HEPATITIS D
 HDV is an incomplete viral particle that
depends on the presence
• of HBV for survival.
 Transmitted through percutaneous or
mucosal contact with
• blood.
 Perinatal transmission can occur at time of
delivery, but neonatal prophylaxis against
hepatitis B is effective at decreasing
transmission rates.
 HEPATITIS E
 More easily acquired, more adverse effects in pregnancy
than nonpregnant state.
 Associated with greater mortality rate in pregnancy.
 Transmitted through :
 Fecal-oral contamination CLINICAL
 Contaminated water supplies PRESENTATIONS :
 Asymptomatic infection (40%)
 Fulminant hepatitis
Associated with increased with hepatic
rates of : encephalopathy
• Abortion (60%)
• Stillbirth  Self-limited disease lasting
• Neonatal deaths 1- 4 weeks.
 GALLSTONES
Occurs more Presentations : CLINICAL FEATURES :
commonly during • Right upper quadrant
pregnancy due to :  Acute Cholecystitis pain
Biliary Colic • Nausea and vomiting
 Gallstone Pancreatitis • Low grade fever
 Decreased gall  Choledocholithiasis
bladder
motility
 Increased
cholesterol
saturation in
bile.
MANGAGEMENT
 CONSTIPATION
 Defined as :
 Straining at defecation at
>25 % bowel movements.
 Hard stool at >25 % bowel
movements.
 Two or fewer movements a
week.
MANAGEMENT :
 Dietary changes
 >8 glasses water per
day
 Increase fiber intake
 Increasing physical
activity
 Using bulking agents
• Isphaghula husk
• Methyl cellulose
• Laxatives
 Liquid paraffin
 Milk of magnesia
 Lactulose
 DIARRHEA

May be infected or non-infected causes. Evaluated by stool examinations.

MANAGEMENT :

Oral rehydration
Correction of potential electrolyte
abnormalities
Bananas and orange juice
Antidiarrheals
Loperamide is safe
Specific treatment for specific causes
 HEMORRHOIDS
 Varicosities in anal canal caused by pressure
from gravid uterus.
 Common in 3rd trimester and immediately postpartum
(pushing
• effort during delivery).
 Symptoms :
 Pruritus, pain and bleeding, bulge at anal verge.

 Management :
 Relief of symptoms
 Recurrent and severe hemorrhoids
 Hemorrhoidectomy
 GERD
 Common, worsen from 1st to 3rd trimester
and disappear after delivery.
 Tends to recur in subsequent pregnancy.
MANAGEMENT :
PATHOGENESIS :
• Lifestyle modifications
 Intrinsic factors • Medications
 Abnormal esophageal motility •Antacids
• Decreased LES pressure
 Increased gastric pressure •Sucralfate
 Mechanical factors •H2 blockers
 Enlarged gravid uterus •PPI
• Increased intraabdominal
pressure
• Displacement of LES
 APPENDICITIS
 Commonest non-obstetric PHYSICAL SIGNS :
cause of acute abdomen in • Abdominal pain
•1st trimester : Right lower
• pregnancy. quadrant
 Diagnosis may be delayed •2nd trimester : Umbilicus
because : •3rd trimester : Diffuse of right
upper
1. Many of the symptoms quadrant
considered to be due to • Nausea, vomiting and anorexia
pregnancy.
2. Displacement of colon by
enlarged uterus causing TREATMENT :
Appendicectomy
appendix changes
location.
 REFERENCES
• Essentials of Obstetrics, Lakshmi Seshadri
& Gita Arjun