Maternal Disease and Complications –Summary Outline
Maternal Disease and Complications –Summary Outline
Maternal Disease and Complications –Summary Outline
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<strong>Maternal</strong> <strong>Disease</strong> <strong>and</strong> <strong>Complications</strong> <strong>–Summary</strong> <strong>Outline</strong><br />
<strong>Maternal</strong> Diabetes: Sonography plays an important role in the management of<br />
a pregnant patient with diabetes. Because of the 3 - 5% rate of fetal mortality<br />
<strong>and</strong> the 6 - 12% chance of a major fetal anomaly, careful prenatal monitoring<br />
<strong>and</strong> management is indicated to reduce these risks.<br />
Definition: Diabetes Mellitus (DM) is a spectrum of disorders involving<br />
carbohydrate, lipid <strong>and</strong> protein metabolism that is due to an absolute or<br />
relative lack of insulin. DM may occur spontaneously (90%) or may be<br />
secondary to pancreatic disease, hormonal imbalances or drug reactions.<br />
There are two general classifications of spontaneous DM:<br />
Type I insulin dependent (juvenile onset)<br />
Type II non-insulin dependent (adult onset, occasionally with insulin<br />
dependence<br />
Poorly managed DM or DM which predates the pregnancy is the type of<br />
diabetes most frequently associated with fetal anatomic anomalies.<br />
Gestational Diabetes: Hormonal <strong>and</strong> metabolic changes associated with<br />
pregnancy can result in a condition referred to as glucose intolerance of<br />
pregnancy. While the term gestational diabetes is frequently used to<br />
describe this condition, it does not fit the pathological picture of true diabetes.<br />
In pregnancy, gestational diabetes is most frequently associated with<br />
macrosomia.<br />
Classification: When diabetes <strong>and</strong> pregnancy coexist, a classification<br />
system may be employed to help predict the outcome of the pregnancy <strong>and</strong><br />
assist in appropriate medical management. Classification is based on the<br />
results of a glucose tolerance test, age at onset of diabetes <strong>and</strong> the presence<br />
of specific maternal pathologic conditions. Perinatal mortality increases as<br />
the classification worsens.<br />
Fetal <strong>Complications</strong>: Pregnancy in diabetic patients can be complicated by<br />
a wide variety of problems. The incidence of congenital anomalies is<br />
increased <strong>and</strong> may include:<br />
Caudal regression<br />
Inguinal hernias<br />
Neural tube defects<br />
Clubfoot (talipes)<br />
Cardiac anomalies<br />
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Single umbilical artery<br />
Renal anomalies<br />
Polydactyly<br />
Gastrointestinal anomalies<br />
Skeletal anomalies<br />
Diabetes also has a significant impact on birth weight of the infant. In<br />
addition to anatomic abnormalities, other fetal complications associated<br />
with diabetes include:<br />
Respiratory distress syndrome<br />
Hypoglycemia (20 - 60%)<br />
IUGR (with maternal DM pre-dating the pregnancy)<br />
Macrosomia (with gestational diabetes)<br />
Hypocalcemia<br />
<strong>Maternal</strong> <strong>Complications</strong>: In addition to fetal complications, associated<br />
maternal complications of diabetes include:<br />
Polyhydramnios (31%)<br />
Preeclampsia (6 - 25%)<br />
Renal dysfunction (2 - 12%)<br />
Hypoglycemia<br />
Peripheral vascular disease<br />
Increased risk of infection<br />
Postpartum hemorrhage<br />
Sonographic Findings:<br />
Fetal Anatomy<br />
Presence of an associated anatomic abnormality<br />
Single umbilical artery<br />
Oligo or polyhydramnios depending on type of fetal anomaly present<br />
Placental Changes<br />
Thickened placenta<br />
Premature aging<br />
Growth Related Changes<br />
IUGR (see section on intrauterine growth restriction)<br />
Macrosomia (more common in Classes A - C). Defined as:<br />
Fetal weight > 4,000 grams or<br />
Birth weight > 90th percentile for gestational age<br />
Associated with:<br />
Hydrops fetalis<br />
Polyhydramnios<br />
Stillbirth<br />
Birth trauma<br />
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Hypertensive Disorders: <strong>Maternal</strong> <strong>and</strong> fetal complications may result if high<br />
blood pressure remains uncontrolled during pregnancy.<br />
Definition: Hypertension is diagnosed when one of the following criteria is<br />
met:<br />
Systolic pressure > 140 mmHG<br />
Increase in systolic pressure of > 30 mmHg (over the pre-pregnant<br />
state)<br />
Diastolic pressure > 90 mmHG<br />
Diastolic pressure increase > 15 mmHG (over the pre-pregnant state)<br />
Careful monitoring of the blood pressure during pregnancy is important in<br />
preventing the onset of preeclampsia/eclampsia. Classifications:<br />
Essential hypertension: the condition exists prior to pregnancy<br />
P I H D: pregnancy induced hypertensive disorder<br />
Toxemia: A disorder of pregnancy characterized by proteinuria, hypertension<br />
<strong>and</strong> neurological symptoms. Traditionally referred to as "toxemia of<br />
pregnancy", it is more accurately defined as GEPH - Gestational Edema<br />
Proteinuria Hypertensive syndrome. It most commonly occurs in<br />
primigravidas <strong>and</strong> is more common with multiple gestations. Diagnosis <strong>and</strong><br />
treatment of preeclampsia is necessary to prevent progression into life<br />
threatening eclampsia.<br />
Preeclampsia<br />
Hypertension<br />
Generalized edema<br />
Proteinuria<br />
Eclampsia: In addition to HTN, edema <strong>and</strong> proteinuria found in<br />
preeclampsia:<br />
Coma<br />
Seizures<br />
Conditions associated with increased incidence of GEPH include:<br />
Primigravida<br />
Multiple gestations<br />
Vascular disease<br />
Polyhydramnios<br />
Hydatidiform mole<br />
Severe undernutrition<br />
Family history<br />
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Pathology: A broad spectrum of pathologic entities is associated with<br />
pregnancy induced hypertensive disorder including:<br />
Abnormal vasospasm leading to hypoxia <strong>and</strong>/or necrosis<br />
Premature placental aging<br />
Renal cellular damage<br />
Disseminated intravascular coagulopathy (DIC)<br />
Periportal hemorrhagic necrosis (liver)<br />
Cerebral edema<br />
Pulmonary edema<br />
Clinical Findings:<br />
Hypertension<br />
Sudden, excessive weight gain (> 5lb/1week)<br />
Ankle swelling<br />
Generalized edema<br />
Headaches<br />
Abdominal pain, vomiting<br />
Sonographic Findings:<br />
IUGR<br />
Oligohydramnios<br />
Decreased placental volume<br />
Accelerated placental aging<br />
Fetal demise<br />
Sonography is used to monitor the pregnancy <strong>and</strong> track fetal growth<br />
<strong>Maternal</strong> Infections: Any severe, systemic maternal infection may cause<br />
spontaneous abortion, fetal death <strong>and</strong> premature labor <strong>and</strong> delivery. Growth<br />
restriction may result from chronic infections. Fetal abnormalities can be caused<br />
by several acute infections. The most common significant in utero infections are<br />
the TORCH infections:<br />
Toxoplasmosis<br />
Other (syphilis, etc.)<br />
Rubella<br />
Cytomegalovirus<br />
Herpes<br />
Toxoplasmosis: Caused by a protozoa, T. gondii, which is commonly<br />
found in cat feces <strong>and</strong> uncooked meat. <strong>Maternal</strong> infection, which<br />
crosses the placental barrier <strong>and</strong> results in fetal infection, may cause:<br />
CNS calcifications<br />
Microphthalmia<br />
IUGR<br />
Chorio-retinitis<br />
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Microcephaly<br />
Thrombocytopenia<br />
Hydrocephaly<br />
Jaundice<br />
Thick placenta<br />
Rubella: Also known as German measles. Extremely teratogenic for<br />
the fetus. Exposure during the first 5 weeks is most dangerous.<br />
Defects include:<br />
Cataracts<br />
Congenital heart disease<br />
Deafness<br />
Mental retardation<br />
Cytomegalovirus: Most common infection in pregnancy. Thought to<br />
cause embryonic demise if exposed in the first trimester. May cause:<br />
Spontaneous abortion<br />
IUGR<br />
Fetal ascites<br />
Fetal death<br />
Cranial anomalies<br />
Chest anomalies<br />
Herpes: The virus is usually transmitted to the fetus during vaginal<br />
delivery. Cesarean section is frequently performed in women with<br />
known disease. Infection may cause:<br />
CNS, eye <strong>and</strong> visceral infection<br />
May be asymptomatic<br />
Generalized multiple organ involvement<br />
Fetal death<br />
Parvovirus: A common respiratory viral infection. If there are<br />
maternal infections during pregnancy, the virus can cross the placental<br />
barrier <strong>and</strong> affect the fetus causing:<br />
Pancytopenia<br />
Possible development of hydrops, necessitating PUBS/ fetal<br />
transfusion<br />
<br />
Sonographic Findings: Careful examination of the fetal anatomy should be<br />
performed in any patient presenting with a history of infection during<br />
pregnancy. Knowledge of the specific defects associated with a particular<br />
infection is necessary so that attention is focused on the proper organ<br />
systems.<br />
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Other <strong>Maternal</strong> <strong>Complications</strong><br />
Incompetent Cervix: also known as painless premature dilatation of the cervix,<br />
it is the inability of the cervix to prevent the premature expulsion of the uterine<br />
contents. May be acquired or congenital <strong>and</strong> is most frequently related to<br />
cervical trauma. Surgical repair of cervical tears following previous vaginal<br />
deliveries may be one cause. Habitual abortion in the 2 nd trimester may be the<br />
only clinical feature.<br />
Sonographic Findings:<br />
Cervical length < 3 cm before 34 weeks<br />
Cervical width > 2 cm in second trimester - MOST RELIABLE<br />
Firm diagnosis cannot always be made using sonography<br />
Diagnosis based on history <strong>and</strong> clinical findings<br />
Bulging membranes<br />
Bladder distention may cause false negative<br />
Pre-term Labor: Onset of labor before 37 weeks. Etiologies include:<br />
Previous uterine surgery<br />
Uterine anomalies<br />
<strong>Maternal</strong> stress<br />
Heavy cigarette smoking<br />
Multiple gestations<br />
Polyhydramnios<br />
Antepartum bleeding (from previa, abruption)<br />
Systemic infections, i.e. appendicitis with sepsis<br />
Idiopathic<br />
Premature Rupture of Membranes (PROM): the spontaneous rupture of the<br />
membranes prior to the on set of labor. If rupture occurs prior to 26 weeks, fetal<br />
demise is imminent.<br />
Clinical Signs: passage of a large amount of watery fluid from vagina<br />
Sonographic Findings:<br />
Oligohydramnios<br />
Anemias: The need for increased perfusion to the highly vascularized placenta<br />
<strong>and</strong> to the increase in maternal breast mass results in a 40% increase in blood<br />
volume. Because increased plasma volume accounts for much of this increase,<br />
hemoglobin (Hb) <strong>and</strong> hematocrit (Hct) values are normally lower in pregnancy<br />
than in the non-pregnant state.<br />
Clinical Signs:<br />
Hb < 10 g/100 ml<br />
Hct < 30%<br />
Types:<br />
Iron deficiency (95%)<br />
Folic acid deficiency<br />
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Aplastic anemia<br />
Drug induced hemolytic anemia<br />
Uterine Rupture: Rupture of the uterus is a potential obstetric catastrophe<br />
<strong>and</strong> a major cause of maternal death. A complete rupture extends across the<br />
entire thickness of the uterine wall <strong>and</strong> usually occurs during labor.<br />
<strong>Complications</strong> include:<br />
Hemorrhage<br />
Shock<br />
Postoperative infection<br />
Death of mother <strong>and</strong>/or child<br />
Ureteral damage<br />
Amniotic fluid embolism<br />
Disseminated intravascular coagulopathy<br />
Clinical Signs: Reliable signs for impending uterine rupture do not exist.<br />
Non-specific findings may include:<br />
Localized pain in uterus<br />
Small amount of vaginal bleeding<br />
Sonographic Findings:<br />
Oligohydramnios<br />
Large amount of peritoneal fluid<br />
Coexisting Masses<br />
Fibroids: also known as leiomyomas, they may increase in size during the<br />
second <strong>and</strong> third trimesters due to the effects of hormones, degenerative<br />
changes or hemorrhage. During delivery, myomas may be responsible for<br />
decreased intensity of uterine contractions, may cause fetal malpresentation<br />
<strong>and</strong> may obstruct delivery. In some cases, cesarean section is indicated.\<br />
Clinical Signs:<br />
Fundal height greater than expected for gestational age<br />
Palpable mass on anterior or lateral uterine wall<br />
Focal tenderness if degeneration has occurred<br />
Sonographic Findings:<br />
Hypoechoic uterine mass distorting the contours<br />
Sonolucent center in degenerated masses<br />
Position of myoma relative to cervix should be ascertained<br />
Size <strong>and</strong> location of each myoma should be documented<br />
May be confused with myometrial contraction<br />
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Ovarian Cysts: Ovarian cystic masses are frequently found in pregnancy.<br />
Regardless of the type of cysts, if it is large enough it may cause dystocia.<br />
Two types of cysts are associated with the pregnancy itself:<br />
Corpus Luteum Cysts produce progesterone <strong>and</strong> usually regresses<br />
by 12 to 15 weeks. They may persist <strong>and</strong> may encourage torsion of<br />
the ovary.<br />
Theca Lutein Cysts: occur with gestational trophoblastic disease <strong>and</strong><br />
are usually bilateral. They are frequently large, multiseptated masses.<br />
Clinical Signs:<br />
Pain, tenderness in the adnexa<br />
High levels of maternal serum Hcg<br />
Palpable adnexal mass on pelvic exam<br />
Sonographic Findings:<br />
Presence of cystic mass in adnexa<br />
May be simple, septated or complex<br />
Location <strong>and</strong> size should be documented<br />
Uterine <strong>and</strong> cervical contour should be examined for possible distortion<br />
Masses: Solid masses found in the pelvis during pregnancy may also cause<br />
dystocia <strong>and</strong> pain. Common pathologic types of solid masses are usually<br />
related to the ovary <strong>and</strong> include dermoids <strong>and</strong> endometriomas. Anatomical<br />
variations <strong>and</strong> abnormalities can also present as coexisting pelvic masses.<br />
Some causes include:<br />
Pelvic kidney<br />
W<strong>and</strong>ering (ectopic) spleen<br />
Non-gravid horn of a bicornuate uterus<br />
Fecal filled colon<br />
Dilated ureter<br />
Clinical Signs:<br />
Presence of a solid mass adjacent to the gravid uterus<br />
Sonographic Findings:<br />
Determine nature of mass i.e., ovarian vs. anatomic variant<br />
Document size <strong>and</strong> number of masses<br />
Uterine <strong>and</strong> cervical contour should be examined for possible distortion<br />
Sonography can be used to follow masses <strong>and</strong> detect change in size<br />
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