Medical complications

Chapter 22 Medical complications

CHAPTER CONTENTS

(v) Psychiatric illness 204

Drug misuser 204

Opioid user 204

Cocaine user 205

User of benzodiapines (temazepam or diazepam) 205

Amfetamine user 205

Cannabis user 205

(i) HAEMATOLOGICAL, COAGULATION, RESPIRATORY AND NEUROLOGICAL DISORDERS

HAEMATOLOGICAL PROBLEMS

Sickle cell disease (HBSS; HBSC; HB THAL)

• Sickle cell haemoglobin (HBS) a β-chain haemoglobin which affects women from Africa, Middle East and the Indian subcontinent can present as persistent anaemia.

• Hypoxia, cold, acidosis, dehydration and infection can precipitate a sickling crisis (Box 22.1) with resultant tissue infarction and pain. Sickling crisis complicates some 35% of pregnancies. Urinary tract infection, pneumonia and puerperal sepsis are more likely. Pulmonary infection or lung infarction can cause an acute chest syndrome characterised by fever, tachypnoea, pleuritic chest pain and leucocytosis. Other causes of chest pain include pulmonary thrombosis, thromboembolism and bone marrow embolism.

• Obstetric complications include increased incidence of preterm labour, early-onset pre-eclampsia, intrauterine growth retardation and antenatal and intrapartum fetal distress. Maternal and perinatal mortality is increased four to six times and morbidity is also increased.

Thalassaemia

Condition affects women from areas where historically malaria was prevalent, for example South East Asia (thalassaemia A and B) Middle East, India and the Mediterranean (mainly thalassaemia B). Most women are thalassaemia B trait with anaemia as the main risk factor. (Low mean corpuscu-lar volume and mean cell haemoglobin with normal mean corpuscular haemoglobin concentration). Diagnosis is by globin chain analysis. Active management of the third stage to limit blood loss is important.

Inherited disorders of coagulation: haemophilia, von Willebrand’s disease and factor IX deficiency

von Willebrand’s disease (VWD) a result of inherited deficiency in von Willebrand’s factor (VWF) affects 0.8–1.3% of women. Type I (70% of VWD) women produce less VWF with resultant defect of factor VIII. Type II is associated with defective VWF and thrombocytopenia. The rare but severe type III has low levels of both VWF and factor VIII.

• Haemophilia A (deficiency in factor VIII) with a prevalence of 1 in 10 000 in the population is five times more common than haemophilia B (deficiency in factor IX).

• Inheritance of haemophilia is through sex linkage with carrier women having factor VIII or IX levels about 50% of normal.

• Bleeding can occur when levels are below 50% of normal and severity of bleeding is proportional to the degree of deficiency.

• Factor VIII levels tend to rise in pregnancy, as does von Willebrand’s factor.

Labour

• Correct low (<50 IU/dl at 36 weeks) levels of factor VIII or IX before labour.

• Notify haematologist when the woman is admitted in labour. Site intravenous cannula. Take blood for full blood count, clotting studies and cross-match 4 units of blood.

• Administer relevant blood products in conjunction with haematological advice in any potentially affected fetus.

• Fetal risks include bleeding, cephalhaematoma, subgaleal and intracranial haemorrhage. Do not use scalp electrodes or perform fetal blood scalp sampling. Ventouse or mid-cavity rotational forceps are contraindicated but a simple lift-out is acceptable.

• Avoid prolonged labour or prolonged second stage.

• A low threshold for caesarean section should be considered in prolonged labours.

• Haemostasis is essential when surgery is performed. Repair episiotomy or tears immediately.

• Infuse Syntocinon for 4–8 hours after delivery to ensure the uterus remains contracted.

• If shown to be useful before pregnancy, 1-deamino-8-arginine vasopressin (DDAVP) can be helpful for postpartum bleeds in haemophilia A carriers or type I and type IIa VWD.

• Clotting levels may require adjustment over 3–4 days (after vaginal delivery) or 4–5 days after caesarean section).

• Physiological low levels of factor IX at birth may complicate early diagnosis of haemophilia in the newborn.

Platelet disorders

Platelet disorders are usually due to platelet destruction or consumption, failure of production or splenic sequestration. The commonest problems encountered in pregnancy are due to destruction/consumption, e.g. gestational thrombocytopenia, autoimmune thrombocytopenia.

• Gestational thrombocytopenia accounts for 70% of this disorder. Normal non-pregnant counts range between 150 and 400 × 10⁹/l. In gestational thrombocytopenia the counts are usually above 80 × 10⁹/l and return to normal by 7 days post partum. Diagnosis is by exclusion since aetiology is not known.

• Autoimmune thrombocytopenia (AITP) accounts for 3% of this complication and is often evident before pregnancy. The disorder can be primary (idiopathic) or secondary to systemic lupus erythematosus, antiphospholipid syndromes, drugs, lymphomas plus viral infections, e.g. human immunodeficiency virus (HIV).

• Non-immune causes include disseminated intravascular coagulation, pre-eclampsia, HELLP syndrome, acute fatty liver and heparin-induced thrombocytopenia.

RESPIRATORY PROBLEMS

Respiratory function during labour may be compromised when there is asthma, infection such as pneumonia or tuberculosis, cystic fibrosis or restrictive lung disease.

Respiratory problems

The fetus is likely to be affected if severe infection causes maternal oxygen saturation to fall below 90% (8 kPa). Infection can precipitate preterm labour. When infection is diagnosed:

• Take blood for full blood count, urea and electrolytes, blood cultures, viral titres and serological test to exclude atypical organisms such as mycoplasma or legionella.

• Collect sputum for culture and sensitivity and to exclude acid-fast bacilli.

• Chest radiology. This is not contraindicated as there is little risk to the fetus.

• Initiate antibiotics (usually intravenous if infection is severe). Isolation procedures, for example for tuberculosis, may be appropriate. For women with tuberculosis, the baby should be separated after birth and treated with isoniazid and vaccinated (bacille Calmette Guérin (BCG)). If mother has been recently treated and cured the baby only requires vaccination.

• An experienced anaesthetist is required if surgical delivery is necessary.

NEUROLOGICAL CONDITIONS

The following are the more usual neurological conditions relevant to labour.

Epilepsy

• This condition affects 0.5–1% of childbearing women.

• Increase renal and liver clearance of anticonvulsant drugs in pregnancy will lower the pregnancy levels by 10–25%. If fits increase, check drug levels and correct dosage accordingly. Ensure medication is continued during labour.

• Avoid sleep deprivation which results in increased frequency of fits.

• Epileptic women have a lower threshold to fit if pre-eclampsia supervenes. Anti-epileptic drugs can potentiate effects of magnesium sulphate. Rule out eclampsia if fits occur during labour.

• Vaginal delivery with epidural anaesthesia is acceptable.

• Lorazepam and diazepam can be used to control fits during labour.

• Anticonvulsants decrease maternal (not significant) and fetal vitamin K levels. It is essential to give baby vitamin K after delivery.

• Maternal phenobarbital can accumulate in baby through breastfeeding.

• Advise women against sleep deprivation. Baths should be no more than 7.5 cm (3 inches) deep. If fits are frequent advise the woman to sit on the floor for breastfeeding to avoid dropping baby.

Raised intracranial pressure

This may be benign (benign intracranial hypertension) or secondary to space-occupying lesions, cerebral oedema, infection, impaired cerebral spinal fluid absorption or drugs.

• Manage secondary raised intracranial pressure with neurologist or neurosurgeon.

• Benign intracranial hypertension is rare but can present for the first time in pregnancy (usually between 8 and 20 weeks). Diagnosis is by exclusion after a normal brain scan and lumbar puncture shows raised intracranial pressure (above 271.9 cmH₂O (200 mmHg)). Presentation includes headaches with or without visual disturbance, bilateral papilloedema and sometimes sixth nerve palsy (inability to abduct eye, with convergent squint and diplopia maximum on lateral gaze to the affected side). Spontaneous resolution in a few months is usual but visual changes can persist. Treatment is to protect visual function.

• Prescribe acetazolamide to reduce cerebrospinal fluid production.

• Repeated lumbar puncture can be performed to drain cerebrospinal fluid.

• Advise weight reduction as condition often occurs in very obese women.

• Vaginal delivery with epidural anaesthesia is acceptable. Pushing does not exacerbate the problem.

Neuromuscular disease

Multiple sclerosis, myasthenia gravis and myotonic dystrophy affect women of childbearing age with implications in labour.

Myasthenia gravis

An autoimmune disorder of acetylcholine receptors with resultant muscle fatigue, visual disturbance, coughing and speech difficulty. Effect of pregnancy on disease is uncertain. During pregnancy treatment is usually with steroid, anticholinesterase, immunosuppression and plasmapheresis for life-threatening exacerbations. Thymectomy can also be considered if diagnosed before pregnancy.

• Vaginal delivery is safe.

• Administer hydrocortisone 100 mg 6 hourly for 48–72 hours if the woman has had recent steroid usage.

• Assisted vaginal delivery is usual to overcome muscle fatigue.

• Use regional anaesthesia for caesarean section. Avoid muscle relaxants and opioids. Respiratory function must be carefully monitored post operatively.

• Magnesium sulphate and gentamicin (neuromuscular blocking properties) are contraindicated.

• Transplacental antibodies cause transient muscle weakness in 20% of newborns. Support is needed for neonatal hypotonia, feeding and respiratory difficulties. Resolution is usually complete by 1 month.

• Breastfeeding is not contraindicated even if women are on steroids or immunosuppressives.

Myotonic dystrophy

Autosomal dominant condition with progressive distal muscle weakness, wasting and impaired muscle relaxation leading to loss of facial expression. Frontal balding and cardiovascular complications, which are often evident before 40 years of age can occur.

• Diagnosis is often made for the first time in early pregnancy. Congenital muscular dystrophy is more common if the mother is affected (rather than the father) as the gene undergoes rapid expansion when passed through the maternal line.

• Perform an electrocardiogram to define cardiovascular status when women are admitted to the labour ward if this has not been done.

• Affected fetuses present with polyhydramnios, positional talipes and reduced movement. Preterm labour, stillbirth and neonatal death rates are increased.

• Prescribe Syntocinon, as labour is often dysfunctional.

• Assisted vaginal delivery is usual for maternal weakness.

• Regional anaesthesia is the preference for analgesia and for caesarean section. Avoid opioids, which potentiate respiratory compromise. Neuromuscular blockade can be difficult to reverse.

• Postpartum haemorrhage is increased. Infuse oxytocin (Syntocinon) for 4–8 hours after delivery.

Arulkumaran S, Rauff M, Ingemarsson I, et al. Uterine activity in myotonia dystrophica. Case Report. British Journal of Obstetrics and Gynaecology. 1986;93:634-636.

Batocchi AP, Majolini L, Evoli A, et al. Course and treatment of myasthenia gravis during pregnancy. Neurology. 1999;52:447-452.

Confavreux C, Hutchinson M, Hours MM, et al. Rate of pregnancy-related relapse in multiple sclerosis. Pregnancy in Multiple Sclerosis Group. New England Journal of Medicine. 1998;339:285-291.

George JN, Woolf SH, Raskob GE, et al. Idiopathic thrombocytopenic purpura – practice guideline developed by explicit methods for the American Society of Hematology. Blood. 1996;8:3-40.

Howard RJ. Management of sickling conditions in pregnancy. British Journal of Hospital Medicine. 1996;56:7-10.

Jaffe R, Mock M, Abramowicz J, et al. Myotonic dystrophy and pregnancy: a review. Obstetrical and Gynecological Survey. 1986;41:272-278.

Lusher JM, McMillan CW. Severe factor VIII and factor IX deficiency in females. American Journal of Medicine. 1978;65:637-648.

Orvieto R, Achiron R, Rotstein Z, et al. Pregnancy and multiple sclerosis: a 2 year experience. European Journal of Obstetrics, Gynecology and Reproductive Biology. 1999;82:191-194.

Ramsahoye BH, Davies SV, Dasani H, et al. Obstetric management in von Willebrand’s disease: a report of 24 pregnancies and a review of the literature. Hemophilia. 1995;1:140-144.

Weisberg LA. Benign intracranial hypertension. Medicine. 1975;54:197-207.

Yerby MS, Freil PN, McCormick K. Antiepileptic drug disposition during pregnancy. Neurology. 1992;42(Suppl):12-16.

(ii) ENDOCRINE DISORDERS

ADRENAL INSUFFICIENCY

Labour and delivery

In response to the stress of labour or surgery the adrenal gland will increase production of corticosteroids. Major stress leads to the secretion of up to 300 mg of cortisol in 24 hours with gradual reduction to usual levels once the stress has been removed. In women with adrenal insufficiency additional corticosteroid therapy is required. This should be considered in:

• Primary adrenal failure, e.g. Addison’s disease

• Secondary adrenal failure, e.g. pituitary disease

• Previous cortisol therapy – within 1 year

• Chronic steroid therapy for other conditions, e.g. asthma

Various regimens include hydrocortisone 50 mg (usually sodium succinate) parenterally at the start of labour or with premedication in elective caesarean section. Repeat 8 hourly. In the absence of complications halve the dose daily and switch to oral therapy until maintenance dose is reached.

Fetus

It is unlikely that the short term increase in dosage at the time of delivery will have any effect on the newborn.

THYROID

Hypothyroid

Thyroxine therapy is often increased during pregnancy. No change in thyroxine therapy is required during labour. After birth, reduce thyroxine therapy to pre-pregnancy dose.

Thyrotoxicosis

During pregnancy women with thyrotoxicosis should be on the lowest possible dose of propylthiouracil or carbimazole. Propylthiouracil is the preferred therapy. Block and replace therapy should not be used. Maintain thyroid function at the upper end of the normal range. Many women become euthyroid and able to discontinue therapy.

Labour and delivery

In well-controlled women problems are unlikely.

Thyroid storm

Thyroid storm is rare but can occur in a poorly controlled or undiagnosed women subjected to stress or surgery. Clinical features include: fever, tachycardia (out of proportion to fever) and other features of thyrotoxicosis, e.g. tremor, restlessness, frequent bowel motions, eye signs.

Tags: Labour Ward Manual

Mar 16, 2017 | Posted by admin in NURSING | Comments Off

Full access? Get Clinical Tree

Get Clinical Tree app for offline access

Get Clinical Tree app for offline access