Chapter 007. Medical Disorders during Pregnancy (Part 3)

Gestational Hypertension This is the development of elevated blood pressure during pregnancy or in the first 24 h post partum in the absence of preexisting chronic hypertension and other signs of preeclampsia. Uncomplicated gestational hypertension that does not progress to preeclampsia has not been associated with adverse pregnancy outcome or adverse long-term prognosis.Renal Disease(See also Chaps. 272 and 280)Normal pregnancy is characterized by an increase in glomerular filtration rate and creatinine clearance. This occurs secondary to a rise in renal plasma flowand increased glomerular filtration pressures. Patients with underlying renal disease and hypertension may expect a worsening of hypertension...
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Chapter 007. Medical Disorders during Pregnancy (Part 3) Chapter 007. Medical Disorders during Pregnancy (Part 3) Gestational Hypertension This is the development of elevated blood pressure during pregnancy or inthe first 24 h post partum in the absence of preexisting chronic hypertension andother signs of preeclampsia. Uncomplicated gestational hypertension that does notprogress to preeclampsia has not been associated with adverse pregnancy outcomeor adverse long-term prognosis. Renal Disease (See also Chaps. 272 and 280) Normal pregnancy is characterized by an increase in glomerular filtrationrate and creatinine clearance. This occurs secondary to a rise in renal plasma flowand increased glomerular filtration pressures. Patients with underlying renaldisease and hypertension may expect a worsening of hypertension duringpregnancy. If superimposed preeclampsia develops, the additional endothelialinjury results in a capillary leak syndrome that may make the management of thesepatients challenging. In general, patients with underlying renal disease andhypertension benefit from aggressive management of blood pressure.Preconception counseling is also essential for these patients so that accurate riskassessment can occur prior to the establishment of pregnancy and importantmedication changes and adjustments can be made. In general, a prepregnancyserum creatinine level This is the valvular disease most likely to cause death during pregnancy.The pregnancy-induced increase in blood volume, cardiac output, and tachycardiacan increase the transmitral pressure gradient and cause pulmonary edema inwomen with mitral stenosis. Pregnancy associated with long-standing mitralstenosis may result in pulmonary hypertension. Sudden death has been reportedwhen hypovolemia has been allowed to occur in this condition. Careful control ofheart rate, especially during labor and delivery, minimizes the impact oftachycardia and reduced ventricular filling times on cardiac function. Pregnantwomen with mitral stenosis are at increased risk for the development of atrialfibrillation and other tachyarrhythmias. Medical management of severe mitralstenosis and atrial fibrillation with digoxin and beta blockers is recommended.Balloon valvulotomy can be carried out during pregnancy. Mitral Regurgitation and Aortic Regurgitation and Stenosis These are generally well tolerated during pregnancy. The pregnancy-induced decrease in systemic vascular resistance reduces the risk of cardiac failurewith these conditions. As a rule, mitral valve prolapse does not present problemsfor the pregnant patient, and aortic stenosis, unless very severe, is well tolerated.In the most severe cases of aortic stenosis, limitation of activity or balloonvalvuloplasty may be indicated. Congenital Heart Disease (See also Chap. 229) The presence of a congenital cardiac lesion in themother increases the risk of congenital cardiac disease in the newborn. Prenatalscreening of the fetus for congenital cardiac disease with ultrasound isrecommended. Atrial or ventricular septal defect is usually well tolerated duringpregnancy in the absence of pulmonary hypertension, provided that the womansprepregnancy cardiac status is favorable. Use of air filters on IV sets during laborand delivery in patients with intracardiac shunts is generally recommended. Other Cardiac Disorders Supraventricular tachycardia (Chap. 226) is a common cardiaccomplication of pregnancy. Treatment is the same as in the nonpregnant patient,and fetal tolerance of medications such as adenosine and calcium channel blockersis acceptable. When necessary, electrocardioversion may be performed and isgenerally well tolerated by mother and fetus. Peripartum cardiomyopathy (Chap. 231) is an uncommon disorder ofpregnancy associated with myocarditis, and its etiology remains unknown.Treatment is directed toward symptomatic relief and improvement of cardiacfunction. Many patients recover completely; others are left with a progressivedilated cardiomyopathy. Recurrence in a subsequent pregnancy has been reported,and women should be counseled to avoid pregnancy after a diagnosis ofperipartum cardiomyopathy.Specific High-Risk Cardiac Lesions