Medical and Surgical

Complications of Pregnancy
Non-obstetric reasons for
admission of a pregnant woman
 Common Medical reasons
 Renal
 GI
 Pulmonary
 Infections
 Surgical Causes
 Appendicitis
 Gall bladder disease
 Pancreatitis
 Bowel Obstruction
 Trauma
 These require multi-specialty team
 OB
 working knowledge of medical and
surgical conditions in women

Non-OB specialists
 familiar with effects of these diseases on
pregnant women and vice versa
 pregnancy induced physiological changes
Surgical Conditions and
Pregnancy
Surgical conditions in pregnancy:
Abdominal pain
 often during pregnancy
 etiology may be pregnancy-specific or non-
pregnancy related
 dynamic changes of pregnancy complicate
diagnosis, especially when abdominal
complaints persist

 1 in 500 pregnancies complicated by a non-

obstetric surgical condition

most common non-obstetric abdominal
surgical conditions seen in pregnancy

 Appendicitis,
 Cholecystitis,
 Pancreatitis,
 Bowel obstruction
Surgical conditions during
pregnancy
Concerns:
Can surgery induce malformations if done 1st
trimester?
 Effect of anesthetic drugs

Can surgery precipitate labor and delivery?

 Uncomplicated operations do not increase risk of
adverse pregnancy outcomes with precautions
 Complications: appendicitis with perforation/peritonitis
maternal / fetal morbidity and even mortality increase
Surgery during pregnancy
Concerns:
 Technical problems
 Gravid uterus poses a technical problem in 3rd trim
 Procedure related complications:
 e.g aspiration of gastric contents during extubation in a
pregnant woman
 Complications arise from:
 Hesitation to operate on a pregnant women delays
treatment
 Difficulty in diagnosis: Physiologic changes in
pregnancy itself may mimic a pathological condition
 Surgical Management Principle

 Never forego a surgical procedure when

maternal health and welfare ordinarily mandates
that the procedure be completed if the mother
were not pregnant.
 Best Treatment
 Electives – early second trimester
 Emergency – prompt operation if compromised
mother regardless of gestational age
 Effect of anesthesia on
pregnancy outcome
 Mazze and Källen (1989) 5405 non-OB
surgery in 720,000 pregnant women 1973-
1981: 1st trim 41%, 2nd trim 35%,
3rd trim 24%
>50% underwent general anesthesia using
nitrous oxide
 Inc incidence of low birth weight and
preterm birth
 Effect of anesthesia on
pregnancy outcome
 No difference in rates of stillbirth and
congenital malformations
 Those that had preterm delivery
 1st trim surgery,
 peritonitis,
 long operations,
 surgery >24 wks
(Stepp and assoc, 2002)
 Anesthetic agents not generally
teratogenic except in Surgery done 4-5
wks AOG
 Significant increase in neural tube defects
(Källen and Mazze,1990)
 Hydrocephaly + eye defects in those exposed
to general anesthesia( Sylvester et al 1994)
Appendicitis
 1 in 10,000 to 1 in 300 with an average rate of 1
in 550 pregnancies.

 Adolescents have a higher risk of appendicitis

in pregnancy than other age groups.

 Other commonly seen conditions that mimic

appendicitis include pyelonephritis, pancreatitis,
cholecystitis, and gastroenteritis, among others
Appendicitis: Signs and
symptoms in pregnancy
 Long-held view that as pregnancy
advances and the uterus enlarges,
the appendix moves upward toward
the right flank, reaching the level of
the iliac crest after the fourth month of
pregnancy, and thus severe
appendicitis pain would be noted
higher in the pregnant abdomen.
 Pain Location by Gestational Age in
Histologically Proven Appendicitis Cases
Estimated No. of Right Right Others
Gestation Patients Upper Lower
al Age Quadrant Quadrant
(wks)
0-12 14 0 12 2

12-24 18 1 15 2

>24 13 2 11 0

Total 48 3 38 4
Mourad J, Elliott J, Erickson L, Lisboa L. Appendicitis in
pregnancy: new information that contradicts long held
clinical beliefs. Am J Obstet Gynecol, 2000, 182;1027-
1029
Signs and Symptoms
 In addition, the point of severe abdominal
tenderness can change with movement.
 Anorexia, nausea, and new onset nausea
and vomiting vary. Although rebound
tenderness and guarding may be elicited,
they are not specific for the diagnosis of
appendicitis.
Diagnosis in Pregnancy
 High-resolution ultrasound with graded
compression technique has been used to aid in the
diagnosis of appendicitis in pregnancy.
Sonographic findings of a normal appendix include
an appendix that is both compressible and less
than 6 mm in diameter.
 Sonographic accuracy similar in the non-pregnant woman,
especially in the first and second trimesters.
 Normal ultrasound, does not always rule out appendicitis in
pregnancy.
 Llimitations: operator skill level and difficulty in obese women
Diagnosis in Pregnancy

 Currently, computed tomography scan is

being used in non-pregnant women with
symptoms suggestive of appendicitis and
may be warranted in extreme cases in
pregnancy.
 No studies have been published to date
on use of computed tomography scanning
in pregnant women with appendicitis.
 Fever and elevated white count are not clear indicators
of appendicitis.
 Serial white blood cell (WBC) counts may be helpful
primarily to see if it is trending upward and can be a
useful indicator of appendicitis when observing a woman
over an extended period of time.
 A left shift (WBC with an increased number of immature
forms) has been noted in acute appendicitis in
pregnancy.
 Two studies have documented an increase in left shift in
patients with acute appendicitis
Surgery
 Surgical techniques depend on which trimester of
pregnancy acute appendicitis occurs.

 Laparoscopy is often performed prior to 20 weeks'

gestation.
 However, laparotomy is still used frequently during all
trimesters.
 The incidence of ruptured appendix is highest in the third
trimester of pregnancy primarily due to the difficulty of
determining a diagnosis prior to surgery.
Complications from appendicitis
during pregnancy
 preterm labor
 risk range 10% to 15%[3] to 15% to 43%.[
 increased risk of delivery the week following surgery
when performed after 23 weeks' gestation.
 the use of tocolytics prior to surgery is not
recommended for prophylactic use due to the
potential risk of fluid overload that can result in
pulmonary edema and adult respiratory distress
syndrome with use of tocolytics.
 A perforated appendix often leads to uterine
contractions and premature labor.
Complications from appendicitis
during pregnancy
An increase in medical complications is noted when
 1) symptomatology > 24 hours or greater prior to
surgery,
 2) rising white count with left shift is noted,
 3) when peritonitis or a perforated appendix is
noted at time of surgery

Increased maternal morbidity

Early fetal delivery or fetal loss.
 Fetal loss varies between 3% and 5% without
perforation and can be as high as 36% when
perforation occurs.
Gallbladder Disease

 A common non-obstetric abdominal complaint.

The incidence of gallbladder disease in
pregnancy is 0.05% to 0.3%.
 Cholelithiasis or calculi/gallstones in the
gallbladder or common duct occurs more
frequently in pregnant women.
 Gallstones can present as an obstructive
disease or as cholecystitis, which is an
inflammation of the gallbladder secondary to
gallstone obstruction of the cystic duct.
Gallbladder Disease

 The gallbladder functions as a storage reservoir

for bile produced by the liver. There is a high
concentration of bile salts, pigments, and
cholesterol within the bile storage pool
 Following the intake of foods high in lipid
content, the gallbladder contracts, ejecting the
bile salts into the intestine. Within the intestinal
tract, bile acid aids the absorption of lipids.
Sign and symptoms
 Gallstones and biliary sludge cause the most
gallbladder-related pain.
 Sludge a precursor to the formation and buildup
of gallstones, which are formed from
crystallization of cholesterol, calcium, or bile
salts.
 Multiparity a risk factor for gallstone
development
 However, gallstones are also noted to increase
with age, and their formation may be mediated
by changes in estrogen and progesterone.
Sign and symptoms
Asymptomatic gallstones are seen in 3.5% to 10%
of pregnancies
Ultrasound findings of the gallbladder in pregnant
women show a decrease in the emptying rate
and an increase in residual volume after
emptying. Eventually, this can lead to stasis and
gallstone formation.
An decrease in gallbladder motility and the larger
amounts of circulating bile salt add to more
sluggish gallbladder functioning during
pregnancy.
Signs and symptoms
 Right upper quadrant colicky or stabbing pain
 Generalized epigastric pain, which can radiate to the
right scapula and flank area due to CBD obstruction of a
stone
 Murphy's sign,
 Other symptoms: anorexia, nausea, vomiting, dyspepsia,
low-grade fever, tachycardia, and fatty food intolerance.
Abdominal guarding is not usually seen.
 Pregnant women usually present with acute epigastric
pain.
Signs and symptoms
 Laboratory testing:
 WBC for elevation
 elevated liver function tests,
 Ultrasound: imaging method of choice
 95% effective in diagnosing gallstones and
has no radiation exposure
 gallstones appear as mobile echogenic
structures with shadowing
 Acute cholecystitis dx distention of the
gallbladder, pericholecystic fluid, and
thickening of the gallbladder wall.
Management of Gallbladder
disease
 Depends on gestational age and severity of symptoms
 Conservative medical management : first consideration
in the first and third trimesters
 use of intravenous fluids, correction of electrolyte
imbalance, bowel rest, narcotics, antispasmodics,
broad spectrum antibiotics, and a fat-restricted diet.
 Fetal assessment and uterine monitoring indicated,
depending on trimester.
 Unless symptoms acute, surgical options delayed into
the second trimester to avoid the risk of spontaneous
abortion in first trimester.
Management of Gallbladder
disease
Relapse rate in gallbladder disease after
100% medical treatment
90%

80%

70%

60%

50%
Relapse
Rate 40%

30%

20%

10%

0%
1st trim 2nd trim 3rd trim
Other surgical techniques

1) endoscopic
retrograde
cholangiopancreato
graphy,
2) open
cholecystectomy,
3) laparoscopic
cholecystectomy.


Other surgical techniques
1) The choice of technique varies by institution, access,
operator availability and skill, severity of symptoms, and
gestational age.
 Most of these surgical procedures are used in patients
with acute biliary colic, acute cholecystitis, and those
with relapsing symptoms.
 Swisher et al. propose that elective second trimester
cholecystectomy is safe and minimizes relapse time.
 Gallstones are present in 12% of all pregnancies,
 more than one-third of patients fail medical treatment
and therefore require surgical endoscopy or
laparoscopy.
 Gallstone pancreatitis and jaundice during pregnancy is
associated with a high recurrence rate, exposing both
fetus and mother to an increased risk of morbidity and
mortality.
Endoscopic retrograde
cholangiopancreatography
 Recently used for pregnant women with severe gallbladder
symptoms and also for persons with gallstone-related pancreatic
symptoms.
 performed by a gastroenterologist
 The woman is placed on an x-ray table after sedation, and drugs
are administrated to induce duodenal hypotonia

 Contrast material is injected under fluoroscopy.

 In pregnant women, fetal shielding is used, and fluoroscopy time
is held to a minimum.
 Visualization of the common bile duct is seen as well as the
whole biliary tract, including the gallbladder.
endoscopic sphincterotomy

 With, an actual incision is

made through which
removal of stones and the
placement of stents can
be performed. Small
stones can be removed
easily or may be pulled
out with a balloon catheter
or basket. Larger stones
will need to be fragmented
initially.
Laparoscopic Chole
 For persons with gallbladder complaints undergoing endoscopic
retrograde cholangiopancreatography, cholecystectomy can be
delayed or may be avoided entirely.
 Laparoscopic cholecystectomy is another surgical option for
gallstones. Graham et al.1998, in a literature review and reported
on 105 cases of laparoscopic cholecystectomy performed in
pregnancy.
 Ninety of these cases noted gestational age at time of surgery;
 12 cases (13%) were performed in the first trimester;
 64 cases (71%) in the second trimester,
 14 cases (16%) in the third trimester.
 There were no spontaneous abortions in the women who
underwent surgery during the first trimester.
Laparoscopic Chole

 Graham et al. 1998. noted one case of fetal demise, 7 weeks after
laparoscopic cholecystectomy, and noted that there have been
anecdotal reports of stillbirths, correlating with the timing of
laparoscopic surgery.
 They suggest using the Hasson open approach during laparoscopy
to prevent inadvertent puncture of the gravid uterus and maintaining
pressure between 10 and 12 mmHg.
 Transvaginal ultrasound for fetal assessment is ideal during
laparoscopy.
 Compared to laparotomy, laparoscopy is associated with a shorter
recovery time, less uterine manipulation, and earlier ambulation.
Complications:
 Cosenza et al. reviewed the surgical management of
biliary gallstones in pregnancy.
 They reported on a total of 32 cholecystectomies, 7 open
common bile duct explorations, and 12 laparoscopic
cholecystectomies.
 One spontaneous abortion was noted in the laparoscopy
group.
 One woman in the cholecystectomy group had a preterm
delivery.
 Monitoring for preterm labor is critical although
laparoscopy has been noted to have a lower incidence
of preterm labor than the incidence noted in women who
undergo laparotomy.
Pancreatitis
 Incidence: ranges from 1 in 1,066 live births to 1 in
3,333 pregnancies.
 Predisposing factor during pregnancy:
 most common, secondary to cholelithiasis
 hypertriglyceride-induced pancreatitis.
 results from the increased estrogen effect of pregnancy and the
familial tendency for some women toward high triglyceride levels.
 Drugs, specifically tetracycline and thiazides (not commonly
used in pregnancy), as well as increased alcohol consumption,
can also cause pancreatitis.
 Recently, pancreatitis has been linked to more than 800
mutations of the cystic fibrosis transmembrane conductance
regular gene.
Symptoms and signs
 midepigastric pain,
 left upper quadrant pain radiating to the left flank,
 anorexia,
 nausea, vomiting,
 decreased bowel sounds,
 low-grade fever,
 and associated pulmonary findings 10% of the time (unknown cause). A pulse
oximeter reading should be obtained. Pulmonary signs often include hypoxemia,
which can lead to full-blown adult respiratory distress syndrome.
 Other symptoms may include jaundice, abdominal tenderness, muscle rigidity, and
hypocalcemia.
 The most common misdiagnosis of pancreatitis in the first trimester is hyperemesis.
Given this constellation of symptoms, it is critical to distinguish between hyperemesis
gravidarum and pancreatitis when evaluating a woman in the first trimester of
pregnancy. In women presenting with severe nausea and vomiting in the first
trimester, consider obtaining amylase, lipase levels, and liver function tests, which
when elevated are diagnostic for pancreatitis. In one study of 25 cases of
pancreatitis, 11 cases were diagnosed in the first trimester.[33]
Symptoms and signs
 midepigastric pain,
 left upper quadrant pain radiating to the left flank,
 anorexia,
 nausea, vomiting,
 decreased bowel sounds,
 low-grade fever,
 and associated pulmonary findings 10% of the time (unknown
cause). A pulse oximeter reading should be obtained. Pulmonary
signs often include hypoxemia, which can lead to full-blown adult
respiratory distress syndrome.
 Other symptoms may include jaundice, abdominal tenderness,
muscle rigidity, and hypocalcemia.
Symptoms and signs
 The most common misdiagnosis of pancreatitis
in the first trimester is hyperemesis.
 Distinguish between hyperemesis gravidarum
and pancreatitis when evaluating a woman in
the first trimester of pregnancy.
 in the first trimester, consider obtaining
amylase, lipase levels, and liver function tests,
which when elevated are diagnostic for
pancreatitis. In one study of 25 cases of
pancreatitis, 11 cases were diagnosed in the
first trimester
Complications
 Pancreatitis in pregnancy had been associated
in the past with a high maternal death rate and
fetal loss rate.
 More recent studies have found declining rates due to
earlier diagnosis and greater treatment options and
improved management of pancreatic symptoms that
can cause preterm labor.
 The relapse rate for gallstone-related pancreatitis is
higher than for other causes—up to 70% with
conservative treatment only.
Complications
Hyperlipidemia during pregnancy (2nd most common cause)
 Lipids and lipoprotein levels increase during pregnancy,
 triglycerides increase threefold peaking in the third trimester
The level of triglycerides required to induce acute pancreatitis is
between 750 and 1,000 mg/dL . The total serum triglyceride
level during pregnancy is usually less than 300 mg/dL. After
delivery, triglyceride levels usually fall
 An increase in cholesterol of 25% to 50% occurs
primarily as a result of higher blood levels of estrogen.
 Fifty percent of women with pancreatitis develop
hypocalcemia secondary to diminished calcium in
pregnancy, which worsens with pancreatitis.
Diagnosis
 Ultrasound is the imaging technique of choice for
pregnant women because it can distinguish a normal
appearing pancreas from one that is enlarged, and it can
also identify gallstones.
 Diagnostic blood tests
 serum amylase (10 to 130 in some labs to 30 to 110 in
others or even up to 150 to 160 in pregnancy) increased
also in bowel obstruction, cholecystitis, ruptured ectopic
In another study, the mean amylase levels in a selected
group of persons presenting with pancreatitis was 1,400
IU/L.
Diagnosis
 Lipase, another enzyme produced by the pancreas, has
norms ranging from 4 to 57 and from 23 to 208 (these
also vary depending on laboratory).
 triglyceride levels
 calcium levels
 complete blood count.
 In one study, an elevated amylase level had a
diagnostic sensitivity of 81%, and adding lipase
increased the sensitivity to 94%.[31] Amylase levels do
not correlate with disease severity. Elevated serum
lipase levels remain elevated longer than amylase
following an episode of pancreatitis.
Diagnosis

Ultrasound is the imaging technique of choice for pregnant women
because it can distinguish a normal appearing pancreas from one
that is enlarged, and it can also identify gallstones.
 Diagnostic blood tests
 serum amylase (10 to 130 in some labs to 30 to 110 in others
or even up to 150 to 160 in pregnancy) increased also in bowel
obstruction, cholecystitis, ruptured ectopic In another study, the
mean amylase levels in a selected group of persons presenting
with pancreatitis was 1,400 IU/L.
 Lipase, another enzyme produced by the pancreas, has norms
ranging from 4 to 57 and from 23 to 208 (these also vary
depending on laboratory).
 triglyceride levels
 calcium levels
 complete blood count.
Diagnosis

 In one study, an elevated amylase level had a

diagnostic sensitivity of 81%, and adding lipase
increased the sensitivity to 94%.
 Amylase levels do not correlate with disease
severity. Elevated serum lipase levels remain
elevated longer than amylase following an
episode of pancreatitis.
Treatment
 Ranson developed criteria for classification of severity of acute pancreatitis based on
non-pregnant persons.
 One set of criteria is used at the time of admission and another after the initial 48
hours

Classification of Severity of Acute Pancreatitis

3 or greater at time of admission
 Age >55 years
 White blood cell count >16,000/mm
 Blood glucose >200 mg/dL
 Serum lactate dehydrogenase more than twice normal
 Serum glutamic-oxaloacetic transaminas more than six times normal

3 or greater after initial 48 hours

 Decrease in hematocrit of >10%
 Serum calcium < 8 mg/dL
 Increase in blood urea nitrogen of >5 mg/dL
 Arterial pO2 < 60 mm Hg
 Base deficit >4 mEq/L
 Estimated fluid sequestration 6,000 mL
Treatment
 In persons with fewer than three prognostic signs, the
risk of death or major complications is small. These
criteria are often used as a guide when treating gravid
women with pancreatitis as well.
 Conservative medical management of pancreatitis
includes intravenous fluids, nasogastric suctioning, total
parenteral nutrition, use of analgesics and
antispasmodics, fat restriction with total parenteral
nutrition, and antibiotics. Lipoprotein apheresis and
plasmapheresis are therapies known to lower serum
triglyceride levels.
Treatment
 Endoscopic retrograde
cholangiopancreatography and endoscopic
sphincterotomy are techniques used to treat
gallstone-related pancreatitis
 Again, fluoroscopy time during pregnancy is
limited or omitted. Fetal shielding can be used in
which a lead apron is placed over the maternal
abdomen, and fluoroscopy is limited to less than
one minute. Increased serum amylase levels are
often elevated transiently following this
procedure.
Endoscopic retrograde
cholangiopancreatography in pregnancy
Jamidar et al.details 23 pregnant women with pancreatic-biliary
disease, treated at several different medical centers, who
underwent diagnostic and therapeutic endoscopic retrograde
cholangiopancreatography.
 Prophylactic antibiotics were administered,
 Abdomen was shielded with a lead apron.
 Fluoroscopy time was kept under 1 minute.
Common bile stones were found in 14 of the 23 women.
 There was one spontaneous abortion in the second trimester, occurring
3 months after endoscopic retrograde cholangiopancreatography and a
 spontaneous abortion after a third stent replacement occurred in
another woman.
 Second trimester is thought to be the ideal time for endoscopic
retrograde cholangiopancreatography to avoid any possible
teratogenic effects of radiation.
Bowel Obstruction
 The most common cause in pregnancy is adhesions secondary to
prior surgery or illness
 77% of the 66 cases presented with known obstruction due to
adhesions from previous abdominal surgery, pelvic surgery, or pelvic
inflammatory conditions or previous cesarean birth
 The incidence of intestinal obstruction in pregnancy varies from 1 in
1,500 to 1 in 66,500 pregnancies.
 Although adhesions is the most common cause the ff contribute ,
 volvulus (25%),
 intussusception (5%)
 malignancies,
 Hernias
 worsening diverticulitis/diverticulosis
 The differential diagnosis includes appendicitis and perforated ulcer.
Bowel Obstruction
Occurs during the fourth to fifth months of pregnancy when
the uterus rises into the abdomen but most often occurs
in the third trimester or postpartum.
 Significant risk for severe morbidity or mortality for both
mother and fetus
 treatment is urgent
 Delays due to errors in diagnosis, or reluctance to
operate during pregnancy all add to increased risk.
 The maternal mortality rate in one study was 4 deaths in
66 women diagnosed with obstruction
Definition
 Partial or complete,
 small or large intestine-related,
 acute or chronic,
 high or low.
 Simple intestinal obstruction refers to an
obstructed portion of lumen without vascular or
neurological involvement.
 Strangulated obstruction is the most serious
because it involves occlusion of the blood
supply.
Definition
Simple obstruction changes the normal secretory and absorptive functions of
the bowel.
 Absorption is decreased, and the wall of the bowel becomes
congested and swollen.
 Motility of intestinal contents changes, and food and intestinal
secretions accumulate proximal to the blockage.
 The more distal portion of the intestine collapses, and a bowel
movement is not uncommon at this point.
 Peristalsis increases in an attempt to push past the obstruction but
can add to edema and inflammation.
 Intestinal gas also accumulates and adds to abdominal distention.
There are waves of peristalsis, with both motility and hypoactivity
adding to the colicky pain.
 Fluid and electrolyte losses can be significant, leading to
hypovolemia, renal problems, shock, and death.
Signs and symptoms
 Obstipation (extreme constipation often secondary to an
obstruction) 30%
 abdominal tenderness 71%
 vomiting are commonly noted symptoms of bowel obstruction 82%
 Intestinal, colicky, crampy pain radiating to the back, along with
abdominal distention, may be noted in persons with obstruction.
 One study of 66 cases of bowel obstruction during pregnancy and
the puerperium revealed 98% of women complained of abrupt onset
pain,
 In women with more complicated, infracted, or strangulated bowel
obstruction, abdominal guarding and rebound tenderness can be
noted.
 Over time, vomitus and stools become more foul smelling
secondary to bacteria being absorbed into the peritoneum.
Signs and symptoms
 Early findings of intestinal obstruction can seem fairly
normal, or more vividly affected persons may present
with pain out of proportion to what might be expected.
 Serial assessments of
 increasing WBC count
 Mild to moderate dehydration can become evident with
noted hemoconcentration and decreased urinary output
 Serum electrolytes and renal function studies can be
altered.
 Fever, tachycardia, marked elevation in WBC, and
localized abdominal pain signify more intensive bowel
sequelae.
Diagnostics
 upright and flat plate x-ray of the abdomen. 82%
sensitive in detecting either air fluid levels and/or
bowel dilatation.
 magnetic resonance imaging (MRI)
 Early imaging and diagnosis are warranted because
bowel necrosis can occur rapidly. Minimal delay in
treatment is key, and early surgical consultation is
necessary to evaluate bowel viability
Treatment
 Fluid and electrolyte replacement must be aggressive
 Use of nasogastric tube and antibiotics are often
necessary.
 Fetal monitoring and maternal oxygen saturation levels
need to be closely evaluated. In one literature review of
66 pregnant and postpartum women, 15 required
resection of nonviable bowel at laparotomy.
 Fetal death rates following maternal intestinal obstruction are
between 20% and 26%.
 Maternal mortality can range from 6% to 20%.[4, 38]
Trauma in Pregnancy
Types:
 Physical Abuse : usually no prenatal care,high
risk for LBW, preterm delivery, chorioamnionitis
 Sexual Assault: usually < 20 wks, STD
 Vehicular Accidents
 Penetrating Injuries
 Burns: Maternal/ fetal survival parallel to
percentage of burned surface area, prognosis
worse for survival when burn≥ 50%
Obstetric Complications in
Trauma in Pregnancy
 Abruptio Placenta:
 minor trauma 1% risk,
 major trauma 50%,
 more likely in accidents > 30 mph
 Uterine Rupture:
 uncommon, <1% of severe cases
 Feto-Maternal Hemorrhage:
 blunt injury to pregnant woman’s abdomen causing placental
fractures or tears caused by stretching.
 30% of pregnant trauma cases.
 Fetus bleeds to maternal circulation
Obstetric Complications in
Trauma in Pregnancy
Fetal Injury :
 only in direct feto-placental injury,
 maternal shock
 pelvic fractures,
 maternal head injury or hypoxia.
Commonly fetal skull and brain injuries
Management
 Resuscitate and stabilize
 Deflect large uterus away from large vessels to
improve cardiac output
 Evaluate for fractures, internal injuries, bleeders
and uterine as well as fetal injuries.
 Surgical exploration if indicated like gunshot
wounds
 Fetal heart rate monitoring: 20% of women with
frequent contractions have an associated
placental abruption
Diagnostic Tests
Are they safe?
Diagnostic Techniques
 X-ray
 Ultrasound

 Magnetic Resonance Imaging

The use of X-ray prior to recognition of

pregnancy …. Cause for concern?
Fetal Effects of Radiation
 Cell death
 Growth restriction
 Congenital malformations
 Carcinogenesis
 Microcephaly and mental retardation
 Sterility
Effects of Ionizing radiation
Human data
Radiation > 100 rad caused
 Microcephaly
 hydrocephaly,
 mental retardation,
 abnormal genitalia,
 growth restriction,
 micropthalmia and cataracts
 (From women with malignancies (Goldstein and Murphy
1929; Dekaban 1968; Brent 1999)
Effects of Ionizing radiation
Human data
2. Increased risk of mental retardation
 exposure at 8 to 15 wks greatest risk of MR
 4% for 10 rad
 60% for 150 rad
 larger exposure dose needed at 16 to 25 wks.
 No mental retardation with exposures < 8wks and >
25 weeks even with doses of >50 rad
(Nagasaki and Hiroshima atomic bomb survivors exposure to
fallout Greskovich Macklis, 2000; otake et al, 1987):
 Dose to Uterus of Common Radiological
Procedures of Concern in OB

Study View Films/study Dose/study

(mrad)
Skull AP,PA, Lat 4.1 <0.05

Chest AP,PA, Lat 1.5 0.02 –0.07

Mammogram CC, Lat 4.0 7-20

Lumbosacral spine AP,PA, Lat 3.4 168-359

Abdomen AP,PA, Lat 1.7 122-245

Intravenous AP,PA, Lat 5.5 686-1398

pyelogram
Hip (single) AP,Lat 2.0 103-213
Diagnostic Imaging
 Xray – most diagnostic procedures do not reach
exposure of 1 rad except for an IVP
 Fluroscopy and Angiography –variable dose but
farther from fetus, less radiation
 CT- 2-5 rads
 Ultrasound – proven to be harmless
 MRI – contrast not recommended otherwise
useful and safe
Diagnostic Radiation
 No singe diagnostic procedure results in a
radiation dose significant enough to
threaten the well-being of the developing
embryo and fetus
American College of Radiology,1991
Guidelines for Diagnostic Imaging
During Pregnancy (ACOG, 1995)
 Counsel Women that x-ray exposure from a single diagnostic
procedure does not result in harmful fetal effects.
 Specifically exposure less than 5 rad has not been associated with an
increase in fetal anomalies or pregnancy loss
 Concern about possible effects of high dose ionizing radiation
exposure should not prevent x-ray medically indicated diagnostic
procedure in pregnant women.
 During pregnancy, As much as possible procedures w/o ionizing
radiation like ultrasound and MRI should be used
 Ultrasound and MRI are not associated with known adverse fetal
effects.However until more info available,MRI not recommended in the
first trimester
 Consult with a radiologist to help estimate radiation dose in multiple
diagnostic x-rays
 Radioactive isotopes of iodine contraindicated for therapy in
pregnancy
Heart Disease
 Philippine General Hospital
 Incidence: 2.8% in the year 2007
Causes:
 Rheumatic Heart Disease – 60.1%
 Congenital Heart Disease – 32.7%
 Mitral Valve Prolapse – 2.9%
 Others (IHD, Cardiomyopathy, Arrhythmia) –
4.3%
Hemodynamics during Pregnancy
 Peripheral Resistance
 Uterine blood flow Cardiac
 Blood volume 40-45% output 30%
 Heart rate 10-20%
 Blood pressure or
 Pulmonary vascular resistance
 Venous pressure in lower extremities
Hemodynamics during Pregnancy
 Cause problems for the mother with
cardiac disease

 Added volume load  compromise a

patient who has impaired ventricular
function and limited cardiac reserve

 Stenotic valvular lesions are less well

tolerated than regurgitant lesions,
because the decrease in peripheral
resistance exaggerates the gradient
across the aortic valve.
Hemodynamics during Pregnancy
 Tachycardia of pregnancy  reduces the
time for diastolic filling in a patient with
mitral stenosis, with resultant increase in
left atrial pressure

 With a lesion such as mitral regurgitation,

the afterload reduction helps offset the
volume load on the left ventricle that
gestation imposes
Hemodynamics during labor and
delivery
Each uterine contraction

500ml of blood is released into the

circulation

Rapid increase in CO and BP

Hemodynamics during labor and
delivery
 Cardiac output is 50% above baseline
during the 2nd stage of labor and may
be even higher at the time of delivery

 Normal vaginal delivery: 400ml of

blood is lost

 Cesarean section: 800ml of blood is

lost  more significant hemodynamic
burden to the parturient
Hemodynamics during labor and
delivery
Following delivery of the baby

Abrupt increase in venous return

(autotransfusion & baby no longer
compresses the inferior vena cava)

Autotransfusion of blood in the 24 to 72

hours after delivery
(pulmonary edema may occur)
 High risk patient with cardiac disease

 Multidisciplinary approach
 Cardiologist and obstetrician should work with
the anesthesiologist to determine the safest
mode of delivery
 Vaginal delivery – feasible and preferable
 Cesarean section – only indicated for
obstetric reasons
 Exceptions:
 Patient anticoagulated with warfarin
 Dilated unstable aorta (e.g. Marfan Syndrome)

 Severe pulmonary hypertension

 Severe obstructive lesion, such as aortic stenosis

 Severe heart failure – may worsen before
mid pregnancy
 Some fail in 3rd trimester during maximal
blood volume
 Majority heart failure peripartum when
there are rapid change in cardiac output
 Clinical Indicators of Heart Disease
during Pregnancy

Symptoms Clinical findings

 Progressive dyspnea/
 Cyanosis
 Clubbing of fingers
orthopnea
 Persistent neck vein
 Nocturnal cough distnetion
 Hemoptysis  Systolic murmur grade
3/6 or greater
 Syncope  Diastolic murmur
 Chest pain  Cardiomegaly
 Persistent arrythmia
 Persistent split S2
Diagnostic Tests
 Electrocardiography: frequent findings in
pregnancy
 Diaphragm elevation caused 15° LAD producing mild ST
changes in inferior leads
 PACs and PVCs frequent
 Echocardiography: normal findings
 Tricuspid regurgitation
 Increased left atrial size
 Left ventricular outflow x-sectional area increased
 Chest X-ray
 To exclude cardiomegaly
 New York Heart Association
Classification Scheme

Class I: Uncompromised – no limitation of

physical activity
Class II: Slight limitation of physical activity –
comfortable at rest, fatigue, palpitations,
dyspnea, angina with regular activity
Class III: Marked limitation of physical activity
– comfortable at rest,fatigue with less than
regular activity
Class IV: Severely Compromised- inability to
perform any physical activity without discomfort
 Class I and II usually without morbidity and
mortality is rare
 Observe for early signs of heart failure, avoid
infections, avoid smoking
 Vaginal delivery
 Watch out for pulmo edema, hypoxia, hypotension
intrapartum
 Semirecumbent with lateral tilt, vital signs monitoring
(maintain PR<100 bpm, RR <24
 Pain relief, epidural anesthesia
 Class III to IV
 Counsel regarding risk of getting pregnant
 If pregnant explain need for prolonged
hospitalization and bed rest
 Operations /CS tolerated poorly
 Risks of Maternal Mortality caused by various
Types of Heart Disease (ACOG, 1992)

Group 1: Group 2: Group 3:

Minimal Risk Moderate Risk Major Risk
0-1% Mortality 5-15% Mortality 25-50% Mortality
ASD MS NYHA Class III and IV Pulmonary Hypertension

VSD Aortic Stenosis Aortic coarctation with

valve involvement
PDA Aortic coarctation w/o Marfan with aortic
valve involvement involvement
Pulmonic or tricuspid Uncorrected TOF
disease Previous MI
Tetralogy Fallot, corrected Marfan S w/ normal aorta

Bioprosthetic valve MS with AF

Mitral Stenosis NYHA Artificial Valve

Class I and II
Pulmonary hypertension
 Primary – idiopathic
 Acquired – secondary to an underlying cardiac or pulmonary
disease
 Cardiac disease with L to R shunting
 Pulmo hypertension develops when pulmo
vascular resistance > systemic vascular
resistance also called Eisenmenger Syndrome
 Poor prognosis for mother and pregnancy
 Mx of labor and delivery problematic
 Greatest risk when there is diminished venous return
and right ventricular filling
Subacute Bacterial Endocarditis
 Infection involving cardiac endothelium
producing vegetations in the valves
 Refers to a low virulence bacterial
infection superimposed on an underlying
heart lesion, usually organisms that
cause indolent bacterial endocarditis like
streptococci or enterococci
Estimates of risk for infective endocarditis with
various types of cardiac lesions
High Risk Moderate Risk Not recommended

Prosthetic heart valves Most congenital HD ASD

not in low or high risk
category
Previous endocarditis Acquired valvular dis Surgically corrected
(RHD) lesions w/o prosthesis
( ASD,VSD, PDA)
Complex congenital Hypertrophic Coronary artery dis with
cyanotic heart dis cardiomopathy previous bypass
Surgically constructed MVP w/ valve MVP w/o regurgitation
systemic pulmo shunts regurgitation and/ or
thick leaflets
Physiologic murmurs

Previous Rheumatic fever

w/o valve dysfunction
Pacemakers
Endocarditis Prophylaxis for Genitourinary
and Gastrointestinal Procedures

High Risk patients Ampicillin + Gentamicin

Penicillin -allergic Vancomycin + Gentamicin

Moderate risk patients Amoxicillin or Ampicillin
(dental procedures)
Pneumonia
 Pneumonia –inflammation of lung parenchyma
beyond large airways … bronchioles and
alveolar units
 Pneumonitis cause loss of ventilatory capacity and
poorly tolerated by pregnant women
 Hypoxia and acidosis poorly tolerated by fetus
 May lead to preterm labor
 Any pregnant woman suspected of having pneumonia
should undergo Chest AP and Lat x-ray
Bacterial Pneumonia
 Common Pathogens
 Streptococcus pneumoniae
 Mycoplasma pneumoniae
 Haemophilus influenzae
 Chlamydia pneumoniae
 Presentation: productive cough, fever, chest
pain and dypnea.
 Mild leukocytosis, sputum Gram stain, Sputum
culture and sensitivity ( poor predictability, only
50% organism identified)
Bacterial pneumonia:
Management
 Hospitalization
 Erythromycin in uncomplicated cases, IV intially
 If Haemophilus pneumonia, Cefotaxime,
cefuroxime, ceftizoxime
 Since 25% penicillin resistant pneumococcal
pneumonica, Levofloxacin drug of choice in
strains resistant to penicillin
 Prevention: Pneumococcal vaccine protective
against 23 vaccine-related serotypes, 60-70%
protective
Viral Pneumonia: Influenza
 Influenza – Orthomyxoviridae family, spread by
aerosolized droplet
 Outbreaks every year with global pandemics every
10-15 yrs
 Influenza A more serious than type B
 Primary pneumonitis most severe form with scanty
sputum and x-ray picture of interstitial infiltrates
 Secondary bacterial infection with strep or staph
Viral Pneumonia: Influenza
Management
 Prevention: VACCINATION after the 1st trimester
recommended in all pregnant women
 If high risk with underlying heart disease, diabetes, asthma,
vaccinate anytime. No evidence for teratogenicity
 Management:
 Supportive rest and anitpyretics
 Amantidine or Rimantidine to reduce severity of
infection, prevents infection in high risk non-
immunized women with exposure
Viral Pneumonia: Varicella-Zoster
 Primary infection “chicken pox” attack rate of
90%
 Fetal Effects: Infection of pregnant woman <20 wks
infects fetus with permanent sequelae: chorioretinitis,
cerebral cortical atrophy, hydronephrosis, skin and
bony leg defects and scarring
 Complications: varicella pneumonia (5-10%)
tachypnea, dry cough, dyspnea, fever, chest pain
 Chest PA characteristic nodular infiltrates and
interstitial pneumonitis
Viral Pneumonia: Varicella
management
 PROPHYLAXIS: Varicella-zoster
immunoglobulin
 to prevent infection after exposure in
susceptible individuals within 96 hours
 Because of severity of varicella during
pregnancy immunoglobulin recommended by
some
 Treatment: Varicella pneumonia with IV
acyclovir
 Prevention: Attenuated live varicella vaccine not
recommended in pregnancy
Asthma in Pregnancy
Reversible airway obstruction from bronchial
smooth muscle contraction, mucus
hypersecretion and mucosal edema
 Airway inflammation and responsiveness to
stimuli like irritants, viral infections, cold air and
exercise
 Chronic inflammatory airway problem with a
major hereditary component
 Spectrum of illness from mild wheezing to
severe bronchocenstriction, respiratory failure
and death
Asthma: Mangement
 Assess pulmonary function
 Avoid/ control environmental precipitants
 Patient education
 Drug therapy:
 Beta-agonist
 Inhaled steroids
 Cromlyn Sodium
 Theophylline
 Leukotriene modifiers
Asthma in Pregnancy
 Treatment same as in non-pregnant
 Continue treatment regimen for asthma
during labor and delivery
 Non histamine-releasing narcotic for pain
relief
 Conduction analgesia preferred since tracheal
intubation can trigger severe bronchospasm
 Antiphospholipid Antibody
Syndrome
Is an immune disorder characterized by
production of moderate to high levels of
antiphospholipid antibodies and special
clinical features:
– Recurrent venous / arterial thrombosis
– Cerebral and nervous system disorders
– Pregnancy complications
Asheron et al eds. The Antiphospholipid Syndrome, 1996
 CRITERIA
CLINICAL CRITERIA
Vascular thrombosis
Confirmed by imaging, doppler or
histopathology
 Pregnancy Morbidity

≥1 unexplained death ≥10th ≥3 consecutive spontaneous

week AOG abortions <10th week AOG
excluding the following as
≥1 premature birth ≤34th causes:
AOG because of:
• Maternal anatomic or
• Severe hormonal
preeclampsia or abnormalities
eclampsia • Maternal and paternal
chromosomal
• Severe placental abnormalities
insufficiency
 NONCRITERIA FEATURES OF APAS

CLINICAL
– Livedo reticularis
– Cardiac valvulopathy
– Seizures, TIA
– Thrombocytopenia
– AIHA
– Pulmonary hypertension
Asherson, 1996
Pregnancy complications
Early and late abortions
Blighted ova
IUGR (30%)
Pre-eclampsia (11-17%)
HELLP syndrome

Asherson et al eds. The antiphospholipid Syndrome, 1996

 Subchorionic
Hemorrhage
(Abruption)

Oligohydramnios
in 1st Trimester
Placental Infarcts
Intervillous Thrombosis
Premature Aging of the Placenta
LABORATORY CRITERIA
Anticardiolipin antibodies
– Medium or high titers of ACL on at least 2
occasions 6 wks apart
– IgG, IgM, IgA (?)
– ELISA
Lupus anticoagulants (KCT, DRVVT, aPTT)

– Prolonged coagulation
– Failure to correct with normal plasma
– Corrected with excess phospholipid

– Anti ß2 Glycoprotein-1 IgG and IgM

Treatment of APS
 Best treatment:
 Low dose aspirin ( 60-80mg OD) to block conversion
of arachidonic acid to thromboxane A2 that
aggregates platelets and causes vasoconstriction
 Low dose heparin (7500 u to 10,000 u SC bid) to
prevent thrombotic episodes
 Other treatment:
 Steroids (Prednisone) not widely used for treatment due to
adverse effects
 Intravenous Immunoglobulins – used when first-line
therapies have failed. Very costly and given monthly
 ACOG Proposed Management for
Women with APLAs, 1998
Features Pregnant
APS with FDU/RPL UFH prophylactic 15,000 –
20,000 u/day + LD ASA
daily +Calcium+Vit D
APS w/ previous VTE or UFH full anticoag. Or as
Stroke prophylactic as above + LD
ASA
APS w/o VTE nor RPL No tx, or daily LD ASA, or
prophylactic UFH + LD ASA
APLAs w/0 APS or low level Uncertain. Same as APS w/o
antibodies VTE nor RPL
Outcome of Treatment for APAS

• Without treatment: 40-50% births

• With treatment 70-80% live births

• However fetal growth restriction and

preeclampsia are still common despite
treatment
Systemic Lupus Erythematosus
and Pregnancy
 SLE, a disease of unknown etiology
 Tissues and cells of different organ
systems are damaged by autoantibodies
and immune complexes
Maternal and Perinatal Effects of SLE
Outcome Description

Maternal

Lupus flare 1/3 of women experience flare during pregnancy

Preeclampsia Controversial if incidence increased

Flare can be life-threatening
Flares associated with worst outcome
Increased incidence with nephritis
Worse with APAs
Preterm labor Increased

Perinatal

Preterm labor Increases with preeclampsia

Growth restriction Increased

Stillbirth Increased with APS

Neonatal lupus About 10%, transient except for heart block

Outcome of pregnancy with SLE
Better if:
1. Lupus quiescent for 6 months
2. No active renal involvement
3. Superimposed preeclampsia does not
develop
4. No evidence of antiphospholipid activity
Neonatal LUPUS
 Syndrome characterized by:
 Skin lesions – lupus dermatitis
 Hematologic: thrombocytopenia, autoimmune
hemolysis
 Diffuse fetal myocarditis and fibrosis in the
region between AV node and bundle of His
causing congenital heart block ( associated with
Anti-SS-A (Ro) and anti-SS-B (La) antibodies)
 Cardiac lesions permanent if affected and
require pacemakers
Urinary Tract Infections
 Most common infection in pregnant women
 BACTERIURIA 2-8%
 Coitus is the most important contributing factor
 UTI can affect any part of the urinary tract
 Urethritis
 Cystitis
 Pyelonephritis
 caused by complex interaction between
virulence of pathogen and host defense
Asymptomatic Bacteriuria
 Persistent, actively multiplying bacteria in the
urinary tract w/o symptoms
 Incidence: routine urinalysis on first consult 2-
7% will be positive
 Bacteriuria seen at initial consult
 If culture negative, symptomatic UTI <1%
 If culture positive and persists after delivery, will have
pyelographic evidence of chronic infection
Asymptomatic Bacteriuria

 Evidence shows it is unlikely that it can

cause low birth weight or prematurity
 Controvesial whether it causes maternal
hypertension, preeclampsia or anemia
 If untreated, 25% develop clinical
infection
How Much BACTERIURIA?

 Clean voided urine specimen( midstream urine sample

after washing external genitalia 2-3x with a cleansing
agent before collecting specimen, with 100,000
organisms of a single uropathogen
 Lesser number from 20,000 to 50,000 organisms should
be treated if symptomatic
 If cultures not possible, presence of >10 WBC/hpf
 Eradication of bacteriuria prevents most of clinical
infections.
 Recurrences, persistenc of infection treates with
suppressive therapy for remainder of pregnancy e.g
Nitrofurantoin 100 mg OD throughout pregnancy
 Single Dose Therapy
Amoxicillin 3g
Ampicillin 2g
Cephalosporin 2g
Nitrofurantoin 200mg
Sulfonamide 2g
Trimethoprim-sulfamethoxazole 320/1600mg

Three day Therapy

Amoxicillin 500 mg TID
Ampicillin 250mg QID
Cephalosporin 250mg QID
Ntrofurantoin 50-100mg QID or 100 mg BID
Sulfonamide 500mg QID

Other Regimens
Nitrofurantoin 100mg QID x 10days
Nitrofurantoin 100mg OD at bedtime x 10 days

Treatment Failures
Nitrofurantoin 100 mg QID x 21 days

Suppression fro Bacterial persistence or recurrence

Nitrofurantoin 100mg OD at bedtime remainder of pregnancy
Seizures in Pregnancy
 Seizure –a paroxysmal disorder of the CNS
characterized by abnormal neuronal discharge with or
without loss of consciousness
 Epilepsy is a condition characterized by a tendency to
have two or more recurrent seizures unprovoked by any
known proximate insult
 Partial – originate in one localized area of the brain,
usually no loss of consiousness
 Generalized – involve both hemispheres of brain
simultaneously, preceded by an aura before an abrupt
loss of conscousness
Effect of Pregnancy on Epilepsy

Seizure control is unpredictable and

variable. Frequency can increase by 30%
1. Nausea and vomiting leading to skipped
doses
2. Decreased GI motility and the use of antacids
reducing drug absorption
3. Expanded intravascular volume lowering
serum drug levels
4. Induction of hepatic, plasma and placental
enzymes that increase drug metabolism
Effect of Pregnancy on Epilepsy

5. Increased GFR, increases drug clearance

6. Lowering of seizure threshold affected by
sleep deprivation and hyperventilation
7. Protein binding of drug is decreased
increasing free drug levels
8. fear of fetal effects
Effects of Maternal Epilepsy on
Pregnancy
Various reports:
 Increased vaginal bleeding
 2x risk of toxemia
 Preterm labor
 Stillbirths due to hypoxia and acidosis
during maternal convulsions
 Effects of Maternal Epilepsy
on Pregnancy
 Risk of fetus inheriting epilepsy
 depends on nature of mothers seizure disorder.
Risk is higher ( about 2-3%) with idiopathic than
acquired causes.
 Increased risk of certain congenital malformations
 caused by the epilepsy itself,
 the anticonvulsant medication
 or combination of both
 Increased risk of neonatal bleeding due to
decreased factors II, VII, IX, X similar to that
produced by vitamin K deficiency
 The Women with Epilepsy Guidelines
Development Group:
Best Practice Guidelines for the Management of
Women with Epilepsy (1999)
 Systematic review of literature (1966-1998)
adopted as UK clinical guidelines

 Preconception counseling offered to all women

of childbearing potential
 Change antiepileptic medication should be
completed before conception and monotherapy is
preferred.

Crawford P, Appleton R, Betts T et al Seizure 1999: 8, 201-217

 Consensus Guidelines: Preconception
Counseling, Management and Care of the
Pregnant Woman with Epilepsy

 Antiepileptic drugs are associated with a 2-3 fold

increased risk of congenital anomalies;
preconceptional counseling is advised.

 A detailed ultrasound scan for fetal anomalies at

20 weeks should be performed.

Delgado-Escueta AV, Janz D (1992) Neurology 42, 149-160 (multi-

national workshop symposium)
Consensus Guidelines: Preconception Counseling,
Management and Care of the Pregnant Woman with
Epilepsy

 Folic Acid supplements are recommended.

 If treatment needed monotherapy is preferred
at the lowest effective dose
 Monitoring unbound or free plasma drug levels
regularly

Delgado-Escueta AV, Janz D (1992) Neurology 42, 149-160

(multi-national workshop symposium)
Prenatal Management

 Short acting benzodiazepine may be given

in the acute stage if seizures recur
 Avoid hypertension
 Search for the cause of the seizure
 Some advocate maternal administration
of Vitamin K during the last 4 weeks of
pregnancy
Treatment of Status Epilepticus during
Pregnancy

 Same as in non-pregnant
 Accurate diagnosis and rapid treatment were
more important than initial choice of
anticonvulsant ( Duley L, Guimezoglu AM, Henderson-
Smart DG et al (2000) Anticonvulsants for women with
preeclampsia. In: Cochrane database of systematic reviews,
issue 2. Oxford: Update Software)
 Ventilate while maintaining anticonvulsants if
anticonvulsants alone fail to control seizures
Labor and delivery

 Must be delivered in a hospital setting

 Continue anticonvulsant medication
 Seizures may occur during
hyperventilation and sleep deprivation
Postnatal Period

 Examine newborn to confirm normality

 Vitamin K to newborn, or FFP if bleeding
excessive
 Monitor seizure control and serum levels
dose adjustment may be necessary
 Breastfeeding is not contraindicated if
anti-epileptics are given
 Overall pregnancy need not be discouraged in
patients with epilepsy
 Risk for fetal congenital anomalies, 2-3x more
than the general population, there is still a>90%
chance of having a normal baby
 Risk of epilepsy in the newborn is more common
in idiopathic causes than acquired causes
 Patient compliance is paramount in successful
management.