الفهرس 
Anatomy Of Female Genital TractOnly 14 pages are availabe for public view
 |  | from | 183 |  |  |
| | | from | 183 | | |
Abstract
Anesthetic management of high risk pregnant female is based on the considerations as in healthy mother or fetus which would include maintenance of maternal cardiovascular function & oxygenation ,improving utero-placental blood flow &delivery of an infant without significant drug effect.
Maternal physiological changes in pregnancy are the normal adaptations that a woman undergoes during pregnancy to better accommodate the embryo or fetus. These physiological changes, include cardiovascular, hematologic, metabolic, renal and respiratory changes that become very important in the event of complications. The body must change its physiological and hemoestatic mechanisms in pregnancy to ensure the fetus is provided for. Increases in blood sugar, breathing and cardiac output are all required.
Pregnancy and delivery are associated with substantial physiological changes that require adaptations in the cardiovascular system. These changes, well – tolerated in pregnant woman without heart disease, expose woman with cardiovascular disease to serious risk. In fact, heart disease is the most frequent cause of maternal death, after psychiatric disorders, and the number of pregnant women with heart disease is expected to grow in the coming years. Preventing cardiovascular complications should be the main aim of every cardiologist involved in managing pregnant woman with congenital or acquired heart disease.
Pre-eclampsia is a pregnancy –specific, multisystem disorder that complicates approximately 5 to7 percent of pregnancies, with an incidence of 23.6 cases per 1.000 deliveries in the United States.
Complications of hypertension are the third leading cause of pregnancy – related deaths, superseded only by hemorrhage and embolism.
HELLP syndrome is a multisystemic disorder that complicates pregnancy and has a poor prognosis. It was first described by Weinstein in 1982. The acronym is for hemolysis (H), elevated liver enzymes (EL), thrombocytopenia (low platelet count – LP).The name of the syndrome (hell + help) suggests the severity of maternal and fetal prognosis. It occurs in 0.7-0.85% of all pregnancies, and is more frequent in older multiparous caucasian women.
HELLP syndrome is frequently associated with severe preeclampsia or eclampsia, but can also be diagnosed in the absence of these disorders. The risk of recurrence in a subsequent pregnancy is estimated at 19-27%.
During pregnancy, valvular heat lesions may carry risk for both mother and fetus. Complications ascribed to valvular heart disease include: increased incidence of maternal cardiac failure and mortality, increased risk of premature delivery, lower APGAR scores and lower birth weight .In addition there is a higher incidence of interventional and assisted deliveries.
All patients with structural cardiac lesions are at risk of developing bacterial endocarditis and need cover with appropriate antibiotics in the peripartum period.
Post partum cardiomyopathy (PPCM) is arelatively rare form of heart failure associated with pregnancy. It was recognized first in the 19th century by Ritchie and is defined as the onset of acute heart failure in the last trimester or early post partum period in the absence of infections, metabolic, toxic, ischemic or valvular causes of myocardial dysfunction.
Prognosis depends on the degree of cardiomegaly at presentation and in the following 6 months. It occurs in about 1 in 4000 deliveries and is often unrecognized, as symptoms of normal pregnancy commonly mimic those of mild heart failure.
The maternal mortality after myocardial infarction during pregnancy is 23% for cesarean section and 14% for vaginal delivery. This does not necessarily imply however that vaginal delivery is the preferred route. Whatever may be the route of delivery, maintaining an adequate balance of myocardial oxygen supply and demand is the key to the successful outcome
Asthma is the most common pulmonary disease in women of childbearing age. Complicating 1-5% of all pregnancies, asthma follows a rule of third. It is unchanged in one third, worsened in one third and improved in one third of patients. Severe asthmatics are likely to have exacerbations of their disease during pregnancy and any woman who has had worsening of her asthma during a previous pregnancy is likely to have a similar experience in subsequent pregnancies.
Pneumonia is a common cause of morbidity in pregnancy and remains a potentially fatal infection in otherwise healthy females. There is an associated increased rate of prematurity, abortion and fatal death.
Normal physiological changes of pregnancy (including increased clotting factors and altered venous compliance) increase the risk of deep venous thrombosis. This translates into propensity for pulmonary emboli during pregnancy. Additional risk factors include age >35, cesarean section, bed rest and obesity.
The incidence of obesity has been dramatically increasing across the globe. Anesthesiologists are increasingly faced with the care for these patients. Obesity in the pregnant woman is associated with a broad spectrum of problems, including dramatically increased risk for cesarean delivery, diabetes, hypertension and preeclampsia. A thorough understanding of the physiology, associated conditions and morbidity, available options for anesthesia and possible complications is therefore important for today’s anesthesiologist.
Diabetics mothers face an increased risk of urgent or emergent delivery; due to decreased utero-placental perfusion in many diabetics, the fetus may be unable to tolerate the stress labor. The high incidence of macrosomia (due to fetal heperglycemia) increases the likelihood of shoulder dystocia or cephalopelvic disproportion, the need for operative intervention or cesarean delivery. Following delivery, diabetics are at increased risk of uterine hypotonia and significant hemorrhage.
Hyperthyroidism occurs in about 2 of every 1000 pregnancies and untreated has been associated with a 6% incidence of neonatal mortality and low birth weight infants. The most common cause is autoimmune thyrotoxicosis or Graves disease even though Graves’s disease tends to remit in late pregnancy.
Diagnosis of PCC during pregnancy may be confusing due to an overlap of symptoms with pre-eclampsia. Symptoms of both can include headache, hypertension, abdominal pain, and visual disturbances. However, with PCC, the symptoms are commonly paroxysmal due to the intermittent nature of hormone secretion.
Hemorrhagic complications can arise at almost any point during pregnancy, labor, and delivery, quickly turning an uneventful pregnancy into an emergent situation requiring prompt, aggressive treatment to ensure the health and wellbeing of mother and infant.
The anesthetic approach to the parturient with neurological or neuromuscular disease must be individualized; because of the dominance of regional anesthesia and central administration of medications in modern obstetric practice, potential interaction with the disease process becomes a primary issue.
Chronic kidney disease is often clinically and biochemically silent until renal impairment is advanced. Symptoms are unusual until the glomerular filtration rate declines to <25% of normal, and more than 50% of renal function can be lost before serum creatinine rises above 120 μmol/l. Women who become pregnant with serum creatinine values above 124 μmol/l have an increased risk of accelerated decline in renal function and poor outcome of pregnancy; Several factors must be considered when managing pregnant women with chronic kidney disease to minimize the adverse effects of pregnancy on maternal renal function and the consequent effects on the fetus.