Physiological Changes Of Pregnancy Research Articles

Considerations Anesthesia Management for Cesarean Section in Pregnancy With COVID 19 - Severe ARDS: A Case Report

Background: Corona Virus Disease 2019 (COVID-19), caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), was labeled a Public Health Emergency of International Concern (PHEIC) by the World Health Organization (WHO) on January 30, 2020. SARS-CoV-2, a new type of enveloped RNA RNA virus, can be transmitted from human to human through droplets and contact. As of May 27, 2020, more than 5.6 million confirmed cases have been documented globally, with over 350,000 deaths. Anatomical, physiological changes in pregnancy, especially in the cardiorespiratory system, make pregnant women more susceptible to COVID-19 infection and cause more serious complications. Severe ARDS is a form of manifestation that often occurs in the peripartum period. Severe complications in pregnancy such as premature birth, fetal death in utero, intensive care unit have been reported. Case: A 31 Year old female with 3rd pregnancy, 26-27 weeks of gestation, accompanied by a locus minoris, a former cesarean section infected with severe COVID-19 with ARDS, complaining of reduced fetal movement after undergoing treatment in the covid isolation room for 24 hours and successful management of anesthesia with regional subarachnoid block anesthesia. Conclusion: In perioperative management, especially in optimizing the cardiorespiratory system, professionals in anesthetic management and multidisciplinary cooperation are important in managing this patient.

Abstract 74: Utility of inferior thyroid artery blood flow velocities to differentiate between gestational transient thyrotoxicosis and Graves’ disease in pregnancy – A pilot study

Background: Thyrotoxicosis is seen in up to 0.1% to 0.5% of pregnancies. Thyrotoxicosis mimics common physiologic changes in pregnancy leading to difficulty in diagnosis. Role of thyroid blood flow velocities to differentiate between Graves disease (GD) and gestational transient thyrotoxicosis (GTT) is not well explored.Aims: To determine the role of inferior thyroid artery- blood flow velocities, assessed by colour-flow Doppler ultrasonography to differentiate between GTT and GD in pregnancy.Methodology: The present cross-sectional study, conducted at Department of Endocrinology, Gandhi Medical College, for a duration of 6 months. 28 subjects participated in the study - 8 with GD and 10 with GTT and 10 Euthyroid pregnant women. The inferior thyroid artery- peak systolic velocity (ITA-PSV) and end-diastolic velocity (EDV) of both right and left sides were evaluated using color doppler ultrasonography.Results: The ITA-PSV and EDV in patients with GTT were significantly lower than those of pregnant patients with GD and significantly higher than those in euthyroid pregnant women. The most appropriate cut off values were obtained by the ROC curve. The optimal cut-off points of ITA-PSV to differentiate between GTT and GD, was 34.5 cm/s, with sensitivity and specificity of 83.42% and 92.43% respectively.Conclusion: Thus ITA-PSV appears to provide excellent sensitivity and specificity to differentiate between GD and GTT, where thyroid scintigraphy is contraindicated.

Considerations for cutaneous physiologic changes of pregnancy that fail to resolve postpartum.

Pregnancy prompts many adaptive and unique physiologic modifications, with cutaneous changes being possibly the most noticeable. These cutaneous changes are of interest to physicians, since they must be diagnosed as anticipated normal physiologic changes or potentially harmful and managed accordingly. Research has been conducted on physiologically normal and abnormal cutaneous manifestations of pregnancy but is lacking in regard to the persistence of these changes after delivery. This prompts the question as to whether these are normal physiologic changes taking longer to resolve, abnormal changes that may have been previously misdiagnosed, or a separate underlying change that is incorrectly attributed to a common dermatosis caused by pregnancy. Some of the conditions that may persist longer than expected during or after pregnancy, and thus require further workup for an underlying condition, include telogen effluvium, severe hirsutism, palmar erythema, and striae. The objective of this review is to focus on these four common cutaneous physiologic changes of pregnancy, and what to consider when they do not resolve as expected.

Maternal Stroke Associated With Pregnancy.

This article summarizes current knowledge of the epidemiology, pathophysiology, prevention, and treatment of cerebrovascular disease in pregnant and postpartum women. Stroke is a leading cause of maternal morbidity and mortality, and most fatal strokes are preventable. Adaptive physiologic changes of pregnancy, including hemodynamic changes, venous stasis, hypercoagulability, and immunomodulation, contribute to increased maternal stroke risk. The highest-risk time period for maternal stroke is the immediate postpartum period. Migraine and hypertensive disorders of pregnancy, including gestational hypertension and preeclampsia, are major risk factors for maternal stroke. Adverse pregnancy outcomes, including gestational hypertension, preeclampsia, preterm delivery, and fetal growth restriction, are important risk factors for cerebrovascular disease later in life. Many catastrophic maternal strokes could be avoided with targeted prevention efforts, early recognition of warning signs, and rapid evaluation of neurologic symptoms. Neurologists play a central role in the care of pregnant patients with cerebrovascular disease, whether acute or chronic, and should be familiar with the unique and complex physiology of pregnancy and its complications, particularly hypertensive disorders of pregnancy.

Physiological Changes in Pregnancy.

Pregnancy is a dynamic process, which induces a multitude of anatomic, physiological, biochemical, and psychological changes. Physiological changes during pregnancy allow the body to meet the increased metabolic demands of the mother and fetus by maintaining adequate uteroplacental circulation, and ensure fetal growth and development. These changes begin early in the first trimester and are brought on by the increased circulating levels of progesterone and estrogen, which are produced by the ovary in the first 12 weeks of pregnancy and thereafter by the placenta. While some of these cause a change in biochemical values, others may mimic symptoms of medical disease. For instance, cardiac changes such as sinus tachycardia, systolic heart murmurs, and cardiac enlargement could be interpreted as signs of heart disease. It is thus crucial, to differentiate between normal physiological changes and pathological changes, particularly for clinicians involved in the care of pregnant patient.How to cite this articleGangakhedkar GR, Kulkarni AP. Physiological Changes in Pregnancy. Indian J Crit Care Med 2021; 25(Suppl 3):S189–S192.

Sepsis in the Parturient.

Sepsis is a leading cause of maternal morbidity with a high case fatality rate and leads to significant perinatal loss. Early identification and appropriate time management can significantly improve maternal and perinatal outcomes. The physiological changes of pregnancy and puerperium make pregnant women more susceptible to sepsis and also pose a challenge for early diagnosis because of overlap of clinical features and laboratory values. The validation of scoring/warning systems for sepsis in parturient needs further research. Infections during puerperium are commonly polymicrobial in nature and warrant broad-spectrum antibiotics. Maternal resuscitation in antepartum period has to be tailored to ensure fetal well-being and adequate placental perfusion. For the management of sepsis in pregnancy, the guidelines from surviving sepsis campaign (SSC) for general adult population are extrapolated with modifications related to physiological alterations in pregnancy and puerperium. Timing of delivery is based on the obstetric indications unless the source of sepsis is intrauterine.How to cite this articleJain V, Arora A, Jain K. Sepsis in the Parturient. Indian J Crit Care Med 2021;25(Suppl 3):S267–S272.

Variation in some Haematological Parameters in Patients with Plasmodiasis Attending Antenatal Clinic in Primary Health Care Centre, Ozuoba, Port Harcourt

Introdction: Haematological parameters are useful in making diagnosis of diseases and also help in the antenatal assessment of women during pregnancy. The physiological changes of pregnancy, due to the influence of hormones such as oestrogen, progesterone also affect haematological indices when compared with the non-pregnant state.
 Aim: The study investigated haematological indices in pregnant women with plasmodiasis attending antenatal clinics in Primary health care centre Ozuoba, Port Harcourt.
 Methodology: This was a cross sectional study, which recruited a total of one hundred (100) subjects, of which (40) were non parasitized pregnant women who served as control, while (60) were parasitized pregnant women who served as test. The samples were analyzed for haematological parameters using (Sysmex XP-300), while microscopy was used to investigated for the presence of malaria parasite.
 Result: Comparing the hematological parameters of the study population at different level of plasmodiasis, showed that WBC, and Neutrophil were significant with p-Value of 0.001 and 0.0089 respectively at P<0.05.
 The other haematological parameters such as, Red Blood Cell, Haemoglobin, Haematocrit, Mean Cell Volume, Mean Cell Haemoglobin, Mean CellHaemoglobin Concentration, Platelet, Plateletcrit, Neutrophils, lymphocyte, monocyte, eosinophil and basophil showed no statistical significant difference at p<0.05. While comparison of the haematological parameters of the study group according to parity showed that WBC count had statistical significance with a p-Value of 0.0035 at p<0.05.
 Conclusion: Findings from this study has shown that there was statistical significant difference in the white blood cell count of malaria-parasitized pregnant subject. It was further revealed that there was no statistical significant difference in the other haematological parameters. The reason for the pattern of result obtained is that some of the pregnant women may have been receiving prophylactic antimalarial drugs before their recruitment, this will in turn minimize the impact of malaria infection on some haematological parameters.

Pulmonary Hypertension in Pregnancy: A Positive Outcome with a Multidisciplinary Team and Individualized Treatment Plan

PULMONARY HYPERTENSION (PH) is a challenging disease to treat and is associated with a great degree of morbidity and mortality. When a right ventricle, which is accustomed to operating at low pressure, faces the increased afterload that is conferred with PH, especially in the acute setting, it is prone to failure and ultimately can result in hemodynamic collapse. The normal physiologic changes of pregnancy, particularly increased blood volume, lower systemic vascular resistance and systemic blood pressure, and increased cardiac output, are particularly deleterious in the patient with PH. Here, the authors describe a case of a woman who was diagnosed with severe PH during pregnancy and was safely navigated through a cesarean section and the subsequent postpartum period.

Anaesthetic management of a patient with sub-valvular aortic stenosis for emergency lower segment caesarean section: A case report

Sub-valvular aortic stenosis (SAS) occurs due to a fibrous membrane or a muscular narrowing causing left ventricular outflow tract obstruction. The physiological changes of pregnancy may exacerbate the cardiac condition posing significant challenges for anaesthesia and surgery. A 34 years primigravida, with 32 weeks gestation, a known case of sub-valvular aortic stenosis presented in the emergency room in view of leaking/bleeding per-vagina. Risk factors such as tachycardia, decrease in afterload, preload and increased left ventricle contractility lead to exacerbation of the obstruction and should be avoided. We report a successful anaesthetic management of her lower segment cesarean section while balancing the physiological changes of pregnancy superimposed by pathology of the disease.

Physical Activity During Pregnancy: Physiological Considerations and Practical Guidelines

Physical activity is a crucial element in preventing and coping with several chronic conditions. Many women become aware of their health issues as they plan pregnancy or become pregnant and consult their physician regarding limitations and recommendations in this situation. This review intends to endow the consulting general practitioner and obstetrician, as well as midwives with the background knowledge for this encounter. It details the physiological changes of pregnancy with regards to physical activity and deals with the range of allowed activities and the major risk groups who should be given special concern. In general, the best judge of a woman's ability to perform physical activity is her subjective feeling of appropriateness of a given effort.

Assessment of the Clinical Profiles of the Obstetric Patients Admitted to ICU in a Tertiary Care Hospital, Madhya Pradesh, India: A Longitudinal Study

Introduction: Management of critically ill obstetric population admitted to Intensive Care Unit (ICU) remains a significant hurdle in developing countries. Aim: To examine demographic characteristics, diagnoses, clinical outcomes, and performance of modified Sequential Organ Failure Assessment (SOFA) score between survivors and non survivors in all obstetric admissions to the ICU. Materials and Methods: This was a longitudinal study conducted in a 12-bedded obstetric ICU at 850 bedded Netaji Subhash Chandra Bose Medical College, Madhya Pradesh, India from March 2016 to August 2017. Clinical profile and outcomes of ICU patients were analysed for total 367 obstetric ICU admission. To determine mortality outcomes of the study population, a modified SOFA score was used to take into account physiological changes in pregnancy. All statistical analyses were performed using Statistical Package for Social Sciences (SPSS) version 15.0 (Inc., Chicago, Illinois, USA). Receiver Operating Characteristics (ROC) curve analyses of SOFA score as a predictor of mortality, and optimum cutoff point value was determined. Results: The mean age of the study population was 24.7±4.0 years. Eclampsia (35.7%) and preeclampsia (13.62%) were the leading indications of admission. The survival of patients was associated significantly with low SOFA scores with mean SOFA score of 6.48±2.804 among survivors and 10.42±3.579 among non survivors (p-value=0.001). Conclusion: Eclampsia and preeclampsia were the leading cause of ICU admission, that can be preventable. Higher SOFA score was related to higher mortality in the obstetric patients requiring ICU.

COVID-19 suspicion and diagnosis in pregnancy: A big conundrum!

This article aims to discuss all the challenges faced in the diagnosis of coronavirus disease 2019 (COVID-19) in pregnancy, isolation of suspected and positive patients, their management, and the strategies to prevent the transmission of infection among the healthy population and medical fraternity. The diagnosis of COVID in pregnancy is influenced by many factors, including normal physiological changes in pregnancy, comorbid conditions associated with pregnancy, and the presence of asymptomatic infection in patients. Suspicion of COVID-19 in pregnant females is of utmost importance at a primary health center for risk mitigation of exposure to medical personnel. A retrospective study was carried out in the labour room in a tertiary care center in India. Two groups were made, suspected COVID and confirmed COVID in pregnant patients. The case records were analysed. Out of a total of 5164 admissions, 95 patients were admitted as suspected (1.8%), but only two patients were COVID-positive amongst them. 84% of COVID-positive patients were asymptomatic. Fever was the most common symptom in both groups (P-value: 0.15). Preeclampsia and anaemia were the most common comorbidities in both groups, not statistically significant. There were 32% of intensive acre unit (ICU) admissions in suspected COVID patients, and 77% of them were having respiratory distress. COVID-19 presents as an asymptomatic infection in most pregnant patients. Physiological changes to the cardiorespiratory and immune systems along with associated comorbidities in pregnancy, increase a woman's susceptibility and delay diagnosis. Consideration of patients as suspected COVID at triage stations on the basis of only contact or travel history poses a great burden on the health care system. Although triage is an essential tool to identify symptomatic COVID patients, universal testing strategies should continue simultaneously. Streamlining medical care professionals into self-sufficient teams ensures adequate clinical coverage amongst the suspected COVID, confirmed COVID, and routine labour room admissions.

Characteristics of COVID-19 positive pregnant patients admitted in a private tertiary hospital and their maternal and neonatal outcomes

Introduction: The severe acute respiratory syndrome coronavirus 2 pandemic has had profound effects globally. Historical experience with previous Coronaviruses has shown increased maternal and perinatal morbidity and mortality, theoretically secondary to the physiologic changes of pregnancy. As of August 2021, the Philippines is the 23rd top country worldwide in terms of total number of cases, yet there remains to be a sparse pool of information both internationally and locally.Objectives: This study aims to present the prevalence, clinical characteristics, as well as the neonatal, obstetric, and maternal outcomes of all pregnant women admitted in the institution who had active or previous COVID-19 infection.Methodology: Retrospective review of data using the hospital's health information system was utilized. Within the study period, all admitted obstetric patients who had at least one positive result in a RT-PCR naso-oropharyngeal swab for SARS-CoV-2 were included in this study and categorized into: (1) symptomatic, (2) recovered, and (3) asymptomatic.Results: A total of 48 patients were included in the study, where prevalence of COVID-19 in pregnancy was 3.65%. Results showed that most patients were in the third trimester, and contrary to the non-pregnant population, majority (60.41%) did not have comorbidities. Most remained asymptomatic (33.33%) or had mild symptoms (18.75%), and underwent abdominal delivery (50%) for obstetric indications. COVID-19 status was not associated with adverse obstetric outcomes in this study population, but had significant association with preterm birth (p=0.019) and NICU admission (P=<0.001). Conclusion: Overall, most cases were asymptomatic and had good prognosis even with the adaptations a pregnant woman undergoes. In addition, neonatal outcomes were generally good regardless of the association with preterm birth and NICU admission. Lastly, there was no appreciated evidence for vertical transmission.

Dermatologic and Cosmetic Procedures in Pregnancy.

Background:Patients may develop a need to undergo procedures while being pregnant and this requires a certain risk-benefit profiling to be done by the clinician. Skin changes during pregnancy such as melasma, striae, varicose veins, hirsutism, and increased skin growths may raise concerns for the lady. Although pregnancy-induced physiologic changes may prompt a surgeon to delay nonessential procedures until after delivery, certain skin conditions may require urgent intervention. Others that may be nonurgent, elective, or cosmetic may need careful analysis.Materials and Methods:Data were extracted from available literature through a PubMed search for the following keywords: “dermatological procedures in pregnancy,” “dermatosurgical procedures during pregnancy,” “aesthetic procedures in pregnancy,” “safety in pregnancy,” “teratogenicity of drugs,” “local anesthesia during pregnancy,” “physiological changes in pregnancy,” “cosmetic procedures during pregnancy,” and “lasers in pregnancy.”Results:Only procedures which are safe and necessary should be carried out in a pregnant woman. Electrocautery, radiofrequency, cryotherapy, and lasers for warts, particularly genital, surgical interventions for skin malignancies, and other small growths should be performed. Safe but cautious outlook is required for intralesional steroid injections, aesthetic procedures such as chemical peeling, botulinum toxin, microdermabrasion, and biopsies for questionable lesions. Absolutely contraindicated procedures include fillers, sclerotherapy, and liposuction.

COVID-19 with Pregnancy: Obstetricians should be Alert for Postpartum Exacerbation

Abstract Introduction: Physiological changes in pregnancy make them more susceptible to infection. SARS-CoV-2 infection ranges in severity from common cold to acute respiratory distress syndrome. With the incredible increase in numbers of coronavirus disease-2019 (COVID-19), multiple studies were done with the significant increase of COVID-19 infected pregnant women. These studies support that pregnant women are not only susceptible to infection but more liable for severity and complications that may end unfortunately by death. Methods: In this review, we discuss the mode and steps of delivery in that situation. There is an argument about fetal transmission, possible methods of transmission, and recorded fetal complications. Breastfeeding is not a source of infection. The separation between the infected mother and her baby is under debate regarding many considerations taken.

Maternal Mortality Due to an Undiagnosed Large Thymoma in Puerperium: A Case Report

Introduction: Delayed or avoided medical care due to coronavirus disease 2019 (COVID-19) related concerns may increase morbidity and mortality associated with both acute and chronic health conditions. Thymoma is uncommon in pregnancy, although it could be accompanied with unfavorable outcomes. We report a puerperal woman presented with dyspnea and cardiac arrest with a recent diagnosis of thymoma that led to maternal mortality. Case Presentation: A 38-year-old woman with occasional dyspnea during pregnancy without medical referral was admitted to the hospital with severe dyspnea and orthopnea three days after cesarean section. Spiral computed tomography (CT) angiography showed a 64 × 84-centimeter mass with soft tissue density in the left perivascular that was originated from the anterior mediastinum; in biopsy, thymoma was suggested. She died shortly after due to severe dyspnea and cardiac arrest. Conclusions: Prenatal care during COVID-19 pandemic should not be postponed. Indeed, any symptom similar to the physiologic changes in pregnancy needs to be evaluated for optimal clinical management.

Hypertension in Pregnancy: Diagnosis, Blood Pressure Goals, and Pharmacotherapy: A Scientific Statement From the American Heart Association.

Hypertensive disorders of pregnancy (HDP) remain one of the major causes of pregnancy-related maternal and fetal morbidity and mortality worldwide. Affected women are also at increased risk for cardiovascular disease later in life, independently of traditional cardiovascular disease risks. Despite the immediate and long-term cardiovascular disease risks, recommendations for diagnosis and treatment of HDP in the United States have changed little, if at all, over past decades, unlike hypertension guidelines for the general population. The reasons for this approach include the question of benefit from normalization of blood pressure treatment for pregnant women, coupled with theoretical concerns for fetal well-being from a reduction in utero-placental perfusion and in utero exposure to antihypertensive medication. This report is based on a review of current literature and includes normal physiological changes in pregnancy that may affect clinical presentation of HDP; HDP epidemiology and the immediate and long-term sequelae of HDP; the pathophysiology of preeclampsia, an HDP commonly associated with proteinuria and increasingly recognized as a heterogeneous disease with different clinical phenotypes and likely distinct pathological mechanisms; a critical overview of current national and international HDP guidelines; emerging evidence that reducing blood pressure treatment goals in pregnancy may reduce maternal severe hypertension without increasing the risk of pregnancy loss, high-level neonatal care, or overall maternal complications; and the increasingly recognized morbidity associated with postpartum hypertension/preeclampsia. Finally, we discuss the future of research in the field and the pressing need to study socioeconomic and biological factors that may contribute to racial and ethnic maternal health care disparities.

Nonobstetric Surgery during Pregnancy: An Overview for Anesthesia Providers

A pregnant patient’s surgery can be challenging for the anesthesia provider—the needs of the parturient and fetus must be addressed while balancing the physiologic and pharmacologic changes that occur during pregnancy. Improved outcomes have led to an increase in the frequency of surgeries in parturients, with approximately 50,000 procedures performed annually in the US. Due to a lack of randomized controlled studies, determining the optimal anesthetic technique for nonobstetric surgery during pregnancy is predicated on understanding the physiologic changes of pregnancy. The anesthesia provider must become familiar with specific changes and challenges in each parturient to formulate a safe anesthetic plan. Here, we review physiologic and pharmacologic conditions observed in common surgical cases that may occur during pregnancy. Our goal is to inform safe clinical practices determined by the latest scientific methods for nonobstetric surgery during pregnancy. This review contains 5 figures, 3 tables and 45 references. Key Words: anesthesia, nonobstetric surgery, obstetric anesthesia, pregnancy, surgery, physiology, pharmacology, gynecology

Nonobstetric Surgery during Pregnancy: An Overview for Anesthesia Providers

A pregnant patient’s surgery can be challenging for the anesthesia provider—the needs of the parturient and fetus must be addressed while balancing the physiologic and pharmacologic changes that occur during pregnancy. Improved outcomes have led to an increase in the frequency of surgeries in parturients, with approximately 50,000 procedures performed annually in the US. Due to a lack of randomized controlled studies, determining the optimal anesthetic technique for nonobstetric surgery during pregnancy is predicated on understanding the physiologic changes of pregnancy. The anesthesia provider must become familiar with specific changes and challenges in each parturient to formulate a safe anesthetic plan. Here, we review physiologic and pharmacologic conditions observed in common surgical cases that may occur during pregnancy. Our goal is to inform safe clinical practices determined by the latest scientific methods for nonobstetric surgery during pregnancy. This review contains 5 figures, 3 tables and 45 references. Key Words: anesthesia, nonobstetric surgery, obstetric anesthesia, pregnancy, surgery, physiology, pharmacology, gynecology

A case of new-onset SLE during pregnancy an initial manifestation with all diagnostic criteria: The challenges of diagnosis and managing a complex disease in a low resource setting

Systemic lupus erythematosus (SLE) is a complex chronic multiorgan autoimmune disease. When newly diagnosed during pregnancy or puerperium, it is known as new-onset SLE during pregnancy. Delayed or missed diagnosis of newonset SLE during pregnancy may occur due to similar clinical manifestation of SLE with normal physiological changes of pregnancy and lupus nephritis with preeclampsia. New-onset SLE during pregnancy has major organ involvement with poor maternal and foetal outcomes. Management options are limited due to teratogenic side effects of drugs in pregnancy. This is further compounded in a low resource setting with lack of health seeking behaviours and inadequate access to timely care. Multidisciplinary management with close medical, obstetric, neonatal monitoring, patient education and improved access to care is essential for better outcomes. Our aim is to report a 19 year old primigravida with new onset SLE in pregnancy and multiorgan involvement fulfilling all criteria for diagnosis of SLE at the first presentation.