It is difficult to accurately quantify the incidence and types of medical and surgical illnesses that complicate pregnancy. Estimates have been derived from other indices of hospitalization as well as birth certificate data (Lydon-Rochelle and associates, 2005). For example, Gazmararian and colleagues (2002) reported an overall antenatal hospitalization rate of 10.1 per 100 deliveries in their managed-care population of more than 46,000 pregnant women. About a third of these were for nonobstetrical conditions such as renal, gastrointestinal, pulmonary, and infectious diseases. In a study from the 2002 Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project, Kuo and associates (2007) used the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) injury and concurrent pregnancy diagnosis codes. From these, they found the injury hospitalization rate to be 4.1 women per 1000 deliveries.
The care for some of these women with medical or surgical disorders will warrant a team effort between obstetricians and maternal-fetal medicine specialists, or with internists, surgeons, anesthesiologists, and other disciplines (American College of Obstetricians and Gynecologists, 2003). It is important that obstetricians have a working knowledge of medical and surgical diseases common to women of childbearing age. Likewise, nonobstetricians who see these women in consultation should be familiar with pregnancy-induced physiological changes that affect various diseases.
A number of generalizations concern the rational approach to management of these nonobstetrical disorders:
- A woman should never be penalized because she is pregnant.
- What management plan would be recommended if the woman was not pregnant?
- If a proposed medical or surgical management plan is altered because the woman is pregnant, what are the justifications for this?
Such an approach should allow individualization of care for most medical and surgical disorders. Moreover, it may be especially helpful when dealing with nonobstetrical consultants.
Pregnancy induces physiological changes in most organ systems. Some of these are profound and may amplify or obfuscate evaluation of coexisting conditions. Results of laboratory tests can also be altered, and some of these would, in the nonpregnant woman, be considered abnormal. Conversely, some may appear to be normal but are not so in the pregnant woman. The wide ranges of pregnancy effects on normal physiology and on laboratory values are discussed in Chapter 5, in the chapters that follow, and in the Appendix.
Antepartum management of nonobstetrical disorders includes administration of various drugs. Fortunately, the vast majority necessary to treat the most commonly encountered complications can be used with relative safety. However, there are a few notable exceptions, which are considered in detail in Chapter 14, as well as with the discussions of specific disorders for which these drugs are given.
The risk of an adverse pregnancy outcome is not appreciably increased in women who undergo most uncomplicated surgical procedures. With complications, however, risks may be increased. For example, perforative appendicitis with feculent peritonitis ...