As reviewed by Williams in 1903, pregnant women are susceptible to any medical and surgical disorder that can afect childbearing-aged women. Some of these, especially those that are chronic, more often precede pregnancy. But, they can acutely complicate an otherwise normal pregnancy. Of estimates, one managed-care population had an overall antenatal hospitalization rate of 10.1 per 100 deliveries (Gazmararian, 2002). Approximately one third was for nonobstetrical conditions that included renal, pulmonary, and infectious diseases. In another study from the 2002 Nationwide Inpatient Sample, the injury hospitalization rate was 4.1 women per 1000 deliveries (Kuo, 2007). Last, approximately 1 in every 635 pregnant women will undergo a nonobstetrical surgical procedure (Corneille, 2010; Kizer, 2011).
Obstetricians should have a working knowledge of the wide-ranging medical disorders common to childbearing-aged women. Many of these are within the purview of the general obstetrician. Other disorders, however, will warrant consultation, and still others require a multidisciplinary team. The latter may include maternal-fetal medicine specialists, hospitalists, internists and medical subspecialists, surgeons, anesthesiologists, and numerous other disciplines (Levine, 2016). The American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine (2014, 2017b) has redefined aspects of maternal care and proposed required levels of specialized care.
It should be axiomatic that a woman must never be penalized because she is pregnant. To ensure this, several questions should be addressed:
What management would be recommended if the woman were not pregnant?
If the proposed management is diferent because the woman is pregnant, can this be justiied?
What are the risks versus benefits to the mother and her fetus, and are they counter to each other?
Can an individualized management plan be devised that balances beneits versus risks of any alterations?
Such an approach allows individualized care for women with most medical and surgical disorders complicating pregnancy.
Pregnancy induces physiological changes in virtually all organ systems. In turn, results of numerous laboratory tests are altered, and some values would, in the nonpregnant woman, be considered abnorml. Conversely, some may appear to be within a normal range but are decidedly abnormal for the gravida. These changes may ampliy or obuscate evaluation of coexisting conditions. he wide range of pregnany efects on normal physiology and laboratory values are discussed in the chapters that follow in this section and are listed in the Appendix (p. 1255).
Fortunately, most medications needed to treat frequently with relative safety. That said, notable exceptions are considered in Chapter 12 and throughout this text.
Regarding surgery, the risk of an adverse pregnancy out come is not appreciably increased in most women who undergo an uncomplicated operative procedure. With complications, however, risks likely are increased. For example, perforative appendicitis with feculent peritonitis has significant maternal and anesthetic techniques are flawless. Conversely, procedure related complications may adversely afect outcomes. For exam ple, a woman who has uncomplicated removal of an inflamed appendix may sufer aspiration of acidic gastric contents dur ing tracheal intubation or extubation. Still, compared with nonpregnant women undergoing similar procedures, pregnant women do not appear to have excessive complications (Silvestri, 2011). In a study of the American College of Surgeons'
National Surgical Quality Improvement Program, outcomes in pregnant women were compared with matched nonpregnant controls (Moore, 2015). The investigators reported similar out comes in the two cohorts, each with 2539 patients. In a smaller study, however, women undergoing nonobstetrical surgery after 23 weeks' gestation had a high rate of subsequent preterm delivery (Baldwin, 2015).