Download MEDICAL DISEASES WITH PREGNANCY

Dr. ROZHAN YASSIN KHALIL
HDOG,
FICOG,CABOG,
MBChB
2011 -2012
MEDICAL DISEASES WITH
PREGNANCY:
 Most medical conditions in this age group do not
result in serious morbidity, though many have the
potential to do so, that is, epilepsy, asthma and
migraine.
 It is important that women receive good advice prepregnancy about the potential impact of their medical
condition and enter pregnancy with appropriate
confidence about routine medication or specific
management plans to alter treatment in the first
trimester
Introduction:
 There are a variety of medical disorders which
may impact on a mother’s health during
pregnancy and the puerperium.
 These may be classified as those that are incidental
to the pregnancy and where no exacerbation is
expected as a result of pregnancy and those that are
clearly prone to exacerbation due to pregnancy.
The latter of greatest concern to obstetricians.
General considerations:
 Mean age of childbearing has increased steadily
in recent years.
 This has the effect of increasing the
chance of a pregnancy being
complicated by coincidental medical
conditions and increases the risk that
such conditions can impact on women’s
health.
Medical diseases complicating pregnancy
includes:
1. Haematological abnormalities.
2. Neurological disorders.
3. Respiratory diseases.
4. Heart disease
5. Hypertensive disorders.
6. Renal disease .
7. Gastroenterology.
8. Psychiatric disorders.
Conti.
9. Liver disease.
10. Connective tissue disease.
11. Endocrinology.
12. Skin disease.
A.Neurological disorders:
 Serious manifestations of neurological
disease are fortunately rare in pregnancy,
though cerebral haemorrhage remains a
significant cause of maternal death.
 Epilepsy and migraine are common causes of
morbidity.
1.Epilepsy:
 Approximately 30% of those with epilepsy are women
in their childbearing years, which means 1-200
pregnant lady complaining of epilepsy.
 Pregnancy has no consistent effect on epilepsy:
some have increase frequency of fits,others a
decrease, and some no difference.
Epilepsy:
 The principles of epilipsy management
are that while the risks to pregnancy
from seizures out weight those from
anticonvulsant medication,
 seizures should still be controlled with
the minimum possible dose of the
optimal drug.
Pre-pregnancy counselling:
of the patients with epilepsy:
1. alter medication according to seizures
frequency.
 2. reduce to monotherapy where posible.
 3. compliance with medication.
 4. pre-conceptional folic acid 5
mg.
 5. explain risk of congenital malformation.
 6. explain risk from recurrent seizures.
Causes of seizures in pregnancy:
 1. epilepsy.
 2. eclampsia .
 3. encephalitis or meningitis .
 4. space – occupying lesions ( tumour ).
 5.cerebral vascular accident.
 6. metabolic abnormalities( hypoglycaemia).
 7. Toxic overdose, alcohol withdrawal )
 8. cerebral malaria or toxoplasmosis.
Risk of congenital anomaly with
epilepsy:
 The principle concern related to epilepsy in pregnancy
is the increased risk of congenital anomaly caused
by anticonvulsant medications, which increase risk
two-three fold (
population .
5-6 %) compared to general
 Approximately doubling of the risk in unexposed
epileptic mothers.
Epileptic medication are :
1. sodium valproate.
2. carbamazepine.
3. phenytoin.
4. phenobarbitone.
Fetal anomaly includes:
 1. neural tube defects.
 2. facial clefts.
 3.cardiac defect.
 4. specific syndrome includes developmental delay,
nail hypoplasia, growth restriction and mid-face
abnormality.
 5. increase chance of epilepsy in offspring of
epileptic mothers.
 Polytherapy increase the risk (15-25%).
Antepartum managements:
 Women of childbearing age who suffer from epilepsy
and are on maintenance therapy must have their
treatment reviewed and monotherapy is
recommended if at all possible.
 Antiepileptic drugs can cause teratogenicity
and folic acid 5 mg daily through out the
pregnancy is generally prescribed in view of the
relative folate deficiency of many mothers on
antiepileptic therapy.
Antepartum managements
 It is important that control of seizures is achieved to
minimize maternal morbidity (fits can be fatal) .
 patients must be monitored during pregnancy
to ensure that dose adjustments are made as
appropriate.
 Sodium valproate is the major cause for
concern in these condition .
Antepartum managements:
 All patients should receive anomaly ultrasound
assessment to exclude specific abnormalities
associated with their medication.
 These are specifically orofacial clefts, neural tube
defects and craniofacial dysmorphism.
 Vitamin K is recommended to be given from 36
weeks onwards to prevent neonatal bleeding
disorders.
Intapartum management:
 Epileptic seizures may occur during labour and as such
may confuse the diagnostic situation that includes
eclampsia.
 Epileptic seizures should be treated in these
circumstances as they would be normally
 Vaginal delivery is recommended unless there is
obstetric complication.
Postpartum management:
 Post-partum drug doses may need to be adjusted
if doses have been increased during pregnancy.
 Specific advice must be given to epileptic women
about childcare, for example, not bathing the baby
on their own.
 Breast feeding can be encouraged.
 Contraception adviced: combined oral
contraception pill better not used with anti
epileptic medication.
2.Migraine:
 Headaches are a common problem in pregnancy
and migraine sufferrs may find their symptoms
worsen during the first trimester.
 Many patients may be using ergot alkaloids to
treat migraine prior to the onset of pregnancy and
they must be advised not to use these during
pregnancy.
Migraine:
 Migraines may improve considerably in the
second and third trimesters but some patients in
who continuing problems exist,
 the strategies that are employed for prophylaxis are
low-dose aspirin, paracetamol and codeine as
pain relief and propranolol if attacks continue to
be troublesome despite these measures.
B. Endocrine disease:
 Thyroid disease is the commonest endocrine
disorder in pregnant women and this will therefore be
considered in more detail than other
endocrinopathies.
 However, pituitary, adrenal and parathyroid
disease may have serious consequences for the
mother and fetus.
1. Thyroid disease:
 Thyroid disease is common in women of child
bearing age.
 However, symptoms of thyroid disease:
such as heat intolerance, constipation,
fatigue, palpitations and weight gain
resemble those of normal pregnancy.
Background
 Throid gland: brownish-red, highly vascular
gland
 Location: ant neck at C5-T1, overlays 2nd – 4th
tracheal rings
 Avg weight:
25-30 g in adults (slightly
more in women)
**enlarges during menstruation and pregnancy**
Anatomy of the Thyroid Gland
Physiological changes of thyroid function
during pregnancy:
 The thyroid hormones thyroxine (T4) and triiodothyronine (T3) are synthesized within the
thyroid follicles.
Thyroid-stimulating hormone (TSH) stimulates
synthesis and release of T3 and T4, in addition to
uptake of iodide which is essential for thyroid
hormone synthesis.
Follicles: the Functional Units of the
Thyroid Gland
Follicles Are the Sites
Where Key Thyroid
Elements Function:
Thyroglobulin (Tg) •
Tyrosine •
Iodine •
Thyroxine (T4) •
Triiodotyrosine (T3) •
Structure
:
the gland capsule extend within the gland
form septae, dividing it into lobes and
lobules
 lobules are composed of follicles = structural
units of the gland  layer epithelium
enclosing a colloid-filled cavity
The colloid contains an iodinated
glycoprotein, iodothyroglobulin
(precursor of thyroid hormones).
Physiological changes:
 During normal pregnancy the circulating levels of
thyroid binding globulin increase, and as a
consequence total T3 and T4 levels also increase.
 Therefore the free hormone levels should be
measured in pregnant women.
 TSH levels should be interpreted with caution in the
first trimester as hCG has a weak stimulatory
effect on the TSH receptor.
Physiological changes:
 The fetus cannot synthesize thyroxine until the
10th week of gestation, and it is therefore dependent
upon transplacental transfer of maternal hormone.
There is increased maternal synthesis of thyroid
hormones in the first trimester as a result of
transplacental passage and the high levels of
thyroid binding globulin.
Physiological changes:

this in turn results in an increased maternal
requirement for iodide.
 In areas of relative iodide deficiency this
may result in the development of maternal
hypothyroxinaemia and goitre.
HYPOTHYROIDISM:
 Hypothyroidism affects approximately 1% of pregnant
women.
 Providing thyroxine replacement therapy is
adequate, hypothyroidism is not associated with
an adverse pregnancy outcome for the mother or
fetus.
poorly controlled hypothyroidism and a
variety of adverse outcomes:including
1. subfertility.
2. congenital abnormalities,
3. hypertension,
4. increased risk of miscarriage
5. premature delivery,
6.fetal growth restriction and
7. post-partum haemorrhage.
8.placental abruption .
HYPOTHYROIDISM:
 Severe hypothyroidism affects the subsequent
intelligence of the offspring of affected mothers.
Women with hypothyroidism should be given thyroxine
replacement at a dose that ensures their thyroid
function tests are normal with a FT4 at the upper end
of the normal range appropriate for each trimester of
pregnancy.
HYPOTHYROIDISM:
 Thyroxine absorption is decreased by certain drugs
including iron and calcium supplements.
 thyroxine is best taken on an empty stomach and
4 h apart from any iron or other supplements.
HYPERTHYROIDISM:
 Hyperthyroidism affects 1
in 500 pregnant women,
90% of whom have Graves’ disease.
 Graves’ disease is caused by TSH receptor
stimulating antibodies.
 Women with well-treated disease rarely have maternal
complications of pregnancy.
HYPERTHYROIDISM:
 the disease may remit during the latter trimesters
such that treatment may need to be reduced or
stopped.
 In the post-partum period the disease may flare
and require treatment with the same or higher
doses of antithyroid medication.
Poorly controlled hyperthyroidism
is associated with pregnancy complications:
 including : 1.maternal thyrotoxic crisis,
2.miscarriage,
3. gestational hypertension,
4. pre-eclampsia and
5. intrauterine growth restriction .
 The risk of these complications is reduced if the
disease is adequately controlled before delivery.
Treatment of hyperthyroidism:
The principal drugs used is (propylthiouracil,
carbimazole) inhibit thyroid hormone synthesis.
 a greater proportion of carbimazole
enters breast milk, and therefore
propylthiouracil is usually the drug of choice
if a woman is diagnosed as having
hyperthyroidism for first time during pregnancy.
Treatment of hyperthyroidism:
 Both drugs may rarely cause neutropenia and
agranulocytosis.
 Therefore patients should be aware that
symptoms of infection, particularly sore throat,
may be associated with bone marrow
suppression and they must have a
neutrophil count checked.
Treatment of hyperthyroidism:
 Once drug treatment has been commenced thyroid
function tests should be carried out and
checked regularly.
Propylthiouracil and carbimazole both cross the
placenta, fetal hypothyroidism is rarely seen.
TSH receptor stimulating antibodies also cross the
placenta and may influence the fetal and neonatal
thyroid status.
Thyrotoxic crisis:
 also called ‘thyroid storm’, is a medical emergency
that can present with exaggerated features of
hyperthyroidism in addition to hyperpyrexia,
congestive cardiac failure, dysrhythmias and an
altered mental state.
 It may be precipitated by infection, abrupt
cessation of treatment, surgery, labour or
delivery and must be treated immediately as it can be
life threatening.
Treatment of thyrotoxic crisis:
involves :
1.administration of intravenous fluids,
2.hydrocortisone,
3.propranolol,
4. oral iodine and carbimazole or
propylthiouracil.
MCQ :
 1. Pre-pregnancy counselling :of the patients with
epilepsy are false except:
 a. stop medication according to seizures frequency.
 b. Increase to polytherapy where posible.
 c. Medication can be stopped if patient has no fit for last
two years.
 d. pre-conceptional folic acid 1 mg .
MCQ
 2. Postpartum management of patients with epilipsy
includes:
 a. Post-partum drug doses should be increased.
 b.Breast feeding is contraindicated.
 c. Contraceptive pill better used with anti
epileptic medication.
 d. Intra uterine contraceptive device can be used.
MCQ
 3. poorly controlled hypothyroidism associated
with:variety of adverse outcomes with pregnancy:
a. Hypertension.
b. increased risk of miscarriage
c. postmature delivery.
d. ante-partum haemorrhage.
e.placental praevia .
MCQ
 4.Regarding hyperthyroidism with pregnancy:
 a. the disease may remit during the first trimesters so
treatment may need to be reduced or stopped.
 b. Hyperthyroidism affects 1 in 200 pregnant women
 c. Graves’ disease is the commonest cause.
 d. The principal drugs used is (propylthiouracil
carbamazipine) inhibit thyroid hormone synthesis.
Answer:
 1. C.
 2.d.
 3. a,b.
 4. c
THANK YOU
Dr. ROZHAN YASSIN KHALIL
HDOG,
FICOG,CABOG,
MBChB
2011 -2012
Liver disorders:
Liver disorders frequently
complicate pregnancy,.
 but fortunately rarely result in long-term
morbidity.
Liver disorders:includes
 1.Cholestasis of pregnancy.
 2. Acute fatty liver with pregnancy.
 3. Hyperemesis.
 4.Gastroenterology.
 5.Inflammatory bowel disease.
 6. Viral hepatitis.
a.Cholestasis of pregnancy:
 Cholestasis of pregnancy is the most common
liver condition affecting pregnancy and it
classically presents with an itch and
consequent lack of sleep in the third
trimester.
 it is associated with an increased risk of
intrauterine death, classically from 37 weeks’
gestation, meconium passage and preterm labour
Cholestasis of pregnancy:
 Laboratory investigations include:
 liver function tests and assay of serum bile acids.
 It is currently uncertain whether the bile acids
themselves may be directly responsible for fetal
demise.
Cholestasis of pregnancy:
 Treatment strategies include :
1.timely delivery,
2. cool aqueous menthol cream to relieve itch,
3. ursodeoxycholic acid and vitamin K.
Ursodeoxycholic acid is currently the mainstay of
treatment .
This condition has a high likelihood of recurrence
(approximately 80%).
b. Acute fatty liver of pregnancy
(AFLP)
 (AFLP) is a serious but rare liver
condition arising in pregnancy which can
be very non-specific at time of presentation.
 It is associated with nausea, vomiting,
abdominal pain and jaundice.
(AFLP):
 Diagnosis is normally confirmed by a moderately
elevated aspartate amino transferase (AST).
 The diagnosis may be supported by imaging
suggestive of fatty change( ultrasound).
 Manifestations of liver failure include
coagulopathy , haemodynamic instability
and hypoglycaemia.
Treatment of (AFLP):
Delivery must be achieved prior
to the development of
coagulation failure, where
necessary at the expense of fetal
maturity.
c.Hyperemesis:
 Hyperemesis gravidarum is defined as vomiting
in early pregnancy sufficient to warrant hospital
admission.
 Vomiting is clearly very common in early
pregnancy, but some women suffer
disproportionately from it.
Hyperemesis:
 This can occasionally result in serious sequelae
including severe dehydration and increased
risk of thromboembolism.
 Pregnancy outcome is generally unaffected,
though there may be an increased incidence of
intrauterine growth restriction (IUGR) where
sustained vomiting results in maternal weight loss.
Hyperemesis:
 In severe cases we must exclude:
 1. multiple gestation ( because high HCG level ).
 2. Gestational tophoblastic diseases.
 3. concomitent severe urinary tract infection.
 4. Non-obstetric causes : like gastrointerstinal
pathology e.g: tumour , gasteritis.
 so it is a diagnosis of exclusion.
Treatment of hyperemesis gravidarum:
include
1. small light snacks,
2.intravenous rehydration
3. antiemetic treatment,Promethazine and
metoclopramide are commonly used .
4.It is important that B vitamins are
replenished as Wernicke’s encephalopathy
can occur.
Treatment:
5.Corticosteroids may have a role.
6. Ondansetron may also have a role , but
clear evidence of safety in the first trimester
is still awaited.
7. Antihistamine : can be used.
8.Total parenteral nutrition may be
required, but this is very rare.
9. Very rarely termination of pregnancy.
Gastroenterology:
 Problems such as appendicitis, pancreatitis and
cholecystitis can arise in pregnancy.
 They must be managed aggressively to minimize
any risk of associated peritonitis which can result
in premature labour and associated sepsis.
 Diagnosis of such complications can be difficult
and requires an experienced opinion.
Gastroenterology:
 It is generally recommended that early
recourse to surgery for an acute
appendicitis is the best option to prevent
the development of peritonitis with possible
serious sequelae, including preterm
delivery.
Inflammatory bowel disease
 Inflammatory bowel disease can also complicate
pregnancy.
 Pregnancy outcome is in general satisfactory,
though there may be some increased risk of
preterm birth and IUGR.
 treated in the same way in pregnancy as in the
non-pregnant state, with steroids and
sulphasalazine the mainstays of treatment.
Inflammatory bowel disease:
. Supplementation of haematinics and vitamin D
maybe
required
Possible sequelae such as perineal and perianal
disease and intra-abdominal adhesions need
to be considered when discussing mode of
delivery.
Viral hepatitis:
Clinical significance 
The principal forms of hepatitis that complicate
pregnancy are hepatitis A, B, C, D and E.
Hepatitis is a relatively benign clinical disorder
.that does not pose a serious risk
Hepatitis A:
is the second most common cause of hepatitis , but
it is relatively uncommon in pregnancy.
It is caused by an RNA virus that is transmitted by
fecal-oral contact.
-Infections in children are usually
asymptomatic; infections in adults are usually
symptomatic.
Infection does not result in a chronic carrier
state, and perinatal transmission essentially
never occurs.
Hepatitis B:
is the most common form of viral hepatitis in
obstetric patients.
It is caused by a DNA virus that is transmitted
parenterally and via sexual contact.
Acute hepatitis B occurs in approximately 1 to 2 per
1000 pregnancies .
The chronic carrier stage is more frequent.
Hepatitis C:
Hepatitis C is caused by an RNA virus that is
transmitted parenterally, via sexual contact,blood
product and perinatally.
Hepatitis D is an RNA virus that depends upon
co-infection with hepatitis B for replication.
Hepatitis E
Hepatitis E is caused by an RNA virus.
The epidemiology of hepatitis E is similar to that of
hepatitis A.
It is endemic in developing countries of the world.,
maternal infection with hepatitis E often has an
alarmingly high mortality,.
A chronic carrier state does not exist, and
perinatal transmission is extremely unlikely.
Clinical manifistation of Hepatitis:
 The typical clinical manifestations include:
 low-grade fever,
 malaise,
 poor appetite.
 right upper quadrant pain and tenderness,
 jaundice
Diagnosis of viral hepatitis:
The best test to confirm the diagnosis of
acute hepatitis A is identification of antihepatitis A-IgM antibody.
Acutely infected patients also may have
elevated liver transaminase enzymes and
elevated serum concentration of direct ,
indirect bilirubin.
Diagnosis:
Hepatitis B virus:
has three distinct antigens:
the surface antigen (HBsAg) which is found in
serum,
the core antigen (HBcAg) which is found only in
hepatocytes,
the e antigen (HBeAg) which also is found in serum.
Detection of the latter antigen is indicative of
an extremely high rate of viral replication
Diagnosis:
Patients who are positive for both the surface
antigen and e antigen have an extremely high
risk of perinatal transmission of infection that
approaches 90% in the absence of neonatal
immunoprophylaxis.
Treatment 0f viral hepatitis:
 Patients with acute hepatitis A require supportive
therapy.
 Their nutrition should be optimized.
 Of great importance, household contacts should
be vaccinated with hepatitis A vaccine.
Patients with acute hepatitis B:
require similar supportive care.
Their household contacts and sexual partners
should receive hepatitis B immune globulin,
followed by the hepatitis B vaccine series.
Infants delivered to mothers with hepatitis B
infection should immediately receive the
hepatitis B immune globulin and first dose of
hepatitis B vaccine while still in the hospital
Complications of Viral Hepatitis
 Obstetric complications:
 1. First trimester spontaneous miscarriage.
 2. preterm delivery.
 3.Fetal growth restriction.
 4. stillbirth.
 5. Preterm rupture of membranes.
 6. Low birth weight and neonatal unit
admission.
Complications of Viral Hepatitis:
Hepatitis B, may result in chronic liver disease
such as chronic active hepatitis, chronic persistent
hepatitis and cirrhosis.
Chronic disease also predisposes to the
development of hepatocellular carcinoma.
- Pregnant women who are infected with
hepatitis B pose a significant risk of
transmission to their offspring.
Complications:
-Most neonates become infected at time of delivery
as a exposure to contaminated blood and genital
tract secretions.
- Patients who are seropositive for surface antigen
alone have at least a 20% risk of transmitting
infection to neonate.
-Women who are seropositive for both the surface
antigen and e antigen have almost a 90% risk
of perinatal transmission
Respiratory disease:
 INTRODUCTION:
 Women with respiratory disorders require careful
assessment when they present for antenatal care.
 For those with risk of respiratory compromise
during pregnancy or delivery investigation with
pulmonary functions tests may be necessary or
exclusion of associated pulmonary vascular disease
by echocardiography.
INTRODUCTION
 An anaesthetic opinion prior to the third trimester
is valuable, including for those with possible
respiratory compromise due to musculoskeletal
problems.
 Breathlessness can be one of the most difficult
symptoms to interpret in pregnancy. Some
increase in breathlessness arises during the course
of a normal pregnancy.
INTRODUCTION:
Breathlessness can be a manifestation o f
1.thromboembolism.
2.cardiac disease .
3. deterioration of background
respiratory disease.
INTRODUCTION:
 Patients should have:
1. a careful clinical assessment by history and
examination.
Oxygen saturation,
3. arterial blood gasses may all help in
differentiating physiological breathlessness from
serious disease
2.
Asthma:
Asthma is the most common respiratory
disorder affecting 3% of women of
childbearing age.
 Pregnancy has a variable effect on asthma :
 1. 1/3 improve.
 2. 1/3 deteriorate.
 3. 1/3 remain the same.
Asthma:
The most common reason that their asthma
symptoms deteriorate is patients reducing
their treatment because of a belief that the
medication may be harmful.
All commonly used medications to
control asthma are safe in pregnancy.
Asthma:
 All patients must be reassured that any flairs of
their asthma must not be ignored and that
treatment with medication such as steroids is
safe both for themselves and for their fetus.
 With regard to the effect of asthma on fetal
outcome, there is no evidence that there is any
significant impact on fetal growth or outcome.
Asthma: cont.
 Any patient whose asthma seems to be
deteriorating, particularly in the third trimester,
should be seen by an obstetric physician for review.

It is obviously desirable that control of
their asthma should be at its optimum
prior to the onset of labour.
Patients presenting in
labour should be managed:
 1.it is unusual for labour to be complicated
by attacks of asthma and this is probably
due to the increased secretion of cortisol
during the process.
 2.However, attacks of asthma during labour can be
managed by conventional treatment, such as
inhaled beta-sympathomimetics.
Patients presenting in
labour should be managed:
 Patients who have been on maintenance
glucocorticoids, for example,
Prednisolone doses in excess of the equivalent
of 5 mg Prednisolone daily, require
hydrocortisone cover during labour.
 If an operative delivery is required, epidural
anaesthesia is preferable to general
anaesthesia.
Pneumonia:
 Pneumonia can be a life-threatening illness in
a woman of childbearing age.
 Acute pneumonia should be managed by
experienced physicians and imaging should not be
withheld if it is important to patient care.
 Most antibiotics are safe for the pregnant mother
and it is important to treat infection vigorously.
Pneumonia:
 The management include prevention of
respiratory compromise where there is a need for
delivery as this will then be very high risk.
 It is also important to prevent the underlying
infection developing into septicaemia with
associated haemodynamic instability.
 Anaesthetic input is required from an early stage
where delivery may need to be considered.
Pneumonia:
 Patients who have pneumonia have an
increased risk of preterm labour, which
presumably relates to the pyrexia and
prostaglandin release.
 Varicella pneumonia is a particular cause for
concern for the pregnant woman requiring
intravenous acyclovir. It can occur in association
with encephalitis and hepatitis.
Tuberculosis:
 Pulmonary tuberculosis can present for the
first time in pregnancy and the obstetrician
must have a high index of suspicion when
presented with symptoms of:
 cough, malaise or weight loss in highrisk groups.
Tuberculosis:
 Most treatment options appear to be safe including:
 1. ethambutol.
 2.rifampicin.
 3. isoniazid .
 4. pyridoxine and also pyrazinamide.
 Streptomycin carries risks of VIII
nerve damage and should be
avoided.
Tuberculosis:
 There is no conclusive evidence that the outcome
of pregnancy is adversely affected by tuberculosis
providing treatment is commenced in the first
half of pregnancy.
-After birth, the neonate should be treated with
prophylactic isoniazid for 3 months and
there after BCG vaccination should be
given, although its efficacy remains
questionable.
MCQ:
 1.Cholestasis of pregnancy are associated with:
 a. Classicaly presented with itching in the first
trimester.
 b. Associated with an increased risk of intrauterine
death, classically before 37 weeks’ gestation.
 c. meconium passage .
 d. post term labour.
MCQ:
 2.Regarding inflammatory bowel disease with
pregnancy:
 a.treatment with sulphasalazine is not save during
pregnancy.
 b. active perineal and perianal disease indication for
delivery by caesarean section.
 c. most of the patients condition were deteriorate during
pregnancy.
 d.increase risk of preterm labour.
MCQ:
 3. pregnant lady with acute hepatitis B :all true except:
 a. the e antigen is indicative of an extremely high rate of
viral replication.
 b.there sexual partner only should receive hepatitis B
immune globulin.
 c.breast feeding is not contraindicated.
 d. Infants should immediately receive the hepatitis B
immune globulin and first dose of hepatitis B vaccine
MCQ:
 4. Acute fatty liver of prgnancy:
 a. (AFLP) is a common but serious liver condition
arising in pregnancy .
 b.complication of (AFLP) includes coagulopathy ,
haemodynamic instability and hyperglycaemia.
 c. Diagnosis is normally confirmed by a decrease level of
aspartate amino transferase (AST).
 d. treatment isdelivery of the fetus.
Answer:
 1.c.
 2.b,d.
 3.a,c,d.
 4.d.
THANK YOU