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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