Transcript Medical disorder with pregnancy

Dr.
Ahmed Jasim
Ass.Prof
MBChB.-DOG-FIBMS
Consultant of gyn.&obst.
THYROTOXICOSIS IN PREGNANCY
ItHazards is
 Abortion and preterm labour.
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During pregnancy, there is increased estrogen
level which causes:
 enlargement of thyroid gland.
 Increase production of thyroid –binding globulin by
liver.
 Increase in total amount of T4 and T3 mostly in
form of protein-bound thyroxin and therefore there
are no changes in the amount of free circulating
active fraction of T4 and T3.
 There is iodine deficiency in pregnancy due to:
 increases Renal clearance of iodine in pregnancy.
 fetal thyroid activity.
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It occur in 1in 500 pregnancies. it is mostly due
to Graves disease. (autoimmune thyrotoxicosis)
Clinical Picture
 Weight loss in spite of good appetite.
 Intolerance to heat.
 Tremors.
 Resting pulse over 100 beats/min.
 Exophthalmos.
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Investigations
 Free T4 (raised) T3 resin uptake (raised)
 Elevated Serum free T4 and suppressed TSH
level establish the diagnosis of
hyperthyroidism.
 Avoid radioactive-iodine testing because of fetal
thyroid pickup and retention.
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EFFECT OF HYPERTHYROIDISM ON PREGNANCY
uncontrolled disease is associated with maternal
and fetal complications including:
 Thyroid storm (thyrotoxic crisis)
 Heart failure.
 miscarriage
 gestational hypertension.
 Pre-eclampsia.
 Premature labour.
 IUGR
 stillbirth
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Treatment
 Propylthiouracil: 100-200 mg t.d.s. or
 Carbimazole: 10-15 mg t.d.s.
 Thyroxine is combined with antithyroid drugs in
the last trimester to protect the neonate from
hypothyroidism. Breast feeding is
contraindicated because the drugs are
excreted in milk.
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SURGICAL MANAGEMENT
may be considered (thyroidectomy) if:
 medical treatment fails
 there is clinical suspicions of cancer
 compressive symptoms due to goiter.
 It is advisable to delay surgery until the second
trimester because the rate of spontaneous
abortion is highest during the first trimester.
 operation is safe if mother properly prepared.
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HYPORTHYROIDISM
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Avoid radioactive-iodine testing because of fetal
thyroid pickup and retention.
It occurs in nearly 1%of pregnant women and is
usually due to autoimmune Hashimotos
thyroiditis or idiopatheic myxoedema or
following treatment of hyperthyroidism.
 Rarely get pregnant if not treated
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EFFECTS OF HYPOTHYROIDISM ON PREGNANCY
Pregnant women on appropriate treatment can
expect a normal pregnancy outcome,
 but untreated maternal hypothyroidism has
been associated with an increased risk of:
 Spontaneous abortion.
 Gestational hypertension and preclampsia.
 Abruption placentae.
 Premature delivery.
 Low birth weight.
 Stillbirth.
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Lower intelligence levels in offspring and
Reduced intelligence quotient(IQ).the insult is
likely to occur in the first trimester and
therefore pre-conceptional optimization of T4
therapy is important.
Investigation:
 Elevated TSH level.
 Low levels of serum T3 and T4
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TREATMENT
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Thyroxin is titrated against biochemical result
and is safe in pregnancy and lactation. thyroid
function test every 2-3 months. more frequent
measurements are made if the clinical or
biochemical condition is deranged.
EPILEPSY IN PREGNANCY
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It is relatively common disorder occurring in 1%
of women of child-bearing age.
EFFECTS OF PREGNANCY ON SEIZURE
Pregnancy has no consistent effect on epilepsy.
seizure frequency during pregnancy may
increase , decrease ,or remain the same.
 Anticonvulsant drug dose may still same as non
pregnant level or need increase and patient
must be monitored during pregnancy to ensure
that dose adjustments are made as
appropriate.
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EFFECTS OF EPILEPSY ON PREGNANCY
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There are pregnancy complication associated with epilepsy:
1. Increase congenital abnormality.(neural tube defect,
cardiovascular malformations and cleft lip and palate).It may
be due to:
a. anticonvulsant medication
b. hypoxia resulting from seizure.
2. Increase perinatal mortality
3. Ante-partum haemorrhage.
4.Post-partum haemorrhage.
5. Pre-eclampsia.
6. Hyperemesis gravidarum.
7. Premature labour.
8. Prolonged labour.
9. Low birth weight
10. Increase intrauterine fetal death.
NEONATAL COMPLICATIONS
Increase risk of epilepsy in child. (4fold
increase)
 Increase risk of haemorrhagic disease of
newborn.
 Drug withdrawal symptoms.
 Neonatal morbidity and mortality
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EFFECTS OF ANTI-EPILIEPTIC DRUGS ON FETUS
AND NEWBORN
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Major and minor congenital abnormalities.
Neonatal withdrawal effects.
Vitamin K deficiency with haemorrhagic disease
in newborn.
Developmental delay or behavioural difficulties.
Increase in childhood malignancies.
MANAGEMENT
Preconceptional care:
 Delay conception until epilepsy is well
controlled.
 Monotherapy is recommended with the lowest
dose of drug.
 Folic acid 5mg/day.
 Discuss risk of fetal malformation and the role
of prenatal diagnosis.
 Discuss the risk of epilepsy in offspring
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ANTENATAL CARE
Women with epilepsy who become pregnant
constitute a high-risk group and need
Multidisciplinary care team with regular
antenatal visits.
 *Proper seizure control is the aim to minimize
maternal morbidity (fits can be fatal) as well as
uncontrolled seizure are more harmful to fetus
than the potential risks of drug therapy so
patients should receive anticonvulsant drug
and must be monitored free drug levels
monthly.
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Advise good diet, sleep and avoidance of
precipitating factors.
 *Offer prenatal diagnosis. All patients should
receive anomaly ultrasound assessment to
exclude specific abnormalities associated with
their medication and fetal echocardigraphy at
about 18 weeks.
 *Vitamin K supplementation given from 36
weeks onward to prevent neonatal bleeding
disorder.
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THE MANAGEMENT OF LABOUR AND DELIVERY
The management of labour and delivery follows
obstetric indications and spontaneous vaginal
delivery should be the aim if no
contraindication.
 *Epileptic seizures may occur during labour
and as such may confuse the diagnostic
situation that includes eclampsia. Epileptic
seizures should be treated and may be reduced
with the use of epidural anaesthesia.
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POSTNATAL CARE (POSTPARTUM)
Vitamin K to neonate.
 *Check for fetal abnormality.
 Monitor for neonatal withdrawal.*
 Breast feeding is safe.*
 *Post-partum drug doses may need to be adjusted
if doses have been increased during pregnancy.
 *Advise about avoidance of seizure related
accident and specific advice must be given about
childcare..
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POSTNATAL CARE (POSTPARTUM):
Contraceptive advice:
 Mirena (medicated intra uterine contraceptive
device)can be used as it is not affected.
 Depo-provera injection(progesterone) every 10
weeks.
 50 µg estrogen combined oral contraceptive
pills if decide to use combined oral
contraceptive pills.
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EPILEPSY IN PREGNANCY
Grand mal epilepsy is the commonest type.
 Treatment: phenobarbitone or phenytoin. Folic
acid should be given with phenytoin as it is
antifolic .
 There is risk of foetal malformations.
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JAUNDICE IN PREGNANCY
Disease
Time of Onset
Cause
Main Symptoms
Prognosis
Recurrent cholestatic
jaundice of pregnancy
Usually last quarter
Oestrogen.
Familial.
Pruritus.
Mild jaundice.
Spontaneous resolution
but recurs with
pregnancy and hormonal
therapy.
Acute fatty liver
Last quarter
Protein malnutrition.
Eclampsia & preeclampsia.
Severe vomiting.
Abdominal pain.
Haematemesis.
Poor, maternal mortality
80%.
Viral hepatitis
Any
Viral.
Malaise.
Anorexia.
Vomiting.
Pyrexia.
Upper abdominal pain.
Hepatomegaly.
Good, but poor in
malnutrition.
Cholecystitis
Any
Biliary obstruction.
Pain.
Vomiting.
Malaise.
Jaundice.
Good, surgical treatment
rarely required.
Acute pancreatitis
Common in late
pregnancy
Severe pain.
Vomiting.
Hypotension.
Rapid pulse.
High mortality 20%.
Haemolytic anaemia
Any
Anaemia.
Jaundice.
Good if proper diagnosis
and treatment is taken.
Drugs.
Anaesthesia.
Incompatible
blood transfusion.
JAUNDICE IN PREGNANCY
Jaundice in pregnancy can be caused by
 1. Obstetric cholestasis Intrahepatic cholestasis
(recurrent)
 2. Complication of severe pre-eclampsia, eclampsia.
 3.Persistant severe hyperemesis gravidarum refractory
to all treatment.
 4. Acute hepatic failure.
 5. Haemolytic jaundice.
 6. Congenital hyperbilirubinaemias
 7. Viral hepatitis.
 8.Side effect of drug (chlorpromazine).
BRONCHIAL ASTHMA
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Asthma is the most common respiratory
disorder affecting 3% of women of childbearing
age.
EFFECT OF PREGNANCY ON BRONCHIAL
ASTHMA
Pregnancy has variable effect on asthma but
for the vast majority of women there is no
impact whatsoever. Pregnancy itself does not
seem to increase the frequency or severity of
asthma.
 About 1in 10 asthmatics will suffer an acute
attack in labour.
 Risk of postpartum deterioration should be
discussed with women.
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EFFECT OF BRONCHIAL ASTHMA ON
PREGNANCY
A. in well controlled asthma No increase in
obstetrical problem.
 B. Severe and poorly controlled asthma does have
a detrimental effect on pregnancy and is
associated with an increased incidence of:
 Abortion.
 Intrauterine fetal death (IUFD).
 intrauterine growth restriction (IUGR).
 hypertensive disorders.
 preterm rupture of membranes.
 preterm labour.
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MANAGING PREGNANCY IN ASTHMATIC
PATIENTS
Preconceptional care:
 It is important that women receive good advice
pre-pregnancy about the potential impact of
their medical condition and enter pregnancy
with appropriate confidence about medication.
 Base line investigation: peak flow
measurement.
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ANTENATAL CARE
Pregnant asthmatics should be followed closely
during pregnancy to ensure adequate maternal
and fetal assessment.
 Standard antenatal care is advised in pregnant
women with well controlled mild and moderate
asthma, while multidisciplinary unit for Poorly
controlled and severe asthma cases.
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prevention is the key, and known triggers of
exacerbations should be eliminated or avoided
in home and at work.
 The management of asthma in pregnancy is
essentially the same as in non-pregnant
patients and continuo treatment which given
before pregnancy. Short-acting and long-acting
beta 2 agonist, inhaled steroids and
theophylline can all be used with confidence in
pregnancy.
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prednisolone is the oral steroids of choice in
pregnancy, as 88% of it is metabolized by the
placenta ,limiting fetal exposure.
corticosteroids are usually only prescribed for
good medical reasons and usually outsides of
the teratogenic period. most agree that if a
need for steroids exists, pregnancy should not
be considered a contraindication.
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 asthma
should be at its optimum prior to the onset of
labour.
 Care should be at optimizing medical treatment
to asthmatic attacks and the use of aggressive
treatment should these attacks occur.
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Asthmatic pregnant women should have:
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peak flow measurement.
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Glucose tolerance test to those receiving
steroids.
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Ultrasound examination for fetal growth and
well-being.
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TIMING OF DELIVERY:
Depend on maternal and fetal status.
 If pregnancy is progressing well, there is no
need for early intervention and it is advisable to
await spontaneous onset of labour.
 Early delivery can be considered for fetal
growth restriction or maternal deterioration.
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MANAGEMENT OF LABOUR AND DELIVERY
Vaginal delivery is the aim and caesarean
section is performed only for obstetric reasons.
 If patient on steroids, hydrocortisone required
to cover labour.
 No form of analgesia is contraindicated.
Epidural is the preferred analgesia and
anaesthesia. General anaesthesia should be
avoided if possible as it increase risk of
broncho-spasm and chest infection.
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Drugs used in obstetrics which should not be
used in asthmatic women as it cause
brochospasm are
 Ergometrin.
 Non-steroidal anti-inflammatory drugs.
 ProstglandinsF2α.
 Aspirin.
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THANK
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