Pregnancy-specific diseases

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Pregnancy-specific diseases. Chao Gu M.D., Ph.D. Dept of Ob/Gyn OB/GYN Hospital, Fudan University. CASE 1. - PowerPoint PPT Presentation

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  • Pregnancy-specific diseasesChao Gu M.D., Ph.D. Dept of Ob/GynOB/GYN Hospital, Fudan University

  • CASE 1What is your next step? Repeat another blood pressure measurement to ascertain the diagnosis of hypertension complicating pregnancy.A 35 year old lady at 32 weeks of gestation in her first pregnancy goes to your office for a minor upper respiratory tract infection. Incidentally, her blood pressure is found to be 155/90 mmHg with a pulse rate of 85/min. The cardiovascular examination and chest examinations are otherwise unremarkable. The size of uterus is appropriate for gestational age.

  • What are the classification of hypertension in pregnancy?Gestational hypertensionPreeclampsiaEclampsiaSuperimposed preeclampsia on chronic hypertensionChronic hypertension in pregnancy

    CASE 1

  • CASE 1What is the definition of various types of hypertension ? Chronic hypertension in pregnancyBP 140/90 mm Hg before pregnancy or diagnosed before 20 weeks' gestation not attributable to gestational trophoblastic disease orHypertension first diagnosed after 20 weeks' gestation and persistent after 12 weeks postpartumGestational hypertensionSystolic BP 140 or diastolic BP 90 mm Hg for first time during pregnancy No proteinuria BP returns to normal before 12 weeks postpartum Final diagnosis made only postpartum .

  • CASE 1What is the definition of various types of hypertension ? PreeclampsiaBP 140/90 mm Hg after 20 weeks' gestation Proteinuria 300 mg/24 hours or 1+ dipstick

    Increased certainty of preeclampsiaBP 160/110 mm Hg Proteinuria 2.0 g/24 hours or 2+ dipstick Serum creatinine >1.2 mg/dL unless known to be previously elevated Platelets < 100,000/ L Microangiopathic hemolysisincreased LDH Elevated serum transaminase levelsALT or AST Persistent headache or other cerebral or visual disturbance

  • CASE 1What is the definition of various types of hypertension ?

    EclampsiaSeizures that cannot be attributed to other causes in a woman with preeclampsia

    Superimposed Preeclampsia On Chronic HypertensionNew-onset proteinuria 300 mg/24 hours in hypertensive women but no proteinuria before 20 weeks' gestation A sudden increase in proteinuria or blood pressure or platelet count < 100,000/ L in women with hypertension and proteinuria before 20 weeks' gestation

  • What is the management? Evaluation Severity Gestational age Presence of preeclampsia OutpatientHospitalization

    Termination of pregnancy is the only cure for preeclampsia

    CASE 1

  • What is the management? High-risk chronic hypertension iassociated maternal and peri-natal complications, superimposed pre-eclampsiaabruptio placentaeCareful monitoring for proteinuria and renal function. Hospitalization should be considered if the blood pressure is not under control. Anti-hypertensive drugs should be considered.

    Once pre-eclampsia is diagnosed, hospitalization is indicated, progress rapidly to multi-system involvement, including eclampsia

    CASE 1

  • INDICATION OF MAGNESIUM SULFATE

    Control eclampsia convulsionsPrevent preeclampsia develop into eclampsiaCASE 1

  • THE USES OF MAGNESIUM SULFATEDAY 1loading dose 25% MgSO4 20ml10% GS 20ml IV in 5-10minMaintenance dose: 25% MgSO4 60ml5%GS 1000ml IV in 10h

    Day 2 to 24h Postpartum 25% MgSO4 60ml5% GS 1000ml IV in 10 hCASE 1

  • CASE 1 absent or very sluggish knee jerka respiratory rate below 16/min a urinary output of less than 100ml in the preceding 4 hours (25ml/hr)Contraindication as follow :

  • Indications of Antihypertensive drugs BP 150/100mmhg,
  • What are the antihypertensive drugs commonly use in pregnancy? Labetalol combined alpha- and beta-adrenoceptor blocker.Nifedipine Calcium Channel Blockers NifedipineBeta-blockersMethyldopaSodium nitroprussideHydralazine

    ACEI () cant use!!!fetal growth restrictionFGRARDS

    CASE 1

  • Too early --- Can fetus survive Complication Too late ---Can mother survive Complicationpreeclampsia patient has no response following medical management for 24-48 hours .preeclampsia patient after 34 weeks of gestationpreeclampsia patient before 34 weeks of gestation with impaired fetoplacental unit function and matured fetus.preeclampsia patient before 34 weeks of gestation with impaired fetoplacental unit function and immatured fetus, use Dexamethasone to promote fetal lung maturity before the termination of pregnancy. Eclampsia control over 2h.CASE 1Termination of pregnancy

  • A 26-year-old female at 32 weeks of gestation presented to the clinic with complaints of generalized itching. Patient reported no rash or skin changes. She denied any change in detergent, soaps, or perfumes. She denied nausea and vomiting .There was no history of any drug intake or previous allergies. There was no fever or any other medical illness.On physical examination, there were no rashes apparent on her skin and only some excoriations were there from itching. Laboratory investigations revealed slightly elevated serum transaminases and bilirubin levels, Alkaline phosphatase levels were much higher than normal.CASE 2

  • What is the patients likely diagnosis? Intrahepatic Cholestasis of Pregnancy. (ICP)

    What is the cause of the patients generalized itching?Increased serum bile salts and accumulation of bile salts in the dermis of the skin are responsible for generalized itching. Generalized pruritus in pregnancy and a characteristic enzymeprofileHigh alkaline phosphatase is a marker of cholestasisSlightly high transaminases (AST, ALT) differentiate it from viral hepatitis Bilirubin is high due to intrahepatic obstruction as a result of cholestasis.CASE 2

  • Intrahepatic cholestasis of pregnancy (ICP) benign disorder that occurs in the second or third trimester and resolves spontaneously after delivery. Cholestasis of pregnancy is a condition in which the normal flow of bile from the gall bladder is impeded, leading to accumulation of bile salts in the body. CASE 2

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    Bed rest, left lateral positionDrugAdenosylmethionine Ursodeoxycholic acid Dexamethasone Phenobarbital NST (Nonstress Test)CASE 2Therapeutic Principle

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  • www.themegallery.comCompany LogoJaundice (+) 36 weeks of gestation Jaundice (-) 37 weeks of gestationSignificantly decreased placental function or Fetal distress ImmediatelyCesarean sectionTermination of pregnancy CASE 2

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  • CASE 330 years oldFirst pregnancy8 weeks gestation by LMPPersistent vomiting for past weekUnable to tolerate food or fluids for past 24 hoursPassing little urineUrien ketones 3+

  • Nausea (70%) and vomiting (60%) common in 1st trimester, Hyperemesis = fluid and electrolyte imbalance and nutritional deficiencyPersistent and severe vomitingMore severe in:Multiple gestationHydatidiform moleWithout treatment can lead to CNS disturbance, liver and renal failureCASE 3What is the patients likely diagnosis? Hyperemesis Gravidarum

  • PRESENTATIONSevere nausea and vomitingDehydrationWeight lossKetosisPtyalism (unable to swallow saliva)CASE 3

  • DIAGNOSISConsider other causes e.g. UTI, gastritis, ketoacidosis, peptic ulceration, Addisons disease, pancreatitisInvestigations:FBC (raised haematocrit)U&E (hyponatraemia, hypokalemia, hypouraemia)LBP (raised transaminases, found in up to 50% cases)TFTs (thyrotoxicosis)Urinalysis and MSU for culture and sensitivityUSS (if not done yet)Weight

    CASE 3

  • www.themegallery.comCompany LogoSerious ComplicationsWernicke syndrome Wernicke Vit B1 deficiency A type of brain damage in which the initial symptoms appear.Abnormal gait and eye movements.Psychiatric disorder, includes dementia and psychosis.coagulation disorder Vit K deficiency CASE 3

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  • INDICATIONS FOR TERMINATION OF PREGNANCYContinuing jaundiceContinuing proteinuriaFever continuing over 38 C Tachycardia ( 120 beats / min)Wernicke syndrome appearsCASE 3

  • 19 year old G1 P0+039 weeks - antenatal care outside your area Contractions 3-4 in 10 minutesExcessive weight gain during pregnancyRecent generalized oedemaCASE 4

  • ON EXAMINATIONFacial & generalised oedema +++Admission BP = 164/102 (repeat 160/100)Urine = +++ proteinVE : Cervix = 4 cm dilated, 100% effaced, station 0, membranes intact - contractions 3-4 in 10 mins, - baseline FHR = 140bpm - normal variability, - no decelerationsCASE 4

  • What concerns you about with this situation?likely to have severe pre-eclampsia both fetal & maternal risks such asrisk of ECLAMPSIAintracranial haemorrhage risk of pulmonary oedema (iatrogenic fluid overload)hepatorenal failure

    CASE 4

  • What lab investigations would you order?Full Blood Count(Coagulation) Group & Save for X-matchUrea, Creatinine & ElectrolytesLiver Function TestsUrateMSU (inc Gram Stain)

    CASE 2

  • What other data do you need at this point?

    her handheld antenatal recordsCASE 4

  • Would you give antihypertensive and/or magnesium sulphate at this point?

    Antihypertensives persistent systolic BP >160mmHg should be treatedMagnesium Sulphate most units would start MgSO4 at this stage (ref MAGPIE study). IN THIS CASE, NEITHER IS GIVEN..CASE 4

  • 30 MINUTES LATER

    While awaiting laboratory results, you are called urgently to delivery suiteThe patient has a grand mal seizure that lasts about 1 minuteCTG shows a fetal bradycardia of 80 bpm after the seizure

    CASE 4

  • WHAT WOULD YOU DO AT THIS POINT?

    CALL FOR HELP +++++INITIATE BASIC ABCs remember left lateral tilt!!A airway cant be inserted during a fit C includes x2 large bore cannulaeInitiate unit Eclampsia prot