8. 20 wks pregnancy with hypertension
• Pre-existing hypertension - prior or before 20wks
- Should be managed with vasodilators or methyldopa
- ACEIs should be avoided
- Diuretics should also be avoided unless there is heart failure
• Gestational hypertension – after 20 wks without any features of
toxemia. Drugs- labetolol/CCB/Methyldopa/doxazosin
• Pre-eclampsia & eclampsia
- Risk factors and S/S
- Pre-eclampsia- control of blood pressure, magnesium sulphate as
seizure prophylaxis, correction of coagulation abnormalities,
monitoring of fluid balance, maintaining the fetus in utero as long
possible
9. 20 wks pregnancy with HYPERGLYCEMIA
• GDM – With first onset or recognition during
pregnancy.
Screened at 24-28 wks/ 1st visit
Diagnosis – FBS≥ 5.1, 1HAG ≥ 10, 2HAG ≥8.5
Treated with Insulin ( 1st choice),
metformin/glibenclamide may be given
Target – in GDM ; FBS ≤ 95 mg/dl, 1 hr post
prandial ≤140, 2 hr post prandial ≤ 120
10. 20 wks pregnancy with HYPERGLYCEMIA
• Pregnancy in women with established diabetes
Cardiac , renal and skeletal malformations, of which the
caudal regression syndrome most characteristic
The risk of fetal abnormalities 20% for those with poor
glycaemic control
If heavy proteinuria and/or renal dysfunction exist prior to
pregnancy, there is a marked increase in the risk of pre-
eclampsia, and renal function can deteriorate irreversibly
during pregnancy.
Associated with an increased risk of ketosis
High -dose folic acid (5 mg daily prior conception)
Careful monitoring of eyes and kidneys is required
throughout pregnancy.
Maintain near normal blood glucose with avoiding
hypoglycemia
11. Pregnancy with hypothyroidism
• Untreated hypothyroidism is associated with
subfertility and so is uncommon in pregnancy
• Require an increase in the dose of levothyroxine of
approximately 25–50 μg daily as soon as she is
pregnant
• Then dose should be adjusted according to
trimester specific reference range
• Hypothyroidism 1st recognised during early
pregnancy should be started with high dose
levothyroxine
12. Pregnancy with thyrotoxicosis
Newly diagnosed hyperthyroidism can be treated
with β-blockers followed by antithyroid drugs.
Propylthiouracil (PTU) is the preferred drug
Who become pregnant while taking carbimazole
or PTU should be advised to continue their current
drug with close monitoring
Smallest dose of antithyroid drug (typically < 150
mg PTU or 15 mg carbimazole per day)
Surgery can be done at 2nd trimester, RIA
contraindicated
PTU preferred during breastfeed
Monitoring of mother & fetus (HR & growh)
Periodic monitoring of thyroid function in
13. Pregnancy with RA
Increased risk of pre-eclampsia, pre-term birth and
small babies
Glucocorticoids, hydroxychloroquine, azathioprine
and sulfasalazine can all be continued as normal but
NSAIDs should be avoided after 20 weeks
Inhibitors of TNF-α(cetrolizumab) are safe during
pregnancy
Disease flares are common in the post-partum period.
Glucocorticoids are a good short-term option to control
such flares, then, reintroduction of DMARDs
Glucocorticoids, hydroxychloroquine, azathioprine,
sulfasalazine, CNIs & NSAIDs are safe in breastfeeding
MTX should be stopped 3 months before &
leflunomide 2 yrs before planning pregnancy
14. Pregnancy & lupus
• Effects of SLE on pregnancy- abortion, still births,
IUGR, Prematurity, neonatal lupus, toxemias of
pregnancy, HTN,DM,UTI
• Effects of pregnancy on SLE - 1/3rd unchanged, 1/3rd
flare & 1/3rd remission
Desired state during conception
- At least 6 months full remission
- With HCQ and low dsoe steroid/AZA
- NO Cyclophosphamaide, MTX, MMF, NSAID, High
dose prednisolone
15. Monitoring during pregnancy
Clinical
During 1st visit-
- CBC with ESR, Urine R/E
- Serum creatinine
- UTP/PCR
- Anti- dsDNA titre
- Serum C3 & C4
- Anti- Ro & anti La,Lupus anticoagulant & anti cardiolipin
antibody
Each visit- CBC & Urine R/E
Additional
- OGTT – 24-28 wks
- BPP from 28 wks
- Foetal HR & foetal echo from 20 wks
16. Management of pregnancy with lupus
• Family education & counselling
• Control of HTN
• Folic acid 400 micrograms/day in 1st trimester
• Axial exercise & calcium supplementation
• HCQ throughout pregnancy
• APS – Aspirin plus LMWH
• No role of flare prophylaxis with steroid
• Mainstay of flare suppression- steroid
• Delivery
- in a hospital with neonatal ICU
- Vaginal delivery preferred
- Steroid stress coverage protocol during de livery
17. Clinical findings Lupus flare Pre-eclampsia Normal pregnancy
hypertension Yes yes No
proteinuria YES YES No
RBC casts YES no No
LFTs normal abnormal Normal
Anti-ds DNA increased unchanged unchanged
C3 &C4 low unchanged unchanged
18. Pregnancy with valvular heart disease
• Regurgitant lesion tolerate better than
stenotic lesion
• Moderate to severe MS (valve area <1.5cm2)
are at risk
• Manage with beta blockers, furosemide &
LMWH
• Continuous hemodynamic compromise
despite optimal medical management-
surgical intervention
19. Pregnancy with myocardial infarction
• Coronary artery dissection & coronary
thrombosis are more common cause
• Management are same except statins &
glycoprotein IIb/ IIIa receptor antagonist
• Clopidogril should be stopped around the
time of delivery
• Bare-metal stents are preferred because
drug-eluting stents require dual anti platelet
therapy
20. AKI IN PREGNANCY
• Pre-renal
- Hyperemesis gravidarum
- Post partum haemorrhage
- Placental abruption
- Septic abortion
• Renal
- Pre -eclampsia
- TTP
- Acute fatty liver of pregnancy
- Acute interstitial nephritis
• Post renal - acute urinary retention
21. Pregnancy with jaundice
• Acute fatty liver of pregnancy
- Typical presentation at third trimester with
vomiting, abdominal pain, jaundice, polyuria and/or
encephalopathy
- Abnormal liver function tests and fatty liver on
ultrasound, rarely liver biopsy
- Management is supportive with delivery of the
fetus
- Diagnostic criteria box 30.16
22. Pregnancy with jaundice
• HELLP Syndrome
- Heamolysis ,elevated live enzyme and low
platelet
- Thought to be part of the spectrum of pre-
eclampsia
- Can be complicated by liver haematoma and
capsular rupture.
- Management involves supportive care, control of
hypertension, correction of coagulopathy and
delivery of the fetus.
23. Pregnancy with jaundice
• Obstetric cholestasis
- The typical presentation is in the third trimester with
pruritus, particularly affecting the soles and palms
- Raised levels of bile acids and abnormal LFTs
- The diagnosis can be made on the basis of these clinical
features when other causes of liver dysfunction and
pruritus have been excluded.
- Treatment is with ursodeoxycholic acid 250 mg twice
daily (initially)
- Aqueous cream with menthol can also be effective in
soothing pruritus.
- There is an increased risk of fetal mortality particularly
when bile acid levels are over 40 μmol/L (97.9 μg/mL).
24. Pregnancy with jaundice
• Viral hepatitis
- Mother HBe positive- 90% chance of vertical
transmission
- Vaccinations & immunoglobulin should be
given to infant
- Antiviral agents to mother after delivery
- HCV & HIV coinfectionantiviral
- HEV Fulminant hepatic failure
25. EASL GUIUDELINE 2017
Screening for HBsAg in the first trimester of pregnancy is
strongly recommended
Without advanced fibrosis, therapy may be delayed until the
child is born
Pregnant women advanced fibrosis or cirrhosis, therapy with
TDF is recommended
In pregnant women already on NA therapy, TDF should be
continued while ETV or other NA should be switched to TDF
In all pregnant women with high HBV DNA levels
(200,000 IU/ml) antiviral prophylaxis with TDF should start at
week 24–28 of gestation and continue for up to 12 weeks
after delivery
Breast feeding is not contraindicated in HBsAg-positive
26. • The prevention of HBV perinatal transmission,
which is considered to occur mainly at
delivery, and causes the majority of chronic
HBV infection is based on the combination of
HBIG and vaccination given within 12 h of
birth. This prophylaxis reduces the rate of
perinatal transmission from >90% to <10%.
27. Pregnancy with thrombocytopenia
• Gestational thrombocytopenia – most common
• ITP- Target platelet > 80,000 during delivery
• SLE
• HELPP
• HUS-TTP
- microangiopathic haemolytic anaemia
- AKI
- Thrombocytopenia
- Neurological deficit (in TTP)
28. Venous thromboembolism in pregnancy
The risk of venous thromboembolism (VTE) is 4–5
times higher in pregnancy
Doppler ultrasound scan is the investigation of
choice, but MRI can also be used
Measurement of D-dimer is not useful in pregnancy
Treatment LMWH at a higher dose than for the
non-pregnant woman, based on the patient’s early
pregnancy (booking) weight
Women who are receiving warfarin or other oral
anticoagulants as prophylaxis should have stopped
prior to conception and LMWH should be
substituted.
36. 50 Yrs male with sudden severe headache
Subarachnoid haemorrhage
Acute bacterial meningitis
Cerebral venous sinus thrombosis
Pituitary apoplexy
37. Unilateral leg swelling
• Indication of thrombophilia scrren
• Identification of compartmental syndrome
(box 10.14)
• Wells score
• Investigation of suspected deep venous
thrombosis
• Management and follow up
• Warfarin vs Ribaroxavan
38. Immediate assessment of deteriorating patient
C - Control of obvious problem like VT
A and B – Airway and breathing ; O2 saturation and
ABGs
C – Circulation; heart rate and rhythm, jugular venous
pressure, evidence of bleeding, signs of shock
D – Disability; GCS, brief neurological examination &
capillary blood glucose
E – Exposure and evidence; exposure- targeted clinical
examination particularly abdomen & lower limbs,
evidence- collateral history, recent investigations &
prescriptions
Use NEWS score to identify physiological deterioration
& frquency of observation
39. Common presentation of deterioration
• Indication of ICU & HDU referral – box 10.18
• Assessment & management of hypoxemia
- box 10.20, page 202 – respiratory support
• Differentiating point between shock with
high CO & low CO – BOX 10.23
• Short note on abdominal compartment
syndrome & rhabdomyolysis –page 195
40. Septic shock
• Management principles
Early recognition
Source control
Early and adequate antibiotic therapy
Early hemodynamic resuscitation and
continued support
Proper ventilator management with low tidal
volume in patients with acute respiratory
distress syndrome (ARDS)
41. The following should be completed within 3 hours:
Obtain the lactate level
Obtain blood cultures before administering antibiotics
Administer broad-spectrum antibiotics
Administer 30 mL/kg of crystalloid solution for
hypotension or for lactate levels of 4 mmol/L or higher
The following should be completed within 6 hours:
Administer vasopressors for hypotension that does not
respond to initial fluid resuscitation to maintain a mean
arterial pressure (MAP) of 65 mm Hg or higher
If hypotension persists despite volume resuscitation or
the initial lactate level is 4 mmol/L or higher, then
measure central venous pressure (CVP) (aiming for ≥8
mm Hg
42. Respiratory support
Early intubation and mechanical ventilation should be
strongly considered for patients with any of the following:
Evidence of ARDS
Dyspnea or tachypnea
Circulatory support
Initial crystalloid fluid challenge of 30 mL/kg (1-2 L) over
30-60 minutes
CVP should not be used to target resuscitation; it should be
used as a stopping rule.
If CVP rapidly increases by more than 2 mm Hg, absolute
CVP greater than 8-12 mm Hg, or signs of volume overload ,
fluid infusion as primary therapy needs to be stopped.
Patients with septic shock often require a total of 4-6 L or
more of crystalloid solution.
43. Vasopressor Therapy
If the patient does not respond to resuscitation with
several liters (usually ≥4 L) of isotonic crystalloid
solution or if evidence of volume overload
vasopressor therapy.
The recommended first-line agent for septic shock is
norepinephrine, preferably administered through a
central catheter.
Inotropes
The 2012 Surviving Sepsis Campaign guidelines
recommend administration of dobutamine dosages up
to 20 µg/kg/min only in the presence of myocardial
dysfunction or persistent hypoperfusion despite
adequate fluid resuscitation.
44. Correction of anemia and coagulopathy
If hemoglobin levels fall below 7 g/dL, red blood cell
(RBC) transfusion is recommended to a target
hemoglobin range of 7-9 g/dL.
Patients with severe sepsis should receive platelet
transfusion if platelet counts fall below 10 × 109/L
(10,000/µL).
Metabolic and nutritional support
Potassium, magnesium, and phosphate levels should be
measured and corrected if deficient.
Early nutritional support is of critical importance in
patients with septic shock. The oral or enteral route is
preferred.
45. Corticosterois
For patients with septic shock, administer
hydrocortisone 200 mg/day IV in 4 divided doses
Corticosteroids (hydrocortisone) should be
considered only for patients with vasopressor-
dependent septic shock
wean steroid therapy when vasopressor therapy is
no longer needed
46. Sepsis six
• O – oxygen
• B – Blood culture
• A – antibiotics
• L – lactate level
• F – fluid
• U- Urinary output
47. • Page 213- short note on organ donation
• Box 10.49- how to write an ICU discharge
summary
49. Adolescent & transition medicine
• Long term condition of childhood that affect adult
health – box31.1
• Principles of prescribing during transition –page 1289
• Box 31.4 & box 31.5
• Factors affecting adherence – box 31.6
• Strategies to improve adherence- box 31.7
• High risk behaviour – box 31.8
• Question may be like
• How will manage a case of JIA/ Epilepsy/ cerebral
palsy/ muscular dystrophy/TOF/ Renal disease
transitioning into adult????
50. Medical ophthalmology
• 27.1 Ophthalmic features of haematological disease
• 27.2 Ophthalmic features of diabetes and other
endocrine disease
• 27.3 Ophthalmic features of cardiovascular disease
• 27.4 Ophthalmic features of respiratory disease
• 27.5 Ophthalmic features of rheumatological/
musculoskeletal disease
• 27.6 Ophthalmic features of gastrointestinal disease
• 27.7 Ophthalmic features of skin disease
• 27.8 Red flag symptoms in visual loss*
51. 1. Describe positive findings
2. 4 possible causes - HTN, retinal vasculitis,
hyperviscocity,glaucoma
3. Possible mechanism – compression of a vein by
an adjacent arteriosclerotic artery
4. Presentation- unilateral painless loss of vision
*** davidson 1177 page
52. This is the eye photograph of a 40 years old woman
presented with abnormal movement.
1. Write 04 others expected finding in eye.
2. Write 04 investigations for this patient.
3. If this patient present with recurrent flaccid weakness,
what may be the possible explanation?
4. After starting treatment, if patient present with
anasarca, what is the possible explanation?
53. 1. POSITIVE FINDINGS
2. 05 POSSIBLE CAUSES
3. PRESENTATION-
www.facebook.com/ospemedicine
Page- OSPE MEDICINE FOR FCPS & MD
57. DIABETIC RETIONOPATHY
Pathogenesis of diabetic retinopathy is local vascular
endothelial growth factor production initiated by
hyperglycaemia-induced capillary occlusion.
• PROLIFERATIVE-
Good control of diabetis
Control of other metabolic abnormalities
Control of hypertension
Pan retinal laser photocoagulation; 2 complications-
secondary optic atrophy and night blindness (nyctalopia),
Intravitreal injections of anti-vascular endothelial growth
factor (e.g. ranibizumab, aflibercept, bevacizumab)
• ** davidson page 1177
