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Miscellaneous medical diseases for 4th year med. students
1. Associate Clinical Prof Dr. Aisha Elbareg ,MD, PhD
Faculty of Medicine, Misurata University, LIBYA
MISCELLANEOUS MEDICAL
Diseases
For 4th year
In pregnancy
Med. Students
2. Common miscellaneous diseases:
Respiratory diseases:
Breathlessness: Asthma
Endocrinogolgical diseases
Hyperthyroidism
hypothyroidism
CNS:
Headache: Migraine
Epilepsy
Chronic renal disease
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May All Be Happy & Healthy.
3. Breathlessness:
Breathlessness can be difficult to
interpret in pregnancy
Causes:
1. Physiological changes of pregnancy
2. Worsening respiratory disease
including Asthma
3. Thromboembolism
4. Cardiac disease
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4. Bronchial Asthma: definition
Chronic inflammatory airway disorder with a
major hereditary component.
Reversible bronchial obstruction due to:
Bronchial smooth muscle contraction
Mucus hypersecretion
Mucosal edema
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5. Asthma: incidence
Occurs in 7% of general population
Occurs in 3% of pregnancy
Status asthmaticus (acute) : 0.2% of pregnancy
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6. Asthma:
Patient may reduce or stop
the drugs due to fear of harm.
So Symptoms may worsen.
Commonly used drugs are safe
in pregnancy. We must
reassure woman about it.
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7. Asthma: Predisposing factors
Air way inflammation and responsiveness to:
Environmental pollutants as smoking, animals, dusts
Respiratory tract infection
Aspirin, cold air, and exercise.
Emotions
More common in patients with atopy
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8. Effects of pregnancy on Asthma
1. During pregnancy
Unchanged in 50%
Improved in 30%
Worsened in 20%
2. During labour: never occur
3. During puerperium: inability to make max.
respiratory effort due to scar pain after delivery
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9. Effect of Asthma on pregnancy
Slight ↑ incidence:
1. Preeclampsia
2. Preterm labor
3. IUGR : in sever uncontrolled asthma due to
chronic hypoxia
4. Perinatal mortality.
5. 6-30% of children develop asthma later in
life.
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10. Asthma: clinical evaluation
Clinical signs of severity:
Breathlessness, tachycardia, prolonged
expiration, use of accessory muscles, central
cyanosis, altered consciousness.
Arterial blood gas analysis (ABG)
Pulmonary function test: routine
Sequential measurement of the FEV1
The peak expiratory flow rate (PEFR)
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11. Asthma- management
Preconceptional counseling
During pregnancy
ᵝ2 agonist (Salbutamol/Salmeterol: long acting): inhalor/
nebulizer
Inhaled glucocorticoids
Inhaled Na chromoglycate, Ipratropium
Theophyllines (Aminophylline):iv or oral
Acute attack: hospitilization, O2 mask, β-agonist inhaled,
iv corticosteroids.
Aim: Po2 >60mmHg along with 95% O2 saturation
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12. Asthma- management
During labor:
Avoid PGE1, PGF2α, ergometrin
If surgery is needed avoid general anesthesia,
use spinal or epidural anesthesia
Adequate maternal oxygenation
Forceps or ventose to shorten 2nd stage
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13. Asthma- management
Status asthmatics :
Hospitalization in ICU, early intubation .
O2 ventilation & IV fluids .
Parenteral steroids .
Postnatal:
Physiotherapy to maintain adequate pulmonary
function
Restart maintenance therapy
Encourage breast feeding
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14. Thyroid disease with pregnancy
Incidence: it is most common endocrine disease
after DM (0.2%)
Normal changes in pregnancy
Thyroid function is stimulated during pregnancy
due to:
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1. ↑ E →↑ TBG →↓ free T4 relative ↑need for I2
↑TSH
Stimulation of thyroid →↑T4 till normal (↑total T4)
2. Production of thyrotropin by the placenta
3. Thyroid stimulating effect of hCG
Thyroid disease with pregnancy
16. Thyroid disease with pregnancy
Hyperthyroidism: 1.9%
Overt: 3.9/1000
Subclinical : 15/1000
Hypothyroidism : 2.5%
Overt: 1.8/1000
Subclinical : 23/1000
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17. Thyroid function test
Sleeping pulse
total serum T3 & T4 (not reliable)
T3 resin uptake, Free T4 index
Free T3 & T4 (most reliable)
Radioactive I2 uptake & thyroid scan are
contraindicated
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18. Simple nodular goiter
Common in areas where I2 is deficient in diet
The gland enlarges during pregnancy
Retrosternal extension is rare but causes
tracheal compression
Treatment
Iodiniszed salt, Small dose of T4
surgery
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20. Clinical picture
Palpitation- tachycardia, arrhythmia, AF
Hypertension, systolic murmur, cardiomyopathy,
and heart failure
irritability- tremors & insomnia
Muscle wasting, loss of weight
Diarrhea & vomiting
Excessive sweating & heat intolerance
Star looking- exophthalmous, lid lag
Thyromegaly 1 September 2017May All Be Happy & Healthy.
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21. Effect of pregnancy on thyrotoxicosis
Variable effect
Patient with mild to moderate disease tolerate
pregnancy well
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22. Effect of hyerthyroidism on pregnancy
Severe disease- amenorrhea, infertility
But can be associated with
PIH, heart failure, thyroid storm
Antibodies cross the placenta- neonatal
thyrotoxicosis or hypothyroidism± goiter
Spontaneous miscarriages
Preterm labor, IUGR, IUFD, LBW
Non-immune hydrops and feta death
Mild to moderate- usually seen in preg.
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23. investigation
free T3 & T4, TSH.
total T4, T3 resin uptake, free thyroid index
Thyroid stimulating Ig: +ve in gravis disease
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24. Treatment
Keep the patient euothyroid & prevent fetal
hypothyroidism
1. Antithyroid drugs:
Propylthiouracil- drug of choice
Carbimazole or methimazole
Potassium perchlorate, propranolol
2. Surgery- rarely indicated
3. Ablation with radioactive iodine- never used
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25. Hypothyroidism
Causes:
1. primary hypothyroidism (TSH is high)
Iodine deficiency
Hashimoto’s thyroiditis
Atrophic thyroiditis
Congenital absence of thyroid
Inadequately treated existing hypothyroid.
Over treated hyperthyroidism
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26. Hypothyroidism
Causes
2. Secondary hypothyroidism (TSH is low)
Secondary to hypothalamic or pituitary
diseases:
Sheehan’s syndrome
Chromophobe adenoma of pituitary
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27. Effects of hypothyroidism on preg.
Usually anovulatory, amenorroeic with dysfunctional
uterine bleeding & rarely get pregnant
Maternal
PIH, accidental hemorrhage, rarely CHF
Fetal:
Recurrent abortion before 12 weeks
IUGR, LBW, stillbirth, developmental ab.
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28. Clinical picture
Weakness, lethargy
Cold intolerance & dry skin
Constipation, parethesias
Hoarseness of voice
Slow tendon jerk, excessive wt gain
Goiter (in 1ry hypothyroidism)
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29. Investigation & treatment
Investigations
T3
TSH depends on the type
Treatment : L-thyroxine
Increase the dose in preg.
Check TFT every 6-8 weeks
Safe during breast feeding
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30. Postpartum thyroiditis
Inflammation of the gland appear 1-8 months
after delivery
Transient autoimmune disorder
Hyperthyroidism phase - 1 to 4 months
Hypothyroidism phase – 6 to 12 month
High % of recurrence
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31. Postpartum thyroiditis
Most recover spontaneously
Hyperthyroid phase: beta-blockers
Hypothyroid phase: L- thyroxine
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33. Headache:
Common causes:
1. Tension headache:
No associated neurological disturbances
Muscle tightness and pain at the back of head
and neck.
Responds to rest, massage, application of heat
or ice, anti-inflammatory drugs, or mild
tranquilizers, stress manage.
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34. Headache
2. Migraine headache
Episodic attack of severe headache with nausea,
vomiting, photophobia
Classic migraine is proceeded by Aura (visual
scotoma and hallucination)
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35. Headacke
2. Migraine headache
Symptoms may worsen during 1st trim. but
improve in 2nd & 3rd trimesters.
Menstrual migraine improves from 1st trimester.
Drugs: Aspirin, paracetamol, Ibuprofen & codeine,
Propranolol if attacks continue,
Serotonin agonist.
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36. Epilepsy: definition & incidence
A seizure is defined as a paroxysmal disorder of
the CNS characterized by an abnormal discharge
with or without loss of consciousness
Complicates 1 in 200 pregnancies
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37. Epilepsy- types
1. Partial seizure: originate in one localized area of
the brain- trauma, abscess, tumor, perinatal
factors or no pathology.
Simple motor seizure: tonic and then clonic
movements, consciousness not lost
Complex partial seizures (temporal lobe) involve
clouding of consciousness
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38. Epilepsy- types
2.Generalized seizures:
Involves both hemispheres of the brain
Proceeded by aura before an abrupt loss of
consciousness
Hereditary component
Grand mal seizures
absence seizures (petit mal seizures)
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39. Epilepsy- causes
Trauma, brain tumour
Alcohol or other drug-induced withdrawal
Biochemical abnormalities
Arteriovenous malformation
Idiopathic : CT scan or MRI
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40. Epilepsy- in pregnancy
Increased seizure frequency
1. Subtherapeutic level:
Nausea, vomiting- missed doses
Decreased GI motility and use of antacids reduce
drug absorption
Expanded plasma volume- dilution
Placental enzymes increases drug metab.
Increased GFR- renal clearance
Self-discontinue - teratogenicity 1 September 2017May All Be Happy & Healthy.
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41. Epilepsy- in pregnancy
Increased seizure frequency
2. Low seizure threshold:
Exhaustion form sleep deprivation
Hyperventilation and pain during labor
Risk of congenital malformation: 2.5x
Risk of CS: 2x
10% risk of inheritance
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42. Epilepsy – management
Preconceptional counseling
Diet , activity, management of vomiting
Switch to least teratogenic drug, single
Folic acid supplements (4 mg).
Postpartum contraception: may cause
breakthrough bleeding and failure
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43. Epilepsy – management
Prenatal care-
The goal is seizure prevention
Treatment of nausea and vomiting
Medication compliance
Seizure-provoking stimuli: avoided
Vit K for women taking phenytoin
Mid-pregnancy USS: Cong. malformation
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Antiepileptic drugs and congenital malformation
45. Chronic Renal Disease (CRD)
Grades
Mild - serum creatinine >1.4mg%
Moderate. - serum creatinine 1.4-2mg%
Severe - serum creatinine >2mg%
Pregnancy is rare when
Serum creatinine > 3mg%
BUN >30mg%
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46. Effect of pregnancy on CRD
Most common cause is HTN, DM, glomerulonephritis,
polycystic kidney disease
Renal hyperperfusion and increased glomerular blood
pressure accelerate nephrosclerosis
In absence of PET, obstetrical hemorrhage and
hypovolemia- pregnancy does not appreciably accelerate
renal insufficiency.
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47. Effect of CRD on pregnancy
Outcome of pregnancy depends on
Degree of HTN, renal insufficiency
Worst in - glomerulonephritis
- nephrosclerosis
Maternal : superimposed PET
Fetal: PTL, IUGR PNMR
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48. Obstetric management of CRD
Early pregnancy Dx, accurate dating
Baseline renal function test
Biweekly follow up until 28-32 weeks then weekly
Serial USS for assessment of fetal growth
Tests for fetal well-being from 28 weeks
Mode of delivery: obstetric indications
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49. Pregnancy in patient on dialysis
Pregnancy occur in 1:200 of pt. on dialysis
Complication: PTL, fetal distress, accidental hag,
maternal bleeding
Management:
Control BP, electrolyte balance
Maintain BUN <50mg/dl by repeated dia.
Treatment of chronic anemia by erythropiotin &
blood transfusion
Continuous FH monitoring during dialysis
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50. Pregnancy with renal transplant
Pregnancy occur in 1:50 of patient after
successful renal transplantation
Preconceptional criteria for pregnancy
Good general health for 2 years
Stable renal function (Cr. <2mg/dl)
Minimal hypertension & /or proteinuria
No pelvicalyceal dilatation on recent pyelogram
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51. Pregnancy with renal transplant
Treatment is stable with
Prednisone
Azathioprine
Cyclosporin .
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52. Pregnancy with renal transplant
Complications
PET, PTL, PROM, Infection, SGA baby
If RFT deteriorates
Hospitalization
Evaluation for rejection, tt toxicity,
superimposed PET
TOP if deteriorates rapidly in spite of tt.
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