Miscellaneous medical diseases for 4th year med. students

Associate Clinical Prof Dr. Aisha Elbareg ,MD, PhD
Faculty of Medicine, Misurata University, LIBYA
MISCELLANEOUS MEDICAL
Diseases
For 4th year
In pregnancy
Med. Students

Common miscellaneous diseases:
 Respiratory diseases:
 Breathlessness: Asthma
 Endocrinogolgical diseases
 Hyperthyroidism
 hypothyroidism
 CNS:
 Headache: Migraine
 Epilepsy
 Chronic renal disease
1 September 2017
2
May All Be Happy & Healthy.

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
1 September 2017May All Be Happy & Healthy.
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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
4

Asthma: incidence
 Occurs in 7% of general population
 Occurs in 3% of pregnancy
 Status asthmaticus (acute) : 0.2% of pregnancy
5

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.
1 September 2017
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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
7

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
8

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.
1 September 2017
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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)
10

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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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
12

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
13

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

 Hyperthyroidism: 1.9%
Overt: 3.9/1000
Subclinical : 15/1000
 Hypothyroidism : 2.5%
Overt: 1.8/1000
Subclinical : 23/1000
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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
17

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
18

Hyperthyroidism (Thyrotoxicosis)
 Causes:
 Graves disease
 Toxic nodule
 Acute & subacute thyroiditis
 Trophoblastic tumour
19

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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Effect of pregnancy on thyrotoxicosis
 Variable effect
 Patient with mild to moderate disease tolerate
pregnancy well
21

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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investigation
  free T3 & T4,  TSH.
  total T4, T3 resin uptake, free thyroid index
 Thyroid stimulating Ig: +ve in gravis disease
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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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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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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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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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Clinical picture
 Weakness, lethargy
 Cold intolerance & dry skin
 Constipation, parethesias
 Hoarseness of voice
 Slow tendon jerk, excessive wt gain
 Goiter (in 1ry hypothyroidism)
28

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
29

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
30

Postpartum thyroiditis
 Most recover spontaneously
 Hyperthyroid phase: beta-blockers
 Hypothyroid phase: L- thyroxine
31

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CNS

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.
33

Headache
2. Migraine headache
 Episodic attack of severe headache with nausea,
vomiting, photophobia
 Classic migraine is proceeded by Aura (visual
scotoma and hallucination)
34

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.
35

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
36

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
37

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)
38

Epilepsy- causes
 Trauma, brain tumour
 Alcohol or other drug-induced withdrawal
 Biochemical abnormalities
 Arteriovenous malformation
 Idiopathic : CT scan or MRI
39

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.
40

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
41

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
42

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
43

44
Antiepileptic drugs and congenital malformation

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%
45

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.
46

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
47

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
48

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
49

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
50

 Treatment is stable with
 Prednisone
 Azathioprine
 Cyclosporin .
51

 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.
52

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