Sunday, 22 December 2013

MEDICAL DISORDERS DURING PREGNANCY

A) Valvular Heart
a) MS
* Most common valvular disease causing death in pregnancy.
* Sudden death if hypovolemia occurs.
* Prone for Tachyarrythmias.
* Digoxin, Beta blockers.
* Treatment-Balloon mitral valvulotomy
b) AS
* Well tolerated.
* Decrease in systemic vascular resistance reduces risk of cardiac failure.
B) Congenital Heart Disease
* Increase risk of congenital cardiac disease in newborn
*ASD/VSD- well Tolerated
C) SVT
* Common
* Adenosine, can be used
* Electrocardioversion – well Tolerated in pregnancy
D) Peripartum Cardiomyopathy
* Uncommon.
* Most recover.
* May progress to DCM.
* Can recur in next pregnancy.
E) Marfans
* High risk of maternal mortality.
* Aortic root diameter < 40mm – favourable prognosis.
* Beta Blockers.
*15% of pregnant women develop a major cardiovascular manifestation during pregnancy.
*Ehlers-Danlos syndrome (EDS) - associated with premature labor, and in type IV EDS, there is increased risk of uterine rupture.(18th edition)
F) PHT
* Primary PHT is a contraindication. (AIIMS 2009), [AI 2010***]
* Vaginal delivery is less stressfull than CS.
*Eisenmenger syndrome - maternal and fetal death occur frequently.
G) DVT
* Hypercoaggulable state.
*Associated with an increase in procoagulants such as factors V and VII, and a decrease in anticoagulant activity, including proteins C and S.(18th edition)
* More common in left leg (compression of lt. iliac vein).
* 25% with DVT have factor V leiden mutation
* Prothrombin G20210A mutation (homo, hetero zygos).
* Methylene Tetrahydrofolate reductase C677T mutation (homozygotes)..
* Trt – LMWH
Warfarin
- 1st Trimester – chondrodysplasia punctata
- 2nd, 3rd Trimester – foetal optic atrophy.
- mental retardation.
- not contraindicated in breast feeding.
H) Obesity
*An increased risk of stillbirth, congenital fetal malformations, gestational diabetes, preeclampsia, urinary tract infections, and post-date deliveries.
*Following bariatric surgery, women should delay conception for one year.(18TH EDITION)
I)Hematologic disease
* Physiologic anemia.
* Thrombocytopenia-immune thrombocytopenia, thrombotic thrombocytopenic purpura(18TH EDITION), and preeclampsia-Benign gestational Thrombocytopenia (common)- also associated with the development of DIC, including retention of a dead fetus, sepsis, abruptio placenta, and amniotic fluid embolism.
* Disseminated intravascular coagulation (DIC)- characterized by thrombocytopenia, prolonged prothrombin time (PT) and activated partial thromboplastin time (aPTT), elevated fibrin degradation products, and a low fibrinogen concentration.(18TH EDITION)
J)HELLP
- A severe preeclampsia.
- Hemolysis.
- Elevated liver enzymes.
- Low platelet.
* Mild preeclampsia – conservative.
* Severe preeclampsia – Delivery.
* Drugs
- Labetol, Hydralazine, Ca channel blockers
- To avoid ACEI, ARBs in 2nd & 3rd Trimester- develop oligohydramnios, caused by decreased fetal renal function.
K) Hyperthyroidism
* 2 per 1000.
* Well Tolerated.
* Severe – spontaneous abortion.
* Treatment
-Propylthiouracil (choice) - can be associated with liver failure.(18TH EDITION)
-Methimazole (crosses placenta more).
-Can cause aplasia cutis.
-propylthiouracil in the first trimester and methimazole thereafter(18TH EDITION)
-KI, Beta blockers.
-Radio Iodine contraindicated.
*Easiest to control in 3rd Trimester & most difficult to treat in 1st trimester*
Hypothyroidism
* Thyroxine requirement increases as early as 5th wk by 30%.
* Increase the thyroxine dose by 30% as soon as pregnancy is diagnosed.

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