Wednesday, 8 January 2014

Health in pregnancy

* Peripheral nerve disorder
* Bells palsy – 3 times more common in 3rd Trimester, post partum.
* Carpal tunnel syndrome. (median n)
* Meralgia paresthetica (lat. femoral cutaneous nerve)-AI-2007***
* Carpal Tunnel – pain worse in night
*Restless leg syndrome is the most common peripheral nerve and movement disorder in pregnancy. Disordered iron metabolism is the probable etiology. (18th EDITION)
*Maternal death is defined as the death occurring during pregnancy or within 42 days of completion of the pregnancy from a cause related to or aggravated by the pregnancy, but not from accident or incidental causes (18th EDITION)
Neoplasia During Pregnancy( a new chapter in 18th edition-all points given below are from 18th edition))
*The four cancers most commonly developing during pregnancy are
• cervical cancer
•breast cancer
•melanoma
• lymphomas (particularly Hodgkin's )

1)CA CERVIX
*Cervical intraepithelial neoplasia has a low risk of progression to invasive cancer during pregnancy (0.4%) and many such lesions (36–70%) regress spontaneously postpartum
*Cone biopsy should not be done within 4 weeks of delivery.
*If the disease is microinvasive, vaginal delivery can take place and be followed by definitive treatment, usually conization.
* If a lesion is visible on the cervix, delivery is best done by caesarian section and followed by radical hysterectomy.

2)Pregnancy-associated breast cancer
*Defined as cancer detected during the pregnancy and up to 1 year after delivery
*45% in the second trimester
*70% of the breast cancers found in pregnancy are estrogen receptor–negative
*Pregnancy retains its protective effects in carriers of BRCA1 mutations
*pregnancy seems to increase the risk of breast cancer among carriers of BRCA2 mutations
*28–58% of the tumors express HER-2
*Even in pregnancy, most breast masses are benign (80% are adenoma, lobular hyperplasia, milk retention cyst, fibrocystic disease, fibroadenoma)
*Lumpectomy followed by adjuvant chemotherapy is frequently used; fluorouracil and cyclophosphamide with either doxorubicin or epirubicin have been given without major risk to the fetus
*Methotrexate and other folate antagonists are to be avoided
*Trastuzumab are unsafe during pregnancy
*Estrogen increases 100-fold; progesterone increases 1000-fold during pregnancy .

3)Melanoma During Pregnancy
* melanoma is not more aggressive during pregnancy
*ipilumimab (antibody to CTLA-4), and in those with BRAF mutation V600E, a BRAF kinase inhibitor .

4)Hodgkin's Disease and Non-Hodgkin's Lymphoma
*May be accompanied by B symptoms (fever, night sweats, unexplained weight loss).
*Women diagnosed in the second and third trimester can be treated safely with combination chemotherapy, usually doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD).
*If symptoms requiring treatment appear during the first trimester, evidence suggests that Hodgkin's disease symptoms can be controlled with weekly low-dose vinblastine
*Non-Hodgkin's lymphomas are more unusual in pregnancy but are usually aggressive
5) Thyroid Cancer During Pregnancy
*Patients with follicular cancer or early papillary cancer can be observed until the postpartum period
*Patient on Radioactive iodine should not become pregnant for 6–12 months after treatment.
*Demand for thyroid hormone increases during pregnancy, and doses to maintain normal function may increase by 30–50%-Total T4 levels are higher during pregnancy
*The target TSH level is lower than 2.5 mIU/L.

6) Gestational Trophoblastic Disease
*Moles are the most common
* A previous molar pregnancy makes choriocarcinoma about 1000 times more likely to occur
*Partial moles result from fertilization of an egg by two sperm, resulting in diandric triploidy.*** (???AIIMS NOV-2013)
* Complete moles usually have a 46,XX genotype;
*95% develop by a single male sperm fertilizing an empty egg and undergoing gene duplication (diandric diploidy);
* 5% develop from dispermic fertilization of an empty egg (diandric dispermy)

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