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Pregnancy-specific diseases. Chao Gu M.D., Ph.D. Dept of Ob/Gyn OB/GYN Hospital, Fudan University. CASE 1.

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slide1
Pregnancy-specific diseases

Chao Gu M.D., Ph.D.Dept of Ob/Gyn

OB/GYN Hospital, Fudan University

case 1
CASE 1

A 35 year old lady at 32 weeks of gestation in her first pregnancy goes to your office for a minor upper respiratory tract infection. Incidentally, her blood pressure is found to be 155/90 mmHg with a pulse rate of 85/min. The cardiovascular examination and chest examinations are otherwise unremarkable. The size of uterus is appropriate for gestational age.

  • What is your next step?
  • Repeat another blood pressure measurement to ascertain the diagnosis
  • of hypertension complicating pregnancy.
slide3
CASE 1
  • What are the classification of hypertension in pregnancy?
  • Gestational hypertension
  • Preeclampsia
  • Eclampsia
  • Superimposed preeclampsia on chronic hypertension
  • Chronic hypertension in pregnancy
slide4
CASE 1
  • What is the definition of various types of hypertension ?
  • Chronic hypertension in pregnancy
    • BP 140/90 mm Hg before pregnancy or diagnosed before 20 weeks' gestation not attributable to gestational trophoblastic disease or
    • Hypertension first diagnosed after 20 weeks' gestation and persistent after 12 weeks postpartum
  • Gestational hypertension
    • Systolic BP 140 or diastolic BP 90 mm Hg for first time during pregnancy
    • No proteinuria
    • BP returns to normal before 12 weeks postpartum
    • Final diagnosis made only postpartum
  • .
slide5
CASE 1
  • What is the definition of various types of hypertension ?
  • Preeclampsia
    • BP 140/90 mm Hg after 20 weeks' gestation
    • Proteinuria 300 mg/24 hours or 1+ dipstick

Increased certainty of preeclampsia

    • BP 160/110 mm Hg
    • Proteinuria 2.0 g/24 hours or 2+ dipstick
    • Serum creatinine >1.2 mg/dL unless known to be previously elevated
    • Platelets < 100,000/ L
    • Microangiopathic hemolysis—increased LDH
    • Elevated serum transaminase levels—ALT or AST
    • Persistent headache or other cerebral or visual disturbance
slide6
CASE 1
  • What is the definition of various types of hypertension ?
  • Eclampsia
    • Seizures that cannot be attributed to other causes in a woman with preeclampsia
  • Superimposed Preeclampsia On Chronic Hypertension
    • New-onset proteinuria 300 mg/24 hours in hypertensive women but no proteinuria before 20 weeks' gestation
    • A sudden increase in proteinuria or blood pressure or platelet count < 100,000/ L in women with hypertension and proteinuria before 20 weeks' gestation
case 11
CASE 1
  • What is the management?
  • Evaluation
    • Severity
    • Gestational age
    • Presence of preeclampsia
    • Outpatient
    • Hospitalization
  • Termination of pregnancy is the only cure for preeclampsia
case 12
CASE 1
  • What is the management?
  • High-risk chronic hypertension iassociated maternal and peri-natal complications,
    • superimposed pre-eclampsia
    • abruptio placentae
  • Careful monitoring for proteinuria and renal function.
  • Hospitalization should be considered if the blood pressure is not under control.
  • Anti-hypertensive drugs should be considered.
  • Once pre-eclampsia is diagnosed, hospitalization is indicated,
  • progress rapidly to multi-system involvement, including eclampsia
indication of magnesium sulfate
CASE 1INDICATION OF MAGNESIUM SULFATE
  • Control eclampsia convulsions
  • Prevent preeclampsia develop into eclampsia
the uses of magnesium sulfate
CASE 1THE USES OF MAGNESIUM SULFATE
  • DAY 1:
  • loading dose: 25% MgSO4 20ml+10% GS 20ml IV in 5-10min
  • Maintenance dose: 25% MgSO4 60ml+5%GS 1000ml IV in 10h
  • Day 2 to 24h Postpartum
  • 25% MgSO460ml+5% GS 1000ml IV in 10 h
slide11
CASE 1

Contraindication as follow :

  • absent or very sluggish knee jerk
  • a respiratory rate below 16/min
  • a urinary output of less than 100ml in the preceding 4 hours (25ml/hr)
slide12
CASE 1

Indications of Antihypertensive drugs

  • BP ≥150/100mmhg, <160/110mmhg,Oral。
  • BP ≥ 160/或/110mmhg,IV。
  • Control to
  • 130-140/85-100 mmhg。
case 13
CASE 1
  • What are the antihypertensive drugs commonly use in pregnancy?
  • Labetalol combined alpha- and beta-adrenoceptor blocker.
  • Nifedipine Calcium Channel Blockers Nifedipine
  • Beta-blockers
  • Methyldopa
  • Sodium nitroprusside
  • Hydralazine
  • ACEI (血管紧张素转换酶抑制剂) can’t use!!!
  • 胎儿生长受限(fetal growth restriction,FGR
  • ARDS
slide14
CASE 1

Termination of pregnancy

  • Too early --- Can fetus survive? Complication ?
  • Too late ---Can mother survive? Complication?
  • preeclampsia patient has no response following medical management for 24-48 hours .
  • preeclampsia patient after 34 weeks of gestation
  • preeclampsia patient before 34 weeks of gestation with impaired fetoplacental unit function and matured fetus.
  • preeclampsia patient before 34 weeks of gestation with impaired fetoplacental unit function and immatured fetus, use Dexamethasone to promote fetal lung maturity before the termination of pregnancy.Eclampsia control over 2h.
slide15
CASE 2
  • A 26-year-old female at 32 weeks of gestation presented to the clinic with complaints of generalized itching. Patient reported no rash or skin changes. She denied any change in detergent, soaps, or perfumes. She denied nausea and vomiting .There was no history of any drug intake or previous allergies. There was no fever or any other medical illness.
  • On physical examination, there were no rashes apparent on her skin and only some excoriations were there from itching.
  • Laboratory investigations revealed slightly elevated serum transaminases and bilirubin levels, Alkaline phosphatase levels were much higher than normal.
slide16
CASE 2
  • What is the patient’s likely diagnosis?
  • Intrahepatic Cholestasis of Pregnancy. (ICP)
  • What is the cause of the patient’s generalized itching?
  • Increased serum bile salts and accumulation of bile salts in the dermis of the skin are responsible for generalized itching.
  • Generalized pruritus in pregnancy and a characteristic enzymeprofile
  • High alkaline phosphatase is a marker of cholestasis
  • Slightly high transaminases (AST, ALT) differentiate it from viral hepatitis
  • Bilirubin is high due to intrahepatic obstruction as a result of cholestasis.
slide17
CASE 2
  • Intrahepatic cholestasis of pregnancy (ICP)
  • benign disorder that occurs in the second or third trimester and resolves spontaneously after delivery.
  • Cholestasis of pregnancy is a condition in which the normal flow of bile from the gall bladder is impeded, leading to accumulation of bile salts in the body.
slide18
CASE 2

Therapeutic Principle

  • Bed rest, left lateral position
  • Drug
  • Adenosylmethionine 腺苷蛋氨酸
  • Ursodeoxycholic acid 熊去氧胆酸
  • Dexamethasone 地塞米松
  • Phenobarbital 苯巴比妥
  • NST (Nonstress Test)

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slide19
CASE 2

Termination of pregnancy

  • Jaundice (+) 36 weeks of gestation
  • Jaundice (-)37 weeks of gestation
  • Significantly decreased placental function or
  • Fetal distress Immediately
  • Cesarean section

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case 3
Case 3

30 years old

First pregnancy

8 weeks gestation by LMP

Persistent vomiting for past week

Unable to tolerate food or fluids for past 24 hours

Passing little urine

Urien ketones 3+

slide21
CASE 3

What is the patient’s likely diagnosis?

Hyperemesis Gravidarum

  • Nausea (70%) and vomiting (60%) common in 1st trimester, Hyperemesis = fluid and electrolyte imbalance and nutritional deficiency
  • Persistent and severe vomiting
  • More severe in:
    • Multiple gestation
    • Hydatidiform mole
  • Without treatment can lead to CNS disturbance, liver and renal failure
presentation
CASE 3Presentation
  • Severe nausea and vomiting
  • Dehydration
  • Weight loss
  • Ketosis
  • Ptyalism (unable to swallow saliva)
diagnosis
CASE 3Diagnosis
  • Consider other causes e.g. UTI, gastritis, ketoacidosis, peptic ulceration, Addison’s disease, pancreatitis
  • Investigations:
    • FBC (raised haematocrit)
    • U&E (hyponatraemia, hypokalemia, hypouraemia)
    • LBP (raised transaminases, found in up to 50% cases)
    • TFTs (thyrotoxicosis)
    • Urinalysis and MSU for culture and sensitivity
    • USS (if not done yet)
    • Weight
slide24
CASE 3
  • Serious Complications
  • Wernicke syndrome (Wernicke 脑病):Vit B1 deficiency
  • A type of brain damage in which the initial symptoms appear.
  • Abnormal gait and eye movements.
  • Psychiatric disorder, includes dementia and psychosis.
  • coagulation disorder (凝血功能障碍):Vit K deficiency

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indications for termination of pregnancy
CASE 3INDICATIONS FOR TERMINATION OF PREGNANCY
  • Continuing jaundice
  • Continuing proteinuria
  • Fever continuing over 38 ° C
  • Tachycardia (≥ 120 beats / min)
  • Wernicke syndrome appears
slide26
CASE 4

19 year old G1 P0+0

39 weeks - antenatal care outside your area

Contractions 3-4 in 10 minutes

Excessive weight gain during pregnancy

Recent generalized oedema

on examination
CASE 4On Examination

Facial & generalised oedema +++

Admission BP = 164/102 (repeat 160/100)

Urine = +++ protein

VE : Cervix = 4 cm dilated, 100% effaced,

station ‘0’, membranes intact

- contractions 3-4 in 10 mins,

- baseline FHR = 140bpm

  • - normal variability,

- no decelerations

slide28
CASE 4
  • What concerns you about with this situation?

likely to have severe pre-eclampsia

 both fetal & maternal risks such as

      • risk of ECLAMPSIA
      • intracranial haemorrhage
      • risk of pulmonary oedema (iatrogenic fluid overload)
      • hepatorenal failure
slide29
CASE 2
  • What lab investigations would you order?

Full Blood Count

(Coagulation)

Group & Save for X-match

Urea, Creatinine & Electrolytes

Liver Function Tests

Urate

MSU (inc Gram Stain)

slide30
CASE 4

What other data do you need at this point?

  • her handheld antenatal records
slide31
CASE 4

Would you give antihypertensive and/or magnesium

sulphate at this point?

  • Antihypertensives –persistent systolic BP >160mmHg should be treated
  • Magnesium Sulphate – most units would start MgSO4 at this stage (ref MAGPIE study)

…. IN THIS CASE, NEITHER IS GIVEN…..

30 minutes later
CASE 430 MINUTES LATER…

While awaiting laboratory results, you are called urgently to delivery suite

The patient has a grand mal seizure that lasts about 1 minute

CTG shows a fetal bradycardia of 80 bpm

after the seizure

slide33
CASE 4

WHAT WOULD YOU DO AT THIS POINT?

CALL FOR HELP +++++

INITIATE BASIC ABCs

remember left lateral tilt!!

‘A’ – airway can’t be inserted during a fit

‘C’ – includes x2 large bore cannulae

Initiate unit ‘Eclampsia protocol’

DO NOT NURSE IN THE DARK!!

Give loading dose MgSO4(…what dose?)

Foley catheter/fluid balance

Keep NBM – review need to treat BP

slide34
CASE 4

How would you deliver when stable - LSCS versus induction with vaginal delivery?

Labour induction can usually be considered if:

  • gestation >32 weeks
  • cervix reasonably favourable (i.e. delivery likely within 12 hours) – cervix is often favourable in pre-eclampsia
  • fetal condition stable (i.e. no severe IUGR)
after the seizure
CASE 4After the seizure...

Meticulous attention to fluid balance -

intake / output assessed hourly

  • 4g loading dose MgSO4 then infusion at 1-2 g/hr
  • Total IV fluids limited to 80-85ml/hr or 1 ml/kg/hr
  • Foley catheter
slide36
CASE 4

Fetal bradycardia recovers with control of seizures, oxygen and left lateral positioning

Contracting 4-5 in 10; lasting 60-90 seconds

ARM - meconium-staining

FHR = 160bpm with decreased variability

Consultant Anaesthetist / Obstetrician and theatre aware of situation

BP = 180/110

slide37
CASE 4

What would you do next?

  • Control Blood Pressure
  • Analgesia as appropriate
slide38
CASE 4
  • Are you worried about her blood pressure?
  • YES – in this case, BP>180/110 puts maternal CNS at risk (intracranial haemorrhage)
slide39
CASE 4
  • How would you control the blood pressure?
  • can you name 2 drugs you could consider using?
      • SL Nifedepine
      • IV hydralazine (bolus +/- infusion)
slide40
CASE 2
  • What are the signs of magnesium toxicity?

IN ORDER

loss of reflexes

somnolence

respiratory depression

paralysis

finally cardiac arrest

slide41
CASE 4
  • What is the antidote for magnesium toxicity?

Calcium gluconate 1g IV over 3 minutes

(10mls 10% calcium gluconate)

slide42
CASE4
  • What action should be taken for absent reflexes?

Stop MgSO4 until reflexes return

slide43
CASE 4
  • What action should be taken for
  • respiratory depression / somnolence?
  • Stop MgSO4
  • Give O2
  • Recovery position (as reduced level of consciousness)
  • Monitor closely
the blood results return
CASE 4THE BLOOD RESULTS RETURN…

Observations BP 140/95

Pulse - 90bpm

Resp rate - 12/min

Temp - 37.8°C

Urine output 30ml over past hour

Blood results Hb 12.0g/dl

WBC 21x109

Platelets 185x109

Coagulation normal / LFTs Normal

Magnesium level is therapeutic

slide45
CASE 4

Case Presentation BP

The patient has another grand mal seizure

What would you do next?

  • general supportive measures (ABCs)
  • second bolus MgSO4 (2g) should be given even if levels are therapeutic, as long as no signs of toxicity
  • consider another neuroleptic if seizures continue despite second bolus
slide46
CASE 2
  • Would you deliver – if so how?
  • once stable, delivery by urgent LSCS may be appropriate
  • after this 2nd fit (assuming vaginal delivery is not imminent)
slide47
CASE 4
  • Is she septic ?

(T = 37.8°C WCC = 21 x 109)

NO -  WCC and pyrexia are more likely related to the grand mal fit

  • Should antibiotics be started ?

NO - unless there are other overt signs of infection

slide48
CASE 4
  • Does she have HELLP syndrome?

NO – HELLP typically presents with:

Haemolysis

Elevated Liver enzymes (ALT/AST)

Low Platelets

the delivery and then
CASE 4The delivery… and then?

Case Presentation BP

  • VE confirms cervix 7cm dilated
  • Oxytocin augmentation
  • Normal delivery within 1 hour
  • Healthy 3.8kg baby boy
  • Apgars = 6 (1 min) + 9 (5 min)
  • Placenta delivered & appears intact
  • No uterine atony or perineal trauma
post delivery
CASE 4Post-delivery

When would you discontinue MgSO4?

  • continue for minimum 24 hours post-delivery
  • (possibly 48 hours if recovery is protracted)
  • More than 40% of all eclampsia occurs post-delivery
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