MEDICAL DISEASES WITH PREGNANCY A Neurological disorders Serious

MEDICAL DISEASES WITH PREGNANCY

A. Neurological disorders: Serious manifestations of neurological disease are fortunately rare in pregnancy, though cerebral haemorrhage remains a significant cause of maternal death. Epilepsy and migraine are common causes of morbidity.

1. Epilepsy: Approximately 30% of those with epilepsy are women in their childbearing years, which means 1200 pregnant lady complaining of epilepsy. Pregnancy has no consistent effect on epilepsy: some have increase frequency of fits, others a decrease, and some no difference.

Epilepsy: The principles of epilipsy management are that while the risks to pregnancy from seizures out weight those from anticonvulsant medication, seizures should still be controlled with the minimum possible dose of the optimal drug.

Pre-pregnancy counselling: of the patients with epilepsy: 1. alter medication according to seizures frequency. 2. reduce to monotherapy where posible. 3. compliance with medication. 4. pre-conceptional folic acid 5 mg. 5. explain risk of congenital malformation. 6. explain risk from recurrent seizures.

Causes of seizures in pregnancy: 1. epilepsy. 2. eclampsia. 3. encephalitis or meningitis. 4. space – occupying lesions ( tumour ). 5. cerebral vascular accident. 6. metabolic abnormalities( hypoglycaemia).

Risk of congenital anomaly with epilepsy: The principle concern related to epilepsy in pregnancy is the increased risk of congenital anomaly caused by anticonvulsant medications, which increase risk two-three fold ( compared to general population. 5 -6 %) Approximately doubling of the risk in unexposed epileptic mothers.

Epileptic medication are : 1. sodium valproate. 2. carbamazepine. 3. phenytoin. 4. phenobarbitone.

Fetal anomaly includes: 1. neural tube defects. 2. facial clefts. 3. cardiac defect. 4. specific syndrome includes developmental delay, nail hypoplasia, growth restriction and mid-face abnormality. 5. increase chance of epilepsy in offspring of epileptic mothers. Polytherapy increase the risk (15 -25%).

Antepartum managements: Women of childbearing age who suffer from epilepsy and are on maintenance therapy must have their treatment reviewed and monotherapy is recommended if at all possible. Antiepileptic drugs can cause teratogenicity and folic acid 5 mg daily through out the pregnancy is generally prescribed in view of the relative folate deficiency of many mothers on antiepileptic therapy.

Antepartum managements It is important that control of seizures is achieved to minimize maternal morbidity (fits can be fatal). patients must be monitored during pregnancy to ensure that dose adjustments are made as appropriate. Sodium valproate is the major cause for concern in these condition.

Antepartum managements: All patients should receive anomaly ultrasound assessment to exclude specific abnormalities associated with their medication. These are specifically orofacial clefts, neural tube defects and craniofacial dysmorphism. Vitamin K is recommended to be given from 36 weeks onwards to prevent neonatal bleeding disorders.

Intapartum management: Epileptic seizures may occur during labour and as such may confuse the diagnostic situation that includes eclampsia. Epileptic seizures should be treated in these circumstances as they would be normally Vaginal delivery is recommended unless there is obstetric complication.

Postpartum management: Post-partum drug doses may need to be adjusted if doses have been increased during pregnancy. Specific advice must be given to epileptic women about childcare, for example, not bathing the baby on their own. Breast feeding can be encouraged. Contraception adviced: combined oral contraception pill better not used with anti epileptic medication.

2. Migraine: Headaches are a common problem in pregnancy and migraine sufferrs may find their symptoms worsen during the first trimester. Many patients may be using ergot alkaloids to treat migraine prior to the onset of pregnancy and they must be advised not to use these during pregnancy.

Migraine: Migraines may improve considerably in the second and third trimesters but some patients in who continuing problems exist, the strategies that are employed for prophylaxis are low-dose aspirin, paracetamol and codeine as pain relief and propranolol if attacks continue to be troublesome despite these measures.

MCQ : 1. Pre-pregnancy counselling : of the patients with epilepsy are false except: a. stop medication according to seizures frequency. b. Increase to polytherapy where posible. c. Medication can be stopped if patient has no fit for last two years. d. pre-conceptional folic acid 1 mg.

MCQ 2. Postpartum management of patients with epilipsy includes: a. Post-partum drug doses should be increased. b. Breast feeding is contraindicated. c. Contraceptive pill better used with anti epileptic medication. d. Intra uterine contraceptive device can be used.

Answer: 1. C. 2. d. 3. a, b. 4. c

Liver disorders: includes 1. Cholestasis of pregnancy. 2. Acute fatty liver with pregnancy. . Viral hepatitis.

a. Cholestasis of pregnancy: Cholestasis of pregnancy is the most common liver condition affecting pregnancy and it classically presents with an itch and consequent lack of sleep in the third trimester. it is associated with an increased risk of intrauterine death, classically from 37 weeks’ gestation, meconium passage and preterm labour

Cholestasis of pregnancy: Laboratory investigations include: liver function tests and assay of serum bile acids. It is currently uncertain whether the bile acids themselves may be directly responsible for fetal demise.

Cholestasis of pregnancy: Treatment strategies include : 1. timely delivery, 2. cool aqueous menthol cream to relieve itch, 3. ursodeoxycholic acid and vitamin K. Ursodeoxycholic acid is currently the mainstay of treatment. This condition has a high likelihood of recurrence (approximately 80%).

b. Acute fatty liver of pregnancy (AFLP) is a serious but rare liver condition arising in pregnancy which can be very non-specific at time of presentation. It is associated with nausea, vomiting, abdominal pain and jaundice.

(AFLP): Diagnosis is normally confirmed by a moderately elevated aspartate amino transferase (AST). The diagnosis may be supported by imaging suggestive of fatty change( ultrasound). Manifestations of liver failure include coagulopathy , haemodynamic instability and hypoglycaemia.

Treatment of (AFLP): Delivery must be achieved prior to the development of coagulation failure, where necessary at the expense of fetal maturity.

Viral hepatitis: Clinical significance The principal forms of hepatitis that complicate pregnancy are hepatitis A, B, C, D and E. Hepatitis is a relatively benign clinical disorder . that does not pose a serious risk

Hepatitis A: is the second most common cause of hepatitis , but it is relatively uncommon in pregnancy. It is caused by an RNA virus that is transmitted by fecal-oral contact. -Infections in children are usually asymptomatic; infections in adults are usually symptomatic. Infection does not result in a chronic carrier state, and perinatal transmission essentially never occurs.

Hepatitis B: is the most common form of viral hepatitis in obstetric patients. It is caused by a DNA virus that is transmitted parenterally and via sexual contact. Acute hepatitis B occurs in approximately 1 to 2 per 1000 pregnancies. The chronic carrier stage is more frequent.

Hepatitis C: Hepatitis C is caused by an RNA virus that is transmitted parenterally, via sexual contact, blood product and perinatally. Hepatitis D is an RNA virus that depends upon co-infection with hepatitis B for replication.

Hepatitis E is caused by an RNA virus. The epidemiology of hepatitis E is similar to that of hepatitis A. It is endemic in developing countries of the world. , maternal infection with hepatitis E often has an alarmingly high mortality, . A chronic carrier state does not exist, and perinatal transmission is extremely unlikely.

Clinical manifistation of Hepatitis: The typical clinical manifestations include: low-grade fever, malaise, poor appetite. right upper quadrant pain and tenderness, jaundice

Diagnosis of viral hepatitis: The best to confirm the diagnosis of acute hepatitis A is identification of antihepatitis A-Ig. M antibody. Acutely infected patients also may have elevated liver transaminase enzymes and elevated serum concentration of indirect bilirubin. direct ,

Diagnosis: Hepatitis B virus: has three distinct antigens: the surface antigen (HBs. Ag) which is found in serum, the core antigen (HBc. Ag) which is found only in hepatocytes, the e antigen (HBe. Ag) which also is found in serum. Detection of the latter antigen is indicative of an extremely high rate of viral replication

Diagnosis: Patients who are positive for both the surface antigen and e antigen have an extremely high risk of perinatal transmission of infection that approaches 90% in the absence of neonatal immunoprophylaxis.

Treatment 0 f viral hepatitis: Patients with acute hepatitis A require supportive therapy. Their nutrition should be optimized. Of great importance, household contacts should be vaccinated with hepatitis A vaccine.

Patients with acute hepatitis B: require similar supportive care. Their household contacts and sexual partners should receive hepatitis B immune globulin, followed by the hepatitis B vaccine series. Infants delivered to mothers with hepatitis B infection should immediately receive the hepatitis B immune globulin and first dose of hepatitis B vaccine while still in the hospital

Complications of Viral Hepatitis Obstetric complications: 1. First trimester spontaneous miscarriage. 2. preterm delivery. 3. Fetal growth restriction. 4. stillbirth. 5. Preterm rupture of membranes. 6. Low birth weight and neonatal unit admission.

Complications of Viral Hepatitis: Hepatitis B, may result in chronic liver disease such as chronic active hepatitis, chronic persistent hepatitis and cirrhosis. Chronic disease also predisposes to the development of hepatocellular carcinoma. - Pregnant women who are infected with hepatitis B pose a significant risk of transmission to their offspring.

Complications: -Most neonates become infected at time of delivery as a exposure to contaminated blood and genital tract secretions. - Patients who are seropositive for surface antigen alone have at least a 20% risk of transmitting infection to neonate. -Women who are seropositive for both the surface antigen and e antigen have almost a 90% risk of perinatal transmission

MCQ: 1. Cholestasis of pregnancy are associated with: a. Classicaly presented with itching in the first trimester. b. Associated with an increased risk of intrauterine death, classically before 37 weeks’ gestation. c. meconium passage. d. post term labour.

MCQ: 3. pregnant lady with acute hepatitis B : all true except: a. the e antigen is indicative of an extremely high rate of viral replication. b. there sexual partner only should receive hepatitis B immune globulin. c. breast feeding is not contraindicated. d. Infants should immediately receive the hepatitis B immune globulin and first dose of hepatitis B vaccine

MCQ: 4. Acute fatty liver of prgnancy: a. (AFLP) is a common but serious liver condition arising in pregnancy. b. complication of (AFLP) includes coagulopathy , haemodynamic instability and hyperglycaemia. c. Diagnosis is normally confirmed by a decrease level of aspartate amino transferase (AST). d. treatment isdelivery of the fetus.

Answer: 1. c. 2. b, d. 3. a, c, d. 4. d.

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