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.

Entrance exam oriented Focus-
1)A new point in the 18th edition -TTP in pregnancy has been framed in AIPG-2012 exam.
2)The other new point regarding Ehlers-Danlos syndrome in pregnancy is a potential one for the upcoming examinations!

EVIDENCES
Pregnant lady with low platelet – 50000- which is the least likely possibility?
I-2012
a. DIC
b. TTP
c. HELLP
d. Evan’s syndrome
ans-d

Which can be used in pregnancy [AIIM
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)