medical disease in pregnancy by dr hanif azhar

1. MEDICAL
DISORDER IN
PREGNANCY
Dr HANIF AZAHAR
Hosp Kemaman

2. OUTLINE
• Asthma In Pregnancy
• Proteinuria in pregnancy
• Hypothyroidism
• Hyperthyroidism

3. Asthma In Pregnancy

4. 27
Goals of management
Minimize risk of
- Exacerbation
- Air flow limitation
- Side effect
- Death
Good symptom control
Maintain normal activity

5. 32
Pharmacological
a) Bronchodilators
b) Corticosteroids
c) Anti leucotrienes
d) Others

6. Bronchodilators
Short acting
B2 Agonist
(SABA)
Long acting B2
agonist (LABA)
Short acting
Anti
muscarinic
(SAMA )
Long acting
anti
muscarinic
(LAMA)
Mech of
action
Stimulate B2 adrenergic receptor Blocks muscarinic receptor in the airways
Teratogenicity Safe in pregnancy Longest safety tract
record (Seretide,
Formoterol ) Less data
for Ultra LABA.
Safe in pregnancy
Min tachycardia
Not reported
Examples Salbutamol
Terbutaline
Albuterol
Salmeterol, Formoterol,
Olodaterol, Vilanterol
Ipratropium Tiotropium

7. Type of inhaler for asthma

8. 34
Corticosteroids
-Suppress eosinophillic inflammation
-improve sx, reduce exacerbation and mortality
- use in exacerbation, maintenance in severe
asthma Budesonide < 800mcg/day,
Beclomethasone < 400 mcg/day
Fluticasone Propionate <500 mcg/day

9.  Cleft palate ( high dose )
 Pre ecclampsia
 Gestational diabetes
 LBW & prematurity (dose
, duration unknown )
Risk could be due to consequence of uncontrolled asthma itself
 Maternal mortality
 Fetal mortality
Corticosteroid No corticosteroid

10. 36
Anti leucotrienes
- leucotrienes pro inflammatory mediators, promote
bronchoconstriction
- modest suppressive effect
- allergic rhinitis, exercise induced sx.
- no significant teratogenic effect
Birth Defects Res 2017;109: 452-459
Eur J Clin Pharmacol 2009;65:1259-1264

11. 39
Other medication
Methlyxantines
• Crossess placenta
• safe in pregnancy and breast feeding
• need frequent dose monitoring
Anti histamines
• Cetirizine, Loratadine ,intranasal steroid
• safe in pregnancy and breast feeding
Subcutaneous or sublingual immunotherapy
• not recommended
Eur Respir J 2019
J Eur Acad Dermatol Venereol 2019;33:1644-1659

12. EXACERBATION
Intensive monitoring
SaO2 >95 %
Early referral to critical care services
Pregnant women may be more difficult
to intubate due to anatomical changes

13. LABOUR
AND
DELIVERY
• Inhalers as usual
• Caesarian section
• Steroids
• > 7.5 mg od for more than 2 weeks – parenteral
hydrocort
• Anesthesia
• Regional vs general

14. POST
PARTUM
• Encourage breast feeding
• Risk of child developing atopic is reduced
• Inhaled medication, oral steroid and methyxantine
are safe when breast feeding

15. SUMMARY
• Asthma in pregnancy carries a small risk but uncertainties on outcome for both parties.
• Management does not differ significantly from outside pregnancy.
• Alleviation of anxiety of pregnant mothers on safety of asthma medication is of utmost
importance in ensuring compliance.
• Drugs with established clinical safety are preferred.

16. Proteinuria in Pregnancy

17. New appearance of protein in urine:
Equal to or greater than 300 mg (0.3g)
of protein in 24-hour collection
Urine protein/creatinine ratio (UPCR)
equal to or greater than 30mg/mmol
(300 mg/g) (0.3 mg/mg)
 +2 or more on urine dipstick testing

18. • In normal pregnancy:
renal plasma flow increases
increase in glomerular filtration rate (GFR) of more than 50%
relative decrease in concentrations of serum creatinine and urea
relative increase in protein excretion

19. CLASSIFICATION OF
PROTEINURIA IN PREGNACY
ISOLATED DE
NOVO
PROTEINURIA
DE NOVO
PROTEINURIA
ASSOICATED WITH
PRE ECLAMPSIA
TRANSIENT
PROTEINURIA DUE
TO UTI IN
PREGNANCY
PROTEINURIA
SECONDARY TO
CHRONIC KIDNEY
DISEASE

20. DEFINITION The appearance of new proteinuria of more than
0.3g/24h (300 mg/g) (0.3mg/mg) (30 mg/mmol) at
any point of time during pregnancy in the absence
of hypertension, UTI, systemic disease or any
apparent other causes
SUBSET
Gestational proteinuria : defined as proteinuria
with onset after 20 weeks in the absence of
hypertension
Isolated De Novo Proteinuria

21. CAUSES
NOT CLEAR
? maternal factors : high body mass index and low
levels of circulating angiogenic factors like placental
growth factor (PlGF)
? as part of the spectrum of preeclampsia
as isolated protenuria may progress to preeclampsia
clinical significance of isolated gestational proteinuria is
not well understood
Isolated De Novo Proteinuria

22. Hypertension in pregnancy is defined as BP greater than 140/90 mm
Hg.
Hypertensive disorders of pregnancy are categorized into 4 groups:
1.preeclampsia/eclampsia,
2.chronic hypertension in pregnancy
3.chronic hypertension with superimposed preeclampsia
4.gestationalhypertension.
 Proteinuria is common in all except gestational hypertension.
De Novo Proteinuria Associated With Preeclampsia

23. • Common due to the urinary
stasis and dilatation of the
urinary tract.
• Urinary tract infection can cause
transient proteinuria and should be
excluded prior to attributing
proteinuria to another cause.
Proteinuria Complicating UTI in Pregnancy

24. INTRODUCTION
Proteinuria before 20 weeks of pregnancy is chronic
proteinuria and is usually due to underlying
kidney disease.
Proteinuria Secondary to Kidney Disease
Proteinuria after 20 weeks of pregnancy is usually
gestational proteinuria but still need to evaluate the
small possibility of kidney disease.

26. Renal Biopsy
REASONS
To establish (or confirm) a specific
disease diagnosis (including a genetic
disease)
To assess potential responsiveness to
treatment (benefit of futility) and to
facilitate the best treatment options
To assess likely prognosis
WHEN
Nephrotic Syndrome of uncertain cause in adults,
older Children and adolescents
Rapidly progressive glomerulonephritis
CKD of uncertain cause
Asymptomatic glomerular hematuria and
proteinuria (? >0.5 – 1g/d)
Suspected genetic disease (e.g. Alport, Fabry, C3G)

27. • De novo onset of nephrotic syndrome or unexplained impaired GFR
with abnormal urine sediment before fetal viability ie before 24
weeks of gestation.
• Nephrotic syndrome after this stage can generally be managed
conservatively until delivery, usually at about 32 to 34 weeks; most
such cases are due to preeclampsia.
Renal Biopsy in Pregnancy

28. • Situations before 32 weeks of gestation in which clinician and patient
have agreed that immunosuppression and/or plasma exchange will be
used if necessary, while prolonging the pregnancy to about 32 weeks.
Rapidly declining GFR without apparent reversible cause in women
with underlying primary glomerulonephritis (GN).
Acute kidney injury with active urine sediment.
Declining GFR or increasing proteinuria in a woman with lupus
nephritis or lupus without previously known nephritis.
Renal Biopsy in Pregnancy

29. ◾ Aware that slight increased GFR and increased protein excretion are physiological
normal pregnancy
◾ Recognise features of proteinuria that could be related to kidney disease or
preeclampsia
◾ Aware of medications to use or not to use as either supportive or
immunosuppressive agents.

31. Diagnosis of
Hypothyroidism
TSH >2.5 mIU/L with decreased
FT4 concentration
TSH >10.0 mIU/L, irrespective of
FT4
(Subclinical hypothyroidism – TSH
between 2.5 and 10 mIU/L with a
normal FT4)

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40. Hyperthyroidism in
pregnancy

41. Definition of Maternal Hyperthyroidism
Maternal hyperthyroidism is defined as suppressed serum TSH level
with elevated free tri-iodothyronine (fT3) and/or free thyroxine (fT4).
Subclinical hyperthyroidism
defined as suppressed serum TSH with normal fT4 and/or fT3 levels.
Subclinical maternal hyperthyroidism has not been associated with
adverse maternal or foetal
outcomes, and treatment for this condition is not recommended.

44. When to start Anti-thyroid Drug (ATD)
-Symptomatic
-If possible after 12 week of pregnancy

45. AIM OF TREATMENT
-Aim T4 upper third normal range or slightly above upper limit
-No need to bother about TSH, TSH does not cross placenta
The lowest effective dose of ATD should be used during pregnancy, targeting fT4
at or just above the reference range.#recommendation
cpg :management thyroid disorder 2019
fT4 should be monitored every 4–6 weeks
after initiation of therapy and after achieving target value

46. Who can stop Anti-thyroid? must fulfill all criteria
- Prepregnancy on hyperthyroid
treatment duration >6 month
- Normal TSH/t4 during treatment
- On dose carbimazole 10 mg or lower
(PTU 200 mg or lower)
- No goiter/ orbitopathy
- TRAb <3x ULN

47. THANK YOU