Скачать презентацию Zareh F MD Asymptomatic bacteriuria n n Скачать презентацию Zareh F MD Asymptomatic bacteriuria n n

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Zareh. F. MD Zareh. F. MD

Asymptomatic bacteriuria n n n n Colony count more than 10000 No symptom incidence Asymptomatic bacteriuria n n n n Colony count more than 10000 No symptom incidence 6% 25 -40% Progress to pyelonephritis. Treatment reduces this 10 -fold Ampicillin or nitrofurantoin 10 -14 days U/c one week following therapy 30% of infection recure n

cystitis n n n . Symptomatic bacteriuria without flank pain or fever Diagnosis and cystitis n n n . Symptomatic bacteriuria without flank pain or fever Diagnosis and treatment as ASB With sterile urine chlamydia trachomatis suspected

pyelonephritis n n n . 1 -3% of pregnant women Febrile patient , chills, pyelonephritis n n n . 1 -3% of pregnant women Febrile patient , chills, urgency, dysuria, nausea, vomiting Right sided, bilateral Bacterial endotoxins Macrophage cytokines Preterm labor

Recurrent pyelonephritis n n n . 10 -18% of patient Nitrofurantoin 100/night u/c every Recurrent pyelonephritis n n n . 10 -18% of patient Nitrofurantoin 100/night u/c every month Treatment: 10 -day course of antibiotics Ivp 3 months postpartum

Urinary calculi n n n n 1/1000 pregnancies Increase uti to 20 -45% Suppressive Urinary calculi n n n n 1/1000 pregnancies Increase uti to 20 -45% Suppressive nitrofurantoin therapy u/c monthly Infection treated aggressively Sonography 60% Single view Ivp 96%(50 mrad( with persisted obstruction ureteral stent or percutaneous nephrostomy is required.

Chronic renal failure Mild cr 1. 4 Disease Decline renal course function. Increased proteinuria, Chronic renal failure Mild cr 1. 4 Disease Decline renal course function. Increased proteinuria, Hypertention. Returns postpartum. Moderate 1. 5 -2. 4 Accelerated deterioration in renal function in 10% Perinat al Mortality 15% Preeclampsia 50% preterm delivery 30 -80% Growth restriction 57% Severe 2. 5 30 -40% with Decline in renal function to end stage dis in 12 yr postpartum

Dialysis n n The goal of dialysis is BUN at 5060 mg/dl Risk of Dialysis n n The goal of dialysis is BUN at 5060 mg/dl Risk of fetal demise is BUN above 80 mg/dl Peritoneal dialysis is superior for minimize fluid shift and does not required anticoagulation Mg-so 4 can be added(serum level 5 meq/l).

Renal transplantation n Avoid of pregnancy for 2 years n n Complications : n Renal transplantation n Avoid of pregnancy for 2 years n n Complications : n n n . With dose of prednisone 15 mg/day , azathioprine 2 mg/kg/day Preeclampsia Infection (cmv, herpes, hepatitis, uti) Parathyroid dysfunction, preterm birth Prematurity 45 -60% and 20% of this babies are IUGR PROM Pregnancy outcome successful 80 -90%

Neurologic disorders n Tension headache n Migaine n Epilepsy n Subarachnoid hemorrhage n Pseudotumor Neurologic disorders n Tension headache n Migaine n Epilepsy n Subarachnoid hemorrhage n Pseudotumor cerebri

Migrain headache n Common, 15% first in pregnancy n R/O B. tumor, stroke, epilepsy Migrain headache n Common, 15% first in pregnancy n R/O B. tumor, stroke, epilepsy n Menstrual migrain, 64% improvement in pregnancy Cerebral artery vasoconstraction n 3 -6 fold ischemic stroke n

treatment Aspirin , acetaminophen with or without caffeine n narcotics, n Phenothiazine n Sumatriptan treatment Aspirin , acetaminophen with or without caffeine n narcotics, n Phenothiazine n Sumatriptan succinate (Imitrex) n Ergotamin(vasoconstrictor) § NSAIDs should be avoided in 3 th trimester. n

Epilepsy in pregnancy n No change 46% n Reduction 20% n Increase 34% Epilepsy in pregnancy n No change 46% n Reduction 20% n Increase 34%

Factors that increase the frequency of seizure Discontinuation of medication For belief that it Factors that increase the frequency of seizure Discontinuation of medication For belief that it harms the fetus n Inability to ingest medication For nausea and vomiting n Sub therapeutic drug level Expanding maternal vascular volume n Lowering of the seizure threshold By sleep deprivation and stress n

druges For many anticonvulsant drugs, the benefit of preventing seizures outweighs any potential risks druges For many anticonvulsant drugs, the benefit of preventing seizures outweighs any potential risks to the fetus The Druges should be avoided n n fetal factors play a role for fetal hydantoin syn n Valproic acid befor 8 w Trimetadione Epoxide hydrolase deficiency Birth defects increases 3% to 7%

management n n n n Lowest medication Minimized stressors Multivitamin , folate Vit K management n n n n Lowest medication Minimized stressors Multivitamin , folate Vit K Sonography During labor antiseizure medication Pain relief n Pain hvt resp. alkalosis sz. threshold

diagnosis n CT scan n CSF exam n angiography diagnosis n CT scan n CSF exam n angiography

M. S n n n Multifocal demyelinating dis of CNS white matter Characterized by M. S n n n Multifocal demyelinating dis of CNS white matter Characterized by : chronic inflammation, selective demyelination, scarring Etiology: unknown, virus-triggered autoimmune phenomen

pregnancy n n n n UTI Constipation Fatigue Morbidity problem With paraplegia or quadriplegia pregnancy n n n n UTI Constipation Fatigue Morbidity problem With paraplegia or quadriplegia at risk for precipitous delivery Lesion at or above T 6 are at risk for autonomic dysreflexia Flares are common during the first 3 postpartum months

Spinal cord injury n n Generally tolerate pregnancy well Bowel dysfunction Pressure necrosis UTI Spinal cord injury n n Generally tolerate pregnancy well Bowel dysfunction Pressure necrosis UTI

Lesion location n Below T 10 -11 feel ut. Cont normally n Above not Lesion location n Below T 10 -11 feel ut. Cont normally n Above not feel “ n “ Above T 6 hyperreflexia risk of autonomic

hyperreflexia n n n Stimuli: labor, urethral catheterization , cervical or rectal exam nerve hyperreflexia n n n Stimuli: labor, urethral catheterization , cervical or rectal exam nerve impulses enter the cord initiate focal segmental reflexes that not inhibited by higher center stimulation of the sympathetic nervous system Symptoms: pilomotor erection , excessive sweating , facial flushing , dilated pupils , severe headache , paroxysmal hypertension , bradycardia Prevention: epidural anesthesia

Endocrine disorders Endocrine disorders

Thyroid disease n Thyroid in pregnancy: modest thyroid enlargement TSH , TRH TBG ( Thyroid disease n Thyroid in pregnancy: modest thyroid enlargement TSH , TRH TBG ( total T 3, T 4 ) free T 4, T 3 in early pregnancy HCG free. T 4

Maternal hypothyroidism n n n n free. T 4 , TSH Excessive fatigue Dry Maternal hypothyroidism n n n n free. T 4 , TSH Excessive fatigue Dry skin Cold intolerance Constipation Bradycardia irritability Myxedema (rare (

complications n n n n Infertility Miscarriage Abruptio Preeclampsia IUGR Fetal demise Post partum complications n n n n Infertility Miscarriage Abruptio Preeclampsia IUGR Fetal demise Post partum hemorrhage Heart failure

Subclinical Hypothyroism n n T 4 , TSH (>10 mu/ml) Asymptomatic 5% of women Subclinical Hypothyroism n n T 4 , TSH (>10 mu/ml) Asymptomatic 5% of women in reproductive age Complication: pregnancy induced hypertension preterm delivery low IQ in children

Maternal hyperthyroidism 1/500 pregnancy Maternal hyperthyroidism 1/500 pregnancy

causes n n n Graves disease (most common) T. S. Is binds to thyroid causes n n n Graves disease (most common) T. S. Is binds to thyroid follicle cell TSH receptor Acute and subacute thyroiditis Toxic nodular goiter Toxic adenoma GTD

diagnosis n n n Symptoms: Shortness of breath Palpitation Heat intolerance Weight loss Poor diagnosis n n n Symptoms: Shortness of breath Palpitation Heat intolerance Weight loss Poor weight gain Increase bowel frequency

diagnosis n n n Laboratory Free T 4 free. T 3 3 -5% TSH diagnosis n n n Laboratory Free T 4 free. T 3 3 -5% TSH Auto antibodies confirm the autoimmune nature and fetal implication

treatment n Medical PTU 300 -450 mg folowed 50 -300 mg daily Methimazole n treatment n Medical PTU 300 -450 mg folowed 50 -300 mg daily Methimazole n Sugary n Radioactive sodium iodine

Drug adverse reaction PTU n n n Skin rash (2 -8%) Bronchospasm Drug fever Drug adverse reaction PTU n n n Skin rash (2 -8%) Bronchospasm Drug fever Hepatitis Oral ulcer Agranulocyopenia Metimazole n Aplasia cutis

Breast feeding PTU is preferable because more strongly bounds to plasma protein Breast feeding PTU is preferable because more strongly bounds to plasma protein

B blockers n Propranolol 20 -40 mg 3 times/day n Reduces sympathetic like syndrome B blockers n Propranolol 20 -40 mg 3 times/day n Reduces sympathetic like syndrome n Inhibitory effect of T 4 T 3

Surgery n If PTU necessary >300 mg/day Surgery n If PTU necessary >300 mg/day

radiation n Contrindicated in pregnancy radiation n Contrindicated in pregnancy

Hyperthyroid complication on pregnancy n n n Preeclampsia Preterm delivery Fetal demise Growth restriction Hyperthyroid complication on pregnancy n n n Preeclampsia Preterm delivery Fetal demise Growth restriction Fetal or neonate thyroid dysfunction

Fetal thyroid function n n Hormon activity by the end of 1 th trimester Fetal thyroid function n n Hormon activity by the end of 1 th trimester and gradually increases T 3 -T 4 CROSS THE PLACENTA MINIMALLY TSIs cross the placenta easily Thyroid H deficiency during fetal development and 2 y after birth irreversible brain damage

Dermatologic diseases Dermatologic diseases

Physiologic changes n n n Hyperpigmentation Vascular change: spider angioma , palmar erythema , Physiologic changes n n n Hyperpigmentation Vascular change: spider angioma , palmar erythema , venous varicosities , Hair: growing/resting Telogen efflovium 1 -4 month postpartum

Intrahepatic cholestasis of pregnancy n n 2 th most common cause of jaundice in Intrahepatic cholestasis of pregnancy n n 2 th most common cause of jaundice in pregnant Increases : n n n n bile salt alk. ph SGOT SGPT Bill recurrence 50% Fetal outcome

Herpes gestation Pemphigoid gestationis n Onset: mid to late pregnancy , postpartum n Severe Herpes gestation Pemphigoid gestationis n Onset: mid to late pregnancy , postpartum n Severe pruritus , urticarial papules , plaques , erythema , vesicles bullae n Abdomen , extremities , or generalized n Exacerbation , remission common n Ig. G depositionat the BM n 5% Dermatologic manif newborn(resolve sev w) § Adverse Fetal out come Recurrence is more severe and earlier n

Pruritic urticarial papules and plaques of pregnancy(PUPPP) n n n n Most common dermatosis Pruritic urticarial papules and plaques of pregnancy(PUPPP) n n n n Most common dermatosis of pregnancy 1% Late preg Not recur Generalize , patchy Abd , buttocks , thigh , arm Absence of Ab or complement deposition Perinatal morbidity no increase

PUPPP PUPPP

PUPPP PUPPP

treatment n Antipruritics and topical steroids n Oral steroid may in severe case treatment n Antipruritics and topical steroids n Oral steroid may in severe case

Impetigo herpetiform n n n n Pustural psoriasis Late preg Intertrigiginous surface ( extend Impetigo herpetiform n n n n Pustural psoriasis Late preg Intertrigiginous surface ( extend to involves entire skin and mucosa membrane) Erythematous patches surounded by sterile pustule Fever , malaise , GI distress , hypocalcemia Maternal sepsis is not uncommon Perinatal morbidity , mortality

treatment n n n Treatment is supportive Maintenance of fluid and electrolyte balance Correction treatment n n n Treatment is supportive Maintenance of fluid and electrolyte balance Correction of hypocalcemia Antibiotic therapy Steroid? Delivery is not necessarily accompanied by resolution