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  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
  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.
  25. 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)
  26. • 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
  27. • 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
  28. ◾ 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.
  29. 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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  35. Hyperthyroidism in pregnancy
  36. 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.
  37. When to start Anti-thyroid Drug (ATD) -Symptomatic -If possible after 12 week of pregnancy
  38. 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
  39. 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

Hinweis der Redaktion

  1. foetal hypothyroidisms why we aim t4 slightly above upper limit