samira-morning-session-2 (2).gynae1.pptx

fetomaternal medicine speciality a branch of general obs & gynae

1. Dr. Samira Moyeen Phase-B Resident Department of Fetomaternal Medicine , BMU

2. Total admitted cases :

3. CASE 1 Name: Mrs. Porina akter Age: 23 yrs. O/H : M/H : Married for: 4 years LMP: 28/10/24 Para : 1 C/S( 1 IUD) +0 EDD: 4/8/25 Gravida :2nd Dx:2nd Gravida with 28+5 weeks pg with hypothyroidism non immune hydrops fetalis with severe oligohydromnios (3.4cm) with Bad obstetric history with h/o 1 cs .

4. Baby of mrs porina

5. Name : Mrs. sathi Age : 26 years O/H : M/H- P- 1vd+0 LMP -15/8/24 . Gravida: 2nd . EDD-31/5/25 MF- 5yr ALC 3yr Dx : 2nd Gravida with 38+2 weeks pg with transverse myelitis with GDM (on diet).   case 2

6. Case-3 name : Mrs. Runa Age : 25 years O/H : M/H : MF: 10yr . LMP:? Para : 2c/s+0 EDD: 14/8/24 Gravida : 3rd ALC 5yr Dx: 3rd Gravida with 27 weeks Pg with gross hydronephrosis of fetal one kidney with severe oligohydromnios with h/o 2 c/s

7. Case-4 Name : Mrs. Maya Age : 34 yrs. O/H : M/H : Married for: 20yr LMP : 22/11/24 Para: 3vd ( 1 ND)+0 E.D.D :9/8/25 Gravida: 4th ALC -12 yr Dx :4th gravida 25+1 wk pregnancy with GDM (on diet) with graves disease with anhydromnios.

8. Case-5 Name : Mrs. nazmun nahar Age : 36 yrs. O/H: M/H: MF: 8 yr LMP : 23/9/24 Para: 1 cs +1ab EDD : 30/06/25 Gravida: 3rd ALC: 3yrs. Dx: 3rd Gravida with 33+5 wks pg with pre eclampsia superimposed on chronic hypertension with H/O 1 CS

9. Case-6 Name : Mrs. Jannat Age : 22 yrs. O/H: M/H: MF: 8yr LMP : 2/10/24 Para: 1vd+0 EDD : 9/07/25 Gravida 2nd ALC 5yr Dx: 2nd gravida with 33+3 wks pg with gestational hypertension with GDM ( on diet) with fetal duodenal atresia and fetal ascites with moderate polyhydramnios .( AFI 3 2.8 cm)

10. Case-7 Name : Mrs. Rimi Age : 30 yrs O/H : M/H : Married for: 7 Years LMP 8/10/24 Para: 0 + 0 EDD: 15/7/25 Gravida: primi Dx :primi 31+4 weeks pg with pre eclampsia with severe feature superimposed on chronic hypertension with gross FGR with hypothyroidism with breech presentation with h/o primary subfertility and OID intake.

11. . Name: Mrs. Nahar Age: 35 yrs O/H: M/H: LMP-6/9/24 MF 16 year . EDD- 13.6.25 Para- 2 CS+0 G- 3rd ALC-13yr . . . Dx: 3rd gravida 36+2 wk pg with antepartam hemorrhage due to placenta previa with placenta percreta with h/o 2CS Case-8

12. CASE 9 Name : Mrs. Shahana Age : 35 yrs O/H : M/H : MF : 18 yr LMP-7/10/24 para : 2 vd+1 EDD-14/7/25 Gravida : 4th ALC -12yr Dx : 4th Gravida with 31+6 wks pg with fetal CNS anomalies (microcephaly, bilateral mild ventriculomegaly, agenesis of inferior cerebellar vermis) with bilateral club foot.

13. Name : Mrs. Smita Age : 27 yrs. O/H: M/H: MF: 2yr LMP : 14/9/24 Para: 0+0 EDD : 21/06/25 Gravida:primi Dx: primi with 35+3 wks pg with pre eclampsia with severe feature with large fibroid( 11.58cm×11.13cm×9.41cm) with RH negative mother. Case 10

14. GRAVES DISEASE

15. Graves disease is an autoimmune disease that leads to generalized overactivity of entire thyroid gland. The most common manifestation of graves disease is thyrotoxicosis with or without a diffuse goitre.

16. Graves' thyrotoxicosis results from the production of lgG antibodies directed against the TSH receptor on the thyroid follicular cell,These antibodies are termed as thyroid-stimulating immunoglobulins or TSH receptor antibodies (TRAb) TRAb binds to TSH receptor which stimulate thyroid homone production and proliferation of follicular cells, leading to goitre in the majority of patients.

17. Genome-wide association study identified that several genes are associated with genetic suseptibility of graves disease, these include HLA DRB Arg74, CTLA4, PTPN22 ,TSHR1,CD25 and CD40. many of these loci have been implicated in pathogenesis of other autoimmune disease. A suggested trigger in genetically susceptible individuals may be infection with viruses or bacteria.

18. it affects Approximately 0.2% pregnant women. Clinical Features of Graves disease : Symptoms of hyperthyroidism Graves ophthalmopathy( lid lag, lid retraction, exophthalmos ) Pretibial myxedema Diffused goiter Graves' disease can occur at any age but is unusual before puberty and mostly affects women aged 30-50 years

19. Symtom of thyrotoxicosis Weight loss despite normal or increased appetite Heat intolerance Palpitation Sweating Frequent motion Tremor Nervousness Amenorrhea Insomnia

20. Lab test Tsh : low Free and total T3 and T4 : elevated TRAB : elevated

21. Maternal complications Miscarriage Placenta abruption Preterm delivery Congestive Heart failure Thyroid Strom Pre-eclampsia Outcome of poorly treated graves disease in pregnancy

22. Fetal complication Hyperthyroidism Prematurity FGR Hydrops fetalis Fetal death/Still birth Fetal anomalies

23. Management : Patients having overt moderate to severe hyperthyroidism due to Graves’ disease are treated. Patient with mild hyperthyroidism with T3/T4 <1.5 times the upper normal limit of the non-pregnant range are not treated. Management should be multidisciplinary approach - with endocrinologist

24. Preconception - Woman on ATD ( anti thyroid drugs) should be euthyroid for 3 month prior to conception. Counselling regarding the risk of birth defect with ATDs also the need for continuation of treatment. Conception should be avoided until 6 month after radioiodine therapy

25. During pregnancy- 1.Anti thyroid drug ( ATDs) – (lowest necessary dose to keep at the FT4 the upper limit of normal range) Propylthiouracil (PTU) in 1st trimester ( upto 12-16 weeks) Dose- initial 50-150 mg orally three times a day. Maintenance dose- 50 mg orally twice/three times in a day

26. Carbimazole/ Methimazole in the 2nd & 3rd trimester Dose- 10-20 mg/day, 2. Beta blocker-to control adrenergic symptoms such as Palpitation, tremor, severe tachycardia & reducing the conversion of T4 to T3. Doses: 20-40 mg tds for short periods of time ,not harmful to the fetus.

27. 3. Surgery- Thyroidectomy -done in second trimester Indication- contraindication of ATDs use( history of agranulocytosis) Intolerant to carbimazole Huge goiter with compressive symptoms. 4. Radioactive iodine therapy- contraindication in pregnancy.

28. FT4,TSH should be monitored in pregnant women and dose of antithyroid drugs adjusted accordingly, Thyroid function test every 3 months, more frequently if dose adjustment are made. Measure TRAb early and late trimester of pregnancy (30-34 wks ) if high -there is a chance of fetal thyrotoxicosis and neonatal thyrotoxicosis accordingly. Maintain FT4 upper limit of normal ranges.

29. Fetal monitoring by USG Serially usg 4-6 weekly from 22 weeks is recommended in pregnant woman with hyperthyroid to check fetal thyroid gland,fetal ,growth,fetal heart rate, amniotic fluid,

30. Very little PTU (0.07%) and carbimazole (0.5%) is excreted in breast milk. Safe PTU<150mg / day and Carbimazole<15mg/day PTU less transfer across the placenta and to breast milk then carbimazole. Studies of breast-fed infants of mothers taking ATDs have demonstrated normal thyroid function and subsequent intellectual development. During lactation

31. Maternal: a. Rash or urticaria (1-5%) b. Neutropenia and agranulocytosis (Rare) c. Fever, arthralgia, cholestatic Jaundice, lupus like syndrome, migratory polyarthritis. Recently carbimazole has become the treatment of choice. Because PTU → causes irreversible liver damage. SIDE EFFECT OF ANTI THYROID DRUG

32. Fetal Most common teratogenicity with carbimazole- Aplasia Cutis (congenital absence of skin with or without absence of underlying structures such as bone) Other teratogenic effect : Choanal atresia Tracheoesophageal fistula Esophageal atresia Ventricular septal defects Omphalomesenteric duct

33. Difference between graves disease and gestational transient thyrotoxicosis Gestational transient thyrotoxicosis- The findings of no prior history of thyroid disease, no stigmata of GD (goiter, orbitopathy), a self limited mild disorder, and symptoms of hyperemesis favor the diagnosis of gestational transient thyrotoxicosis. It occurs in the first trimester and resolves spontaneously. Graves’ disease- Patient with GD usually have a personal history of hyperthyroidism or have been previously diagnosed with Graves’. GD typically improves during the 2nd and 3rd trimesters, and often relapses in the post-partum period.

34. THANK YOU