Book of Medical Disorders in Pregnancy - Tintash

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differentiate from hemodynamically significant murmurs if the patient has not been examined before. If the murmur is loud and transmitted to the axilla or neck vessels, and its association with a palpable thrill is established, it is abnormal without exception. It is conventional to grade murmurs according to their intensity. The grades vary from one to six. The grade I murmur can be heard with special effort only. The grade II murmur is very faint but is recognizable with some experience. The grade III murmur is prominent but is not so loud; a grade IV murmur is much louder. The grade V murmur is also loud while the grade VI murmur is the loudest and can even be heard with stethoscope while it is barely in contact with the chest wall. In the absence of heart disease a pregnant patient should have no murmur louder than grade II. Blood flow murmurs associated with pregnancy are heard along the left sternal border in nearly 90 per cent of pregnant women. They do not usually radiate to the axilla, and are not associated with thrills of any sort. The diastolic murmur of aortic regurgitation is usually faint and some times, inaudible during pregnancy. This murmur is heard while the patient is squatting or performing strenuous work. Diastolic cardiac murmurs in pregnancy always indicate cardiac pathology. A diastolic bruit originating in the internal mammary artery may be misinterpreted as being cardiac in origin. A murmur which originates from the breast vasculature can be heard in about 10 per cent pregnant women, during the third trimester. Heart sounds and murmurs - A parasternal systolic murmur is heard in most cases and is due to increase in 75 blood volume which occurs in normal pregnancy. This is the murmur of organic mitral regurgitation and careful interpretation is necessary since the presence of an S3 gallop signifies left ventricular failure. More than 80 per cent of women develop a third heart sound at some time during pregnancy. The frequency parallels the increase in cardiac output. Systolic murmurs increase in intensity during pregnancy. This is due to increased blood flow across normal cardiovascular valve s. This is particularly so in murmurs arising in the pulmonic and aortic areas. Systolic murmurs produced by mitral regurgitation usually become softer during pregnancy, because systemic arterial resistance falls. Murmur in mitral valve prolapse syndrome: In this syndrome an apical systolic murmur is noted and is preceded by a mid systolic click. The majority of patients with a mitral valve prolapse syndrome have uneventful gestation. These patients are susceptible to subacute bacterial endocarditis and should be protected with antibiotics at delivery. Chest X-ray: A chest X-ray is useful to assess the degree of enlargement of the heart. Similarly, enlargement of a particular chamber of the heart can be detected and the presence of pulmonary over circulation diagnosed. It is wise not to expose the fetus to radiation, unless it is absolutely necessary.
120mmHg Aortic Value opens 80mmHg Mitral Value Closes S4 S1 S2 S3 Fig5.8: Shows heart sounds. Electrocardiography: The mean QRS axis shifts to the left in the frontal plane\of the electrocardiogram. A "Q" wave may develop in lead III, but disappear on deep inspiration. The electrocardiogram is quite useful in assessing the presence or absence of ventricular hypertrophy and atrial enlargement. (LBBB) allow the P2 sound to be heard before the A2 sound during expiration. With LBBB, inhala-tion brings A2 and P2 closer together where they cannot be audibly distin-guished. PR segment P QRS Complex R PR interval Q QT interval S Fig5.9: Shows ECG. Aortic Value Closes Aortic Pressure Mitral Value opens LA Pressure LV Pressure ST segment Normal adult 12-lead ECG: The diagnosis of the normal electrocar- T 9 76 diogram is made by excluding any recognized abnormality. Its description is therefore quite lengthy. Normal sinus rhythm: Each P wave is followed by a QRS, P waves normal for the subject, P wave rate 60 - 100 bpm with 10% = sinus arrhythmia. Normal QRS axis, normal P waves, height < 2.5 mm in lead II and width < 0.11 s in lead II for abnormal P waves see right atrial hypertrophy, left atrial hypertrophy, atrial premature beat, hyperkaliemia, normal PR interval and 0.12 to 0.20 s (3 - 5 small squares) for short PR segment consider Wolff- Parkinson-White syndrome or Lown- Ganong-Levine syndrome (other causes - Duchenne muscular dystrophy. Type II glycogen storage disease (Pompe's), HOCM), for long PR interval see first degree heart block and 'trifascicular' block, normal QRS complex, < 0.12 s duration (3 small squares), for abnormally wide QRS consider right or left bundle branch block, ventricular rhythm, hyperkaliemia, etc. No pathological Q waves, no evidence of left or right ventricular hypertrophy and normal QT interval. Calculate the corrected QT interval (Q TC) by dividing the QT interval by the square root of the proceeding R - R interval. Normal = 0.42 s. Causes of long QT interval, myocardial infarction, myocarditis, diffuse myocardial disease, hypocalcaemia, hypothyroidism , subar-achnoid hemorrhage, intracerebral hemorrhage, drugs (e.g. sotalol, amiodarone), hereditary, Romano Ward syndrome (autosomique
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MEDICAL DISORDERS IN PREGNANCY M. S
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PREFACE Almost all medical disorder
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Dedication This manuscript is dedic
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Uri. Elkayam MD Professor of Cardio
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Chapter No: 1 Anaemia in pregnancy:
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performance. Tiredness, listlessnes
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pregnancy and labour. The monthly b
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Fig 1.3: Shows developmental stages
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Prophylactic this includes routine
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granulocytes and thrombocyte is als
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or because the hemoglobin A is repl
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iron. Decrease in the number of gra
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Labor/delivery: Expedite for normal
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Risk factors: The risk of GDM incre
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to a large extent on the measure of
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vomiting, or through intercurrent i
Page 34 and 35: largely related to the problems of
Page 36 and 37: femoral epiphyses can help in asses
Page 38 and 39: in a randomized design the efficacy
Page 40 and 41: of the previous day’s dose of ins
Page 42 and 43: women with vascular disease are awa
Page 44 and 45: Chapter No 3 THYROID DISEASE IN PRE
Page 46 and 47: such as phenobarbitone 30 mg given
Page 48 and 49: REFERENCES: 1. Hawe, P. and Francis
Page 50 and 51: Incidence - Its incidence varies ac
Page 52 and 53: cerning the disturbance in the Reni
Page 54 and 55: Renal function: In normal pregnant
Page 56 and 57: severe pre eclampsia and eclampsia
Page 58 and 59: Epipastic pain: It is also a late s
Page 60 and 61: arely occurs. However, if pregnancy
Page 62 and 63: differentiating between chronic hyp
Page 64 and 65: fetuses. Recent studies indicate th
Page 66 and 67: to procrastinate all available meth
Page 68 and 69: cases are said to occur up to 1 wee
Page 70 and 71: has been carried out. There can be
Page 72 and 73: intensive care room for the next 48
Page 74 and 75: Severe pre eclampsia at or remote f
Page 76 and 77: Chapter No: 5 HEART DISEASE IN PREG
Page 78 and 79: pregnancy. The increase in volume i
Page 80 and 81: Fourth Heart sound - This is rarely
Page 82 and 83: Class III - With cardiac disease pr
Page 86 and 87: dominant). Jervell + Lange Nielson
Page 88 and 89: striking of which is stippling seen
Page 90 and 91: increase venous pressure and burden
Page 92 and 93: determine whether she will be safe
Page 94 and 95: supplemental 02. Fetal surveillance
Page 96 and 97: 11. Percutaneous transluminal angio
Page 98 and 99: ureter at the pelvic brim may play
Page 100 and 101: Fig6.3: Shows location of kidney in
Page 102 and 103: A clear cut history of streptococca
Page 104 and 105: (a) Polycystic renal disease - Fort
Page 106 and 107: with patients in this category. In
Page 108 and 109: 2. Beard, R.W.and Roberts, A.P. (19
Page 110 and 111: increases slightly. Arterial blood
Page 112 and 113: scan, 0.004 Gy; pulmonary angiograp
Page 114 and 115: CD4 + cell count (200/ml) should re
Page 116 and 117: embark upon a pregnancy. Severe air
Page 118 and 119: Chapter No: 8 LIVER DISEASE IN PREG
Page 120 and 121: owel, but conjugated bilirubin is n
Page 122 and 123: Hepatic causes - Viral hepatitis bo
Page 124 and 125: Immunoprophylaxis at birth followed
Page 126 and 127: highest reported rate of vertical t
Page 128 and 129: curs in 60 to 70 percent of subsequ
Page 130 and 131: Chronic liver disease: An increased
Page 132 and 133: 22. Riely CA. Hepatic disease in pr
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ilirubin is transported across the
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when the titre is greater than 1: 3
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Induction of labour: When screening
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Blood brain barrier and bilirubin e
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place if the infant develops jaundi
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REFERENCES 1. UpToDate a. “Pathog
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of embolus formation is far less in
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Unfortunately this faculty is not a
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hours. The maximal effect takes 36
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may complain of constricting type o
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When the embolus is small and non f
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3. Sukal S, Geronemus R. "Deep Veno
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damage specific cells in the tissue
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is capable of breaking off and deve
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Chapter No: 12 PARASITIC INFECTIONS
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sporozoite stage. The main characte
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insect repellents and insecticide s
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is 2 tablets i.e. (400 mgs) thrice
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Cardiac failure resulting from seve
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dysmenorrhea, dysuria, and even obs
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Chapter No: 13 VIRAL DISEASES IN PR
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after exposure favors but does not
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Fig13.4: shows CMV infection rash o
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three quarters of HYH strains isola
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where 'T' stands for toxoplasmosis
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Chapter No: 14 Introduction: The dr
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hexacyanoferrate (II) 2H2O (Prussia
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Restricted indications: Anti lepros
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potential Teratogen and inhibits ma
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placental abruption, and intrauteri
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Inhalation of volatile organic comp
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Chapter No: 15 Pregnancy is a norma
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time periods during the pregnancy f
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y the maternal kidney in urine or b
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continues after the end of the uter
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Amniography - In this technique rad
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at the cranial end of the neural tu
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least maceration: placenta, lung, a
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fetal hydrops with monosomy X, or T
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cause progressive renal failure as
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9. Papageorgiou, E.A.; Karagrigorio
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position of the head. The student s
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centimeter ruler is placed alongsid
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echoes in B mode. The operator appl
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also affects depth resolution and t
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From twelve week onwards the bipari
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tract. Normal kidneys can easily be
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3.19, 1.29 and 1.30, respectively [
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iodinated contrast during pregnancy
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Only tiny amounts of iodinated or g
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intraperitoneal hemorrhage, or inju
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REFERENCE: 1. Stewart A, Webb J, Gi
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cardiac defects 181, 200 cardiac di
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gestational age 26, 31, 40, 165, 19
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monitoring, invasive 83-6 monosomy
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sensitization 124-5 sepsis 22, 95-6
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Book of Medical Disorders in Pregnancy - Tintash

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