Z Score,T Score, Percential Rank and Box Plot Graph
CNS and Liver in Pregnancy
1. CME ON MEDICAL DISORDERS IN PREGNANCY NERVOUS SYSTEM AND LIVER Prof. Dr. S Sundar’s Unit Dr. Deepu Sebin, PG in Internal Medicine
2. CNS in Pregnancy Liver Challenges us with the diagnosis Challenges are both in diagnosis and treatment Brain and Liver – There are changes with pregnancy , but not much ! Liver in Pregnancy CVAs and Seizures Pregnancy specific liver diseases
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9. 1. Bushnell CD, Jamison M, James AH. Migraines during pregnancy linked to stroke and vascular diseases: US population based case-control study. BMJ 2009;338:b664.
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17. Stroke and Pregnancy: Postpartum Cerebral Angiopathy 1. Singhal AB, Kimberly WT, Schaefer PW, Hedley-Whyte ET. Case 8-2009: A 36-year-old woman with headache, hypertension and seizure 2 weeks post partum N Engl J Med 2009;360:1126-37.
25. Does She even Need AED ? Polytherapy to Monotherapy Therapy Taper to Lowest Possible Dose Replace Valproate Add Folate 4 mg, Vitamin K in third trimester Adequate Sleep Plan conception after 6 months Use barrier contraception
27. Does She even Need AED ? Polytherapy to Monotherapy Therapy Taper to Lowest Possible Dose, Replace Valproate Add Folate 4 mg. Vitamin K in 3 rd trimester Adquate Sleep Plan conception after 6 months Use barrier contraception Beware of Possble dilution Consider plams drug level monitoring if possible
28. 3.A patient with a seizure in pregnancy or delivery or postpartum Emergency
29. Consider Masulf IF: >20 wks of pregnancy or postpartum Seizure not controlled with IV AED & Sedation Any Features of Preeclampsia in current or previous pregnancy ? No Yes * The initial diagnosis of preeclampsia may be postpartum Suspect CVA/CVT/CNS infection Manage as similar to non pregnant seizure Magnesium Sulphate Diazepam Lorazepam if not resolving
34. Normal Pregnancy Viral Hepatitis H. Gravidarum IHCP HEELP AFLP S .Bilurubin Slightly down AST Normal ALT Normal ALP 3x in 3 rd timester GGT Normal S. Bile Acid Normal PT, INR Normal S.Ammonia Normal Total Count Normal Platelets Normal RBS Normal S.Creatine Normal LDH Normal DIC No
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42. Normal Pregnancy Viral Hepatitis H. Gravidarum IHCP HEELP AFLP S .Bilurubin Slightly down < or >5 AST Normal >1000 ALT Noraml >1000 ALP 3x in 3 rd timester Raised in choleststic ph S. Bile Acid Normal Nl or raised PT, INR Normal Normal S.Ammonia Normal Normal Total Count Normal Normal Platelets Normal Normal RBS Normal Normal S.Creatine Normal Normal LDH Normal Normal DIC No No
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45. Normal Pregnancy Viral Hepatitis H. Gravidarum IHCP HEELP AFLP S .Bilurubin Slightly down < or >5 <5 AST Normal >1000 <500 ALT Noraml >1000 <500 ALP 3x in 3 rd timester Raised in choleststic ph Normal S. Bile Acid Normal Nl or raised Normal PT, INR Normal Normal Normal S.Ammonia Normal Normal Normal Total Count Normal Normal Normal Platelets Normal Normal Normal RBS Normal Normal Normal S.Creatine Normal Normal Normal LDH Normal Normal Normal DIC No No No
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52. Normal Pregnancy Viral Hepatitis H. Gravidarum IHCP HEELP AFLP S .Bilurubin Slightly down < or >5 <5 <5 , direct AST Normal >1000 <500 <300 ALT Noraml >1000 <500 <300 ALP 3x in 3 rd timester Raised in choleststic ph Normal Elevated S. Bile Acid Normal Nl or raised Normal Raised PT, INR Normal Normal Normal Can be elevate S.Ammonia Normal Normal Normal Normal Total Count Normal Normal Normal Normal Platelets Normal Normal Normal Normal RBS Normal Normal Normal Normal S.Creatine Normal Normal Normal Normal LDH Normal Normal Normal Normal DIC No No No No
60. Normal Pregnancy Viral Hepatitis H. Gravidarum IHCP HEELP AFLP S .Bilurubin Slightly down < or >5 <5 <5 , direct <5 AST Normal >1000 <500 <300 >500 ALT Noraml >1000 <500 <300 >500 ALP 3x in 3 rd timester Raised in choleststic ph Normal Elevated Normal S. Bile Acid Normal Nl or raised Normal Raised Normal PT, INR Normal Normal Normal Can be elevate May be elevat S.Ammonia Normal Normal Normal Normal Normal Total Count Normal Normal Normal Normal Normal Platelets Normal Normal Normal Normal Low RBS Normal Normal Normal Normal Normal S.Creatine Normal Normal Normal Normal Usually Nl LDH Normal Normal Normal Normal Raised DIC No No No No Can Occur
75. Normal Pregnancy Viral Hepatitis H. Gravidarum IHCP HEELP AFLP S .Bilurubin Slightly down < or >5 <5 <5 , direct <5 <5 AST Normal >1000 <500 <300 >500 <500 ALT Noraml >1000 <500 <300 >500 <500 ALP 3x in 3 rd timester Raised in choleststic ph Normal Elevated Normal Normal S. Bile Acid Normal Nl or raised Normal Raised Normal Normal PT, INR Normal Normal Normal Can be elevate May be elevat Elevated S.Ammonia Normal Normal Normal Normal Normal Elevated Total Count Normal Normal Normal Normal Normal High Platelets Normal Normal Normal Normal Low Low RBS Normal Normal Normal Normal Normal Low S.Creatine Normal Normal Normal Normal Usually Nl Can be raised LDH Normal Normal Normal Normal Raised Raised or normal DIC No No No No Can Occur Yes
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Notas do Editor
Not su
Folic acid supplementation — Low serum folate levels in women with epilepsy are independently associated with an increased risk of major fetal malformations [3] . It has not yet been conclusively determined if folic acid supplementation prevents neural tube defects in women receiving AEDs. However, animal studies have shown that valproate and phenytoin decrease the concentration of certain forms of folate and are associated with neural tube defects [4,5] .
Pregnancy is accompanied by many alterations in drug metabolism, including increased liver metabolism, renal clearance, and volume of distribution, and decreased gastrointestinal absorption and plasma protein binding [15,23,24] . As an example, for AEDs that are highly protein bound (eg, phenytoin, valproate), the total plasma drug level may decrease with impaired protein binding, but the physiologically important free or unbound drug concentration may not change. As a result, free drug levels for these AEDs may be more reliable during pregnancy. However, medication dosage should be adjusted if the patient's seizures are not controlled, not because the free or total level has decreased.
immunisation
The origin of the liver disease associated with hyperemesis gravidarum is unclear. Not all affected patients have liver disease; therefore, the vomiting does not appear to be secondary to the liver involvement. Starvation alone does not seem to be an adequate explanation for the liver dysfunction, particularly in as much as biopsy in affected patients fails to show the fatty infiltration typical of starvation .
pedaitrician
Low haptoglobin – most sensitive measure for hemolysis. Seen before plt count drops.
Maternal complication seen in 12-65% of cases
50% mortality due to hepatic hematoma with rupture
