Australian Doctor 3rd November 2023 3rd Nov 23 | Page 48

48 HOW TO TREAT : MEDICAL DISORDERS IN PREGNANCY

48 HOW TO TREAT : MEDICAL DISORDERS IN PREGNANCY

3 NOVEMBER 2023 ausdoc . com . au
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Figure 4 . Thrombosis of the external iliac vein caused by compression of the common iliac vein during pregnancy .
Figure 4A . Longitudinal view .
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Image courtesy Dr T Geertsma , Ultrasound Cases .
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Figure 4B . Longitudinal view .
Kurdoglu Z et al . Case Rep Med 2014 / CC BY 3.0 / bit . ly / 40ZqsMA
Figure 4C . Longitudinal view .
Figure 4D . Compression of the common iliac vein during pregnancy .
Figure 5 . A 41-year-old woman presented at 39 weeks ’ gestation with progressive visual impairment and confusion . Neurological examination revealed focal deficits and symptoms related to raised intracranial pressure . MRI with gadolinium showed a mass lesion compressing the olfactory sulcus , consistent with meningioma . An infant was delivered by caesarean section , and the tumour was then removed via craniotomy . Three days post-surgery , the woman developed persistent hypotension and recurrent seizures , followed by diffuse brain infarction and maternal death .
Box 4 . Postpartum follow-up
• Medication : — Doses that have been increased during pregnancy ( such as thyroid replacement , antiepileptic drugs , insulin , antihypertensive drugs ) often need to be reduced to pre-pregnancy doses . — Medications that are important for the long-term management of chronic conditions ( for example , statins ,
ACEIs , warfarin , NOACs ) need a plan for reintroduction .
• Pregnancy-related blood test and urine abnormalities : — Follow up to ensure these all return to normal ; common issues include gestational thrombocytopenia , abnormal
LFTs , abnormal renal function and proteinuria .
• Thromboembolism during pregnancy : — These women require a screen for underlying thromboembolic risk . — Perform this after the cessation of all postpartum coagulation , and beyond six weeks postpartum , when protein S and protein C return to pre-pregnancy levels .
• Hypertension :
— All women with hypertensive disorders of pregnancy require careful follow-up of blood pressure , reducing doses of antihypertensive medications , and a careful secondary screen for underlying causes of hypertension , should there be persistent hypertension at 3-4 months postpartum .
• Gestational diabetes : — All women with gestational diabetes require an oral glucose tolerance test to assess for type 2 diabetes at 2-4 months postpartum .
Akazawa M et al . Case Rep Obstet Gynecol 2020 / CC BY 4.0 / bit . ly / 3NsXkdH
Figure 6 . Sagittal T2- weighted MRI examination showed the possibility of a benign ovarian cyst in a 29-year-old woman . Pregnancy and the cyst were diagnosed at the time of investigation for sudden onset of abdominal pain . Urgent oophorectomy was performed for a torsion at 15 weeks of pregnancy and cytology returned a high-grade mucinous adenocarcinoma . A second laparotomy was performed for fertility sparing surgery and an emergency caesarean section at 31 weeks for sudden massive ascites from a recurrence of ovarian cancer .
and lack of regular expression of breastmilk in the first 48 hours postpartum can all result in delayed lactogenesis . Women in this situation may require the support of a lactation consultant , additional support with expressing breastmilk , close surveillance for the development of mastitis , and treatment with lactogogues such as domperidone .
In cases where it is expected that these issues will arise peripartum , lactation support before delivery can be very helpful .
Women with medical conditions known to be associated with increased difficulty in establishing breastfeeding ( for example , cystic fibrosis , diabetes ) benefit from additional antenatal education regarding breastfeeding .
Postpartum support of breastfeeding in women with medical disorders requires an understanding of the use of drugs in breastfeeding . Obstetric physicians , obstetric medicine registrars and specialist pharmacists can be contacted in major maternity centres for advice regarding the use of drugs during breastfeeding . LactMed is an excellent online resource for information regarding the use of drugs during breastfeeding . 10
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Soto-Trujillo D et al . Cureus 2020 / CC-BY 4.0 / bit . ly / 3Vqzxgk
Figure 7 . A 36-year-old woman in her second trimester with a palpable mass in the left breast that presents with growth in the past three months .
A . Ultrasound showing at 2:00 a hypoechoic nodule with micronodulated margins of 2.8cm , and doppler showing peripheral vascularity .
B . Mediolateral oblique projection on mammography of the left breast showing a hyperdense nodule of irregular margins ( blue arrow ) that causes skin retraction . A percutaneous biopsy is performed , and shows this is a triple-negative high-grade infiltrating ductal carcinoma .