Obstetrics and Gynaecology
Medical Disorders in Pregnancy: Heart, Renal, Liver, HIV and Rh
Cardiac, renal, liver disease, HIV and Rh isoimmunisation in pregnancy for MBBS, with anti-D and PMTCT, mapped to NMC code OG12.
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Medical Disorders in Pregnancy: Heart, Renal, Liver, HIV and Rh
Cardiac, renal, liver disease, HIV and Rh isoimmunisation in pregnancy for MBBS, with anti-D and PMTCT, mapped to NMC code OG12.
This chapter continues medical disorders in pregnancy, covering heart disease, urinary and renal problems, liver disorders, HIV and Rh isoimmunisation. It highlights the extra cardiac load in labour, the treatment of urinary infection, the liver-specific conditions of pregnancy, the prevention of mother-to-child HIV transmission and the use of anti-D to prevent haemolytic disease.
High-yield: Medical Disorders in Pregnancy: Heart, Renal, Liver, HIV and Rh
- Cardiac disease is a leading indirect cause of maternal death, and the rise in cardiac output stresses a diseased heart most in labour and immediately after delivery.
- Women with significant heart disease are graded by the New York Heart Association class, which guides the risk and mode of delivery.
- Warfarin is teratogenic and is generally replaced by heparin in the first trimester and near term in women needing anticoagulation.
- Asymptomatic bacteriuria in pregnancy is treated because it can progress to pyelonephritis and preterm labour.
- Acute pyelonephritis in pregnancy needs admission and intravenous antibiotics because of the risk to mother and foetus.
- Intrahepatic cholestasis of pregnancy causes itching without a rash, especially of the palms and soles, with raised bile acids.
- Cholestasis of pregnancy is treated with ursodeoxycholic acid and may warrant planned delivery because of the risk of stillbirth.
- HELLP syndrome is haemolysis, elevated liver enzymes and low platelets, a severe variant of pre-eclampsia.
- Acute fatty liver of pregnancy is rare but life-threatening, presenting with vomiting, jaundice and liver failure late in pregnancy.
- All pregnant women are offered HIV testing, and antiretroviral therapy sharply cuts mother-to-child transmission.
- Elective caesarean and avoidance of breastfeeding are considered when the maternal HIV viral load is not suppressed.
- Rh isoimmunisation occurs when an Rh-negative mother forms antibodies against Rh-positive foetal red cells.
- Anti-D immunoglobulin given to non-sensitised Rh-negative women prevents isoimmunisation and haemolytic disease of the foetus and newborn.
- In a sensitised pregnancy, middle cerebral artery Doppler peak systolic velocity screens for foetal anaemia.
Key management points
- **Cardiac disease:** Graded by NYHA class; greatest strain in labour and immediate puerperium.
- **Urinary infection:** Treat even asymptomatic bacteriuria to prevent pyelonephritis and preterm labour.
- **Cholestasis of pregnancy:** Itching without rash, raised bile acids; ursodeoxycholic acid and timed delivery.
- **Rh isoimmunisation:** Prevent with anti-D; MCA Doppler screens for foetal anaemia if sensitised.
NMC competencies in this chapter
- **OG12.4:** Heart disease in pregnancy
- **OG12.5:** Urinary tract infection and renal disease in pregnancy
- **OG12.6:** Liver disease in pregnancy
- **OG12.7:** HIV in pregnancy and prevention of mother-to-child transmission
- **OG12.8:** Rh isoimmunisation and red cell alloimmunisation
Frequently Asked Questions
When is the heart most stressed in a pregnancy with cardiac disease?
In labour and the immediate postpartum period, when auto-transfusion from the contracting uterus adds to an already increased cardiac output. Delivery planning aims to limit this strain.
Why treat asymptomatic bacteriuria in pregnancy?
Untreated, it can ascend to cause pyelonephritis and is associated with preterm labour, so it is screened for and treated even without symptoms.
How is Rh isoimmunisation prevented?
By giving anti-D immunoglobulin to non-sensitised Rh-negative women after sensitising events and routinely in the third trimester, which stops maternal antibody formation.
How is mother-to-child HIV transmission reduced?
By universal antenatal HIV testing and antiretroviral therapy, with mode of delivery and infant feeding decisions guided by the maternal viral load.
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