The drug of choice for eclampsia and pre-eclampsia is magnesium sulphate. It is given as a loading dose of 4g i/v over 5 minutes, followed by an infusion for the next 24 hours at the rate of 1g/hr. If the seizures are not controlled, an additional dose of MgSO4 2-4gm i/v can be given over five minutes. Patients with eclampsia or pre-eclampsia can develop any of the following symptoms: persistent headache, visual abnormalities like photophobia, blurring of vison or temporary blindness, epigastric pain, dyspnoea and altered mental status.

Pituitary tumours, the most common pathologic cause of galactorrhoea can result in hyperprolactinemia by producing prolactin or blocking the passage of dopamine from the hypothalamus to the pituitary gland. Approximately 30 percent of patients with chronic renal failure have elevated prolactin levels, possibly because of decreased renal clearance of prolactin. Primary hypothyroidism is a rare cause of galactorrhoea in children and adults. In patients with primary hypothyroidism, there is increased production of thyrotropin-releasing hormone, which may stimulate prolactin release. Nonpituitary malignancies, such as bronchogenic carcinoma, renal adenocarcinoma and Hodgkin’s and T-cell lymphomas, may also release prolactin.

Counselling her about the risks associated with obesity during pregnancy will be the best possible advice to give this patient. A combined follow up by an obstetrician and a diabetes specialist at a high-risk pregnancy clinic is required to formulate the best ways in management of gestation with obesity.
An oral glucose tolerance test should be done at 26 weeks of her pregnancy, along with advising her on controlling her weight by diet and lifestyle modifications. During the early weeks of their pregnancy all obese patients must be routinely tested for pre-existing diabetes.

It is highly inappropriate to advice her not to get pregnant.

Without making a proper diagnosis of diabetes, it is wrong to ask her to start oral hypoglycemic agent and/or insulin.

Checking urinary proteins is not indicated at this stage, but can be considered as a part of antenatal check up.

As they respond differently to different drugs, a thorough distinguishing must be done between the two major groups of epilepsies while approaching a woman, who wishes to become pregnant while on antiepileptic drugs.

Partial epilepsies will respond to most of the antiepileptic drugs, but in case of idiopathic generalized epilepsies, especially in juvenile myoclonic epilepsy, seizure can be controlled only with a reasonably low dose of sodium valproate. Although lamotrigine may be helpful but substitution of sodium valproate with lamotrigine is not the right choice. This is because lamotrigine is not as effective as sodium valproate and will sometimes worsens myoclonic seizures in juvenile myoclonic epilepsy.

Topiramate and levetiracetam are found to be effective in idiopathic generalized epilepsy, while carbamazepine, phenytoin and gabapentin may worsen some seizure types, especially in myoclonic and absence seizures. For some women with idiopathic generalized epilepsies, there will be no effective alternative to sodium valproate as cessation of sodium valproate will lead to recurrence of the generalized seizures, especially juvenile myoclonic epilepsy. Hence, it is not advisable to discontinue the drug in auch patients.

On the other hand, sodium valproate have the highest reported teratogenicity potential among antiepileptic drugs and the Australian Pregnancy Register has reported the risk to be as high as 16% if used in first trimester. Sodium valproate should be avoided in women of reproductive age and if a patient on the medication is willing to become pregnant, she should be well informed about the risk of teratogenicity and the decision must be left to her. If she decides to accept the risks and continue with pregnancy, the lowest possible effective dose should be prescribed to her.

If the dose of sodium valproate has been reduced to minimum during pregnancy to reduce the possible teratogenesis, it is recommended to re-establish the prepartum effective dose before the onset of labor. This is because, it is the time with increased risk for seizures, especially in patients with idiopathic generalised epilepsy who are very sensitive to sleep deprivation. Valproate therapy is found to be safe during breastfeeding.

The correct answer is Obstetric Cholestasis.
The characteristics (elevated bile acids, conjugated bilirubin, and alkaline phosphatase (ALP) levels) are typical with obstetric cholestasis, which affects roughly 3-4 percent of pregnant women in Australia. Obstetric cholestasis is diagnosed when otherwise unexplained pruritus occurs in pregnancy and abnormal liver function tests (LFTs) and/or raised bile acids occur in the pregnant woman and both resolve after delivery. Pruritus that involves the palms and soles of the feet is particularly suggestive.
Liver function tests and bile acid levels measurements are used to validate this diagnosis.
All of the other diagnoses are theoretically possible, but unlikely.
On liver function tests, hepatitis A and acute fatty liver of pregnancy (which is frequently associated with severe vomiting in late pregnancy) usually show substantially worse hepatocellular damage.
Pre-eclampsia is connected with hypertension and proteinuria (along with changes in renal function and, in certain cases, thrombocytopenia), while cholelithiasis is associated with obstructive jaundice and pale stools due to a stone in the CBD.

Gas gangrene is synonymous with myonecrosis and is a highly lethal infection of deep soft tissue, caused by Clostridium species, with Clostridium perfringens being the most common. This organism has also had increased incidence as the cause of deep tissue infections associated with childbirth and infections after gynaecologic procedures including septic abortions, which can cause gas gangrene of the uterus.
Health care workers should suspect gas gangrene if anaerobic gram-positive bacilli are present in a wound with necrosis of soft tissue and muscle. The organisms produce a gas identifiable on x-ray or CT scans.
Patients with gas gangrene (myonecrosis) present with signs of infection such as fever, chills, pain, and less superficial inflammation at the site of infection than one would expect given the deep penetrating nature of these infections. The condition of the patient can rapidly progress to sepsis and death if not treated aggressively. The wound discharge is often dishwater looking with a musty order.

Continuous CTG produces a paper recording of the baby’s heart rate and the mother’s labour contractions. Although continuous CTG provides a written record, mothers cannot move freely during labour, change positions easily, or use a birthing pool to help with comfort and control during labour. It also means that some resources tend to be focused on the need to constantly interpret the CTG and not on the needs of a woman in labour.

Continuous CTG was associated with fewer fits for babies although there was no difference in cerebral palsy; both were rare events. However, continuous CTG was also associated with increased numbers of caesarean sections and instrumental births, both of which carry risks for mothers. Continuous CTG also makes moving and changing positions difficult in labour and women are unable to use a birthing pool. This can impact on women’s coping strategies. Women and their doctors need to discuss the woman’s individual needs and wishes about monitoring the baby’s wellbeing in labour.

Future research should focus on events that happen in pregnancy and labour that could be the cause of long term problems for the baby.

Any new onset of hypertension associated with proteinuria after 20 weeks of gestation in a previously­ normotensive woman is referred to as Preeclampsia.
Most commonly found risk factors for pre-eclampsia are:
– Preeclampsia in a previous pregnancy
– Family history of preeclampsia
– a prior pregnancy with poor outcome like placental abruption, IUGR, fetal death in utero, etc
– An interdelivery interval greater than 10 years
– Nulliparity, increases risk by 8 times
– Pre-existing chronic medical conditions or chronic hypertension
– pre-existing or gestational Diabetes
– chronic Renal disease
– Thrombophilias g. protein C and S deficiency, antithrombin Ill deficiency, or Factor V Leiden mutation
– Antiphospholipid syndrome
– Systemic lupus erythematous
– Maternal age greater than or equal to 40 years
– Body Mass Index (BMI) greater than 30 kg/m2
– Multiple pregnancy
– Raised blood pressure at booking
– Gestational trophoblastic disease
– Fetal triploidy

Maternal age between 18 and 40 years is found to be associated with a decreased risk for developing preeclampsia, and not an increased risk.
NOTE– Previously, age 16 years or younger was thought to be a risk factor for developing preeclampsia; however, recent studies conducted had failed to establish any meaningful relationship between the two.

Incidental thrombocytopenia of pregnancy is the most common cause of thrombocytopenia in an otherwise uncomplicated pregnancy. The platelet count finding in this case is of little concern unless it falls below 50×109/L.

Immune thrombocytopenia is a less common cause of thrombocytopenia in pregnancy. The anti-platelet antibodies cam cross the placenta and pose a problem both to the mother and the foetus. Profound thrombocytopenia in the baby is a common finding of this condition.

Thrombocytopenia can occur in patients with severe pre-eclampsia. However, it is usually seen concurrent with other signs of severe disease.

Maternal antibodies that target the baby’s platelets can rarely cause thrombocytopenia in the mother. Instead, it can lead to severe coagulation and bleeding complications in the baby as a result of profound thrombocytopenia.

Systemic lupus erythematosus is unlikely to explain the thrombocytopenia in this patient.

The best antibiotic of choice for empirical treatment of a urinary tract infection (UTI) during pregnancy is cephalexin. Nitrofurantoin and amoxicillin-clavulanate are second and third in-line respectively.
Patients allergic to penicillin, which is manifested as a rash can also be safely treated with cephalexin. But cephalosporins are not recommended if the presentation of allergic reaction to penicillin was anaphylactic, instead they should be treated with nitrofurantoin.

NOTE– Asymptomatic bacteriuria, such as >10 to power of 5 colony count in urine culture of an asymptomatic woman in pregnancy, should best be treated with a one week course of antibiotics, followed by confirming the resolution of infection via a urine culture repeated 48 hours after the completion of treatment.

Amoxicillin without clavulanate is recommended only in cases were the susceptibility of the organism is proven.

Macrolides like clarithromycin are usually not recommended for the treatment of UTI.

Aminoglycosides are coming under category D drugs should be avoided during pregnancy, unless there is a severe indication of gram negative sepsis.

Tetracycline, due to their potential teratogenic effects, are contraindicated in pregnancy.