Chapter 007. Medical Disorders during Pregnancy (Part 7)

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Gastrointestinal and Liver Disease Up to 90% of pregnant women experience nausea and vomiting during the first trimester of pregnancy. Occasionally, hyperemesis gravidarum requires hospitalization to prevent dehydration, and sometimes parenteral nutrition is required. Crohn's disease may be associated with exacerbations in the second and third trimesters. Ulcerative colitis is associated with disease exacerbations in the first trimester and during the early postpartum period. Medical management of these diseases during pregnancy is identical to the management in the nonpregnant state (Chap. 289). Exacerbation of gall bladder disease is commonly observed during pregnancy. In part this may be due to pregnancy-induced alteration...

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Chapter 007. Medical Disorders during Pregnancy (Part 7) Gastrointestinal and Liver Disease Up to 90% of pregnant women experience nausea and vomiting during the first trimester of pregnancy. Occasionally, hyperemesis gravidarum requires hospitalization to prevent dehydration, and sometimes parenteral nutrition is required. Crohn's disease may be associated with exacerbations in the second and third trimesters. Ulcerative colitis is associated with disease exacerbations in the first trimester and during the early postpartum period. Medical management of these diseases during pregnancy is identical to the management in the nonpregnant state (Chap. 289).
Exacerbation of gall bladder disease is commonly observed during pregnancy. In part this may be due to pregnancy-induced alteration in the metabolism of bile and fatty acids. Intrahepatic cholestasis of pregnancy is generally a third-trimester event. Profound pruritus may accompany this condition, and it may be associated with increased fetal mortality. It has been suggested that placental bile salt deposition may contribute to progressive uteroplacental insufficiency. Therefore, regular fetal surveillance should be undertaken once the diagnosis of intrahepatic cholestasis is made. Favorable results with ursodiol have been reported. Acute fatty liver is a rare complication of pregnancy. Frequently confused with the HELLP syndrome (see "Preeclampsia," above) and severe preeclampsia, the diagnosis of acute fatty liver of pregnancy may be facilitated by imaging studies and laboratory evaluation. Acute fatty liver of pregnancy is generally characterized by markedly increased levels of bilirubin and ammonia and by hypoglycemia. Management of acute fatty liver of pregnancy is supportive; recurrence in subsequent pregnancies has been reported. All pregnant women should be screened for hepatitis B. This information is important for pediatricians after delivery of the infant. All infants receive hepatitis B vaccine. Infants born to mothers who are carriers of hepatitis B surface antigen should also receive hepatitis B immune globulin as soon after birth as possible and
preferably within the first 72 h. Screening for hepatitis C is recommended for individuals at high risk for exposure. Infections Bacterial Infections Other than bacterial vaginosis, the most common bacterial infections during pregnancy involve the urinary tract (Chap. 282). Many pregnant women have asymptomatic bacteriuria, most likely due to stasis caused by progestational effects on ureteral and bladder smooth muscle and later in pregnancy due to compression effects of the enlarging uterus. In itself, this condition is not associated with an adverse outcome of pregnancy. However, if asymptomatic bacteriuria is left untreated, symptomatic pyelonephritis may occur. Indeed, ~75% of cases of pregnancy-associated pyelonephritis are the result of untreated asymptomatic bacteriuria. All pregnant women should be screened with a urine culture for asymptomatic bacteriuria at the first prenatal visit. Subsequent screening with nitrite/leukocyte esterase strips is indicated for high-risk women, such as those with sickle cell trait or a history of urinary tract infections. All women with positive screens should be treated. Abdominal pain and fever during pregnancy create a clinical dilemma. The diagnosis of greatest concern is intrauterine amniotic infection. While amniotic infection most commonly follows rupture of the membranes, this is not always the
case. In general, antibiotic therapy is not recommended as a temporizing measure in these circumstances. If intrauterine infection is suspected, induced delivery with concomitant antibiotic therapy is generally indicated. Intrauterine amniotic infection is most often caused by pathogens such as Escherichia coli and group B streptococcus. In high-risk patients at term or in preterm patients, routine intrapartum prophylaxis of group B streptococcal (GBS) disease is recommended. Penicillin G and ampicillin are the drugs of choice. In penicillin-allergic patients, clindamycin is recommended. For the reduction of neonatal morbidity due to GBS, universal screening of pregnant women for GBS between 35 and 37 weeks gestation with intrapartum antibiotic treatment of infected women is recommended. Postpartum infection is a significant cause of maternal morbidity and mortality. While rare after vaginal delivery, postpartum endomyometritis develops in 5% of patients having elective repeat cesarean section and in 25% of patients after emergency cesarean section following prolonged labor. Prophylactic antibiotics should be given to all patients undergoing cesarean section. As most cases of postpartum endomyometritis are polymicrobial, broad-spectrum antibiotic coverage with a penicillin, aminoglycoside, and metronidazole is recommended (Chap. 157). Most cases resolve within 72 h. Women who do not respond to antibiotic treatment for postpartum endomyometritis should be evaluated for septic pelvic thrombophlebitis. Imaging studies may be helpful in establishing the
diagnosis, which is primarily a clinical diagnosis of exclusion. Patients with septic pelvic thrombophlebitis generally have tachycardia out of proportion to their fever and respond rapidly to intravenous administration of heparin. All patients are screened prenatally for gonorrhea and chlamydial infections, and the detection of either should result in prompt treatment. Ceftriaxone and azithromycin are the agents of choice (Chaps. 137 and 169). Viral Infections Cytomegalovirus Infection Viral infection in pregnancy presents a significant challenge. The most common cause of congenital viral infection in the United States is cytomegalovirus (CMV) (Chap. 175). As many as 50–90% of women of childbearing age have antibodies to CMV, but only rarely does CMV reactivation result in neonatal infection. More commonly, primary CMV infection during pregnancy creates a risk of congenital CMV. No currently accepted treatment of CMV during pregnancy has been demonstrated to protect the fetus effectively. Moreover, it is impossible to predict which fetus will sustain life-threatening CMV infection. Severe CMV disease in the newborn is characterized most often by petechiae, hepatosplenomegaly, and jaundice. Chorioretinitis, microcephaly, intracranial calcifications, hepatitis, hemolytic anemia, and purpura may also
develop. CNS involvement, resulting in the development of psychomotor, ocular, auditory, and dental abnormalities over time, has been described.