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.Crohns 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...
Nội dung trích xuất từ tài liệu:
Chapter 007. Medical Disorders during Pregnancy (Part 7) Chapter 007. Medical Disorders during Pregnancy (Part 7) Gastrointestinal and Liver Disease Up to 90% of pregnant women experience nausea and vomiting during thefirst trimester of pregnancy. Occasionally, hyperemesis gravidarum requireshospitalization to prevent dehydration, and sometimes parenteral nutrition isrequired. Crohns disease may be associated with exacerbations in the second andthird trimesters. Ulcerative colitis is associated with disease exacerbations in thefirst trimester and during the early postpartum period. Medical management ofthese diseases during pregnancy is identical to the management in the nonpregnantstate (Chap. 289). Exacerbation of gall bladder disease is commonly observed duringpregnancy. In part this may be due to pregnancy-induced alteration in themetabolism of bile and fatty acids. Intrahepatic cholestasis of pregnancy isgenerally a third-trimester event. Profound pruritus may accompany this condition,and it may be associated with increased fetal mortality. It has been suggested thatplacental bile salt deposition may contribute to progressive uteroplacentalinsufficiency. Therefore, regular fetal surveillance should be undertaken once thediagnosis of intrahepatic cholestasis is made. Favorable results with ursodiol havebeen reported. Acute fatty liver is a rare complication of pregnancy. Frequently confusedwith the HELLP syndrome (see Preeclampsia, above) and severe preeclampsia,the diagnosis of acute fatty liver of pregnancy may be facilitated by imagingstudies and laboratory evaluation. Acute fatty liver of pregnancy is generallycharacterized by markedly increased levels of bilirubin and ammonia and byhypoglycemia. 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 isimportant for pediatricians after delivery of the infant. All infants receive hepatitisB vaccine. Infants born to mothers who are carriers of hepatitis B surface antigenshould also receive hepatitis B immune globulin as soon after birth as possible andpreferably within the first 72 h. Screening for hepatitis C is recommended forindividuals at high risk for exposure. Infections Bacterial Infections Other than bacterial vaginosis, the most common bacterial infections duringpregnancy involve the urinary tract (Chap. 282). Many pregnant women haveasymptomatic bacteriuria, most likely due to stasis caused by progestationaleffects on ureteral and bladder smooth muscle and later in pregnancy due tocompression effects of the enlarging uterus. In itself, this condition is notassociated with an adverse outcome of pregnancy. However, if asymptomaticbacteriuria is left untreated, symptomatic pyelonephritis may occur. Indeed, ~75%of cases of pregnancy-associated pyelonephritis are the result of untreatedasymptomatic bacteriuria. All pregnant women should be screened with a urineculture for asymptomatic bacteriuria at the first prenatal visit. Subsequentscreening 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. Allwomen with positive screens should be treated. Abdominal pain and fever during pregnancy create a clinical dilemma. Thediagnosis of greatest concern is intrauterine amniotic infection. While amnioticinfection most commonly follows rupture of the membranes, this is not always thecase. In general, antibiotic therapy is not recommended as a temporizing measurein these circumstances. If intrauterine infection is suspected, induced delivery withconcomitant antibiotic therapy is generally indicated. Intrauterine amnioticinfection is most often caused by pathogens such as Escherichia coli and group Bstreptococcus. In high-risk patients at term or in preterm patients, routineintrapartum 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 toGBS, universal screening of pregnant women for GBS between 35 and 37 weeksgestation with intrapartum antibiotic treatment of infected women isrecommended. Postpartum infection is a significant cause of maternal morbidity andmortality. While rare after vaginal delivery, postpartum endomyometritis developsin 5% of patients having elective repeat cesarean section and in 25% of patientsafter emergency cesarean section following prolonged labor. Prophylacticantibiotics should be given to all patients undergoing cesa ...