Hyperemesis,gastrointestinal and liver disorders in pregnancy

Pregnant women may be affected by diseases of the gastrointestinal tract or liver. These disorders can be related or unrelated to pregnancy. Conditions unrelated to pregnancy can be pre-existing or co-incident. These diseases have varying effects on obstetric outcome. Severe liver disease in pregnancy is rare. We present some common gastrointestinal and liver disorders focussing on the diagnosis, management and effects on pregnancy outcomes.     

Pregnancy with an artificial pacemaker

Complete heart block in pregnancy is not a common encounter. The first case was reported in 1914 by Nanta and today some 100 cases are documented. Heart block may be congenital or acquired secondary to cardiac surgery, rheumatic heart disease, or infective disorders. Heart block, whether congenital or acquired, rarely creates any special obstetric problems. Today there is an increasing use of cardiac pacemakers in younger people and the first reported obstetric experience with a cardiac pacemaker implanted before pregnancy was by Shouse and Acker. This review will document the course and outcome of all reported pregnancies in women conceiving with an artificial pacemaker, and discuss complications and principles of management. We will also report our experience with a woman suffering from a complete heart block in whom an internal cardiac pacemaker was inserted before pregnancy.     

Pregnancy,work conditions and obstetric outcomes: Methodological issues and advice for further research

Abstract

The possible effects of work on women's health during pregnancy are frequently measured by looking at obstetric outcome. The relationship between working conditions and obstetric outcome is interesting but not straightforward. This paper briefly reviews some of the methodological issues that may influence the measurement of outcome, for example psychosocial factors, the nature of obstetric care, pre-existing treatment for infertility and epidemiology. In addition, the paper provides some suggestions for future research in the area of pregnancy and work.     

Medical disorders in pregnancy, including hypertensive diseases

Medical disorders, including hypertensive diseases, may exist prior to pregnancy (eg, connective tissue diseases, chronic hypertension, thyroid disease) or may manifest themselves for the first time during pregnancy (eg, gestational diabetes, gestational hypertension). The outcome for a particular pregnancy will depend on the nature of the disease, the severity of the disease process at onset of pregnancy, and the quality of obstetric and medical management used. Management of pregnancies with preexisting medical disorders should begin before conception. These women should be evaluated to determine the severity of the disorder and to establish the presence of possible target organ damage. In addition, they should be counseled regarding the potential adverse effects of the disease on pregnancy outcome and the effects of pregnancy on their disease. These women should be instructed regarding the importance of early onset of prenatal care and compliance with frequent prenatal visits.     

Assessment and Management of Cardiac Disease in Pregnancy

Approximately 1% of pregnancies are affected by congenital or acquired cardiac disease. The obstetric care provider requires an understanding of the expected cardiorespiratory adaptations to pregnancy in order to anticipate when and how the cardiac patient may decompensate. Although the majority of women with cardiac disease in pregnancy can expect a positive outcome, women should be evaluated for predictors of poor perinatal outcome to aid in determining the appropriate location for and surveillance in labour. Women affected with congenital heart disease require counselling about the risk of recurrence in their offspring. The discussion of contraceptive needs for the woman with cardiac disease is critical in the appropriate planning of her family.     

产科感染性休克的诊治

感染性休克是导致孕产妇死亡的重要原因。产科感染性休克可诱发早产、胎儿宫内感染的发生。妊娠期脓毒症起病隐匿,可迅速进展为感染性休克、多器官功能障碍乃至死亡。产科感染性休克的诊治依赖早期发现、及时识别感染源和有针对性的早期目标靶向治疗,包括1 h内启动容量复苏、经验性静脉使用抗生素、血流动力学监测等。感染科医师、熟悉妊娠期生理变化的重症监护医师及产科医师等多学科医师协作可以改善预后。     

Pregnancy in women with renal disease. Part II: specific underlying renal conditions

The obstetric outcome in women with kidney disease has improved in recent years due to continuous progress in obstetrics and neonatology, as well as better medical management of hypertension and renal disease. However, every pregnancy in these women remains a high-risk pregnancy. When considering the interaction between renal disease and pregnancy, maternal outcomes are related to the initial level of renal dysfunction more than to the specific underlying disease. With regards to fetal outcomes, though, a distinction may exist between renal dysfunction resulting from primary renal disease and that in which renal involvement is part of a systemic disease. In part II of this review, some specific causes of renal failure affecting pregnancy are considered.     

Imitators of severe pre-eclampsia/eclampsia

Several microangiopathic disorders that are encountered during pregnancy provide physicians with a formidable diagnostic challenge. Severe pre-eclampsia with hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome and many other obstetric and medical or surgical conditions produce similar clinical presentations and laboratory study results to pre-eclampsia. Pre-eclampsia is frequently superimposed on one of the above disorders, further confounding an already difficult differential diagnosis. Because of the remarkably similar clinical and laboratory findings of these disease processes, even the most experienced physician will face a diagnostic challenge. An effort should be made to make an accurate diagnosis, given the fact that management strategies and outcome may differ among these conditions.     

Immune thrombocytopenic purpura in pregnancy: the ongoing debate surrounding obstetric management

Thrombocytopenia is a common hematologic complication of pregnancy. Most cases are the result of gestational thrombocytopenia, which poses no threat to mother or fetus. In contrast, other cases may be secondary to immune thrombocytopenic purpura (ITP), which may cause significant hemorrhagic morbidity in both. For this reason, diagnosing and treating ITP in pregnancy is important. The medical management of the disease is well established and has changed little. Conversely, obstetric management protocols have changed a great deal as our perception of fetal risk has been altered. Throughout the 1990s, many authors have reviewed the literature and challenged the existing belief that ITP is frequently associated with significant fetal morbidity. This has forced a revision of previous obstetric management recommendations. Despite evidence provided by these recent reviews, obstetric management of ITP in pregnancy remains an area of considerable controversy.     

Hyperemesis gravidarum,gastrointestinal and liver disease in pregnancy

Up to 80% of pregnant women experience discomfort due to symptoms originating from the gastrointestinal tract; ∼5% of them have more severe disease that can adversely affect maternal and fetal outcome. This review presents options of symptomatic relief for the common complaints of the gastrointestinal tract. It also discusses the management of the commonest or most serious conditions of the gastrointestinal tract and liver that can coexist or appear for the first time in pregnancy.     

Gastrointestinal disease

Gastrointestinal diseases in pregnancy can be divided into diseases specific to pregnancy, for example, hyperemesis gravidarum, obstetric cholestasis, HELLP syndrome and acute fatty liver of pregnancy, and diseases incidental to pregnancy, for example, inflammatory bowel disease, dyspepsia, peptic ulcer disease and viral hepatitis. Disorders in the second category may present for the first time in pregnancy. This chapter considers the drug management of each of these conditions, with the exception of HELLP syndrome and acute fatty liver. The preferred drug treatment and the known complications associated with their use in pregnancy are also described. Where possible, studies relating to the safety of different therapeutic options are discussed.     

Drugs in pregnancy. Gastrointestinal disease.

Gastrointestinal diseases in pregnancy can be divided into diseases specific to pregnancy, for example, hyperemesis gravidarum, obstetric cholestasis, HELLP syndrome and acute fatty liver of pregnancy, and diseases incidental to pregnancy, for example, inflammatory bowel disease, dyspepsia, peptic ulcer disease and viral hepatitis. Disorders in the second category may present for the first time in pregnancy. This chapter considers the drug management of each of these conditions, with the exception of HELLP syndrome and acute fatty liver. The preferred drug treatment and the known complications associated with their use in pregnancy are also described. Where possible, studies relating to the safety of different therapeutic options are discussed.     

妊娠合并抗磷脂综合征的诊治

抗磷脂综合征（antiphospholipid syndrome,APS）是一种由抗磷脂抗体引起的非炎症性自身免疫病。妊娠合并APS易发生早期反复自然流产,孕晚期胎死宫内,胎儿生长受限,血小板减少,子痫前期或子痫以及胎盘功能障碍等不良妊娠结局,严重危及母儿健康。临床上应充分重视妊娠合并APS的诊断和治疗。     

Acute fatty liver of pregnancy with survival of mother and child: a case report.

A case of acute fatty liver of pregnancy (obstetric acute yellow atrophy or acute fatty metamorphosis of the liver) is reported in which cesarean section was made and both mother and child survived. The authors suggest that the prognosis was improved by rapid termination of pregnancy. The course of the disease, differential diagnosis, treatment and prognosis are discussed.     

Connective tissue and dermatological disorders in pregnancy

Connective tissue disorders, particularly those that are autoimmune, are being seen with increasing frequency in the pregnant population. The care of these patients in pregnancy ranges from the routine to the complicated, with some of the conditions posing significant risks both to the mother and the fetus. Dermatological conditions are often encountered in pregnancy, and again range from the benign to those resulting in serious fetal and maternal morbidity, with a number being specific to pregnancy. An important issue for both groups of disorders is the use of particular medications during pregnancy. Those with pre-existing disease should ideally be counselled pre-pregnancy to optimize treatment and adjust medication as appropriate. During pregnancy, frequency of review and degree of treatment will depend on the severity of the condition, and may require multidisciplinary team involvement to optimize both maternal and fetal outcome, including obstetric physicians, obstetricians, anaesthetists, neonatologists, and geneticists.     

Antenatal detection of abnormal liver function tests - a marker for poor perinatal outcome.

The purpose of this study was to examine (a) the incidence of liver disease diagnosed in our antenatal population, (b) the diagnostic value of initial symptoms and liver function tests (LFTs), (c) the adequacy of investigation and management of the liver disorder and (d) the obstetric and neonatal outcome in this group of patients. Women with abnormal LFTs that delivered at our hospital over a 2-year period were identified from computerised hospital records and data was obtained from chart review. Forty-six out of a total of 13 181 (0.35%) women had liver disease diagnosed in pregnancy: Diagnoses included intrahepatic cholestasis of pregnancy (13), pre-eclampsia and the HELLP syndrome (eight), acute fatty liver of pregnancy (three), hyperemesis gravidarum (one), hepatitis C (13), B (four) and hepatitis A (one), cholelithiasis (two) and hepatitis of unknown aetiology (one). Symptoms at presentation were more predictive of the final diagnosis than the initial LFT profile. Investigation of the liver disorder was incomplete in 50% of cases.One mother required intensive care for 6 weeks postpartum and three others had significant postpartum haemorrhage. There was one neonatal death and 24 neonates were admitted to the special care baby unit. Eighteen women attended for their postnatal check up at 6 weeks. Eight of these women were referred to a hepatologist. Detection of liver disease in pregnancy identifies a group at risk of poor neonatal and maternal outcome. Structured guidelines should be implemented in obstetric units to facilitate appropriate investigation, treatment and referral patterns for these women.     

Sickle cell disease in pregnancy

With advances in management, many women with sickle cell disease now survive to have children. The high risk of fetal and maternal sequelae mandates multidisciplinary management involving an obstetrician, a haematologist, an anaesthetist and a haemoglobinopathy specialist nurse. Hydroxyurea, a new treatment for sickle cell disease, is contraindicated in pregnancy. Exchange transfusion may be indicated in women with a serious obstetric or haematological complications. In those with sickle cell disease, the entire pregnancy is a high-risk period that warrants close monitoring. It is thus important for every obstetrician to be familiar with the condition.     

Hepatitis C virus infection in pregnancy

Objective To evaluate the clinical aspects of hepatitis C virus (HCV) liver disease in anti-HCV + ve mothers, both during pregnancy and six months after delivery, and to assess the outcome of pregnancy.
Setting Obstetric department for high risk pregnancies of the University of Padova, Italy.
Participants Seventeen hundred consecutive pregnant women were studied.
Methods Each woman underwent the following: 1. serological screening for hepatitis surface antigen (HBsAg), antibodies to HCV (anti-HCV), antibodies to human immunodeficiency virus type 1 (HIVI) within the first trimester of pregnancy; and 2. clinico-biochemical assessment in order to ascertain previous or active liver disease and risk factors for viral infections.
Results Twenty-nine (1.7%) of the 1700 women were found anti-HCV positive. Eight of them had an associated positivity for HIV infection. HCV-RNA was positive in 64.2% of anti-HCV positive women. Liver function tests (included transaminases) were within the normal range in 27 mothers (both during and six months after delivery). Only 2/29 women had a slight increase in AST/ALT; liver biopsy in these cases was compatible with mild chronic active hepatitis. In all women the outcome of pregnancy was favourable (12/29 anti-HCV positive mothers underwent caesarean delivery for causes independent from HCV infection).
Conclusions A substantial proportion of anti-HCV positive pregnant mothers, even if asymptomatic, have circulating HCV-RNA. The pregnancy does not induce a deterioration of liver disease, and vice versa, HCV infection does not increase the risk of obstetric complications.     

Obstetric outcome in women with endometriosis--a matched case-control study

BACKGROUND: Immunological deficiencies, altered angiogenic activity, infiltrative potential and growth factors are plausible factors behind endometriosis. The aim of this study was to determine whether endometriosis interferes with the course or outcome of pregnancy. STUDY DESIGN: In this matched case-control study, we analyzed obstetric outcome among 137 women with endometriosis and 137 controls matched as regards IVF procedures and parity who gave singleton births at Kuopio University Hospital between January 1994 and December 2000. In affected women, the diagnosis was histologically verified, whereas the controls were eligible for the study only if they had undergone laparoscopy/tomy in connection with tubal sterilization, or infertility unrelated to endometriosis. RESULTS: No statistically significant differences were detected in reproductive risk factors in women with endometriosis, with the exception of mean maternal age (31.2 years in the cases vs. 34 years in the controls). The mean birth weight (+/-SD) among those delivering at term (>37 completed weeks) was 3,600 (+/-542) g in the control group and 3,547 (+/-456) g in the study group. Placental weight was comparable in both groups. Overall pregnancy characteristics and pregnancy outcome measures were similar in women affected by endometriosis when compared with the control group. CONCLUSIONS: Any potential negative effect of endometriosis on obstetric outcome was undetectable.     

Fliegen während der Schwangerschaft

The effects of flying on pregnancy – whether as an airline passenger, cabin or flight deck crew, air force pilot, or astronaut – are reviewed in terms of their impact on fetal and maternal health. Based on theories of altitude physiology and experiments with pregnant women under actual flying conditions in modern jets, it has been shown that flying does not impair the fetal oxygen supply. The cosmic radiation burden is too low in occasional fliers to warrant anything other than the unreserved recommendation of flying as an appropriate method of travel during pregnancy. The few relative contraindications comprise flying near term, a history of miscarriage and premature labor, marked anemia, cardiopulmonary disease, and extreme fear of flying. Major obstetric risk factors, e.g., placenta previa, are absolute contraindications. As for airline crew, the risk from added occupational exposure to cosmic radiation must be weighed against the practical disadvantages of systematically grounding pregnant personnel. Many airlines have no such policy in force, and protection against such radiation is not covered in national legislations (in Germany, either measure would be redundant in that the Protection of Mothers Law already bans shift work during pregnancy). As for the multiply greater and more varied stresses confronted by air force pilots and astronauts, a preoperational negative pregnancy test remains standard on common sense safety grounds despite the isolated report of a normal pregnancy outcome in a NASA pilot flying until the 36th week.