Medical disorders in pregnancy

Although there is still controversy regarding the management of these patients, the therapy and testing that is now available enables us to formulate a reasonable individualized management plan. The maternal platelet count should be monitored carefully during pregnancy and treated according to the prior information. In addition, platelet antibodies may assist in predicting more effectively the potentially affected fetuses. In these cases, deliveries by cesarean section should be considered. If a fetal scalp platelet count is possible at the onset of labor, this should be performed, and if the count is less than 50,000 per mm3, the fetus should be delivered by immediate cesarean section. Clearly, it is necessary to have facilities available for immediate cesarean section prior to performing the platelet count. The use of steroid therapy near term appears to have a beneficial effect on the neonatal platelet count and should be strongly considered. Further information relating to the neonatal effects of high-dose intravenous immunoglobulin therapy may indicate this as a preferential prophylactic form of fetal therapy that may be available prior to delivery.     

Hypertension in pregnancy

Any pregnancy complicated by hypertension must be considered to be at increased risk. Proper management dictates early diagnosis, liberal use of hospitalization, appropriate antihypertensive therapy, and timely intervention with consideration being given to maternal and fetal compromise if the pregnancy is allowed to continue. Unfortunately, the decision as to the proper timing for delivery is not always easily made, especially if the fetus is premature and there is an absence of compelling complications. Consequently, the liberal use of perinatal referral sources in these cases is both appropriate and indicated. Fortunately, the diligence and the care employed by the physician in dealing with these patients can be expected to be rewarded by a good outcome for both mother and infant.     

Prophylactic use of antimalarials during pregnancy

Question Some of my pregnant patients wish to travel to malaria-endemic regions. Are there medications that can be used safely during pregnancy for malaria prophylaxis?Answer Pregnant women should avoid travel to malaria-endemic areas if possible. However, if travel cannot be avoided, measures to prevent mosquito bites, along with an effective chemoprophylaxis regimen, should be implemented. Chloroquine or hydroxychloroquine are considered safe to use in all trimesters of pregnancy. Mefloquine is the agent of choice for chloroquine-resistant areas, and evidence suggests it is not associated with an increased risk to the fetus. Although the atovaquone-proguanil drug combination is not currently recommended for use during pregnancy, limited data suggest that it is not harmful to the fetus. Doxycycline and primaquine are not recommended during pregnancy.     

Acute hypertensive crisis in pregnancy

Severe pre-eclampsia is a state of acute afterload increase where compensation may be total by use of the Frank-Starling mechanism and/or increased adrenergic drive, or may be uncompensated in a patient with limited or exhausted preload reserve. As such, we are presented with a diverse group of patients and antihypertensive therapy ideally should be individualized. In reality we are dealing with a complex situation because of the presence of the fetus raising concerns about direct effects on the fetus as well as on uteroplacental blood flow. This limits our choice of agents to those with extensive use in pregnancy except in complicated or resistant cases. For these reasons, hydralazine is the antihypertensive agent of choice for treatment of acute hypertensive emergencies in pregnancy. In the complicated case other agents such as sodium nitroprusside or nitroglycerin may be more appropriate and, in these cases, hemodynamic monitoring should be performed to allow not only greater safety, but also to tailor therapy to the individual hemodynamic profile.     

Caring for the mother, concentrating on the fetus: intravenous N-acetylcysteine in pregnancy

Acetaminophen is one of the most common toxicities in pregnancy, thus providers should be aware of treatment options. We use a case presentation to demonstrate the successful use of a 20-hour protocol of intravenous N-acetylcysteine. A 26-year-old woman, gravid3para1102, at an estimated gestational age of 32 weeks 2 days presented with a reported ingestion of 9.75 g of acetaminophen 1.5 hours before arrival. The patient was treated with activated charcoal and intravenous N-acetylcysteine. After brief inpatient admission and management, the patient went on to deliver a full-term infant without further sequelae. Acetaminophen toxicity in pregnancy can be treated successfully with intravenous N-acetylcysteine if used in a timely manner with minimal adverse affects on the fetus and mother.     

Acute therapy of maternal and fetal arrhythmias during pregnancy

Atrial premature beats are frequently diagnosed during pregnancy. Supraventricular tachycardia (atrial tachycardia, atrioventricular nodal reentrant tachycardia, circus movement tachycardia) is diagnosed less frequently. For acute therapy, electrical cardioversion with 50 to 100 J is indicated in all unstable patients. In stable supraventricular tachycardia, the initial therapy includes vagal maneuvers to terminate tachycardias. For short-term management, when vagal maneuvers fail, intravenous adenosine is the first choice drug and may safely terminate the arrhythmia. Ventricular premature beats are also frequently present during pregnancy and are benign in most patients; however, malignant ventricular tachyarrhythmias (sustained ventricular tachycardia, ventricular flutter, or ventricular fibrillation) may occur. Electrical cardioversion is necessary in all patients who are hemodynamically unstable with life-threatening ventricular tachyarrhythmias. In hemodynamically stable patients, initial therapy with ajmaline, procainamide, or lidocaine is indicated. In patients with syncopal ventricular tachycardia, ventricular fibrillation, ventricular flutter, or aborted sudden death, an implantable cardioverter-defibrillator is indicated. In patients with symptomatic bradycardia, a pacemaker can be implanted using echocardiography at any stage of pregnancy. The treatment of the pregnant patient with cardiac arrhythmias requires important modifications of the standard practice of arrhythmia management. The goal of therapy is to protect the patient and fetus through delivery, after which chronic or definitive therapy can be administered.     

Smoking cessation therapy during pregnancy

Question Despite being highly motivated to quit, many of my patients struggle with smoking cessation during pregnancy. Can you comment on the current treatment options and discuss their safety and efficacy during pregnancy?Answer Given the considerable and well-documented adverse effects of antenatal smoking on mother and fetus, pharmacotherapy for smoking cessation should be considered. Available medications include nicotine replacement therapy, sustained-release bupropion, and varenicline. Nicotine replacement therapy and bupropion do not appear to increase the risk of major malformations; however, there is currently limited evidence on the use of varenicline during pregnancy. Given that these agents are only marginally successful in smoking cessation, their use should always be accompanied by behavioural counseling and education to maximize quit rates.     

Antiarrhythmic drugs in pregnancy

The risk of arrhythmia development or recurrence is increased during pregnancy. For those arrhythmias that are unresponsive to conservative therapy, such as vagal maneuvers or life style interventions, or that present a higher risk to the mother or fetus, medical therapy may be necessary. In each case, the patient and provider must carefully consider the risks and benefits of a particular therapy. This requires an understanding of the data regarding the safety and efficacy of any particular drug, which in some cases may be extensive and in others quite limited. Fortunately, options exist for the treatment of arrhythmias during pregnancy.     

Headaches in pregnancy

Most women with migraine improve during pregnancy. Some women have their first attack. Migraine often recurs postpartum and can begin for the first time. Drugs are commonly used during pregnancy despite insufficient knowledge about their effects on the growing fetus. Most drugs are not teratogenic. Adverse effects, such as spontaneous abortion, developmental defects and various postnatal effects depend on the dose and route of administration and the timing of the exposure relative to the period of foetal development. While medication use should be limited, it is not absolutely contraindicated in pregnancy. Nonpharmacologic treatment is the ideal solution; however, analgesics such as acetaminophen and opioids can be used on a limited basis. Preventive therapy is a last resort.     

Pelvic inflammatory disease during pregnancy

Pelvic inflammatory disease associated with pregnancy is not commonly reported. We present three illustrative cases at ten, 13, and 26 weeks of gestation. Unlike pelvic abscess, which may be discovered at any stage of gestation, acute salpingitis during pregnancy occurs more commonly in the first trimester. Both processes are associated with substantial fetal wastage. Diagnosis may be difficult if the obstetrician is not aware that these infections can occur during pregnancy. The diagnosis is often made at laparotomy by a physician expecting appendicitis or another inflammatory condition. Since salpingitis during pregnancy, like salpingitis generally, is amenable to antibiotic therapy, surgery may be avoided if appropriate antibiotic therapy is quickly instituted. The pregnant patient and her fetus may be spared general anesthesia and the attendant risks of abdominal surgery.     

如何重新评价与解释围产期TORCH感染筛查

妊娠期TORCH感染代表以病毒及其他微生物引起的一组围产期感染性疾病.在我国20多年前进行血清筛查后,较为明确地认为,TORCH感染对胎、婴儿危害较大,同时已具有较成熟的诊断与治疗手段.因此,必须对乙型病毒性肝炎、梅毒、HIV感染等做早孕期,甚至孕前筛查.对风疹的筛查最好在孕前进行,如风疹IgM+则不必处理;如阴性,最好在获得免疫力后再妊娠.然而,现不主张对巨细胞病毒感染、弓形虫病、单纯疱疹等病做孕期筛查.因这3种病原体感染所导致胎儿异常,可行孕期超声检查,并进一步行羊水或脐血穿刺查病原体以确诊.     

Preconception health care

Appropriate preconception health care improves pregnancy outcomes. When started at least one month before conception, folic acid supplements can prevent neural tube defects. Targeted genetic screening and counseling should be offered on the basis of age, ethnic background, or family history. Before conception, women should be screened for human immunodeficiency virus and syphilis infection and begin treatment to prevent the transmission of disease to the fetus. Immunizations against hepatitis B, rubella, and varicella should be completed, if needed. Women should be counseled on ways to prevent infection with toxoplasmosis, cytomegalovirus, and parvovirus B19. Environmental toxins such as cigarette smoke, alcohol, and street drugs, and chemicals such as solvents and pesticides should be avoided. In women with diabetes, it is important to optimize disease control through intensive management before pregnancy. Medications for hypertension, epilepsy, thromboembolism, depression, and anxiety should be reviewed and changed, if necessary, before the patient becomes pregnant. Counseling about exercise, obesity, nutritional deficiencies, and the overuse of vitamins A and D is beneficial. Physicians may also choose to discuss occupational and financial issues related to pregnancy and to screen patients for domestic violence.     

Safety of radiographic imaging during pregnancy

Maternal illness during pregnancy is not uncommon and sometimes requires radiographic imaging for proper diagnosis and treatment. The patient and her physician may be concerned about potential harm to the fetus from radiation exposure. In reality, however, the risks to the developing fetus are quite small. The accepted cumulative dose of ionizing radiation during pregnancy is 5 rad, and no single diagnostic study exceeds this maximum. For example, the amount of exposure to the fetus from a two-view chest x-ray of the mother is only 0.00007 rad. The most sensitive time period for central nervous system teratogenesis is between 10 and 17 weeks of gestation. Nonurgent radiologic testing should be avoided during this time. Rare consequences of prenatal radiation exposure include a slight increase in the incidence of childhood leukemia and, possibly, a very small change in the frequency of genetic mutations. Such exposure is not an indication for pregnancy termination. Appropriate counseling of patients before radiologic studies are performed is critical.     

Interferon therapy for acute hepatitis C during pregnancy

OBJECTIVE: Due to their antiproliferative activity, the probable effects of interferons on a fetus are a concern. We report on a pregnant patient who developed acute hepatitis C during pregnancy and was treated with a short course of interferon alfa therapy with a successful outcome. CASE SUMMARY: A 26-year-old woman was diagnosed with acute hepatitis C at the 16th week of pregnancy. She received a total dose of 72 million units of interferon alfa-2b during a 2 1/2 month period. Although the therapy was discontinued due to adverse effects, a complete biochemical and virologic response was obtained. Premature labor occurred and healthy, but growth-restricted, twin infants were born transvaginally. At 18 months of age, they had normal development, with a negative hepatitis C serology. DISCUSSION: The rate of transmission of hepatitis C virus from mother to infant is within the range of 1-5%. Although acute hepatitis C during pregnancy is a very rare occurrence, the mother is at a great risk for chronic infection. There is scarce literature about the probable effects of interferon use during pregnancy due to a lack of controlled studies in this special population. A total of 8 infants, including ours, exposed to interferon alfa and/or ribavirin during pregnancy showed no congenital anomalies or malformations. CONCLUSIONS: Patients with chronic hepatitis whose therapy can be delayed should not be treated with interferon due to a lack of controlled studies. However, women exposed to interferon inadvertently during pregnancy may be encouraged to continue pregnancy. In patients with acute hepatitis C during pregnancy, the use of interferon therapy should be considered with close monitoring.     

Anticonvulsant use during pregnancy

Although antiepileptic medications may play a role in fetal malformations, this risk appears no greater than the risk associated with either the seizures themselves or a change in medication during pregnancy. In general, the number and the dose of antiepileptic medications should be minimized during pregnancy. Potential complications during the pregnancy must be anticipated. Drug levels must be monitored. Because the fetus is at a somewhat higher risk, ultrasound studies may be useful in monitoring the pregnancy. Delivery should take place in a center where appropriate facilities are available if intervention is required during labor or if the baby is malformed. Both the infant and the mother should be monitored closely after the delivery.     

Use of antibiotics during pregnancy

Pregnancy is occasionally complicated by infections that necessitate antibiotic therapy. When considering therapeutic options for pregnant women, both the physiologic changes of pregnancy and the prenatal effects of the drug must be weighed. Antibiotics should be selected with regard to the trimester of pregnancy. Some antibiotics are safe for use throughout pregnancy, while others are completely contraindicated. Choosing the proper antibiotic requires balancing the seriousness of the infection with the antibiotic's safety and antimicrobial activity.     

The early development of neurosonology: II. Fetal and neonatal echoencephalography.

The obscuring effect of the diploe in the skull for attempts to use ultrasonic energy to image the brain is not present in the fetus, neonate or infant prior to ossification of the skull. Initially, however, the fetal examination was largely confined to a single measurement of the size of the skull, usually in the bi-parietal plane, just prior to labour. In this way it became possible to identify immature fetuses where delivery should be delayed as long as possible, as well as cases of cephalo-pelvic disproportion where the large size of the fetal head would make vaginal delivery difficult. Measurements made earlier in pregnancy, in order to predict the gestational age and estimated date of delivery, would only be accurate if all fetal heads were the same size at every gestational age. Similarly, attempts to predict birthweight from the size of the fetal head at any given gestational age foundered both upon the uncertainty of determining the gestational age from the menstrual history and upon the variations in the size of fetuses for various gestational ages. By making serial measurements of fetal head size, the rate of fetal growth can be measured. In this way, it is possible to separate the normal fetus which appeared to be small for its gestational age because the gestational age had been erroneously calculated from the menstrual history, from two clinically important groups. In the first group, the fetus is small and grows abnormally slowly throughout the whole pregnancy because of some congenital defect; and in the second the rate of growth becomes slowed towards the end of pregnancy because the placenta is no longer able to supply the increased nutritional needs of the mature fetus. Where it is not possible to make serial measurements throughout pregnancy, they can often be restricted to two measurements. The first is made in mid-pregnancy and, if the size of the fetal head agrees with that predicted from the menstrual history, it is assumed that the fetus is not abnormally small due to some congenital defect. In such cases the only other examination that needs to be made is another measurement near term to identify cases of placental insufficiency. If the first measurement does not coincide with that expected from the menstrual history, then more frequent measurements should be made in order to separate those normal fetuses in which the gestational age was wrongly calculated from the menstrual history from those fetuses with growth retardation throughout pregnancy due to some abnormality.(ABSTRACT TRUNCATED AT 400 WORDS)     

Anorexia nervosa and bulimia nervosa: chronic conditions affecting pregnancy

Anorexia nervosa and bulimia nervosa primarily affect women who are in the childbearing years. While many anorectic patients are unable to ovulate second to the disruptions of normal body function associated with anorexia, there are still women who will ovulate and become pregnant. Bulimia nervosa may also disrupt the normal menstrual cycle if the disease is very severe. However, many bulimic patients will become pregnant. Both of these disease states cause a decrease in circulating plasma volume, fluid and electrolyte shifts, and other alterations that may increase the risk to a pregnancy and developing fetus. Severe disease states are associated with intrauterine fetal growth retardation (IUGR). The nursing care of the anorectic or bulimic patient who becomes pregnant is specialized and requires coordination between nursing, perinatology, and the psychiatric team, as well as support services including nutritionists. The nursing care of anorectic patients is difficult and requires an understanding of the complex psychological and physical pathophysiology of the disease. Bulimia nervosa also requires a complete understanding of the psychological and pathophysiology of the disease process. This article provides a review of the syndromes, risk factors, definitions of the disease states, and the nursing management of those patients experiencing a pregnancy complicated by the predisposing factors of anorexia nervosa, and/or bulimia nervosa.     

Haemolytic disease of the fetus and newborn due to anti-Fya and the potential clinical value of Duffy genotyping in pregnancies at risk

Haemolytic disease of the newborn (HDN) caused by anti-Fy^a is uncommon and usually mild. Current guidelines recommend that pregnant women with anti-Fy^a are monitored less rigorously than those with anti-D, -c or -K. However, in a review of our recent experience of 68 pregnancies where anti-Fy^a was detected, three were identified where the fetus was severely anaemic; in two cases the fetus received intrauterine transfusions. Our data suggest that pregnancies in which anti-Fy^a is detected at significant titres (> 64) should be closely monitored in a similar way to pregnancies where other 'significant' antibodies are present. Moreover, in the presence of high or rising antibody titres, if the father is heterozygous and functional assays suggest the antibody is active, then fetal genotyping should be offered to help plan the future management of that pregnancy.     

Prevention of perinatal HIV transmission during pregnancy

Transmission of the human immunodeficiency virus (HIV) from mother to child can occur in utero, during labour or after delivery from breastfeeding. The majority of infants are infected during delivery. Maternal HIV-1 plasma viral load at delivery is the most important predictor of vertical transmission. For this reason, efforts to interrupt transmission have focused on the use of antiretroviral therapy. Zidovudine has been shown to reduce significantly vertical HIV transmission when used antepartum and intrapartum by the mother and postpartum by the newborn for 6 weeks. However, zidovudine monotherapy increases the risk of developing zidovudine resistance and may jeopardize the goal of durable viral suppression and allow HIV disease progression in the mother and transmission to the infant. Potent antiretroviral therapy is now recommended for all HIV-infected pregnant women using the same criteria for non-pregnant individuals. If possible, combination antiretroviral regimens should include the use of zidovudine but not at the expense of long-term viral suppression. The use of elective Caesarean section should probably be reserved for women who fail to achieve viral suppression at the time of delivery or if indicated for obstetrical reasons. The practice of breastfeeding has been shown to diminish the long-term efficacy of perinatal antiretroviral therapy. All HIV-infected mothers should avoid breastfeeding the newborn if possible. This review summarizes major prospective and retrospective antiretroviral treatment studies in HIV-infected pregnant women. Pharmacokinetic information as it relates to pregnancy and adverse event profiles of antiretroviral agents are also discussed. The impact of recent advances in the management of HIV infection in pregnancy is discussed with regard to their feasibility in resource-poor countries.