Chapter 007. Medical Disorders during Pregnancy (Part 7) docx

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.