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maturity).
Indicationsfor D eliveryinP reeclampsia
Maternali ndications Gestationalagegreaterthan
orequal to38w eeksofgesta­
tion
Plateletcountl essthan
100,000cel lsperm m3
Deterioratingl iverfuncti on
Progressivedeteri orationi n
renalfuncti on
Abruptiopl acentae
Persistentsevereheadaches
orvi sualchanges
Persistentsevereepi gastric
pain,nausea,orvom iting
Fetali ndications Severefetal grow threstri ction
Nonreassuringresul tsfrom
fetaltesting
Oligohydramnios
G. Route of de livery. D elivery i s usual ly by the vagi nal
route, with cesarean del ivery reserved for obstetri cal
indications. C ervical ri pening a gents ma y b e u sed i f
thecervi xi snotfavorabl e.
H. Anticonvulsantther apy
1. Anticonvulsanttherapy i s initiated duringl aborunti l
24 to 48 hours postpartum . M agnesium sul fate i s
thedrugofchoi ceforsei zurepreventi on.
2. Magnesium r egimen. A l oading dose of 6 g
intravenously i s gi ven, fol lowed by 2 g/h as a
continuousi nfusion.
I. Postpartum c ourse. Hypertension due to
preeclampsia resolves postpartum,oftenw ithinafew
days,butsom etimestak esafew w eeks.
V. Management ofeclam psia
A. Maintenance of ai rway patency and preventi on of
aspiration are the i nitial m anagement priorities. T he
patient shoul d be rolled onto her l eft si de and a pad­
dedtonguebl adepl acedi nherm outh,i fpossi ble.
B. Controlofconv ulsions. Magnesium sulfate, 2to4g
IVpushrepeatedevery 15 minutes toam aximumof6
g.M aintenancedose ofm agnesiumsulfate: 2to3
g/hour by continuousi ntravenousi nfusion.D iazepam
may al so be gi ven as 5 m g I V push repeated as
needed to a m aximum cum ulative dose of 20 m g to
stoptheconvul sions;how ever,benz odiazepines have
profounddepressanteffectsonthefetus.
VI. Preexistenthy pertension
A. Methyldopa (Aldomet) has beenm ostw idelyusedand
long-termsafety tothefetushasbeencl earlydem on­
strated. A CE i nhibitors shoul d not be conti nued i n
pregnancy. ß-bl ockers are general ly safe, al though
they m ay i mpair fe tal grow th w hen used earl y i n
pregnancy,parti cularlyatenol ol.T hiazide diuretics can
beconti nuedasl ongasvol umedepl etion is avoided.
TreatmentofH ypertensioni nP regnancy
Drug Dose
Methyldopa 250m gB IDoral ly,m aximumdose4
(Aldomet) g/day
Labetalol 100m gB IDoral ly,m aximumdose
(Trandate) 2400m g/day
B. Risksofchr onich ypertension. Chronichy pertension
is associ ated w ith a th reefold i ncrease i n peri natal
mortality,atw ofoldi ncreasei nabrupti o placentae, and
an i ncreased rate of i mpaired fetal growth. T here i s
alsoahi gher rate of pretermdel iverybefore35w eeks
ofgestati on.
C. Indications for tr eatment. I ndications for
antihypertensive therapy are a di astolic press ure
persistentlyabove100m m Hg, systolicpressure> 150
to 180 m m Hg or signs of hy pertensive end-o rgan
damage. S evere hy pertension (bl ood pressure of
180/110 m mHg or higher) requi res i ntravenous ther­
apy. Hydralazine andl abetalolarethedrugsofchoi ce
fori ntravenousadm inistration.
D. Fetal surveillance is w arranted w hen there i s
preeclampsia or i ntrauterine growth restriction. S erial
sonographic assessm ent of fetal grow th i s i ndicated,
with nonstress testi ng or bi ophysical profi le examina­
tion w eeklystarti ng at 28 w eeks, i ncreasing to tw ice­
weeklyat32w eeks.
E. Delivery. W oman w ith m ild, uncom plicated chroni c
hypertension can be al lowed to go i nto spon taneous
labor and del iver at term . E arlier del ivery can be
considered f or w omen with superimposed
preeclampsia or p regnancy com plications (eg, fetal
growthr estriction,p reviousstillb irth).
References:S eepage166.
Herpes Simplex Vir us Infections in
Pregnancy
Herpes simplexvi rus(H SV)ty pe2i spri marilyresponsi ble for
genital H SV di sease. M aternal-fetal transm ission of H SV i s
them ajorconsequenceofm aternal HSV infection,resul ting
in encephalitis,di sseminateddi sease,andsk in disease. The
most co mmon mode of transm ission i s vi a contact of the
fetusw ithi nfectedvagi nalsecreti onsduri ngdel ivery.
I. Diagnosis
A. Riskfactor s.B lackorH ispanic race, age,andy earsof
sexual ex perience are hi ghly correl ated w ith H SV-2
infection. Other factors i nclude l ower fam ily i ncome,
lowerl evelofeducati on,m ultiplesex ual partners, and
havingothersex uallytransm itteddi seases.
B. Thegol dstandardfordi agnosis of acuteH SVi nfection
is vi ral cul ture, w hich m aybecom e posi tive w ithin tw o
tothreeday safteri noculation.
C. Polymerase chai n reacti on (P CR) i s used to rapi dly
detectH SVD NAfrom l esions or genitalsecreti onsand
is superior to othertests.P CRhasbeenused to detect
HSV from pregnant w omen w ith recurrent H SV at
delivery and their i nfants i n i nstances i n w hich H SV
culturesw erenegati ve.
II. Clinicalpr esentation
A. Primarygenitalepi sodegeni talH SVi scharacteri zed
by m ultiple pai nful ve sicles i n cl usters. T hey m ay be
associated w ith pruri tus, d ysuria, vagi nal di scharge,
and tender regional adenopathy . Fever, m alaise, and
myalgia often occur one to tw o day s pri or to the ap­
pearance of l esions. T he l esions mayl ast four to fi ve
days prior to crusting. T he skin w ill reepithelializ e in
about 10 day s. V iral sheddi ng m ay l ast for 10 to 12
daysafterreepi thelialization.
B. Nonprimary fi rst-episode geni tal H SV refers to
patients w ith preex isting anti bodies to one of the tw o
typesofvi rusw hoacqui retheothervi rusanddevel op
genitall esions.N onprimarydi seasei sl essseverew ith
fewersy stemicsy mptoms,andl essl ocalpai n.
C. Recurrent H SV episodes are characteri zed by l ocal
painorparesthesi a followed by vesicularl esions.T hey
are generally fewer i n num ber and often unilateral but
maybepai nful.
III. Pregnancy
A. Estimatedr isksofm aternal-fetaltr ansmission:
1. Primary or nonpri mary fi rst epi sode w ith an acti ve
lesionatdel ivery:50percent
2. Asymptomaticfi rstepi sode:33percent
3. RecurrentH SVw ithacti vel esion:3to4percent
4. Asymptomaticr ecurrence:0.04percent
IV. Neonataleffects
A. HSVneonatal i nfectioni sm ostoftenacqui redthrough
the bi rth canal . T he i ncidence of neonatal H SV infec­
tion i s 1 i n 3000. A pproximately 60 to 70 percent of
infectedneonatesarei nfectedw ithH SV-2.
B. Categories of neonatal disease i nclude l ocalized
disease of the sk in, ey es and m outh (S EM), central
nervous sy stem (C NS) di sease w ith or w ithout SEM
involvement,anddi sseminateddi sease
C. The m ortality rate i s 1 5 percent am ong chi ldren w ith
CNS di sease and 57 percent w ith d isseminated di s­
ease.
V. Treatment
A. Primaryin fection
1. Acyclovir (Zovi rax) the rapy (200 m g P O fi ve ti mes
per day or 400 m g P O T ID for 7 to 14 day s) and
analgesia i s recom mended. Acyclovir i s safe i n
pregnancy. A cyclovir reduc es the durati on of vi ral
shedding.
2. Suppressive therapy (400 m g P O B ID) for the
remainderofpregnancy shoul d usuallybeadm inis­
tered because acy clovir m ayp revent sy mptomatic
HSVrecurrencesatterm .
B. Recurrenti nfection.A cyclovirreducessheddi ngby 80
percentandm ay reducecl inicalrecurrences.W omen
with freque nt HSV recurrences m ay benefi t from
suppression(acy clovir400m gP OB ID)nearterm .
C. Roleofcesar eansection
1. Cesareansecti on shouldbeofferedtow omenw ho
have acti ve l esions or sy mptoms of v ulvar pai n or
burning at the ti me of del ivery and a hi story of
genitalherpes.
2. Prophylacticcesareansecti oni snot recommended
for w omen w ith recur rent H SV and no evi dence of
activel esionsattheti me ofdel ivery.Lesi onsw hich
have crusted ful ly are consi dered heal ed and not
active.
3. Cesarean secti on i s not recom mended for women
withrecurrentgeni talherpes and activenongeni tal
HSVl esions.T hel esionsshoul dbecoveredw ithan
occlusivedressi ng.
D. Verypr eterm infants ( [ Pobierz całość w formacie PDF ]