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8 Hypertensive Disease
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Hypertensive disease in women of childbearing age is usually essential hypertension, but secondary causes should be considered: coarctation of the aorta, pheochromocytoma, hyperaldosteronism, and renovascular and renal hypertension Preeclampsia is superimposed on 20% of pregnancies in hypertensive women and appears earlier, is more severe, and is more often associated with intrauterine growth restriction It may be difficult to determine whether or not hypertension in a pregnant woman precedes or derives from the pregnancy if she is not examined until after the 20th week Serum uric acid can help differentiate, since it is elevated with preeclampsia and generally normal in chronic hypertension unless the patient is receiving diuretics If hypertension persists for 6 8 weeks postpartum, essential hypertension is likely Pregnant women with chronic hypertension require medication only if the diastolic pressure is sustained at or above 100 mm Hg For initiation of treatment, methyldopa has the longest record of safety in a starting dosage of 250 mg orally twice daily Therapy with -blockers or calcium channel blockers is also acceptable (see Tables 11 7, 11 9) The goal is to keep the diastolic pressure between 80 mm Hg and 100 mm Hg
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10 Acute Fatty Liver of Pregnancy
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Acute fatty liver of pregnancy is a disorder limited to the gravid state It occurs in the third trimester of pregnancy and involves acute hepatic failure With improved recogni-
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tion and immediate delivery, the mortality range is now 20 30% The disorder is usually seen after the 35th week of gestation and is more common in primigravidas and those with twins The incidence is about 1:14,000 deliveries The cause of acute fatty liver of pregnancy is not known However, as many as 20% of cases may be due to a homozygous fetal deficiency of long-chain 3-hydroxyacylcoenzyme A dehydrogenase (LCHAD) deficiency in a heterozygous mother Pathologic findings are unique to the disorder, with fatty engorgement of hepatocytes Clinical onset is gradual, with flu-like symptoms that progress to the development of abdominal pain, jaundice, encephalopathy, disseminated intravascular coagulation, and death On examination, the patient shows signs of hepatic failure Laboratory findings show marked elevation of alkaline phosphatase but only moderate elevations of alanine aminotransferase (ALT) and aspartate aminotransferase (AST) Prothrombin time and bilirubin are also elevated The white blood cell count is elevated, and the platelet count is depressed Hypoglycemia may be extreme The differential diagnosis is that of fulminant hepatitis However, liver aminotransferases for fulminant hepatitis are higher (> 1000 units/mL) than those for acute fatty liver of pregnancy (usually 500 1000 units/mL) It is also important to review the appropriate history and perform the appropriate tests for toxins that cause liver failure Preeclampsia may involve the liver but typically does not cause jaundice The elevations in liver function tests in patients with preeclampsia usually do not reach the levels seen in patients with acute fatty liver of pregnancy Diagnosis of acute fatty liver of pregnancy mandates immediate delivery Supportive care during labor includes administration of glucose, platelets, and fresh frozen plasma as needed Vaginal delivery is preferred Resolution of encephalopathy occurs over days, and supportive care with a low-protein diet is needed Recurrence rates for this liver disorder are unclear but probably increased in families with proven LCHAD deficiency Most authorities advise against subsequent pregnancy, but there have been reported cases of successful outcomes in later pregnancies
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Ko H et al Acute fatty liver of pregnancy Can J Gastroenterol 2006 Jan;20(1):25 30 [PMID: 16432556]
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and phenytoin should receive vitamin supplements, including folic acid and vitamin D, throughout pregnancy Oral vitamin K, 10 20 mg/d, is administered during the last month to help prevent bleeding problems in the newborn, who is at risk of bleeding tendencies due to decreased levels of clotting factors Such infants should receive an injection of vitamin K1, 1 mg subcutaneously immediately after delivery, and should have clotting studies 2 4 hours later Breast-feeding is not contraindicated for infants of mothers taking antiseizure medications
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Tettenborn B et al Management of epilepsy in women of childbearing age: practical recommendations CNS Drugs 2006;20(5):373 87 [PMID: 16696578]
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12 Syphilis, Gonorrhea, & Chlamydia trachomatis Infection (See also s 33 and 34)
These STDs have significant consequences for mother and child Untreated syphilis in pregnancy will cause late abortion, stillbirth, transplacental infection, and congenital syphilis Gonorrhea will produce large-joint arthritis by hematogenous spread as well as ophthalmia neonatorum Maternal chlamydial infections are largely asymptomatic but are manifested in the newborn by inclusion conjunctivitis and, at age 2 4 months, by pneumonia The diagnosis of each can be reliably made by appropriate laboratory tests, which should be included in all prenatal care The sexual partners of women with STDs should be identified and treated also if that can be done
Centers for Disease Control and Prevention Sexually transmitted disease treatment guidelines 2006 MMWR Recomm Rep 2006 Aug 4;55(RR-11):1 94 [PMID: 16888612]
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