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15 Thyroid Disease
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Thyrotoxicosis during pregnancy may result in fetal anomalies, late abortion, or preterm labor and fetal hyperthyroidism with goiter Thyroid storm in late pregnancy or labor is a life-threatening emergency Radioactive isotope therapy must never be given during pregnancy The thyroid inhibitor of choice is propylthiouracil, which acts to prevent further thyroxine formation by blocking iodination of tyrosine There is a 2- to 3-week delay before the pretreatment hormone level begins to fall The initial dose of propylthiouracil is 100 150 mg orally three times a day; the dose is lowered as the euthyroid state is approached It is desirable to keep free T4 in the high normal range during pregnancy A maintenance dose of 100 mg/d minimizes the chance of fetal hypothyroidism and goiter Recurrent postpartum thyroiditis occurs 3 6 months after delivery A hyperthyroid state of 1 3 months duration is followed by hypothyroidism, sometimes misdiagnosed as depression Thyroperoxidase antibodies and thyroglobulin antibodies are present Recovery is spontaneous in over 90% of cases after 3 6 months Maternal hypothyroidism even subclinical hypothyroidism manifested only by elevated levels of TSH may adversely affect subsequent neuropsychological development of the child Mothers with known or suspected hypothyroidism should have the TSH level measured at the first prenatal visit Replacement therapy with levothyroxine should be adjusted to maintain levels of TSH in the normal range
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Lao TT Thyroid disorders in pregnancy Curr Opin Obstet Gynecol 2005 Apr;17(2):123 7 [PMID: 15758602]
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16 Tuberculosis
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The diagnosis of tuberculosis in pregnancy is made by history taking, physical examination, and skin testing, with special attention to women from ethnic groups with a high prevalence of the disease (such as women from southeast Asia) Chest films should not be obtained as a routine screening measure in pregnancy but should be used only in patients with a skin test conversion or with suggestive findings in the history and physical examination Abdominal shielding must be used if a chest film is obtained If adequately treated, tuberculosis in pregnancy has an excellent prognosis There is no increase in spontaneous abortion, fetal problems, or congenital anomalies
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Treatment is with isoniazid and ethambutol or isoniazid and rifampin (see s 9 and 33) Because isoniazid therapy may result in vitamin B6 deficiency, a supplement of 50 mg/d of vitamin B6 should be given simultaneously Streptomycin, ethionamide, and most other antituberculous drugs should be avoided in pregnancy
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17 Urinary Tract Infection
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The urinary tract is especially vulnerable to infections during pregnancy because the altered secretions of steroid sex hormones and the pressure exerted by the gravid uterus upon the ureters and bladder cause hypotonia and congestion and predispose to urinary stasis Labor and delivery and urinary retention postpartum also may initiate or aggravate infection Escherichia coli is the offending organism in over two-thirds of cases From 2% to 8% of pregnant women have asymptomatic bacteriuria, which some believe to be associated with an increased risk of prematurity It is estimated that pyelonephritis will develop in 20 40% of these women if untreated A first-trimester urine culture is indicated in women with a history of recurrent or recent episodes of urinary tract infection If the culture is positive, treatment should be initiated as a prophylactic measure Nitrofurantoin (100 mg orally twice daily), ampicillin (500 mg orally four times daily), and cephalexin (500 mg orally four times daily) are acceptable medications for 3 7 days Sulfonamides should not be given in the third trimester because they may interfere with bilirubin binding and thus impose a risk of neonatal hyperbilirubinemia and kernicterus Fluoroquinolones are also contraindicated because of their potential teratogenic effects on fetal cartilage and bone If bacteriuria returns, suppressive medication (one daily dose of an appropriate antibiotic) for the remainder of the pregnancy is indicated Acute pyelonephritis requires hospitalization for intravenous administration of antibiotics until the patient is afebrile; this is followed by a full course of oral antibiotics
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Mittal P et al Urinary tract infections in pregnancy Clin Perinatol 2005 Sep;32(3):749 64 [PMID: 16085031]
the right, away from McBurney s point, as the uterus enlarges, and localization of pain does not always occur Nausea, vomiting, fever, and leukocytosis occur regularly Any right-sided abdominal pain associated with these symptoms should arouse suspicion In at least 20% of obstetric patients, the diagnosis of appendicitis is not made until rupture occurs and peritonitis has become established Such a delay may lead to premature labor or abortion With early diagnosis and appendectomy, the prognosis is good for mother and baby
Cohen-Kerem R et al Pregnancy outcome following nonobstetric surgical intervention Am J Surg 2005 Sep;190(3): 467 73 [PMID: 16105538]
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