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Are You Suprised ? MY REFERENCE BOOK IN OBSTETRICS NIELS JØRGEN SECHER PROFESSOR Department of Obstetrics and Gynecology Copenhagen University Hospital in Hvidovre 2650 Hvidovre E-mail: [email protected] Reappraised in January 2006 2 TABLE OF CONTENTS FOREWORD ..........................................................................4 ANTIPHOSPHOLIPID SYNDROME (APS)..............................5 (Acgurred thrombophilia) ....................................................5 Secondary Antiphospholipid Syndrome: ............................................... 6 BLEEDING ANTEPARTUM .....................................................9 Volume Replacement.........................................................................10 Abruptio Placenta..............................................................................10 Placenta Previa .................................................................................11 BLEEDING POST PARTUM .................................................13 CYTOMEGALOVIRUS ..........................................................21 DIABETES IN PREGNANCY.................................................25 Gestational Diabetes..........................................................................25 Glucose Tolerance Test: .....................................................25 Diabetic ketoacidosis (DKA) ...............................................................29 INSULIN AND DELIVERY....................................................................33 GBS-SYNDROME.................................................................37 HEPATITIS .........................................................................40 Hepatitis A virus (HA) ........................................................................40 Hepatitis B virus (HBV) ......................................................................40 Hepatitis C virus (HCV) ......................................................................42 Hepatitis delta virus (HDV).................................................................42 (co-infection with Hepatitis B). ...........................................................42 Hepatitis E (HEV) ..............................................................................42 Herpes simplex hepatitis (HSV) ..........................................................43 HERPES ..............................................................................44 HIV AND PREGNANCY........................................................46 HYDROPS FETALIS AND FETAL ASCITIS............................50 HYPEREMESIS GRAVIDARUM ............................................53 HYPERTENSION AND PREECLAMPSIA IN PREGNANCY .....55 MANAGEMENT OF PRE-EXISTING HYPERTENSION IN PREGNANCY......58 MANAGEMENT OF HYPERTENSION AND SLIGHT TO MODERATE PREECLAMPSIA.................................................................................58 MANAGEMENT OF SEVERE HYPERTENSION, PREECLAMPSIA AND HELLP ........................................................................................................59 MANAGEMENT OF SEVERE HYPERTENSION........................................60 ( > 160/110 mmHg)..........................................................................60 Drugs ...............................................................................................62 TREATMENT OF ECLAMPSIA ..............................................................64 INDUCTION OF LABOR.......................................................68 3 INTRAUTERINE GROWTH RESTRICTION (IUGR) .............72 NEONATAL ALLOIMMUNE THROMBOCYTOPENIA..............80 PARVOVIRUS......................................................................83 PRETERM PREMATURE RUPTURE OF MEMBRANES (PPROM) (< 34 [37] weeks)..............................................................85 PREMATURE RUPTURE OF MEMBRANES (PROM) ..............88 (>34 [37] WEEKS ) .............................................................88 PRETERM LABOR WITH INTACT MEMBRANES...................90 TOCOLYSIS.......................................................................................91 Acute ...............................................................................................91 Tocolysis in premature labor ..............................................................91 RED GROUP CELL IMMUNIZATION ....................................96 (Rhesus Immunization) .....................................................96 RUBELLA...........................................................................101 SHOULDER DYSTOCIA......................................................103 SKIN AND PREGNANCY....................................................105 Pruritus gravidarum (also called obstetric cholestasis) .......................106 Obstetric cholestasis (Pruritus gravidarum) .......................................106 Herpes gestationis (or pemphigoid gestationis) .................................107 Pruritic urticarial papules and plagues of pregnancy (PUPPP) .............108 Striae distensae ..............................................................................108 SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)......................109 NEONATAL LUPUS SYNDROME ........................................111 THROMBOCYTOPENIA IN PREGNANCY ...........................113 Gestational thrombocytopenia..........................................................113 ITP - Idiopathic (autoimmune) Thrombocytopenic (purpura)..............113 THROMBOEMBOLISM AND PROPHYLAXIS IN PREGNANCY .........................................................................................116 Recommendations (KFSH&RC):........................................................120 THROMBOPHILIA IN PREGNANCY (Inherited)................131 THYROID DISEASE IN PREGNANCY.................................141 Fetal and neonatal Grave´s disease..................................................143 TOXOPLASMOSIS .............................................................147 TRAVEL AND VACCINATION.............................................151 ULTRASOUND SCREENING...............................................156 Risk if parent or previous child has chromosome abnormality.............157 Soft ultrasound markers in trisomy...................................................158 VACUUM EXTRACTION/FORCEPS ....................................163 VARICELLA/CHICKEN POX...............................................166 4 FOREWORD This manual is a combination of Guidelines and Protocols of patient management in Obstetrics. I hope it will be a concise reference, readily accessible in a clinical setting, decreasing the need to access a detailed textbook, which may not always be available. I compiled this manual in order to refresh my memory regarding the complex medical cases we see here, and in an attempt not to omit any important steps in the management or treatment of these cases. These guidelines are not the official protocols of Copenhagen University Hospital at Hvidovre, but they express my personal opinions and are as ‘evidence based’ as possible. I wish to thank my colleagues at King Faisal Specialist Hospital, Kingdom of Saudi Arabia, who helped me with the first edition, when I worked there as the Chairman, and my colleagues in Denmark (the Sandbjerg Guidelines and Guidelines at Hvidovre Hospital) as well as my secretaries Ms. Zenaida C. Viktoria and Mette Krøll, who painstakingly dedicated their time and effort in completing this reference. Niels J. Secher, MD Professor Department of Obstetrics and Gynecology Hvidovre Hospital Denmark January 2006 5 ANTIPHOSPHOLIPID SYNDROME (APS) (Acgurred thrombophilia) Definition: Criteria for the classification of the APS: At least one of the following clinical criteria and one of the following laboratorial criteria should be met: Clinical Criteria: 1. Vascular thrombosis and/or 2. Pregnancy morbidity (Poor Obstetric History) a. Unexplained death of a morphological normal fetus at or beyond 16 weeks. b. One or more premature deliveries before 34 week of gestation because or severe preeclampsia/eclampsia or severe IUGR. c. Three or more unexplained consecutive abortions before 10 weeks of gestation (controversial, if no fetal heart has been seen, as some believe that very early abortion is not caused by APS) Laboratory Criteria: Antiphospholipids/antibodies: - Lupus anticoagulant (LA) , activity which is an otherwise unexplained aim of the prolonged activated partial thromboplastin time. - Beta 2- glycoprotein-1 antibodies - Anticardiolipin (aCL) antibody - Medium or high titer on two or more occasions presented in at least 6 weeks apart. Medium titer: 20 – 50 anticardiolipin IgG and 20 –80 anticardiolipin IgM. 6 Secondary Antiphospholipid Syndrome: When antibodies is found in association with systemic lupus (SLE) (see also page 109), other rheumatic disease, autoimmune disorders, infections and medicine. Prevalence: 2 – 5% of all pregnant women have cardiolipin antibodies or lupus anticoagulant but very few has antiphospholipid syndrome. 30% of women with severe early onset preeclampsia may have antiphospholipid antibodies. Background: Anticardiolipin antibodies react with proteins bound to phospholipids in the cell membrane such as cardiolipin. Different isotypes and subclasses are associated with aCL including IgA, IgM, and IgG subclasses 1 to 4. Elevated levels of IgG anticardiolipin antibodies (particularly IgG2) incur a greater risk. Risks: Maternal thromboembolism is highly variable and exacerbated by co-existent hereditary coagulopathies. In one study thrombosis during pregnancy
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