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 May 2008 2 TABLE OF CONTENTS Forword ....................................................................................... 4 Antiphospholipid syndrome(APS) (Acgurred Acquired thrombophilia) ............................................................................ 5 Bleeding antepartum.................................................................. 8 Volume Replacement......................................................... 8 Abruptio Placenta............................................................... 8 Placenta Previa.................................................................. 9 Bleeding post partum............................................................... 11 Cytomegalovirus ...................................................................... 17 Diabetes in pregnancy ............................................................. 20 GBS-Syndrome ......................................................................... 32 Hepatitis .................................................................................... 34 Herpes ....................................................................................... 37 Hydrops fetalis (nonimmune) and fetal ascites ..................... 39 Hyperemesis gravidarum......................................................... 41 Hypertension and preeclampsia in pregnancy ..................... 43 Drugs ............................................................................... 46 Management of server hypertension, preeclampsia and HEELP ............................................................................. 47 Management of severe hypertension (>160/110 mm Hg) 48 Treatment of eclampsia ................................................... 49 Induction of labour ................................................................... 52 Intrauterine growthrestriction (IUGR) ..................................... 56 Lupus erytthematosus (SLE)................................................... 63 Lupus syndrome (NEONATAL) ............................................... 65 Necrotizing infection of the skin and fascia........................... 67 Necrotizing cellulitis ......................................................... 67 Necrotizing fasciitis .......................................................... 67 Recommendations:.......................................................... 68 Neonatal alloimmune thrombocytopenia (NAIT).................... 70 Parvovirus................................................................................. 72 Preterm premature rupture of membranes(PPROM) (< 34 [37] weeks) ....................................................................................... 74 Premature rupture of membranes (PROM) (>34 [37] weeks . 76 Preterm labour with intact membranes .................................. 78 Tocolysis.......................................................................... 79 Red group cell immunization (Rhesus immunization) .......... 82 Rubella....................................................................................... 86 Shoulder dystocia .................................................................... 88 Skin and pregnancy ................................................................. 90 Obstetric cholestasis (Pruritus gravidarum) ..................... 91 Herpes gestationis (or pemphigoid gestationis) ............... 92 Pruritic urticarial papules and plagues of pregnancy (PUPPP) .......................................................................... 92 Striae distensae ............................................................... 92 Streptococcal toxic shock syndrome (STSS) ........................ 93 Staphylococcal toxic shock syndrome (tampon syndrome) 95 3 Thrombocytopenia in pregnancy ............................................ 97 Gestational thrombocytopenia ......................................... 97 ITP - Idiopathic (autoimmune) Thrombocytopenic (purpura)97 Thromboembolism in pregnancy ............................................ 99 Congenital Thrombophilia: ............................................... 99 Antithrombin III deficiency................................................ 99 Acquired Thrombophilia: .................................................. 99 D V T:............................................................................... 99 Pulmonary embolus (PE) ............................................... 100 Drugs: ............................................................................ 100 Treatment: ..................................................................... 101 Propfylactic regime in prevention thromboembolic disease:103 Prevention of Osteoporosis................................................... 104 Labour, epidural and Cesarean sectio:................................. 104 Thrombophilia in pregnancy (Inherited)............................... 107 Thyroid disease in pregnancy ............................................... 111 Fetal and neonatal Grave´s disease .............................. 113 Toxoplasmosis ....................................................................... 118 Travel and vaccination........................................................... 121 Ultrasound screening............................................................. 124 Risk if parent or previous child has chromosome abnormality .................................................................... 127 Soft ultrasound markers in trisomy................................. 127 Soft ultrasound markers in trisomy................................. 127 Vacuum, extraction / Forceps................................................ 133 Varicella / Chicken pox .......................................................... 137 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, 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, Mette Krøll and Karen Eckhoff, who painstakingly dedicated their time and effort in completing this reference. Thanks to my young colleagues Birger Breum, B. Baldur-Felskov, Suher Hassan, Bo Rud and R. Svetlana for their input. I also want to thank Lars Krag Moeller, MD for his comments and making it possible to see the book on the Internet at: http://www.gyncph.dk/secher/index.htm Niels J. Secher, MD Professor Department of Obstetrics and Gynecology Copenhagen University Hospital in Hvidovre Denmark E-mail: [email protected] May 2008 5 Antiphospholipid syndrome(APS) (Acgurred Acquired thrombophilia) Definition: Criteria for the classification of the APS: At least one of the following clinical criteria and one of the following paraclinical/laboratorial criteria should be met: Clinical Criteria: 1. Vascular thrombosis and/or 2. Pregnancy morbidity (Poor Obstetric History) a) Unexplained death of a morphologically normal fetus at or beyond 10 weeks. b) One or more premature deliveries before 34 week of gestation because of 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) Paraclinical/laboratory Criteria: The presence of Antiphospholipid antibody (aPL) on two or more occations at least 12 weeks apart Antiphospholipid (aPL) antibodies: - Lupus anticoagulant (LA) directed against phospholipidbinding plasm proteins prolonged activated partial thromboplastin time. - Beta 2- glycoprotein-1 antibodies, β2-GP >99th percentile - Anticardiolipin (aCL) antibody Medium titer: 20 - 50 anticardiolipin IgG and 20 -80 anticardiolipin IgM. Secondary Antiphospholipid Syndrome: When antibodies is found in association with systemic lupus (SLE) (see also page 63 ), other rheumatic disease, autoimmune disorders, infections and medicine. Prevalence: 2 - 5% of all pregnant women have cardiolipin antibodies or lupus anticoagulant but very few have 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 was 5% among women with known antiphospholipid syndrome. 6