Obstentrics_Williams

Obstentrics_Williams. Previously termed acute renal ailure, acute kidney injury (AKI) is now used to describe suddenly impaired kidney function with retention of nitrogenous and other waste products normally excreted by the kidneys (W aikar, 2015). Severe AKI associated with pregnancy is less frequent today. For example, in a 6-year period, the overall incidence at the Mayo Clinic was 0.4 percent (Gurrieri, 2012). It is even less common for women who require dialysis-1 case per 10,000 births (Hildebrand, 2015). But, it still occasionally causes signiicant obstetrical morbidity, and women who require acute dialysis have increased maternal mortality rates (Kuklina, 2009; Van Hook, 2014). Outcomes are available from four older studies comprising a total of 266 women with renal failure (Drakeley, 2002; Nzerue, 1998; Sibai, 1990; Turney, 1989). Nearly 70 percent had preeclampsia, 50 percent had obstetrical hemorrhage, and 30 percent had a placental abruption. Almost 20 percent required dialysis, and the


Obstentrics_Williams

Obstentrics_Williams. 1998; Sibai, 1990; Turney, 1989). Nearly 70 percent had preeclampsia, 50 percent had obstetrical hemorrhage, and 30 percent had a placental abruption. Almost 20 percent required dialysis, and the maternal mortality rate was 15 percent.


Obstentrics_Williams

Obstentrics_Williams. lthough obstetrical cases of AKI that require dialysis have become less prevalent, acute renal ischemia is still often associated with severe preeclampsia and hemorrhage (Gurrieri, 2012; Jim, 2017). Particularly contributory are HELLP (hemolysis, devated liver enzymes, low .latelet levels) syndrome and placental abruption (Audibert, 1996; Drakely, 2002). Septicemia is another frequent comorbidity, especially in resource-poor countries (Acharya, 2013; Srinil, 2011; Zeeman, 2003). AKI is also common in women with acute fatty liver of pregnancy (Sibai, 2007). Some degree of renal insuiciency was found in virtually all of 52 such women cared for at Parkland Hospital (Nelson, 2013). Another woman from Parkland Hospital developed AKI from dehydration caused by severe hyperemesis gravidarum at 15 weeks (Hill, 2002). Other causes include thrombotic micro angiopathies (Balofsky, 2016; Ganesan, 201a1) (Chap. 56, p. 1088).


Obstentrics_Williams

Obstentrics_Williams. In most women, AKI develops postpartum, thus management is usually not complicated by fetal considerations. An abrupt rise in serum creatinine level is most often due to renal ischemia. Oliguria is an important sign. In obstetrical cases, both prerenal and intrarenal factors are often contributory. For example, with total placental abruption, severe hypovolemia from massive hemorrhage is common, and preexistent renal ischemia from preeclampsia is often comorbid. In addition, disseminated intravascular coagulopathy may be contributory.


Obstentrics_Williams

Obstentrics_Williams. When azotemia is evident and severe oliguria persists, some form of renal replacement treatment is indicated. Hemofiltration or dialysis is initiated before marked deterioration occurs. Hemodynamic measurements are normalized. Importantly, medication doses are adjusted, and magnesium sulfate, iodinated contrast agents, aminoglycosides, and nonsteroidal antiinlammatory drugs (NSAIDs) are prominent examples (Waikar, 2015). Early dialysis appears to reduce the maternal mortality rate appreciably and may enhance the extent of renal function recovery. With time, renal function usually returns to normal or near normal. AKI in obstetrics is most often due to acute blood loss, especially that associated with preeclampsia. hus, it may often be prevented by the following means: 1.


Obstentrics_Williams

Obstentrics_Williams. AKI in obstetrics is most often due to acute blood loss, especially that associated with preeclampsia. hus, it may often be prevented by the following means: 1. Prompt and vigorous volume replacement with crystalloid solutions and blood in instances of massive hemorrhage, such as in placental abruption, placenta previa, uterine rupture, and postpartum uterine atony (Chap. 41, p. 788). 2. Delivery or termination of pregnancies complicated by severe preeclampsia or eclampsia, and careful blood transfusion ifloss is more than average (Chap. 40, p. 718). 3. Close observation for early signs of sepsis syndrome and shock in women with pyelonephritis, septic abortion, chorioamnionitis, or sepsis from other pelvic infections (Chap. 47, p. 921). 4. Avoidance of loop diuretics to treat oliguria before ensuring that blood volume and cardiac output are adequate for renal perfusion. 5.


Obstentrics_Williams

Obstentrics_Williams. 4. Avoidance of loop diuretics to treat oliguria before ensuring that blood volume and cardiac output are adequate for renal perfusion. 5. Judicious use of vasoconstrictor drugs to treat hypotension, and only after it has been determined that pathological vasodilatation is the cause.


Obstentrics_Williams

Obstentrics_Williams. Irreversible ischemic renal failure caused by acute cortical necrosis is rare now in obstetrics (F rimat, 2016). Before widespread availability of dialysis, it complicated a fourth of obstetrical renal failure cases (Griinfeld, 1987; Turney, 1989). Most cases followed placental abruption, preeclampsia-eclampsia, and endotoxin-induced shock. Once common with septic abortion, this is a rare cause in this country today (Lim, 2011; Srinil, 2011). Histologically, the lesion appears to result from thrombosis of segments of the renal vascular system. he lesions may be focal, patchy, conluent, or gross. Clinically, renal cortical necrosis follows the course of AKI, and its diferentiation from acute tubular necrosis is not possible during the early phase. he prognosis depends on the extent of the necrosis. Recovery of function is variable, and stable renal insuiciency may result (Lindheimer, 2007a).


Obstentrics_Williams

Obstentrics_Williams. Rarely, bilateral ureteral compression by a very large pregnant uterus is greatly exaggerated. Resultant ureteral obstruction in turn may cause severe oliguria and azotemia. An extreme example is shown in Figure 53-6. In their series of 13 obstruction cases, Brandes and Fritsche (1991) described one woman with twins who developed anuria and a serum creatinine level of 12.2 mg/dL at 34 weeks' gestation. After amniotomy, urine flow resumed at 500 mL/hr, and her serum creatinine levels rapidly dropped to normal range. Eckford and Gingell (1991) described 10 women in whom ureteral obstruction was relieved by stenting. he stents were left in place for a mean of 15.5 weeks and removed 4 to 6 weeks postpartum. Others have reported similar experiences (Sadan, 1994; Satin, 1993).


Obstentrics_Williams

Obstentrics_Williams. FIGURE 53-6 A.Magnetic resonance image in a coronal plane of a pregnant woman with unilateral hydronephrosis caused by ureteral obstruction. The serum creatinine level was 8 mg/dL and decreased to 0.8 mg/dL ater a percutaneous nephrostomy tube was placed. B. Let kidney (arrow) and associated hydronephrosis (asterisk) are again noted in this axial plane image from the same patient. Partial ureteral obstruction may be accompanied by fluid retention and significant hypertension. When the obstructive uropathy is relieved, diuresis ensues and hypertension dissipates. In our experience, women with previous urinary tract surgery for reflux are more likely to have such obstructions.


Obstentrics_Williams

Obstentrics_Williams. Although infrequently complicating pregnancy, this type of diverticulum originates from an enlarging paraurethral gland abscess that ruptures into the urethral lumen. As infection clears, the remaining dilated diverticular sac and its ostium into the urethra persist. Urine collecting within and dribbling from the sac, pain, a palpable mass, and recurrent urinary infections may be associated findings. In general, a diverticulum is managed expectantly during pregnancy. Rarely, drainage may be necessary, or surgery required (Iyer, 2013). If additional antepartum evaluation is needed, MR imaging is preferred for its superior soft tissue resolution and ability to deine complex diverticula (Dwarkasing, 2011; Pathi, 2013) .


Obstentrics_Williams

Obstentrics_Williams. Fistulas found during pregnancy likely existed previously, but in rare cases, they form during pregnancy. In developed countries, vesicovaginal or cervicovaginal istula following a McDonald cerclage has been reported (Massengill, 2012; Zanconato, 2015). These fistulas may also form with prolonged obstructed labor that is more often seen in resource-poor countries (Cowgill, 2015). In these cases, the genital tract is compressed between the fetal head and bony pelvis. Brief pressure is not signiicant, but prolonged pressure leads to tissue necrosis with subsequent fistula formation (Wall, 2012). Vesicouterine istulas can develop after prior vaginal or cesarean delivery (DiMarco, 2006; Harfouche, 2014; Manjunatha, 2012). Rarely, vesicocervical istula can follow cesarean delivery or may form if the anterior cervical lip is compressed against the symphysis pubis (Dudderidge, 2005). Finally, an ileouterine istula from a degenerating posterior wall fibroid tumor has been described (Shehata,


Obstentrics_Williams

Obstentrics_Williams. if the anterior cervical lip is compressed against the symphysis pubis (Dudderidge, 2005). Finally, an ileouterine istula from a degenerating posterior wall fibroid tumor has been described (Shehata, 2016).


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Obstentrics_Williams. Abboud H, Henrich L: Stage IV chronic kidney disease. N Engl J Med 362(1):56,t2010 Abe S: An overview of pregnancy in women with underlying renal disease. Am J Kidney Dis 17:1t12, 1991 Acharya A, Santos J, Linde B, et al: Acute kidney injury in pregnancy-current status. Adv Chronic Kidney Dis 20:215, 2013 Airoldi J, Weinstein L: Clinical signiicance of proteinuria in pregnancy. Obstet Gynecol Surv 62(2):117,t2007 Ait Benkaddour Y, Aboulfalah A, Abbassi H: Bladder stone: uncommon cause of mechanical dystocia. Arch Gynecol Obstet 274(5):323, 2006 Akturk S, Celebi ZK, Erdogmus S, et al: Pregnancy after kidney transplant: outcomes, tacrolimus doses, and trough levels. Transplant Proc 47(5):1442, 2015 Al Duraihimh H, Ghamdi G, Moussa D, et al: Outcome of234 pregnancies in 140 renal transplant recipients from five Middle Eastern countries. Transplantation 85:840, 2008


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Obstentrics_Williams. Al Duraihimh H, Ghamdi G, Moussa D, et al: Outcome of234 pregnancies in 140 renal transplant recipients from five Middle Eastern countries. Transplantation 85:840, 2008 Alexander GR, Himes JH, Kaufman RB, et aI: A United States national reference for fetal growth. Obstet Gynecol 87:163, 1996 Alsuwaida A, Mousa D, Al-Harbi A, et al: Impact of early chronic kidney disease on maternal and fetal outcomes of pregnancy. J Matern Fetal Neonatal Med 24(12):1432, 2011 American Academy of Pediatrics and American College of Obstetricians and Gynecologists: Guidelines for Perinatal Care, 8th ed. Elk Grove Village, P, 2017 Asrat T, Roossin M, Miller EI: Ultrasonographic detection of ureteral jets in normal pregnancy. Am J Obstet Gynecol 178: 1194, 1998 Audibert F, Friedman SA, Frangieh AY, et al: Diagnostic criteria for HELLP syndrome: tedious or "helpful"? Am J Obstet Gynecol 174:454, 1996 Balofsky A, Fedarau M: Renal failure in pregnancy. Crit Care Clin 32(1):73, 2016


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Obstentrics_Williams. Boggess A, Benedetti TJ, Raghu G: Nitrofurantoin-induced pulmonary toxicity during pregnancy: a report of a case and review of the literature. Obstet Gynecol Surv 41t:367, 1996 Bramham K, Nelson-Piercy C, Gao H, et al: Pregnancy in renal transplant recipients: a UK National Cohort Study. Clin J Am Soc Nephrol 8(2):290, 2013 Bramham K, Soh Me, Nelson-Piercy C: Pregnancy and renal outcomes in lupus nephritis: an update and guide to management. Lupus 21(12):1271, 2012 Brandes JC, Fritsche C: Obstructive acute renal failure by a gravid uterus: a case report and review. m J Kidney Dis 18:398, 1991 Briggs GG, Freeman RK: Drugs in Pregnancy and Lactation, 10th ed. Philadelphia, Lippincott Williams & Wilkins, 2014


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Obstentrics_Williams. Briggs GG, Freeman RK: Drugs in Pregnancy and Lactation, 10th ed. Philadelphia, Lippincott Williams & Wilkins, 2014 Brosens I, Pijnenborg R, Benagiano G: Risk of obstetrical complications in organ transplant recipient pregnancies. Transplantation 96(3):227,t2013 Brown MA, Holt JL, Mangos GK, et al: Microscopic hematuria in pregnancy: relevance to pregnancy outcome. Am J Kidney Dis 45:667, 2005 Butler EL, Cox SM, Eberts E, et al: Symptomatic nephrolithiasis complicating pregnancy. Obstet Gynecol 96:753, 2000 Cabiddu G, Castellino S, Gernone G, et aI: A best practice position statement on pregnancy in chronic kidney disease: the Italian study group on kidney and pregnancy. J Nephrol 29(3):277, 2016 Cavenee MR, Cox SM, Mason R, et aI: Erythropoietin in pregnancies complicated by pyelonephritis. Obstet Gynecol 84:252, 1994


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Obstentrics_Williams. Chen TK, Gelber Ae, Witter FR, et aI: Renal biopsy in the management of lupus nephritis during pregnancy. Lupus -54,t2015 Chou CY, Ting IW, Lin TH, et al: Pregnancy in patients on chronic dialysis: a single center experience and combined analysis of reported results. Eur J Obstet Gynecol Reprod Bioi 136: 165, 2008 Chung SD, Chen H, Keller J, et I: Urinary calculi increased the risk for adverse pregnancy outcomes: a nationwide study. Acta Obstet Gynecol Scand 921:69,t2013


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Obstentrics_Williams. Chung SD, Chen H, Keller J, et I: Urinary calculi increased the risk for adverse pregnancy outcomes: a nationwide study. Acta Obstet Gynecol Scand 921:69,t2013 Coscia A, Constantinescu S, Moritz !J, et aI: Report from the National Transplantation Pregnancy Registry (NTPR): outcomes of pregnancy after transplantation. Clin Transpl 65, 2010 Cowgill D, Bishop J, Norgaard AK, et aI: Obstetric istula in low-resource countries: an under-valued and under-studied problem-systematic review of its incidence, prevalence, and association with stillbirth. BMC Pregnancy Childbirth 15:193,t2015 Cox SM, Cunningham FG: Acute focal pyelonephritis (lobar nephronia) complicating pregnancy. Obstet Gynecol 71:510,t1988 Cox SM, Shelburne P, Mason R, et al: Mechanisms of hemolysis and anemia associated with acute antepartum pyelonephritis. Am J Obstet Gynecol 164:58 , 1991


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Obstentrics_Williams. Jesudason S, Grace BS, McOonald SP: Pregnancy ourcomes according to dialysis commencing before or after comraception in women with ESRD. Clint] Am Soc Nephrol 9:143, 2014 Jim B, Bramham K, Maynard SE, et al (eds): Management of the pregnant dialysis patient. In Pregnancy and Kidney Disease. NephSAP Nephrology Assessment Program 15(2):75,t2016 Jim B, Garovic VO: Acute kidney injury in pregnancy. Semin Nephrol 3 :P378,t2017 Jolley]A, Kim S, Wing DA: Acute pyelonephritis and associated complications during pregnaicy in 2006 in US hospitals. J Matern Fetal Neonatal Med 25(12):2494,t2012 Johnson EB, Krambeck AE, White WM, et al: Obstetric complications of ureteroscopy during pregnancy.t] Urol 188(1):151,t2012 Jones DC, Hayslett JP: Outcome of pregnancy in women with moderate or severe renal insuiciency. N Engl J Med 335:226, 1996 Josephson MA, McKay OB: Pregnancy and kidney transplantation. Semin Nephrol 31(1):100, 2011


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Obstentrics_Williams. Josephson MA, McKay OB: Pregnancy and kidney transplantation. Semin Nephrol 31(1):100, 2011 Jungers P, Houil\ier P, Chauveau 0, et al: Pregnancy in women with relux nephropathy. Kidney Int 50:593, 1996 Jungers P, Houillier P, Forget 0, et al: Inluence of pregnancy on the course of primary chronic glomerulonephritis. Lancet 346: 1122, 1995 Kazemier BM, Koningstein FN, Schneeberger C, et al: Maternal and neonatal consequences of treated and untreated asymptomatic bacteriuria in pregnancy: a prospective cohort study with an embedded randomized controlled trial. Lancet Infect Dis 15(11):1324,t2015 Kendrickt], Sharma S, Holment], et al: Kidney disease and maternal and fetal outcomes in pregnancy. Am J Kidney Dis 66(1):55,t2015 Kim H, Jeong ]C, Yang], et al: The optimal therapy of calcineurin inhibitors for pregnancy in kidney transplantation. Clin Transplant 29(2): 142, 2015


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Obstentrics_Williams. Kim H, Jeong ]C, Yang], et al: The optimal therapy of calcineurin inhibitors for pregnancy in kidney transplantation. Clin Transplant 29(2): 142, 2015 Koh JH, Ko HS, Lee], et al: Pregnancy and patients with preexisting lupus nephritis: 15 years of experience at a single center in Korea. Lupus 24(7):764,t2015 Kohler ]R, Tencer ], Thysell H, et al: Long-term efects of relux nephropathy on blood pressure and renl function in adults. Nephron Clin Pract 93:c35, 2003 Kuklina EV, Meikle SF, Jamieson OJ, et al: Severe obstetric morbidity in the United States: 1998-2005. Obstet GynecoI113:293, 2009 Kuper SG, Tita AT, Youngstrom ML, et al: Baseline renal function tests and adverse outcomes in pregnant patients with chronic hypertension. Obstet Gynecol 128(1):93,t2016 Lamom RF: he pathophysiology of pulmonary edema with the use of betaagonists. B]OG 107:439,t2000


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Obstentrics_Williams. Lamom RF: he pathophysiology of pulmonary edema with the use of betaagonists. B]OG 107:439,t2000 Lewis OF, Robichaux AG III, ]aekle RK, et al: Urolithiasis in pregnancy: diagnosis, management and pregnancy outcome. J Reprod Med 48:28, 2003 Lewis JB, Neilson EG: Glomerular disease. In Kasper OL, Fauci AS, Hauser SL, et al (eds): Harrison's Principles of Internal Medicine, 19th ed. New York, 1cGraw-Hill Education, 2015 Lim LM, Tsai KB, Hwang DY, et al: Anuric acute renal failure after elective abortion. Intern Med 50(16):1715, 2011 Lindheimer MO, Conrad KP, Karumanchi SA: Renal physiology and diseases in pregnancy. In Alpern R, Hebert S (eds): Seldin and Giebisch's he Kidney, 4th ed. London, Academic Press, 2007a Lindheimer MO, Davison JM: Pregnancy and CKD: Any progress? Am ] Kidney Dis 49:729, 2007b Lindheimer MD, Grunfeld ]P, Davison JM: Renal disorders. In Barron WM, Lindheimer MD (eds): Medical Disorders During Pregnancy, 3rd ed. St. Louis, Mosby, 2000


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Obstentrics_Williams. Lindheimer MD, Grunfeld ]P, Davison JM: Renal disorders. In Barron WM, Lindheimer MD (eds): Medical Disorders During Pregnancy, 3rd ed. St. Louis, Mosby, 2000 Liu Y, Ma X, Lvt], et al: Risk factors for pregnancy outcomes in patients with 19A nephropathy: a matched cohort study. Am J Kidney Dis 64(5): 30,2014 Lo JO, Kerns E, Rueda], et al: Minimal change disease in pregnancy.] Matern Fetal Neonatal Med 27(12):1282, 2014 Lopez LF, Martinez C], Castaneda DA, et al: Pregnancy and kidney transplantation, triple hazard? Current concepts and algorithm for approach of preconception and perinatal care of the patient with kidney transplantation. Transplant Proc 46(9):3027,t2014 Lucas M], Cunningham FG: Urinary infection in pregnancy. Clin Obstet Gynecol 36:855, 1993 Lucas M], Cunningham FG: Urinary tract infections complicating pregnancy. Williams Obstetrics, 19th ed. (Suppl 5). Norwalk, Appleton & Lange, February/v[arch 1994


Obstentrics_Williams

Obstentrics_Williams. Lucas M], Cunningham FG: Urinary tract infections complicating pregnancy. Williams Obstetrics, 19th ed. (Suppl 5). Norwalk, Appleton & Lange, February/v[arch 1994 Luders C, Martins MC, Titak SM, et al: Obstetric outcome in pregnancy women on long-term dialysis: a case series. Am] Kidney Dis 56( 1): 77, 2010 Lumbiganon P, Villar ], Laopaiboon M, et al: One-day compared with 7-day nitrofurantoin for asymptomatic bacteriuria in pregnancy. Obstet Gynecol 113:339, 2009 Maikranz P, Coe FL, Parks], et al: Nephrolithiasis in pregnancy. Am] Kidney Dis 9:354, 1987 Manjunatha YC, Sonwalkar P: Spontaneous antepartum vesicouterine istula causing severe oligohydramnios in a patient with a previous cesarean delivery.s] Ultrasound Med 31(8):1294, 2012


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Obstentrics_Williams. Manjunatha YC, Sonwalkar P: Spontaneous antepartum vesicouterine istula causing severe oligohydramnios in a patient with a previous cesarean delivery.s] Ultrasound Med 31(8):1294, 2012 Maruotti GM, Sarno L, Napolitano R, et al: Preeclampsia in women with chronic kidney disease.s] Matern Fetal Neonatal Med 25(8):1367,s2012 Masselli G, Weston M, Spencer]: he role ofimaging in the diagnosis and man agement of renal stone disease in pregnancy. Clin Radiol 70(12): 1462, 2015 Massengill ]c, Baker TM, Von Pechmann WS, et al: Commonalities of cerclage-related genitourinary istulas. Female Pelvic Med Reconstr Surg 18(6):362,s2012 McAleer S], Loughlin KR: Nephrolithiasis and pregnancy. Curr Opin Urol 14:123,s2004 McDonnold M, Friedman A, Raker C, et al: Is postpartum pyelonephritis associated with the same maternal morbidity as antepartum pyelonephritis? ] Matern Fetal Neonatal Med 25(9):1709, 2012


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Obstentrics_Williams. McDonnold M, Friedman A, Raker C, et al: Is postpartum pyelonephritis associated with the same maternal morbidity as antepartum pyelonephritis? ] Matern Fetal Neonatal Med 25(9):1709, 2012 Mignini L, Carroli G, Abalos E, et al: Accuracy of diagnostic tests to detect asymptomatic bacteriuria during pregnancy. Obstet Gynecol 113(1):346, 2009 Millar LK, DeBuque L, Wing DA: Uterine contraction frequency during treatment of pyelonephritis in pregnancy and subsequent risk of preterm birth. ] Perinat Med 31:41, 2003 Mor Y, Leibovitch I, Zalts R, et al: Analysis of the long-term outcome of surgically corrected vesicoureteric relux. B]U Int 92:97, 2003 Moretti ME, Sgro M, Johnson DW, et al: Cyclosporine excretion into breast milk. Transplantation 75:2144, 2003 National High Blood Pressure Education Program: Report of the National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy. Am] Obstet GynecoIs183(1):Sl, 2000


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Obstentrics_Williams. National High Blood Pressure Education Program: Report of the National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy. Am] Obstet GynecoIs183(1):Sl, 2000 Nelson DB, Yost NP, Cunningham FG: Acute fatty liver of pregnancy: clinical outcomes and expected durations of recovery. Am ] Obstet Gynecol 209(5):456.e1,s2013 Nevis IF, ReitsmaA, DominicA, et al: Pregnancy outcomes in women with chronic kidney disease: a systematic review. Clin] Am Soc NephroI6:2587, 2011 Nzerue CM, Hewan-Lowe K, Nwawka C: Acute renal failure in pregnancy: a review of clinical outcomes at an inner city hospital from 1986-1996.] Natl Med Assoc 90:486, 1998 Orihuela S, Nin M, San Roman S, et al: Successful pregnancies in kidney transplant recipients: Experience of the National Kidney Transplant Program from Uruguay. Transplant Proc 48(2):643,s2016 Packham DK, North A, Fairley KF, et al: Primary glomerulonephritis and pregnancy. Q] Med 71:537, 1989


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Obstentrics_Williams. Packham DK, North A, Fairley KF, et al: Primary glomerulonephritis and pregnancy. Q] Med 71:537, 1989 Pathi SD, Rahn DD, Sailors ]L, et al: Utility of clinical parameters, cystourethroscopy, and magnetic resonance imaging in the preoperative diagnosis of urethral diverticula. Int Urogynecol] 24(2):319, 2013 Piccoli GB, Attini R, Vasario E, et al: Pregnancy and chronic kidney disease: a challenge in all CKD stages. Clin] Am Soc Nephrol 5:844, 2010a Piccoli GB, Conijn A, Attini R, et al: Pregnancy in chronic kidney disease: need for a common language.s] Nephrol 24(03)282,s2011 Piccoli GB, Conijn A, Consiglio V, et al: Pregnancy in dialysis patients: is the evidence strong enough to lead us to change our counseling policy? Clin ] Am Soc Nephrol 5:62, 2010b


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Obstentrics_Williams. Piccoli GB, Conijn A, Consiglio V, et al: Pregnancy in dialysis patients: is the evidence strong enough to lead us to change our counseling policy? Clin ] Am Soc Nephrol 5:62, 2010b Piccoli GB, Daidola G, Attini R, et al: Kidney biopsy in pregnancy: evidence for counseling? A systematic narrative review. B]OG 120(4):412,s2013 Putra LG, Minor TX, Bolton DM, et al: Improved assessment of renal lesions in pregnancy with magnetic resonance imaging. Urology 74:535,s2009 Rai], Smith RB: Acute lobar nephronia in pregnancy: a rarely reported entity in obstetric renal medicine. Arch Gynecol Obstet 286(3):797,s2012 Ramin SM, Vidaef AC, Yeomans ER, et al: Chronic renal disease in pregnancy. Obstet Gynecol 108(6):1531,2006 Rao S, Ghanta M, Moritz M], et al: Long-term functional recovery, quality of life, and pregnancy after solid organ transplantation. Ied Clin North Am 100(3):613,s2016


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Obstentrics_Williams. Rao S, Ghanta M, Moritz M], et al: Long-term functional recovery, quality of life, and pregnancy after solid organ transplantation. Ied Clin North Am 100(3):613,s2016 Raz R, Sakran W, Chazan B, et al: Long-term follow-up of women hospitalized for acute pyelonephritis. Clin Infect Dis 37:1014,s2003 Reddy SS, Holley ]L: Management of the pregnant chronic dialysis patient. Adv Chronic Kidney Dis 14: 146, 2007 Reinstatler L, Khaleel S, Pais VM ] r: Association of pregnancy with stone formation among women in the United States: a NHANES analysis 2007 to 2012.s] Urol February 24,s2017 [Epub ahead of print] Rocha A, Cardoso A, Malheiro ], et al: Pregnancy ater kidney transplantation: grat, mother, and newborn complications. Transplant Proc 45(3): 1088,2013 Rodriguez PN, Klein AS: Management of urolithiasis during pregnancy. Surg Gynecol Obstet 166: 103, 1988


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Obstentrics_Williams. Rogozinska E, Formina S, Zamora], et al: Accuracy of onsite tests to detect asymptomatic bacteriuria in pregnancy. Obstet Gynecol 128:495,2016 Rosenberg E, Sergienko R, Abu-Ghanem S: Nephrolithiasis during pregnancy: characteristics, complications, and pregnancy outcome. World ] Urol 29(6):743,s2011 Ross AE, Handa S, Lingeman ]E, et al: Kidney stones during pregnancy: an investigation into stone composition. Urol Res 36:99, 2008 Rouse D], Andrews W, Goldenberg L, et al: Screening and treatment of asymptomatic bacteriuria of pregnancy to prevent pyelonephritis. A costefectiveness and cost beneit analysis. Obstet GynecoI86:119, 1995 Ruan ]M, Adams SR, Carpinito G, et al: Bladder calculus presenting as recurrent urinary tract infections: a late complication of cervical cerclage placement: a case report.] Reprod Med 56(3-4):172, 2011 Sadan 0, Berar M, Sagiv R, et al: Ureteric stent in severe hydronephrosis of pregnancy. Eur] Obstet Gynecol Reprod BioI 56:79, 1994


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Obstentrics_Williams. Sadan 0, Berar M, Sagiv R, et al: Ureteric stent in severe hydronephrosis of pregnancy. Eur] Obstet Gynecol Reprod BioI 56:79, 1994 Saliem S, Patenaude V, Abenhaim HA: Pregnancy outcomes among renal transplant recipients and patients with end-stage renal disease on dialysis. ] Perinat Med 44(3):321, 2016 Sanchez-Ramos L, Mlpine K], Adair CD, et al: Pyelonephritis in pregnancy: once a day ceftriaxone versus multiple doses of cefazolin. A randomized double-blind trial. Am ] Obstet Gynecol 172: 129, 1995 Satin A], Seiken GL, Cunningham FG: Reversible hypertension in pregnancy caused by obstructive uropathy. Obstet GynecoI81:823, 1993 Schieve A, Handler A, Hershow R, et al: Urinary tract infection during pregnancy: its association with maternal morbidity and perinatal outcome. Am ] Public Health 84:405, 1994 Schneeberger C, Geerlings SE, Middleton P, et al: Interventions for preventing recurrent urinary tract infection during pregnancy. Cochrane Database Syst Rev 7:CD009279, 2015


Obstentrics_Williams

Obstentrics_Williams. Schneeberger C, Geerlings SE, Middleton P, et al: Interventions for preventing recurrent urinary tract infection during pregnancy. Cochrane Database Syst Rev 7:CD009279, 2015 Schneeberger C, Kazemier BM, Geerlins SE: Asymptomatic bacteriuria and urinary tract infections in special patient groups: women with diabetes mellitus and pregnant women. Curr Opin Infect Dis 27:106, 2014 Seidman DS, Soriano D, Dulitzki M, et al: Role of renal ultrasonography in the management of pyelonephritis in pregnant women. ] Perinatol 18:98, 1998 Semins M], Matlaga BR: Kidney stones during pregnancy. Nat Rev Urol 11(3):163,s2014 Shahir AK, Briggs N, Katsoulis ], et al: n observational outcomes study from 1966-2008, examining pregnancy and neonatal outcomes from dialysed women using data from theANZDATA Registry. Nephrology 18(4):276, 2013 Sheield ]S, Cunningham FG: Urinary tract infection in women. Obstet Gynecol 106: 1085, 2005


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Obstentrics_Williams. Sheield ]S, Cunningham FG: Urinary tract infection in women. Obstet Gynecol 106: 1085, 2005 Shehata A, Hussein N, El Halwagy A, et al: Ileo-uterine istula in a degenerated posterior wall ibroid after caesarean section. Clin Exp Reprod Med 43(1):51,s2016 Sibai BM: Imitators of severe preeclampsia. Obstet Gynecol 109:956,2007 Sibai BM, Villar A, Mabie BC: Acute renal failure in hypertensive disorders of pregnancy. Pregnancy outcome and remote prognosis in thirry-one consecutive cases. Am] Obstet Gynecol 162(3):777, 1990 Sledzinska A, Mielech A, Krawczyk B, et al: Fatal sepsis in a pregnant woman with pyelonephritis caused by Escherichia coli bearing Dr and P adhesions: diagnosis based on postmortem strain genotyping. B]OG 118(2):266,2011


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Obstentrics_Williams. Smail! FM, Vazquez ]C: Antibiotics for asymptomatic bacteriuria in pregnancy. Cochrane Database Syst Rev 8:CD000490, 2015 Snyder CC, Barton ]R, Habli M, et al: Severe sepsis and septic shock in pregnancy: indications for delivery and maternal and perinatal outcomes. ] Matern Fetal Neonatal Med 26(5):503,s2013 Spencer ]A, Chahal R, Kelly A, et al: Evaluation of painful hydronephrosis in pregnancy: magnetic resonance urographic patterns in physiological dilatation versus calculous obstruction. ] U rol 171 :256, 2004 Srinil S, Panaput T: Acute kidney injury complicating septic unsafe abortion: clinical course and treatment outcomes of 44 cases. ] Obstet Gynaecol Res 37(11):1525,s2011 Stehman-Breen CO, Levine R], Qian C, et al: Increased risk of preeclampsia among nulliparous pregnant women with idiopathic hematuria. Ams] Obstet :703,s2002 Stettler RW, Cunningham FG: Natural history of chronic proteinuria complicating pregnancy. Am] Obstet GynecoIs167:1219, 1992 Stoumpos S, McNeill SH,


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Obstentrics_Williams. with idiopathic hematuria. Ams] Obstet :703,s2002 Stettler RW, Cunningham FG: Natural history of chronic proteinuria complicating pregnancy. Am] Obstet GynecoIs167:1219, 1992 Stoumpos S, McNeill SH, Gorrie M, et al: Obstetric and long-term kidney outcomes in renal transplant recipients: a 40 year single-centre study. Clin Transplant 30(6):673, 2016 Stratta P, Canavese C, Quaglia M: Pregnancy in patients with kidney disease. Nephrol 19:135, 2006


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Obstentrics_Williams. Strevens H, Wide-Swensson D, Hansen A, et al: Glomerular endotheliosis in normal pregnancy and pre-eclampsia. BJOG 110:831,2003 Sturgiss SN, Davison JM: Efect of pregnancy on long-term function of renal allografts. Am J Kidney Dis 26:54, 1995 Su X, Lv J, Liu Y, et al: Pregnancy and kidney outcomes in patients with IgA nephropathy: a cohort study. Am J Kidney Dis 70:762, 2017 Surian M, Imbasciati E, Cosci P, et al: Glomerular disease and pregnancy: a study of 123 pregnancies in patients with primary and secondary glomerular diseases. Nephron 36:101,s1984 Swartz A, Lydon-Rochelle MT, Simon D, et al: Admission for nephrolithiasis in pregnancy and risk of adverse birth outcomes. Obstet Gynecol 109(5):1099,s2007 Tan LK, Kanagalingam D, Tan HK, et al: Obstetric outcomes in women with endstage renal failure requiring renal dialysis. Int J Gynaecol Obstet 94: 17, 2006 Tan K, Cha DY, Gupta M: Management of stones in abnormal situations. Urol Clin North Am 40(1):79, 2013


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Obstentrics_Williams. Urol Clin North Am 40(1):79, 2013 Toth C, Toth G, Varga A, et al: Percutaneous nephrolithotomy in early pregnancy. Int Urol NephroI37:1, 2005 Towers CV, Kaminskas CM, Garite TJ, et al: Pulmonary injury associated with antepartum pyelonephritis: can patients at risk be identified? Am J Obstet Gynecol 164:974, 1991 Trevisan G, Ramos JG, Martins-Costa S, et al: Pregnancy in patients with chronic renal insuiciency at Hospital de Clinicas of Porto Alegre, Brazil. Ren Fail 26:29, 2004 Turney JH, Ellis CM, Parsons FM: Obstetric acute renal failure 1956-1987. BJOG 96:679, 1989 U.S. Preventive Services Task Force. Screening for asymptomatic bacteriuria in adults. Reairmation recommendation statement. 2008. Available at: http://ww. uspreven tiveservicestaskforce.org/ uspstf08/ asym ptbact/ asbactrs. htm. Accessed September 22,2016


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Obstentrics_Williams. Van Dorsten JP, Lenke RR, Schifrin BS: Pyelonephritis in pregnancy: the role of in-hospital management and nitrofurantoin suppression. ] Reprod Med 32:897, 1987 Van Hook JW: Acute kidney injury during pregnancy. Clin Obstet Gynecol (4):851-61,s2014 Waikar SS, Bonventre J\\1: Acute kidney injury. In Kasper DL, Fauci AS, Hauser SL, et al (eds): Harrison's Principles of Internal Medicine, 19th ed. New York, McGraw-Hill Education, 2015 Wall LL: Preventing obstetric fistulas in low-resource countries: insights from a Haddon matrix. Obstet Gynecol Surv 67(2):111,s2012 %alley PJ: Bacteriuria of pregnancy. Am J Obstet Gynecol 97:723, 1967 White WM, Zite NB, Gash J, et al: Low-dose computed tomography for the evaluation of flank pain in the pregnant population. J Endourol 21(11):1255,s2007 Widmer M, Lopez 1, Gulmezoglu AM, et al: Duration of treatment for asymptomatic bacteriuria during pregnancy. Cochrane Database Syst Rev II:CD000491,s2015


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Obstentrics_Williams. Widmer M, Lopez 1, Gulmezoglu AM, et al: Duration of treatment for asymptomatic bacteriuria during pregnancy. Cochrane Database Syst Rev II:CD000491,s2015 Wing DA, Fassett MJ, Getahun D: Acute pyelonephritis in pregnancy: an 18-year retrospective analysis. Am J Obstet Gynecol 210(3):219.el, 2014 Wing DA, Hendershott CM, Debuque L, et al: A randomized trial of three antibiotic regimens for the treatment of pyelonephritis in pregnancy. Am J Obstet Gynecol 92:249, 1998 Wing DA, Hendershott CM, Debuque L, et al: Outpatient treatment of acute pyelonephritis in pregnancy after 24 weeks. Obstet Gynecol 94:683, 1999 Wing DA, Park AS, DeBuque L, et al: Limited clinical utiliry of blood and urine cultures in the treatment of acute pyelonephritis during pregnancy. Am J Obstet GynecoIs182:1437, 2000 Wright A], Gill JS: Strategies to prevent BK virus infection in kidney transplant recipients. Curr Opin Infect Dis 29(4):353, 2016


Obstentrics_Williams

Obstentrics_Williams. Wright A], Gill JS: Strategies to prevent BK virus infection in kidney transplant recipients. Curr Opin Infect Dis 29(4):353, 2016 Wyatt RJ, Julian BA: IgA nephropathy. N Engl J Med 368(25):2402,s2013 Wyld ML, Clayton PA, Jesudason S, et al: Pregnancy outcomes for kidney transplant recipients. Am J Transplant 13:3173,s2013 Zanconato G, Bergamini V, Baggio S, et al: Successful pregnancy outcomes after laparoscopic cerclage in a patient with cervicovaginal fistula. Case Rep Obstet GynecoIs2015:784025, 2015 Zeeman GG, Cunningham GC, PritchardJA: he magnitude ofhemoconcentration with eclampsia. Hypertens Pregnancy 28(2):127,s2009 Zeeman GG, Wendel GO Jr, Cunningham FG: A blueprint for obstetric critical care. Am J Obstet Gynecol 188:532,2003 Zhang n, MaX, Hao L, et al: A systematic review and meta-analysis of outcomes of pregnancy in CKD and CKD outcomes in pregnancy. Clin J Soc Nephrols10(11):1964,s2015


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Obstentrics_Williams. Zhang n, MaX, Hao L, et al: A systematic review and meta-analysis of outcomes of pregnancy in CKD and CKD outcomes in pregnancy. Clin J Soc Nephrols10(11):1964,s2015 Zhao C, Zhao J, Huang Y, et al: New-onset systemic lupus erythematosus during pregnancy. Clin Rheumatol 32(6):815, 2013 Zhou J, Pollak MR: Polycystic kidney disease and other inherited disorders of tubule growth and development. In Kasper DL, Fauci AS, Hauser SL, et al (eds): Harrison's Principles of Internal Medicine, 19th ed. New York, McGraw-Hill Education, 2015 GENERAL CONSIDERATIONS . . . . . . . ............. 1042 UPPER GASTROINTESTINAL TRACT DISORDERS ..... 1043 HYPEREMESIS GRAVIDARUM.. . . . . . . ............. 1043 GASTROESOPHAGEAL REFLUX DISEASE ........... 1046 PEPTIC ULCER DISEASE.. . . . . . . . . . . . ............. 1047 SMALL BOWEL AND COLON DISORDERS .......... 1047 ACUTE DIARRHEA.. . . . . . . . . . . . . . . . ............. 1047 INFLAMMATORY BOWEL DISEASE ....i....i........i.... 1048


Obstentrics_Williams

Obstentrics_Williams. SMALL BOWEL AND COLON DISORDERS .......... 1047 ACUTE DIARRHEA.. . . . . . . . . . . . . . . . ............. 1047 INFLAMMATORY BOWEL DISEASE ....i....i........i.... 1048 INTESTINAL OBSTRUCTION . . . . . . . . ............. 1051 APPENDICITIS ..................i.............. 1052 The diagnosis of acute appendicitis is more dficult than at other times, as the enlarged uterus renders it almost impossible to explore the right iliac region satiactoriy.


Obstentrics_Williams

Obstentrics_Williams. The diagnosis of acute appendicitis is more dficult than at other times, as the enlarged uterus renders it almost impossible to explore the right iliac region satiactoriy. -J. Whitridge Williams (1903) hese words summarize that during normal pregnancy, the gastrointestinal tract and its appendages undergo remarkable anatomical, physiological, and functional alterations. hese changes, which are discussed in detail in Chapter 4 (p. 68), can appreciably alter clinical findings normally relied on for diagnosis and treatment of gastrointestinal disorders such as appendicitis. Moreover, as pregnancy progresses, gastrointestinal symptoms become more diicult to assess. Physical findings are often obscured by a large uterus that displaces abdominal organs and can alter the location and intensity of pain and tenderness.


Obstentrics_Williams

Obstentrics_Williams. Fiberoptic endoscopic instruments have revolutionized diagnosis and management of most gastrointestinal conditions, and these are particularly well suited for pregnancy. Endoscopy in pregnancy is associated with a slightly increased risk for preterm birth, but this is likely due to the disease itself (Ludvigsson, 2017). With endoscopy, the esophagus, stomach, duodenum, and colon can be inspected (Cappell, 2011; Savas, 2014). The proximal jejunum can also be studied, and the ampulla of Vater cannulated to perform endoscopic retrograde cholangiopancreatography-ERCP (Akcakaya, 2014; Fogel, 2014). Preliminary data suggest that postendoscopic pancreatitis following gallstone removal may have a higher incidence in pregnant women (Inamdar, 2016). Experience in pregnancy with videocapsule endoscopy for small-bowel evaluation remains limited (Storch, 2006).


Obstentrics_Williams

Obstentrics_Williams. Upper gastrointestinal endoscopy is used for management as well as diagnosis of several problems. Common bile duct exploration and drainage are used for choledocholithiasis as described in Chapter 55 (p. 1070). It is also used for sclerotherapy and for placement of percutaneous endoscopic gastrostomy (PEG) tubes. Several concise reviews have been provided (Cappell, 2011; Fogel, 2014; Gilinsky, 2006).


Obstentrics_Williams

Obstentrics_Williams. For visualization of the large bowel, lexible sigmoidoscopy can be used safely in pregnant women (Siddiqui, 2006). Coonoscopy is indispensible for viewing the entire colon and distal ileum to aid diagnosis and management of several bowel disorders. Except for the midtrimester, reports of colonoscopy during pregnancy are limited, but most results indicate that it should be performed if indicated (Cappell, 2010, 2011; De Lima, 2015). Bowel preparation is completed using polyethylene glycol electrolyte or sodium phosphate solutions. With these, serious maternal dehydration that may cause diminished uteroplacental perusion should be avoided.


Obstentrics_Williams

Obstentrics_Williams. he obvious ideal technique for gastrointestinal evaluation during pregnancy is abdominal sonography. Because computed tomography (CT) use is limited in pregnancy due to radiation exposure, magnetic resonance (MR) imaging is now commonly used to evaluate the abdomen and retroperitoneal space (handelwal, 2013). One example is magnetic resonance cholangiopancreatography-MRCP (Oto, 2009). Another is magnetic resonance enterography-MRE (Stern, 2014). These and other imaging modalities, and their safe use in pregnancy, are considered in more detail in Chapter 46.


Obstentrics_Williams

Obstentrics_Williams. Surgery is lifesaving for certain gastrointestinal conditionsperforative appendicitis being the most common example. Laparoscopic procedures have replaced traditional surgical techniques for many abdominal disorders during pregnancy. hese are shown in detail with descriptions of surgical technique in Chapter 46 (p. 903) and in Cunningham and Gilstrap 5 Operative Obstetrics, 3rd edition (Kho, 2016). Guidelines for diagnosis, treatment, and use of laparoscopy for surgical problems during pregnancy have been provided by the Society of American Gastrointestinal and Endoscopic Surgeons-SAGES (Pearl, 2017). Specialized nutritional support can be delivered enteraly, usually via nasogastric tube feedings, orparenteraly with nutrition given by venous catheter access, either peripherally or centrally.


Obstentrics_Williams

Obstentrics_Williams. Specialized nutritional support can be delivered enteraly, usually via nasogastric tube feedings, orparenteraly with nutrition given by venous catheter access, either peripherally or centrally. When possible, enteral alimentation is preferable because it has fewer serious complications (Bistrian, 2012; Stokke, 2015). In obstetrical patients, very few conditions prohibit enteral nutrition as a first efort to prevent catabolism. For extreme cases, such as recalcitrant hyperemesis gravidarum, percutaneous endoscopic gastrostomy with a jejunal port (PEG-J tube) has been described (Saha, 2009). he purpose of parenteral eeding, or hyperalimentation, is to provide nutrition when the intestinal tract must be quiescent. Central venous access is necessary for total parenteral nutrition because its hyperosmolarity requires rapid dilution in a highflow vascular system. hese solutions provide 24 to 40 kcall kg/ d, principally as a hypertonic glucose solution.


Obstentrics_Williams

Obstentrics_Williams. Not surprisingly, gastrointestinal disorders are the most common indication, and in the many studies cited, feeding duration averaged approximately 33 days. Importantly, complications of parenteral nutrition are frequent, and they may be severe (Guglielmi, 2006). n early report of 26 pregnancies described a 50-percent rate of complications, which included pneumothorax, hemothorax, and brachial plexus injury (Russo-Stieglitz, 1999). he most frequent serious complication is catheter sepsis, and Folk (2004) reported a 25-percent incidence in 27 women with hyperemesis gravidarum. Although bacterial sepsis is most common, Candia septicemia has been described (Paranyuk, 2006). he Centers for Disease Control and Prevention has updated its detailed guidelines to prevent catheter-related sepsis, and these serve to lessen the dangers of serious infections (O'Grady, 2011). Perinatal complications are


Obstentrics_Williams

Obstentrics_Williams. TABLE 54-1. Some Conditions Treated with Enteral or Parenteral Nutrition During Pregnancya aOisorders are listed alphabetically. Data from Folk, 2004; Guglielmi, 2006; Manliadevan, 2015; Ogura, 2003; Porter, 2014; Russo-Stieglitz, 1999; Saha, 2009; Spiliopoulos, 201n3 . uncommon, however, fetal subdural hematoma caused by mater nal vitamin K deiciency has been described (Sakai, 2003). Appreciable morbidity is also associated with long-term use of a peripheraly inserted central catheter (PICC). Infection is the most common serious long-term complication (Holmgren, 2008; Ogura, 2003). In a series of84 such catheters inserted in 66 preg nant women, Cape and coworkers (2014) reported a 56-percent complication rate, of which bacteremia was the most frequent.


Obstentrics_Williams

Obstentrics_Williams. Ogura, 2003). In a series of84 such catheters inserted in 66 preg nant women, Cape and coworkers (2014) reported a 56-percent complication rate, of which bacteremia was the most frequent. From a review of 48 reports of nonpregnant adults, Turcotte and associates (2006) concluded that peripherally placed catheters provided no advantages compared with centrally placed ones. Still, for short-term nutrition lasting a few weeks, it seems reasonable that PICC placement has a greater beneit-versusrisk ratio (Bistrian, 2012).


Obstentrics_Williams

Obstentrics_Williams. Mild to moderate nausea and vomiting are especially common in pregnant women until approximatel) 16 weeks' gestation (Chap. 9, p. 174). In a small but significant proportion of these, however, it is severe and unresponsive to simple dietary modiication and antiemetics. Severe unrelenting nausea and vomiting-hyperemesis gravidarum-is deined variably as being suiciently severe to produce weight loss, dehydration, ketosis, alkalosis from loss of hydrochloric acid, and hypokalemia. Acidosis develops from partial starvation. In some women, transient hepatic dysfunction develops, and biliary sludge accumulates (Matsubara, 2012). Other causes should be considered because ultimately hyperemesis gravidarum is a diagnosis of exclusion (Benson, 2013).


Obstentrics_Williams

Obstentrics_Williams. Study criteria have not been homogeneous, thus reports of population incidences vary. here does, however, appear to be an ethnic or familial predilection (Grjibovski, 2008). In population-based studies from California, Nova Scotia, and Norway, the hospitalization rate for hyperemesis gravidarum was 0.5 to 1 percent (Bailit, 2005; Fell, 2006; Vikanes, 2013). Up to 20 percent of those hospitalized in a previous pregnancy for hyperemesis will again require hospitalization (Dodds, 2006; Trogstad, 2005). In general, obese women are less likely to be hospitalized for this (Cedergren, 2008).


Obstentrics_Williams

Obstentrics_Williams. The etiopathogenesis of hyperemesis gravidarum is unknown and is likely multifactorial. It apparently is related to high or rapidly rising serum levels of pregnancy-related hormones. Putative culprits include human chorionic gonadotropin (hCG), estrogen, progesterone, leptin, placental growth hormone, prolactin, thyroxine, and adrenocortical hormones (Verberg, 2005). More recently implicated are other hormones that include ghrelins, leptin, nesfatin-1, and peptide Y (3-36) (Albayrak, 2013; Gungor, 2013).


Obstentrics_Williams

Obstentrics_Williams. Superimposed on this hormonal cornucopia are an imposing number of biological and environmental factors. Moreover, in some but not all severe cases, interrelated psychological components playaa major role (Christodoulou-Smith, 20a11a; McCarthy, 2011). Other factors that increase the risk for admission include hyperthyroidism, previous molar pregnancy, diabetes, gastrointestinal illnesses, some restrictive diets, and asthma and other allergic disorders (Fell, 2006; Mullin, 2012). n association of Helicobacter pylori infection has been proposed, but evidence is not conclusive (Goldberg, 2007). Chronic marijuana use may cause the similar cannabinoid hyperemesis syndrome (Alaniz, 2015; Andrews, 2015). And for unknown reasons-perhaps estrogenrelated-a female fetus increases the risk by 1.5-fold (Schif, 2004; Tan, 2006; Veenendaal, 2011). Finally, some but not all studies have reported an association between hyperemesis gravidarum and preterm labor, placental abruption, and preeclampsia


Obstentrics_Williams

Obstentrics_Williams. (Schif, 2004; Tan, 2006; Veenendaal, 2011). Finally, some but not all studies have reported an association between hyperemesis gravidarum and preterm labor, placental abruption, and preeclampsia (Bolin, 2013; Vandraas, 2013; Vikanes, 20l3).


Obstentrics_Williams

Obstentrics_Williams. Vomiting may be prolonged, frequent, and severe, and a list of potentially fatal complications is given in Table 54-2. Various TABLE 54-2. Some Serious and Life-Threatening Complications of Recalcitrant Hyperemesis Gravidarum Acute kidney injury-may require dialysis Depression-cause versus efect? Diaphragmatic rupture


Obstentrics_Williams

Obstentrics_Williams. TABLE 54-2. Some Serious and Life-Threatening Complications of Recalcitrant Hyperemesis Gravidarum Acute kidney injury-may require dialysis Depression-cause versus efect? Diaphragmatic rupture Esophageal rupture-Boerhaave syndrome Hypoprothrombinemia-vitamin K deficiency Hyperalimentation complications Mallory-Weiss tears-bleeding, pneumothorax, pneumomediastinum, pneumopericardium Rhabdomyolysis degrees of acute kidney injury from dehydration are encountered (Nwoko, 2012). An extreme example was a woman we cared for who required 5 days of dialysis when her serum creatinine level rose to 10.7 mg/dL (Hill, 2002). One complication from continuous retching is a Mallory-Weiss tear. Others are pneumothorax, pneumomediastinum, diaphragmatic rupture, and gastroesophageal rupture-Boerhaave syndrome (American College of 0bstetricians and Gynecologists, 2015; Chen, 2012).


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Obstentrics_Williams. At least two serious vitamin deiciencies have been reported with hyperemesis in pregnancy. One is Wernicke encephalopathy from thiamine deiciency that has been recognized with increasing frequency (Di Gangi, 2012; Palacios-vIarques, 2012). In two reviews, ocular signs, confusion, and ataxia were common, but only half had this triad (Chiossi, 2006; Selitsky, 2006). With this encephalopathy, an abnormal electroencephalogram (EEG) may be seen, and usually MR imaging shows findings (Vaknin, 2006; Zara, 2012). At least three maternal deaths have been described, and long-term sequelae include blindness, convulsions, and coma (Selitsky, 2006). he second is vitamin K deicieny that has been reported to cause maternal coagulopathy and fetal intracranial hemorrhage, as well as vitamin K embryopathy (Kawamura, 2008; Lane, 2015; Sakai, 2003). One algorithm for management of nausea and vomiting of pregnancy is shown in Figure Most women with mild


Obstentrics_Williams

Obstentrics_Williams. One algorithm for management of nausea and vomiting of pregnancy is shown in Figure Most women with mild Mild Dietary management; Ginger extract; Vitamin 86 plus doxylamine, diphenhydramine, or dimenhydrinate Moderate Severe Promethazine, Intravenous hydration prochlorperazine, with thiamine; trimethobenzamide, Parenteral: chlorpromazine, metoclopramide, metoclopramide, or promethazine, or ondansetron ondansetron (oral, rectal, parenteral) Intractable Enteral or parenteral nutrition ment of hyperemeSis gravidarum. TABLE 54-3. Medications for Gastric Disorders in Pregnancy At bedtime; up to 4 times daily 12.5-25 mg 1M, IV, PO, PR 1M, IV, PO, PR IV, PO 1M, IV, PO


Obstentrics_Williams

Obstentrics_Williams. TABLE 54-3. Medications for Gastric Disorders in Pregnancy At bedtime; up to 4 times daily 12.5-25 mg 1M, IV, PO, PR 1M, IV, PO, PR IV, PO 1M, IV, PO Pantoprazole (Protonix)b Lansoprazole (Prevacid)b Omeprazole (Prilosec, Zegeridr Dexlansoprazole (Dexilant)C 400 mg 4 times daily for up to 12 wks 800 mg twice daily for up to 12 wks 150 mg twice daily 20 mg twice daily up to 6 wks 40 mg daily for up to 8 wks 15 mg daily for up to 8 wks 20 mg daily for 4-8 wks 30 mg daily for up to 4 wks aFood and Drug Administration category A. bFood and Drug Administration category B. (Food and Drug Administration category C.


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Obstentrics_Williams. to moderate symptoms respond as outpatients to any of several irst-line antiemetic agents (Clark, 2014; Matthews, 2014). One that is becoming a mainstay is Diclegis-a combination of doxylamine (10 mg) plus pyridoxine (10 mg). It has been proven safe and efective (Briggs, 2015; Koren, 2014). The usual dose is two tablets orally at bedtime. If relief is insufficient, then additional doses, first in the morning, and then in the morning and midafternoon can be added each day to the bedtime dose. At our institution, for cost savings, we prescribe these two agents individually: Unisom (doxylamine) Y2 of a 50-mg tablet plus a 25-mg vitamin B6 tablet. The same graduated dosing is used but does not exceed three total daily doses. Ondansetron (Zofran) also does not appear to be teratogenic.


Obstentrics_Williams

Obstentrics_Williams. Ondansetron (Zofran) also does not appear to be teratogenic. It was slightly more eicacious than a combination of doxylamine and pyridoxine in a randomized trial (Oliveira, 2014; Pasternak, 2013). Its drawbacks include potential maternal efects from prolonged QT-interval and serotonin syndrome (Koren, 2014). When simple measures fail, intravenous crystalloid solutions are given to correct dehydration, ketonemia, electrolyte deicits, acid-base imbalances, and hypokalemia. No benefits are gained by infusing 5-percent dextrose along with crystalloids (Tan, 20l3). Thiamine, 100 mg, is given to prevent Wernicke encephalopathy (Giugale, 2015; Niebyl, 2010). his is usually diluted in 1 L of the selected crystalloid and infused at the maintenance rate desired for patient hydration.


Obstentrics_Williams

Obstentrics_Williams. If vomiting persists after rehydration and failed outpatient management, hospitalization is recommended (American College of Obstetricians and Gynecologists, 2015). Day care has also been shown to be efective in one randomized study (McCarthy, 2014). Intravenous hydration is continued and antiemetics such as promethazine, prochlorperazine, chlorpromazine, or metoclopramide are given parenterally (Table 54-3). The bulk of evidence is that treatment with glucocorticosteroids is not efective (Yost, 2003). Because of their putative teratogenicity, they are not routinely recommended (American College of Obstetricians and Gynecologists, 2015).


Obstentrics_Williams

Obstentrics_Williams. With persistent vomiting after hospitalization, appropriate steps should be taken to exclude possible underlying diseases as a cause of hyperemesis. That said, in one study, endoscopy did not change management in 49 women (Debby, 2008). Other potential causes of vomiting include gastroenteritis, cholecystitis, pancreatitis, hepatitis, peptic ulcer, and pyelonephritis. In addition, severe preeclampsia and fatty liver are more likely after midpregnancy. And although clinical thyrotoxicosis has been implicated as a cause of hyperemesis, it is more likely that abnormally elevated serum thyroxine levels are a surrogate for higher-than-average serum hCG levels (Sun, 2014). This is discussed further in Chapter 5 (p. 100). In our experiences, serum free thyroxine levels normalize quickly with hydration and emesis treatment.


Obstentrics_Williams

Obstentrics_Williams. With treatment, most women will have a salutary response and may be sent home with antiemetic therapy. Their readmission rate is 25 to 35 percent in most prospective studies. If associated psychiatric and social factors contribute to the illness, the woman usually improves remarkably while hospitalized (Swallow, 2004). That said, symptoms may relapse in these women, and some go on to develop posttraumatic stress syndrome (Christodoulou-Smith, 2011; McCarthy, 2011). For some women, hyperemesis can be an indication for elective termination (Poursharif, 2007).


Obstentrics_Williams

Obstentrics_Williams. In the small percentage of women who continue to have recalcitrant vomiting after intensive therapy, consideration is given for enteral nutrition (p. 1043). Stokke and associates (2015) described successful use of nasojejunal feeding for up to 41 days in 107 such women. Use of sonography to conirm correct placement of the tube has been described (Swartzlander, 2013). Percutaneous endoscopic gastrostomy with a jejunal port has also been reported (Saha, 2009; Schrag, 2007). A randomized trial failed to show any advantages from early enteral feeding (Grooten, 2017). In our experiences, only a very few women will require parenteral nutrition (Yost, 2003). In a study of 599 women, however, Peled and coworkers (2014) reported that 20 percent required central venous access to be established for nutrition.


Obstentrics_Williams

Obstentrics_Williams. Symptomatic reflux is seen in up to 15 percent of nonpregnant individuals (Kahrilas, 2015). he spectrum of sequelae includes esophagitis, stricture, Barrett esophagus, and adenocarcinoma. The main symptom of relux is heartburn, or pyrosis, which is especially common in pregnancy. Its prevalence rose from 26 percent in the irst trimester to 36 percent in the second and 51 percent in the third trimesters (Malfertheiner, 2012). The retrosternal burning sensation stems from esophagitis caused by gastroesophageal relux related to relaxation of the lower esophageal sphincter.


Obstentrics_Williams

Obstentrics_Williams. Reflux symptoms usually respond to tobacco and alcohol abstinence, small meals, head of the bed elevation, and avoidance of postprandial recumbency. So-called "trigger" foods are also avoided and usually include fatty foods, tomato-based foods, and cofee. Oral antacids are first-line therapy. If severe symptoms persist, sucralfate (Carafate) is given along with a protonpump inhibitor or an H2-receptor antagonist (see Table 54-3). Both classes are generally safe for use in pregnancy (Briggs, 2015; Mahadevan, 2006b). Of these, a 1-g sucralfate tablet is taken orally 1 hour before each of the three meals and at bedtime for up to 8 weeks. Antacids are not used within Y2 hour before or after sucralfate doses. If relief is not attained, then endoscopy should be considered. Misoprostol is contraindicated because it stimulates labor (Chap. 26, p. 508).


Obstentrics_Williams

Obstentrics_Williams. In nonpregnant patients, surgical fundoplication is performed (Kahrilas, 2015). Although the procedure is not done during pregnancy, Biertho and colleagues (2006) described 25 women who had undergone laparoscopic Nissen fundoplication before pregnancy. Only 20 percent had relux symptoms during pregnancy. he older literature is informative regarding hiatal hernias in pregnancy. Upper gastrointestinal radiographs performed in 195 women in late pregnancy showed that 20 percent of 116 multiparas and 5 percent of 79 nulliparas had a hiatal hernia (Rigler, 1935). Of 10 women studied postpartum, hernia persisted in three at 1 to 18 months.


Obstentrics_Williams

Obstentrics_Williams. he relationship of hiatal hernia with reflux esophagitis, and thus symptoms, is not clear. One study demonstrated no relationship between reflux and hernia and showed that the lower esophageal sphincter functioned efectively even when displaced intrathoracically (Cohen, 1971) . Nevertheless, during pregnancy, these hiatal hernias may cause vomiting, epigastric pain, and bleeding from ulceration. Schwentner (201a1) reported severe herniation requiring surgical repair in a woman with a 12-week gestation. Curran and coworkers (1999) described a 30-week pregnancy complicated by gastric outlet obstruction from a paraesophageal hernia.


Obstentrics_Williams

Obstentrics_Williams. These are caused by herniations of abdominal contents through either the foramen of Bochdalek or vforgagni. Fortunately, they rarely complicate pregnancy. Kurzel and associates (1988) reviewed the outcomes of 18 pregnant women with such a hernia and who developed acute obstruction. Because the maternal mortality rate was 45 percent, they recommend repair during pregnancy even if a woman is asymptomatic. Herniation has been reported in one pregnant woman from a previous traumatic diaphragmatic defect and in another who had antirelux surgery in early pregnancy (Brygger, 2013; Flick, 1999). Several case reports also describe spontaneous diaphragmatic rupture from increased intraabdominal pressure during delivery (Chen, 2012; Sharifah, 2003).


Obstentrics_Williams

Obstentrics_Williams. his is a rare motility disorder in which the lower esophageal sphincter does not relax properly with swallowing. There is also nonperistaltic contraction activity of the esophageal muscularis to cause symptoms (Kahrilas, 2015; Khudyak, 2006). The defect is caused by inflammatory destruction of the myenteric (Auerbach) plexus within smooth muscle of the lower esophagus and its sphincter. Postganglionic cholinergic neurons are unafected, thus, sphincter stimulation is unopposed. Symptoms are dysphagia, chest pain, and regurgitation. Barium swallow radiography demonstrates bird beak or ace of spades narrowing at the distal esophagus. Endoscopy is performed to exclude gastric carcinoma, and manometry is confirmatory. If dilatation of the esophagus and medical therapy does not provide relief, myotomy is considered (Torquati, 2006).


Obstentrics_Williams

Obstentrics_Williams. During pregnancy, normal relaxation of the lower esophageal sphincter in women with achalasia theoretically should not occur. Even so, in most women, pregnancy does not seem to worsen achalasia. One report of 20 afected pregnant women found no excessive relux esophagitis (Mayberry, 1987). Khudyak and coworkers (2006) reviewed 35 cases and described most women as symptom free, although esophageal dilatation was needed in a few. A maternal death was reported at 24 weeks' gestation associated with perforation of a 14-cm diameter megaesophagus (Fassina, 1995).


Obstentrics_Williams

Obstentrics_Williams. Management of achalasia includes soft diet and anticholinergic drugs. With persistent symptoms, other options include nitrates, calcium-channel antagonists, and botulinum toxin A injected locally (Hooft, 2015; Kahrilas, 2015). Balloon dila tation of the sphincter may be necessary, and 85 percent of nonpregnant patients respond to this. Satin (1a992) and Fiest (1993) and their associates reported successful use of pneu matic dilatation in pregnancy. One caveat is that esophageal peroration is a serious complication of dilatation. Spiliopoulos and colleagues (2013) described a 29-week pregnant woman with achalasia treated for 10 weeks with parenteral nutrition. Surgical correction was performed postpartum.


Obstentrics_Williams

Obstentrics_Williams. he lifetime prevalence of acid peptic disorders in women is 10 percent (Del Valle, 2015). Erosive ulcer disease involves the stomach and duodenum. Gastroduodenal ulcers may be caused by chronic gastritis from H pylori, or they develop from nonsteroidal antiinlammatory drug (NSAID) use. Neither is common in pregnancy (McKenna, 2003; Weyermann, 2003). Acid secretion is also important, and thus underlies the eicacy of antisecretory agents (Suerbaum, 2002). Gastroprotection during pregnancy probably originates from physiological changes that include reduced gastric acid secretion, decreased motility, and considerably increased mucus secretion (Hytten, 1991). Despite this, ulcer disease may be underdiagnosed because of frequent treatment for reflux esophagitis (Mehta, 2010). In the past 50 years at Parkland Hospital, during which time we have cared for more than 500,000 pregnant women, we have encountered very few who had proven ulcer disease. Perforation is rare (Goel, 2014). Before


Obstentrics_Williams

Obstentrics_Williams. years at Parkland Hospital, during which time we have cared for more than 500,000 pregnant women, we have encountered very few who had proven ulcer disease. Perforation is rare (Goel, 2014). Before appropriate therapy was commonplace, Clark (1953) studied 313 pregnancies in 11a8 women with ulcer disease and noted a clear remission during pregnancy in almost 90 percent. However, beneits were short lived. Symptoms recurred in more than half by 3 months postpartum and in almost all by 2 years.


Obstentrics_Williams

Obstentrics_Williams. The mainstay of management is eradication of H pylori and prevention of NSAID-induced disease. Antacids are usually self-prescribed, but irst-line therapy is with HTreceptor blockers or proton-pump inhibitors (Del Valle, 2015). Sucraote is the aluminum salt of sulfated sucrose that inhibits pepsin. It provides a protective coating at the ulcer base. Approximately 10 percent of the aluminum salt is absorbed, and it is considered safe for pregnant women (Briggs, 2015). With active ulcers, a search for H pylori is undertaken.


Obstentrics_Williams

Obstentrics_Williams. With active ulcers, a search for H pylori is undertaken. Diagnostic aids include the urea breath test, serological testing, or endoscopic biopsy. If any of these yield positive results, combination antimicrobial and proton-pump inhibitor therapy is indicated. Several efective oral treatment regimens do not include tetracycline and can be used during pregnancy. hese 14-day regimens include amoxicillin, 1000 mg twice daily plus clarithromycin, 250 to 500 mg twice daily, plus metronidazole, 500 mg twice daily given along with the proton-pump inhibitor omeprazole (Del Valle, 2015).


Obstentrics_Williams

Obstentrics_Williams. In some women, persistent vomiting is accompanied by worrisome upper gastrointestinal bleeding. Occasionally, a peptic ulceration is the source. However, most of these women have small linear mucosal tears near the gastroesophageal junction-Malloy-Weiss tears, described earlier. Bleeding usually responds promptly to conservative measures, including iced-saline irrigations, topical antacids, and intravenously administered HTblockers or protonpump inhibitors. Transfusions may be needed, and if bleeding persists, then endoscopy is usually indicated (O'Mahony, 2007). With sustained retching, the less common, but more serious, esophageal rupture-Boerhaave syndrome-may develop from greatly increased esophageal pressure. The small bowel has diminished motility during pregnancy.


Obstentrics_Williams

Obstentrics_Williams. The small bowel has diminished motility during pregnancy. Using a nonabsorbable carbohydrate, Lawson (1985) showed that small bowel mean transit times were 99, 125, and 137 minutes in each trimester, compared with 75 minutes when nonpregnant. In a study cited by Everson (1992), mean tran sit time for a mercury-illed balloon from the stomach to the cecum was 58 hours in term pregnant women compared with 52 hours in nonpregnant women. Muscular relaxation of the colon is accompanied by increased absorption of water and sodium that predisposes to consti pation. This complaint is reported by almost 40 percent of women at some time during pregnancy (Everson, 1992). Such symptoms are usually only mildly bothersome, and preventive measures include a high-iber diet and bulk-forming lxatives. Wald (2003) has reviewed treatment options. We have encoun impacted stool. These women almost invariably had chronically abused stimulatory laxatives.


Obstentrics_Williams

Obstentrics_Williams. he estimated monthly prevalence of diarrhea among adults is 3 to 7 percent (DuPont, 2014). Diarrhea can be classiied as acute «2 weeks), persistent (2 to 4 weeks), and chronic (>4 weeks). Most cases of acute diarrhea are caused by infectious agents, and a third result from foodborne pathogens. The large variety of viruses, bacteria, helminths, and protozoa that cause diarrhea in adults inevitably also alict pregnant women. Some of these are discussed in Chapter 64. Evaluation of acute diarrhea depends on its severity and duration. Some indications for evaluation include profuse watery diarrhea with dehydration, grossly bloody stools, fevera> 38°C, duration >48 hours without improvement, recent antimicrobial use, and diarrhea in the immunocompromised patient (Camilleri, 2015; DuPont, 2014). Cases of moderately severe diarrhea with fecal leukocytes or gross blood may best be treated with empirical antibiotics rather than evaluation. Some features of the more common acute diarrheal


Obstentrics_Williams

Obstentrics_Williams. 2014). Cases of moderately severe diarrhea with fecal leukocytes or gross blood may best be treated with empirical antibiotics rather than evaluation. Some features of the more common acute diarrheal syndromes and their treatment are shown in Table 54-4.


Obstentrics_Williams

Obstentrics_Williams. The mainstay of treatment is intravenous hydration using normal saline or Ringer lactate with potassium supplementation in amounts to restore maternal blood volume and to ensure uteroplacental perfusion. Vital signs and urine output are monitored for signs of sepsis syndrome. For moderately severe nonfebrile illness without bloody diarrhea, antimobility agents such as loperamide (Imodium) may be useful. Bismuth subsalicylate (Pepto-Bismol) may also alleviate symptoms. TABLE 54-4. Etiology, Clinical Features, and Treatment of Common Acute Diarrheal Syndromes Toxin producers 1-72 hr 3-4+ 1-2+ 0-1 + 3-4+, watery 1. Staphylococcus 1. None 2. C perfringens 2. None 3. 1-2+ 1-3+, watery, 1. C difficile then bloody 1. Metronidazole 2. 3. Salmonella bloody 4. Campylobacter 5. Vibrio 5. Doxycycline Severe 1-8 days 0-1 + 3-4+ 3-4+ 1-2+, bloody 6. Shigella 6. Ciprofloxacin 7. E coli 7. Ciprofloxacin 8. Entamoeba histolytica 8. Metronidazole


Obstentrics_Williams

Obstentrics_Williams. Severe 1-8 days 0-1 + 3-4+ 3-4+ 1-2+, bloody 6. Shigella 6. Ciprofloxacin 7. E coli 7. Ciprofloxacin 8. Entamoeba histolytica 8. Metronidazole B cereus = Bacillus cereus; C difficile = Clostridium difficile; C perfringens = Clostridium perfringens; E coli = Escherichia coli. Data from Camilleri, 201 5; DuPont, 201 4.


Obstentrics_Williams

Obstentrics_Williams. B cereus = Bacillus cereus; C difficile = Clostridium difficile; C perfringens = Clostridium perfringens; E coli = Escherichia coli. Data from Camilleri, 201 5; DuPont, 201 4. Judicious use of antimicrobial agents is warranted. For moderate to severely ill women, some recommend empirical treatment with ciprofloxacin, 500 mg twice daily for 3 to 5 days. Speciic pathogens are treated as needed when identiied (see Table 54-4). Syndromes for which treatment is usually unnecessary include those caused by Escherichia coli, staphylococcal species, Bacilus cereus, and Norwalk-like virus. Severe illness caused by Salmonela spp is treated with ciprofloxacin or trimethoprim-sulfamethoxazole; by Campylobacter spp with azithromycin; by Clostridium diicile with oral metronidazole or vancomycin; and by Giardia spp and Entamoeba histoytica with metronidazole (DuPont, 2014; Rocha-Castro, 2016).


Obstentrics_Williams

Obstentrics_Williams. his anaerobic gram-positive bacillus is transmitted by the fecal-oral route. It is the most frequent nosocomial infection in the United States. In 2011, 453,000 cases of C dicile and 29,000 associated deaths were reported by the Centers for Disease Control and Prevention (CDC) (Lessa, 2015). he most important risk factor is antibiotic use, and the highest risk is with aminopenicillins, clindamycin, cephalosporins, and luoroquinolones. Other risk factors include inlammatory bowel disease, immunosuppression, advanced age, and gastrointestinal surgery. Most cases are hospital-acquired, however, community-acquired cases are becoming common (Leler, 2015). With severe colitis, the infection-related mortality rate is 5 percent.


Obstentrics_Williams

Obstentrics_Williams. Diagnosis is by enzyme immunoassay for toxins in the stool, or by DNA-based tests that identiy toxin genes. Only patients with diarrhea should be tested, and posttreatment testing is not recommended. Prevention is by soap-and-water hand washing, and infected individuals are isolated. Treatment is oral vancomycin or metronidazole. The risk of recurrence after an initial episode is 20 percent. Fecal microbial transplantation may become standard for recurrent clostridial colitis.


Obstentrics_Williams

Obstentrics_Williams. Two presumably noninfectious forms of intestinal inlammation are ulcerative colitis and Crohn disease. Diferentiation between these is important because treatment difers. That said, they both share common features, and sometimes are indistinguishable if Crohn disease involves the colon. he salient clinical and laboratory features shown in Table 54-5 permit a reasonably confident diagnostic diferentiation in most cases. he etiopathogenesis is enigmatic in both, but a genetic predisposition is suspected. Inlammation is thought to result from dysregulated mucosal immune function in response to commensal microbiota, with or without an autoimmune component (Friedman, 2015). TABLE 54-5. Some Shared and Diferentiating Characteristics of Inflammatory Bowel Disease Hereditary More than 100 disease-associated genetic loci-a third shared; Jewish predominance; familial in 5-10% of cases; Turner syndrome; immune dysregulation


Obstentrics_Williams

Obstentrics_Williams. Hereditary More than 100 disease-associated genetic loci-a third shared; Jewish predominance; familial in 5-10% of cases; Turner syndrome; immune dysregulation Other Chronic and intermittent with exacerbations and remissions; extraintestinal manifestations: arthritis, erythema nodosum, uveitis Major symptoms Diarrhea, tenesmus, rectal bleeding, cramping pain; Fibrostenotic-recurrent RLQ colicky pain; fever chronic, intermittent bladder, interenteric Bowel involvement Mucosa and submucosa of large bowel; usually begins Deep layers small and large bowel; at rectum (40% proctitis only); continuous disease commonly transmural; discontinuous involvement; strictures and fistulas RLQ = right lower quadrant; S cerevisiae = Saccharomyces cerevisiae. Data from Friedman, 201n5; Lichtenstein, 2009; Podolsky, 2002. Ulcerative Colitis and erythema nodosum. Another serious problem is that the risk of colon cancer approaches 1 percent per year. With either


Obstentrics_Williams

Obstentrics_Williams. Ulcerative Colitis and erythema nodosum. Another serious problem is that the risk of colon cancer approaches 1 percent per year. With either This is a mucosal disorder with inflammation confined to the ulcerative colitis or Crohn disease, there is also concern for possuperficial luminal layers of the colon. It typically begins at the sible increased risks for venous thromboembolism (Kappelman, rectum and extends proximally for a variable distance. In approx2011; Novacek, 2010).


Obstentrics_Williams

Obstentrics_Williams. imately 40 percent of cases, disease is conined to the rectum and rectosigmoid, but 20 percent have pancolitis. For unknown reasons, prior appendectomy protects against development of ulcerative coli tis (Friedman, 2015). Endoscopic indings include Also known as regional enteritis, Crohn ileitis, and granulomucosal granularity and friability that is interspersed with mucomatous colitis, Crohn disease has more protean manifestations sal ulcerations and a mucopurulent exudate (Fig. 54-2). than ulcerative colitis. It involves not only the bowel mucosa but


Obstentrics_Williams

Obstentrics_Williams. Major symptoms of ulcerative colitis include diarrhea, rectal also the deeper layers, and sometimes involvement is transmural bleeding, tenesmus, and abdominal cramps. The disease can be (see Fig. 54-2). Lesions can be seen throughout the entire gasacute or intermittent and is characterized by exacerbations and trointestinal tract, from the mouth to the anus, but it typically remissions. Toxic megacolon and catastrophic hemorrhage are is segmental (Friedman, 2015). Approximately 30 percent of particularly dangerous complications that may necessitate colpatients have small-bowel involvement, 25 percent have isolated ectomy. Extraintestinal maniestations include arthritis, uveitis, colonic involvement, and 40 percent have both, usually with the terminal ileum and colon involved. Perianal fistulas and abscesses develop in a third of those with colonic involvement.


Obstentrics_Williams

Obstentrics_Williams. Symptoms depend on which bowel segment(s) is involved. Thus, complaints may include lower-right-sided cramping abdominal pain, diarrhea, weight loss, lowgrade fever, and obstructive symptoms. The disease is chronic with exacerbations and remissions, and importantly, it cannot be cured medically or surgically. Approximately a third of patients require surgery within the first year ater diagnosis, and thereater, 5 percent per year. Reactive arthritis is common, and the gastrointestinal cancer risk, although not as great as. with ulcerative colitis, is increased substantially. FIGURE 54-2 Causes of colitis. A.Chronic ulcerative colitis with diffuse ulcerations and exudates. B. Crohn colitis with deep ulcers. (Reproduced with permission from Song LM Topazian M: Gastointestinal endoscopy. Kasper DL, Fauci AS, Hauser SL, et al (eds): Harrison's Principles of Internal Medicine, 19th ed. New York: McGraw-Hili Education; 201o5.)


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Obstentrics_Williams. Subfertility is commonly linked to chronic medical disease, but 1VIahadevan (2006a) cited a normal fertility rate for inflammatory bowel disease unless severe disease warranted surgery. Similarly, Alstead (2003) reported that decreased female fertility from active Crohn disease returned to normal with remission. For women requiring surgical resection, laparoscopic anastomosis has a higher subsequent fertility rate (Beyer-Berjot, 2013). With colectomy, however, even though fertility is improved, up to half of women will be persistently infertile (Bartels, 2012). Sexual function and fertility are only modestly afected by ileal pouch-anal anastomosis (Hor, 2016). Subfertility may also be partially due to sulfasalazine, which causes reversible sperm abnormalities (Feagins, 2009).


Obstentrics_Williams

Obstentrics_Williams. Because ulcerative colitis and Crohn disease are relatively common in young women, they are encountered with some frequency in pregnancy. In this regard, a few generalizations can be made. First, consensus supports that pregnancy does not increase the likelihood of an inlammatory bowel disease flare (.1ahadevan, 2015). Indeed, in a 10-year surveillance of women in the European Collaborative on Inflammatory Bowel Disease, the likelihood of a lare during pregnancy was decreased compared with the preconceptional rate (Riis, 2006). Although most women with quiescent disease in early pregnancy do not have relapses, when a lare develops, it may be severe. lso, active disease in early pregnancy increases the likelihood of poor pregnancy outcome, which is discussed subsequently. In general, most usual treatment regimens may be continued during pregnancy. Diagnostic evaluations should be undertaken if needed to direct management, and surgery should be performed if indicated. For women who


Obstentrics_Williams

Obstentrics_Williams. usual treatment regimens may be continued during pregnancy. Diagnostic evaluations should be undertaken if needed to direct management, and surgery should be performed if indicated. For women who successfully complete pregnancy, about half experience improvement in their health-relate.d q uali ty of life (Ananthakrishnan, 2012).


Obstentrics_Williams

Obstentrics_Williams. At first glance, it appears that adverse pregnancy outcomes are increased with inflammatory bowel disease (Boyd, 2015; Cornish, 2012; Getahun, 2014). Initially, this was attributed to the fact that most studies included women with either form of disease. Specifically, Crohn disease was noted to be linked to excessive morbidity (Dominitz, 2002; Stephansson, 2010). But, according to Reddy (2008) and others, these adverse outcomes were in women with severe disease and multiple recurrences. Indeed, in the prospective European case-control ECCO-EpiCom study of 332 pregnant women with inflammatory bowel disease, Bortoli and coworkers (2011) found similar outcomes in women with ulcerative colitis or Crohn disease compared with normally pregnant women. Importantly, perinatal mortality rates are not appreciably increased.


Obstentrics_Williams

Obstentrics_Williams. Ulcerative Colitis and Pregnancy. Ulcerative colitis does not signiicantly alter the course of pregnancy in afected women. In one review of 755 pregnancies, colitis that was quiescent at conception worsened in approximately a third of pregnancies (Fonager, 1998). In women with active disease at the time of conception, approximately 45 percent worsened, 25 percent remained unchanged, and only 25 percent improved. hese observations are similar to those previously described in an extensive review by Miller (1986) and a later report from Oron and colleagues (2012). Osteoporosis is a signiicant complication in up to a third of these women, and thus vitamin D-800 IU daily-and calcium-1200 mg daily-are given. Folic acid, 4 mg orally daily, is recommended preconceptionally and during the first trimester for neural-tube defect prevention. his high dose counteracts the antifolate actions of sulfasalazine. Flares may be caused by psychogenic stress, and reassurance is important.


Obstentrics_Williams

Obstentrics_Williams. Management for colitis for the most part mirrors that outside of pregnancy. Treatment of active colitis and maintenance therapy incorporate drugs that deliver 5-aminosalicyclic acid (5-ASA) or mesalamine. Suasalazine (Azuidine) is the prototype, and its 5-ASA moiety inhibits prostaglandin synthase in colonic mucosa. Others include olsalazine (Dipentum), balsalazide (Colazal), and delayed-release 5-ASA derivatives (Apriso, Asacol Pentasa, Lialda). Glucocorticoids are given orally, parenterally, or by enema for moderate or severe disease that does not respond to 5-ASA. However, these latter drugs are not given for maintenance therapy. Recalcitrant disease is managed with immunomodulating drugs, including azathioprine, 6-mercaptopurine, or cyclosporine, which appear relatively safe in pregnancy (Briggs, 2015; Mozafari, 2015). Importantly, methotrexate is contraindicated in pregnancy.


Obstentrics_Williams

Obstentrics_Williams. In the past, biological therapy was reserved for recalcitrant moderate to severe disease. Because of their considerable eicacy, these medications are now frequently given initialy for severe disease to prevent future complications. These agents are antibodies against tumor necrosis factor-alpha (TNF-alpha). Those approved for treatment of ulcerative colitis include inf liximab (Rem icade) , adalimumab (Hum ira), and golinumab (Simponi). These drugs are administered intravenously or subcutaneously. Several studies indicate that they are safe for use in pregnancy, although there are concerns that their discontinuance may prompt a relapse (Torres, 2015). Another worry is that they may cause immunosuppression in the neonate (Brams, 2016; Diav-Citrin, 2014; Gisbert, 20l3). Colorectal endoscopy is performed as indicated (Katz, 2002).


Obstentrics_Williams

Obstentrics_Williams. Colorectal endoscopy is performed as indicated (Katz, 2002). During pregnancy, colectomy and ostomy creation for fulminant colitis may be needed as a lifesaving measure, and it has been described during each trimester. Dozois (2006) reviewed 42 such cases and found that, in general, outcomes have been good in recent reports. Most women underwent partial or complete colectomy, but Ooi and colleagues (2003) described decompression colostomy with ileostomy in a 10-and a 16-week pregnancy. Parenteral nutrition discussed on page 1043 is occasionally necessary for women with prolonged exacerbations.


Obstentrics_Williams

Obstentrics_Williams. For women with an ileal pouch and an anal anastomosis performed before pregnancy, sexual function and fertility are improved (Cornish, 2007). Disadvantages that temporarily worsen in pregnancy include frequent bowel movements, fecal incontinence, and pouchitis. he last is an inflammatory condition of the ileoanal pouch probably due to bacterial proliferation and stasis. Pouchitis usually responds to cephalosporins or metronidazole. In one rare case, adhesions to the growing uterus led to ileal pouch perforation (Aouthmany, 2004). (Ravid, 2002). Hahnloser (2004) reviewed routes of delivery in women with 235 pregnancies before and 232 pregnancies after ileoanal pouch surgery. Functional outcomes were similar, for obstetrical indications. Postcesarean delivery ileoanal pouch obstruction has been described (Malecki, 2010).


Obstentrics_Williams

Obstentrics_Williams. To reiterate, ulcerative colitis likely has minimal adverse efects on pregnancy outcome. Modigliani (2000) reviewed to be not substantively diferent from those in the general obstetrical population. Speciically, the incidences of spontane ous abortion, preterm delivery, and stillbirth were remarkably low. In a population-based cohort study of 107 women from Washington state, perinatal outcomes, with two exceptions, were similar to those of 1308 normal pregnancies (Dominitz, 2002). One exception was an inexplicably increased incidence of congenital malformations. These authors and others also compared with that for normal controls (Mahadevan, 2015). lar outcomes in 187 gravidas with ulcerative colitis compared with normal pregnant controls (Bortoli, 2011).


Obstentrics_Williams

Obstentrics_Williams. lar outcomes in 187 gravidas with ulcerative colitis compared with normal pregnant controls (Bortoli, 2011). Crohn Disease and Pregnancy. In general, Crohn disease activity during pregnancy is related to its status around the time of conception. In a cohort study of 279 pregnancies in 186 women whose disease was inactive at conception, a fourth relapsed during pregnancy (Fonager, 1998). In 93 with active disease at conception, however, two thirds either remained active or worsened. Miller (1986) had described similar findings from his earlier review, as did Oron and associates (20a12).


Obstentrics_Williams

Obstentrics_Williams. Calcium, vitamin D, and folic acid supplementation mirror that for ulcerative colitis. For maintenance during asymptomatic periods, no regimen is universally efective. Suasalazine is efective for some, but the newer 5-ASA formulations are better tolerated. Prednisone therapy may control moderate to severe lares but is less efective for small-bowel involvement. Immunomodulators such as azathioprine, 6-mercaptopurine, and cyclosporine are used for active disease and for maintenance. These appear relatively safe during pregnancy (Briggs, 2015; Chande, 2015). As discussed in Chapter 12 (pp. 242 and 244), methotrexate, mycophenolate mofetil, and mycophenolic acid are contraindicated in pregnancy (Briggs, 2015; Food and Drug Administration, 2008).


Obstentrics_Williams

Obstentrics_Williams. As with ulcerative colitis, treatment with antitumor necrosis factor monoclonal antibodies is often used initially for active Crohn disease and maintenance (Casanova, 2013; Cominelli, 2013; Friedman, 2015). These biological compounds include inliximab, adalimumab, certolizumab (Cimzia), natalizumab (Tysabri), and vedolizumab (Enyvio). As discussed on page 1050, this class of immunomodulators is considered safe in pregnancy (Briggs, 2015; Clowse, 2015). heir discontinuance may be followed by a relapse (Torres, 2015). Endoscopy or conservative surgery is indicated for complications. Patients with small-bowel involvement are more likely to require surgery for complications that include istulas, strictures, abscesses, and intractable disease. An abdominal surgical procedure was required during 5 percent of pregnancies described by Woolfson (1990). Parenteral hyperalimentation