HEPATOBILIARY DISEASES
INFECTONS
SUBSTANCE ABUSE IN PREGNANCY
lek. Kazimierz Kowalski
HEPATOBILIARY DISEASES
Hepatitis
Cholestasis in Pregnancy
Cholelitiasis in Pregnancy
Acute Fatty Liver of Pregnancy
HEPATITIS
Main cause of jaundice(bilirubin>4 mg/%)
during pregnancy.
Types: A B C E
HEPATITIS VIRALIS TYPE A(HAV)
This type is speard by ingestion of contaminated food or water and fecal-oral transmission.
Approximately 10% of cases of hepatitis in pregnancy, incubation 15-50 days, symthoms are
often vague.
Pregnant woman exposed can be given Gamma-globulin.
HEPATITIS VIRALIS TYPE B
The most common hepatitis in pregnancy(80% of cases).
It is speard by infected blood or percutaneous/permucosal routes.
Serum include elevated transaminase levels often above 1000 mU/ml and increased albumin.
HEPATITIS VIRALIS TYPE B(HBV)
Most patients recover completly within
3-6months
10% develop chronic infection with circulating HBV antigens.
Sequelaes:
Hepatic crcinoma
Cirhosis
HEPATITIS VIRALIS TYPE B(HBV)
Vertical transmission to the fetus at delivery is now recognized to pose significant danger to the
neonate.
that’s why pregnant woman should have universal screening of the HbsAg.
If mother is HbsAg(+) neonate should recive:
- both active immunization(HBV vaccine)
- passive immunisation (HBIG)-antibodies 48
hours of exposure.
CHOLESTASIS IN PREGNANCY
(pruritus gravidarum)
Occurs in<0,1% of pregnancies
It’s second reason of jaundice in gestation
It usually occures in third third trimester
CHOLESTASIS IN PREGNANCY
ETIOLOGY
Etiology is not clear
Probably involves an increased hepatic sensivity to estrogen
There is no hepatocellular damage
CHOLESTASIS IN PREGNANCY
SYMPTHOMS
Pruritus (often associated with fatigue)
Joundice
Dark urine (not always)
CHOLESTASIS IN PREGNANCY
LABORATORY TESTS
Bile acids levels elevated even to 100 times normal
Alkaline phosphatase elevated to 10 times normal
Bilirubin levels elevated up to
5 mg/ml
CHOLESTASIS IN PREGNANCY
MAIN EFFECTS
Discomfort of intense pruritus
Coagulation abnormalities as a result of decreased vitamin K absorbtion
CHOLESTASIS IN PREGNANCY
TREATMENT
ANTIPRURITICS:
-diphenhydramine hydrochloride(Benadryl)
-hydroxyzine hydrochloride(Vistaril)
OTHERS:
-Cholestyramine
-Phenobarbital
CHOLELITIASIS IN PREGNANCY
It occurs at the same incidence of 0,1% in pregnancy as without pregnancy.
Pathogenesis and phatophisiology in gestation is also unchanged.(supersaturation of bile with
cholesterol being folowed by cristalisation and formation of gallstones).
Association with fatty food intake is note.
CHOLELITIASIS IN PREGNANCY
MAIN REASON DURING GESTATION
In pregnancy, increased estrogen/progesterone concentration may increase the concentration of
cholesterol and the rate of stone formation.
CHOLELITIASIS IN PREGNANCY
COMPLICATIONS AND SYMTHOMS
Jaundice
Biliary collic
Unconfortable distension of the gallbladder
CHOLELITIASIS IN PREGNANCY
The clinical history of food-associated colic and laboratory evidence of elevated liver enzymes
and bilirubin should be confirmed by ultrasonography of the gallbladder.
CHOLELITIASIS IN PREGNANCY
TREATMENT
Asymptomatic cholelitiasis in pregnancy requires no treatment except admonitions about fatty
food intake.
Biliary colic is treated with:
-nasogastric suction
-hydration
-analgesia
-antibiotics (if needed)
CHOLELITIASIS IN PREGNANCY
BILIARY COLLIC-TREATMENT
Papaverin+Buscolisin+Petidin(Dolcontral) i.v in one iniection.
Drotaverin(NoSpa)+Petidin(Dolcontral)+Hioscin i.v. in one iniection.
ACUTE FATTY LIVER OF PREGNANCY
It’s a rare complication of gestation but its severity.
Maternal mortality rate of 30%, that’s why it should be timely diagnose and timely treated.
ACUTE FATTY LIVER OF PREGNANCY- risk indicators
Primigravidas
Last 12 weeks of gstation
ACUTE FATTY LIVER OF PREGNANCY- sympthoms
Vague gastrointestinal sympthoms becoming worse over several days’time
Headache
Mental confusion
Epigastric pain.
ACUTE FATTY LIVER OF PREGNANCY-complications
If untreated there may be rapid development of:
-coagulopathy
-coma
-multiple organ failure
-death
ACUTE FATTY LIVER OF PREGNANCY-laboratory tests
Bilirubin value-modest elevation
Transaminase levels- modest elevation at the initial time.
Magnitude of this elevations is not great and the disease may be misdiagnosed.
ACUTE FATTY LIVER OF PREGNANCY-treatment
Treatment of this serious complication is:
-correction of coagulopathy
-correction of electrolyte imbalances
-cardiorespiratory support
-delivery as soon as feasible by the
vaginal route, if possible
INFECTIOUS DISEASES IN PREGNANCY
URINARY TRACT INFECTIONS (UTIs)
GROUP B STREPTOCOCCUS
BACTERIAL VAGINOSIS
CANDIDA VULVOVAGINITIS
TRICHOMONAS VAGINITIS
VIRAL INFECTIONS
URINARY TRACT INFECTION(UTIs)
Approximately 8% of all woman(pregnant and nonpregnant) have greater than 10 colonies of a
single bacteria on a midstream culture.
25% of the pregnant portion of this group develop an acute, symthomatic UTI.
URINARY TRACT INFECTION(UTIs)
Asympthomatic bacteriuria in pregnancy is more likely to lead to:
-cystitis
-pyelonephritis
URINARY TRACT INFECTION(UTIs)
MAIN REASONS
URINARY STASIS- is a result of:
-progesterone associated decreased ureteral tone
-mechanical compression of the ureters and bladder
GLUCOSURIA-in pregnancy
INCREASED pH OF THE URINE(bicarbonate excretion)-enhances bacterial growth
URINARY TRACT INFECTION(UTIs)
ASYMPTOMATIC BACTERIURIA
Requires treatment:
-Ampicillin 500mg p.o./day
-Sulfisoxazole(Gantrisin) 1000mg p.o/day
(may produce hyperbilirubinemia of the newborn)
-Nitrofurantoin 50 mg p.o/day
(may produce hemolysis)
Treatment for 7-10 days is usually quite effective,
because most common bacteria is Escherichia coli.
URINARY TRACT INFECTIONS(UTIs)
25-30% of patients not treated for asymptomatic bacteriuria proceed to symptomatic UTI.
Suppresive antimicrobial therapy (Nitrofurantoine 50-100mg p.o./day)
is indicated if there are repetitive UTIs during pregnancy.
URINARY TRACT INFECTION(UTIs)
ACUTE CYSTITIS-sympthoms
Occurs in 1% pregnancies.
Patient complain of:
-urinary frequency,urgency,dysuria and
bladder discomfort
-occasionally, hematuria is also seen
-there should be no fever(presence suggest
upper UTI)
URINARY TRACT INFECTION(UTIs)
ACUTE CYSTITIS-treatment
Treatment is the same as that of ASYMPTOMATIC BACTERIURIA:
-Ampicillin 500mg p.o./day
-Sulfisoxazole(Gantrisin) 1000mg p.o/day
-Nitrofurantoin 50 mg p.o/day
URINARY TRACT INFECTION(UTIs)
PYELONEPHRITIS-sympthoms
Fever
Costovertebral tenderness
General malaise is not good
dehydration
URINARY TRACT INFECTION(UTIs)
PYELONEPHRITIS
It occurs in 2% of all pregnant patients
20% of these ill patients demonstrate increased uterine activity and preterm labor
It is one of the most common medical complication of pregnancy requiring hospitalization
URINARY TRACT INFECTION(UTIs)
PYELONEPHRITIS-Treatment
After obtain urinalysis and urine culture
patients are treated with:
-intravenous hydration
-intravenous antibiotics, comonly first
generation cephalosporin or ampicillin.
If improvement does not occur within 48-72 hours, urinary tracr obstruction or urinary calculus
should be considered along with a reevaluation of antibiotic.
URINARY TRACT INFECTION(UTIs)
PYELONEPHRITIS-preterm labor-why?
Most common patogen E.coli can produce phospholipase A, which in turn can promote
prostaglandin synthesis, resulting in uterine contractions.
TOCOLITIC therapy may be required:
-Beta 2 mimetics:Fenoterol
-Drotaverin(NoSpa)
-Calcium blockers: Nifedypine
-MgSO4
URINARY TRACT INFECTION(UTIs)
PYELONEPHRITIS-evaluation
A single-shot intravenous pyelogram and/or ultrasonography with attention to the ureters and
kidneys is an integral part of evaluation.
BACTERIAL VAGINOSIS(BV)
Bacterial vaginosis is current term for vaginitis perviously called nonspecyfic vaginitis which
depents on:
-Hemophilus vaginalis
-Corynebacterium vaginalis
-Gardenella vaginalis
BACTERIAL VAGINOSIS(BV)
SYMPTHOM
Elevated pH- change in a vaginal flora, resulting in a loss of lactobacili.
COMMON VAGINAL INFECTIONS
INFECTIONS
Characterisitic Normal Bacterial
vaginosis
Common patient
complaint
None
Candida
Trichomonas
Vulvovaginitis
vaginitis
Discharge:
fishy odor,
possibly worse
after intercourse
Vaginal pH
Discharge
Apperance
Itching, burning
discharge
Frothy
discharge
bad odor
vulvar pruritus
dysuria
<4,5 (usually)
>4,5
White,curdy,
Yellow,gren,
„cottage cheese”
frothy,
adherent
Absent
Often fishly
Mycelia budding,
Trichomonads,
yeast,
WBCs present
3,8-4,2
>4,5
White
Thin
flocculent white, grey,
adherent
Amine odor (KOH) Absent
Present
Microscopic
Lactobacili Clue cells,
coccobacillary
bacteria, no WBCs
Treatment
Metronidazol
Natamycin(Pimafucin) Metronidazol
GROUP B STREPTOCOCCUS
The group B Streptococcus is an important cause of perinatal infections.
Asymptomatic cervical colonization occurs in up to 30% of pregnant woman
50% of infants exposed to the organism in the lower genital tract will become colonized.
2-3 infants per 1000 live births, occurs significant clinical infection.
GROUP B STREPTOCOCCUS
MANIFESTATIONS
There are two manifestations of clinical infection of the newborn:
-Early-onset infection
-Late-onset infection
GROUP B STREPTOCOCCUS
EARLY-ONSET INFECTION IS MANIFEST AS:
-Septicemia and septic shock
-Pneumonia
-Meningitis
Such an infection is much more likely in premature infants then in term gestation.
The mortality rate exceeds 50%.
GROUP B STREPTOCOCCUS
LATE-ONSET INFECTION:
-occurs up to 4 weeks after delivery
-meningitis is the most common specyfic
infection
-mortality rate is about 25%
-prematurity is not a factor for late-onset
infection
GROUP B STREPTOCOCCUS
TREATMENT
Recommendations include:
- treatment of patients at high risk for perinatal infection:(AMPICILLIN 3x1000mg/day)
-Preterm labor
-Ruptured membranes
- screening of all patients late in pregnancy(inoculation).
Neither approach is perfect.
SUBSTANCE ABUSE IN PREGNANCY
SMOKING
ALCOHOL
COCAINE
MARIJUANA
SUBSTANCE ABUSE IN PREGNANCY
smoking
It is estimated that 25% of reproductive-age women smoke.
In pregnancy, placental perfusion is altered by vasoconstriction inducted by NICOTINE
SUBSTANCE ABUSE IN PREGNANCY
Reproductive Effects of Smoking
Decreased fertility
Increased risk of spontaneous abortion
Increased risk of ectopic pregnancy
Decreased birth weit
Increased risk of preterm delivery(preterm labor,PROM)
Increased risk of abruptio placentae and placenta previa
Increased risk of sudden infant death syndrome
Increased risk of developmental problems
SUBSTANCE ABUSE IN PREGNANCY
ALCOHOL-Fetal Alcohol Syndrome
Mental retardation:
-Performance defects
-Lowered IQ
Growth:
-Prenatal and postnatal growth restriction
Congenital anomalies:
-Brain defects, cardiac defects(especially
ventricular septal defects), spinal defects.
SUBSTANCE ABUSE IN PREGNANCY
ALCOHOL-Fetal Alcohol Syndrome
Craniofacial anomalies:
-flattened nasal bridge
-broad upper lip
-micrognathia
-microphthalmia
-short nose
-short palpebral fissure
SUBSTANCE ABUSE IN PREGNANCY
COCAINE ACTION
LOCAL ANESTHETIC
SYMPATHOMIMETIC ACTION BY DOPAMINE POTENTIATION(it blocks reception of
dopamine and norepinephrine)
CENTRAL NERVOUS STIMULATION
SUBSTANCE ABUSE IN PREGNANCY
Cocaine
Cocaine use is associated with:
-an increased incidence of spontaneus
abortion
-in utero fetal demise (death)
-PROM
-preterm labor
-intrauterine growth restriciton
-meconium-stained amniotic fluid
-placental abruption
-limb-reduction defects
-intestinal atresia
SUBSTANCE ABUSE IN PREGNANCY
MARIJUANA
5-15% PREGNANCY WOMAN USE MARIJUANA OR HASHISH
THC- 9-TETRAHYDROCANNABINOL IS A HIGHLY ACTIVE PSYCHOTROPIC
COMPOUND THAT IS TERATOGENIC IN ANIMAL MODELS.(EQUIVOCALLY SO IN
HUMAN STUDIES).
ITS USE SHOULD BE AVOIDED IN PREGNANCY
THIS IS THE END
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