Medical care and pregnancy - Medical care of common acute conditions

Self-limited acute illnesses can often be treated with non-pharmacological measures and/or common symptomatic medications. Table 9.6 lists some symptoms and medications that may be used for a variety of common problems. Systemic corticosteroids should be used, as indicated, for treatment of severe asthma attacks and when indicated in autoimmune disorders. Many antiarrhythmic and cardiac medications have been used in pregnancy with good outcome. Vaginitis Pregnant women commonly present with vaginal infection. Although a number of medications may be designated as category C, topical use of these medications has not been associated with significant absorption, and the risk of use seems minimal. Examples include antifungal preparations for candida vulvovaginitis. Diflucan has been associated with fetal defects in high doses (continuous administration at 400 mg/day) but is probably safe used in brief courses at standard doses.26 Treatment of symptomatic vaginal trichomoniasis with metronidazole continues to be a concern to some clinicians because of theoretical concerns of teratogenicity, despite meta-analysis and large population-based studies demonstrating no increased risk of defects,27,28 and long-term population-based studies showing no increase in childhood cancers.29 Viral infections Acute viral infections are often viewed as benign, selflimited conditions outside of pregnancy. During pregnancy, viral illness (such as rubella) may represent a threat to the fetus or a potentially serious threat to the mother’s health. Influenza The 1918 Spanish influenza pandemic and other severe influenza epidemics during the twentieth century manifested disproportionate mortality in pregnant women.30 In the USA, influenza vaccination has been recommended during pregnancy by the Center for Disease Control for more than a decade. Despite the agreement that vaccination should be given during pregnancy by more than 90% of obstetricians, vaccination rates remain low in this population, ranging from 1.5–40%.31,32 One population-based study determined the number needed to treat to prevent one influenza-like illness was between 20 and 43 pregnant women.33 Limited outcome data are available, with one study finding no difference in hospitalizations for women or their infants with viral respiratory illnesses during the flu season based on vaccination status.34 Herpes Genital herpes is a common recurrent problem in young women. It is associated with potential neonatal morbidity and mortality, and an increased rate of cesarean delivery. Two adequately powered randomized controlled trials now demonstrate a decrease in positive herpes cultures and cesarean deliveries with no increase in newborn infection when women with genital herpes simplex infection are treated with 500 mg of valcyclovir given twice daily starting at 36 weeks gestation.35,36 A cost-effectiveness study found acyclovir prophylaxis to be cost-effective and costsaving using a wide range of assumptions.37 Strength of recommendation A. Hepatitis Hepatitis A infection does not pose a threat to the newborn via perinatal transmission. Hepatitis B infection may be transmitted perinatally, as well as hepatitis C, D, and E. Immunization against hepatitis B and administration of hepatitis B immunoglobulin immediately at birth is protective against perinatal transmission of hepatitis B and D.38 The risks of neonatal transmission are increased with HBeAg-positive status and up to 90% if acute infection takes place during the third trimester.38 Chronic infection occurs in more than 90% of infected infants. Hepatitis C infection is rarely transmitted perinatally. Transmission usually occurs in mothers with concomitant HIV infection or with very high levels of hepatitis C virus RNA. Routine screening is not recommended, since no treatment is available to prevent infection, but women at high risk may warrant evaluation, and pediatric follow-up is warranted if hepatitis C is detected because of the risk of chronic liver disease in the infant. Common acute bacterial infections are usually treated as they would be in non-pregnant women. There are several antibiotics that should not be used in pregnancy unless an effective alternative is not available (e.g. quinolones, tetracycline). However, any therapeutic decision must weigh the risks to the pregnancy of possible medication ill effects versus the potential risk to the mother and the fetus of failure to adequately treat significant infections. Table 9.7 contains commonly used medications for infection.

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