Maternal-Fetal Medicine by Mary E. D’Alton, Errol Norwitz, Thomas McElrath (editors)
By Mary E. D’Alton, Errol Norwitz, Thomas McElrath (editors)
Cambridge Pocket Clinician / Maternal-Fetal medication is designed to supply the busy clinician with exactly the info wanted the place and whilst it really is wanted. The textual content covers a large choice of subject matters on the topic of maternal and fetal drugs, in addition to scientific questions that may problem prone either within the outpatient environment and on hard work & supply. certain recognition has been paid to incorporating an evidence-based method of obstetric administration, and a couple of chapters were incorporated to aid within the administration of obstetric emergencies. In overall, over 000 illnesses and stipulations are mentioned intimately.
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Herpes simplex virus Physical examination Clinical Dx; confirm isolated lower (not upper) motor neuron palsy ■ Exclude other neurologic features ■ Diagnostic tests Laboratory tests: none ■ Specific diagnostic tests: may include EMG studies, nerve biopsy, but not routinely indicated ■ Imaging tests: not indicated ■ differential diagnosis Upper motor neuron facial palsy (usually pontine lesion) Facial hemispasm ■ Multiple sclerosis ■ Simultaneous bilateral facial weakness may suggest meningitis, HIV, sarcoidosis, Lyme disease ■ ■ complications Maternal complications: permanent facial palsy (10%), eye infections ■ Fetal complications: unaffected ■ 21 19:23 P1: SBT 0521790342-secA 22 CUNY1083/D’alton 0 521 79034 2 Bell’s Palsy May 4, 2007 Breech Presentation prognosis Typically resolves over days to weeks; 10% have severe & permanent disfigurement ■ Poor prognostic features include complete palsy, pain, advanced age, loss of taste, no resolution in 4 wk ■ Pregnancy does not alter natural course of paralysis ■ management General measures ■ Rx aimed at decreasing inflammation around facial nerve ■ Steroids may affect outcome but evidence suggests they do not hasten resolution or improve prognosis ■ Neurology consult, if indicated Specific treatment ■ Consider short course of high-dose prednisone (80 mg/d tapered over 10 d) ■ Surgery to decompress facial nerve has not shown any benefit subsequent management ■ Recurrent Bell’s palsy common BREECH PRESENTATION background Refers to fetus presenting buttocks first Types: frank (70%), complete (10%), footling/incomplete (20%) ■ Incidence: 3–4% at term ■ ■ diagnosis History ■ Confirm gestational age ■ Fetal movements unhelpful in Dx 19:23 P1: SBT 0521790342-secA CUNY1083/D’alton 0 521 79034 2 May 4, 2007 Breech Presentation ■ Risk factors: prematurity (28% at 28 wk, 15% at 30 wk), uterine anomalies, polyhydramnios, prior breech, multiple pregnancy, previa, fetal anomalies (anencephaly, goiter, hydrocephaly) Physical examination Check presentation by Leopold maneuvers, bimanual exam ■ Check position of breech by bimanual exam (defined relative to sacrum) ■ Diagnostic tests Imaging tests: ultrasound to confirm Dx; check gestational age, associated factors (multiple pregnancy, uterine/fetal anomalies, polyhydramnios) ■ differential diagnosis ■ ■ Transverse, oblique lie Variable/unstable lie complications ■ ■ Maternal complications: preterm delivery, pelvic trauma Fetal complications: cord prolapse, increased risk of birth injury (incl.
Protein S) ■ differential diagnosis ■ ■ Pregnancy-related edema Preeclampsia complications Maternal complications: PE, maternal mortality; heparin Rx assoc. w/ bleeding, thrombocytopenia, osteoporosis ■ Fetal complications: prematurity, placental abruption, intrauterine growth restriction, stillbirth; warfarin (Coumadin) teratogenic (not heparin) ■ prognosis ■ If untreated, 15–25% of women w/ DVT will have PE vs. 0 U/mL); change over to UFH at 35–36 wk because LMWH has long t1/2 & is resistant to reversal by protamine sulfate ■ Continue Rx throughout pregnancy & for 6–12 wk postpartum ■ In general, schedule delivery at 39 wk; hold 1–2 doses of UFH (?
5 mg/kg IV q8h; consider adding clindamycin 900 mg IV q8h to cover anaerobes ■ Continue antibiotics until 24–48 h afebrile, asymptomatic ■ Side effects & complications of treatment Adverse reaction to specific antibiotic ■ Risk of Asherman’s syndrome, esp. S. (behind embolism), accounting for 15% of all maternal deaths/y ■ Refers to hypertension prior to pregnancy w/ or w/o treatment; consider Dx in women w/ sustained elevation in BP >=140/90 mmHg prior to 20 wk gestation ■ diagnosis History ■ Usually asymptomatic ■ May present w/ headache ■ Risk factors: coexisting maternal disease (chronic renal insufficiency, diabetes, hyperlipidemia, pheochromocytoma), family Hx, advanced maternal age Physical examination Check BP (use appropriate-size BP cuff, pt should be sitting at rest, use disappearance of sounds [5th Korotkoff sound] for diastolic measurement in pregnancy) ■ 35 19:23 P1: SBT 0521790342-secA 36 CUNY1083/D’alton 0 521 79034 2 May 4, 2007 Chronic Hypertension Examine for features of longstanding hypertension (eg, retinal changes) ■ Examine for features of underlying coexisting medical conditions ■ Diagnostic tests ■ Remains clinical diagnosis based on serial BP measurements ■ Check baseline liver function tests, platelet count, proteinuria, renal function in 2nd trimester (given increased risk of superimposed preeclampsia) ■ Consider evaluation for cause of chronic hypertension (ultrasound to exclude renal artery stenosis, 24-h urinary VMA or total catecholamines for pheochromocytoma) differential diagnosis ■ ■ ■ ■ ■ Other hypertensive disorders of pregnancy (gestational hypertension, preeclampsia) Pheochromocytoma Complication of drug therapy (eg, long-term corticosteroid therapy) Drug withdrawal, esp.