Chapter 007. Medical Disorders
during Pregnancy
(Part 7)

Gastrointestinal and Liver Disease
Up to 90% of pregnant women experience nausea and vomiting during the
first trimester of pregnancy. Occasionally, hyperemesis gravidarum requires
hospitalization to prevent dehydration, and sometimes parenteral nutrition is
required.
Crohn's disease may be associated with exacerbations in the second and
third trimesters. Ulcerative colitis is associated with disease exacerbations in the
first trimester and during the early postpartum period. Medical management of
these diseases during pregnancy is identical to the management in the nonpregnant
state (Chap. 289).
Exacerbation of gall bladder disease is commonly observed during
pregnancy. In part this may be due to pregnancy-induced alteration in the
metabolism of bile and fatty acids. Intrahepatic cholestasis of pregnancy is
generally a third-trimester event. Profound pruritus may accompany this condition,
and it may be associated with increased fetal mortality. It has been suggested that
placental bile salt deposition may contribute to progressive uteroplacental
insufficiency. Therefore, regular fetal surveillance should be undertaken once the
diagnosis of intrahepatic cholestasis is made. Favorable results with ursodiol have
been reported.
Acute fatty liver is a rare complication of pregnancy. Frequently confused
with the HELLP syndrome (see "Preeclampsia," above) and severe preeclampsia,
the diagnosis of acute fatty liver of pregnancy may be facilitated by imaging
studies and laboratory evaluation. Acute fatty liver of pregnancy is generally
characterized by markedly increased levels of bilirubin and ammonia and by
hypoglycemia. Management of acute fatty liver of pregnancy is supportive;
recurrence in subsequent pregnancies has been reported.
All pregnant women should be screened for hepatitis B. This information is

clindamycin is recommended. For the reduction of neonatal morbidity due to
GBS, universal screening of pregnant women for GBS between 35 and 37 weeks
gestation with intrapartum antibiotic treatment of infected women is
recommended.
Postpartum infection is a significant cause of maternal morbidity and
mortality. While rare after vaginal delivery, postpartum endomyometritis develops
in 5% of patients having elective repeat cesarean section and in 25% of patients
after emergency cesarean section following prolonged labor. Prophylactic
antibiotics should be given to all patients undergoing cesarean section. As most
cases of postpartum endomyometritis are polymicrobial, broad-spectrum antibiotic
coverage with a penicillin, aminoglycoside, and metronidazole is recommended
(Chap. 157). Most cases resolve within 72 h. Women who do not respond to
antibiotic treatment for postpartum endomyometritis should be evaluated for septic
pelvic thrombophlebitis. Imaging studies may be helpful in establishing the
diagnosis, which is primarily a clinical diagnosis of exclusion. Patients with septic
pelvic thrombophlebitis generally have tachycardia out of proportion to their fever
and respond rapidly to intravenous administration of heparin.
All patients are screened prenatally for gonorrhea and chlamydial
infections, and the detection of either should result in prompt treatment.
Ceftriaxone and azithromycin are the agents of choice (Chaps. 137 and 169).
Viral Infections
Cytomegalovirus Infection
Viral infection in pregnancy presents a significant challenge. The most
common cause of congenital viral infection in the United States is
cytomegalovirus (CMV) (Chap. 175). As many as 50–90% of women of
childbearing age have antibodies to CMV, but only rarely does CMV reactivation
result in neonatal infection. More commonly, primary CMV infection during
pregnancy creates a risk of congenital CMV. No currently accepted treatment of
CMV during pregnancy has been demonstrated to protect the fetus effectively.
Moreover, it is impossible to predict which fetus will sustain life-threatening CMV