Pregnancy and Acute Respiratory Disease, Influenza
Acute respiratory disease and influenza are common infectious diseases, which occur in obstetrical practice. During flu epidemics 40 % of population fall ill; lethal outcome of flu and acute respiratory disease (ARD) makes up 0.6% of population.
Influenza is a sharp viral disease spread by respiratory ways. The basic serologic types of flu virus are A, B, and C. Viruses penetrate through the upper respiratory ways, affect the cylindrical epithelium of respiratory passages. Permeability of vascular wall increases that results in disturbance of microcirculation and hemorrhagic complications (petechial skin rash on the mucous membranes of mouth, eyes, hemoptysis, nosebleeds, hemorrhagic pneumonia). Flu decreases immunological resistance, thus being a reason of exacerbation of chronic infections in organism.
The incubation period is 12-24 hours. The onset of the disease is acute: body temperature rises till 38-40°. There is fever, headache, weakness, muscular pains (in the loin, arms, legs, chest), pain in the eyes, adynamy. Dizziness and vomiting can occur. Such signs as tickling in throat, stuffiness in nose, difficult nasal breathing, rhinitis occur very quickly. These are accompanied by phenomena of tracheobronchitis, pneumonia, which can be an immediate reason of death. Furthermore influenza can cause such complications, as myocarditis, otitis, sinusitis.
The diagnosis of influenza is based on revealing the virus in nasopharynx secretion or on the data of a four-times increase of titre of specific antibodies in serum of blood, taken twice: during the first 6 days of disease and on the 10-14th day.
The differential diagnosis is made with acute respiratory disease of other etiology.
Effect of Influenza and Acute Respiratory Infection on the Course of Pregnancy. In women, who had influenza and ARD during pregnancy, spontaneous abortions (early and late), premature birth, congenital anomalies of fetus are frequently observed. Influenza is a reason of fetopathies and embryopathies (depending on term of gestation, at which influenza occurred). The frequency of perinatal mortality due to past influenza or ARD is increased.
Labor in the acute period of disease, more often premature, produces an unfavorable effect on the fetus and newborn. Children are born with a low body mass, signs of physical and functional underdevelopment, frequent attacks of secondary asphyxia; the intrauterine pneumonia is diagnosed in them. The fetus infected by virus of influenza quite often dies in labor, just after the beginning of labor pains.
Especially dangerous complication is the occurrence of puerperal septic diseases, which frequency sharply increases on a background of suppression of immune and protective properties due to the past viral infection. In postpartum period pyelonephritis, cystitis, mastitis frequently develop.
Effect of Pregnancy on the Course of Influenza and Acute Respiratory Infection. During the last months of pregnancy women are less resistant to infections because of features of hormonal and immunological changes characteristic of gestational process, and that is why they are especially subjected to catarrhal and viral diseases. At pregnant severe and complicated forms of flu develop more often. Under the influence of viral infection the substantial changes in the immune system of organismtake place, which are manifested by exacerbation of chronic, latent course of infection. An infectious-toxic action of flu virus is instrumental in the origin of hypovitaminosis, hyperacidosis that can result in disturbance of the course of gestation process. Special danger is presented by such complication as pneumonia, which can be the reason of death of pregnant, woman in childbirth, puerperant.
Management of Pregnancy and Labor at Acute Respiratory Infection and Influenza. Influenza and ARI are not an absolute contraindication for continuation of pregnancy. However at occurrence of these diseases in early term of gestation (about 12 weeks) the woman is usually recommended to interrupt pregnancy in view of high risk of development of congenital anomalies of the fetus, and also of necessity of application of anti-inflammatory and antiviral preparations, which can be contraindicated in early period of gestation.
If pregnancy is kept nevertheless, such women call for special approach to conducting pregnancy and labor.
The treatment of pregnant woman, who has fallen ill with influenza, is provided at home. Plentiful alkaline drink, antipyretic and analgetic agents (indomethacin, acetylsalicylic acid, analgin), vitamins C, A, B, Е are recommended. Expectorants, vasoconstrictive agents for improvement of respiration through nose (farmazolin, halazolin), hot and cold inhalation of essential oils (sage, eucalyptus, fennel oils) are administered. Expectorants include: mixture of thermopsis, marsh mallow root.
At a complicated course of influenza, i.e. development of tracheitis, bronchitis, hospitalization at the in-patient department is indicated and administration of antibacterial, infusion, symptomatic therapy. Patients at the in-patient department are administered γ-globulin (3-5 ml intramuscularly), nasal inhalation of dry antigrippal serum with sulfanilamides and semisynthetic penicillin 3 times a day, prednisolone by 30-50 mg intramuscularly a day. At the development of severe complications the problem of artificial abortion by medical indication is solved.
The delivery of such women is more often conducted through maternity passages. In postpartum period the prophylaxis of septic puerperal complications is carried out.
Pregnancy and Viral Hepatitis. Several variants of acute viral hepatitis are distinguished:
- viral hepatitis A (VHА)
- viral hepatitis B (VHВ)
- viral hepatitis C (VHС)
- viral hepatitis D (VHD)
- viral hepatitis Е (VHЕ).
Laboratory signs of disease: the increase of level of transaminase, alanine aminotransferase, aspartate aminotransferase. Recovery occurs in 4-6 weeks. Jaundice is manifested by icteric color of eyes, oral mucous membrane, skin, by discoloration of faeces, urine gets a dark, saturated color.
Effect of Pregnancy on the Course of Viral Hepatitis. It is known that pregnancy due to features of hormonal and immunological alteration incident to gestational process leads to exacerbation of extragenital diseases, especially acute ones, such as viral hepatitis. The course of viral hepatitis in pregnancy is more severe than in nonpregnant patients.
Viral hepatitis in the second half of pregnancy proceeds more severely than in the first one. In the 2nd and 3rd trimester of pregnancy there are an increased risk of incidence and development of acute hepatic (liver) failure followed by encephalopathy and coma. The lethality of pregnant with hepatitis is up to 10 %, while in nonpregnant it is 1-4%.
Contraindication for Pregnancy. Arresting of pregnancy in acute stage of viral hepatitis is dangerous for mother due to increased risk of worsening of hepatitis and development of its chronic or prolonged form. Thus, pregnancy may be arrested in a convalescent stage.
Viral Hepatitis A (VHA) with Pregnancy. An acute viral hepatitis A is most investigated at pregnancy. The causative agent of illness is hepatitis A virus, referring to a type of enteroviruses. The source of infection is a person infected with HАV. The infection spreads by a fecal-oral type. The patient is infectious at the end of incubatory period and in a preicteric stage. The duration of incubatory period makes up 7-50 days, more often — 15-30 days. The preicteric (prodromal) period proceeds from 2 to 14 days.
The icteric stage lasts 5-20 days and is characterized by the basic clinical signs, such as nausea, vomiting, liquid stool, pain in the right hypochondrium and epigastrium, weakness, headache, irritability, rheumatic pain in the body. Liver and spleen increase in size and become sickly.
In general, virus hepatitis A has no dramatic effect on the course of gestation. One of the most often complications at acute viral hepatitis A during pregnancy is abortion. In the II and III trimester of pregnancy the risk of discontinuing is much higher than in the first one. The development of late gestoses of pregnant, bleeding is possible too.
Viral Hepatitis B (VHB) with Pregnancy. Viral hepatitis B in pregnancy proceeds much more severely, and represents danger to mother and her fetus. Viral hepatitis B affects liver cells, is transferred from the patient or virus carrier with blood and other biological liquid (urine, saliva, milk, semen). The incubator period is long — from 6 weeks to 6 months. A prodromal stage is 1-4 weeks.
The preicteric stage proceeds from 5 to 30 days and is characterized by dyspepsia, allergy in a form of skin eruption, arthralgia, and significant intoxication.
The icteric period proceeds from 1 week to 2-3 months with exacerbation of intoxication, intensive itch, splenomegaly, hepatomegaly. There is discoloration of excrement; urine gets a dark, saturated color.
Clinical manifestations: nausea, vomiting, loss of appetite, pain in the right hypochondrium, hepatolienomegaly, arthralgias. Temperature rises seldom, and it is insignificant. With occurrence of icterus the intoxication increases, hemorrhagic signs occur. Acute hepatic failure, encephalopathy, hemorrhagic diathesis, disturbances of albumin synthesis and liver dysfunction, severe general intoxication develop. Massive necrosis of liver and death of the patient are frequently possible.
The convalescence occurs slowly, almost always results in development of chronic hepatitis.
In the stage of icterus augmenting the disease results in premature birth. Newborns in the process of labor are usually infected with HBV, subsequently in 80 % of children chronic hepatitis develops.
Hepatitis B virus (HBV) has a high rate of vertical transmission causing fetal and neonatal hepatitis. Additionally, maternally and neonatally transmitted HBV infection predisposes to liver cirrhosis and hepatocellular carcinoma in young adults.
Thus, in contrast to VHА, viral hepatitis B represents real danger to life of the mother, fetus and newborn. Acute VHВ produces an unfavorable effect on course of pregnancy. In its turn, pregnancy and labor exacerbate the course and prognosis of VHB. The aggravation of symptoms in the second half of pregnancy can be complicated with acute liver impairment with encephalopathy and coma, with high lethality. At development of the disease in the III trimester of pregnancy premature birth (in 47 %), anomaly of labor pains (in 19 %), bleedings — (in 12 %), fetus hypotrophy (in 22 %) frequently develop. Late forms of gestoses are also frequent. The perinatal mortality at acute VHВ makes up 140‰. Acute hepatic insufficiency and coma often develop.
Labor in acute stage of VHB is conducted through maternal passages according to obstetrical situation.
Viral Hepatitis C (VHC) with Pregnancy. The causative agent of illness is hepatitis C virus, which is single-stranded, flavivirus-like RNA agent, 29-35 nm in diameter, and very changeable. The changeability of the virus leads to its rapid mutation, so significant immunity is almost absent in patients with VHC.
Contamination occurs by parenteral, infusion and sexual type.
The duration of incubatory period makes up 3-4 months.
The preicteric period lasts from 2 to 14 days and is characterized by gradual intensification of dyspepsia and asthenovegetative syndrome.
The icteric period lasts for 14-21 days with a moderate intoxication. It is very important that only 5 % of sick people have symptoms of intoxication and icterus, while the rest have an asymptomatic (masked) form of VHC.
Convalescence occurs slowly, a complete recovery takes place in 50% of patients, thus in 50-80% of them the disease terminates with the development of chronic hepatitis (more often in a form of active hepatitis or cirrhosis). Sometimes hepatocellular carcinoma may occur.
The most probable complications in pregnancy with VHC are:
· miscarriages,
· premature labors (immature infants), most often in 28-30 and 34-35 weeks of gestation,
· congenital anomalies of the fetus in case of happening of VHC in the 1st trimester of pregnancy,
· worsening of mother’s general condition in the 2nd and 3rd trimester of pregnancy.
Viral Hepatitis D (VHD) with Pregnancy. The causative agent of illness is hepatitis D virus, composed of ribonucleic acid (RNA), satellite viruses of plants, being 28-39 nm in diameter. Contamination occurs through blood, placenta; a sexual type is also possible.
Two variants of clinical course are distinguished:
· co-infection with VHB and VHD in patients without previous history of VHB,
· superinfection in established chronic VHB.
In case of co-infection the incubator period is 3-8 weeks. The clinical features of preicteric stage are similar to those at VHB, but more severe. A diphasic clinical course is characteristic of these patients; the phases are characterized by increased peak of transaminase activity, hyperbilirubinemia and exacerbation of general condition of patient. The interval between peaks is 15-32 days. There is an increase of icterus intensity, general intoxication in icteric stage. The outcome is favourable, as a rule.
In case of superinfection a severe course of VHD develops, fulminant hepatitis is not rare due to necrotic processes in the liver and occurrence of progressive acute hepatitis and cirrhosis. The incubator period is from 6 weeks to 6 months. The clinical picture is like in VHB, but more serious.
Convalescence occurs slowly, in a few months.
On the other hand, asymptomatic (masked) course of VHD is possible, and its incidence is 2 times more often in nonpregnant women than in pregnant.
Viral Hepatitis E (VHE) with Pregnancy. This form is widespread in tropical countries, Latin America and Asia.
The causative agent of illness is hepatitis E virus, composed of ribonucleic acid (RNA), 32-34 nm in diameter. Its antigenic structure has not been studied till nowadays.
Contamination occurs by a fecal-oral type. The incubator period lasts for 1-9 days, but may be 30-40 days.
The course of VHE in pregnants is severe; 20% of patients die if the disease occurs in the 2nd half of pregnancy, the day before delivery or abortion.
The preicteric stage lasts for 1-9 days (on average 3-4 days). It is characterized by intensification of weakness (asthenia), lethargy, nausea, vomiting, pains in the right hypochondrium. Hyperthermia is possible.
The icteric stage proceeds for 1-3-weeks. The main symptoms are skin and mucous icterus, enlargement and morbidity of the liver, itch, etc.
In severe forms of VHE DIC develops and leads to intravascular hemolysis and acute renal-hepatic insufficiency.
Diagnostics of Viral Hepatitis. It includes:
· blood test
· urine test
· urobilin and bile acids in urine,
· biochemical blood test:
§ glucose in blood serum
§ residual nitrogen
§ cholesterol
§ total bilirubin, and its fractions
§ total protein and its fractions
§ transaminase, glutamic acid, aldolase and alkaline phosphatase activity
§ blood clotting activity
§ mercuric chloride and thymol tests
· Serologic markers of viral hepatitis
· US of abdominal cavity.
Management of labor With Viral Hepatitis. The following should be taken into account:
· Labor in acute stage of VHA does not threaten the parturient woman with any complications connected to hepatitis. So if labor proceeds without any complications any additional measures are not required.
· In case of VHB, C, D, E the rate of complications significantly increases:
· abnormalities of labor pains (the rate of primary and secondary weakness of labor pains is 19%), premature and early rupture of amniotic membranes (in 30-34%), intrauterine fetal hypoxia (25%), bleedings in the 2nd and 3rd stages of labor due to decrease of blood coagulability and uterine hypo- and atonia (for about 14-15%) are frequent.
· Labor in acute VH should be conducted with optimal analgesia and sedation (seduxen, promedol, baralgin, droperidol, nitrous oxide, epidural anaesthesia are widely used). Prophylaxis and correction of uterine contractility should be made. In addition to intrauterine infusion of oxytocin at the end of the 2nd stage of labor 1 ml of methylergometrine IV should be injected during the head disengagement for prophylaxis of maternal bleedings. As there is DIC due to acute VH frozen plasma, dicinon, aminocapronic acid should be administered intravenously.
During labor in acute stage of VH the fetus is always in the condition of hypoxia, therefore it is necessary to apply oxygenation and medicamental treatment of hypoxia of the fetus. At conducting labor in acute VH it is necessary to take into account the fetus general condition; most often premature delivery is preferable for saving life of the fetus, irrespective of duration of gestation.
· VH is not contraindicated for cesarean section depending on obstetric indication. Upon the whole, the rate of cesarean section in patients with VH is 2.5%.
· The duration of fetus’ delivery should be shortened due to perineotomy (or episiotomy), application of obstetric forceps (by indication).
· In postpartum period at puerperas, who had acute viral hepatitis, the risk of development of puerperal septic diseases is high. Therefore preventive therapy is necessary.
From the moment of occurrence of icterus in pregnant woman, who was ill with VHА, she ceases to be dangerous to the environment, and her child is not dangerous to other children.
Date added: 2022-12-25; views: 178;