Obstetric complications

Infectious diseases: HIV and viral hepatitis

In HIV infection, breastfeeding is not recommended, as it increases the risk of virus transmission. The infant is immediately transferred to exclusive formula feeding.

Among hepatitis types, forms A, B, and C are the most relevant (D and E occur predominantly in the tropics). Management of such patients is carried out jointly with an infectious disease specialist.

• Hepatitis A: Proceeds in the same manner as in non-pregnant women. There is no risk of antenatal fetal infection. In rare severe cases, premature birth or spontaneous miscarriage may occur. Vaginal delivery is preferred, and active drug therapy is usually not required.
• Hepatitis B: Chronic form rarely complicates gestation. However, acute hepatitis B increases maternal mortality by 3 times (the main cause of death is acute liver failure). The disease aggravates preeclampsia, causes growth restriction and fetal hypoxia. At the peak of the disease, the risk of massive obstetric hemorrhage is high. Infection of the child occurs mainly intrapartum (risk up to 70% in acute form in the 3rd trimester and 10% in carriers). Delivery is carried out strictly in an infectious diseases hospital with an obstetric department.

Management of preeclampsia: labor and postpartum period

There is no specific drug prevention for preeclampsia; the basis of prevention is preconceptional preparation of risk groups (patients with arterial hypertension, diabetes mellitus, antiphospholipid syndrome, multiple pregnancy, homozygosity for the T_{235} gene).

• First stage of labor: Magnesium sulfate infusion and antihypertensive agents are prescribed. The volume of administered fluid is strictly minimized. The optimal anesthesia method is continuous epidural anesthesia.
• Second stage: Oxytocin is used to prevent uterine inertia. At the end of the stage, perineotomy or episiotomy must be performed.
• Emergency delivery: If the condition of the mother or fetus worsens, tactics depend on the biomechanism. If the fetal head is in the wide part of the pelvic cavity, emergency Cesarean section is performed; if in the narrow part, obstetric forceps or vacuum extraction is applied.
• Hemorrhage prevention: Oxytocin (5 IU) or carbetocin (100 mcg) is administered intravenously.

After delivery, magnesium sulfate infusion is continued for up to 48 hours. If multiorgan failure develops, transfer to the ICU is indicated. At the outpatient stage, follow-up by a therapist is necessary to prevent late complications (hypertension, kidney pathology, lipid metabolism disorders).

Neurological and ophthalmological pathology

• Epilepsy: The frequency of seizures during gestation may increase due to a drop in blood plasma drug concentration (circulating blood volume increases, elimination accelerates). Neurological examination is required monthly. Anticonvulsant drugs have a teratogenic effect (cause neural tube defects, cleft palate, heart defects) and provoke a deficiency of vitamin K-dependent clotting factors in the fetus. Therapy during labor is not interrupted. Cesarean section is performed only in status epilepticus or frequent relapses before delivery. Breastfeeding is allowed with observance of trauma safety measures.
• Myopia: Physiologically, during pregnancy, intraocular pressure and blood flow decrease due to arteriolar spasm. Circulatory deficiency of the visual organ is aggravated by anemia, diabetes mellitus, and hypotension. Severe preeclampsia can provoke optic nerve edema, retinal hemorrhage, and retinal detachment. Ophthalmological examination is mandatory in each trimester, and the final conclusion on the method of delivery is issued at 36–37 weeks.

Antithrombotic therapy

At high risk of thrombosis (genetic thrombophilias, antiphospholipid syndrome, recurrent thrombosis), anticoagulant therapy is indicated throughout pregnancy, starting from the fertile cycle.

• Drugs of choice: Low-molecular-weight heparins (LMWH). They do not cross the placenta, have a low risk of bleeding, and are convenient to use (1 injection per day).
• Application regimen: Drugs are discontinued on the eve of delivery and resumed 6–8 hours after it. The duration of postpartum prophylaxis is 10–14 days.
• Efficacy criteria: Normalization of laboratory markers (D-dimer, platelet aggregation) and absence of clinical complications (preeclampsia, premature placental abruption).

As additional support, folic acid, vitamins B6 and B12, antioxidants, and polyunsaturated fatty acids are prescribed.

Class and exam questions

What else to study on this topic

• Pathogenesis of acute liver failure in pregnant women with hepatitis B.
• Regimens of passive-active immunization of newborns against hepatitis B virus.
• Laboratory markers of thrombophilia (TAT, F1+2, D-dimer) and their clinical significance.
• Effect of anticonvulsant drugs on folic acid metabolism and the formation of malformations.
• Genetic and anamnestic risk factors for the development of preeclampsia.

Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.