Acute Care Issues in Pregnancy

Headache

• For tension and migraine headaches during pregnancy, first-line therapies are nonpharmacologic, including relaxation, stress management, and biofeedback.
• For tension headache, acetaminophen or ibuprofen can be used if necessary. All NSAIDs are contraindicated in the third trimester because of the potential for closure of the ductus arteriosus. Avoid aspirin in the third trimester, as it may also cause closure of the ductus arteriosus, maternal and fetal bleeding, and decreased uterine contractility. Opioids are rarely used.
• For migraine headache, acetaminophen and ibuprofen can be used. Opioids have been used, but they can contribute to nausea, and long-term use can cause neonatal withdrawal. For nonresponsive migraines, sumatriptan can be used. Ergotamine and dihydroergotamine are contraindicated. For migraine-associated nausea, promethazine, prochlorperazine, and metoclopramide can be used.
• For pregnant women with severe headaches (usually migraine) not responsive to other treatments, propranolol, at the lowest effective dose, can be used as preventive treatment. Alternatives include amitriptyline or nortriptyline, 10 to 25 mg daily by mouth.

Urinary Tract Infection

• The principal infecting organism is Escherichia coli, but Proteus mirabilis, Klebsiella pneumoniae, and group B Streptococcus cause some infections. Untreated bacteriuria may result in pyelonephritis, preterm labor, preeclampsia, transient renal failure, and low birth weight.
• Treatment of asymptomatic bacteriuria is necessary to reduce the risk of pyelonephritis and premature delivery. Treatment for 7 to 14 days is common. Repeat urine cultures are recommended monthly for the remainder of gestation.
• Cephalexin is considered safe and effective for asymptomatic bacteriuria. E. coli resistance to ampicillin and amoxicillin is problematic. Nitrofurantoin is not active against Proteus and should not be used after week 37 due to concern for hemolytic anemia in the newborn. Sulfa-containing drugs may increase the risk for kernicterus in the newborn and should be avoided during the last weeks of gestation. Folate antagonists, such as trimethoprim, are relatively contraindicated during the first trimester because of their association with cardiovascular malformations. Regionally, increased rates of E. coli resistance to trimethoprim-sulfa limit its use. Fluoroquinolones and tetracyclines are contraindicated.

Sexually Transmitted Diseases

• Pharmacotherapy for selected sexually transmitted infections is shown in Table 32–1.
• Complications of Chlamydia trachomatis include pelvic inflammatory disease, ectopic pregnancy, and infertility. Chlamydia infection can be transmitted at birth to the neonate and cause conjunctivitis and a subacute, afebrile pneumonia.
• Penicillin is the drug of choice for syphilis, and it is effective for preventing transmission to the fetus and treating the already infected fetus.
• Neisseria gonorrhoeae is a risk factor for pelvic inflammatory disease and preterm delivery. Symptoms in the neonate (e.g., rhinitis, vaginitis, urethritis, ophthalmia neonatorum, and sepsis) usually start within 2 to 5 days of birth. Blindness can occur.
• The overriding concern with genital herpes is transmission of the virus to the neonate during birth. Maternal use of acyclovir during the first trimester is not associated with an increased risk of birth defects. Valacyclovir is an alternative. For famciclovir, safety data are more limited.
• Bacterial vaginosis is a risk factor for premature rupture of membranes, preterm labor, preterm birth, intraamniotic infection, and postpartum endometritis.
• Data are conflicting concerning treating women at low risk for preterm labor