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225 Obstetrics
234
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Vol. 38 No. 6
Review Article
Obstetrics
247 Newborn Stem Cells: Types, Functions and Basics for Obstetricians
This article provides a basic knowledge of newborn stem cells and their potential clinical and
cryopreservation opportunities, to assist obstetricians in their important role of educating expectant
mothers.
Jennifer Sze Man Mak, Juan Bolaños, Wing Cheong Leung, Richard Boyd, Robert Kien Howe Chin
P
Continuing Medical Education 3 SK
247
257 Preconception Care
The evidence for the effectiveness of commonly practised preconception care will be examined in this
article. A practical checklist for preconception care in the primary health care setting will also be provided.
Lee Chin Peng
257
The Journal of Paediatrics, Obstetrics and Gynaecology contains articles under licence from UBM Media LLC. The articles
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Referensi:
Peer Reviewed Journal Watch
ethinyl oestradiol dose of 20 µg, the increase in risk There were significant increases in the sling group
GYNAECOLOGY was less in general, and there was no increased in urinary tract infection (31.0% vs 18.3%), major
risk with drospirenone as the progestin. Transder- bleeding (3.1% vs 0%), and incomplete bladder
Hormonal contraception and mal patches were not associated with significantly emptying 6 weeks after surgery (3.7% vs 0%).
cardiovascular risk increased risk for either thrombotic stroke or myo- The insertion of a midurethral sling was ef-
cardial infarction. Vaginal ring was associated with fective in reducing the risk of postoperative urinary
a significant 2.5-fold increase in risk of thrombotic incontinence but at the expense of increased risk
stroke but a non-significant increase in risk of myo- of complications.
cardial infarction.
Wei JT et al. A midurethral sling to reduce incontinence after vaginal
Although hormonal contraception may in- prolapse repair. NEJM 2012; 366: 2358–2367; Iglesia CB. Vaginal prolapse
repair – place midurethral sling now or later: Ibid: 2422–2424 (editorial).
crease the risks of thrombotic stroke and myocar-
dial infarction, the absolute risks are low. An edito-
rialist concludes that they are ‘safe enough’.
Effect of contraception on
Lidegaard Ø et al. Thrombotic stroke and myocardial infarction with
hormonal contraception. NEJM 2012; 366: 2257–2266; Petitti DB. maternal mortality rates
Hormonal contraceptives and arterial thrombosis – not risk-free but safe
enough. Ibid: 2316–2318 (editorial).
The Millennium Villages project in who have not received antiretroviral therapy in
Africa pregnancy is uncertain. Three regimens have been
compared in an international trial.
The Millennium Villages project began in nine A total of 1,684 bottle-fed infants of moth-
African countries (Nigeria, Mali, Senegal, Ghana, ers who received a diagnosis of HIV-1 infection late
Uganda, Kenya, Rwanda, Tanzania, and Malawi) in pregnancy were randomized within 48 hours of
in 2006. In each country, a rural population (aver- birth in Brazil, South Africa, Argentina, or the USA
age, 35,000 people) with high levels of poverty and to one of three treatment regimens: zidovudine for
undernutrition was selected. Finance amounting to 6 weeks (Z6), zidovudine for 6 weeks plus three
around US$120 per person was provided annually doses of nevirapine in the first 8 days (Z6 + Nev), or
to support agriculture, the environment, business zidovudine for 6 weeks plus nelfinavir and lamivu-
development, education, infrastructure, and health, dine for 2 weeks (Z6 + Nelf L). The overall rate of in
in partnership with communities and local govern- A total of 699 patients aged 10–17 years utero HIV transmission was 5.7% and was the same
ments. Average spending per person was $27 at with type 2 diabetes (mean duration, 7.8 months) in all three groups. Transmission during labour oc-
baseline and $116 by year 3. There were improve- and obesity (body mass index, 85th percentile or curred in 4.8% (Z6), 2.2% (Z6 + Nev), and 2.4% (Z6
ments in water supplies and sanitation, poverty higher for age and sex) were randomized to metfor- + Nelf L). Overall, 8.5% of infants were infected by
levels, food security, stunting, and malaria preva- min alone (M), metformin plus rosiglitazone (MR), 3 months, 11.0% in the Z6 group, 7.1% in the Z6
lence at Millennium Village sites after 3 years. or metformin plus a weight-loss lifestyle interven- + Nev group, and 7.4% in the Z6 + Nelf L group,
Under-5s mortality fell by 22% in these sites and tion (MW). Over an average follow-up of 3.9 years, a significantly greater rate in the zidovudine-only
by 33% relative to matched comparison sites. Pro- loss of glycaemic control (glycated haemoglobin at group compared with the other two groups. HIV-1
vision of many maternal–child health interventions least 8% for 6 months or sustained metabolic de- transmission was significantly associated with zi-
was improved. compensation needing insulin) occurred in 45.6% dovudine monotherapy, higher maternal HIV load,
The multifaceted intervention was beneficial of participants overall. The group rates for this and maternal use of illegal substances. Neutrope-
in several ways including reduced child mortality. outcome were 51.7% (M), 38.6% (MR), and 46.6% nia occurred in 16.4%, 14.9%, and 27.5% of the
(MW). MR was significantly better than M, but MW three groups, respectively.
Pronyk PM et al. The effect of an integrated multisector model for
achieving the Millennium Development Goals and improving child survival was not significantly different from M or MR. The Z6 + Nev and Z6 + Nelf L regimens were
in rural sub-Saharan Africa: a non-randomised controlled assessment.
Lancet 2012; 379: 2179–2188; Malenga G, Molyneux M. The Millennium
MR was the best of the three options. Most more effective than the Z6 regimen, and the Z6 +
Villages project. Ibid: 2131–2133 (comment).
young people with type 2 diabetes will probably Nev was less toxic than Z6 + Nef L.
need combination drug therapy or insulin within a
Nielsen-Saines K et al. Three postpartum antiretroviral regimens to
few years of diagnosis. prevent intrapartum HIV infection. NEJM 2012; 366: 2368–2379.
Management of type 2 diabetes TODAY Study Group. A clinical trial to maintain glycemic control in youth
in children and adolescents with type 2 diabetes. NEJM 2012; 366: 2247–2256; Allen DB. TODAY – a
stark glimpse of tomorrow. Ibid: 2315–2316 (editorial).
Imaging Paediatric
Brain Tumours
Dietary Intervention
Tang Phua Hwee, MBBS, FRCR, MMed Diagnostic Radiology
in Eczema
Jackelina Pando Kelly, MMSc, MRCPCH; Jonathan Hourihane, MB, DM, FRCPCH
INTRODUCTION
Eczema, also known as atopic dermatitis has been proposed as a cutaneous manifes-
tation of a systemic disorder that also gives rise to asthma, food allergy, and allergic
rhinitis. It is a common, chronic, pruritic, and relapsing inflammatory dermatosis that
typically manifests during early childhood.
The current prevalence of eczema in developed countries is about 20%, represent-
ing a twofold to threefold increase during the past decades. The reason for this increase
remains unclear.
PATHOGENESIS
There is no convincing evidence that delaying the introduction their child’s eczema, rather than using prescription
of solid foods, including those considered to be highly allergic,
medications that they have been told, also errone-
beyond 6 months of age has a significant protective effect on
the development of eczema. ously, have major toxic side effects.
Food-allergic sensitization. Allergic sensiti-
zation to food allergens is frequent in infants and
children with eczema. The highest rates of food-
allergic sensitization occur during the first 2 years
of life, and they closely parallel the onset of eczema.
There is a direct correlation between eczema
severity and food allergen sensitization. The dem-
onstration of food allergen-specific IgE in infancy
is predictive not only of eczema severity, as shown
by the fact that sensitization to food and inhalant
allergens is present in 70–80% of patients with
moderate-to-severe eczema, but also of eczema per-
sistence and of the onset of allergic airways disease
later in childhood.
Food-allergic disease in patients with
eczema. Ingested food allergens are able to acti-
vate cutaneous mast cells and skin-associated lym-
phoid tissue, and in the sensitized host, they can
produce intense pruritus, causing scratching and
rubbing that lead to typical eczematous lesions.
At a cellular level, positive oral food challenges
in patients with eczema result in a sharp increase in
plasma histamine concentrations, activation of eo-
sinophils, and clonal expansion of allergen-specific
We will briefly review the association between skin homing T-cells.
food allergy and eczema and some of the dietary It has been reported that approximately one-
strategies that have been proposed in eczema. third of children with moderate-to-severe eczema
have food allergy and up to two-thirds of infants < 2
FOOD ALLERGY AND ECZEMA years with severe or refractory eczema. Only 10%
of infants with mild eczema are affected by food
Patients or parents of children with eczema com- allergy.
monly perceive that specific foods, more commonly The defective epithelial skin barrier as a
cow’s milk, cause flare-ups of their child’s eczema. route for allergic sensitization. It has been pro-
Other foods that have been implicated in hypersen- posed that allergen sensitization occurs as a sec-
sitivity reactions in eczema include citrus, nuts, and ondary consequence of a defective skin barrier in
fish. Families may wish to change their diet in the which the penetration of microbes and allergens is
erroneous belief that an external trigger is causing enhanced. The recent identification of loss-of-func-
tion mutations in the epidermal structural protein Table 1. Food allergy phenotypes
filaggrin appears to be a major risk factor for severe
eczema, peanut allergy, multiple atopic sensitiza- IgE-mediated IgE/non-IgE-mediated Non-IgE-mediated
tion, and coexisting asthma. Immediate Allergic eosinophilic Food protein–induced
Phenotypes of food allergy in patients with food allergy/ gastritis enterocolitis
eczema. Food-allergic reactions have been broadly Anaphylaxis Allergic eosinophilic Food protein–induced
classified into allergic (IgE or non-IgE-mediated) Oral allergy gastroenteritis proctitis
and non-allergic hypersensitivity reactions. The al- syndrome Food protein–induced
lergic reactions may be immediate IgE-mediated or Eczema enteropathy
Coeliac disease
delayed non-IgE-mediated. Intolerance is defined as
Eczema
a non-allergic reaction to a food and includes food
Any time, peak
aversion, and toxic, enzymatic or pharmacological
in early life Infancy–adolescence Usually infancy
reactions to foods.
Cox H, Hourihane J. 2011.
There is considerable overlap between IgE-
mediated and non-IgE-mediated reactions, and most
of these phenotypes can coexist in patients with Table 2. Common food triggers of eczema
eczema (Table 1). Therefore, it is important to under-
stand the natural history and clinical presentation of Food-allergic triggers Non-allergic food triggers
food allergy in order to make or refute a diagnosis of of eczema of eczema
such in patients with eczema. Milk Tomato
IgE-mediated reactions to specific foods cause Egg Citrus
Peanut Acidic fruits and kiwi
stereotyped symptoms typically within 0–2 hours
Soya Yeast extract
(but nearly always within 30 minutes) of ingestion,
Wheat Others
affecting the skin, gastrointestinal tract, and res-
piratory and cardiovascular systems. These acute
allergic reactions are often followed by a delayed an infant with the combination of infantile eczema
flare of eczema. and features of altered gut motility (colic, reflux,
Non-IgE-mediated reactions are typified by persistent crying, etc).
symptoms that involve also the skin, gastrointes- The diagnosis of food allergy in patients
tinal tract, and respiratory tract (eczematous reac- with eczema. An accurate diagnosis of food aller-
tions, vomiting, diarrhoea or constipation, cough, gy is important as it allows for a targeted approach
wheeze). Delayed reactions to food allergens in the to allergen avoidance, but also for a relaxation of
gastrointestinal tract predominate in infancy and dietary restrictions when it has erroneously been
early childhood and tend to improve with age. imposed on children.
The most common food triggers of eczema are The gold standard test for food allergy
shown in Table 2. diagnosis is the double-blind, placebo-controlled
In infants with moderate-severe eczema, the food challenge, but as this is not accessible to many
relationship between milk ingestion and the devel- patients, the diagnosis of food allergy needs to rely
opment of eczema is likely to be more obvious. A on a stepwise approach which includes a detailed
high index of suspicion is required when evaluating allergy-focused history and food-specific allergy
The diagnosis of food allergy in children with eczema includes taking a detailed allergy-focused history.
tests. If in doubt after this, oral provocations tests food proteins excreted in breast milk.
are needed after a trial period of dietary elimination – The relationship of eczema onset to the in-
to make the diagnosis of food allergy. troduction of formula feeds.
The history. A detailed allergy-focused his- – The type of formula feed.
tory should focus on the following areas: • Gastrointestinal symptoms: The presence of
• Family history of atopy: The risk of atopy in gastrointestinal symptoms, such as colic, ab-
creases if a parent or sibling has atopic dis- dominal pain, vomiting, reflux, feeding aver-
ease ( 20–40% and 25–35%, respectively), and sion, diarrhoea, constipation, blood or mucus
is higher still if both parents are atopic (40– in stools, and failure to thrive, in a patient with
60%). eczema should raise the possibility of food
• Infant feeding: allergy.
– A history of breast vs formula feeding, • History of immediate reactions to specific foods:
detailing period of exclusive breastfeed- A history of immediate reactions to food is
ing, and taking into account that the onset important to ascertain. This should explore the
of severe eczema during a period of exclu- time of onset in relation to ingestion, the
sive breastfeeding may be secondary to quantity of food required to cause a reaction,
any previous reaction or prior tolerance of that picion is high, the tests are useful for confirming al-
food, and whether the reaction was of suffi- lergy, and conversely when the index of suspicion is
cient s everity to cause anaphylaxis. It is neces- low, the tests are useful for ruling out a diagnosis of
sary to determine reactions to foods in infancy allergy. When there is a lack of correlation between
as well as current reaction to establish a mean- the history and tests of specific IgE or when the his-
ingful picture of the child’s allergic status, tak- tory and tests are equivocal, confirmation by way
ing in account that the natural history is for of an open or blinded provocative challenge test is
children to acquire tolerance to most food al- usually required to make the diagnosis.
lergens over time.
• History of eczematous or gastrointestinal reac-
tions to specific foods: A history of food caus-
It is difficult to prove
ing an eczematous flare in patients with per-
sistent eczema is frequently absent. In a place- that specific foods
bo-controlled study which demonstrated a induce the eczema
60% improvement in eczema patients adhering
because clinical cases
to milk- and egg-free diet, there was no corre-
lation between the parents’ suggestions that do not always
milk and/or eggs triggered their child’s eczema. correlate well
• Current diet and prior history of tolerance to
with skin prick
foods:
– Which of the main allergenic foods are in- testing and IgE levels
cluded within the current diet?
– Has there been any previous attempt to
eliminate foods from the patient’s diet? Tests for the diagnosis of food allergy include
• Age of onset of eczema: Eczema onset in early skin prick tests, specific IgE tests, and the atopy
infancy is far more likely to be associated with patch test. None of these tests, however, confirms
food allergy than eczema onset in a child >5 or refutes the diagnosis of food allergy in the ab-
years. sence of an individual patient history which seeks to
• Eczema severity: The probability of food allergy establish the prior probability of the allergen being
is greater in young children, infants, and those causal. The selection of allergens for testing should
with severe disease. When associated with be based on the clinical history and patients’ age.
symptoms of gut dysmotility, the association be- It is difficult to prove that specific foods induce
tween food allergy and eczema is strengthened. the eczema because clinical cases do not always
• Co-morbid associations: Food allergy and ecze- correlate well with skin prick testing and IgE levels.
ma can coexist with other diseases such as Clinical history is the most important tool to help
asthma. with the diagnosis.
Asthma is a risk factor for anaphylaxis, and Oral food challenges (OFCs). OFC testing
children, who will have food challenges, should first remains the gold standard for diagnosing food al-
have their asthma well controlled. lergy, and the aim is to accurately identify causative
Allergy-specific test. When the index of sus- allergens.
Oral food challenge should only be used when the child suspected dermatologist and an intensive treatment, including
of having food allergy has severe eczema. moisturizers, topical steroids, and in some cases an-
tibiotics. The aim is to gain control of their eczema-
tous inflammation so that the skin is relatively clear
at the time of challenge.
A clarification of the presence or absence of
food allergy is important, as a positive diagnosis
can empower the child and family to safely proceed
with an appropriate management plan and advice on
specific allergen avoidance. Conversely, a negative
diagnosis allows for removal of unnecessary dietary
restrictions.
DIETARY MANAGEMENT IN
CHILDREN WITH ECZEMA
Current data do not support prolonged dietary Box 1. Consensus statements from the NICE guideline on atopic
eczema for children aged 0–12 years
elimination for most children with eczema. In situa-
tions where special diets are attempted, the recom-
mendation is to do so for 4–8 weeks and then return
to a normal diet to assess the efficacy of the dietary • A diagnosis of food allergy should be considered in children
intervention. A dietician should be involved during with atopic eczema who have reacted previously to a food
the process, as prolonged unsupervised dietary re- with immediate symptoms, or in infants and young children
with moderate or severe atopic eczema that has not been
strictions in children can have severe nutritional
controlled by optimum management, particularly if associated
consequences.
with gut dysmotility (colic, vomiting, altered bowel habit) or
failure to thrive.
PRACTICAL APPROACH TO SPECIFIC • A 6–8 week trial of an extensively hydrolyzed protein formula
DIETARY ALLERGEN EXCLUSION IN or amino acid formula in place of cow’s milk formula for
ECZEMA bottle-fed infants aged less than 6 months with moderate or
severe atopic eczema that has not been controlled by optimal
An approach to the dietary elimination of foods treatment with emollients and mild topical corticosteroids.
causing reactions was proposed by a European task • Children with atopic eczema who follow a cow’s milk–free
force in 2007 and a German guideline task force in diet for longer than 8 weeks should be referred for specialist
dietary advice.
2009. These parameters rely on initial treatment
• Diets based on unmodified proteins of other species’ milk (ie,
of eczema prior to dietary elimination and OFC. If
goat’s milk) or partially hydrolyzed formulas should not be
treatment of eczema leads to sustained periods of used in children with atopic eczema for the management of
eczema clearance with minimal need for topical suspected cow’s milk allergy. Diets including soya protein can
corticosteroids, no further dietary intervention is be offered to children aged 6 months or over with specialist
required unless there is a specific history of imme- dietary advice.
diate reactions to food. The guidelines recommend
allergy testing in all patients with suspected food NICE = National Institute for Health and Clinical Excellence.
the gastrointestinal tract, and certain strains are in- world, has led to an altered immune response (TH2-
volved in maintaining the integrity of the intestinal skewed) that ultimately increases the risk of atopy.
barrier in children with eczema. Breastfeeding has Probiotics have not been proven to be a viable
been shown to promote the colonization of Lacto- treatment for established eczema yet, and there is
bacillus and bifidobacteria in the intestinal tract of conflicting evidence of their clinical effectiveness in
infants, and this might partially explain the benefits the prevention of eczema.
of breastfeeding on atopic disease. Nutritional intervention to impact eczema is a
In animal models, probiotics have shown to complete new field, and further studies are needed
reduce dietary antigen load by degradation of mac- to better guide patients and physicians in this area.
romolecules, reducing subsequent development of
dietary antigen hypersensitivity, as it is known that FURTHER READING
antigen degradation is necessary to develop toler-
Cox H, Hourihane J. Food allergy and eczema. In: Irvine A,
ance to dietary antigens. Hoeger P, Yan A, eds. Textbook of Pediatric Dermatology.
3rd ed. Blackwell Publishing Ltd; 2011:chap 31.
Finch J, Munhutu MN, Whitaker-Worth D. Atopic dermatitis and
nutrition. Clin Dermatol 2010;28:605–614.
Guidelines for the diagnosis and management of food allergy in
the United States: report of the NIAID-Sponsored Expert
Panel. Allergy Clin Immunol 2010;6:S1–S58.
Bath-Hextall F, Delamere FM, Williams HC. Dietary exclusions
for improving established atopic eczema in adults and
The results of several children: systematic review. Allergy 2009;64:258–264.
Greer F, Sicherer S, Burks W, the Committee on Nutrition and
studies suggest that Section on Allergy and Immunology. Effects of early
nutritional interventions on the development of atopic
exclusive breastfeeding
disease in infants and children: the role of maternal
for a minimum of 4 months dietary restriction, breastfeeding, timing of introduction
of complementary foods, and hydrolyzed formulas. Pediat-
could be recommended rics 2008;121:183–191.
Muraro A, Dreborg S, Halken S, et al. Dietary prevention of aller-
as a potential method of gic diseases in infants and small children, part III: criti-
cal review of published peer-reviewed observational and
eczema prophylaxis interventional studies and final recommendations. Pediatr
Allergy Immunol 2004;15:291–307.
von Berg A, Koletzko S, Grübl A, et al. The effect of hydrolyzed
cow’s milk formula for allergy prevention in the first year
of life: the German Infant Nutritional Intervention Study,
a randomized double-blind trial. J Allergy Clin Immunol
2003;111:533–540.
Gastroesofageal refluks (GER) adalah keluarnya isi perlu diperhatikan. Posisi yang dianjurkan adalah posisi
lambung secara pasif ke dalam tenggorokan (esofagus) telentang dengan garis punggung-bokong membentuk
karena adanya relaksasi sementara atau menahun sudut 60 derajat dengan alasnya. Posisi ini diharapkan
(kronis) dari otot sfingter bawah esofagus. Regurgitasi dapat mengurangi aliran balik dari lambung ke esofagus.
atau gumoh merupakan gejala dari GER yang paling
sering ditemukan pada bayi. Jika keadaan GER ini Langkah selanjutnya adalah pemberian nutrisi.
mempunyai komplikasi maka disebut dengan GERD Pemberian thickening agent formula atau susu
yang jika berat akan mengalami kesulitan menelan formula anti regurgitasi (AR) dapat dipertimbangkan
(disfagi). Gejala GERD antara lain muntah, sakit perut, karena telah terbukti dapat mengurangi regurgitasi,
bermasalah dengan makan, gagal tumbuh, rewel dan meningkatkan berat badan, membuat bayi tidur
nyeri dada. menjadi lebih lelap dan jarang menangis.
Salah satu studi mengenai regurgitasi yang dilakukan Hegar B dkk (2008) melakukan penelitian prospektif,
oleh Hegar B dkk (2009) pada 163 bayi, dan 130 acak, intervensi selama 1 bulan pada 60 bayi dengan
bayi yang di-follow up selama 1 tahun menunjukkan, regurgitasi ≥ 4 kali/hari dalam seminggu. Intervensi
kejadian tertinggi regurgitasi dijumpai pada bulan- dibagi menjadi 3 grup: A (formula standar), B (formula
bulan pertama kehidupan (73%) dan secara bertahap standar + sereal beras) dan C (formula dengan locust
akan berkurang 50% pada usia 5 bulan. Selama 2 bulan bean gum). Setelah 1 bulan, penambahan berat badan
pertama, 20% bayi mengalami regurgitasi lebih dari 4 pada bayi yang mendapat formula dengan locust bean
kali per hari. Namun setelah usia 12 bulan, yang masih gum (AR) secara signifikan lebih tinggi dibandingkan
mengalami regurgitasi setiap hari berkisar 4%. dua grup lainnya (gambar 1).
Penanganan regurgitasi
Pemberian ASI tetap dilanjutkan, karena kejadian
regurgitasi pada bayi yang mendapat ASI lebih sedikit
dibandingkan dengan bayi yang mendapatkan susu
formula. Gambar 1. Hubungan antara jenis formula dan kenaikan berat badan
pada bayi dengan regurgitasi.
Parental reassurance merupakan langkah awal yang Orenstein SR dkk (1987) dalam Vandenplas (1988)
perlu dilakukan. Posisi bayi setelah diberi minum juga melakukan penelitian yang menilai pemberian formula
yang dikentalkan pada bayi dengan regurgitasi. Hasilnya
menunjukkan pemberian formula yang dikentalkan
dapat mengurangi waktu menangis dan meningkatkan
waktu tidur pada bayi (gambar 2).
Referensi
1. Orenstein SR, Magill HL, Brooks P. Thickening of infant feedings for therapy of gastroesophageal reflux. J. Pediatr 110: 181-186, 1978 in Vandenplaz Y, Lifshitz, Orenstein MD, et al.
Nutritional management of regurgitation in infants. Journal of the American College of Nutrition. 1998. Vol 17, No 4; 308-316.
2. Hegar B, Regurgitasi suatu keadaan normal atau hal yang perlu diperhatikan, www.idai.or.id. Diakses Agustus 2012
3. Hegar B, Dewanti NR, Kadim M, Alatas S, Firmansyah A, Vandenplas Y. Natural evolution of regurgitation in healthy infants, Acta Paediatr. 2009 Jul;98(7):1189-93
4. Hegar B, Rantos R, Firmansyah A, et al. Natural evolution on infantile regurgitation versus efficacy of thickened formula. JPGN. 2008;47:26-30.
’Air Susu Ibu adalah yang terbaik untuk bayi dan memberikan banyak manfaat. Adalah penting bahwa dalam persiapan untuk dan
selama menyusui, Anda melakukan diet yang sehat dan seimbang. Menggabungkan pemberian ASI dan botol pada minggu pertama
kehidupan dapat mengurangi suplai ASI Anda, dan sulit untuk dapat menyusui kembali bila telah berhenti. Implikasi sosial dan keuangan
perlu dipertimbangkan bila akan memberikan susu formula. Penggunaan formula bayi yang tidak benar atau pemberian makanan
dan cara pemberian yang tidak benar dapat menyebabkan bahaya terhadap kesehatan. Kalau Anda menggunakan formula bayi,
Anda harus mengikut petunjuk penggunaannya dengan seksama – kegagalan mengikuti petunjuk dengan benar dapat membuat bayi
sakit. Selalu berkonsultasi dengan dokter, bidan atau ahli medis lainnya untuk nasihat pemberian makan bayi Anda.
© 2012 UBM Medica. All rights reserved. No part of this publication may be reproduced in any
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Imaging Paediatric
Infectious Disease in Pregnancy
Brain Tumours
Sarah Logan, FRCP; Laura Price, FRCP
Tang Phua Hwee, MBBS, FRCR, MMed Diagnostic Radiology
INTRODUCTION
All infectious diseases can occur in pregnant women. There are some that occur more
frequently in this group owing to the immunosuppressive nature of pregnancy. There
are others that cause increased concern in pregnancy owing to their potential fetal
complications. In this article, we will focus on some of the general principles for man-
agement of any infection in pregnant women and then discuss some of the diseases in
more detail.
PHYSIOLOGICAL CHANGES
Physiological and immune changes occur in pregnancy, making women more susceptible
to infections, and these are still not fully understood. A shift from cell-mediated to
humoral immunity occurs, which may affect susceptibility to and severity of some infec-
tious diseases, including an increased incidence of certain intracellular pathogens, such
as toxoplasmosis, listeriosis, influenza, and varicella.
Urinary tract infections are more common, related to progesterone effects and me-
chanical compression by the gravid uterus, as well as higher urinary glucose and pH
facilitating bacterial growth.
Respiratory infections may be more severe for several reasons. Diaphragmatic el-
evation reduces secretion clearance and functional residual capacity, and with the in-
creased oxygen demand, reduces tolerance to hypoxia, particularly in the third trimester.
Gastric acid aspiration is more common, and increased interstitial lung water is seen,
increasing the risk of acute lung injury.
ANTENATAL SCREENING AND Pregnant women should take precaution to prevent toxoplasmosis
infection.
PREVENTION
Screening
Since 2003, the UK Department of Health has rec-
ommended screening for hepatitis B, human immu-
nodeficiency virus (HIV), rubella and syphilis early
in pregnancy with a single blood sample, as well as
asymptomatic bacteriuria (ASB) with a urine sam-
ple. There is currently no clear evidence of benefit
from screening for other infections, although wom-
en may request additional screening, particularly if
they have experience of health care systems over-
seas. Whilst the current guidance in the UK is not
to screen women for group B Streptococcus (GBS),
cytomegalovirus (CMV) and toxoplasmosis, each
case should be considered on an individual basis,
and consultation with local infectious diseases/
virology services may be required. For women at
high-risk for HIV, it is important to repeat the HIV
test in the third trimester. A negative test at book-
ing can be falsely reassuring, and seroconversion
during pregnancy carries a higher risk of mother-to-
child transmission.
Primary Prevention
Mothers are advised about primary prevention childhood should protect during childbearing years.
measures to avoid toxoplasmosis infection such as The single vaccine has been in place since 1970,
thorough hand washing, cooking raw meats, and and the measles-mumps-rubella (MMR) since 1988.
avoiding contact with cat litter and soil. Listeria Until recently, the UK childhood immunization rates
avoidance includes not eating unpasteurized dairy were 92%. Following the 2003 negative press cov-
products or pate and washing salads thoroughly. erage, rates dropped to 80%, although they have
started to increase again. Women planning a family
Immunization should ensure immunity.
Ideally, women should be immunized prior to con- Live varicella vaccines are available pre-preg-
ception, but there are a few situations where im- nancy, and zoster immune globulin (IG) should be
munization of a pregnant woman is indicated. Live given to pregnant women non-immune to varicella
vaccines are usually avoided though, owing to the and up to 10 days following exposure. Varicella se-
risk of fetal infection. rology is also available, although immunity is usu-
UK immunization programmes for rubella in ally assumed from the history of typical rash.
Influenza vaccination (inactivated) may be the risk of neonatal necrotizing enterocolitis in one
considered and is deemed safe throughout preg- study of preterm premature rupture of membranes
nancy. In light of the recent outbreak of H5N1 influ- (PROM) prevention, and although no animal studies
enza and its increased severity in pregnant women, have shown harm, further human studies are need-
all women should be offered the seasonal vaccine ed. Cephalosporins cross the placenta less com-
which will give protection to the most common cir- monly and appear to have no adverse fetal effects.
culating strains. Other antibiotics are relatively contraindicat-
ed in pregnancy, but their use may be appropriate
INVESTIGATION AND depending on the clinical situation. Nitrofurantoin
MANAGEMENT is generally considered safe but should be avoided
at term because of the risk of haemolytic anaemia
Principles in the neonate. There are reports of ciprofloxacin
A good history is essential, considering the preg- causing an arthropathy in animal studies, but no ad-
nancy, gestational age, prior ASB, sexually trans- verse human effects have been reported. Trimetho-
mitted infections (STIs), travel, occupation, HIV risk prim has also caused adverse effects in animals,
factors, contacts with infectious diseases, and prior so should be used with caution in pregnancy, espe-
tuberculosis (TB) infection. There may only be non- cially as it may interfere with folic acid metabolism.
specific symptoms and signs, but these are impor- It should be avoided near term when used as co-
tant to consider, as obstetric sepsis can present this trimoxazole in combination with a sulfonamide, as
way before rapid deterioration. the later can cause fetal kernicterus. Tetracyclines
Involvement of the feto-maternal multidisci- increase the risk of fulminant maternal hepatitis in
plinary team is essential, including clinical micro- the third trimester and may stain fetal teeth after
biologists/virologists/infectious diseases, local TB 20 weeks’ gestation. Chloramphenicol should be
services, and the critical care team when appropri- used with caution because of the association with
ate. With evidence of STIs, genitourinary physi- the ‘grey baby syndrome’ (characterized by cyano-
cians should be involved, and screening for other sis, flaccidity and cardiovascular collapse) when
STIs should be undertaken. used in newborn infants. Aminoglycoside use (eg,
gentamicin) risks fetal ototoxicity and should only
Antibiotic Use in Pregnancy be used if there is evidence of serious gram-neg-
In general, penicillins, cephalosporins, and mac- ative infection. Similarly, vancomycin has been as-
rolides such as erythromycin (although less data on sociated with fetal nephrotoxicity and ototoxicity.
clarithromycin) are safe. Clindamycin is also prob-
ably safe although clinical experience is limited. MATERNAL INFECTION SYNDROMES
Penicillins are only 50% protein-bound and can
cross the placenta to achieve fetal concentrations Sepsis
that are therefore 50% of maternal levels. Amoxi- Obstetric sepsis is the most important cause of UK
cillin has increased renal clearance in pregnancy, maternal mortality; in the most recent confidential
therefore theoretically higher doses are needed, enquiry, the mortality related to sepsis increased
although in clinical practice, doses are used as out- from 0.85 deaths per 100,000 mortalities in 2003–
side pregnancy. Augmentin was shown to increase 2005 to 1.13 deaths in 2006–2008, making sepsis
the most common cause of direct maternal death. can be serious, especially when associated with
The commonest source is the genital tract, notably GAS and Streptococcus agalatiae (GBS). GAS ne-
from Streptococcus pyogenes (group A Streptococ- crotizing fasciitis and toxic shock syndrome can
cus, GAS), although it is important to remember occur unexpectantly following an uncomplicated
that any systemic infections can present as sepsis pregnancy and delivery, and management includes
or septic shock. antibiotic therapy with broad-spectrum antimicro-
Sepsis can present at any time before, during bials according to local policy and early surgical
or following delivery, and is important to recognize intervention. Thirty percent of the fevers seen in
and treat early, for example using early warning women who have just delivered are due to endome-
score systems for ward patients, and with commu- trial infection. The risk is higher post CS and after
nity midwives being astute for signs of infection. a PROM, prolonged delivery or in the presence of
Mothers often present with vague symptoms and retained products of conception. Infections are of-
signs, but it is important to recognize these early, as ten polymicrobial, with aerobes and anaerobes, and
the course can be fulminant. Management of septic Chlamydia can cause late endometritis. Endometri-
shock is similar to that outside pregnancy. Preven- tis can also result from CS wound incisions (more
tative measures include good perineal hygiene. commonly seen following emergency CS), which
Most obstetric sepsis occurs post partum, is important to recognize, as utero-cutaneous fis-
and may relate to genital tract infections, mastitis, tulae may result requiring surgery. Late endometri-
thrombophlebitis, episiotomy, and perineal tear in- tis more typically follows vaginal delivery. A 2002
fections, caesarean section (CS) wound infections, Cochrane review concluded that a single dose of
gastric acid aspiration, or post-general anaesthesia ampicillin or first-generation cephalosporins was
pneumonia. sufficient to reduce puerperal infections related to
Antepartum infections include chorioamnio- uncomplicated CS, given as a single dose after cord
nitis which may follow prolonged PROM (pPROM) clamping.
and prolonged labour. pPROM complicates only For an excellent summary of sepsis see chap-
2% of pregnancies but is associated with 40% of ter 16 of the recent 2006–2008 confidential enquiry
preterm deliveries, and is suspected with a sug- into maternal deaths.
gestive maternal history and on a sterile speculum
examination. Mothers should be observed 12-hour- Urinary Tract Infections
ly for signs of clinical chorioamnionitis. First-line Urinary tract infections (UTIs) are divided accord-
prophylaxis for pPROM is erythromycin. Diagnosis ing to the site of bacterial proliferation into ASB,
of chorioamnionitis is suggested by fever late in cystitis, and pyelonephritis.
pregnancy, uterine tenderness, offensive vaginal ASB is defined as urine colonization greater
discharge, and fetal tachycardia. Consequences in- than 105 colony-forming units per mL on two con-
clude PROM and premature labour, increased risk of secutive clean-catch urine samples (without ni-
neonatal pneumonia, bacteraemia, meningitis, and trites or leucocytes on dipstick). It occurs in 4–7%
death. Treatment is with broad-spectrum antibiotics of pregnant women and is important to recognize,
(ampicillin and gentamicin) and delivery. as symptomatic UTIs develop in 20–40% of cases,
Endometritis is a spectrum of endometrial, and there is an increased incidence of preterm de-
myometrial and parametrial infections, all of which livery and low-birth-weight infants. This has lead to
Studies showing the prevention of urinary tract infections in ten with symptoms of cystitis. Pyelonephritis is the
pregnancy with cranberry juice ingestion are lacking.
most common cause of septic shock in pregnancy,
and adult respiratory distress syndrome (ARDS) oc-
curs in 1–8% of cases, so patients should be closely
monitored. Diagnosis is based on the presence of
significant bacteriuria following mid-stream urine
culture, and the history and clinical signs. A renal
tract ultrasound scan should be performed to ex-
clude hydronephrosis and structural abnormalities.
Organisms are similar to those in lower tract UTIs,
with E coli in 70–80%, and Klebsiella pneumonia
and Proteus species less commonly, but important
in recurrent cases. Antibiotic choice reflects local
guidelines, usually with a first-generation cephalo-
sporin or combination ampicillin with gentamicin.
Most will be afebrile and asymptomatic following
48 hours of appropriate antibiotic treatment, and
intravenous therapy is then continued until the
patient has been afebrile for 48 hours. Failure to
respond after the initial 72 hours usually indicates
a resistant organism, renal tract stone, or anatomi-
cal obstruction. When discharged home, the mother
should be more closely watched for recurrence with
UK screening being recommended (see NICE guide- monthly urine cultures. Fetal effects of untreated
lines). ASB is due to Escherichia coli in 75–90% of pyelonephritis include preterm delivery and low
cases, and cephalosporins are more appropriate birth weight. If GBS is detected in maternal urine,
than amoxicillin, given the 60% E coli beta-lactam it should be treated and appropriate intra-partum
resistance seen. Up to 15% will require a further prophylaxis administered (see later).
course later in pregnancy. Cranberry juice has been used traditionally
Cystitis or bladder infection occurs in 1–4% of to prevent and treat UTIs. It contains proanthocy-
pregnancies and pyelonephritis, where the kidney anidins which prevent the adherence of bacterial
is the focus in 2% of all pregnancies. pathogens to the uroepithelium. A recent Cochrane
Pyelonephritis is a serious medical condition review showed a significant reduction in UTIs com-
in pregnancy, associated with fetal and maternal pared with placebo, although this was not specific
morbidity, and leads to an increased risk of pre- to pregnancy.
mature labour. Two-thirds of cases present in the
second or third trimester, and 27% post partum. Respiratory Tract Infections
The right kidney is most often affected owing to Bacterial pneumonia has a similar incidence and
dextro-rotation of the uterus. The common present- outcome in pregnancy, although viral pneumonias
ing features are fever, loin pain, rigors, and less of- are more common and run a more severe course
in pregnancy. Investigation and management are vasive mechanical ventilation, veno-venous extra-
similar, although delay in obtaining a chest X-ray is corporeal membrane oxygenation may be required.
common; remember that the radiation exposure is This is a form of ‘lung bypass’ to rest the lungs
only 0.05% that of the maximum recommended 0.2 while they recover, and successful cases have been
rad. Influenza and varicella pneumonia in pregnant reported during pregnancy and immediately post
women have historically been associated with a partum.
higher rate of morbidity and mortality. Some impor- Varicella pneumonia – primary varicella in-
tant pathogens are considered below, and others, fections are more severe in pregnancy, and progres-
including TB, in later sections. sion to varicella pneumonia is more common (10–
20% of those infected). Maternal mortality from
Respiratory Pathogens in Pregnancy varicella pneumonia is higher in pregnancy (35%
Upper respiratory tract infection – pregnant versus 11%), thus prevention of primary infections
women often find that they have a persistent cold is of great importance. Oral mucosal ulceration is
in the last trimester. Whilst this may be due to any common, and respiratory illness ranges from cory-
of the common viral pathogens such as rhinovirus, zal symptoms to severe respiratory failure requiring
there is no treatment and in the absence of lower mechanical ventilation. Classically, the chest X-ray
respiratory tract symptoms does not need investi- shows bilateral miliary nodular shadowing, and
gation. later pulmonary calcification.
Bacterial pneumonia – the most common
cause of pneumonia in pregnant women remains
the same as in the general population – Strepto-
coccus pneumoniae. This is usually fully sensitive
to amoxicillin (with some decreased susceptibility
Primary varicella
in strains from abroad).
Influenza pneumonia – influenza infection infections are more
presents with similar self-limiting symptoms, but if severe in pregnancy,
they last more than 5 days, complications are not
and progression to
unusual. Pneumonia has a greater mortality rate (up
to 50%) in pregnancy and may result from a second- varicella pneumonia
ary bacterial pneumonia (Staphylococcus aureus,
is more common
Pneumococcus, or Haemophilus influenzae) or viral
parenchymal infection.
Complications from pandemic influenza A
(H1N1) are more common in pregnancy, notably
severe ARDS. Treatment is with the neuraminidase Other causes of pneumonia – Pneumocystis
inhibitor oseltamivir, which should be started as jiroveci pneumonia (PCP, previously called P cari-
soon as possible until clinical improvement occurs, nii pneumonia) in HIV-positive patients is associ-
although data are limited in pregnancy. See World ated with adverse obstetric outcome, and should
Health Organization guidelines for further details. be treated with co-trimoxazole. PCP is also increas-
In cases that remain hypoxic despite maximal in- ingly being seen in immunocompetent hosts, previ-
ously only associated with immunodeficiency. One At least 6% of hepatitis C–positive pregnant
study showed that asymptomatic nasal carriage women will transmit this to their baby perinatally.
of P jiroveci is more common in pregnancy, and This risk is increased in the presence of co-infec-
another that PCP is more severe in pregnancy. In tion with HIV to 15%. Elective CS may reduce the
HIV-positive women, P jiroveci may be transmitted transmission risk. There is no role for treatment of
perinatally. HCV in pregnancy, and there is no vaccine available.
Chlamydia psittaci is an unusual cause of Screening is not routinely carried out but should be
atypical pneumonia, (ie, those organisms not caus- considered in high-risk groups – mainly those with
ing a ‘typical’ lobar pneumonia). It is usually trans- a history of injecting drug use.
mitted via infected birds and may cause a severe ill- Hepatitis E virus is water-borne and transmit-
ness during pregnancy, but recovery is usually full. ted faeco-orally, usually causing a mild self-limiting
Fungal pneumonia, although unusual, may also run infection. However, in pregnancy, there is a sixfold
a more severe course in pregnancy, especially in the increase in maternal mortality, especially in the
final trimester. third trimester, with 15% of cases leading to fulmi-
nant hepatic failure where the mortality is 5%. The
Hepatitis mechanism may relate to immunologic imbalance
Viruses causing hepatitis include the hepatitis associated with a predominant T helper subtype
viruses A–E, as well as Epstein-Barr virus, CMV, 2 cell response and suppression of cell-mediated
toxoplasmosis, and herpes simplex virus. immunity seen in pregnancy. There is no specific
Overall, the clinical course of hepatitis A, B, treatment.
C and D viruses is unchanged in pregnancy, but Herpes simplex virus (usually herpes simplex
prevention of vertical transmission is important. virus type 2) can also lead to fulminant hepatic
Vertical transmission with maternal hepatitis A failure in pregnancy, often with associated pneu-
virus infection is rare, and the neonate should be monitis or encephalitis. Diagnosis is made on liver
given IG at birth. Hepatitis B virus is screened for biopsy and serology, and specific treatment for the
antenatally as the risk of vertical transmission from mother and infant with acyclovir is available.
asymptomatic mothers is high; rates are up to 95%
if mothers are hepatitis B surface antigen- and e- Rash
antigen-positive. Vertical transmission usually oc- There are comprehensive guidelines on the man-
curs at delivery and is more likely if the hepatitis B agement of rashes in pregnancy from the Health
virus infection is associated with a high viral load. Protection Agency (www.hpa.org.uk).
Several strategies including vaccination and use of The important infections to consider in the dif-
hepatitis B virus specific IG are in place to decrease ferential diagnosis include rubella, parvovirus B19,
the chance of transmission. There is sometimes a varicella, measles, enteroviruses, and infectious
need to treat newly diagnosed pregnant women mononucleosis. The first three are discussed in a
with oral anti-viral agents for her own health. All later section.
new diagnoses should be referred urgently to the Measles infection in pregnancy can lead to in-
local hepatitis service. There is clear guidance on trauterine death and preterm delivery, although not
management available through the Department of congenital infection or damage. Indigenous measles
Health Green Book (see Further Reading). is rare in the UK following introduction of the MMR
vaccine, although it is endemic in some countries. isoniazid therapy to prevent peripheral neuropathy.
Human normal IG may attenuate measles, but there Streptomycin, however, should be avoided, as fetal
is no evidence that it prevents intrauterine death or eighth nerve damage has been associated in a sig-
preterm delivery. nificant number of cases. Infants born to mothers
Enteroviruses (including coxsackievirus A, B with smear-positive TB should be treated with iso-
and echovirus) can cause a wide range of manifes- niazid syrup for 6 weeks as chemoprophylaxis, and
tations such as meningitis and myocarditis. Neona- then a tuberculin skin test performed. Breastfeeding
tal infection, especially with echoviruses, can have can continue as normal, as minimal anti-tuberculous
multisystem life-threatening complications. No agents are secreted in breast milk.
vaccines are available except for poliovirus, and IG
is advised for prophylaxis in exposed neonates. Malaria
Infectious mononucleosis is caused by primary Malaria contributes significantly to maternal
Epstein-Barr virus infection with no specific risk to mortality and morbidity in the developing world. In
the fetus. the UK, 2,000 cases are reported annually, mostly
in travellers from endemic areas. Untreated falci-
SPECIFIC PATHOGENS parum malaria is life-threatening in any population,
and pregnant women are more susceptible; anaemia
Tuberculosis can be severe, and there is an increase in maternal
The UK and worldwide TB infection rates are rising. mortality, preterm birth, miscarriage, and stillbirth.
Incidence peaks in the childbearing years (25–34 Immunity to malaria is altered by pregnancy,
years). In the UK, infection is most common in especially in primiparous women with high parasite
Asian and West-African populations. Pregnancy is loads, although the risk is reduced with successive
thought not to change the course of TB, although it pregnancies. Drugs are used for prevention in en-
does increase preterm births, especially in the de- demic areas, with effective reduction in maternal
veloping world. As in the non-pregnant population, anaemia, birth weight and possibly perinatal death.
transmission of Mycobacterium tuberculosis is via In the UK, women with malaria in pregnancy should
respiratory droplets. Overall 10% of those infected be admitted as there is an increased risk of severe
(initial infection is usually asymptomatic) will de- disease and hypoglycaemia. Suitable regimes de-
velop active TB, usually 1–2 years after infection. pend on the type of malaria and local resistance
More extra-pulmonary TB is being seen with HIV patterns, and chloroquine is the choice for Plasmo-
co-infection, and 5–10% of pregnant women have dium vivax, P malariae, P ovale, and quinine for P
extra-pulmonary disease (similar to the non-preg- falciparum. All regimes should be supplemented
nant population). Pregnancy and the peri-partum with folic acid.
period is a common time for latent TB to reactivate. Malaria prophylaxis: travel to a malarial
Diagnosis is by usual methods, and tuberculin skin area in pregnancy should be avoided; getting malar-
testing is safe in pregnancy. ia whilst pregnant increases the risk of miscarriage
Management is similar to in non-pregnant pa- as well as being life-threatening to the mother. No
tients. All four first-line drugs are thought safe and antimalarial is 100% effective, and women should
have been used for many years, including etham- seek advice from a local travel clinic. There are
butol and isoniazid. Pyridoxine should be added to guidelines available on the choice of agent to use
if travel is unavoidable from the Royal College of lin to high-risk mothers. These are identified for-
Obstetrics and Gynaecology (see Further Reading). tuitously by high vaginal swabs performed for a va-
Mefloquine is first line for prophylaxis after the riety of reasons during pregnancy, including those
first trimester. women complaining of vaginal discharge, those
with possible preterm membrane rupture, women
Human Immunodeficiency Virus in preterm labour, temperature greater than 38°C in
HIV worldwide infection is increasing. UK sero- labour, preterm PROM, ROM for more than 18 hours
prevalence in pregnant women is 0.21%, with over prior to delivery, or a previously affected child.
300 HIV-infected women giving birth annually.
There is an increased risk of preterm delivery, low-
birth-weight infants and miscarriage with maternal
HIV infection, worse in mothers with advanced
The common vaginal
disease and poor nutrition. Antenatal screening is
done routinely in the UK. commensal, group B
The mother-to-child transmission rate in the Streptococcus, can lead
UK is now less than 1%. This has been achieved
to life-threatening
through a variety of interventions, notably the use
of antiretroviral combination therapy, a multidisci- neonatal effects
plinary approach to both the timing and method of
delivery, post-exposure prophylaxis for the infant,
and an avoidance of breastfeeding. Management
of each case is highly individualized and should Chlamydia trachomatis
be done in conjunction with a team of health care Genital tract infection with Chlamydia trachomatis
professionals including a midwife, obstetrician, is common in the UK and may lead to ectopic preg-
HIV specialist, and a neonatologist and paediatric nancy, preterm labour, puerperal infection, and oph-
nurse. Some antiretroviral drugs are safe in preg- thalmia neonatorum. Erythromycin is the advised
nancy although currently very few are licensed. treatment.
Guidelines are available (see Further Reading).
Bacterial Vaginosis
Group B Streptococcus This STI, caused by Gardnerella vaginalis, may
This common vaginal commensal can lead to cause chorioamnionitis, preterm delivery, and post-
life-threatening neonatal effects. Of the 20% partum fevers. Treatment is with erythromycin or
of mothers that carry it, 40–70% of infants be- metronidazole.
come colonized in the first week of life. Neonatal
infection can be early or late, presenting with pneu- Herpes Simplex Virus
monia, sepsis, meningitis, and death in up to 10% Maternal genital herpes is more virulent in preg-
(higher in preterm infants). As the overall UK infec- nancy. Early miscarriage (but not fetal abnormali-
tion rate in infants is 1%, routine screening is not ties) may occur, and late maternal primary infec-
currently offered. Neonatal disease is reduced by tion can lead to severe neonatal infection. Genital
administration of intra-partum intravenous penicil- lesions, especially in primary infection, contain
high viral concentrations, and transmission at de- are common, seen in 80–90% survivors infected
livery may exceed 41%. Neonatal herpes carries a in the first trimester. Fetal abnormalities due to
high mortality rate. Disease can be (1) localized to rubella infection in the second trimester are less
skin, eyes and mouth, where death when treated common (in 15% survivors) – usually sensorineural
is uncommon, (2) encephalitis, or (3) disseminated hearing loss, and infection prior to conception or af-
infection with multi-organ involvement, with mor- ter 20 weeks carries minimal risk. Maternal rubella
tality up to 30% often with long-term neurological reinfection is mostly subclinical and is diagnosed
manifestations. Maternal infection is confirmed by a rising antibody titre.
using viral culture or polymerase chain reaction, Suspected cases of rubella should be inves-
and serology differentiates between primary and tigated promptly with serology testing for rising
recurrent infections. Primary infections should be antibody titre and rubella-specific IgM as clinical
treated with oral or intravenous acyclovir. In the diagnosis is limited.
UK, caesarean section is the recommended mode Before rubella vaccine became available,
of delivery following primary infections in the late 200–300 babies were born each year with congeni-
second and third trimesters, and discussion should tal rubella syndrome in the UK. Routine rubella vac-
be with women presenting in labour with recurrent cination for schoolgirls was introduced in England
(secondary) herpes attacks regarding the small risk and Wales in 1970, and subsequently for suscepti-
of perinatal transmission associated with vaginal ble women post partum. It is a live attenuated vac-
birth in this situation. The risk is low, but some may cine, so is contraindicated in pregnancy, but should
choose caesarean delivery. be offered to non-immune mothers 1 month post
partum and preconceptually.
INFECTIONS WITH SIGNIFICANT
FETAL MALFORMATION RISKS
HSM = hepatosplenomegaly; IM = infectious mononucleosis; IUGR = intrauterine growth retardation; PDA = patent ductus arteriosus; SNHL = sensorineural hearing loss; TOP = termination of pregnancy; ZIG = zoster
immune globulin.
tal varicella syndrome occurs in 1% of fetuses in- ops clinical chickenpox in the period 5 days prior to
fected before 20 weeks, especially 13–20 weeks. birth until 2 days after. Neonatal infection carries a
Note that this is less than the 85% risk of rubella high mortality rate.
fetal damage, hence there is currently no UK rou- Shingles (dermatomal reactivation of latent
tine screening policy. Varicella is also important to virus) when localized carries no apparent risk to the
recognize and treat in pregnancy as maternal com- fetus. However, it is uncertain whether dissemina-
plications are more severe. tion, for example in an immunocompromised pa-
Treatment in pregnancy is safe with acyclovir. tient, carries a fetal/neonatal risk.
If delivery is imminent and infection occurs within
10 days of delivery, it is advisable to wait 5–7 days Cytomegalovirus
for passive transfer of maternal IG if possible. If Fetal CMV infection is the second most prevalent
not, the neonate should be given zoster IG, as there cause of mental retardation after Down syndrome.
is a 20% neonatal infection risk if the mother devel- Childhood infection is common in developing coun-
Most infected women are asymptomatic, and posi- morbidity and mortality. Screening and vaccination
tive serology is detected at antenatal screening. programmes are important. Investigation and man-
Maternal infections treated with high-dose penicil- agement of infection may be complex and the mul-
lin will reduce the risk of fetal infection. Twenty-five tidisciplinary approach is essential, involving the
percent of fetal infections result in preterm labour obstetric team, as well as fetal medicine, genitou-
and 25% in fetal loss. In survivors, congenital syph- rinary and critical care physicians.
ilis may result with polyhydramnios, hepatomegaly,
osteochondritis, purpura, and late interstitial kera- FURTHER READING
titis. Fetal infection is suggested by antigen testing
National Institute for Clinical Excellence. Antenatal care: routine
of amniotic fluid or fetal blood, although these have
care for the healthy pregnant woman, Clinical Guideline 6.
a poor negative predictive value. London: National Institute for Clinical Excellence; October
2003.
Hepatitis guidelines: http://www.dh.gov.uk/prod_consum_dh
Listeria monocytogenes /groups/dh_digitalassets/@dh/@en/documents/digital
Listeriosis is caused by Listeria monocytogenes, asset/dh_108820.pdf.
HIV guidelines: www.bhiva.org.
a gram-positive bacillus, and although an unusual
Mackenzie I, Lever A. Management of sepsis. BMJ
infection, may have serious adverse outcome in 2007;335:929–932.
pregnancy. There are about 20 cases of Listeria as- Malaria prophylaxis: http://www.nathnac.org/pro/misc/pdfs
/RCOGPreventionMalariaPregnancy0410.pdf.
sociated with pregnancy in the UK per year. It is Maternal mortality. Saving Mothers Lives: Reviewing maternal
food-borne, from unpasteurized dairy products, and deaths to make motherhood safer: 2006–2008. The eighth
report of the Confidential Enquiries into Maternal Deaths
pregnant women should avoid such high-risk foods.
in the UK, 118. London: BJOG; 2011:1–203.
It can survive at low temperatures (such as the Nelson-Piercy C. Handbook of Obstetric Medicine. 4th ed. Obstet
fridge) on raw vegetables, hence the importance of Med 2011;4:87. doi:10.1258/om.2011.110023.
Royal College of Obstetricians and Gynecologists. Chickenpox
washing food in pregnancy. Maternal symptoms can in pregnancy: Guideline No 17. London: RCOG; September
be asymptomatic or with flu-like symptoms, and can 2007.
Royal College of Obstetricians and Gynecologists. Genital herpes in
range from mild to severe with ARDS. The diagnosis pregnancy: Guideline No 30. London: RCOG; September 2007.
is based on a high index of clinical suspicion, and Royal College of Obstetricians and Gynecologists. HIV in preg-
nancy: Guideline No 39. London: RCOG; April 2004.
on positive Gram stain from maternal blood, liquor
Royal College of Obstetricians and Gynecologists. Preterm prela-
or neonatal samples. bour rupture of membranes: Guideline No 44. London:
Maternal infection can lead to miscarriage, RCOG; November 2006.
Smaill F, Vazquez JC. Antibiotics for asymptomatic bacteriuria
premature labour, and if the infant survives, to pregnancy. Cochrane Database Syst Rev 2007;(2):CD000490.
perinatal listeriosis. Congenital listeriosis has also Tookey P. Rubella in England, Scotland and Wales. Euro Surveill
2004;9:21–23.
been reported following transplacental passage
WHO guidelines for treatment of severe H1N1 influenza A:
and can lead to fetal hydrops. Treatment is with http://www.who.int/csr/resources/publications/swine
high-dose ampicillin and gentamicin. flu/h1n1_guidelines_pharmaceutical_mngt.pdf.
ASl adalah makanan terbaik untuk bayi. ASl menyediakan nutrisi terbaik serta memberikan
perlindungan terhadap penyakit. ASl sebaiknya diberikan secara eksklusif selama 6 bulan
pertama kehidupan bayi dan dianjurkan sampai anak berusia 2 tahun dengan pemberian
makanan tambahan yang sesuai.
OBSTETRICS
OBSTETRICS II Peer
Peer Reviewed
Reviewed
for Babies
Richard Boyd, BSc (Hons), PhD; Robert Kien Howe Chin, MBBS, FRCOG, FHKCOG, FHKAM (O&G)
Ch’ng Ying Chia, MA (Applied Social Studies); Jemie Biwen Wang, Bachelor of Psychology (Hons);
Helen Chen, MBBS, M Med (Psych), Dip. Psychotherapy
INTRODUCTION
There is a major unmet clinical need of millions of patients globally suffering many ma-
jor diseases, which, in all cases, severely compromise the quality of life and frequently
lead to death. While advances are being made with more traditional drug-based thera-
pies, it is now clear that a major new impetus is required. The potential revolution in sci-
ence and medicine that stem cells represent is rapidly emerging as the new frontier in
clinical therapies. Given that stem cells are ‘regenerative medicine factories’, they may
be delivered as ‘stand-alone treatments’; but more likely, they will be potent adjuvants
and be combined with current strategies. Clearly, a great deal of preclinical and clinical
research on stem cells is required not only to capitalize on their treatment potential
but also to ensure that safety and ethical requirements are met. It is also imperative to
select the most appropriate source of stem cells for the variety of treatments. Ideally,
these stem cells should be derived from the patients themselves to overcome any issues
of immune rejection. It is now evident that the time of birth is a remarkable once-in-a-
lifetime opportunity to collect and cryopreserve a panel of stem cells, which effectively
represent nature’s ‘body repair kit’ for the duration of the newborn’s life. There are also
stem cells available for maternal utility.
Once regarded as medical waste, the umbilical cord, based on extensive ground-
breaking research, has now been revealed as an invaluable source of haematopoietic
stem cells (HSCs) and pluripotent mesenchymal cells (MSCs) both of which now have
increasing application in regenerative medicine. In addition, the amnion membrane is a
very rich source of pluripotential MSCs which, being equivalent to embryonic stem cells
(ESCs), are able to differentiate into many different types of tissues.
Accordingly, these advances in stem cell research, coupled with the ever-increas-
ing clinical efficacy, have led to the fast-growing establishment of cord blood banks
Figure 2. The cell lineage of each organ system in the human body.
sound alternative is adult stem cells, which exist in regard to the public perception of the ethical issues
virtually every tissue, albeit being difficult to iden- and the safety concerns, alternate sources of stem
tify and isolate. Adult stem cells also possess lim- cells were sought after. In 1983, Edward Boyse pro-
ited differentiation potential, but one of their major posed the idea of using UCB as a potential source
advantages is that they pose no risk of rejection as of stem cells for haematopoietic transplantation,
they are used in autologous transplants. thereby highlighting research on placental/new-
born stem cells. This was followed by experiments
Newborn Stem Cells in irradiated mice revealing that murine blood from
Given the difficulty in settling the dilemmas as- near-term and neonatal mice contained adequate
sociated with the use of human ESCs legally, with numbers of HSCs to effect bone marrow recovery.7
Obstetricians can educate pregnant women about umbilical cord blood banking.
The first pioneering haematopoietic cord blood ditions (eg, leukaemia), non-neoplastic conditions
transplant was performed to treat a 6-year-old boy such as inherited disorders (eg, thalassaemia ma-
with Fanconi anaemia in 1988 in Paris, France, 8
jor), immunodeficiency, osteoporosis, and acquired
with the first successful unrelated UCB transplant conditions (eg, aplastic anaemia). In the autologous
performed in the United States in 1994. 9
setting, they can be used to treat autoimmune dis-
In vitro cultures of CD34 cells (as a marker of
+
orders like aplastic anaemia; but in advance-stage
HSC) from umbilical cord yielded a higher rate of solid tumours, their use is currently limited. HSCs
proliferation than similar cells from marrow. 10 Be- are also being investigated for efficacy in treat-
sides, UCB HSCs may also have a greater capacity ing cerebral palsy, stroke, and as a means of gene
for self-renewal and long-term growth in culture. 11
therapy. Autologous cord blood stem cells are not
However, although UCB is proportionally rich in suitable for treating inborn errors of metabolism or
HSCs, its use is limited because of the relatively some genetic diseases such as childhood leukae-
low volume of blood and hence total HSC dose. mia in which chromosomal translocations in fetal
The transplanted cell dose is approximately 10% blood were detected in children who finally devel-
of a marrow transplant. HSCs can be used in al-
12
oped leukaemia. 13,14 The use of autologous stem
logeneic and autologous settings. In the allogeneic cells would also negate the beneficial graft-versus-
setting, they can be used to treat neoplastic con- leukaemic effect that occurs with allogeneic stem
cell transplants by its residual T lymphocytes in the and 90% expected their obstetrician to answer
haematopoietic progenitor cell product. 15
their questions on UCBB.18 Similar results were also
UCB as a source of HSC for transplant is more reported by Fernandez et al1 and Dinç and Sahin.2
superior than, for example, bone marrow, as it ap- In one study, almost one-third of the partici-
pears to have a higher tolerability of HLA mismatch, pants did not realize that they had the option to
which may be explained by its high content of im- retain their cord blood at delivery; only 50% were
mune suppressing cells called regulatory T cells, aware that they could store their cord blood in a pri-
which are able to suppress immune responses; ac- vate bank and half of the respondents thought cord
cordingly, they have been used for treating type 1 blood donation to the public bank was to protect
diabetes and multiple sclerosis. This is an impor- their child’s future health.19
tant and often unrecognized value of UCB.16 A recent research article about our Hong Kong
locality showed that among 2,000 women recruited,
THE PATIENT’S KNOWLEDGE OF 93.3% completed the questionnaire. The majority
STEM CELLS AND UCBB (78.2%) had no idea about the chance of using self-
stored stem cells. Most were unclear about which
In 2003, Fernandez et al examined pregnant wom-
1
diseases other than leukaemia are amenable to
en’s knowledge and attitudes relating to UCB and treatment with UCB stem cells. This is not taking
UCBB; 70% reported poor or very poor knowledge into account that if the child developed leukaemia,
about UCB; 66% expected the physician to talk to their UCB would not be used for haematological
them about cord blood collection and said they rescue because autologous stem cells lack the
would specifically like to receive such information graft-versus-leukaemia effect as well as because
from health care professionals or in prenatal class of the fear of cancer contaminants within the UCB.
(70%). Twenty-five percent overestimated the risk Only 20.3% of women knew that stem cells are
of a child needing a bone marrow transplant before available from the Red Cross (a local public cord
his or her 10th birthday—the risk is reported as be- blood bank) in case their children needed haemat-
tween 1 in 200,000 and 1 in 10,000. Eighty-three
17
opoietic cell transplantation. Hence, most patients
percent expected to be asked about UCBB before have inadequate knowledge about stem cells and
30 weeks of pregnancy. In a post hoc analysis, this UCBB, creating an obstacle to UCBB. They would
level of knowledge was not associated with the like to receive more information from health care
choice between public and private banking. 1
providers, especially their obstetricians, and be
In 2006, Perlow et al demonstrated that among provided with the relevant knowledge accordingly
the 425 patients recruited in the survey in USA, in early pregnancy so that they can have adequate
37% had no knowledge of UCBB. Older patients and time to contemplate their choices.20
those more educated were more aware of UCBB.
Among patients familiar with UCBB, only 2.6% felt THE OBSTETRICIAN’S ROLE IN
extremely knowledgeable while 74% felt ‘minimal- CONVEYING DETAILED AND
ly informed’. Seventy-one percent of patients were ACCURATE INFORMATION TO
not planning UCBB with the main reasons of ex- THE PUBLIC
pense and insufficient knowledge. Only 14% were
educated about UCBB by the nurse or obstetrician, Given this background, it is imperative that the ob-
Therefore, the mother, who shares the prenatal au- tion with consideration of paternal objection to do-
thority, would be the one to give consent on behalf nation and for public cord blood banking. The con-
of the baby. If the cord blood is stored for the child’s sent process should not include a promise that the
use, then the mother will hold in trust till the child cells may be available at a later date for use by the
attains the age of 18 years, by which time the use family. The consent should be obtained before la-
of stem cells will be decided by the child. If the
21
bour, preferably in late third trimester. The consent
cord blood is donated, this may then be considered process should also include disclosure for units that
as a manipulation of human body parts without the do not meet quality standards.32
individual’s knowledge.30 In order to translate the It is recommended by the Royal College of
ethical debate from the speculative level into prac- Obstetricians and Gynaecologists that the service
tice, it is important to get good informed consent should not be made available for cases in which
for stem cells use. the attending clinician believes it to be contrain-
dicated. Details of the hospital’s policy should be
made available to all patients.
Figure 3. A variety of progenitor cells in umbilical cord, cord blood, amnion, and placenta/chorion.
surance, which can also be used for other family cipient could have developed these disorders.
members. Private banks provide a life insurance by having
It is recommended that balanced information the cord blood available for the lifetime, depending
for both autologous and allogeneic donation should on its commercial viability of the enterprises, 35 and
be provided to pregnant patients in the antenatal the estimated utility of autologous UCB is approxi-
period. 32
mately 1 in 20,000 28 to 37 in 100,000 (1 in 2,700).20
In public banks, the donated cord blood is not
assured of being banked or being made available Regulatory Issues
to donors if required in the future. Safety is a con- To establish a uniform standard for collection and
cern as the donated cord blood may carry genetic quality assurance, it is important that establish-
defects for disorders, such as congenital anaemia ments provide standardization of procurement, test-
or immunodeficiency, that are not apparent in the ing, processing, storage, distribution, documenta-
donor for months or years, by which time all iden- tion, labelling, equipment control, and cord blood
tifying information has been removed while the re- bank operations.
In the United Kingdom, cord blood collection Table 1. Conditions for the use of mesenchymal cells for repair
is regulated by the Human Tissue Authority (HTA);
for an HTA-licensed establishment, a third party
Lung fibrosis, chronic obstructive pulmonary disease37,38
agreement is required. The HTA stresses on four
Heart and vascular damage39
aspects of cord blood collection: safety, quality, Spinal disc injury40
consent, and lawfulness. The HTA does not regu- Suppress graft-versus-host disease in allogeneic bone marrow
late or provide advice about the effectiveness of transplant
Inhibit autoimmunity, eg, multiple sclerosis, diabetes, arthritis41
treatments using cord blood.36 Ageing tissues: tendon, muscle, cartilage, bone (hips, joints)42
In the United States, many cord blood banks Sporting injuries43
have undergone voluntary accreditation through
the American Association of Blood Banks or the
NetCord Foundation for the Accreditation of Cel- human mesenchymal progenitor cell for in vitro
lular Therapy. In our locality, we do not have an expansion. Human placenta-derived mesenchy-
establishment as such, and there is currently no mal progenitor cells support culture expansion of
guideline available on cord blood collection or long-term culture-initiating cells from cord blood
use of collected stem cells. Therefore, health CD34 + cells.44
care providers, especially obstetricians, should Besides placenta and cord blood, more focus
help in conveying detailed and balanced informa- has been put on the amnion, which is made by
tion on stem cells to couples to ensure thorough the baby and therefore is a safe and effective al-
understanding and aid their decisions. ternative to ESCs. Amniotic epithelial stem cells
have remarkable potential to form virtually all
FUTURE DEVELOPMENT cells in the body and have strong anti-inflamma-
tory properties, and can be considered for repair
Stem cell research has heralded a new horizon of tissues. They have been used for over 15 years
in clinical medicine. While appreciating the value to treat burns and cornea. Currently, there is re-
of cord blood, it is recognized that there is a va- search on stems cells in adult lung disease like
riety of progenitor cells, besides HSCs, in cord pulmonary fibrosis and the immune system. The
blood and placenta; they are the MSCs in umbili- immune system degenerate drastically with age
cal cord, chorion, and placenta, namely, MSCs in and causes problems like being at high risk for
umbilical cord tissue (Wharton’s jelly), amniotic opportunistic infections, poor vaccine responses,
MSCs, and amniotic epithelial stem cells (Figure higher incidence and complications of cancer, risk
3), which may be a new platform for tissue trans- of death from infection and relapse after chemo-
plant, ie, bone, cartilage, fat, myocardial muscle, therapy and radiotherapy, and failure to recover
and neural tissue, owing to its anti-inflammatory, from human immunodeficiency virus infections.
immunosuppressive, and pro-reparative proper- Therefore, this generates immense research on
ties (Table 1). using amniotic epithelial stem cells to reverse the
As addressed above, allogeneic transplanta- ageing process to restore the thymus function.
tion with UCB in adult recipients is limited by a Therefore, newborn cells can be regarded
low CD34 + cells from UCB in vitro. However, hu- as a natural body repair kit. Yet this novel infor-
man placenta can now serve as a novel source of mation is scarce to the public, thus limiting the
potential clinical use of invaluable pluripotent stem ethical and medical risks associated with the use
cells. Health care providers should serve as an im- of ESCs.
portant channel to convey such invaluable informa-
tion to the public.
About the Authors
Dr Mak is Resident Trainee in the Department of Obstetrics and
CONCLUSION
Gynaecology, Kwong Wah Hospital, Hospital Authority, Hong
Kong. Mr Juan Bolaños is Research Fellow at ProStemCell Ltd,
This article reviews the current trends in UCB stor- Hong Kong. Dr Leung is Chief of Service in the Department of
Obstetrics and Gynaecology, Kwong Wah Hospital, Hospital
age, as well as recent consensus in the ethical and Authority, Hong Kong. Dr Boyd is Professor and Director in
commercial activities related to private and public the Monash Immunology and Stem Cell Laboratories, Monash
University, Australia. Dr Chin is Honorary Consultant in the
UCBB. Adult stem cells offer a new and realistic Department of Obstetrics and Gynaecology, Kwong Wah Hospi-
approach for the treatment of diseases, without the tal, Hospital Authority, Hong Kong.
References
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Taweel S, Baylis F. Knowledge and attitudes of related donors in adults with acute leukemia. N bone marrow from unrelated donors in adults American Society of Hematology 49th Annual
pregnant women with regard to collection, test- Engl J Med 2004;351:2276–2285. with leukemia. N Engl J Med 2004;351:2265– Meeting and Exposition; December 8–11, 2007;
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2003;168:695–698. Nat Med 1998;4:150–151. 25. Hows JM. Status of umbilical cord blood 35. Fisk NM, Roberts IA, Markwald R, Mironov
2. Dinç H, Sahin NH. Pregnant women’s knowl- 14. Greaves MF, Wiemels J. Origins of chromo- transplantation in the year 2001. J Clin Pathol V. Can routine commercial cord blood banking be
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6. Sell S. Stem Cells Handbook. New Jersey: Hu- 18. Perlow JH. Patients’ knowledge of umbilical 1999;340:1521–1524. amnion epithelial cells prevent bleomycin-in-
mana Press; 2004. cord blood banking. J Reprod Med 2006;51:642– 29. Munzer SR. The special case of property duced lung injury and preserve lung function. Cell
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ASI adalah nutrisi terbaik bagi Ananda. Namun jika terdapat indikasi medis dan dalam kondisi
spesifik (prematur / berat badan lahir rendah), SGM BBLR dengan formula yang disempurnakan
hadir memberikan solusi untuk Ananda berkebutuhan khusus agar tetap tumbuh kembang optimal.
1
Wu, G.; et al. (August 2004.Journal of Nutritional Biochemistry 15 (8): 332-451)
Bayi prematur membutuhkan
nutrisi khusus untuk :
1 Mengejar pertumbuhan bayi normal.
ASI adalah nutrisi terbaik bagi Ananda. Namun jika terdapat indikasi medis
dan dalam kondisi spesifik (prematur/berat badan lahir rendah), SGM BBLR
dengan formula yang disempurnakan hadir memberikan dukungan untuk
Ananda berkebutuhan khusus agar tetap tumbuh kembang optimal.
1. ESPGHAN 2010
2. Codex Alimentarius 2007
Continuing Medical Education
P
3 SK
Preconception Care
Lee Chin Peng, MBBS, FRCOG, FHKAM(O&G)
INTRODUCTION
suspect that they are pregnant. PREVENTION OF INFECTIONS HAART (highly active antiretroviral ther-
apy with multiple agents) together with
AVOIDANCE OF IRRADIATION Some maternal infections can be transmitted intrapartum and postnatal zidovudine for
to the baby during pregnancy and/or delivery, the baby is highly effective.15 Therefore,
Diagnostic X-ray should be avoided during causing grave consequences to the baby. it may not be necessary to advise against
the luteal phase of the menstrual cycle Rubella infection in pregnancy can pregnancy in carriers. With compliance,
and deferred to the follicular phase if pos- cause major congenital abnormalities. perinatal transmission rate can be reduced
sible. However, most diagnostic X-rays, Vaccination against rubella is part of the to less than 1%, but in rare instances the
except those done under fluoroscopy, have vaccination programme for children and baby can still be infected. Knowing the HIV
irradiation doses below the estimated ter- adolescents in many countries. However, status before pregnancy may change the
atogenic threshold (0.1 Gy). Therefore, ur-
9
even in countries with such vaccination reproduction plan for some women or may
gent diagnostic X-ray should not be withheld programmes, doctors must be aware that help HIV-positive individuals to be better
if there is a strong indication or if alterna- immigrants may not have been vaccinated prepared to start a family. However, nega-
tive non-irradiation tests are not available. in their original country. Therefore, check- tive screening before pregnancy does not
Abdominal shield should be used. ing the immune status and providing the mean that the individual is not susceptible
Therapeutic irradiation, including ra- vaccination to women is an important part to infection after the screening or during
dioactive iodine, is absolutely contraindi- of preconception care. Chickenpox infec- the pregnancy.
cated during pregnancy. tion during pregnancy can also cause scar-
ring and deformity in the baby in a small TREATMENT FOR OBESITY
ADVICE AGAINST LIFESTYLE proportion of cases. Vaccination against
SUBSTANCE USE chickenpox in susceptible women before It has increasingly been shown that obe-
pregnancy can be an option. 13
sity has adverse effects on pregnancy.
Alcohol consumption is associated with Hepatitis B vaccination should be The association of obesity with maternal
increased risk of miscarriages and fetal provided to susceptible health care work- mortality and morbidity is well proven.
malformation. However, whether a low in- ers and non-immune women whose part- There is also evidence suggesting that
take (less than 5 units per week) is safe is ners are carriers. However, women who fetal congenital abnormalities and peri-
uncertain. Therefore, women planning to
10
are hepatitis B carriers should not be un- natal morbidities are also increased in
get pregnant should be advised to abstain duly worried, because effective prevention obese mothers.16 Weight reduction may
from alcohol. of perinatal transmission is available.14 potentially be harmful during pregnancy.
Cigarette smoking is not teratogenic Screening for HIV and syphilis are Therefore, weight reduction should ideally
but doubles the risk of intrauterine growth part of routine antenatal care. However, be achieved before pregnancy.17
restriction and increases the risk of miscar- it can be done before pregnancy. Syphilis
riages and perinatal mortality by one-third. 11
can be effectively treated before preg- ATTENTION TO DENTAL
Women should be encouraged and be nancy. This also allows time for contact HYGIENE
helped to stop smoking before pregnancy. tracing and for more effective prevention
There is an association between use of re-infection during pregnancy. There is Periodontal disease in pregnant women
of recreational drugs and fetal congenital no curative treatment for HIV, but carriers has been found to be associated with in-
abnormalities, in particular, gastroschi- can remain healthy with monitoring and creased risk of preterm delivery. 18 However,
sis.12 Cocaine use is associated with in- early antiretroviral treatment. Prevention treatment of the disease during pregnancy
creased incidence of placental abruption. of perinatal transmission with antepartum has been shown to be ineffective in reduc-
riers of haemoglobin E, which is preva- Preconception care checklist for primary care physicians
lent in Thailand, and haemoglobin E–β-
thalassaemia heterozygous may have History
transfusion-dependent anaemia.) Further • Family history, including genetic diseases
investigations, such as haemoglobin pat- • Past health
tern analysis and DNA studies may be • Past obstetric history, including all pregnancy losses
needed after excluding iron deficiency. • Use of alcohol, cigarette, and recreational drugs
• Psychological readiness for pregnancy and child rearing
Iron deficiency can be excluded by iron
profile studies, but a simple and practi-
Physical examination
cal way to exclude iron deficiency is a • Weight and height
therapeutic trial of iron supplement for 4 • Blood pressure
weeks. If red cell microcytosis is due to • Urine (for glucose and albumin)
iron deficiency alone, it should be cor- • Examination of the cardiovascular system
rected by supplement. Which genetic dis-
Investigations
eases to screen for and how they should
• Rubella immune status
be screened for should be determined to • Varicella immune status (if no known history of chickenpox or varicella zoster)
suit the local population. In general, it • Hepatitis B surface antigen (HBsAg)
is important that a screening test should • HIV screening
have a high sensitivity with a low false- • Syphilis screening
positive rate. There is some controversy • Complete blood count (to screen for anaemia and thalassaemia)
as to whether screening should be done • Cervical smear (if not already in a screening programme)
References
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Olsen J, Melbye M. Maternal age and fetal loss: Medical Radiation. Annals of the ICRP Volume 30/1. 16. Nuthalapaty FS, Rouse DJ. The impact of tion care for diabetic women for improving mater-
population based register linkage study. BMJ Elsevier 2000;1–39. obesity on obstetrical practice and outcome. Clin nal and infant health. Cochrane Database Syst Rev
2000;320:1708–1712. 10. Royal College of Obstetricians and Gynaecolo- Obstet Gynecol 2004;47:898–913. 2010;(12):CD007776.
3. De-Regil LM, Fernandez-Gaxiolo AC, Dowsell gists. Alcohol consumption and outcomes of preg- 17. Davies GA, Maxwell C, McLeod L, et al; Society 23. Schmidt KT, Rosendahl M, Ernst E, et al. Auto-
T, Pena-Rosas JP. Effects and safety of pericon- nancy. RCOG Statement No. 5; 2006. of Obstetricians and Gynaecologists of Canada. transplantation of cryopreserved ovarian tissue in
ceptional folate supplementation for prevent- 11. Walsh RA. Effects of maternal smoking on SOGC clinical practice guidelines: obesity in preg- 12 women with chemotherapy-induced premature
ing birth defects. Cochrane Database Syst Rev adverse pregnancy outcomes: examination of the nancy. No. 239, February 2010. Int J Gynecol Obstet
ovarian failure: the Danish experience. Fertil Steril
2010;(10):CD007950. criteria of causation. Hum Biol 1994;66:1059–1092. 2010;110:167–173.
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4. Lam YH, Tang MH. Risk of neural tube defects in 12. Draper ES, Rankin J, Tonks AM, et al. Recre- 18. Jeffcoat MK, Geurs NC, Reddy MS, Cliver SP,
24. Lau YL, Chan LC, Chan YY, et al. Prevalence and
the offspring of thalassaemia carriers in Hong Kong ational drug use: a major risk factor for gastroschi- Goldenberg RL, Hauth JC. Periodontal infection and
genotypes of alpha- and beta-thalassemia carriers
Chinese. Prenat Diagn 1999;19:1135–1137. sis? Am J Epidemiol 2008;167:485–491. preterm birth: results of a prospective study. J Am
13. Royal College of Obstetricians and Gynaeco- Dent Assoc 2001;132:875–880. in Hong Kong—implications for population screen-
5. Blencowe H, Cousens S, Modell B, Lawn J. Folic
acid to reduce neonatal mortality from neural tube logists. Chickenpox in pregnancy. RCOG Green-top 19. Polyzos NP, Polyzos IP, Zavos A, et al. Obstetric ing. N Engl J Med 1997;336:1298–1301.
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7. Rothman KJ, Moore LL, Singer MR, Nguyen US, and hepatitis-B immunoglobulin. Double-blind institutional evaluation. Am J Obstet Gynecol tive randomized trial comparing prednisone with
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Program pendidikan kedokteran berkelanjutan ini dipersembahkan oleh Medical Progress Institute,
sebuah institusi yang didedikasikan untuk pembelajaran CME, bekerjasama dengan Ikatan Dokter
Indonesia.
Setelah membaca artikel ‘Preconception Care’, jawab pertanyaan berikut kemudian kirimkan dengan
menggunakan formulir jawaban yang sudah disediakan ke CME Medical Progress/ Journal of Paediatrics,
Obstetrics & Gynaecology, untuk mendapatkan 3 SKP.
P
Artikel CME: 3 SK
Preconception Care
Jawab pertanyaan di bawah ini dengan Benar atau Salah
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Answers
JPOG advanced online publication; 1 July 2012 • 263 JPOG NOV/DEC 2012 • 263
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