Women's Health and Education Center (WHEC)

Medical Disorders and Pregnancy

List of Articles

  • Chronic Kidney Disease and Pregnancy
    Chronic kidney disease represents a heterogenous group of disorders characterized by alterations in the structure and function of the kidney. Its manifestations are largely dependent on the underlying cause and severity of the disease, but typically include decreased function, hypertension, and proteinuria, which can be severe. Chronic kidney disease significantly increases the risk of adverse maternal and perinatal outcomes, and these risks increase with the severity of the underlying renal dysfunction, degree of proteinuria, as well as the frequent coexistence of hypertension. The review discusses current management of pregnant patients with chronic kidney diseases, early diagnosis and postpartum management. Renal transplantation and pregnancy is also discussed. Avoidance of nephrotoxic and teratogenic medications is necessary, and renal dosing of commonly used medications must also be considered. Successful management of women with chronic kidney disease during pregnancy requires teamwork between primary care clinicians, midwives, specialists, and the patient. Frequent monitoring of simple clinical and biochemical features will guide timely expert intervention to achieve optimal pregnancy outcome and conservation of maternal renal function.

  • Sickle Cell Disease in Pregnancy
    Pregnancy complicated by sickle cell disease is high-risk for both mother and fetus. Surveillance helps manage problems such as vaso-occlusive crises and alloimmunization. Maternal problems can arise from chronic underlying organ dysfunction such as renal disease or pulmonary hypertension, from acute complications of sickle cell disease such as vaso-occlusive crises and acute chest syndrome, and/or from pregnancy-related complications. Fetal problems include alloimmunization, opioid exposure, growth restriction, preterm delivery, and stillbirth. Couples should be counseled that a pregnancy with sickle cell disease is high risk for both fetus and mother and be made aware of the increased risks of adverse pregnancy outcome. Risks of adverse fetal outcomes are reduced but not eliminated with fetal surveillance. This review provides recommendations, screening and clinical management during prenatal and puerperium of patients with sickle cell disease. Genetic screening can identify couples at risk for offspring with sickle cell disease and other hemoglobinopathies and allow them to make informed decisions regarding reproduction and prenatal diagnosis.

  • Inherited Thrombophilias in Pregnancy
    Identification of inherited thrombophilias has increased our understanding of one potential etiology for venous thromboembolism and of hypercoagulability in general. Over the past 10 years, some studies have suggested that inherited thrombophilia may be associated with preeclampsia and other adverse outcomes in pregnancy. There is limited evidence to guide screening for and management of these conditions in pregnancy. This document reviews common thrombophilias and their association with maternal venous thromboembolism risk and adverse pregnancy outcomes, indications for screening to detect these conditions, and management options in pregnancy. The literature on fetal thrombophilia and its role in explaining some cases of perinatal stroke that lead, ultimately, to cerebral palsy are also discussed.

  • Psychiatric Disorders During Pregnancy
    This review focuses on the interrelationships between common psychiatric illnesses and the course of pregnancy, postpartum, and breastfeeding. Within the life cycle context, the impact of childbearing on existing disorders or vulnerabilities in the female patient is of primary interest, as well as episodes that are etiologically related to childbearing. Treatment considerations for psychiatric disorders during childbearing invoke special modifications of the risk-benefit decision-making process. Mental health is fundamental to health. For the pregnant woman, the capacity to function optimally, enjoy relationships, manage the pregnancy, and prepare for the infantís birth is critical. Perinatal health can be conceptualized within a model that integrates the complex social, psychological, behavioral, environmental, and biologic forces that shape pregnancy. Unipolar and bipolar mood disorders, which are common in pregnant and postpartum women, deserve the attention of obstetric providers. Procedures to identify those at risk should begin in pregnancy if not in the preconceptional period.

  • Depression During Pregnancy
    Even though pregnancy is a period of emotional well-being, in some women, when pregnant, experience their first depressive episode, whereas others, with a history of depression, are at risk for its recurrence, suggesting that pregnant women show the same risk for depression as other women of child-bearing age. The purpose of this document is to address the maternal and neonatal risks of both depression and antidepressant medication exposure. It focuses on periconceptional and antenatal management. For the pregnant woman, the capacity to function optimally, enjoy relationships, manage pregnancy, and prepare for the infantís birth is critical. Perinatal health can be conceptualized within a model that integrates the complex social, psychological, behavioral, environmental and biologic forces that shape pregnancy. Antenatal depression affects the health and well-being of the mother, baby, and family. Early identification and management of depressive symptoms in pregnant women may improve their sense of well-being.

  • Thyroid Storm: Critical Care In Obstetrics
    The review evidence-based research and approaches for diagnosis and management of thyroid storm during pregnancy. Especially relevant is the intimate relationship between maternal and fetal thyroid function, particularly during the first half of pregnancy. Significant fetal brain development continues considerably beyond the first trimester, making thyroid hormone also important later in gestation. Importantly, although overt maternal thyroid failure during the first half of pregnancy has been associated with several pregnancy complications and intellectual impairment in offspring, it is currently less clear whether milder forms of thyroid dysfunction have similar effects on pregnancy and infant outcomes

  • Parathyroid Diseases in Pregnancy
    Parathyroid diseases are uncommon in pregnancy, may produce significant perinatal and maternal morbidity and mortality if not diagnosed and properly managed. It reviews calcium homeostasis, primary hyperparathyroidism, hypoparathyroidism, and osteoporosis during pregnancy. PTH promotes resorption of calcium from the bones. Thus, all events of PTH action are directed at increasing serum calcium levels. The successful treatment of maternal PHP may transiently improve some of the clinical findings of preeclampsia and preterm labor.

  • Obesity in Pregnancy
    Obesity is now epidemic in many developed countries secondary to decreased physical activity combined with an abundance of cheap, high-caloric foods. Maternal obesity increases the risk of multiple adverse pregnancy outcomes including congenital anomalies, miscarriage, preeclampsia, gestational diabetes (GDM), fetal macrosomia, and stillbirth. Obesity also is associated with multiple labor abnormalities, including an increased risk of induction of labor, post-dates pregnancy, prolonged labor, labor augmentation with oxytocin, excessive blood loss at delivery, and cesarean delivery. Obese women who are delivered by cesarean are at greater risk of complications such as longer operative times, excessive blood loss, wound infections, and post-operative endometritis. Not only are large numbers of women overweight or obese prior to pregnancy, but many women gain an excessive amount of weight during pregnancy, thus compounding their obstetrical risks and making them more likely to retain weight postpartum.

  • Gestational Diabetes: A Comprehensive Review
    The prevalence of gestational diabetes mellitus (GDM) continues to rise in the face of the obesity epidemic affecting up to 14% of the population. It is the most common clinical issues facing obstetricians and gynecologists and their patients. This document is to provide a comprehensive review of understanding of gestational diabetes mellitus (GDM) and provide management guidelines. Because the risk factors for GDM (particularly obesity) are independent risk factors for fetal macrosomia, the role of maternal hyperglycemia has been widely debated. Considerable controversy remains regarding the exact relationship of these complications to maternal hyperglycemia. Women with GDM are more likely to develop maternal and fetal complications. Whether the relationship with GDM is casual or not, clinicians should be aware of these risks. In addition, women with GDM have an increased risk of developing diabetes later in life.

  • Diabetes In Pregnancy
    Diagnosis of gestational diabetes is typically made on the basis of an oral glucose tolerance test. A lack of consensus exists regarding the optimal testing protocol and threshold to identify women and infants with increased risk of complications. The majority of women with pregnancy complicated by diabetes have gestational diabetes (GDM). The American Diabetes Association defines GDM as any degree of glucose intolerance with onset or first recognition during pregnancy. Long-term risks of gestational diabetes include increased risk of recurrent GDM in subsequent pregnancies, risk of diabetes in the mother, and increased risk of childhood obesity, glucose intolerance and diabetes in the offspring.

  • Medical Nutrition Management of Gestational Diabetes
    A cornerstone of blood glucose management of GDM is Medical Nutrition Therapy (MNT). The goal of MNT is to help the woman achieve normoglycemia without ketosis and optimal nutritional intake for maternal health and fetal growth. An estimated 50-75% of pregnancies complicated by GDM can be successfully managed with MNT alone. It is important to initiate such intervention as soon as possible after diagnosis. Referral to a Registered Dietitian (RD) should be made within 48 hours of diagnosis so that intervention can be initiated within one week after diagnosis.

  • Chronic Hypertension in Pregnancy
    This review discusses the effects of chronic hypertension on pregnancy, to clarify the terminology and criteria used to define and diagnose it during pregnancy, and to review the available evidence for treatment options. Chronic hypertension complicates pregnancy and is associated with several adverse outcomes, including premature birth, intrauterine growth restriction (IUGR), fetal demise, placental abruption, and cesarean delivery. An additional diagnostic complication may arise in women with hypertension who begin prenatal care after 20 weeks of gestation.

  • Renal Disorders and Pregnancy
    Among the various physiologic alterations that occur in normal pregnancy, few are as striking as those affecting the urinary tract. Changes in the urinary tract during normal pregnancy are so marked that norms in the nonpregnant cannot be used for obstetric management. Awareness of all alterations is essential if kidney problems in pregnancy are to be suspected or detected and then handled correctly. Most women with mild to moderate renal disease tolerate pregnancy well and have a successful obstetric outcome without adverse effect on the natural history of the underlying renal lesion. Crucial determinants are renal functional status at conception, the presence or absence of hypertension, and the type of renal disease.

  • Cardiovascular Diseases and Pregnancy
    The current guidelines to manage cardiovascular diseases affecting pregnancy, and preconception counseling are discussed. The new guidelines for antibiotic prophylaxis for infective endocarditis are also discussed. There is some controversy over the optimal approaches to clinical assessment and treatment of women with cardiac diseases. Management hinges on the severity of cardiac diseases, gestational age and evaluation of relative risks. Additional guidelines on the basis of consensus and expert opinion also are presented. Without accurate diagnosis and appropriate care, heart disease in pregnancy can be a significant cause of maternal mortality and morbidity.

  • Thyroid Disease in Pregnancy
    Thyroid disease is the second most common endocrine disease affecting women of reproductive age; obstetricians often care for patients who have been previously diagnosed with alterations in thyroid gland function. In addition both hyperthyroidism and hypothyroidism may initially manifest during pregnancy. The interactions between pregnancy and the thyroid gland are fascinating from at least three aspects: pregnancy induces increased thyroid-binding globulin, intimate relationship between maternal and fetal thyroid function, and a number of related abnormal pregnancy and thyroid conditions that at least appear to interact. The purpose of this document is to review the thyroid-related patho-physiologic changes created by pregnancy, and the maternal-fetal impact of thyroid disease.

  • Seizure Disorders and Pregnancy
    Roughly one out of every 100 pregnancies occurs in a woman with epilepsy. These pregnancies present a unique challenge to obstetricians and neurologists due to the interrelationship of the effects of epilepsy and pregnancy, the variable effects of anti-convulsant medications on mother and fetus, and the changes in pharmacokinetics of these medications during pregnancy. The obstetricians and neurologist should work together prior to conception and throughout the patient's pregnancy to determine the safest and most effective medical therapy. Furthermore, the pediatrician selected by the patient to care for her baby should be included in pre-pregnancy discussions to address the potential increase in congenital malformations, the potential for neonatal sedation with certain medications, and questions concerning breast-feeding. The purpose of this document is to provide the current information on this issue and to offer practical advice on managing patients.

  • Fetal Alcohol Syndrome: Recognition & Prevention
    Maternal alcohol abuse is associated with impaired fetal growth; virtually all neonates with fetal alcohol syndrome (FAS) will exhibit significant growth restriction. The physicians should counsel patients presenting with drug or alcohol problems and refer them to an appropriate treatment resource when available. Physicians who detect the serious medical condition of addiction (drugs and/or alcohol) are obligated to intervene during pregnancy or Preconceptional counseling. On the one hand, no person has a right to use illegal drugs, and a pregnant woman has a moral obligation to avoid use of both illicit drugs and alcohol in order to safeguard the welfare of her fetus. On the other hand, effective intervention with respect to substance and alcohol abuse by a pregnant or a non-pregnant woman requires that a climate of respect and trust exist within the physician-patient relationship. Patients who begin to disclose behaviors that are stigmatized by society may be harmed if they feel that their trust is met with disrespect.

  • Asthma In Pregnancy
    Acute asthma attacks render both the mother and fetus vulnerable to progressive hypoxia and potentially disastrous results. Early studies of pregnant women with asthma revealed high rates of perinatal complications, including perinatal loss, prematurity, preeclampsia, and low birth-weight. Prospective studies performed in the last decade demonstrate essentially normal perinatal outcomes with modern management of asthma. Poor outcomes with some evidence of increased perinatal mortality and morbidity are also seen if the intensity of asthma therapy is decreased. Pregnant patients with asthma should be managed proactively to achieve a good perinatal outcome. Initial and ongoing assessment of the severity of an asthmatic woman's condition facilitates the stepwise addition of medication to optimize control of symptoms and prevent acute attacks. Educating patients is the key to their ability to use medication appropriately and initiate treatment before an acute disease process becomes critical.

  • Smoking during Pregnancy
    The perinatal complications associated with maternal tobacco use include preterm delivery, premature rupture of membranes, spontaneous abortion, ectopic pregnancy, low birth weight, intra-uterine growth restriction, placental abruption, placenta previa, still birth, and sudden infant death syndrome (SIDS). Smoking cessation and the resources available are also discussed. Screening for tobacco use can be done efficiently as a vital sign at every clinical visit. Tobacco control is one of the most rational, evidence-based policies in medicine. The Millennium Development Goals do not include an explicit target for reducing tobacco use, but this article explains how lower tobacco use could contribute to their achievement.

  • Isoimmunization (Rh Disease) in Pregnancy
    When any fetal group factor inherited from the father is not possessed by the mother, antepartum or intrapartum fetal-maternal bleeding may stimulate an immune reaction by the mother. The term hemolytic disease of the fetus/newborn, for instance has replaced hemolytic disease of the newborn because modern diagnostic techniques now allows us to detect the disorder much earlier. To prevent the disease, routine postpartum use of Rhesus immune globulin (Rh I G) in Rh-negative patients was introduced in the United States over 40 years ago. A subsequent recommendation for routine antenatal use at 28 weeks' gestation was introduced 20 years later. Despite these efforts, a recent review of the 2001 birth certificates in the US by the Centers for Disease Control and Prevention indicates that Rh sensitization still affects 6.7 out of every 1,000 live births. Maternal immune reactions can also occur from blood product transfusion.

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