Medical Problems During Pregnancy - Springer Link

Hennessey, MD Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA. Whelan, MD Beth Israel Deaconess Medical Center, Department of Medicine, Division of Cardiology, Boston, MA, USA.

Gastroesophageal Reflux Case 1

Continued

For symptoms unresponsive to lifestyle changes, the risks and benefits of drug therapy should be discussed (Tables 1 and 2). Antacids containing sodium bicarbonate, which have the potential to cause metabolic alkalosis and fluid overload, should be avoided during pregnancy [4, 17].

Table 1 US Food and Drug Administration (FDA) categories a FDA

Functional Bowel Disorders Case 2

Continued

Its systemic absorption is also low, but its safety during pregnancy is not well established and is classified as category C. Castor oil, category X, has a potential association with induction of labor and is therefore not recommended for use during pregnancy.

Case 3

Peppermint oil has been shown in animal models to reduce calcium influx, leading to the relaxation of gastrointestinal smooth muscle [69]. This mechanism of action may account for its use in the treatment of IBS and abdominal pain.

Inflammatory Bowel Disease Case 4

Continued

Therefore, it is recommended that this patient remain on IFX at conception and throughout pregnancy. The AGA and ECCO consider these drugs to be of low risk for use during pregnancy [17, 99].

Table 6 Safety of medications used for the management of IBD during pregnancy and lactation Drug

Outcome of pregnancy in women with inflammatory bowel disease treated with anti-tumour necrosis factor therapy. Safety of anti-TNF agents during pregnancy and lactation in women with inflammatory bowel disease.

Medical Complications of Pregnancy/Headache

During pregnancy, radiation should be avoided if possible especially during the first trimester although exposure to the fetus from a non-contrast head CT is less than 0.01 rad. There are very few data on gadolinium contrast safety, and contrast should be avoided if possible.

Case One

Minimizing medication is important whenever possible, but if the mother's disability from a non-concerning headache diagnosis such as migraine is great enough to impair her ability to function, medication may be necessary. During pregnancy, patients can be treated with low molecular weight heparin; after delivery, the mother can be switched to warfarin [6].

Case Two

Susan began a course of cognitive behavioral therapy before her pregnancy and was often able to use meditation to reduce the pain when she did have a migraine. Susan was admitted to the hospital and after a hypercoagulable screen was drawn, she was started on IV heparin and oral warfarin.

Case Three

A neuro-ophthalmologist monitors her carefully; fenestration of the optic nerve sheath can be performed safely during pregnancy. According to the IHS criteria, it is possible to make a diagnosis of IIH in the absence of papilledema based on the pressure of the cerebrospinal fluid in accordance with the description of the headache.

Other Secondary Causes of Headache

There is no prodrome or build-up of the headache; rather, it is consistent and often quite severe. Classic imaging signs such as "slit-like ventricles" or empty sella are not pathognomic for IIH.

Postpartum Headaches

Headache and Breast-Feeding

Gestational Diabetes in 2015

Case #1

The Carpenter and Coustan values are lower because the thresholds derived from the older Somogyi-Nelson method of glucose analysis have also been corrected to account for the enzymatic assays currently in use. The values are lower because the thresholds derived from the older Somogyi-Nelson method of glucose analysis have been corrected to account for the enzymatic assays currently in use.

Table 1 Diagnostic criteria for the 100-g 3-h GTT to diagnose gestational diabetes mellitus Plasma or serum glucose level Plasma level

Case #2

Metformin has both supportive and non-supportive data about reducing the risk of miscarriage when used in the first trimester. The risk of shoulder dystocia is increased in patients with GDM compared to women without GDM.

Table 3 Association of major malformations in IDM with initial maternal glycohemoglobin level

Case #3

Atlantic diabetes in pregnancy: prevalence and outcomes of gestational diabetes mellitus using new diagnostic criteria. Postprandial versus preprandial blood glucose monitoring in women with gestational diabetes mellitus requiring insulin therapy.

Thrombophilia and Thrombocytopenia in the Pregnant Woman

Pregnancy and Venous Thromboembolism Introduction

Case 1

Data on pregnant women with antithrombin deficiency are limited, but given the high risk of VTE in the nonpregnant population with antithrombin deficiency, this is considered a particularly severe thrombophilia during pregnancy and is treated with antenatal antithrombotic therapy (Conard et al. the risk of VTE in the postpartum period is high in severe thrombophilias that justify antithrombotic treatment [4, 82].

Table 1 Inherited thrombophilias and prophylactic anticoagulation Observed or

Case 2

Furthermore, the benefit of antithrombotic therapy in women with late pregnancy loss or pregnancy complications related to placental insufficiency remains unclear. The value, if any, of antithrombotic therapy in women with obstetric APS associated with late pregnancy loss or placental insufficiency remains unknown. Therefore, current guidelines recommend the use of antithrombotic therapy in women with unexplained recurrent pregnancy loss ([4]; Royal College of Obstetricians and Gynecologists 2011).

Table 2 Revised classification criteria for APS

Thrombocytopenia in Pregnancy Case 1

A Cochrane database systematic review on aspirin or anticoagulants for the treatment of recurrent miscarriage in women without APS subsequently reinforced the findings of the SPIN and ALIFE studies (de Jong et al. 2014). ITP is the second most common cause of isolated thrombocytopenia in pregnancy and accounts for approximately 3 % of cases (Sainio et al. 2000). Christiaens GC, Nieuwenhuis HK, von dem Borne AE, Ouwehand WH, Helmerhorst FM, van Dalen CM, et al.

Table 4Typical characteristics of thrombocytopenic disorders of pregnancy CausePrevalence

Infectious Diseases in Pregnancy

Objectives

Her urine culture is in progress at the time of the appointment and she is sent home on oral amoxicillin. Because of the increased risk of complications, the IDSA recommends routine screening for asymptomatic bacteriuria at least once in early pregnancy with urine culture and treatment if the results are positive. For this reason, the initial treatment of pyelonephritis in pregnant women should be started as hospital treatment.

Table 1 Antibiotics for asymptomatic bacteriuria and cystitis in pregnancy

Case #2 Influenza and Pregnancy

Only the clinical diagnosis in the conditions of an epidemic is correct in about 80% of cases. Live intranasal influenza vaccine is not recommended for pregnant women, but can be given in the postpartum period. In the United States, oseltamivir and zanamivir are FDA pregnancy category C drugs, the result of a lack of studies to evaluate safety in pregnant patients.

Fig. 1 Common antivirals active against influenza A and B

Case #3 TORCH Infections

Treatment with spiramycin is recommended by many investigators in the United States and Europe during the first 18 weeks of pregnancy. This regimen is avoided in the first 18 weeks because of the risk of pyrimethamine teratogenicity. Maternal-fetal transmission is highest if infection occurs in the first 16 weeks of pregnancy.

Fig. 2 Preventing toxoplasmosis in pregnant patient

Case #4 Parvovirus

Women who are diagnosed with acute infection in the first 20 weeks of pregnancy should be advised that there is a risk of fetal loss that can reach 10%, as well as fetal anemia and hydrops. Women who are diagnosed with infection in the second half of pregnancy, as our patient was, have a much lower risk of fetal death, but hydrops fetalis and severe anemia can occur, making serial ultrasounds important even in this case. group. Since the risk of infection in the home and community exceeds that of the workplace, it does not make sense to exclude pregnant women from higher-risk occupations.

Table 3 Presentation of parvovirus B19 infection Maternal:

Case #5 Lyme Disease

In addition to avoiding exposure to ticks, early tick removal is currently one of the best ways to prevent Lyme disease [50]. The clinical stages of Lyme disease can be divided into three groups: early localized, early disseminated and late disease (see Table 4) [51]. It should be noted that EM alone is sufficient to diagnose Lyme disease on clinical grounds.

Fig. 7 A single erythema migrans lesion of 8.5 × 5.0 cm on the abdomen. The lesion is homogeneous in color, except for a prominent central punctum (presumed site of preceding tick bite) (Reprinted with permission from Oxford University Press)

Thyroid Disease During Pregnancy

An Overview for the Primary Care Physician

Case I

The authors recommended treatment with levothyroxine for all pregnant women with TSH greater than 2.0 mIU/L or high TPO antibody titers [22]. The authors concluded that targeted screening of only the high-risk group would miss approximately one-third of pregnant women with overt or subclinical hypothyroidism [23]. In euthyroid women with TPO antibody positivity at risk for miscarriage and preterm delivery, LT4 therapy is associated with a reduced risk of these complications [22].

Case II

Patients may be asymptomatic with only decreased TSH, or may have hyperemesis gravidarum with decreased TSH and mildly elevated FT4. As with gestational thyrotoxicosis, patients may be asymptomatic with decreased TSH or have hyperemesis gravidarum with decreased TSH and elevated FT4. As with other etiologies of hyperthyroidism, patients may be asymptomatic with decreased TSH or present with hyperemesis gravidarum and symptoms of thyrotoxicosis with decreased TSH and elevated FT4.

Case III

American Thyroid Association guidelines for the diagnosis and management of thyroid disease during pregnancy and postpartum. Korevaar TI, Schalekamp-Timmermans S, de Rijke YB, Visser WE, Visser W, de Muinck Keizer-Schrama SM, et al. Timing and magnitude of increases in levothyroxine requirements during pregnancy in women with hypothyroidism.

Cardiovascular Disease in Pregnancy

Congenital Heart Disease, Bicuspid Valve
Arrhythmia in Pregnancy
Valvular Stenosis, Mitral Stenosis
Prosthetic Valve
Peripartum Cardiomyopathy
Myocardial Infarction in Pregnancy

She was given adenosine 6 mg IV once, with resolution of tachycardia and reestablishment of sinus rhythm. The risk of valvular complications during pregnancy depends on the type and age of the valve, the position of the valve (ie, mitral versus aortic), left ventricular function, and the presence of atrial arrhythmias. Guidelines for the management of valvular heart disease: The Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology.

Table 1 New York Heart Association functional classification NYHA class Symptoms

Musculoskeletal Pain in Pregnancy

Case #1: Foot Pain and Pain Medications

In the general population, plantar fasciitis is related to overuse or can be caused by an injury, changes in activity patterns, or poor footwear, although the natural history of the disease is not understood [5]. Stretching the foot in dorsiflexion, with the help of a belt or band or towel, before getting out of bed in the morning, first relieves the pain. It is important to instruct the patient to remove the boot regularly throughout the day, as stiffness in the ankle and atrophy of the calf from prolonged disuse can lead to unintended pain and weakness.

Case #2: Knee Pain and Exercise Guidelines

Classical teaching says that the cause is improper movement of the patella in the femoral groove during repetitive knee flexion. The foot and ankle, meanwhile, control the alignment of the tibia and then the entire leg and thigh. It is important to check the range of motion and strength of the hip, knee and ankle, paying attention to any differences between the symptomatic and asymptomatic side.

Case #3: Back Pain and Imaging Guidelines

One can determine the range of motion of the lumbar spine in the standing position by having the patient bend forward with the knees straight and then by leaning back, hinged from the lumbosacral spine and hips. This test is not positive if it only produces back pain or tightness in the hamstring. Tightness or trigger points in the QL or piriformis can cause isolated low back pain or can radiate pain down the back of the leg, mimicking a herniated disc.

Case #4: Hip and Pelvic Pain and the Use of Contrast Media

Evaluation of the hip involves checking flexion, internal and external rotation, and abduction and adduction of the joint. Diagnosis of impingement and labral pathology is confirmed with MR arthrogram of the hip [44]. Given all the biomechanical changes associated with pregnancy, muscles can activate differently and lead to trigger points in the peripelvic area.

Case #5: Wrist Pain and the Safety of Corticosteroid Injections

While compression of the median nerve at the wrist – carpal tunnel syndrome – is also common in pregnant women [51], it differs from de Quervain's in the location and nature of pain and peresthesias. Manual compression of the median nerve at the carpal tunnel reproduces pain, numbness, and tingling through the nerve distribution in the hand and fingers. The initial treatment of de Quervain's is to use a spica splint of the thumb to stabilize and rupture the APL and EPB and limit friction of the tendons during ulnar deviation [52].

Epilepsy in Pregnancy

Case

Discussion

There are no data to suggest that folate administration is harmful to women with epilepsy. Unfortunately, perhaps one third of women with epilepsy have an increase in seizure frequency during pregnancy [2, 17]. It is important to consider the potential for pregnancy-related complications in women with epilepsy.

Conclusion

Fetal exposure to antiepileptic drugs and cognitive outcomes at 6 years of age (NEAD study): a prospective observational study. Community-based, prospective, controlled study of the obstetric and neonatal outcome of 179 pregnancies in women with epilepsy.

Pregnancy and Chronic Kidney Disease

In chronic kidney disease (CKD), the physiologic increase in GFR (and decrease in serum creatinine) may not occur. During pregnancy, the goals for blood pressure treatment differ from those in the general population. In the first trimester, <9 weeks of gestation, one study showed an increased risk of cleft palate compared to the general population [88], but a more recent population study from Norway showed no increased risk of orofacial clefts with first-trimester prednisone exposure [89].

Fig. 1 Normal physiologic changes in pregnancy (Adapted using data from Ueland and Metcalfe [1], Davison and Dunlop [2], Hytten and Paintin [3])

Breastfeeding Patients with CKD

What do we really know about controlling blood pressure in patients with chronic kidney disease? Centers for Disease Control and Prevention Post-marketing surveillance of the use of angiotensin-converting enzyme inhibitors during the first trimester of pregnancy - United States, Canada and Israel, 1987-1995. Renal disease is an independent risk factor for adverse fetal and maternal outcomes during pregnancy.

Fig. 3 NTPR trend in breastfeeding practices of transplant recipients (Published with permission from National Transplantation Pregnancy Registry (NTPR)

Index