Author : Patricia Robertson MD Professor,
Department of Obstetrics, Gynecology, and Reproductive Sciences,
University of California at San Francisco
2008-07-22
2008-07-22
Introduction
Pregnancy is a state of dynamic, physiologic adaptations. While pregnancy is a normal, natural, and healthy process, in some women pre-existing medical problems or findings during the pregnancy can change the risks to the mother and to the fetus, and in the way that the pregnancy progresses.This description of high risk pregnancy describes some of the pre-existing medical conditions and diagnoses during pregnancy that affect the way that a pregnancy is managed. Exercise, nutrition, and healthy habits are just as important in a high risk pregnancy as they are in a normal pregnancy. Women with high risk pregnancies are able to enjoy their pregnancies, and plan for their babies just like women with normal pregnancies.
Common tools used for managing a high risk pregnancy
Women
with high risk pregnancies may be referred for consultation with a
maternal-fetal medicine specialist, (perinatologist.) A perinatologist
is an obstetrician who has had advanced training in how to care for
women with complications during pregnancy. Sometimes the perinatologist
will be the primary obstetric provider, and at other times, may
co-manage the pregnancy with the primary obstetric provider. If there is
a co-management plan, communication between the two providers will
usually be by phone calls and letters. As the pregnancy advances, a
recommendation will be made as to whether you should delivery your baby
in your community hospital, or deliver the baby at a referral hospital.
There are three levels of baby nurseries, and if your baby will be sick
at birth or premature, you should consider delivering at a hospital with
a Level 3 Intensive Care Unit. A Level 2 Intensive Care Unit takes care
of preterm babies, about 32 weeks or older, and a Level 1 Baby Nursery
takes care of full term babies who are not significantly ill. If you
happen to deliver at a Level 1 hospital, and your baby is sick, the baby
may need to be transported to a higher level of care at another
hospital. If this is the case, you should check to see if you can also
be transferred to that hospital if you still need to be hospitalized, so
you can be near your baby. 
If you have a pre-existing medical condition, your doctor will develop a plan for the management of your pregnancy that takes two key questions into account:
- How will the medical condition affect the pregnancy?
- How will the pregnancy affect the medical condition?
If you have a complication that arises during pregnancy, your doctor will determine how this development will change the way that the rest of your pregnancy will be managed. In some cases, your doctor may recommend more intensive monitoring for you or your fetus in order to assess well-being. Monitoring may include blood pressure checks, laboratory tests, or physical exams. Commonly used techniques for monitoring the fetus include ultrasound pictures of the fetus, monitoring of the fetus’s heart rate, and occasionally, magnetic resonance imaging or MRI pictures of the fetus.
Ultrasound of the fetus
Sometimes, intervention or treatment may be needed during the pregnancy. This may consist of medications for the mother, testing such as amniocentesis to determine if a fetus has a genetic condition, or even sampling of the blood in the umbilical cord to determine the baby’s blood count. If there is a concern that the baby may need to be delivered early, a steroid called betamethasone (two injections 24 hours apart) or dexamethasone (pills or injections) may be given to you to help decrease the likelihood of complications to the baby. If you need to take medications, a useful phone number to have to check out the safety of the medication during pregnancy and breastfeeding is: 1-800-532-3749 ( University of California at San Diego).
The goal of your obstetric practitioner’s care is to safeguard the well-being of you and your baby so that you can have the safest and most uncomplicated pregnancy, labor and delivery, and postpartum course.
Medical complications in pregnancy
Obesity
Obesity is a significant problem in the United States. The Centers for Disease Control estimate that over 50% of American women of reproductive age are overweight (Body Mass Index of 25-29.9), and 30% are obese (Body Mass Index over 30). (Click here to calculate your BMI: http://www.nhlbisupport.com/bmi/) During pregnancy, the recommended weight gain for women who are overweight is 15-25 pounds, and for obese women, it is less than 15 pounds. A nutritionist is often available through the obstetric practice to talk with pregnant women about how to best approach these weight targets.Early in pregnancy, obesity[PR1] increases the risk of miscarriage and birth defects. Later in pregnancy, obesity increases the risk of high blood pressure in pregnancy (preeclampsia), elevated blood sugars in pregnancy (gestational diabetes), preterm delivery, and stillbirth. For the fetus, there is an increased risk of growing too big, which can lead to increased complications at the time of birth, after birth, and later in the child’s life. At the time of delivery, there is an increased risk of cesarean delivery and complications resulting from surgery.
[PR2] A healthy diet, exercise, and appropriate weight gain during pregnancy are the best approach to decrease the likelihood of pregnancy complications due to obesity. Pregnancy is a great time to make lifestyle changes and adopt healthy habits that will benefit you and your baby during and after the pregnancy. Breastfeeding is recommended, both for the benefits to the baby and to the mother.
For more information on nutrition during pregnancy:
American College of Obstetrics and Gynecology
http://www.acog.org/publications/patient_education/bp001.cfm
USDA Food pyramid for pregnancy and breastfeeding:
http://mypyramid.gov/mypyramidmoms/index.html
High blood pressure in pregnancy
Hypertension is the most common medical disorder during pregnancy. Most women diagnosed with high blood pressure in pregnancy have high blood pressure only during pregnancy.Chronic hypertension
Women diagnosed with high blood pressure (> or equal to140/90 mm Hg) prior to pregnancy are at increased risk for developing high blood pressure and protein in their urine during pregnancy (preeclampsia), as well as early separation of the placenta from the uterus (abruption), early delivery, and a small baby (intra-uterine growth restriction). In addition, having high blood pressure increases health risks to the mother, just as they do for people who are not pregnant.There are a number of medications that can be used to control blood pressure safely during pregnancy. However, some of the medications commonly used outside of pregnancy are not recommended for women who are trying to conceive or during pregnancy, so women with high blood pressure should talk to their doctors if they are planning to have a baby. The category of medications to avoid is “ACE inhibitors.” Other medications, such as hydrocholothiazide, methyldopa, beta-blockers, and calcium channel blockers are commonly used during pregnancy. In addition, long term high blood pressure can lead to damage to a woman’s eyes, heart, and kidneys, so the doctor may want to evaluate these organs before a woman is pregnant or at the first prenatal visit. Pregnancy puts increased demands on the body, and in some women with severe hypertension, the risk of complications to the mother and the fetus can be high. Being seen early and frequently will help your obstetric practitioner have the information needed to make your pregnancy as safe as possible.
Diet and exercise are an important part of the management of high blood pressure. Laboratory tests and frequent blood pressure checks will be used to see how the mother is doing; ultrasound or fetal testing may be used to monitor how the fetus is growing and assuring that the placenta is working well. If there are no complications to the pregnancy, women with chronic hypertension usually have their labors induced at 39 or 40 weeks (40 weeks represents your due date).
If medications are needed to control the blood pressures after delivery, there are medications that are safe for breastfeeding. Just as with other healthy women, breastfeeding is recommended for women with chronic hypertension.
Gestational Hypertension and Preeclampsia
Gestational hypertension refers to an elevation in blood pressure of 140/90 mm Hg or greater, after 20 weeks gestation. It is more common in women having their first baby, women who have had high blood pressure in pregnancy before, and women carrying twins or triplets. About 30% of women who develop high blood pressure in pregnancy will also have protein in the urine; this combination hypertension and protein in the urine is called preeclampsia. The reason that preeclampsia develops is not known. If preeclampsia develops, additional complications can occur such as seizures, and kidney or liver complications.Most of the time, high blood pressure in pregnancy develops after 37 weeks. If the blood pressures are very high (>160/110 mm Hg), the risk of complications increases. For women who develop gestational hypertension or preeclampsia early in their pregnancies, the risk of having a small baby or the placenta separating too early (abruption) is increased. These pregnancies require more intensive monitoring of the mother and the fetus; in some cases, this requires that the mother be hospitalized.
Preeclampsia is cured by the delivery of the baby and the placenta. Since there are risks for the mother associated with preeclampsia including seizure, stroke, liver damage, and kidney damage, it is always safer for the mother for the baby to be delivered. However, if preeclampsia is diagnosed early in the pregnancy, the risk to the baby of being born early must be balanced against the risk to the mother of continuing the pregnancy. If the pregnancy is continued after preeclampsia has been diagnosed, the mother and fetus are monitored closely with laboratory tests, ultrasound, and fetal heart rate testing and hospitalization may be indicated. If symptoms or effects on the mother’s organs develop (pain in the right side of the abdomen, changes in vision, severe headache, seizure), then delivery of the baby is the best plan for both mother and baby.
One of the risks of preeclampsia is a seizure (eclampsia). A seizure may be the first symptom a woman has of preeclampsia. Magnesium sulfate, a medication given intravenously, decreases the likelihood of seizures. Depending on the severity of the preeclampsia or hypertension, women may be given this medication during labor and for the first day after delivery to decrease the likelihood of a seizure.
Most women who develop high blood pressure during pregnancy will have normal blood pressure after delivery. Sometimes, women will require medications to lower the blood pressure for a short time after delivery. Women with a history of preeclampsia have an increased risk of developing high blood pressure associated with pregnancy in their next pregnancy. Just as with other healthy women, breastfeeding is recommended for women with hypertension.
For more information on High Blood Pressure and Pregnancy:
American College of Obstetricians and Gynecologists
http://www.acog.org/publications/patient_education/bp034.cfm
American Heart Association
http://www.americanheart.org/presenter.jhtml?identifier=3028465
March of Dimes- Hypertension
http://www.marchofdimes.com/pnhec/188_1054.asp
Up-To-Date Patient Information
http://patients.uptodate.com/topic.asp?file=pregnan/4563
National Institute of Child health and Human Development
http://www.nichd.nih.gov/health/topics/Preeclampsia_and_Eclampsia.cfm
For more information on medications for high blood pressure in pregnancy:
American Heart Association
http://www.americanheart.org/presenter.jhtml?identifier=3028464
Diabetes
Diabetes is a disease in which the body is not able to control the level of glucose (sugar) in the blood, leading to elevated blood sugar levels. Since glucose crosses the placenta and the fetus receives its nutrients from the mother, if the blood sugar of the mother is high, the fetus will receive extra sugar as well. Depending on whether blood sugar is high prior to pregnancy (pre-existing diabetes) or is diagnosed during pregnancy (gestational diabetes), it has different effects on how the fetus forms and grows. Women with gestational diabetes or pre-existing diabetes have increased risks of high blood pressure associated with pregnancy (preeclampsia), early delivery, and cesarean delivery.Pre-Existing Diabetes
Women who have diabetes before they are pregnant should see their doctor before they decide to conceive. Long term diabetes can damage women’s eyes, kidneys, heart, and blood vessels. Pregnancy can put increased stress on these organs, and depending on how severe the diabetes is, doctors may have recommendations for when a pregnancy would be safest. For all women with diabetes, getting the blood sugar as close to the normal range as possible before getting pregnant is very important. If the blood sugar is high at the time that the fetus is forming (weeks 5-8), this can lead to a higher risk of miscarriage and birth defects. Women who have well-controlled blood sugars before conception can decrease their likelihood of birth defects and miscarriage. One way of checking for overall glucose control is a blood test called a Hemoglobin A1C. This test gives an estimate of the average blood glucose level after the past several months.As pregnancy progresses, there is a risk that the fetus may grow to be bigger than expected, or smaller than expected, depending on the effect of elevated blood sugars on the fetus and the placenta. In addition, the placenta may begin to work less effectively due to the effects of elevated blood sugars. There is also an increased risk of stillbirth. Women with pre-existing diabetes may have extra ultrasounds and monitoring of the baby’s fluid and heartbeat to make sure the baby is growing as expected and the placenta is working well.
Gestational Diabetes
Gestational diabetes refers to elevated blood sugars diagnosed for the first time during pregnancy. The placenta produces hormones that make the body resistant to the action of insulin, the hormone responsible for lowering blood sugar. This effect is seen most in the third trimester, so for most women, a screening test is performed for gestational diabetes in the beginning of the third trimester. If the screening test is elevated, usually a three hour glucose tolerance test is done after a fasting blood sugar is drawn. If two out of the four values are elevated, gestational diabetes is diagnosed, and the woman is referred to a specialist in diabetes. Elevated blood sugars in the third trimester can cause the baby to grow larger, which can lead to complications at the time of delivery.Blood Sugar Control
For all women with diabetes, keeping the blood sugars in a normal range decreases the likelihood of problems during the pregnancy. Management of diabetes in pregnancy involves controlling the blood sugar with a combination of diet, exercise, and treatment with insulin or pills, if needed. Blood sugars will need to be checked frequently for monitoring. Women with diabetes before pregnancy will likely be on medication from the start of pregnancy. Because of the action of the hormones of the placenta, the amount of insulin that is needed usually increases as the pregnancy progresses. For women with gestational diabetes, insulin is used when blood sugars cannot be controlled with diet and exercise alone.Effects on the baby
After birth, babies born to mothers with gestational or pre-existing diabetes need to be monitored for low sugars and other changes brought about by exposure to elevated blood sugars and elevated insulin levels during pregnancy. Sometimes, these complications mean that the baby has to stay in the hospital for a longer time after delivery. Babies born to women with high blood sugars during pregnancy are at increased risk for becoming overweight or developing diabetes when they get older. Breastfeeding is good for moms with diabetes and for babies born to moms with diabetes.Postpartum
For women with pre-existing diabetes, insulin requirements will decrease quickly after delivery. Women with gestational diabetes usually do not need insulin after delivery, but they do need to have their sugar checked at about 6 weeks postpartum to be sure that the glucose levels are normal after pregnancy. Women who have had gestational diabetes are at higher risk of developing gestational diabetes in a later pregnancy or diabetes later in life; weight loss and exercise can help to decrease the risk of diabetes.For more information on Diabetes and Pregnancy:
Centers for Disease Control
http://www.cdc.gov/ncbddd/bd/diabetespregnancy.htm
March of Dimes
http://www.marchofdimes.com/pnhec/188_1025.asp
For more information on pregnancy in women with pre-existing diabetes:
Up-To-Date Patient Resources
http://patients.uptodate.com/topic.asp?file=pregnan/5061
For more information on Gestational Diabetes:
American Diabetes Association
http://diabetes.org/gestational-diabetes.jsp
National Institute of Child health and Human Development
http://www.nichd.nih.gov/health/topics/Gestational_Diabetes.cfm
For more information of postpartum ways to decrease the risk of diabetes later in life
National Diabetes Education Program
http://www.ndep.nih.gov/campaigns/SmallSteps/SmallSteps_nevertooearly.htm
Thyroid disease
The thyroid gland makes and stores hormones that help regulate body temperature, heart rate, blood pressure, and metabolism. Pregnancy causes short term changes in thyroid hormones. The mother also provides the thyroid hormone necessary for the developing fetus until 12 weeks, when the fetal thyroid begins to work.Hypothyroidism
Symptoms of low thyroid, or hypothyroidism, include fatigue, muscle cramps, constipation, and cold intolerance. Women who have a low thyroid hormone level that is not corrected are at increased risk for miscarriage, high blood pressure brought on by pregnancy (preeclampsia), and early separation of the placenta (abruption). However, treatment of low thyroid hormones decreases the likelihood of these problems.Low thyroid hormone is treated with thyroid replacement taken as a pill. The doctor will monitor the levels of the hormone TSH (Thyroid Stimulating Hormone) in order to make sure the right dose of thyroid medication is being given. Because of the changes in the thyroid during pregnancy, the amount of thyroid medication that a woman needs may increase during her pregnancy. The amount of replacement usually returns to normal after delivery.
Hyperthyroidism
Symptoms of increased thyroid hormones, or hyperthyroidism, include nervousness, excessive sweating, weight loss, or tremor. The most common cause of hyperthyroidism is Graves Disease, in which an antibody stimulates the thyroid. Women with Graves’ disease have an increased risk of having a small baby, delivering early, and having high blood pressure associated with pregnancy (preeclampsia). Treatment of increased thyroid hormone levels decreases the likelihood of these problems.Increased thyroid hormone levels are usually treated with a medication called propylthiouracil (PTU). Hormone levels are monitored until they reach a normal level. In women with Graves’ Disease, the antibody is present in the blood even when the thyroid level is normal. These antibodies can cross the placenta and may lead to short- term thyroid problems in the baby after it is born.
Postpartum
For women with low thyroid hormone levels, the dose of replacement usually returns to the level of thyroid hormone used before the pregnancy started. Levothyroxine, the most commonly used thyroid replacement medication, is found in breast milk, but the levels are so low, it will not affect the baby. People with hyperthyroidism who are not pregnant are usually offered more permanent treatment options after the pregnancy. Just as with other healthy women, breastfeeding is recommended in women with thyroid disease.About 10% of women will develop transient thyroid problems after pregnancy; this is called postpartum thyroiditis. Women with postpartum thyroiditis usually have a period where the thyroid hormone is high, followed by a period when the thyroid hormone is low. They may require thyroid replacement for 6 to 12 months. About a third of women with postpartum thyroiditis continue to need thyroid replacement after 12 months.
For more information on thyroid disease in pregnancy:
March of Dimes
http://www.marchofdimes.com/pnhec/188_8923.asp
American Thyroid Association
http://www.thyroid.org/patients/patient_brochures/pregnancy.html
Endocrine Society/Hormone Foundation- Hyperthyroid
http://www.hormone.org/pdf/hyperthyroid_women.pdf
Endocrine Society/Hormone Foundation- Hypothyroid
http://www.hormone.org/pdf/hypothyroid_women.pdf
Respiratory Disease
Asthma is a chronic irritation or inflammation of the airways in the lungs that leads to narrowing of the airways. Because of the hormonal effects of pregnancy and the effect of the growing uterus, many women may report feeling short of breath at rest or with exercise during pregnancy. Asthma refers to more persistent symptoms of chest tightness, cough, and shortness of breath.Women with asthma have an increased likelihood of needing to be in the hospital during the pregnancy as well as postpartum, and may also have an increased likelihood of developing an increase in blood pressure during pregnancy (preeclampsia), having a small baby, and delivering early. Specific therapy targeted for asthma decreases the likelihood of these complications.
Medications used to treat asthma in pregnancy commonly include beta- agonists like albuterol, and inhaled steroids, which are safe in pregnancy. In more severe cases, steroids by mouth or other medications may be added. The severity of the asthma can be measured by pulmonary function tests, which are done by the doctor, or by peak flow meter readings, which are done by the patient. In addition to medical treatment, avoiding asthma triggers like dust and irritants is helpful.
Only small amounts of the medications used to treat asthma are excreted in the breast milk. The only exception is theophylline, which can cause neonatal effects. Just as with other healthy women, breastfeeding is recommended.
For more information on Asthma and Pregnancy:
Up-To-Date Patient Information
http://patients.uptodate.com/topic.asp?file=pregnan/2993
Depression and Other Mood Disorders
Many women have experienced depression or other psychiatric disorders either before, during, or after their pregnancies. Pregnancy can worsen mood disorders and for many women the supposed “glow” of pregnancy will not counter-balance their emotional pain.The most common pregnancy mood disorders - depression and anxiety - are usually treated with medication and/or therapy. Planning a pregnancy should involve evaluation of mood concerns, medication history, and a decision regarding continuing medication that has been treating a psychiatric condition. The most commonly prescribed anti-depression medications (SSRIs) can be associated with a slightly increased risk of birth defects. However, the overwhelming majority of women on these medications have healthy babies. Deciding to go off of medication during the conception period, as well as the first trimester, can be made in order to decrease the risk of negative fetal exposure. Women who decide to do this can also choose to resume the medication in the second trimester. Since conception may take up to a year, it is also an option for women to go off their medication with the first positive pregnancy test. Since 60% of women who discontinue their depression medication are likely to relapse, it is wise to have a therapist involved during this process and to strongly consider stabilizing moods by resuming medication. In fact, many women choose to continue their medication throughout the pregnancy since many experts in this field believe that untreated anxiety and depression can negatively affect a developing fetus.
Postpartum exacerbation of depression is very common - research estimates this likelihood at 10%. It is therefore important that evaluation and treatment resources for new mothers be accessible. Untreated postpartum depression can have negative effects not only for the suffering mother, but for her infant. When a new mother is depressed, her ability to positively attach to her infant can be severely compromised. Research has shown that children of depressed mothers are slower than other children in achieving cognitive milestones and have an increased risk of other behavioral and psychiatric problems as they grow older.
Anxiety disorders can co-exist with depression or occur without depression. These disorders can express themselves in panic attacks or obsessive-compulsive behaviors - during and/or after pregnancy. It is important to consider medication and/or therapy. Bipolar disorder and schizophrenia are also treatable during pregnancy. Women are best served when psychiatrists are involved in the medication planning for these, as they are serious disorders. As in the case of depression and anxiety, it is always best to find a way to help women achieve emotional stability during both their pregnancies and postpartum course.
For more information about depression and other psychiatric disorders in pregnancy:
www.nimh.nih.gov
www.nmha.org
www.nami.org
www.ndmda.org
www.depressionafterdelivery.com
www.postpartum.net
www.womensmentalhealth.org
Autoimmune Disease
Autoimmune diseases such as systemic lupus erythematosus, rheumatoid arthritis, and scleroderma result from the immune system attacking the body instead of defending it. Autoimmune disorders may get better, get worse, or stay the same in pregnancy.Systemic Lupus Erythematosus (SLE) is a chronic inflammatory disease that can affect the skin, joints, kidneys, lungs, brain, liver, and other organs. Most women with SLE have intermittent periods of improving and worsening symptoms, even when they are not pregnant. It is not clear if women with SLE have a higher risk of a flare (worsening symptoms) during pregnancy. Women with SLE who have kidney problems as a result are at risk for worsening kidney function during pregnancy; sometimes this is permanent. Overall, the best way to increase the likelihood of a successful pregnancy is to make sure that lupus symptoms are well controlled prior to pregnancy. While there are many medications used to treat lupus that are safe during pregnancy, some are not (like cyclophosphamide, methotrexate, aspirin, ibuprofen); seeing a doctor prior to becoming pregnant will allow them to make sure that all the drugs being used will be safe in pregnancy. Some women with lupus have antibodies that increase their chance of having a blood clot; depending on the history, they may need to be treated with blood thinners during pregnancy. If a woman has SSA or SSB antibodies, her fetus is at a small risk for developing a slow heart rate (heart block), which is a serious condition.
Women with lupus need to be carefully monitored during pregnancy as they have an increased risk of pregnancy loss, high blood pressure associated with pregnancy (preeclampsia), delivering early, and having a small baby (IUGR). In addition, some babies born to women with lupus can develop “neonatal lupus,” which can affect the baby’s heart or skin. Finally, women can develop lupus flares during pregnancy which can be difficult to identify and treat. Some women may also have a flare of lupus symptoms after they deliver.
Rheumatoid arthritis (RA) is a chronic inflammatory condition of the joints. Many patients with RA improve during pregnancy, although most also have increasing and decreasing symptoms throughout pregnancy. Women with RA may be at higher risk for miscarriage, but do not seem to be at increased risk for other pregnancy complications. While there are many medications used to treat RA that are safe during pregnancy, some are not (like methotrexate, aspirin, ibuprofen); seeing a doctor prior to becoming pregnant will allow them to make sure that all the drugs being used will be safe in pregnancy.
Systemic Sclerosis or Scleroderma is an autoimmune disorder that can affect the blood vessels, heart, lungs, kidneys, and other internal organs. Pregnancy can be very dangerous in women with scleroderma if their heart, lungs, or kidneys have been severely damaged. During pregnancy, women with scleroderma are at increased risk for pregnancy loss, high blood pressure associated with pregnancy (preeclampsia), delivering early, and having a small baby (IUGR).
For more information on autoimmune diseases and pregnancy:
American College of Rheumatology
http://www.rheumatology.org/public/factsheets/pregnancy.asp
For more information on Lupus and pregnancy:
Lupus Foundation http://www.lupus.org/webmodules/webarticlesnet/templates/new_aboutindividualized.aspx?articleid=314&zoneid=18
Up-To-Date Patient Information
http://patients.uptodate.com/topic.asp?file=arth_rhe/8273
For more information on rheumatoid arthritis and pregnancy:
Up-To-Date Patient Information
http://patients.uptodate.com/topic.asp?file=arth_rhe/9738
For more information on scleroderma:
National Institute of Arthritis and Musculoskeletal and Skin Diseases
http://www.niams.nih.gov/Health_Info/Scleroderma/default.asp
Venous Thromboembolism
Pregnancy increases the likelihood of blood clots due to the effect of pregnancy on the clotting system, the increased blood volume, and increased pooling of the blood in the legs (venous stasis). Women with a prior history of a deep venous thrombosis or a pulmonary embolism, women with a genetic susceptibility to clotting, and women with a mechanical heart valve should receive blood thinners during pregnancy to decrease the likelihood of blood clots. Blood thinners are usually safe in pregnancy (warfarin can be associated with birth defects if given during the first trimester of pregnancy however, and many obstetricians only use heparin or Lovenox by injection during the pregnancy). There is the usual 10% risk of bleeding that also occurs when a patient is on blood thinners. When it is time for delivery, blood thinners must be briefly stopped in order to allow the safe use of epidural anesthesia, if desired. After delivery, treatment usually is continued for 6 weeks as the risk of thromboembolism continues in the postpartum period. Breastfeeding is compatible with the use of Lovenox and heparin: some pediatricians prefer that mothers on warfarin not breastfeed, but other pediatricians are comfortable with it.Women on bedrest and women undergoing cesarean delivery are at increased risk of venous thromboembolism. Depending on the situation, these women may receive nonmedical therapies (leg massagers) or medications to decrease the likelihood of blood clot.
Thromboembolism may be difficult to diagnose during pregnancy as symptoms may be vague and some of the lab tests used in nonpregnant women are not accurate during pregnancy. Ultrasound of the legs or CT scan of the chest are the studies that are usually done to diagnose deep venous thrombosis or pulmonary embolism. More rarely, MRI may be useful.
Once venous thromboembolism is diagnosed, treatment with blood thinners should be started. If this is the first time a woman has had a venous thromboembolism, she is usually treated at least until 6-12 weeks postpartum. As with non-pregnant women, a first episode of venous thromboembolism is usually treated with 6 months of anticoagulation, so depending on the time that the clot is diagnosed, medications may be continued for more than three months postpartum.
Cardiac Disease
During pregnancy, the volume of blood and the number of blood cells in the body increases to meet the needs of the growing baby. For women who have a problem with their heart, the extra workload for the heart that this creates can cause complications during the pregnancy. Risks associated with maternal cardiac disease and pregnancy include growth problems for the baby, early delivery, and danger to the mother’s health. In addition, if the heart problem that the mother has is a birth defect, then the baby is at increased risk for having a heart birth defect as well. A specialized ultrasound of the baby’s heart (fetal echocardiogram) is done at around 16 weeks to check for this.Because of the potential risks of pregnancy to the health of a woman with a heart condition, when possible, pregnancy should be planned after discussion with the woman’s heart doctor (cardiologist). A dedicated ultrasound of the mother’s heart (echocardiogram) may be helpful to see how the heart is functioning at baseline. Based on the type of heart problem and the way that the heart is functioning, the cardiologist and perinatologist can get a better idea of the risks of pregnancy to the mother’s health. There are some heart conditions like Eisenmenger’s Syndrome and pulmonary hypertension in which there is a high chance that pregnancy can be fatal for the mother because the heart is not able to handle the extra workload.
Some women will have repairs of their heart valves or heart structure before pregnancy. The maternal and fetal risks for these women also depend on how the heart is working before pregnancy. In addition, for women who have a mechanical heart valve, it is important that they are on blood thinners during pregnancy. Finally, women with certain problems with the valves of the heart or women who have had valve surgery may need to be given antibiotics during labor and delivery to prevent infection of the heart (endocarditis).
During pregnancy, the growth of the fetus and how the mother’s heart is functioning will be monitored closely. In some cases, if the heart is not functioning well at the end of the pregnancy, the baby may need to be delivered early. Some women with heart problems are able to push to deliver their babies; others need to have an assisted delivery, in which the doctor uses forceps or a vacuum to help deliver the baby, and the mother is asked not to push. After the delivery, the mother must be watched carefully, as she is at risk during that time as well. Breastfeeding is good for the mother and the baby.
For more information on Heart Disease and Pregnancy:
American Heart Association
http://www.americanheart.org/presenter.jhtml?identifier=4688
Kidney Disease
Pregnancy leads to an increase in the workload of the kidneys, which can lead to complications in women who have kidney disease before pregnancy. Though there are increased pregnancy complications in women with renal disease, most women can have happy, successful pregnancies.Complications of renal disease for the mother include development of preeclampsia, worsening of kidney function, low blood count (anemia), early delivery, and cesarean delivery. For the baby, complications include being born small and the complications related to being born early.
The most important predictor of pregnancy complications in women with kidney disease are the level of kidney function before pregnancy (usually estimated by the creatinine level in the blood along with the analysis of a collection of all urine for 24 hours for total protein and for creatinine clearance), and whether or not there is high blood pressure prior to pregnancy. If the kidney disease is severe and associated with high blood pressure, there is a risk that the stress of the pregnancy will cause the kidney function to get worse, potentially leading to permanent kidney failure (which can be treated with either dialysis or kidney transplant).
During pregnancy and labor and delivery, the mother and the baby need to be monitored closely for signs or symptoms of the problems that can arise. Most women with kidney disease will be followed by a kidney doctor (nephrologist) as well as an obstetrician and/or perinatologist during pregnancy.
For more information on kidney disease and pregnancy
National Kidney Foundation
http://www.kidney.org/ATOZ/atozItem.cfm?id=104
Obstetric Complications
Twins or more (Multi-fetal Gestation)
Multi-fetal gestation occurs when there are two or more babies in the uterus together. Twins are the most common; triplets and quadruplets occur more rarely. Multi-fetal gestation occurs more commonly when assisted reproductive technology (e.g., IVF) is used. Multi-fetal gestations have many risks including increased risk of early delivery (at least 50% of the babies deliver prematurely, three weeks or more before the due date), high blood pressure, cesarean delivery, fetal growth restriction, birth defects, and postpartum bleeding. Women with multi-fetal pregnancies are also more likely to be hospitalized during the pregnancy. Early and regular prenatal care is important to reduce the risk of complications. Many women have uncomplicated twin pregnancies.Based on how they develop, there are a number of different kinds of twin pregnancies. Dichorionic diamniotic twins may form from the development of two separate embryos or from the very early division of a single embryo. Dichorionic diamniotic twins each have their own placenta and amniotic sac. Monochorionic diamniotic twins result from splitting of one embryo a little later in pregnancy and share a placenta, but each has an individual amniotic sac. Because of the shared placenta, there is a risk of a complication called twin to twin transfusion syndrome (TTTS) in 15% of monochorionic diamniotic twins. This results when one twin receives more blood flow from the placenta than the other. Over time, this can be unhealthy for both the twins: one gets too much blood flow and the other twin gets too little blood flow. Without treatment, this can result in serious compromise or even death of one or both twins. However, there is treatment for this condition that is fairly successful (reduction of amniotic fluid by amniocentesis in the sac of the twin with too much amniotic fluid, and/or laser surgery of the placenta). Monochorionic monoamniotic twins result from even later division of a single embryo, and both twins are in the same sac in this case. Because they share the same sac, monochorionic monoamniotic twins are at high risk of getting their umbilical cords tangled. This can lead to injury or death of one or both twins. Often women with monoamniotic twins are hospitalized at 28 weeks with continuous fetal monitoring, and cesarean delivery is performed about 6 to 8 weeks before the due date. Performing an early ultrasound at about 12 to 14 weeks from the last menstrual period is the easiest way to determine which kind of twin pregnancy is present.
During pregnancy, mothers with multiples need to increase their caloric intake over that of a singleton pregnancy as well as their iron and folate supplementation. [PR3] Ultrasounds and monitoring of the babies’ heart beats are performed to see how they are growing and to check for symptoms of the specific complications that they may be at risk for during the pregnancy. Mothers are monitored closely for signs or symptoms of pregnancy-induced hypertension or preterm labor.
If the monitoring remains reassuring, twins are usually delivered at 38-39 weeks. However, 50% of twins are born at less than 37 weeks, and triplets even earlier. Depending on the position, number, and size of the babies, vaginal delivery may be an option. In other cases, cesarean delivery may be recommended. Breastfeeding is possible and encouraged.
For more information on Twins:
National Institutes of Health
http://www.nlm.nih.gov/medlineplus/twinstripletsmultiplebirths.html
American College of Obstetrics and Gynecology
http://www.acog.org/publications/patient_education/bp092.cfm
American Society for Reproductive Medicine- Patient Information
http://www.asrm.org/Patients/patientbooklets/multiples.pdf
Preterm Labor
A preterm delivery is a delivery that occurs between 20 and 37 weeks of gestation. Preterm birth is the biggest cause of neonatal complications. About 75% of preterm deliveries result from women going into spontaneous labor or breaking their water. The other 25% occur in women with a complication during their pregnancy that results in a need to deliver the baby early (like preeclampsia or diabetes).Preterm labor can be defined as persistent contractions associated with opening of the cervix, the entrance to the uterus. Preterm labor seems to result either from infection or inflammation, bleeding during pregnancy, the uterus being overfilled (with extra fluid, twins, or triplets), or the activation of the normal mechanisms of labor too early in pregnancy. Preterm labor is more likely in women with a prior preterm delivery, women who smoke, women with low or high weight gain in pregnancy, women with vaginal bleeding during pregnancy, and women with twins or triplets. When a woman is diagnosed with preterm labor, the main goals are to try and delay the delivery of the baby for long enough to give betamethasone or dexamethasone to the mother (optimally to have at least 48 hours from the first dose to the delivery, if delivery is imminent). These steroids decrease the likelihood of complications in babies that are born early, and allow time for the mother to be taken to a hospital where they have the doctors and facilities necessary to take care of a baby that is born early. Early detection of preterm labor is difficult because many of the symptoms, such as contractions, pelvic pressure, or vaginal discharge, also occur in normal pregnancies.
Evaluating the cervix with ultrasound to detect early dilation or thinning out and testing for chemicals released prior to delivery (fetal fibronectin) are two ways to identify women at risk for preterm labor and to make the diagnosis of preterm labor in women who present with symptoms.
The cervix can be examined with ultrasound. This exam is usually done with an ultrasound probe (a transducer that looks like a wand) that is inserted in the vagina in order to get the most accurate measurement possible. There are many characteristics of the cervix can be examined, but the closed length of the cervix is the most helpful measurement. A cervix that is greater than 3 cm. long is normal. A normal cervical length is reassuring, and decreases the likelihood of preterm delivery.
Fetal fibronectin is a protein that helps to attach the fetus’s amniotic sac to the uterus. If fetal fibronectin is present in the back part of the vagina, it is worrisome (about a 1 in 5 chance that the baby will be born in the next two weeks.) If the fetal fibronectin is not present (negative), then there is a 98% chance that the baby will not be born in the next two weeks.
Once a woman is diagnosed with preterm labor, she may be admitted to the hospital, and be given medication to try and decrease contractions, as well as a steroid shot or pills to help decrease the complications for the baby if the delivery is early. She may also be given antibiotics to decrease the likelihood of infection with Group B streptococcus if the baby is born early. If the contractions go away and the woman does not deliver, she may be able to go home. Women with preterm labor are often told to reduce their activity level. Many women who are diagnosed with preterm labor will remain pregnant for some time after the diagnosis; some will even go to or beyond their due date.
For women who have a history of preterm delivery, progesterone (one of the hormones of pregnancy), can be given to reduce the likelihood of preterm delivery during the current pregnancy. Progesterone is usually given as a weekly injection, starting after 16 weeks and continuing until 36 weeks.
For more information on preterm labor:
March of Dimes
http://www.marchofdimes.com/pnhec/188_1080.asp
National Institute of Child health and Human Development
http://www.nichd.nih.gov/health/topics/Preterm_Labor_and_Birth.cfm
Up-To-Date Patient Information
http://patients.uptodate.com/topic.asp?file=pregnan/6340
Sidelines- a support network for women with premature births
http://www.sidelines.org
Preterm Premature Rupture of Membranes
Preterm premature rupture of membranes (PPROM) refers to the water breaking before 37 weeks. More than half of women who break their water early will deliver within 7 days. The complications associated with PPROM include infection, separation of the placenta (abruption), and compression of the fetus’s umbilical cord. The earlier that PPROM occurs, the greater the risk of complications for the baby. For women who break their water after 34 weeks, the risks of continuing the pregnancy usually outweigh the benefits, and delivery is usually recommended. For women who break their water between 24 and 34 weeks, the complications associated with early delivery are high enough that if the mom and baby appear to be healthy, the pregnancy will be continued, usually in the hospital with the mother on bedrest. Since the membranes surrounding the baby are the barrier to the outside world, the main risk of continuing a pregnancy with PPROM is developing an infection that can make the mother and baby sick.PPROM is usually diagnosed based on history, physical exam, and ultrasound. Once PPROM has been diagnosed, if there are no signs of labor or infection, antibiotics may be started to try and increase the length of time between when the water breaks and when the delivery occurs. Steroids such as betamethasone or dexamethasone are usually given to the mother to decrease the likelihood of complications if the baby is born early. The mother and baby are monitored carefully to look for signs of infection, separation of the placenta (abruption), or fetal distress (low heart rate of the fetus on the monitor or periodic dips in the heart rate). Sometimes an amniocentesis is performed to test the fluid around the baby for infection and./or lung maturity. Because of the risk to the baby and the mother, most women with PPROM remain in the hospital from the time that they are diagnosed until they deliver.
Cervical Insufficiency
Cervical insufficiency refers to the opening of the cervix in the absence of any contractions. This usually happens in the late second trimester or the early third trimester of pregnancy (16 to 22 weeks from the last menstrual period). Risk factors for cervical insufficiency include a history of surgery on the cervix or abnormal formation of the cervix. Another term used for this condition is cervical incompetence.Women who have a history of pregnancy loss in the second trimester or preterm delivery consistent with cervical insufficiency may be monitored with ultrasound measurements of the cervix during the pregnancy, or they may be offered a cerclage. A cerclage is a stitch that is placed in the cervix to try and prevent it from dilating early. When a cerclage is placed due to a history of cervical insufficiency, the surgery is usually performed at 13-14 weeks of pregnancy. If a woman is monitored with cervical ultrasound, a cerclage may be performed when cervical shortening is noted. The risks of cerclage include bleeding, infection, rupture of the membranes, and pregnancy loss. These risks are increased when the cerclage is placed later in pregnancy, or if the cervix is dilated at the time of the surgery.
For more information on cervical insufficiency:
March of Dimes
http://www.marchofdimes.com/pnhec/188_20201.asp
Intrauterine Growth Restriction (IUGR)
Growth restriction occurs when a fetus is not able to grow to its genetically determined potential size. This occurs when the fetus is not able to get the nutrients and oxygen that it needs, due to decreased levels of oxygen and nutrients in the mother’s blood, or due to problems with the placenta that keep the nutrients in the mother’s blood from being transferred to the baby. Problems with the placenta can result from medical problems in the mother such as high blood pressure, diabetes, autoimmune disease, smoking, and problems leading to increased blood clots. Problems with the baby’s genes (chromosomal anomalies) or the way that the placenta formed (velamentous cord insertion) can lead to growth restriction as well. Intrauterine growth restriction leads to increased risks for the baby, both before, during, and after birth.It is difficult to determine what a fetus’s genetically determined growth potential would be, so intrauterine growth restriction is diagnosed by ultrasound estimate of the baby’s weight. Small for gestational age (SGA) is defined as babies who are in less than the 10th percentile for their gestational age. However, it is important to remember that some of these babies may be genetically destined to be small, and so are entirely normal, and not at increased risk for complications. Since obstetric practitioners can’t easily determine which fetuses are meant to be small and which ones are not, all fetuses who are estimated to be small are monitored for potential complications. Follow-up ultrasounds to see how the baby is growing, measuring the blood flow in the umbilical cord, monitoring the fluid around the baby, monitoring the fetal heart rate as well as determining how the baby is moving are all ways to monitor how the baby is doing.
The decision to deliver a baby with growth restriction depends on the gestational age of the baby, the presence of other complications in the mother or baby, and the indicators of how the baby is doing. Once there is evidence that the risk to the baby of staying in the womb is greater than the risk of delivery, delivery is indicated. After delivery, the baby will be evaluated by the pediatrician to see if there are any signs that the baby was not getting all the nutrients that it needed during the pregnancy. Breastfeeding is important for both the mother and the baby.
Placental Abruption
Placental abruption is defined as premature separation of the placenta from the uterus. Abruption increases the risk of preterm delivery as well as risk of injury to the mother and baby. Risk factors for abruption include smoking, high blood pressure, preeclampsia, preterm premature rupture of the membranes, trauma, and drug use.The symptoms of abruption are usually vaginal bleeding and abdominal pain. Abruption is diagnosed based on history, symptoms, and physical exam. Ultrasound may be used to assess the well being of the fetus and look for a separation of the placenta. If an abruption is seen, the likelihood that there is an abruption is very high, but ultrasound will not detect more than half of abruptions. A blood test to see if there are fetal blood cells in the maternal circulation is sometimes checked as well. This test (Kleihauer-Betke) can confirm the diagnosis when it is positive, but does not rule out the diagnosis when it is negative.
Management of a woman with an abruption depends on the gestational age and the well-being of the mother and the fetus. If an abruption occurs early in pregnancy and the mother and baby are stable, the pregnancy may be continued. Steroids such as betamethasone or dexamethasone are given to decrease the likelihood of complications if the baby is born early. If there is evidence that bleeding is leading to distress in the mother or the baby, then delivery is indicated. Blood in the uterus stimulates contractions, so some women with abruptions will go into labor on their own.
For more information on abruption:
March of Dimes
http://www.marchofdimes.com/pnhec/188_1135.asp
Placenta Previa
Placenta previa refers to a placenta that is over the opening to the uterus, the cervix. The reason why the placenta implants over the cervix is not clear. Placenta previa is associated with bleeding during pregnancy and at the time of delivery, a need for blood transfusion, an increased risk of hysterectomy, and an increased likelihood of early delivery. Women with a placenta previa must be delivered by cesarean as the placenta is blocking the opening to the birth canal.Placenta previa is usually diagnosed on ultrasound. Many women who are thought to have a placenta previa in early pregnancy will not have a placenta previa later in pregnancy.
The primary symptom of placenta previa is painless bleeding, although some women do have painful contractions with bleeding. Women with bleeding from a placenta previa will be admitted if the bleeding is significant enough to cause the mother or fetus to be in distress, or if it occurs after 24 weeks. During the admission, the woman is monitored to make sure that the bleeding stops, and given steroids such as betamethasone or dexamethasone to decrease the likelihood of complications if the baby is born early. If the bleeding stops, a woman may be able to go home if she lives close to a hospital and has someone available to take her to the hospital if bleeding occurs. Women who have multiple episodes of bleeding or ongoing bleeding may remain in the hospital. Because there is always a risk of bleeding with placenta previa, most women are delivered by 36-37 weeks, when the likelihood of complications from prematurity is low.
Women with a placenta previa are at increased risk for having a placenta that is abnormally adherent to the uterus (placenta accreta). More rarely, the placenta may invade the muscular layer of the uterus or push through the uterus entirely (placenta increta or percreta, respectively). Placenta accreta can sometimes be diagnosed by ultrasound and MRI. Women who have had cesarean deliveries in the past are at increased risk for placenta accreta. Placenta accreta is associated with high blood loss at the time of delivery, the need for blood transfusion, an increase in surgical complications, and need for cesarean hysterectomy (removal of the uterus at the time of cesarean delivery.)
If the hospital has an interventional radiology unit, sometimes catheters can be placed into the femoral arteries of the mother, and manipulated into the pelvic vessels with the infusion of coils or pledgets to decrease the bleeding so that hysterectomy might be avoided.
Vasa previa refers to the situation where fetal vessels run over the cervix, unprotected by the umbilical cord. When the water breaks, these vessels are at risk for rupturing also, resulting in bleeding from the baby. Since the baby has only a small amount of blood, this bleeding can result in compromise to the baby or even death. Vasa previa is sometimes diagnosed by ultrasound. Women with vasa previa are delivered by cesarean delivery to avoid the water breaking and damaging the fetal vessels usually before 37 weeks of gestation.
For more information on placenta previa or accreta:
March of Dimes- Placenta Previa
http://www.marchofdimes.com/pnhec/188_1132.asp
March of Dimes- Placenta Accreta
http://www.marchofdimes.com/pnhec/188_1128.asp
Rh Alloimmunization
Alloimmunization refers to a process when there is a specific difference in Rhesus (Rh) factor[PR4] between the mother (Rh negative) and the fetus (Rh positive): the mother’s immune system can then attack the fetus’s red blood cells, causing the fetus to have a low blood count (anemia). During the course of a normal pregnancy, there is a small amount of mixing of the fetus’s blood and the mother’s blood. If the baby is Rh positive and the mom is Rh negative, when the fetus’s blood is in the mother’s circulation, the immune system recognizes something new, and gets ready to respond to it by making antibodies. The next time that a woman is pregnant, if the baby is Rh positive, the antibodies that were made attach themselves to the fetal red blood cells, which causes them to be removed from the circulation and destroyed. Depending on how much of the antibody the mother makes, the fetus may become very anemic, which can make the baby sick both before and after it is born.Luckily, there is a way to prevent the mother’s body from making these antibodies. All women who are Rh negative should have a shot called Rhogam if they have bleeding during pregnancy, an amniocentesis, an abortion, a miscarriage, or a version (turning the position of the baby around from head up to head down). Rhogam is also routinely given to women at between 28 to 32 weeks in their pregnancy for the very tiny chance that this sensitization might occur during the current pregnancy. At delivery, the baby’s blood type is determined, and if the baby is Rh positive, the mother should receive a Rhogam shot before leaving the hospital.
All women get a blood type with Rh factor and antibody screen at the beginning of the pregnancy. If a woman is found to have a certain antibody that has the capability of causing problems to the fetus during the pregnancy, the father’s blood type may be determined. If he has the same blood type as the mother, the baby will have the same blood type as well, and so will not be affected by the antibody. If the mother and father have different blood types, an amniocentesis can be performed to determine the blood type of the baby.
If the blood type of the baby is different from the mom, then the baby could be affected by the antibodies. The antibody level correlates with the likelihood of the baby being affected, so the antibody test will be checked every month. If the antibody is high enough, then the baby needs to be tested to see if anemia has developed.
Originally, testing to see whether the baby was anemic was done by amniocentesis, but now an ultrasound can be done that estimates how anemic the baby is by measuring the speed that the blood is traveling in one of the main blood vessels in the brain (middle cerebral artery dopplers). If the speed is high, the likelihood of anemia is high. The next step is to test the blood count of the fetus directly by putting a needle in the fetus’s umbilical cord and testing the baby’s blood count. If the blood count is low, the baby can be given a blood transfusion while the needle is still inside the uterus. The transfusion may have to be performed several times over the next few weeks to keep the baby from becoming anemic. If a woman has had a pregnancy where her baby was anemic, the likelihood of complications in the next pregnancy is increased.
For more information about Rh factor and pregnancy:
American College of Obstetricians and Gynecologists
http://www.acog.org/publications/patient_education/bp027.cfm
National Institute of Health
http://www.nlm.nih.gov/medlineplus/ency/presentations/100217_1.htm
Birth Defects
Birth defects are abnormalities in the way that the baby formed, that are present when the baby is born. Birth defects can be caused by a problem with the genes, a problem with the number of chromosomes (e.g., Down Syndrome), an exposure to an infection or a chemical during pregnancy, or an unknown cause. Some birth defects can be diagnosed during pregnancy, while others can only be seen after the baby is born. There are screening tests to determine the risk of chromosomal abnormalities (Quad Screen and First Trimester Nuchal Translucency and Blood Screening). Many babies with chromosomal abnormalities have birth defects, but not all babies with birth defects have chromosomal abnormalities. Some birth defects are diagnosed by ultrasound. Ultrasound may be able to see a problem with the baby’s heart (problems with the heart valves or blood vessels of the heart), spinal cord (spina bifida or neural tube defects), or abdominal wall (gastroschisis or omphalocele).Once a birth defect is diagnosed, mothers are often referred to a hospital where they have experience taking care of babies with birth defects. Depending on the specific problem, the doctors may recommend delivery at a hospital with specialists in taking care of newborns (neonatologists) and pediatric surgeons. In some cases, there may be a treatment or surgery that can be performed while the fetus is in the uterus to help the fetus develop more normally.
For more information on birth defects, fetal therapy and genetic testing:
UCSF Fetal Treatment Center
http://fetus.ucsfmedicalcenter.org
National Institute of Child Health and Human Development
http://www.nichd.nih.gov/womenshealth/research/pregbirth/birthdefects.cfm
March of Dimes
http://www.marchofdimes.com/pnhec/4439.asp
Infection in Pregnancy
Urinary Tract Infections
Urinary tract infections are the most common infection in pregnant women. Because of the changes to the body during pregnancy, pregnant women are at high risk of developing bladder and kidney infections. Some pregnant women have bacteria in the urine without having symptoms of a bladder infection; if this is not treated, the likelihood of developing a kidney infection is increased. The symptoms of kidney infection include fever, chills, and pain in the abdomen and back. A kidney infection can be life threatening for the mother and can increase the risk of early delivery of the baby, so most women with kidney infections are admitted to the hospital. After a woman has had a kidney infection in pregnancy, antibiotics are continued at a low dose for the rest of the pregnancy to prevent another kidney infection.Infections that are especially concerning during pregnancy
There are a number of infections that women can get during pregnancy that may be transmitted to the fetus and cause birth defects or stillbirth. These infections include toxoplasmosis, rubella, cytomegalovirus, parvovirus, listeria, and herpes simplex virus.Toxoplasmosis is an infection that is transmitted to people by eating inadequately cooked meat or having contact with cat feces. The risks to the mother are minimal, but depending on the time of the infection, the baby may have problems with hearing or developmental delay. The best way to prevent toxoplasmosis infection is to avoid eating undercooked meat, to wash hands and kitchen surfaces thoroughly after contact with raw meat, and to avoid contact with cat feces (e.g. wear gloves while gardening).
Most people are vaccinated against rubella, and all pregnant women are tested to see if they are immune, or protected from this infection.
Cytomegalovirus (CMV) is a virus that is transmitted from person to person by contact with bodily fluids. Women who work with young children (such as women working at a daycare center) are at increased risk of infection. Women who get CMV for the first time during pregnancy have the highest risk of passing the infection to the fetus. About 50% of women have been exposed to CMV; people who have been exposed before can still pass the infection to the fetus, but the effects are not usually as severe. Cytomegalovirus infection in the baby can lead to hearing loss, developmental delay, and eye problems. Depending on the time in the pregnancy when the infection happens, amniocentesis may be used to help determine if the baby is infected, but no test before birth can tell for sure what the effects on the baby will be. The best way to avoid cytomegalovirus infection is to practice good handwashing and safe sex.
Parvovirus (Fifth disease) is a viral infection spread from person to person. Children with parvovirus may have a characteristic “slapped cheek” rash. The symptoms in the mother may include a rash and joint pain. Sometimes there no symptoms at all and transmission is by exposure to an infected person. If the fetus is infected, there is a chance that the fetus will become anemic (low blood count). This can lead to stillbirth. If a woman is exposed to parvovirus for the first time during pregnancy and develops the infection herself, then the fetus will be monitored with ultrasound to see if there is evidence of anemia. If anemia develops, sometimes it can be treated by giving a transfusion into the umbilical cord. If there is no anemia, there are no other effects of the infection. The best way to avoid parvovirus infection is to wash your hands frequently and avoid contact with children who are sick.
Listeria is an uncommon infection that is transmitted by eating unpasteurized dairy products or deli meats. The main symptoms in the mother are fever and malaise, like the flu. If the fetus is infected, it can lead to stillbirth. The best way to prevent listeria infection is to avoid eating foods that could contain the bacteria: hot dogs, deli meats (unless reheated to steaming), soft cheeses like brie, feta, camembert, and queso fresco, pate, meat spreads, smoked salmon, or unpasteurized milk.
Herpes is a virus that causes cold sores and genital herpes infection. Symptoms of genital infection include pain and burning, usually in the presence of tiny blisters. Because of the immune system changes during pregnancy, if a woman is infected with herpes for the first time during pregnancy, the infection can become more serious, leading to effects on the mother’s liver and brain. If the baby is infected during pregnancy, the infection can have effects on the brain or lead to death. Most of the time, if a baby becomes infected, it is during delivery, through an infected birth canal. For women who know that they have herpes, medication (acyclovir) can be given during the last month of pregnancy to decrease the likelihood of infection at the time of delivery. Any women with symptoms of herpes infection at the time of delivery will have an exam of the vagina and vulva; if there are herpes sores present, a cesarean delivery may be recommended to decrease the likelihood of the baby getting infected.
Human Immunodeficiency Virus (HIV)
All pregnant women are offered testing for human immodeficiency virus (HIV) during pregnancy. For women with HIV who are not treated with any anti-HIV medications during pregnancy or labor and delivery, there is about a 25% risk of giving the infection to the baby during delivery, and an additional risk of infection during breastfeeding. The best way to reduce the likelihood of transmission to the baby is to treat the mother’s HIV during pregnancy. Women with HIV should see a doctor before conception to make sure that they are on medications that are safe in pregnancy, and to assure that the level of infection (viral load) is as low as possible. Additional anti-HIV medications will be given during labor and delivery to decrease the likelihood of transmission to the baby. For women with a low viral load, the risk of transmission is the same with vaginal delivery or cesarean delivery. For women with a higher viral load, a cesarean delivery before labor decreases the likelihood that the baby will be infected. The baby will be given anti-HIV medications after delivery to further reduce the risk of infection. With all of these measures, the risk of transmission to the baby can be reduced to less than 2%. Because of the risk of transmission of HIV, women with HIV should not breastfeed.http://www.nlm.nih.gov/medlineplus/aidsandpregnancy.html
For more information about infections in pregnancy:
National Institutes of Health
http://www.nlm.nih.gov/medlineplus/infectionsandpregnancy.html
For more information about toxoplasmosis and pregnancy:
Centers for Disease Control
http://www.cdc.gov/toxoplasmosis/pregnant.html
For more information on cytomegalovirus and pregnancy:
Centers for Disease Control
http://www.cdc.gov/cmv/pregnancy.htm
For more information about parvovirus and pregnancy:
Centers for Disease Control
http://www.cdc.gov/ncidod/dvrd/revb/respiratory/B19&preg.htm
For more information about listeria and pregnancy:
United States Department of Agriculture
http://www.fsis.usda.gov/Fact_Sheets/Protect_Your_Baby/index.asp
For more information about herpes and pregnancy:
National Institutes of Health
http://www.nlm.nih.gov/medlineplus/ency/article/001368.htm
For more information about HIV and pregnancy
Centers for Disease Control
http://www.cdc.gov/hiv/topics/perinatal/index.htm
National Institutes of Health
http://www.nlm.nih.gov/medlineplus/aidsandpregnancy.html
Dermatologic Disorders in Pregnancy
The skin is affected by the changes in hormones and metabolism during pregnancy. Common normal changes in the skin seen during pregnancy include darkening of the skin (hyperpigmentation or melasma), changes in superficial blood vessels, stretch marks, and changes in the hair and nails. Pregnant women are at risk for the same skin disorders that nonpregnant women are; in addition, there are several skin conditions that are directly related to pregnancy.Pruritic Urticarial Papules and Plaques of Pregnancy (PUPPS) is the most common skin condition associated with pregnancy. It primarily occurs in women having their first baby, and usually starts towards the end of pregnancy. Frequently, the first lesions are within the stretch marks on the abdomen. Lesions can look many different ways, and can spread over the chest and extremities, although usually not on the face. Though PUPPS can be uncomfortable, it does not increase the risk to the mother or the baby.
Herpes gestationis an autoimmune disorder that is seen during the second or third trimester, usually starting with itchy lesions on the abdomen. Shortly after the initial itchy lesions, the skin forms bubbles or bullae (large blisters) all over the body. These lesions can increase at the time of delivery. Other than infection and discomfort, there is no significant risk to the mother, and it usually resolves after the baby is born. The baby may be at risk for being small, being born early, and having mild skin lesions at the time of birth.
For more information on skin disorders during pregnancy:
American College of Obstetricians and Gynecologists
http://www.acog.org/publications/patient_education/bp169.cfm
Cholestasis of Pregnancy
Cholestasis of pregnancy is a problem with the mother’s liver that increases risk for the fetus. The primary symptom of cholestasis of pregnancy is itching without a rash. Itching typically involves the palms and soles, the legs, or the whole body. The level of bile acids in the blood or the level of liver enzymes in the blood is elevated in cholestasis, so blood tests are helpful. The diagnosis of cholestasis is usually made by excluding other possible causes of the symptoms.The main effect of cholestasis on the mother is the symptom of itching, which can be intense. Medications can be used to help control the itching. Cholestasis carries an increased risk of stillbirth, early delivery, and meconium staining of the amniotic fluid. Once cholestasis is diagnosed, there is increased monitoring of the baby. To try and avoid stillbirth, women with cholestasis are often delivered before their due date; depending on how early the delivery is, the baby may have complications because of being born early. Cholestasis resolves after delivery.
More links for general pregnancy information:
National Institutes of Health
http://www.nlm.nih.gov/medlineplus/pregnancy.html
Department of Health and Human Services Healthy Pregnancy
http://www.womenshealth.gov/pregnancy/
March of Dimes- Pregnancy Toolkit
http://www.marchofdimes.com/pnhec/28699.asp
Nutrition During Pregnancy Resource List for Consumers
http://www.nal.usda.gov/fnic/pubs/bibs/topics/pregnancy/pregcon.html
Centers for Disease Control
http://www.cdc.gov/ncbddd/pregnancy_gateway/default.htm
For general information on high risk pregnancy:
National Institute of Child health and Human Development
http://www.nichd.nih.gov/health/topics/high_risk_pregnancy.cfm
Sidelines- a support network for women with high risk pregnancies and premature births
http://www.sidelines.org