Counseling for women with preeclampsia or eclampsia

Preconception counseling may address issues such as nutrition, prevention and prediction of preeclampsia, utility of prenatal visits and fetal surveillance, risk of superimposed preeclampsia, recurrence risks for future gestation, diagnosis of underlying predisposing factors, and potential impact on future maternal and fetal health. Although certainty is lacking in medicine, it appears that minimal risk to either mother or fetus is attributable to mild chronic hypertension complicating pregnancy. Increased maternal and fetal morbidity is associated with superimposed preeclampsia. Unfortunately, we are unable to predict which of these gravidas will have superimposed preeclampsia and thus suffer added morbidity. There appears to be a greater than 50% chance of maternal or fetal morbidity for those women entering pregnancy with severe chronic hypertension in association with other renocardiovascular complications. Unfortunately, for the majority of women whose medical condition falls between these two extremes, the current predictive value remains vague. The best option is to review the existing literature with patients in a nondirective manner, allow them their decisions, and provide them the best available prenatal care.     

Ambulatory management of chronic hypertension in pregnancy

Chronic hypertension in pregnancy is one of the most common medical diseases affecting pregnancy. It is associated with serious maternal and fetal complications, including superimposed pre-eclampsia, fetal growth restriction, premature delivery, placental abruption, and stillbirth. Baseline evaluation as early as possible is important to differentiate women with essential hypertension from those with severe hypertension, coexisting end-organ damage, and secondary causes of hypertension, as their risks of poor outcomes are increased. An optimal plan for maternal treatment and fetal surveillance can then be formulated. Coordination of care after delivery is important for long-term maternal health and future pregnancies.     

Maternal–fetal relationships and psychological health: emerging research directions

Maternal representations of, and relationships with, the unborn baby appear to be associated with psychological health in pregnancy and beyond, and might play an important role in identifying women who need additional support, as well as providing an arena to develop positive pregnancy experiences. The mechanisms and pathways linking maternal–fetal relationships, psychological health and important outcomes are complex. This article provides an overview of some of the key findings in this area and identifies some important emerging directions for future research: the nature and form of maternal–fetal relationships and how best to measure them, the mediating and moderating factors linking maternal–fetal relationships with psychological health and other outcomes in pregnancy and beyond, and the importance and acceptability of the concept of maternal–fetal relationships to women.     

Pregnancy after organ transplant

The frequency and variety of solid organ transplantation in reproductive-age women increases each year. Pregnancy is no longer contraindicated in transplant recipients provided that their graft is functioning well and they are in good general health. Physicians who care for pregnant transplant recipients should be aware of the surmounting data that are available in the literature and through registries of maternal, fetal, and neonatal risks and complications as well as outcome data. Newer immunosuppressive agents preserve graft function and registry data attest to their safety in pregnancy.For optimal maternal and neonatal outcomes, a multispecialty care approach that includes the obstetrician/maternal-fetal specialist,transplant team, anesthesiologist, and neonatal team is prudent when caring for pregnancies after organ transplantation.     

Determinants of Maternal Mortality in the Developing World

Maternal mortality is the culmination of a series of detrimental events in a woman's life, pregnancy being the last one. The underlying pathology is the lack of education, sanitation, accessible health care, as well as poor nutrition and poverty. These affect women during pregnancy and childbirth when they are more vulnerable. This 10-year review of literature from the developing world focuses on, and discusses the determinants of maternal mortality. Methods of reducing maternal mortality through policy addressing health care needs are touched on.     

Contraception and preconception counseling in women with autoimmune disease

Appropriate contraception and preconception counseling are critical for women of reproductive age with systemic autoimmune diseases (AIDs) because clinical diagnosis, rheumatology medications, and disease activity may impact the safety or efficacy of certain contraceptives as well as the risk of adverse pregnancy outcomes. The presence of antiphospholipid (aPL) antibodies (anticardiolipin, anti-β2 glycoprotein I, and lupus anticoagulant) is the most important determinant of contraception choice, as women with these antibodies should not receive estrogen-containing contraceptives because of the increased risk of thrombosis. Prepregnancy counseling generally includes the assessment of preexisting disease-related organ damage, current disease activity, aPL antibodies, anti-Ro/SS-A and anti-La/SS-B antibodies, and medication safety in pregnancy. Quiescent AID for six months on pregnancy-compatible medications optimizes maternal and fetal/neonatal outcomes for most patients.     

Excessive Gestational Weight Gain

Excessive gestational weight gain (GWG) is associated with an increasing incidence of maternal and neonatal complications, including hypertensive disorders of pregnancy, fetal macrosomia, and increased cesarean birth rates. In the United States, it is recommended that health care providers use an individualized approach to counsel a woman about pregnancy weight gain goals that is based on the woman's initial body mass index (BMI) and to track GWG throughout the pregnancy by evaluating maternal weight at each visit. Studies have shown that women entering pregnancy with a higher BMI are at increased risk for excessive GWG and postpartum weight retention. Research also demonstrates an increased risk of childhood obesity in children born to women with excessive GWG. Specific counseling about exercise and diet, as well as technology and motivational interviewing, are some tools prenatal care providers can use that have been shown to be effective in reducing excessive GWG. This article reviews the current research regarding maternal and neonatal risks associated with excessive GWG, as well as the interventions that have demonstrated promise for addressing this problem.     

The findings of the MBRRACE-UK confidential enquiry into Maternal Deaths and Morbidity

Reports from the UK Confidential Enquiries into Maternal Deaths and Morbidity are now published annually. In 2013–15, the maternal mortality rate was 8.8 per 100,000 maternities. Over two thirds of women died from medical and mental health causes and less than one third from obstetric causes. Cardiac disease remained the leading cause of maternal death in the UK. With the majority of women dying from pre-existing conditions, there remain multiple opportunities to reduce women's risk of complications in pregnancy through early and forward planning of the care of women with known pre-existing medical and mental health problems. Provision of appropriate advice and optimisation of medication prior to pregnancy, referral early in pregnancy for the appropriate specialist advice and planning of antenatal, intrapartum and postnatal care and effective postnatal provision of advice concerning risks and planning for future pregnancies are the key improvements needed to prevent women dying in the future.     

Lebererkrankungen in der Schwangerschaft

Liver diseases in pregnancy can result in maternal as well as fetal complications. Intrahepatic cholestasis in pregnancy may lead to a high fetal risk of IUD, meconium-stained amniotic fluid, premature delivery, asphyxia and arrhythmia. Concerning a good fetal outcome there is no evidence-based therapy. Pruritus and elevated cholic acid can be treated and controlled well by ursodeoxycholic acid. Since there is a higher risk of intrauterine death, most common at 37+ weeks of gestation, delivery is recommended starting at 36+ weeks, even earlier when excessively high cholic acid levels occur. Acute fatty liver of pregnancy is linked to higher maternal and fetal mortality. There are regular crossovers to the HELLP syndrome. Cholelithiasis causes 6% of all jaundice in pregnancy and thus has to be considered as another differential diagnosis particularly in multiparity. If operative treatment is required for cholecystolithiasis during pregnancy the best fetal outcome is achieved in the second trimester. It is likely that in the future chronic liver diseases such as Wilson??s disease and autoimmune hepatitis will be seen more often during pregnancy since there are increasingly better options for treatment. The same applies to pregnant women who have already undergone liver transplantation. An interdisciplinary approach with hepatologists in these high-risk pregnancies is mandatory.     

Pregnancy in women with renal disease. Part II: specific underlying renal conditions

The obstetric outcome in women with kidney disease has improved in recent years due to continuous progress in obstetrics and neonatology, as well as better medical management of hypertension and renal disease. However, every pregnancy in these women remains a high-risk pregnancy. When considering the interaction between renal disease and pregnancy, maternal outcomes are related to the initial level of renal dysfunction more than to the specific underlying disease. With regards to fetal outcomes, though, a distinction may exist between renal dysfunction resulting from primary renal disease and that in which renal involvement is part of a systemic disease. In part II of this review, some specific causes of renal failure affecting pregnancy are considered.     

The 1988 National Maternal and Infant Health Survey: Design,Content, and Data Availability

ABSTRACT: The 1988 National Maternal and Infant Health Survey was conducted by the National Center for Health Statistics to study factors related to poor pregnancy outcome, such as adequacy of prenatal care; inadequate and excessive weight gain during pregnancy; maternal smoking, drinking, and drug use; and pregnancy and delivery complications. The survey is a nationally representative sample of 11,000 women who had live births, 4000 who had late fetal deaths, and 6000 who had infant deaths in 1988. Mothers were mailed questionnaires based on information from certificates of live birth, reports of fetal death, and certificates of infant death. Information supplied by the mother, prenatal care providers, and hospitals of delivery was linked with the vital records to expand knowledge of maternal and infant health in the United States. Data collection from the Longitudinal Followup of mothers in the survey began in January 1991. It provides information on health and development of low- and very low-birthweight babies, child care and safety, maternal health, maternal depression, and plans for adoption and foster care. Both surveys will provide useful data for clinicians in maternal and child health.     

Periconceptional care of women with diabetes mellitus

Pregestational diabetes is a common complication of pregnancy that can be associated with severe maternal and fetal morbidity. In addition, some women could have progression of diabetic complications secondary to pregnancy. Preconception care can significantly reduce pregnancy complications with a dramatic impact on the diabetic mother and her infant. For those women whose condition could be hastened by conception education, better understanding and an improved decision should be available to them and their families. Because unplanned pregnancy is common among diabetic women, they should be counseled early for the importance of preconception care in the progression of this disease.     

Maternal obesity and pregnancy outcome

The increasing prevalence of maternal obesity worldwide provides a major challenge to obstetric practice from preconception to postpartum. Maternal obesity can result in unfavorable outcomes for the woman and fetus. Maternal risks during pregnancy include gestational diabetes and chronic hypertension leading to preeclampsia. The fetus is at risk for stillbirth and congenital anomalies. Intrapartum care, normal and operative deliveries, anesthetic and operative interventions in the obese demand extra care. Obesity in pregnancy can also affect health later in life for both mother and child. For women, these risks include heart disease and hypertension. Children have a risk of future obesity and heart disease. Women and their offspring are at increased risk for diabetes. Obstetrician-gynecologists should be well informed to prevent and treat this epidemic. Interventions directed at weight loss and prevention of excessive weight gain during pregnancy must begin in the preconception period.     

Thyroid (dys-)function in normal and disturbed pregnancy

Introduction

During pregnancy, physiologic changes in maternal thyroid function take place especially due to hormonal as well as metabolic processes. Human chorionic gonadotropin activates the maternal thyroid gland leading to increased thyroid hormone production. A sufficient availability of maternal thyroid hormones is essential for fetal development, especially during the first trimester of pregnancy, when the fetal thyroid gland is not yet functional.

Materials and Methods

Current knowledge of thyroid dysfunction including thyroid autoimmunity, hypothyroidism or hyperthyroidism is summarized with special focus on miscarriage and pregnancy disorders. Therefore, a Medline research as well as an analysis of current guidelines on thyroid function and pregnancy was performed.

Results

A study focusing on TSH levels in normal and disturbed pregnancies, the risk of miscarriage in association with thyroid autoantibodies, and (subclinical) hypothyroidism in infertile and fertile women were included.

Conclusion

Maternal thyroid dysfunction negatively affects pregnancy outcome. Besides a routine iodine supplementation in pregnant women and treatment of hypo as well as hyperthyroidism, TSH levels should routinely be measured in women during childbearing years and adjusted to concentrations <2.5 mIU/l in order to optimize maternal health and fetal development.     

Micronutrients in women's reproductive health: I. Vitamins

Proper nutritional status of women before, during, and after pregnancy is an important element of reproductive health. It maintains maternal health and reduces the risk of adverse pregnancy outcome, birth defects and chronic disease in children later in postnatal life. Pregnancy creates a special metabolic demand for high-quality nutrients. With careful food selection, it is possible to obtain most of the recommended levels of nutrients. Apart from the dietary intake, nutrition is highly dependant on economic status, social and cultural environment, and personal habits of the mother. Nutritional imbalance could cause detrimental effects to the pregnant woman, influence pregnancy outcome, and impair breast milk composition. Despite the extensive research, we still do not have a complete understanding how nutritional status of the mother influences her health as well as fetal growth and development. It is well known that fetal growth and development is strongly linked with maternal supply of essential nutrients, e.g. vitamins. The exact role of the variety of micronutrients in fetal growth and development has yet to be explored in detail. It is estimated that up to 30% of pregnant women suffer from a vitamin deficiency. Without supplementation, about 75% would show a deficit of at least one vitamin. Moreover, multivitamin deficit combinations often co-exist, and subclinical depletations are probably common; consequences could be severe. Studies carried on in developing countries have shown that improving micronutrient intake in deficient women can reduce maternal morbidity and mortality. Also, proper maternal intake of important micronutrients directly enhances the quality of breast milk. To meet the increasing demands during pregnancy and the breastfeeding period women should not be dependent only upon the dietary intake: adequate reserve is essential for the successful pregnancy outcome.     

Cancer in pregnancy: fetal and neonatal outcomes

Cancer during pregnancy represents a potential conflict between optimal maternal treatment and fetal development. Traditionally, clinicians operated under the assumption that cancer treatment during pregnancy is incompatible with normal fetal development. However, recent evidence suggests that many diagnostic and treatment modalities cause little or no harm to the developing fetus. As such, both maternal and neonatal interests should be considered when developing management strategies for pregnant cancer patients. In this review, we will discuss issues related to fetal and neonatal health associated with conventional diagnostic and treatment approaches in the care of pregnant women with cancer. In addition, we offer recommendations on strategies to maximize fetal outcomes in pregnancies complicated by cancer.     

Maternal cardiac disease in pregnancy

The 2019 MBRRACE-UK report highlighted the prevalence of cardiac disease amongst pregnant women, and its role as a driver in maternal mortality. Advancing maternal age, a rise in cardiovascular co-morbidities, and the improvements in congenital heart disease care have all contributed to this static prevalence, despite improvements in obstetric and cardiac care. In this review we consider the importance of pre-conception counselling for women with known heart disease, review the physiological changes of pregnancy which place increased demand on the cardiovascular system, and explore maternal risk, from a cardiovascular perspective. Contemporary management of women with moderate to severe heart disease during pregnancy should be delivered by the pregnancy heart team, a term coined by the European Society of Cardiology in its 2018 guidelines. Individualized care empowers trust and shared decision making and early access to multidisciplinary care is vital in optimizing maternal and fetal outcomes.     

The Fascinating and Complex Role of the Placenta in Pregnancy and Fetal Well‐being

Existing evidence implicates the placenta as the origin of some common pregnancy complications. Moreover, some maternal conditions, such as inadequate nutrition, diabetes, and obesity, are known to adversely affect placental function, with subsequent negative impact on the fetus and newborn. The placenta may also contribute to fetal programming with health consequences into adulthood, such as cardiovascular, metabolic, and mental health disorders. There is evidence that altered placental development, specifically impaired trophoblast invasion and spiral artery remodeling in the first trimester, is the origin of preeclampsia. Prenatal care providers who understand the relationships between placental health and maternal‐newborn health can better inform and guide women to optimize health early in pregnancy and prior to conception. This article reviews the current understanding of placental function; placental contributions to normal fetal brain development and timing of birth; and impact of maternal nutrition, obesity, and diabetes on the placenta.     

Management of pregnancy in women with genetic disorders: Part 2: Inborn errors of metabolism, cystic fibrosis, neurofibromatosis type 1, and Turner syndrome in pregnancy

With early diagnosis and increasingly effective medical care, more women with genetic syndromes are undergoing pregnancy, often presenting challenges for providers. Each year more women with genetic disease reach childbearing age. Advances in assisted reproductive technology have enabled pregnancy in a cohort of woman who experience impaired fertility because of their underlying diagnosis. Management of these women requires health care providers from multiple specialties to provide coordinated care to optimize outcomes. Potentially, serious medical issues specific to each diagnosis may exist in the preconception, antepartum, intrapartum, and postpartum periods, all of which must be understood to allow timely diagnosis and treatment. The fetus may also face issues, both related to risk for inheritance of the genetic disorder observed in the mother as well as risks related to her chronic disease status. In this article, the second of a 2-part series, we will review the key issues for managing women with various inborn errors of metabolism during pregnancy. Additionally, we will discuss the care of women with Turner syndrome, neurofibromatosis type 1, and cystic fibrosis. TARGET AUDIENCE: Obstetricians & Gynecologists and Family Physicians. LEARNING OBJECTIVES: After the completing the CME activity, physicians should be better able to classify the pulmonary and nutritional issues facing women with cystic fibrosis in pregnancy, assess the baseline evaluation that should take place in women with Turner syndrome, NF1 and cystic fibrosis before attempting pregnancy and evaluate the fetal risks that can be observed in women with untreated inborn errors of metabolism.