Respiratory disease in pregnancy

Breathlessness in the absence of an underlying pathology is common in pregnancy. Asthma affects about 7% of women of childbearing age. Treatment is the same as for the non-pregnant population and most drugs are safe in pregnancy. Educating women to continue preventer inhaled corticosteroid therapy will reduce the risk of attacks. Respiratory infections are associated with a higher morbidity in pregnancy and should be treated aggressively. Most chronic pulmonary diseases do not alter fertility. Large reserves in respiratory function allow the fetus and mother to survive without compromise in most cases. The use of chest X-rays should not be avoided in pregnancy. Women with a chronic respiratory disease should receive pre-pregnancy counselling and education. Women should be managed in a multidisciplinary setting with the respiratory team. The presence of pulmonary hypertension and cor pulmonale is associated with a high risk of death in pregnancy.     

Respiratory disease in pregnancy

Breathlessness in the absence of an underlying pathology is common in pregnancy, but serious causes should be excluded depending on symptoms. The use of chest X-rays should not be avoided in pregnancy.Asthma affects about 7% of women of child-bearing age. Treatment is the same as for the non-pregnant population and most drugs are safe in pregnancy. It is important to educate women to continue inhaled corticosteroid preventer therapy to reduce the risk of attacks. Respiratory infections are associated with a higher morbidity in pregnancy and should be treated aggressively.Women with a chronic respiratory disease should receive pre-pregnancy counselling and education, and during pregnancy managed in a multidisciplinary setting with the respiratory team. Most chronic pulmonary diseases do not alter fertility, and in the majority of cases large reserves in respiratory function allow a good pregnancy outcome for fetus and mother. In contrast, the presence of pulmonary hypertension and cor pulmonale is associated with a high risk of death in pregnancy.     

Chronic hypertension in pregnancy

Chronic hypertension in pregnancy is associated with increased rates of adverse maternal and fetal outcomes both acute and long term. These adverse outcomes are particularly seen in women with uncontrolled severe hypertension, in those with target organ damage, and in those who are noncompliant with prenatal visits. In addition, adverse outcomes are substantially increased in women who develop superimposed preeclampsia or abruptio placentae. Women with chronic hypertension should be evaluated either before conception or at time of first prenatal visit. Depending on this evaluation, they can be divided into categories of either "high risk" or "low risk" chronic hypertension. High-risk women should receive aggressive antihypertensive therapy and frequent evaluations of maternal and fetal well-being, and doctors should recommend lifestyle changes. In addition, these women are at increased risk for postpartum complications such as pulmonary edema, renal failure, and hypertensive encephalopathy for which they should receive aggressive control of blood pressure as well as close monitoring. In women with low-risk (essential uncomplicated) chronic hypertension, there is uncertainty regarding the benefits or risks of antihypertensive therapy. In my experience, the majority of these women will have good pregnancy outcomes without the use of antihypertensive medications. Antihypertensive agents are recommended and are widely used in these women despite absent evidence of either benefits or harm from this therapy. These recommendations are based on dogma and consensus rather than on scientific evidence. There is an urgent need to conduct randomized trials in women with mild chronic hypertension in pregnancy.     

Multiple sclerosis: management issues during pregnancy

Care of pregnant women with multiple sclerosis (MS) is challenging because of the multiple physiological changes associated with pregnancy and the need to consider the impact of any intervention on the foetus. Pregnancy is associated with clinical MS stability or improvement, while the rate of relapse rises significantly during the first three months post-partum before coming back to its level prior to pregnancy. Gestational history has no influence on long-term disability and MS does not seem to influence pregnancy or the child's health. Apart from methotrexate and cyclophosphamide, most drugs used regularly to treat MS can safely be used by pregnant women. Intravenous steroids may be used with relative safety during pregnancy. Maternal use of azathioprine is not associated with an increased risk of congenital malformations, though impaired foetal immunity, intrauterine growth retardation and prematurity are occasionally observed. Cyclosporin is not teratogenic, but may be associated with growth retardation and prematurity. Pregnancy should be avoided in women treated with methotrexate because of its known abortifacient effects and risk of causing typical malformations. Cyclophosphamide is teratogenic in animals, but population studies have not conclusively demonstrated its teratogenicity in humans. Until information is available regarding safety, glatiramer acetate, mitoxantrone, interferon-beta-1a and interferon-beta-1b should be discontinued before an anticipated pregnancy. Women with MS are no more likely to experience delivery complications than are women without MS and the mode of delivery should be decided strictly on obstetrical criteria. Spinal, epidural and general anaesthesia can all be used safely in MS patients. Young women with MS who desire children can be reassured that their infants are not at increased risk of malformations, preterm delivery, low birth weight, or infant death. The progressive nature of the disease may motivate affected women to start or complete their families as soon as possible.     

Chronic renal disease in pregnancy

The purpose of this review was to examine the impact of varying degrees of renal insufficiency on pregnancy outcome in women with chronic renal disease. Our search of the literature did not reveal any randomized clinical trials or meta-analyses. The available information is derived from opinion, reviews, retrospective series, and limited observational series. It appears that chronic renal disease in pregnancy is uncommon, occurring in 0.03-0.12% of all pregnancies from two U.S. population-based and registry studies. Maternal complications associated with chronic renal disease include preeclampsia, worsening renal function, preterm delivery, anemia, chronic hypertension, and cesarean delivery. The live birth rate in women with chronic renal disease ranges between 64% and 98% depending on the severity of renal insufficiency and presence of hypertension. Significant proteinuria may be an indicator of underlying renal insufficiency. Management of pregnant women with underlying renal disease should ideally entail a multidisciplinary approach at a tertiary center and include a maternal-fetal medicine specialist and a nephrologist. Such women should receive counseling regarding the pregnancy outcomes in association with maternal chronic renal disease and the effect of pregnancy on renal function, especially within the ensuing 5 years postpartum. These women will require frequent visits and monitoring of renal function during pregnancy. Women whose renal disease is further complicated by hypertension should be counseled regarding the increased risk of adverse outcome and need for blood pressure control. Some antihypertensives, especially angiotensin-converting enzyme inhibitors and angiotensin-receptor blockers, should be avoided during pregnancy, if possible, because of the potential for both teratogenic (hypocalvaria) and fetal effects (renal failure, oliguria, and demise).     

Diabetes: lessons for midwives

This study is larger than any other in describing pregnancy outcomes for women with pre-gestational diabetes. From the report, the three main messages for midwives are: Women with type 2 diabetes have a risk of poor outcome similar to those with type 1 diabetes. The same support and management of women with type 1 diabetes should be applied to women with type 2 diabetes pre-conceptionally and throughout the pregnancy and neonatal period. Pre-pregnancy care and advice should be made more flexible and advertised well in a variety of settings where diabetic women of childbearing age are most likely to see it. Women with diabetes should be encouraged and supported to breastfeed their babies from birth by giving them an understanding of the general and specific benefits this will provide.     

Pregnancy outcomes in women with chronic hypertension: a population-based study

OBJECTIVE: To determine the pregnancy outcomes associated with maternal chronic hypertension. STUDY DESIGN: Retrospective, population-based cohort study of maternal and infant discharge records linked to birth records in California from 1991 to 2001 were examined for demographics and pregnancy outcomes, and comparisons were made between those with and without chronic hypertension. One randomly selected pregnancy per subject was included. RESULTS: The number of women who delivered with chronic hypertension (0.69% incidence) was 29,842. As compared to non-chronic hypertensive patients, fetal and neonatal mortality and in-hospital maternal mortality were increased (ORs and 95% CIs 2.3, (2.1, 2.6); 2.3, (2.0, 2.7); and 4.8, (3.1, 7.6) respectively). Major maternal morbidity was increased: stroke, OR 5.3, (3.7, 7.5); renal failure, OR 6.0, (4.4, 8.1); pulmonary edema, OR 5.2, (3.9, 6.7); severe preeclampsia, OR 2.7, (2.5, 2.9); and placental abruption OR 2.1, (2.0, 2.3). Neonatal morbidity was increased as well: fetal growth restriction, OR 4.9, (4.7, 5.2); prematurity, OR 3.2, (3.1, 3.3); low birth weight, OR 5.4, (5.2, 5.5); very low birth weight, OR 6.5, (6.2, 6.8); and respiratory distress syndrome, OR 4.0, (3.8, 4.2). CONCLUSION: Pregnant women with chronic hypertension have significantly increased risks of maternal and perinatal morbidity and mortality. Women with this condition should be treated as high risk with appropriate maternal and fetal surveillance.     

Myasthenia gravis: management issues during pregnancy

Myasthenia gravis (MG) often affects women in the second and third decades of life, overlapping with the childbearing years. The course of the disease is unpredictable during pregnancy; however, worsening of symptoms occurs more likely during the first trimester and postpartum. MG can be well managed during pregnancy with relatively safe and effective therapies. Anticholinesterase drugs are the mainstay of treatment, when MG symptoms are not satisfactorily controlled, corticosteroids, azathioprine and in some cases cyclosporin A can be used. Until information is available regarding safety, mycophenolate mofetil should be discontinued before pregnancy. Pregnancy should be avoided in women treated with methotrexate because of the risk of causing typical malformations. Plasmapheresis and intravenous immunoglobulins have been successfully used in the treatment of MG crisis during pregnancy. Caesarean section is recommended only for obstetric reasons; forceps delivery and vacuum extraction are sometimes required. Epidural anesthesia is advised to reduce physical and emotional stress. MG during pregnancy can lead to serious life-threatening conditions, including respiratory insufficiency; therefore, intensive checkups by a gynaecologist and a neurologist are necessary. Women with myasthenia gravis should not be discouraged from conceiving; however, they should discuss their plan for pregnancy with their neurologist and their gynaecologist.     

Chronic hypertension in pregnancy

Pregnant women with chronic hypertension are at risk for maternal and perinatal morbidity. Careful assessment and management of these patients during pregnancy are the keys to reducing maternal and fetal complications. Antihypertensive treatment should be used in women with high-risk chronic hypertension, whereas drug therapy does not improve pregnancy outcome in women at low risk. Prophylactic low-dose aspirin started early in pregnancy in women with chronic hypertension is not effective in reducing the frequency of superimposed preeclampsia and should be avoided.     

Progression of diabetic retinopathy in pregnancy: association with hypertension in pregnancy.

OBJECTIVE: To test the hypothesis that women with insulin-dependent diabetes and chronic or pregnancy-induced hypertensive disorders are at increased risk for developing retinopathic complications during pregnancy. STUDY DESIGN: One hundred fifty-four women with insulin-dependent diabetes were prospectively followed in an intensive program of diabetes in pregnancy. Ophthalmologic evaluations were obtained through pregnancy and at 6 to 12 weeks post partum, and findings were graded by a standard scale. Association of retinopathic progression with risk factors was tested with chi 2 and multiple logistic regression analysis. RESULTS: Fifty-one women had progression of retinopathy during pregnancy; postpartum regression was observed in 13 women. Changes in glycemic control early in pregnancy, chronic hypertension, and pregnancy-induced hypertension were significantly associated with progression of retinopathy. CONCLUSION: Women with insulin-dependent diabetes who have hypertensive disorders in pregnancy are at increased risk for progression of retinopathy.     

Pregnancy-related changes in tobacco, alcohol and cannabis use reported by antenatal patients at two public hospitals in South Australia

Background: Australian substance use data do not demonstrate pregnancy-related changes or distinguish between pregnant and lactating women.
Aims: To determine such changes by antenatal patients at two South Australian public hospitals accounting for 35% of the state's births.
Methods: In 2005–2006, all first visit antenatal women at the two hospitals were asked by clinic staff to complete an anonymous, self-administered questionnaire prompting details of substance use, current and previous (while not pregnant or lactating).
Results: Questionnaires were returned by 748 women, 34.4% of 2173 eligible in the study period. Women reported use at significantly lower rates than before pregnancy. Tobacco was most used in pregnancy (18.5%), followed by alcohol (11.8%) and cannabis (4.5%), with negligible use of other illicit substances. There was no significant difference in substance use related to trimester. Women with previous pregnancy losses were significantly more likely to use tobacco and alcohol. Younger women were more likely to use tobacco and cannabis, with no age-related differences in alcohol consumption. First pregnancy was the only factor independently associated with the likelihood of ceasing substance use when pregnant, but only in relation to alcohol.
Conclusions: Women were less likely to use all substances when pregnant, and health-care providers should reinforce and support these decisions. The use of cannabis and alcohol while pregnant was below expectations. Reported tobacco use was concordant with existing data and confirms that the risk of smoking in pregnancy remains a message difficult to communicate in the context of chronic nicotine dependence.     

Monitoring bei Präeklampsie und kardiovaskulären Erkrankungen in der Schwangerschaft

Women with preexisting cardiovascular diseases and women with severe preeclampsia are severely endangered by and during pregnancy. The delivery of the baby—ending the pregnancy—is often the only way to save the mother’s life. If pregnancy is continued to protect the child from very early preterm birth, the pregnant women has to be closely monitored. For women with preexisting heart disease, World Health Organization (WHO) offers distinct management recommendations depending of the kind and severity of the underlying disease. Women with a WHO risk classification IV should be advised not to become pregnant. In women with severe hypertension in pregnancy, the main threat are cerebral bleeding and eclampsia. Therefor close monitoring of blood pressure is essential in these cases.     

Cardiovascular health in women with polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is arguably the most common endocrinopathy among women of reproductive age. Women with PCOS have clinical characteristics that are associated with insulin resistance, vascular dysfunction, hypertension, and dyslipidemia. Although definitive data for increased cardiovascular events in women with PCOS are lacking, case-control studies have documented an increased risk of preclinical cardiovascular disease. Thus, PCOS should be viewed as a chronic condition that may ultimately have long-term health impacts and patients should be counseled to reduce cardiovascular risk factors through weight control, exercise, and/or pharmacologic treatments.     

Pregnancy course and outcome following blunt trauma

Objective: To investigate short- and long-term outcome following blunt trauma in pregnancy, and to identify risk factors for adverse pregnancy outcome in these cases. Methods: A retrospective cohort study of all pregnant women who were admitted following blunt trauma (N?=?411). Women who experienced immediate complications (N?=?13) were compared with those who did not (N?=?398). Pregnancy outcome of women who experienced trauma during pregnancy and did not deliver during the trauma admission (N?=?303) were compared with a control group of women matched to by maternal age and parity in a 3:1 ratio (N?=?909). Results: The overall rate of immediate complications was 3.2%, with the most common complications being preterm labor (2.0%) and placental abruption (1.7%). Independent risk factors for immediate complications were higher severity of trauma, multiple gestation, vaginal bleeding and uterine contractions at admission. Patients who experienced trauma were at increased risk for long-term adverse outcome including preterm labor, placental abruption, and perinatal morbidity. Increased trauma severity (ISS ≥ 5) and the need for laparotomy during the trauma hospitalization were independently associated with long-term adverse pregnancy outcome. Conclusion: Trauma during pregnancy is associated with both immediate and long-term adverse pregnancy outcome. Women who experience trauma should be followed more closely throughout pregnancy.     

心脏病史女性孕前保健和管理

心脏病女性在妊娠期易发生心血管并发症,是孕产妇非产科因素死亡的重要原因,应加强孕前保健和管理。结合患者病史和检查进行孕前风险评估,能够手术矫正者建议其孕前手术治疗,不宜妊娠者应建议其避孕,允许继续妊娠者孕期应联合多学科管理,提高妊娠分娩安全性。     

Effectiveness of influenza vaccine during pregnancy in preventing hospitalizations and outpatient visits for respiratory illness in pregnant women and their infants

The Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention recommends influenza vaccination for women who will be in the second or third trimester of pregnancy during the influenza season. We analyzed hospital admissions with principal diagnoses of influenza or pneumonia and influenza-like illness (ILI) outpatient visits to study the effectiveness of influenza vaccine during pregnancy in protecting women and infants from influenza-related morbidity. Estimates of influenza vaccine effectiveness across five flu seasons (Fall 1997 to Spring 2002) were calculated using Cox proportional hazards models for women and infant study populations in Kaiser Permanente Northern California. Outpatient utilization outcomes included physician visits with a diagnosis of upper respiratory infection, pharyngitis, otitis media, asthma, bronchial asthma, viral infection, pneumonia, fever, cough, or wheezing associated with respiratory illness. Inpatient outcomes included hospitalizations with principal diagnoses of influenza or pneumonia. Women who received influenza vaccine during pregnancy had the same risk for ILI visits compared with unvaccinated women, adjusting for women's age and week of delivery. When asthma visits were excluded from the outcome measure, we also found no difference in the risk of outpatient visits for vaccinated and unvaccinated women. Hospital admissions for influenza or pneumonia for women in the study population were quite rare and no women died of respiratory illness during pregnancy. Infants born to women who received influenza vaccination had the same risks for influenza or pneumonia admissions compared with infants born to unvaccinated women, adjusting for infant's gender, gestational age, week of birth, and birth facility. Maternal influenza vaccination was also not a significant determinant of risk of ILI (excluding otitis media) outpatient visits for infants, nor did it significantly affect the risk of otitis media visits. Influenza vaccination during pregnancy did not significantly affect the risk of cesarean section, adjusting for the woman's age. It also did not affect the risk of preterm delivery. Although the immunogenicity of influenza vaccination in pregnancy in mother and infant has been well documented, in this study, we were unable to demonstrate the effectiveness of influenza vaccination with data for hospital admissions and physician visits. One possible interpretation of these findings is that typical influenza surveillance measures based on utilization data are not reliable in distinguishing influenza from other respiratory illness. Hospitalizations for respiratory illness were uncommon in both vaccinees and nonvaccinees.     

Congenital heart disease and pregnancy: maternal and fetal risks

Women with congenital heart disease (CHD) now comprise most patients with heart disease seen during pregnancy, accounting for 80% of all patients. In general, pregnancy is well tolerated in patients with CHD. For some women with particularly high-risk lesions and poor functional class, however, pregnancy poses significant risk for cardiovascular complications, including premature death. As result, preconception counseling and risk stratification are mandatory and should be done in all women of childbearing age with CHD.     

Chronic hypertension in pregnancy.

Women with chronic hypertension who are considering pregnancy should undergo extensive evaluation and work-up prior to conception. This evaluation is important to establish the cause and severity of the hypertension. The patient should be seen early in pregnancy and counseled regarding the possible adverse effects of hypertension and the importance of adherence to prenatal visits and prescribed medications. Patients classified to have high-risk hypertension are at increased risk for significant maternal and perinatal complications. These patients should have intensive antenatal follow-up and will require antihypertensive therapy irrespective of the severity of the hypertension. In contrast, in women with mild uncomplicated hypertension, good perinatal outcome is expected with proper obstetric care, without the use of antihypertensive drugs. Finally, most of the poor perinatal outcome in such pregnancies is related to the development of superimposed preeclampsia.     

Respiratory disease in pregnancy

The pregnant patient is at risk of several pregnancy-specific pulmonary complications, including amniotic fluid embolism, tocolytic-associated pulmonary oedema and pulmonary oedema complicating pre-eclampsia. In addition, the pregnant state increases the risk of other respiratory complications, particularly pulmonary embolism and gastric acid aspiration. Community-acquired pneumonia occurs in pregnant women at a similar incidence to the non-pregnant population, but the risk of varicella pneumonitis is increased. AIDS-related pulmonary infections should always be considered in this sexually active population.Management of the pregnant patient with pulmonary disease must take into account the anatomic and physiological changes affecting the respiratory system in pregnancy. Although management is similar to that in the non-pregnant patient, the welfare of the fetus must be considered in radiological investigations and pharmacological therapy.     

Inherited thrombophilias and anticoagulation in pregnancy

Thromboprophylaxis, primary or secondary, should be considered in selected pregnant women with inherited thrombophilias; such women may be divided into high-, medium- and low-risk categories on the basis of the specific thrombophilic defect and any personal or family history of venous thromboembolism (VTE). Women at high risk of VTE should receive treatment doses of low-molecular-weight heparin (LMWH) throughout pregnancy and should remain on anticoagulation for 6 weeks postpartum, or, where appropriate, long-term. Women at moderate risk should be treated with prophylactic fixed-dose LMWH throughout pregnancy and for 6 weeks postpartum. Women at low risk should receive prophylactic fixed-dose LMWH for 6 weeks postpartum, and low-dose aspirin LDA should be considered during pregnancy. LWMH offers important advantages over unfractionated heparin (UFH); heparin-induced thrombocytopaenia (HIT) and osteopaenia are rarely seen. For treatment doses of LMWH, dosage adjustment based on anti-Xa levels is usually required as pregnancy progresses. Warfarin should be avoided throughout pregnancy. LMWH, UFH and warfarin are safe for breast-feeding mothers.