Transcript Medical Problems in Pregnancy

IN THE NAME OF GOD
Preconception
Counseling for women
Dr,B.Khani
Questions
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What is preconception care?
What is the role of the ob&gyn in providing
preconception care?
What are risks of pregnancy in patients with
chronic medical problems?
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Opportunities for preconception counseling
occur ;
Premarital examination and testing
Contraception counseling
Evaluation for sexually transmitted disease or
vaginal infection
After a negative pregnancy test
Presents for a periodic health examination
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Barriers to preconception counseling
Unplanned pregnancy
Risk factors for adverse outcome that cannot be
modified(maternal age or genetic history)
Financial issues
Inadequate training of health care providers and
long waiting times for appointments
Typical Patient Visit
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Chief Complaint
History of Present Illness
Past Medical History
Medications
Family History
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Social History
Physical Exam
Assessment and Plan
Chief Complaint/HPI
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Ask about reproductive life plan
½ pregnancies in the US are unintended
 Remember that any one who is menstruating and
having sex can get pregnant.
 Help patients and partners develop a plan, and help
them implement it
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Past Medical History
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Infections
Immunizations
Previous Pregnancies
Chronic Diseases
Infection History
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TORCHES
 Toxoplasmosis: increased risk with handling raw meats, cat
litter
 Other: Listeria, Coxsackie virus, Parvovirus
 Rubella
 CMV: seroconversion highest risk for day care workers
caring for 12-36 month old children
 Hepatitis B,
 Syphilis
HIV, Herpes viruses
Immunizations
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TORCHES: Rubella, Hepatitis B, Varicella
Tetanus
Pertussis
Flu: If woman expects to be at least 3 months
pregnant during flu season
Reproductive History
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Pregnancies
Outcome
 Perinatal difficulties
 Control of chronic diseases during pregnancy
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Chronic Hypertension-Maternal
Morbidity
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Preeclampsia:
25% of women with chronic HTN
 40% with severe HTN
 Renal failure, HELLP syndrome, Eclampsia
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Peripartum cardiomyopathy
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Exacerbated by increased blood volume, decreased
oncotic pressure
Chronic Hypertension-Neonatal
Morbidity
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2/3 Preterm delivery
1/3 Small for Gestational Age
Mortality
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2-4 times above baseline rate for population
Other complications
Placental Abruption
 Cesarean Delivery
 Intrauterine Growth Restriction
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Glycemic Changes during Pregnancy
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ENHANCED insulin sensitivity- late first trimester
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More hypoglycemia, especially with coexistent vomiting
Increased caloric requirements- 300kcal/day
REDUCED insulin sensitivity- throughout pregnancy
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Allows for continuous glucose delivery to fetus, even at
fasting state
Increased cortisol, placental growth factor, progesterone,
prolactin, human placental lactogen, others
Diabetes-Maternal Morbidity
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Ketoacidosis
Develops more rapidly with less severe
hyperglycemia than non pregnant patients
 Risk factors: new onset DM, infection, poor
compliance, antenatal corticosteroids and tocolytics
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Preeclampsia
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Up to 50% of pts with Diabetes and Nephropathy
Diabetes- Maternal Morbidity
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Retinopathy
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PROGRESSION of retinopathy due to tight
glucose control
Long term risk is not altered by pregnancy
Nephropathy
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Risk Factors: baseline creatinine >1.5mg/dL,
severe proteinuria
Diabetes-Congenital Malformations
•Risk of malformation proportional to HbA1c
•Overall double the risk compared to
infants born to non-diabetics
•5% risk if HbA1c is 7%
•23% risk if HbA1c is 8.6%
Diabetes-Congenital Malformations
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Cardiac: Transposition of great vessels, VSD,
Coarctation, Patent Ductus Arteriosis, Situs
Inversus
Renal: Ureteral Duplication, Agenesis
Neurologic: Anencephaly, Microcephaly,
Neural tube defects
Gastrointestinal: Duodenal atresia, imperforate
anus, anorectal atresia
Skeletal: Caudal Regression Syndrome
Diabetes- Neonatal Morbidity
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Neonatal hypoglycemia
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Transient fetal hyperglycemia leads to β-cell
hyperplasia and hyperinsulinemia
Macrosomia
Increased risk shoulder dystocia at delivery
 Higher rates of primary cesarean delivery
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Typical Patient Visit
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Chief Complaint
History of Present Illness
Past Medical History
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Immunizations
Infections
Previous Pregnancies
Chronic Diseases
Medications
Family History
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Social History
Physical Exam
Assessment and Plan
Medications
Up To Date 15.3, 2007
Analgesic Drugs
•NSAIDS
•Acetaminophen is class B, throughout pregnancy
•Ibuprofen, Naproxen, Diclofenac are class B, in first and
second trimesters
•All NSAIDS are class D in third trimester
•Narcotics: Class C
Antidepressants/Anxiolytics
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SSRIs, Mirtazepine, Trazodone, Venlafexine:
Class C
Tricyclics: Class D
Buspirone, Zolpidem: Class B
Benzodiazepines: Class D
Lithium: Class D
Antimicrobials
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Penicillins, Cephalosporins, Clindamycin,
Metronidazole, Macrolides: Class B
Sulfonamides: Class B first and second trimester, Class
D third trimester
Quinolones, Trimethoprim, Vancomycin: Class C
Tetracyclines: Class D
Nystatin: Class B
Fluconazole: Class D first trimester, Class C second and
third trimesters
Allergy Treatments
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Diphenhydramine, Loratadine, Cetirizine : Class
B
Fexofenadine, Bromphenphiramine : Class C
Pseudoephedrine: class C in second and third
trimesters
Guaifenesin: class C
GI Medications
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Ranitidine, Lansoprazole, Sulcrafate: Class B
Omeprazole: Class C
Metoclopromide, Dimenhydrinate (Dramamine):
Class B
Promethazine, Prochlorperazine: Class C
Bismuth subsalicylate: Class D
Others
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Nicotine replacement: Patches, nasal spray,
inhaler are Class D, gum is Class X
Isotretinoin(Accutane): Class X
Chronic Hypertension- Treatment
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No data that treatment of Mild Hypertension
will improve maternal/fetal outcomes
Consider stopping/reducing RX in women who
become pregnant.
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Restart for women with SBP>150-160 or
DBP>100-110
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Ferrer et al. Obst Gynecol 2000
Chronic Hypertension-Treatment
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Safe Agents: Class C
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Some Risk: Class D
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Methyldopa
Labetalol
Nifedipine
Diuretics
Selective beta blockers, during second and third trimesters
Avoid: Class D
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ACE-Inhibitors/ARBs
Diabetes-Treatment
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Good control BEFORE conception
During Pregnancy
Diet, Exercise, and Insulin therapy
 Close Monitoring
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Goals:
fasting glucose <95mg/dL
 nighttime glucose >60mg/dL
 Hemoglobin A1c <6%
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Diabetes-Treatment
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Insulin therapy
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Range from .7-1.2 U/kg/day
Oral Agents:
Glyburide: Class C, but does not cross placenta,
comparable to insulin in improving control without
evidence of complications
 Metformin: Class B
 TZDs: Not well studied, Class C
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Typical Patient Visit
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Chief Complaint
History of Present Illness
Past Medical History
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Immunizations
Infections
Previous Pregnancies
Chronic Diseases
Medications
Family History
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Social History
Physical Exam
Assessment and Plan
Carrier Screening by Ethnicity
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Caucasian: Cystic Fibrosis
Black: Sickle cell, Beta-Thalassemia
European Jewish: Tay-Sachs
French Canadian: Tay-Sachs
Mediterranean: Alpha-, Beta-Thalassemia
Southeast Asian: Alpha-, Beta-Thalassemia
Indian, Middle Eastern: Sickle Cell, Alpha-,
Beta-Thalassemia
Typical Patient Visit
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Chief Complaint
History of Present Illness
Past Medical History
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Immunizations
Infections
Previous Pregnancies
Chronic Diseases
Medications
Family History
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Social History
Physical Exam
Assessment and Plan
Social History
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Environmental Exposures
Diet
Social Stressors
Substance abuse
Environmental Toxins
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Organic solvents (paint, cleaning fluids,
pesticides)
Anesthetic gases
Radiation
Heavy Metals
Diet
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vegetarians may need supplements
Fish: Limit to 12oz of safe fish per week. Unsafe fish:
Shark, swordfish, king mackerel, tile fish, tuna
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Canned tuna (<2 cans per week) is OK
Caffeine
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Associated with increased risk of miscarriage in one study:
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12.5% nonusers, 15% users of <200mg/day, 25% users
>200mg/day
Folic Acid intake: Recommended 400mcg/day
Weng, X; Odolui, R; Li, DK. Am J of Obstetrics and Gynecology, 2008
Social Stressors
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Emotional abuse
Physical abuse
Substance Abuse
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Alcohol consumption: even small amounts can
cause persistent neurobehavioral deficits.
Tobacco: preeclampsia, placental abruption, low
birthweight
Illicit drug use: wide variety of effects
Typical Patient Visit
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Chief Complaint
History of Present Illness
Past Medical History
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Immunizations
Infections
Previous Pregnancies
Chronic Diseases
Medications
Family History
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Social History
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Environmental exposures
Diet
Substances
Social Stressors
Physical Exam
Assessment and Plan
Physical Exam
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Screening for/ evaluation of Chronic diseases
Pulse, blood pressure
 Thyroid disease
 Hypoxemia
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Weight
Oral Care
Obesity
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Obesity is defined as BMI of 30-35 kg/m2
Morbid Obesity is BMI > 35 kg/m2
Obesity- Maternal Morbidity
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Gestational diabetes (GDM)
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Preeclampsia
Placental abruption
Cesarean delivery
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NYC study: women 200-300+ lbs were 4 to 5 times
more likely to develop GDM
Even when controlling for macrosomia
Endometritis and wound infections
Rosenberg et al. Obstet Gynecol 2003
Obesity-Neonatal Morbidity
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Macrosomia
Mount Sinai Study: mean birth weight 83 g (3
ounces) heavier
 Increased even when controlling for GDM
 Significant increase risk among morbidly obese
women who gained >25 lbs during pregnancy
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Increased risk NICU stay
Bianco, Et al. Obstet Gynecol 1998
Periodontal Disease
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Perhaps related to preterm birth
Multiple studies, varying designs/quality
3 studies: Treatment lead to significant reduction in
preterm low birthweight infants, no significant
difference in total preterm births
 800 women randomized to tx during pregnancy vs tx
postpartum: No difference in preterm birth, low
birthweight
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Thought to be a marker for excessive local
response to bacteria
Xiong, X et al.. BJOG 2006; 113:135.
Typical Patient Visit
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Chief Complaint
History of Present Illness
Past Medical History
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Immunizations
Infections
Previous Pregnancies
Chronic Diseases
Medications
Family History
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Social History
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Physical Exam
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Environmental exposures
Diet
Substances
Social Stressors
BMI
Oral Care
Sign of chronic illness
Assessment and Plan
Reproductive Life Plan
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Encourage her to talk with partner, develop a
plan for more children.
Offer contraception
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Consider IUDs, contraceptive implants
Infections/Immunizations
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Screen for
Rubella immunity
 Syphilis, HIV, Hepatitis B
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Vaccinate
Routine: Pneumovax, Flu, Tetanus, Pertussis
 Consider Hepatitis B, HPV if risk factors
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Chronic Diseases
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Screen for
Anemia
 Hypothyroidism
 Cervical dysplasia
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Treat known diseases
HTN
 DM
 Obesity
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Hypertension Treatment
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Change Class D/X drugs before pregnancy,
Consider Class C
Change ACE-I to labetalol, methyldopa, thiazide,
calcium channel blocker
 Remember that BP may drop early in pregnancy, pt
may need to stop medications initially
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Diabetes Treatment
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Delay pregnancy until good control achieved
Educate regarding risks to fetus/patient
Consider change to better studied agent
Insulin
 Metformin, Glyburide
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Obesity Treatment
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Diet and Exercise
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Goal to get to at least “overweight” BMI
Surgical Treatment
Less likely to develop GDM, hypertension, and
macrosomia
 Avoid pregnancy during 12-18 months after surgery
 Fertility may be enhanced in some women after
weight loss
 Nutritional supplements
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Family History
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Specific questioning
Consider genetic testing in certain groups
Environmental Exposures
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Collect material data safety sheets from
employer
Discuss safe practices: mask, clothing, etc
Consider contraception/duty change if pt
around potential hazards
Diet
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Folic Acid: 400mcg/day all women of
reproductive age
Prevents Neural Tube Defects
 May decrease preterm birth
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38,000 women, self reported Folic Acid intake
 Those with one year of prenatal Folic Acid intake
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70% decrease in very early preterm delivery (20-28 WGA)
50% decrease in early preterm delivery (28-32 WGA)
March of Dimes Foundation, Feb 2008
Diet
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Reduce/eliminate caffeine
Reduce fish, especially cold water, denser fish
Consider supplementation for specific
populations
Vegan, vegetarian
 Post Bariatric Surgery
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Substances
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Smoking cessation
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Nicotine replacements may be dangerous in early
pregnancy
Limit alcohol
Avoid illicit substances
Take Home Points
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Preconception counseling fits in to every phase
of the patient visit
Discuss a Reproductive Life Plan with every
patient of childbearing potential
Consider perinatal risk when managing chronic
disease
Folic Acid 400mcg/ day for ALL Reproductive
age Women
References
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Kaaja RJ, Greer IA. Manifestations of Chronic Disease During Pregnancy. JAMA 2005; 294(21):2751-57.
Lu, MC. Recommendations for Preconception Care. Am Family Physician. 2007; 76:397-400
Frey KA. Preconception Care by the Nonobstetrical Provider. Mayo Clin Proc 2002; 77:469-73
Brundage, SC. Preconception Health Care. Am Family Physician. 2002; 2507-14
American College of Obstetrics and Gynecology. Clinical Management Guidelines for Obstetrician-Gynecologists- Chronic
Hypertension in Pregnancy. ACOG Practice Bulletin 2005; 29.
Gregg AR. Hypertension in Pregnancy. Obstet Gynecol Clin. 2004;31(2):223-41.
Obstetric Analgesia and Anesthesia: 1980 Bonica JJ. World Federation of Anaesthesiologists, Amsterdam, from
http://homepages.ed.ac.uk/asb/SHOA2/chpt1.htm
Rosenn B, Miodovnik M, Kranias G, et al. Progression of diabetic retinopathy in pregnancy: association with hypertension in
pregnancy. AM J Obstet Gynecol 1992;13:34-40.
Jovanovic, L. Pre-pregnancy counseling in women with diabetes mellitus. Up To Date 15.3
Ferrer RL, Sibai BM, Mulrow CD, et al. Management of mild chronic hypertension during pregnancy; a review. Obstet Gynecol.
2000; 96: 849-860
Driul L, Cacciaguerra G, Citossi A. Prepregnancy BMI and adverse pregnancy outcomes. Arch Gynecol Obstet. 2007
Bianco AT, Smilen SW, Davis Y, Lopez S, Lapinski R, Lockwood CJ. Pregnancy outcome and weight gain Recommendations for
the morbidly obese. Obstet Gynecol. 1998;91:97-102
Rosenberg TJ, Garbers S, Chavkin W, Chiasson MA. Prepregnancy weight and adverse perinatal outcomes in an ethnically diverse
population. Obstet Gyneco. 2003;102:1022-7.
Xiong, X, Buekens, P, Fraser, WD, et al. Periodontal disease and adverse pregnancy outcomes: a systematic review. BJOG 2006;
113:135.
March of Dimes Foundation. Huge Drop in Preterm Birth Risk among Women. 2008 February 1
Weng, X; Odoluli, R; Li, DK. Maternal caffeine consumption during pregnancy and the risk of miscarriage: a prospective cohort
study. Am J Obstet Gynecol. 2008; 198:279
Oncken C; Dornelas E; Green J; et al. Nicotine gum for pregnant smokers: a randomized controlled trial. Obstet Gynecol. 2008;
112:859-67