DE LA RETENCIÓN DEL IMPUESTO

and management

The main implication of the thalassaemias on pregnancy is the risk of inheritance of the thalassaemia genes. Partner testing will identify women who are at risk of carrying a homozygous fetus who can then be referred for prenatal testing. Problematic anaemia may need to be treated with transfusions in pregnancy. Iron therapy must be used cau- tiously as women are at risk of iron overload.

CONCLUSIONS

CONCLUSIONS

It is essential to have a framework for considering the implications of medical conditions in pregnancy. These now are responsible for an increasing number of maternal deaths and adequate understanding is essential if this trend is to be reversed.

Essential information Essential information

Minor complaints in pregnancy Minor complaints in pregnancy

• These are usually due to physiological changes in pregnancy, but it is important to ensure there is not a pathological cause

Anaemia Anaemia

• In the UK, this is defined as a haemoglobin level <11 g/dL (some use<10.5 g/dL) especially towards the start of the third trimester

• Usually caused by:

– Inadequate intake of dietary iron

– Impaired absorption of iron (gastric achlorhydria, malnutrition, chronic diarrhoea, hookworm) • Investigations – MCV, HCHC, serum iron and iron-

binding, ferritin folate and vitamin B; others if cause still obscure

• Management usually with oral iron/folic acid

Diabetes Diabetes

• Classified as type 1, type 2, or gestational • Needs strict management with the aim of keeping

capillary glucose in the non-diabetic range • Management by diet and insulin (type 1); diet,

oral hypoglycaemic agents± insulin (type 2); diet ± oral hypoglycaemic agents± insulin (gestational diabetes)

Infections acquired in pregnancy Infections acquired in pregnancy

• Some infections in pregnancy can adversely affect the mother and the fetus though not alwas equally seriouslyVertical transmission of HIV can be reduced to a minimum by anti-retroviral therapy during pregnancy. If virus is detectable at the end of pregnancy elective delivery by caesarean section is recommended

Essential obstetrics | 22 |

Section

• The main management strategy in women with either hepatitis, A, B or C is to implement a variety of measures to prevent vertical transmission, though an elective caesarean section does not appear to help this • The main risk of tuberculosis in pregnancy is on the

health of the woman. Placental transfer is rare. Steptomycin is the only anti-tuberculous drug that is contraindicated

• Asymptomatic and symptomatic bacteriuria are common infections in pregnancy and prompt recognition and treatment is necessary to prevent progression to peyelonephritis

• Some infections can be prevented by prior immunization and some can be treated effectively during pregnancy

Thromboembolism Thromboembolism

• This is one of the major causes of maternal deaths • A previous history of the condition and hereditary

conditions with increased coagulability increase the risk • Every mother should be assessed in the antenatal

period, during labour and postpartum for the possible risk and prophylactic measures (especially using low molecular weight heparin) should be undertaken • If a deep vein thrombosis or pulmonary embolism is

suspected clinically full anticoagulation should be commenced until the results investigations are available. If the diagnosis is not confirmed the treatment is stopped

Liver disease Liver disease

• Obstetric cholestasis is of uncertain aetiology. • It produces intense itching of the woman’s palms and

soles of feet

• It is associated with an increased risk of fetal death and elective delivery at 37–38 weeks is often advocated to lessen that risk

Renal disease Renal disease

• Moderate–severe chronic renal disease usually worsens during pregnancy and may not improve after delivery • Renal disease causes increased rates of intrauterine

growth restriction, preterm delivery and perinatal loss • Multidisciplinary management is necessary to optimize

the outcome for woman and fetus

Thyroid disease Thyroid disease

• Hypothyroidism is most commonly due to autoimmune disease or iatrogenic (post-thyroidectomy). Iodine deficiency is less common. Raised levels of TSH are diagnostic, and the effectiveness of thyroxine treatment should be monitored with TSH levels

• Hyperthyroidism in pregnancy is usually due to Graves’ disease. It can cause low birth weight, and premature labour and birth. Treatment is with anti-thyroid drugs

Obesity Obesity

• Ideally obese women should defer pregnancy until they reach their optimal BMI.

• Obese women should have hospital-based care because of the increased risks

• Screening should be undertaken for gestational diabetes and excessive fetal growth

• Special preparation is necessary for a caesarean section (e.g., a large operating table)

Epilepsy Epilepsy

• A minority of women have an increase in fit frequency in pregnancy

• All anti-epileptic drugs have been reported to be teratogenic, with sodium valproate appearing to have the greatest risk. However, the hazards of epilepsy exceed risks of treatment

• The main priority in pregnancy is to prevent seizures with the fewest drugs and at the lowest dose

Cardiac disease Cardiac disease

• The risks for the woman and fetus vary with the diagnosis

• The NYHA classification gives an indication to the severity of the cardiac disease in the woman, though some of the symptoms of cardiac disease are also normal physiological complaints in pregnancy

• Surveillance and management should be by a multidisciplinary team and individualized

Respiratory disease Respiratory disease

• Asthma

– This is common in pregnancy and is not commonly exacerbated by the pregnancy

– Some symptoms are normal complaints in pregnancy

– Baseline peak flow measurements should be taken at the start of pregnancy

– Treatment for both acute attacks and ongoing maintenance is the same as for non-pregnant individuals and is considered safe

• Cystic fibrosis

– Though an uncommon condition it associated with increased risk for woman and fetus

– Surveillance and management should be by a multidisciplinary team and individualized

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Chapter

Congenital abnormalities and assessment