Medical care and pregnancy - Medical care of chronic illness in pregnancy General approach

Preconception care of women with chronic illness falls into two categories: the assessment by physician and patient of special risk and the tailoring of care to enhance the safety and optimal outcome of pregnancy. Women should be given the opportunity to understand the extent of risk they may encounter, both to themselves and their babies, during pregnancies complicated by certain chronic conditions, especially chronic cardiovascular, renal, autoimmune, and hemoglobin disorders. See Table 9.2 for a list of disorders with a high risk of maternal complications. Most women will benefit from an understanding that their medical condition should not significantly lessen the chance of successful pregnancy outcome. A number of conditions, including rheumatoid arthritis and multiple sclerosis, demonstrate a tendency to improve during pregnancy. Other conditions, such as inflammatory bowel disease, migraine headaches, and asthma are variable in their clinical course during pregnancy. Women with severe preexisting lifethreatening disorders may be managed with good success during pregnancy, including women who have been treated for malignancy and renal transplantation. Perinatal consultation may be helpful as a preconception event in a number of high risk medical conditions and in women with an unexplained history of poor reproductive outcomes. A growing list of metabolic problems and hematological disorders are associated with preeclampsia, growth retardation, abruption, and other complications in late pregnancy. These include hyperhomocysteinemia, Factor V Leiden deficiency, Protein C and Protein S deficiency, and the antiphospholipid antibody syndrome. This includes patients with and without preexisting diagnoses of systemic lupus with anticardiolipin antibody or lupus anticoagulant. Treatment of several common disorders should be modified before conception. Asthma generally does not require preconception attention, but patients will frequently have questions about their medications. Heart disease in women of childbearing age encompasses a wide range of conditions, congenital and acquired, with variable risks and prognoses in pregnancy. Women with other neurological disorders, such as paraplegia and mysathenia gravis, may require changes in management, for the most part, during the intrapartum period. Specific preconception issues regarding common chronic disorders are addressed along with antepartum medical care in the latter part of this chapter. Common conditions that benefit from preconception evaluation and manipulation of treatment include hypertension, seizure disorders, and diabetes.

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