Care for pregnant women differs fundamentally from most other medical
endeavours. ‘Routine’ care during pregnancy and birth interferes in the
lives of healthy people, and in a process which has the potential to be
an important life experience. It is diffi cult to measure the extent to which
our efforts may, for example, disturb the development of a confi dent,
nurturing relationship between mother and baby. The harmful effects we
measure in randomised trials are limited to those we have predicted may
Medicine Chapter 7. Medical Disorders during Pregnancy
Medical Disorders during Pregnancy: Introduction
Approximately 4 million births occur in the United States each year. A significant proportion of these are complicated by one or more medical disorders. Three decades ago, many medical disorders were contraindications to pregnancy.
Thyroid Disease (See also Chap. 335) In pregnancy, the estrogen-induced increase in thyroxine-binding globulin causes an increase in circulating levels of total T 3 and total T4. The normal range of circulating levels of free T4, free T3, and thyroidstimulating hormone (TSH) remain unaltered by pregnancy.
The thyroid gland normally enlarges during pregnancy. Maternal hyperthyroidism occurs at a rate of ~2 per 1000 pregnancies and is generally well tolerated by pregnant women. Clinical signs and symptoms should alert the physician to the occurrence of this disease.
Marfan Syndrome (See also Chap. 357) This is an autosomal dominant disease, associated with a high risk of maternal morbidity. Approximately 15% of pregnant women with Marfan syndrome develop a major cardiovascular manifestation during pregnancy, with almost all women surviving.
Diabetes Mellitus in Pregnancy: Treatment Pregnancy complicated by diabetes mellitus is associated with higher maternal and perinatal morbidity and mortality rates. Preconception counseling and treatment are important for the diabetic patient contemplating pregnancy and can reduce the risk of congenital malformations and improve pregnancy outcome. Folate supplementation reduces the incidence of fetal neural tube defects, which occur with greater frequency in fetuses of diabetic mothers.
Gastrointestinal and Liver Disease Up to 90% of pregnant women experience nausea and vomiting during the first trimester of pregnancy. Occasionally, hyperemesis gravidarum requires hospitalization to prevent dehydration, and sometimes parenteral nutrition is required.
Crohn's disease may be associated with exacerbations in the second and third trimesters. Ulcerative colitis is associated with disease exacerbations in the first trimester and during the early postpartum period.
Rubella (See also Chap. 186) Rubella virus is a known teratogen; first-trimester rubella carries a high risk of fetal anomalies, though the risk decreases significantly later in pregnancy. Congenital rubella may be diagnosed by percutaneous umbilical blood sampling with the detection of IgM antibodies in fetal blood. All pregnant women should be screened for their immune status to rubella. Indeed, all women of childbearing age, regardless of pregnancy status, should have their immune status for rubella verified and be immunized if necessary.
Gestational Hypertension This is the development of elevated blood pressure during pregnancy or in the first 24 h post partum in the absence of preexisting chronic hypertension and other signs of preeclampsia. Uncomplicated gestational hypertension that does not progress to preeclampsia has not been associated with adverse pregnancy outcome or adverse long-term prognosis.
(See also Chaps. 272 and 280)
Normal pregnancy is characterized by an increase in glomerular filtration rate and creatinine clearance.
Mifepristone and a prostaglandin have been used successfully to terminate pregnancy in Europe and China. We report the results of a large U.S. study of mifepristone and misoprostol in women with pregnancies of up to nine weeks’ duration.
The combination of mifepristone (RU 486) and a prostaglandin analogue given either intramuscularly or intravaginally is effective in terminating early pregnancy, but the prostaglandin component of the regimen is cumbersome to administer and has side effects. We conducted two studies to determine the efficacy of 600 mg of mifepristone followed by a small dose of misoprostol, an orally active prostaglandin E1 analogue, for the same purpose.
Ectopic pregnancy is defined as a pregnancy in which the implantation of the embryo occurs out- side the uterine cavity, most frequently in one of the two fallopian tubes or, more rarely, in the abdo-minal cavity or the cervix .
The spectrum of GTD includes: Choriocarcinoma, placental site trophoblastic Risk factors for GTD are: tumor PSTT) and epithelioid trophoblastic; teenage pregnancies tumor (ETT) which are all malignant degenera; pregnancies in women above the age of 35 years tions of placental tissue. Very rarely no antecedent; history of molar pregnancy: the risk of recur-pregnancy can be identified. PSTT and ETT are rence is 1% after one molar pregnancy and rare and are not discussed further in this book.
This chapter explains briefly the conditions associated
with lower abdominal pain in the first trimester of pregnancy. More details of some of the conditions are found in specific chapters. The diagnosis and management of medical and surgical causes of lower abdominal pain in pregnancy is beyond the scope of this chapter.
A health-care provider in the field of gynecology will certainly encounter numerous patients with vaginal bleeding who are unaware of their early pregnancy. All female patients of reproductive age presenting with vaginal bleeding should therefore be assessed for possible pregnancy.
The second edition, like the first one, is intended to provide practical guidance
to clinicians looking after patients with heart disease, or who may be at risk of
cardiac problems, in pregnancy and the puerperium. These will be hospital
physicians and cardiologists, obstetricians, general practitioners and specialist
nurses who provide direct care as well as the anaesthetists responsible for making
delivery safe and the geneticists who answer the many questions posed by
couples with a personal or family history of heart disease....
More than seven hundred thousand teenagers a year get pregnant in the United States. The teen
pregnancy rate has fallen thirty-eight percent since the early nineteen nineties.
And the National Campaign to Prevent Teen and Unplanned Pregnancy says the teen birth rate has
fallen by almost as much. Six out of ten pregnant teenagers in two thousand six gave birth.
Infertility is defined as the failure to conceive after one year of attempting pregnancy. Primary infertility denotes those patients who have never conceived. Secondary infertility applies to patients who have conceived previously. Approximately 15% of couples experience infertility, which may result from subfertility or sterility (the innate inability to conceive) in either partner or both. The female is responsible in 40%–50% of cases. The male is responsible in 30% and is contributory in another 20%–30% of couples.
Multiple pregnancy involves more than one embryo (fetus) in any one gestation. Two independent mechanisms may lead to multiple gestation: segmentation of a single fertile ovum (identical, monovular, or monozygotic) or fertilization of separate ova by different spermatozoa (fraternal or dizygotic) multiple pregnancy. In the development of twins (the most frequent higher-order gestation), monozygotism is constant ( 2.3–4/1000 deliveries), whereas dizygotism has certain predispositions. Dizygotic twinning is inherited as a recessive autosomal trait via the female descendants.
The hypertensive disorders of pregnancy have been variously classified without consensus being achieved as to a lasting classification. A practical classification may be achieved by modification of the system proposed by the American Committee on Maternal Welfare (1985). I. Pregnancy Induced Hypertension (Preeclampsia-eclampsia, toxemia, EPH, and gestosis)
The view that a midwife is the expert in normal pregnancy is not new
but the context within which midwifery is practised has changed over
the years. From the early 1960s the most usual place to give birth
moved from being a woman’s home to hospital settings and the
majority of women now give birth in hospital. In recent years larger
tertiary maternity units have been developed, housing a range of
specialised services, and there has also been an increase in the number
of midwife-led units.