IN THIS CHAPTER
Treating infections from the common cold to bladder infections
Handling asthma, diabetes, and other preexisting health problems
Pregnancy may give you a “maternal glow” and make you feel as if something magical is happening to your body. But face it: Pregnancy doesn’t make you superhuman. You’re still susceptible to all the illnesses and other health problems that can affect anyone who’s not expecting a baby. When illnesses arise during pregnancy, they can have special consequences. This chapter explains how a variety of medical conditions affect pregnant women.
Getting an Infection While Pregnant
Try as you may, avoiding every person who’s carrying an infection during your pregnancy may be impossible. Keep in mind that most infections don’t hurt the baby at all; they just make life more uncomfortable for you for a while. This section covers the most common infections as well as some of the more unusual ones.
Bladder and kidney infections
Bladder infections come in two basic types: with and without symptoms. Silent (symptom-free) bladder infections are common, occurring in about 6 percent of pregnant women. The other kind, called cystitis, comes with symptoms that include
· Constantly feeling that you need to urinate
· Discomfort above your pubic bone (where the bladder is)
· More frequent urination
· Pain with urination
If you develop either type of bladder infection, your doctor treats it with antibiotics.
If left untreated, a bladder infection can progress into a kidney infection, also known as pyelonephritis. A kidney infection produces the same symptoms as cystitis, plus a high fever and flank pain — pain over one or both kidneys (see Figure 3-1). Flank pain also can occur in someone who has kidney stones. The difference: A kidney infection causes a constant pain, whereas kidney stones produce more-severe but intermittent pain. Also, kidney stones are more often accompanied by small quantities of blood in the urine.
Illustration by Kathryn Born, MA
FIGURE 3-1: Bladder infections, kidney infections, and kidney stones have their own unique symptoms.
If your practitioner diagnoses you with pyelonephritis, she may want to admit you to the hospital for a few days so you can get intravenous antibiotics. Because kidney infections tend to recur during pregnancy, your practitioner may also want to keep you on a daily antibiotic for the remainder of your pregnancy.
Chickenpox
The varicella-zoster virus causes chickenpox. The first time someone comes down with an infection caused by this virus, usually in childhood, she gets chickenpox. Chickenpox is pretty rare in adults, and pregnant women stand no greater risk of contracting this virus than women who aren’t pregnant.
If you’ve already had chickenpox, you aren’t likely to get it again because your body has produced antibodies that make you immune. Even if you’ve never had chickenpox, you have a good chance of having these protective antibodies in your blood because you’ve probably had some exposure to the virus in the past, even though it didn’t produce any illness. However, if you know that you’ve never been exposed to chickenpox and you haven’t recently been vaccinated, or if you’re unsure about your prior exposure, have your blood checked to see whether you’re immune. Most of the time, antibodies to the varicella virus are checked at the first prenatal visit with all the rest of the routine prenatal labs.
Because the chickenpox vaccine is relatively new, there’s very little information about how safe it is for pregnant women, which is why the vaccine’s manufacturer recommends that pregnant women be given it after delivery. The recommendation is that women wait three months after receiving the vaccine before they get pregnant. If you get the vaccine and then suddenly find out you were pregnant at the time, let your doctor know. The little experience that pregnant women have had with the vaccine suggests that it probably doesn’t increase the chances of birth defects, nor has it led to any cases of congenital varicella syndrome in the baby (see the bulleted list that follows).
If you aren’t immune to chickenpox and you’re exposed to someone with the infection while you’re pregnant, let your practitioner know immediately so you can receive an injection known as VZIG (varicella-zoster immune globulin), which may reduce the risk of infection to you and the baby. Get this injection within three days of exposure, if possible. If you contract chickenpox within several days of giving birth (before or after), your baby should receive VZIG.
Chickenpox can cause three potential problems during pregnancy:
· It can make the mother ill with flu-like symptoms, plus produce the infamous skin rash (lots of little red blemishes). In rare circumstances, pneumonia develops two to six days after the rash appears. If you have chickenpox and you develop symptoms like shortness of breath or a dry cough, let your doctor know right away.
· If you contract chickenpox during the first four months of pregnancy, the fetus has a small chance of developing the infection, too, leading to congenital varicella syndrome. With this syndrome, the fetus can have scarring (the same kinds of scars that little kids get on their bodies from chickenpox), some abnormal development of the limbs, problems with growth, and developmental delays.
Fortunately, congenital varicella syndrome is very rare. It happens in less than 1 percent of cases in which the infection occurs in the first trimester, 2 percent if in the early second trimester.
· If you contract chickenpox within the interval from five days before to five days after giving birth, the baby is at risk for developing a serious varicella infection in the newborn period. You can greatly reduce this chance by giving the baby VZIG.
The same varicella-zoster virus that causes chickenpox can also produce a recurrent form of the infection called shingles or herpes zoster. Most babies born to pregnant women who develop shingles are completely normal. Because shingles is much less common than chickenpox in pregnancy, doctors don’t really know how common birth defects are after a pregnant woman develops this condition, although the incidence is thought to be less than the 1 to 2 percent seen with chickenpox.
If you know that you’re susceptible to chickenpox, avoid direct contact with anyone who has shingles or herpes zoster; the lesions contain the varicella-zoster virus and can cause a chickenpox infection in susceptible women.
EXPECTANT MOTHERS ASK …
Q: “Is getting the flu vaccine safe while I’m pregnant?”
A: Yes, the vaccine is completely safe. In fact, not only is it safe, but it’s recommended that pregnant women get vaccinated for flu season. This is because pregnant women who get the flu can become much sicker than nonpregnant women. There’s no evidence that additives in the vaccine cause any problems for the baby (like birth defects or autism). Remember, the vaccine doesn’t protect against all flu viruses, only the ones that researchers believe will be common in your area.
Colds and the flu
Most people get a cold about once a year, so the fact that most women get one during pregnancy isn’t surprising. Nothing about pregnancy makes you more vulnerable to a cold virus, but the fatigue and congestion that go along with pregnancy can make a cold seem worse. In any case, the common cold is perfectly harmless to the developing fetus. As everyone knows, there’s no cure for a cold, so the only option is to treat the symptoms. Contrary to popular belief, most cold medications — antihistamines, cough suppressants, and the like — are safe for pregnant women when taken in the recommended doses.
Following are a few suggestions for dealing with cold and flu symptoms:
· Drink fluids, fluids, and more fluids. All viral illnesses promote dehydration, and being pregnant only makes the problem more extreme. If you’re normally hydrated, your urine will be a pale yellow color or colorless, and you’ll typically urinate every four to six hours. If you go for hours without urinating or notice dark yellow or orange urine, then you’re probably dehydrated.
To keep from getting dehydrated when you have a cold or the flu, drink plenty of water, juice, or soda. Try to stay away from milk; many pregnant women complain that it makes the nausea often associated with the flu feel worse. If you think you may be dehydrated, you can try some of the over-the-counter oral rehydrating electrolyte solutions sold at your drugstore (like Rehydralyte or CeraLyte), but if you don’t notice that your urine is turning lighter quickly or that you’re going to the toilet at more typical intervals, then you should contact your healthcare provider for advice.
· Take a fever reducer. Taking acetaminophen (Tylenol) in the recommended doses is okay to help bring a fever down. This action alone helps some people feel better. If your fever persists for more than a few days, however, call your doctor.
· Take a decongestant. Pseudoephedrine (Sudafed) is the decongestant of choice during pregnancy. No evidence suggests that Sudafed taken in normal doses after the first trimester has any harmful effects.
· Try nasal spray, but not for long. Nasal spray decongestants are okay if you use them only short-term (the same is true for people who aren’t pregnant). Used intermittently, decongestant sprays may allow you to breathe more comfortably. Used day after day, they may only make the problem last longer. Saline nasal sprays are fine long-term, but they often aren’t as effective in reducing congestion.
· Eat some comfort food. Last but certainly not least, eat some chicken soup. Scientific studies have shown that chicken soup has properties that help cold sufferers feel better, even though no one knows exactly what those properties are.
You can use the same treatments for the common cold and for influenza infections. If you get the flu while you’re pregnant, you’re likely to have the same experience as when you’re not pregnant.
Many patients ask about the use of echinacea during pregnancy. People in Asia have used this herb for centuries to fight inflammation and the common cold. Typically, people use a preparation or supplement containing echinacea when they feel the first signs of a cold coming on. No evidence suggests that echinacea causes a problem during pregnancy. In a study that included only a small number of patients, no adverse effects were found; however, drawing any conclusions from such a limited study is difficult.
If your fever persists for more than a few days or if you develop a cough with greenish or yellow phlegm or have difficulty breathing, call your doctor to make sure that you’re not developing pneumonia.
Seasonal allergies and hay fever
People commonly take antihistamines to treat seasonal allergies. The older, first-generation medications, such as chlorpheniramine (Chlor-Trimeton or Sinutab), have been around for a long time, and most obstetricians are comfortable with their use in pregnancy. The newer antihistamines, such as Claritin or Zyrtec, have an additional benefit of not causing as much drowsiness. Researchers haven’t studied these newer medications as much in pregnancy. A third, very effective option is a nasal spray containing cromolyn or low-dose steroids.
Cytomegalovirus (CMV) infections
Cytomegalovirus (CMV) is a viral illness that’s common among preschool-age children. The symptoms are very similar to the ones you get with the flu — fatigue, malaise, and aches. In most cases, though, an infection produces no symptoms at all. By the time they’re old enough to have children, more than half of women have already had a CMV infection at some time in their lives, as evidenced by antibodies present in their blood.
Most practitioners don’t routinely test for antibodies because of the very small chance that a woman would acquire the infection during pregnancy. Also, the infection doesn’t usually cause any symptoms, so a woman would have to be repeatedly tested to see whether she develops the infection during her pregnancy. However, checking for susceptibility to the infection (that is, checking for antibodies) in women who are at higher risk — for example, women in close contact with preschool-age children — may be useful.
The importance of CMV infection during pregnancy is that the virus can pass to the fetus and cause a congenital infection. Actually, congenital CMV is the most common cause of an infection inside the uterus, and it occurs in 0.5 to 2.5 percent of all newborns. However, most of the time, babies born with this infection are healthy at birth.
If you do develop CMV during pregnancy (and only 2 percent of susceptible pregnant women do), the infection is transmitted to the fetus only about one-third of the time. Options for diagnosing the fetal infection include undergoing amniocentesis to check for evidence of infection in the amniotic fluid and having ultrasound exams. Even in those babies who contract CMV, 90 percent have no symptoms of the infection at birth (although a small percentage experience symptoms later in life, such as hearing loss or developmental problems).
If your baby contracts CMV in utero, the chances of the baby having serious problems vary according to the following:
· The baby’s gestational age when the infection occurs
· Whether the mother comes down with CMV for the first time during pregnancy (a primary infection) or whether she’s had it in the past (a recurrent infection)
If the mother comes down with the infection after the second trimester or if it’s a recurrent infection, the chances of serious problems in the newborn are much lower.
Severe symptomatic congenital CMV is rare and occurs in only about 1 in 10,000 to 20,000 newborns. It can lead to hearing impairment, visual problems, and even some mental deficiencies. Because CMV is a virus, antibiotics don’t help.
German measles (rubella)
The rubella virus causes German measles, which are the only kind that have any significant impact on pregnancy. If you contract rubella within the first trimester, the baby has about a 20 percent chance of developing congenital rubella syndrome. The chances of this, however, vary even within the first trimester from the first month to the third month. Fortunately, acute rubella infection during pregnancy is extremely uncommon because most people in the United States are vaccinated at childhood.
Hepatitis
Various types of hepatitis affect the mother and baby in different ways:
· Hepatitis A is transmitted by person-to-person contact or by exposure to contaminated food and water. Serious complications from hepatitis A in pregnancy are rare. The virus isn’t passed to the developing baby. If you’re exposed during pregnancy, take immune globulin within two weeks after exposure. Hepatitis A isn’t transmitted in breast milk, so it’s okay to breastfeed after you’ve had hepatitis A.
· Hepatitis B virus is transmitted through sexual contact, intravenous drug use, or through a blood transfusion. A small percentage of women with hepatitis B infection have a chronic condition, which can lead to liver damage. Women who have high amounts of the virus in their blood or who became pregnant while on therapy should discuss antiviral therapy with their doctors. Although not that common, hepatitis B infection can be transmitted to the fetus. If you’re positive for hepatitis B infection, inform the baby’s pediatrician after delivery so that the baby can receive the appropriate immunizations and be a candidate for breastfeeding.
· Hepatitis C is transmitted in the same way as hepatitis B. Less than 5 percent of hepatitis C–positive women transmit the infection to their baby. The CDC, American Congress of Obstetricians and Gynecologists, and American Academy of Pediatrics all support breastfeeding in a mom who has hepatitis C. They recommend not breastfeeding only when Mom’s nipples become sore and cracked to the point that they bleed.
Hepatitis D, E, and G are much less common. Ask your practitioner if you want information on these conditions.
Herpes infections
Herpes is a common virus that infects the mouth, the throat, the skin, and the genital tract. If you have a history of herpes, rest assured that the infection poses no risk to the developing fetus. The main concern is that you may have an active genital herpes lesion when you go into labor or when your water breaks. If you do, there’s a small risk of transmitting the infection to the baby as she passes through the birth canal. If it’s your first herpes infection, the chance of the fetus contracting the virus is greater because you have no antibodies to the virus. Studies show that women with a history of recurrent herpes may lower the chance of having an active herpes infection at delivery by taking a medication called acyclovir or valacyclovir in the last month of pregnancy.
If you have active genital herpes lesions at the time of labor or ruptured membranes, let your practitioner know. She’s likely to perform a cesarean delivery to avoid infecting the baby. If you see no lesions but you feel as if you may be developing them, also tell your doctor. In this case, having a cesarean may also be advisable.
Human immunodeficiency virus (HIV)
Over the past few years, studies have shown that some of the medications used to treat HIV infection can dramatically reduce the chance of the virus being transmitted from a mother to her baby. For this reason, doctors recommend that women undergo HIV testing early in pregnancy; if a woman is HIV-positive, they suggest that she receive these medications during pregnancy as well as during labor. Some states even require that every pregnant woman be tested, and if the testing hasn’t been performed, that her newborn be tested prior to discharge from the hospital. HIV testing is often repeated at about 35 weeks to see whether the infection was contracted during the pregnancy so that treatment during labor can be initiated.
To decrease the chances your baby will become infected with HIV, avoid any invasive procedures that can cause bleeding, such as amniocentesis or CVS, unless they’re required. Most doctors recommend that the mother receive IV doses of antiviral medications immediately before these procedures to minimize the chances of infecting the fetus.
Depending on your individual situation, most experts recommend that you not breastfeed if you’re infected with HIV because you may transmit the virus to your baby. Whatever form of birth control you choose, the additional use of condoms is necessary.
If you’re HIV-positive, maintain close contact with HIV specialists so you may benefit from the ever-improving treatments.
Listeria
Many women ask us about whether they can eat “soft” cheese. What they’re usually concerned about is an infection called listeriosis, which is caused by eating food contaminated with the bacterium Listeria monocytogenes.Listeria is a cause for concern because it can lead to fetal infection, miscarriage, or preterm birth. When infection occurs during pregnancy, antibiotics given promptly can often prevent infection of the fetus or newborn.
Listeria can be found in a variety of different foods — packaged salads, hot dogs, luncheon meats, cheeses, and raw fruits and vegetables. Cheese is a concern because some outbreaks of Listeria have been reported with certain unpasteurized cheeses. In the United States, all cheese that is sold is supposed to be either pasteurized or, if it’s raw, aged for 60 days (the aging process prevents the growth of the bacteria). The good news is that it really is quite uncommon. Your chances of contracting Listeria during pregnancy are about 0.12 percent.
Because of the rarity of infection and the ubiquity of the bacteria — and because you can’t avoid eating everything! — try to limit your exposure to the highest-risk foods:
· Don’t eat hot dogs from the fridge without heating them completely.
· Make sure the cheese you eat is either pasteurized or aged.
· Wash all raw fruits and vegetables well.
Lyme disease
Lyme disease is an infection transmitted through a deer tick bite. Pregnancy doesn’t predispose you to getting Lyme disease or make it any worse if you get it. The great news is that no evidence suggests that Lyme disease causes any harm to the fetus. The main problem is that it may make you sick.
If you think a deer tick has bitten you, let your practitioner know. She may want to draw blood to see whether you’ve contracted Lyme disease and possibly start you on antibiotics to prevent long-term effects.
Parvovirus infection (fifth disease)
Parvovirus is a common childhood infection that comes with a fever and a characteristic “slapped cheek” rash. In adults, the infection can bring on flu-like symptoms — fever, aches, sore throat, runny nose, and joint pain — but may not cause a rash at all. Or it may come without any symptoms whatsoever. Three-fourths of all pregnant women are immune to parvovirus, so even if they’re exposed to someone who has it, no problems come of it.
If you aren’t immune to parvovirus or don’t know whether you are and you come in contact with an infected person, let your practitioner know so you can be tested. Pregnant women who spend a great deal of time around school-age children (teachers or daycare workers, for example) may undergo routine testing before pregnancy or in the early first trimester.
Even if you contract this illness, chances are very good that your baby will be born healthy. No evidence indicates that parvovirus causes any birth defects. However, in rare cases, it can increase the risk of early miscarriage or the development of anemia in the fetus. For this reason, your practitioner may recommend that you have periodic ultrasound exams to look for signs of fetal anemia and to measure blood flow in a particular blood vessel in the brain, which can also indicate fetal anemia. (These are called MCA or middle cerebral artery Dopplers and are usually done on a weekly basis for 12 weeks after exposure.) If anemia does occur, doctors can perform a fetal blood transfusion (see Book 2, Chapter 2) while the baby is still inside you or suggest that the baby be delivered, if you’re nearing the end of pregnancy.
The ultimate good news: Recent studies show that babies infected with parvovirus during pregnancy, even if they develop anemia, are likely to be born as healthy as any other baby if they’re adequately treated.
Stomach viruses (gastroenteritis)
A bout of stomach flu can occur any time, regardless of whether you’re pregnant. Symptoms include stomach cramps, fever, diarrhea, and nausea, with or without vomiting, and they last anywhere from 24 to 72 hours. The viruses that cause gastroenteritis usually don’t harm your baby.
Don’t worry that your baby won’t get adequate nutrition if you can’t eat for a few days. Fetuses do just fine even when their mothers miss a few meals.
If you get a stomach virus, make sure that you drink plenty of liquids. Dehydration can lead to premature contractions and can contribute to fatigue and dizziness. Try chicken soup as well as other liquids — water, ginger ale, tea, or broth. Take care of yourself in the same way you would if you weren’t pregnant. If your symptoms persist for more than 72 hours, call your doctor.
Toxoplasmosis
Toxoplasmosis is an infection caused by a parasite that lives in raw meat and in cat feces. If the parasite enters a person’s bloodstream, it may lead to flu-like symptoms or, in some cases, no symptoms at all. This type of infection is very rare in the United States, and infections in pregnant women are rarer still, occurring in only 2 out of every 1,000 women, whereas in France, infection is more common.
If a pregnant woman is infected, the chances that she will transmit the infection to her baby, and the effects it may have, depend largely on when she contracts it. If she contracts it during the first trimester, the chances of the baby becoming infected are less than 2 percent. Later on in pregnancy, the chances of the baby being infected are greater, but the effects of infection are less severe. In a fetus, early toxoplasmosis infection can cause abnormalities of the central nervous system and in vision.
If you’ve had the infection in the past and therefore have antibodies in your blood, you’re highly unlikely to get the infection again. If a screening indicates that you may have been recently infected, your practitioner is likely to have your blood tested by a special laboratory to confirm that the positive test result was real. (Many initial tests produce false positives.) If the result still comes back positive and you appear to have contracted the infection after you became pregnant, your practitioner can give you special antibiotics to reduce your fetus’s chances of infection. Then, in the second trimester, your practitioner may perform an amniocentesis to find out whether the fetus has been infected. If so, taking additional antibiotics for the rest of the pregnancy is necessary. Your practitioner may advise you to consult a maternal-fetal medicine specialist to discuss all your options.
If you get toxoplasmosis, keep in mind that recent studies from France indicate that the vast majority of fetuses who are infected with the parasite and are treated with appropriate antibiotics have an excellent prognosis.
No vaccine exists to prevent toxoplasmosis. The best way to avoid the disease is to minimize your exposure to raw or undercooked meat. Skip the carpaccio. Order your steaks cooked at least medium. Also avoid cat feces. If you have an outdoor cat, ask someone else to change the litter. (Indoor cats that have never been outdoors and never come in contact with mice or rats are extremely unlikely to have the parasite.) If no one else can change the litter, wear rubber gloves when you do it. Also wear gloves if you work in a garden that neighborhood cats may play in.
Vaginal infections
Bacteria and other organisms, when given half a chance, readily make themselves at home in a vagina, where the conditions — warm and moist — are perfect for them to grow and reproduce. A woman can get an infection at any time, even when she’s pregnant.
Bacterial vaginosis
Bacterial vaginosis (BV) is a common vaginal infection. Symptoms include a whitish-yellow, odorous discharge that gets worse after sexual intercourse. Research has linked BV to a slightly higher risk for premature delivery, which is why some practitioners screen for BV in patients known to be at risk for preterm delivery. Treatment includes oral antibiotics or vaginal antibiotic creams.
Chlamydia
Chlamydia is one of the more common sexually transmitted diseases. It often comes with no symptoms. Some practitioners routinely perform a culture from the cervix to check for chlamydia at the same time they do a Pap smear. If you have a positive culture, your doctor will prescribe a medication to treat the infection. Chlamydia can be passed to your newborn during vaginal delivery, increasing the chances your baby will develop conjunctivitis (an eye infection) or, less likely, pneumonia. Most hospitals routinely place an ointment in a newborn’s eyes shortly after delivery to prevent conjunctivitis, regardless of whether the mother is infected with chlamydia.
Yeast infections
Yeast infections are very common in pregnancy. The large amounts of estrogen that circulate in the bloodstream during pregnancy promote the growth of yeast in the vagina. Symptoms of an infection are vaginal itching and a thick, whitish-yellow discharge. However, many women get infections without any symptoms. Often the only treatment needed is a short course of vaginal suppositories or creams. For stubborn infections, your doctor can prescribe oral medications.
Yeast infections usually don’t cause problems for the fetus or newborn.
Handling Pre-Pregnancy Conditions
The following sections detail conditions that you may have before you get pregnant and how those conditions may affect your pregnancy and vice versa.
Asthma
Predicting how pregnancy can affect a woman’s asthma is difficult. Some women find that their condition improves when they’re expecting. Some find it gets worse, and about half notice no difference at all.
The main concern that women with asthma have is whether they can safely continue taking their medications during pregnancy. Remember, the biggest problem with asthma isn’t the medications; it’s the possibility of pregnant women with asthma under-treating themselves. If you’re having trouble breathing, you may not be getting enough oxygen to the baby. Most commonly used asthma treatments are quite safe for the baby, including the following:
· Beta-agonists (Serevent, albuterol [Proventil], metaproterenol, terbutaline, Alupent)
· Corticosteroids (prednisone)
· Cromolyn sodium
· Theophylline (Theo-Dur)
· Inhaled steroids (Flovent, Vanceril, Beclovent, Azmacort, and so on)
You can take preventive measures to control acute attacks. Predicting attacks by self-monitoring is useful for asthmatic patients with peak expiratory flow rates (most asthma patients know what these are — if you don’t, ask your lung specialist). Naturally, it helps to avoid situations that trigger attacks.
Chronic hypertension
Chronic hypertension refers to high blood pressure that occurs independently of pregnancy. Although many women who have this condition are aware that they have it before they conceive, doctors occasionally diagnose it during pregnancy. If you have mild or moderate chronic hypertension, chances are good that you’ll have an uneventful pregnancy. However, your doctor will be on the lookout for certain conditions that can affect you or the baby.
Women with chronic hypertension stand an increased risk of developing preeclampsia, so your doctor will look for any signs that you’re developing this condition. The main risk for the baby is intrauterine growth restriction (IUGR) or placental abruption (see Book 6, Chapter 2). Your doctor may use repeated sonograms to check on the baby’s growth and to make sure that you have adequate amniotic fluid. She may also suggest that you undergo some tests later during your pregnancy for fetal well-being, such as non-stress tests (NSTs; see Book 2, Chapter 3). The overall management of your pregnancy depends on how well-controlled your blood pressure is, your overall health, and how the baby grows.
EXPECTANT MOTHERS ASK …
Q: “Are blood pressure medications safe?”
A: Most medications are safe, but many haven’t been well-studied during pregnancy. Discuss this important question with your doctor. Certain medications, however, should be avoided. Angiotensin converting enzyme inhibitors (known as ACE inhibitors) pose some risk for kidney problems in the fetus. Beta-blockers and certain calcium channel blockers are generally considered safe in pregnancy. Commonly used anti-hypertensive medications include labetalol, nifedipine, and Aldomet (methyldopa). Also, diuretics are best avoided, unless they’re the only way of treating the high blood pressure.
Deep vein thrombosis and pulmonary embolus
A deep vein thrombosis (DVT) is a blood clot that develops within a deep vein, most commonly in the leg. A pulmonary embolus is a blood clot within the lung, often a clot that has dislodged itself from one of the deep veins of the leg and made its way to the lung. Both of these conditions are rare, affecting far less than 1 percent of pregnant women.
Symptoms of a DVT include pain, swelling, and tenderness, usually in the calf, and a rope-like hardness running down the back of the lower leg. Diagnosing DVT before it has the chance to lead to a pulmonary embolus is important.
Keep in mind that muscle pain, cramping, and swelling are common symptoms of a normal pregnancy, and a DVT is quite unusual. Let your doctor know when you’re experiencing the sudden onset of these symptoms, but don’t panic about them.
Diabetes
Diabetes comes up as a problem in pregnancy in two ways:
· You already have the condition before you become pregnant.
· You develop what’s called gestational diabetes, which is unique to pregnancy and usually goes away after pregnancy.
Diabetes before pregnancy
If you have a history of diabetes, talk to your doctor about it before you get pregnant. If you have your blood sugar level under good control before you conceive, your pregnancy is more likely to proceed smoothly. Women with pregestational diabetes stand a higher-than-average risk of having a fetus with certain birth defects, but you can reduce this risk down to the normal range if you achieve excellent glucose control.
Some doctors suggest that you have a blood test called a hemoglobin A1C to check how well your sugar has been controlled over the past few months. Your doctor may also suggest that you have a special sonogram called a fetal echocardiogram (see Book 2, Chapter 2) to make sure that the baby’s heart is okay. If you take an oral medication to control your blood sugar, your practitioner may suggest you switch to insulin injections for better control. Some women with diabetes suffer kidney complications, but this kind of problem isn’t likely to worsen during pregnancy. If you have eye problems related to diabetes (proliferative retinopathy), have your doctor closely monitor and possibly treat your eyes during pregnancy.
The vast majority of diabetic women proceed through pregnancy without a hitch. However, your doctor may need to adjust your insulin dose. Your doctor will also be on the lookout for high blood pressure and follow the baby’s growth with periodic ultrasound exams. In the third trimester, your doctor will probably begin to monitor the fetus closely, performing certain tests for fetal well-being (periodic NSTs, for example — see Book 2, Chapter 3).
When you’re in labor, your doctor will keep a close eye on your glucose level and may give you insulin. With optimal glucose control and close monitoring of the baby and mother-to-be, most women with diabetes have an excellent outlook for pregnancy.
Gestational diabetes
Gestational diabetes is one of the most common medical complications in pregnancy, occurring in 2 to 3 percent of all pregnant women. Your practitioner can diagnose gestational diabetes by giving you a special blood test. (See Book 2, Chapter 2 for information on this test.)
If you have gestational diabetes and you don’t control your glucose levels, your baby may be at higher risk for certain problems. If your blood sugar levels are high, the fetus’s are, too. And high blood sugar levels cause the fetus to produce certain hormones that stimulate fetal growth, which may cause her to grow too large (see Book 6, Chapter 2). Furthermore, if the fetus has high blood sugar levels while still in the uterus, she may have temporary problems with sugar regulation after birth. If the mother’s (and fetus’s) glucose levels are controlled during pregnancy, the risk of these complications drops dramatically.
You need to control your sugar levels if you have gestational diabetes. Most of the time, altering your diet is enough. (Most women have a consultation with a nurse and/or a nutritionist to come up with a specific diet plan.) Exercise also helps. Only in rare cases do women need to resort to taking medication to keep their sugar levels under control.
Traditionally, doctors prescribed insulin injections to control blood glucose levels, but recent research suggests that an oral agent called glyburide is safe and effective. If you develop gestational diabetes, your doctor will ask you to check your sugar level several times during the day or on a weekly basis. You do this by pricking your finger (called a fingerstick) and placing the drop of blood onto a test strip, which you then insert into a small meter that gives immediate results.
EXPECTANT MOTHERS ASK …
Q: “If I develop gestational diabetes, will I recover when my pregnancy ends?”
A: Most women do recover completely, but a minority remains diabetic. In these cases, pregnancy itself didn’t cause the diabetes. Instead, the women were already at risk for developing the condition. If you develop gestational diabetes, being tested for diabetes within a few months after you deliver is important. Also, keep in mind that your risk for developing diabetes at some point later in your life increases.
Fibroids
Fibroids (also called uterine myomas) are benign growths of the muscle cells that make up the uterus. They’re extremely common, and your practitioner often diagnoses them during routine sonograms. The high levels of estrogen in a pregnant woman’s bloodstream can encourage fibroids to grow larger. However, predicting whether any woman’s fibroids will grow, stay the same, or shrink during pregnancy is difficult. Most of the time, fibroids cause no problems for a pregnancy.
In extreme cases, fibroids can cause difficulties, such as the following:
· Fibroids may grow so fast that they outgrow their blood supply and begin to degenerate, which sometimes causes pain, uterine contractions, and even preterm labor. Symptoms of degeneration include pain and tenderness directly over the fibroid (in the lower abdomen). Short-term treatment with anti-inflammatory medications (Motrin or Indocin, for example) may help.
· Very large fibroids in the lower portion of the uterus or near the cervix may interfere with the baby’s ability to make her way through the birth canal. Thus, they may increase the risk for cesarean delivery, although this situation is quite unusual.
· Large fibroids within the uterus can sometimes increase the likelihood that the baby will be in the breech or transverse position. But this possibility, too, is rare.
Most commonly, fibroids cause no problem at all. And most often, they shrink after delivery.
Immunological problems
Immunological problems are conditions in which a person’s immune system produces atypical antibodies, which can lead to a variety of problems. In most cases, women who have immunological problems already know they have them before they become pregnant. If you’re one of those women, discuss your problem with your doctor before you become pregnant or as early in your pregnancy as possible.
Antiphospholipid antibodies
Antiphospholipid antibodies are a class of antibodies that circulate in some women’s blood. The two most common kinds are lupus anticoagulant and anticardiolipin antibodies. They may be found in some women with collagen vascular diseases (such as lupus), in women who have had blood clots, and in some women with no known medical problems. They’re significant in pregnancy because they’ve been associated with recurrent miscarriages, unexplained fetal death, early onset of preeclampsia, and intrauterine growth restriction.
Doctors don’t routinely screen for these antibodies because many women who have them experience no resulting problems. But if you have one of the following conditions, your doctor will probably want to test you:
· Autoimmune platelet conditions
· A false positive test for syphilis
· A history of spontaneous blood clots in the legs or lungs
· A history of stroke or transient ischemic attacks (a “temporary” kind of stroke)
· Lupus (or other collagen vascular disease)
Your doctor may also want to test you if you’ve had any of the following obstetrical problems in the past:
· Early-onset preeclampsia
· Problems with fetal growth (intrauterine growth restriction)
· Recurrent miscarriages
· Unexplained stillbirth or fetal death
Antiphospholipid antibody syndrome is diagnosed when a woman has antiphospholipid antibodies in her bloodstream plus one of the listed risk factors. If you have the syndrome, depending on its severity, your doctor may recommend that you take baby aspirin, heparin, oral steroids, or some combination of these medications. She probably will also recommend that you have periodic ultrasound exams to make sure the baby is growing appropriately and that you undergo tests for fetal well-being (see Book 2, Chapter 3).
This syndrome may sound scary, but the good news is that most women who receive adequate medical care have normal pregnancies and healthy babies.
Lupus
Systemic lupus erythematosus (SLE), or lupus, is one of several so-called collagen vascular diseases. Pregnancy doesn’t make the disease worse, but some women do experience more flare-ups during pregnancy.
On the other hand, lupus can affect pregnancy in some cases, depending on the problem’s severity going into pregnancy. If you have a mild form of lupus, chances are it will have little effect on your pregnancy. Some women with more severe lupus stand an increased risk of miscarriage, problems with fetal growth, and preeclampsia (see Book 6, Chapter 2). Depending on your medical history, your doctor may recommend certain medications such as heparin, baby aspirin, or oral steroids. She may also recommend more frequent sonograms and other measures of fetal well-being. Your best bet for a successful pregnancy is to have the disorder under control as much as possible before you become pregnant.
Inflammatory bowel disease
The two kinds of inflammatory bowel disease are Crohn’s disease and ulcerative colitis. Fortunately, pregnancy does nothing to exacerbate either condition. If you have inflammatory bowel disease but your symptoms were minor or nonexistent during the months before you became pregnant, chances are good that they’ll remain at bay during your pregnancy. Doctors often recommend that women whose symptoms are frequent and severe postpone pregnancy until the disease abates or is brought under control. Most medications to control symptoms are considered to be safe and effective during pregnancy.
Seizure disorders (epilepsy)
Most women who have epilepsy can have an uneventful pregnancy and give birth to a perfectly healthy baby. However, epilepsy does require that a woman’s obstetrician and her neurologist work together to come up with the right strategy for controlling seizures.
Studies show that women whose seizures are well-controlled on a minimal dose of a single medication before they get pregnant have the best pregnancy outcomes. So by all means, consult your neurologist before you get pregnant, and don’t stop taking your medications unless your doctor advises you to.
All medications used to treat seizures pose some risk of birth defects. The problems they can cause vary, depending on the particular medication, but they include facial abnormalities, cleft lip and cleft palate, congenital heart defects, and neural tube defects. For this reason, women who take seizure medications need to have an ultrasound to evaluate fetal anatomy and a fetal echocardiogram (see Book 2, Chapter 2) to look for abnormalities in the baby’s heart.
Women with seizure disorders should begin taking extra folic acid about three months before trying to conceive, because some seizure medications can affect folic acid levels.
Don’t adjust or stop your medications on your own, especially after you become pregnant. Your seizure activity could increase, which would probably be worse for the developing baby than the medications themselves.
Thyroid problems
Problems with thyroid function are relatively common in women of reproductive age. Although these conditions require extra testing, they usually don’t cause significant problems for pregnancy.
Hyperthyroidism (overactive thyroid)
There are many causes of hyperthyroidism, but the most common by far is Grave’s disease, which is associated with its own special set of antibodies (thyroid-stimulating immunoglobulins, or TSIs) in the blood. These antibodies cause the thyroid to make too much thyroid hormone. Women with an overactive thyroid must receive adequate treatment during pregnancy (ideally, beginning before conception) in order to reduce their risk of complications such as miscarriage, preterm delivery, and low birth weight.
If you have an overactive thyroid, unless your condition is extremely mild, your doctor is most likely to recommend that you take certain medications to lower the amount of thyroid hormone circulating in your blood. Some of these medications may cross the placenta, so your doctor will watch the fetus closely, usually by performing regular sonograms, to look for any evidence that the medications are lowering the baby’s thyroid levels too much. Specifically, she’ll monitor the baby’s growth and heart rate to see that they’re normal and check for any evidence that the fetus has developed a goiter (an enlarged thyroid).
Your doctor probably also will monitor the levels of thyroid-stimulating antibodies in your blood because these antibodies may, in some rare cases, cross the placenta and stimulate the baby’s thyroid. After delivery, your baby’s pediatrician will watch the baby carefully for any evidence of thyroid problems.
Some women develop hyperthyroidism in the first trimester due to high levels of the pregnancy hormone hCG. This is usually self-limited and resolves without treatment.
Hypothyroidism (underactive thyroid)
A woman with an underactive thyroid (hypothyroidism) can have a healthy pregnancy as long as her condition is adequately treated. If it’s not, she stands a higher risk of developing certain complications, such as a low birth-weight baby. The condition is treated with a thyroid replacement hormone (Synthroid, for example). This medication is safe for the baby because very little of it crosses the placenta. If you have an underactive thyroid, your doctor may want to periodically check your hormone levels to see whether your medication needs to be adjusted. Although some doctors recommend routine testing (and possibly treatment) for hypothyroidism in the first trimester in women without a history of thyroid disease, this isn’t actually recommended by major obstetrical organizations such as the American Congress of Obstetricians and Gynecologists (ACOG).