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Medical Disorders During Pregnancy

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Medical Disorders During Pregnancy

- Armando G. Milano, PHD

Although relatively few medical disorders can prevent pregnancy, virtually the entire spectrum of disease can complicate it. This section highlights some of the most frequently encountered medical disorders during pregnancy. In each case the unique interaction of medical disease and pregnancy is emphasized. Recommendations for treatment reflect the understanding that management of serious medical disorders frequently requires the use of medications potentially harmful to the fetus. Yet many untreated medical diseases are detrimental to the fetus and jeopardize the health of the mother as well.

Endocrine Disorders

Diabetes Mellitus, Type I
Beginning in early gestation, glucose and various gluconeogenic amino acids reach the fetus against a concentration gradient by facilitated diffusion.

Gestational Diabetes
Gestational diabetes is defined as carbohydrate intolerance of variable severity with onset during the present pregnancy.

Thyroid Disease
Several special considerations of thyroid dysfunction during pregnancy should be kept in mind. First, signs and symptoms of disordered thyroid function may be mimicked by pregnancy itself.

Hyperparathyroidism
Primary hyperparathyroidism does not appear to impair fertility, but it is known to result in a high rate of fetal complications such as spontaneous abortions, stillbirths, and neonatal tetany.

Pituitary Adenomas
Prolactin-secreting adenomas account for approximately 30% of all pituitary adenomas. Fewer than 7% of patients with intrasellar microadenomas (size less than 10 mm) manifest clinical evidence of tumor expansion during pregnancy.



Renal Disorders

Pregnancy is associated with a variety of anatomic and functional changes of the kidneys and lower urinary tract. Caliceal, pelvic, and ureteral dilatation occurs during the first trimester and persists throughout gestation up to 12 weeks postpartum. Hydronephrosis and hydroureter have direct clinical consequences because urinary stasis contributes to the propensity to develop pyelonephritis in women with asymptomatic bacteriuria.



Hypertensive Disorders

Hypertension is among the most commonly seen medical disorders of pregnancy. Up to 30% of pregnancies are complicated by hypertension, about half being chronic essential hypertension. Preeclampsia occurs in 5% to 10% of pregnant women. Arterial blood pressure greater than 140 mm Hg systolic and 90 mm Hg diastolic or a rise in blood pressure more than 30 mm Hg systolic and 15 mm Hg diastolic over baseline warrant a diagnosis of hypertension. A useful classification of hypertensive disorders of pregnancy is presented in Box 372-1.

Preeclampsia and Eclampsia
Preeclampsia is a multiorgan disease unique to pregnancy. The condition is characterized by the development of elevated blood pressure, proteinuria, and generalized edema.

Chronic Hypertension
Without documentation of elevated blood pressure before pregnancy, chronic hypertension can only be presumed. The vast majority of patients who present with elevated blood pressure before the twentieth week of gestation, however, have chronic hypertension.

Late or Transient Hypertension
Hypertension without proteinuria or abnormal edema that develops late in gestation or in the puerperium is referred to as late or transient hypertension.





Cardiovascular Disorders

Normal pregnancy is accompanied by changes in blood volume, heart rate, blood pressure, cardiac output, and ventilation. Cardiac output begins to rise during the first trimester, peaks at an approximate 40% increase by 20 to 24 weeks, then declines during the last 8 weeks of gestation. The increase in cardiac output during early pregnancy is primarily caused by an increase in stroke volume. As pregnancy advances, heart rate increases, whereas stroke volume falls to nonpregnant levels.



Thromboembolic Disorders

Thromboembolic disease is the leading cause of nonobstetric postpartum maternal mortality. In the United States, one half of all thromboembolic events in women younger than 40 years are related to pregnancy.



Asthma

Asthma is one of the most common illnesses and the most common obstructive pulmonary disease encountered during pregnancy. Asthma may occur for the first time during pregnancy.



Hepatic Disorders

Infectious Diseases

Rheumatic Disorders

Neurologic Disorders

Hematologic Disorders

Digestive Tract Disorders





BIBLIOGRAPHY
Barbour LA, Pickard J: Controversies in thromboembolic disease during pregnancy: a critical review, Obstet Gynecol 86:621, 1995.

Bishnoi A, Sachmechi I: Thyroid disease during pregnancy, Am Fam Physician 53:215, 1996.

Boumpas DT et al: Systemic lupus erythematosus: emerging concepts, Ann Intern Med 123:42, 1995.

Garner P: Type I diabetes mellitus and pregnancy, Lancet 346:157, 1995.

Hillier SL et al: Association between bacterial vaginosis and preterm delivery of a low-birth-weight infant, N Engl J Med 333:1737, 1995.

Jackson P, Bash DM: Management of the uncomplicated pregnant diabetic client in the ambulatory setting, Nurse Pract 19:64, 1994.

Knox TA, Olans LB: Liver disease in pregnancy, N Engl J Med 335:569, 1996.

Lee SH et al: Effects of pregnancy on first onset and symptoms of paroxysmal supraventricular tachycardia, Am J Cardiol 76:675, 1995.

Maccato M: Herpes in pregnancy, Clin Obstet Gynecol 36:869, 1993.

Mestman JH, Goodwin TM, Montoro MM: Thyroid disorders of pregnancy, Endocrinol Metabol Clin North Am 24:41, 1995.

Mishra L, Seeff LB: Viral hepatitis, A through E, complicating pregnancy, Gastroenterol Clin North Am 21:873, 1992.

Page RL: Treatment of arrhythmias during pregnancy, Am Heart J 130:871, 1995.

Petri M: Systemic lupus erythematosus and pregnancy, Rheum Dis Clin North Am 20:87, 1994.

Report of the Working Group on Asthma and Pregnancy Executive Summary: Management of asthma during pregnancy, NIH Pub. No. 93-3279A, 1993.

Sibai BM: Treatment of hypertension in pregnant women, N Engl J Med 335:257, 1996.

Sturridge F, de Swiet M, Letsky E: The use of low molecular weight heparin for thromboprophylaxis in pregnancy, Br J Obstet Gynaecol 101:69, 1994.

Usta IM et al: Acute fatty liver of pregnancy: an experience in the diagnosis and management of fourteen cases, Am J Obstet Gynecol 171:1342, 1994.

Wendel PJ, Wendel GD: Sexually transmitted diseases in pregnancy, Semin Perinatol 17:443, 1993.

Zamorski MA, Green LA: Preeclampsia and hypertensive disorders of pregnancy, Am Fam Physician 53(5):1595, 1996.

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