Pre-existing disease in pregnancy

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A pre-existing disease in pregnancy is a disease that is not directly caused by the pregnancy, in contrast to various complications of pregnancy, but which may become worse or be a potential risk to the pregnancy (such as causing pregnancy complications). A major component of this risk can result from necessary use of drugs in pregnancy to manage the disease.

Contents

In such circumstances, women who wish to continue with a pregnancy require extra medical care, often from an interdisciplinary team. Such a team might include (besides an obstetrician) a specialist in the disorder and other practitioners (for example, maternal-fetal specialists or obstetric physicians, dieticians, etc.). [MMHE 1]

Chronic hypertension

Chronic hypertension in pregnancy can lead to increased complications for both the mother and fetus. Maternal complications include superimposed pre-eclampsia and caesarean delivery. Fetal complications include preterm delivery, low birth weight, and death. Increasing rates of obesity and metabolic syndrome play a key role in the increased prevalence of chronic hypertension and associated complications. [1] Women who have chronic hypertension before their pregnancy are at increased risk of complications such as premature birth, low birthweight or stillbirth. [2] Women who have high blood pressure and had complications in their pregnancy have three times the risk of developing cardiovascular disease compared to women with normal blood pressure who had no complications in pregnancy. Monitoring pregnant women's blood pressure can help prevent both complications and future cardiovascular diseases. [3] [4] While high blood pressure treatment has been shown to decrease the incidence of severe hypertension during pregnancy, there was no significant difference in pregnancy complications (for example, superimposed pre-eclampsia, stillbrith/neonatal death, small for gestational age). [5]

Endocrine disorders

Diabetes mellitus

Diabetes mellitus and pregnancy deals with the interactions of diabetes mellitus (not restricted to gestational diabetes) and pregnancy. Risks for the child include miscarriage, growth restriction, growth acceleration, fetal obesity (macrosomia), polyhydramnios and birth defects.

Thyroid disease

Thyroid disease in pregnancy can, if uncorrected, cause adverse effects on fetal and maternal well-being. The deleterious effects of thyroid dysfunction can also extend beyond pregnancy and delivery to affect neurointellectual development in the early life of the child. Demand for thyroid hormones is increased during pregnancy which may cause a previously unnoticed thyroid disorder to worsen. The most effective way of screening for thyroid dysfunction is not known. [6] A review found that more women were diagnosed with thyroid dysfunction when all pregnant women were tested instead of just testing those at 'high-risk' of thyroid problems (those with family history, signs or symptoms). [6] Finding more women with thyroid dysfunction meant that the women could have treatment and management through their pregnancies. However the outcomes of the pregnancies were surprisingly similar so more research is needed to look at the effects of screening all pregnant women for thyroid problems. [6]

Hypercoagulability

Hypercoagulability in pregnancy is the propensity of pregnant women to develop thrombosis (blood clots) such as a deep vein thrombosis with a potential subsequent pulmonary embolism. Pregnancy itself is a factor of hypercoagulability (pregnancy-induced hypercoaguability), as a physiologically adaptive mechanism to prevent post partum bleeding. [7] The pregnancy associated hypercoaguability is attributed to an increased synthesis of coagulation factors, such as fibrinogen, by the liver through the effects of estrogen.

When combined with any additional underlying hypercoagulable state, the risk of thrombosis or embolism may become substantial. [7] Multiple pre-existing genetic disorders can worsen the hypercoaguable state observed in pregnancy. Examples include:

Infections

Vertically transmitted infections

Many infectious diseases have a risk of vertical transmission to the fetus, known as TORCH infections. Examples based on the TORCHES acronym include:

Infections in pregnancy also raise particular concerns about whether or not to use drugs in pregnancy (that is, antibiotics or antivirals) to treat them. For example, pregnant women who contract H1N1 influenza infection are recommended to receive antiviral therapy with either oseltamivir (which is the preferred medication) or zanamivir. [11] Both amantadine and rimantadine have been found to be teratogenic and embryotoxic when given at high doses in animal studies. [11]

Candidal vulvovaginitis

In pregnancy, changes in the levels of female sex hormones, such as estrogen, make a woman more likely to develop candidal vulvovaginitis. During pregnancy, the Candida fungus is more prevalent (common), and recurrent infection is also more likely. [12] There is no clear evidence that treatment of asymptomatic candidal vulvovaginitis in pregnancy reduces the risk of preterm birth. [13] Candidal vulvovaginitis in pregnancy should be treated with intravaginal clotrimazole or nystatin for at least 7 days. [14]

Bacterial vaginosis

Bacterial vaginosis is an imbalance of naturally occurring bacterial flora in the vagina. Bacterial vaginosis occurring during pregnancy may increase the risk of pregnancy complications, most notably premature birth or miscarriage. [15] However, this risk is small overall and appears more significant in women who have had such complications in an earlier pregnancy. [16]

Valvular heart disease

In case of valvular heart disease in pregnancy, the maternal physiological changes in pregnancy confer additional load on the heart and may lead to complications.

In individuals who require an artificial heart valve, consideration must be made for deterioration of the valve over time (for bioprosthetic valves) versus the risks of blood clotting in pregnancy with mechanical valves with the resultant need of drugs in pregnancy in the form of anticoagulants.

Other autoimmune disorders

Celiac disease

Untreated celiac disease can cause spontaneous abortion (miscarriage), intrauterine growth restriction, small for gestational age, low birthweight and preterm birth. Often reproductive disorders are the only manifestation of undiagnosed celiac disease and most cases are not recognized. Complications or failures of pregnancy cannot be explained simply by malabsorption, but by the autoimmune response elicited by the exposure to gluten, which causes damage to the placenta. The gluten-free diet avoids or reduces the risk of developing reproductive disorders in pregnant women with celiac disease. [17] [18] Also, pregnancy can be a trigger for the development of celiac disease in genetically susceptible women who are consuming gluten. [19]

Systemic lupus erythematosus

Systemic lupus erythematosus and pregnancy confers an increased rate of fetal death in utero and spontaneous abortion (miscarriage), as well as of neonatal lupus.

Behçet's disease

Pregnancy does not have an adverse effect on the course of Behçet's disease and may possibly ameliorate its course. [20] [21] Still, there is a substantial variability in clinical course between patients and even for different pregnancies in the same patient. [20] Also, the other way around, Behçet's disease confers an increased risk of pregnancy complications, miscarriage and Cesarean section. [21]

Multiple sclerosis

Being pregnant decreases the risk of relapse in multiple sclerosis; however, during the first months after delivery the risk increases. [22] Overall, pregnancy does not seem to influence long-term disability. [22] Multiple sclerosis does not increase the risk of congenital abnormality or miscarriage. [23] [24]

Mental health

Depression in pregnancy

The effects of depression during pregnancy are difficult to parse from depression before pregnancy as the symptoms of the two overlap. However, the biggest risk factor of depression during pregnancy is a prior history of depression. [25] Most of the research is focused on the consequences of untreated depression regardless if the depression developed during pregnancy or if it was there before conception. Untreated depression has been linked to premature birth, low birth weight, fetal growth restriction, and postnatal complications. [25] On the other hand, however, anti-depressant medications also come with a small risk of pre-term birth, low birth weight, and persistent pulmonary hypertension. [26] [25]

Respiratory disease

Asthma

In the United States, the prevalence of asthma among pregnant women is between 8.4% and 8.8%. [27] Asthma in pregnant women is strongly associated with multiple adverse health outcomes, including pre-eclampsia, preterm birth, and low birth weight. [28] [29] Other conditions such as gestational diabetes, placenta previa, and hemorrhage are inconsistently correlated to asthma. [30] Additionally, women with Asthma face a higher likelihood of complications during labor and delivery, such as breech presentation and caesarean delivery. [31] Poorly controlled and severe asthma may exacerbate conditions associated with maternal and neonate morbidity and mortality. [30] [32] Asthma treatment recommendations during pregnancy are similar to those in non-pregnant women. [33]

As of 2018, Asthma was the most prevalent respiratory disorder to complicate pregnancy, remaining a high-risk condition despite therapeutic advancements. [34] Preventing asthma exacerbations during pregnancy is crucial to reduce the risk of complications and poor outcomes. [31]

The course of asthma during pregnancy

The course of asthma during pregnancy can vary, with some patients experiencing worsening symptoms while others see improvement.

As of 2006, it was believed the course of asthma during pregnancy varied with a similar proportion of women improving, remaining stable, or worsening. [35] However, as of 2013, it was found that deterioration may manifest in approximately 20% of women, improvement in around 30%, and no significant change observed in the remaining 50%. [36]

Structural (congenital) abnormalities of the uterus

Structural abnormalities of the uterus include conditions like septate uterus, bicornuate uterus, arcuate uterus, and didelphys uterus. [37] Most of these abnormalities occur when the Müllerian ducts are fused improperly or incompletely. Women with these congenital abnormalities are usually unaware as these conditions do not usually do not present any symptoms. During pregnancy, these conditions are associated with infertility, preterm birth, fetal malpresentation, and early miscarriages. Among these uterine abnormalities, those with canalization defects, i.e., not having a normal uterine canal such as septate defects have the worse pregnancy outcomes. [37] Surgical treatment is only recommended for individuals who have had recurrent miscarriages and have a septate uterus; however, the risks of surgery, especially scarring of the womb should be considered. Further evidence from randomized controlled trials are required to establish conclusively whether surgery is the better option when its risks and rewards are compared with the risks of the adverse pregnancy outcomes. [37]

Others

The following conditions may also become worse or be a potential risk to the pregnancy:

Related Research Articles

Obstetrics is the field of study concentrated on pregnancy, childbirth and the postpartum period. As a medical specialty, obstetrics is combined with gynecology under the discipline known as obstetrics and gynecology (OB/GYN), which is a surgical field.

<span class="mw-page-title-main">Miscarriage</span> Natural death and expulsion of an embryo or fetus before its independent survival

Miscarriage, also known in medical terms as a spontaneous abortion, is the death and expulsion of an embryo or fetus before it is able to survive independently. The term miscarriage is sometimes used to refer to all forms of pregnancy loss and pregnancy with abortive outcome before 20 weeks of gestation.

<span class="mw-page-title-main">Pre-eclampsia</span> Hypertension occurring during pregnancy

Pre-eclampsia is a multi-system disorder specific to pregnancy, characterized by the onset of high blood pressure and often a significant amount of protein in the urine. When it arises, the condition begins after 20 weeks of pregnancy. In severe cases of the disease there may be red blood cell breakdown, a low blood platelet count, impaired liver function, kidney dysfunction, swelling, shortness of breath due to fluid in the lungs, or visual disturbances. Pre-eclampsia increases the risk of undesirable as well as lethal outcomes for both the mother and the fetus including preterm labor. If left untreated, it may result in seizures at which point it is known as eclampsia.

<span class="mw-page-title-main">Preterm birth</span> Birth at less than a specified gestational age

Preterm birth, also known as premature birth, is the birth of a baby at fewer than 37 weeks gestational age, as opposed to full-term delivery at approximately 40 weeks. Extreme preterm is less than 28 weeks, very early preterm birth is between 28 and 32 weeks, early preterm birth occurs between 32 and 34 weeks, late preterm birth is between 34 and 36 weeks' gestation. These babies are also known as premature babies or colloquially preemies or premmies. Symptoms of preterm labor include uterine contractions which occur more often than every ten minutes and/or the leaking of fluid from the vagina before 37 weeks. Premature infants are at greater risk for cerebral palsy, delays in development, hearing problems and problems with their vision. The earlier a baby is born, the greater these risks will be.

Recurrent miscarriage or recurrent pregnancy loss (RPL) is the spontaneous loss of 2-3 pregnancies that is estimated to affect up to 5% of women. The exact number of pregnancy losses and gestational weeks used to define RPL differs among medical societies. In the majority of cases, the exact cause of pregnancy loss is unexplained despite genetic testing and a thorough evaluation. When a cause for RPL is identified, almost half are attributed to a chromosomal abnormality. RPL has been associated with several risk factors including parental and genetic factors, congenital and acquired anatomical conditions, lifestyle factors, endocrine disorders, thrombophila, immunological factors, and infections. The American Society of Reproductive Medicine recommends a thorough evaluation after 2 consecutive pregnancy losses, however, this can differ from recommendations by other medical societies. RPL evaluation be evaluated by numerous tests and imaging studies depending on the risk factors. These range from cytogenetic studies, blood tests for clotting disorders, hormone levels, diabetes screening, thyroid function tests, sperm analysis, antibody testing, and imaging studies. Treatment is typically tailored to the relevant risk factors and test findings. RPL can have a significant impact on the psychological well-being of couples and has been associated with higher levels of depression, anxiety, and stress. Therefore, it is recommended that appropriate screening and management be considered by medical providers.  

<span class="mw-page-title-main">Placental abruption</span> Medical condition

Placental abruption is when the placenta separates early from the uterus, in other words separates before childbirth. It occurs most commonly around 25 weeks of pregnancy. Symptoms may include vaginal bleeding, lower abdominal pain, and dangerously low blood pressure. Complications for the mother can include disseminated intravascular coagulopathy and kidney failure. Complications for the baby can include fetal distress, low birthweight, preterm delivery, and stillbirth.

Bloody show or show is the passage of a small amount of blood or blood-tinged mucus through the vagina near the end of pregnancy. It is caused by thinning and dilation of the cervix, leading to detachment of the cervical mucus plug that seals the cervix during pregnancy and tearing of small cervical blood vessels, and is one of the signs that labor may be imminent. The bloody show may be expelled from the vagina in pieces or altogether and often appears as a jelly-like piece of mucus stained with blood. Although the bloody show may be alarming at first, it is not a concern of patient health after 37 weeks gestation.

<span class="mw-page-title-main">Pregnancy</span> Time of offspring development in mothers body

Pregnancy is the time during which one or more offspring develops (gestates) inside a woman's uterus (womb). A multiple pregnancy involves more than one offspring, such as with twins.

Prenatal development includes the development of the embryo and of the fetus during a viviparous animal's gestation. Prenatal development starts with fertilization, in the germinal stage of embryonic development, and continues in fetal development until birth.

<span class="mw-page-title-main">Complications of pregnancy</span> Medical condition

Complications of pregnancy are health problems that are related to, or arise during pregnancy. Complications that occur primarily during childbirth are termed obstetric labor complications, and problems that occur primarily after childbirth are termed puerperal disorders. While some complications improve or are fully resolved after pregnancy, some may lead to lasting effects, morbidity, or in the most severe cases, maternal or fetal mortality.

<span class="mw-page-title-main">Nutrition and pregnancy</span> Nutrient intake and dietary planning undertaken before, during and after pregnancy

Nutrition and pregnancy refers to the nutrient intake, and dietary planning that is undertaken before, during and after pregnancy. Nutrition of the fetus begins at conception. For this reason, the nutrition of the mother is important from before conception as well as throughout pregnancy and breastfeeding. An ever-increasing number of studies have shown that the nutrition of the mother will have an effect on the child, up to and including the risk for cancer, cardiovascular disease, hypertension and diabetes throughout life.

Maternal health is the health of women during pregnancy, childbirth, and the postpartum period. In most cases, maternal health encompasses the health care dimensions of family planning, preconception, prenatal, and postnatal care in order to ensure a positive and fulfilling experience. In other cases, maternal health can reduce maternal morbidity and mortality. Maternal health revolves around the health and wellness of pregnant women, particularly when they are pregnant, at the time they give birth, and during child-raising. WHO has indicated that even though motherhood has been considered as a fulfilling natural experience that is emotional to the mother, a high percentage of women develop health problems and sometimes even die. Because of this, there is a need to invest in the health of women. The investment can be achieved in different ways, among the main ones being subsidizing the healthcare cost, education on maternal health, encouraging effective family planning, and ensuring progressive check up on the health of women with children. Maternal morbidity and mortality particularly affects women of color and women living in low and lower-middle income countries.

<span class="mw-page-title-main">Maternal–fetal medicine</span> Branch of medicine

Maternal–fetal medicine (MFM), also known as perinatology, is a branch of medicine that focuses on managing health concerns of the mother and fetus prior to, during, and shortly after pregnancy.

Tobacco smoking during pregnancy causes many detrimental effects on health and reproduction, in addition to the general health effects of tobacco. A number of studies have shown that tobacco use is a significant factor in miscarriages among pregnant smokers, and that it contributes to a number of other threats to the health of the foetus.

Thyroid disease in pregnancy can affect the health of the mother as well as the child before and after delivery. Thyroid disorders are prevalent in women of child-bearing age and for this reason commonly present as a pre-existing disease in pregnancy, or after childbirth. Uncorrected thyroid dysfunction in pregnancy has adverse effects on fetal and maternal well-being. The deleterious effects of thyroid dysfunction can also extend beyond pregnancy and delivery to affect neurointellectual development in the early life of the child. Due to an increase in thyroxine binding globulin, an increase in placental type 3 deioidinase and the placental transfer of maternal thyroxine to the fetus, the demand for thyroid hormones is increased during pregnancy. The necessary increase in thyroid hormone production is facilitated by high human chorionic gonadotropin (hCG) concentrations, which bind the TSH receptor and stimulate the maternal thyroid to increase maternal thyroid hormone concentrations by roughly 50%. If the necessary increase in thyroid function cannot be met, this may cause a previously unnoticed (mild) thyroid disorder to worsen and become evident as gestational thyroid disease. Currently, there is not enough evidence to suggest that screening for thyroid dysfunction is beneficial, especially since treatment thyroid hormone supplementation may come with a risk of overtreatment. After women give birth, about 5% develop postpartum thyroiditis which can occur up to nine months afterwards. This is characterized by a short period of hyperthyroidism followed by a period of hypothyroidism; 20–40% remain permanently hypothyroid.

<span class="mw-page-title-main">High-risk pregnancy</span> Medical condition

A high-risk pregnancy is one where the mother or the fetus has an increased risk of adverse outcomes compared to uncomplicated pregnancies. No concrete guidelines currently exist for distinguishing “high-risk” pregnancies from “low-risk” pregnancies; however, there are certain studied conditions that have been shown to put the mother or fetus at a higher risk of poor outcomes. These conditions can be classified into three main categories: health problems in the mother that occur before she becomes pregnant, health problems in the mother that occur during pregnancy, and certain health conditions with the fetus.

Obstetric medicine, similar to maternal medicine, is a sub-specialty of general internal medicine and obstetrics that specializes in process of prevention, diagnosing, and treating medical disorders in with pregnant women. It is closely related to the specialty of maternal-fetal medicine, although obstetric medicine does not directly care for the fetus. The practice of obstetric medicine, or previously known as "obstetric intervention," primarily consisted of the extraction of the baby during instances of duress, such as obstructed labor or if the baby was positioned in breech.

Hypertensive disease of pregnancy, also known as maternal hypertensive disorder, is a group of high blood pressure disorders that include preeclampsia, preeclampsia superimposed on chronic hypertension, gestational hypertension, and chronic hypertension.

Fetal programming, also known as prenatal programming, is the theory that environmental cues experienced during fetal development play a seminal role in determining health trajectories across the lifespan.

Maternal health outcomes differ significantly between racial groups within the United States. The American College of Obstetricians and Gynecologists describes these disparities in obstetric outcomes as "prevalent and persistent." Black, indigenous, and people of color are disproportionately affected by many of the maternal health outcomes listed as national objectives in the U.S. Department of Health and Human Services's national health objectives program, Healthy People 2030. The American Public Health Association considers maternal mortality to be a human rights issue, also noting the disparate rates of Black maternal death. Race affects maternal health throughout the pregnancy continuum, beginning prior to conception and continuing through pregnancy (antepartum), during labor and childbirth (intrapartum), and after birth (postpartum).

References

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  2. ↑ Al Khalaf, Sukainah Y.; O'Reilly, Éilis J.; Barrett, Peter M.; B. Leite, Debora F.; Pawley, Lauren C.; McCarthy, Fergus P.; Khashan, Ali S. (2021-05-04). "Impact of Chronic Hypertension and Antihypertensive Treatment on Adverse Perinatal Outcomes: Systematic Review and Meta‐Analysis". Journal of the American Heart Association. 10 (9). doi:10.1161/JAHA.120.018494. ISSN   2047-9980. PMC   8200761 . PMID   33870708.
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  1. ↑ Merck. "Overview of Disease During Pregnancy". Merck Manual Home Health Handbook. Merck Sharp & Dohme.
  2. ↑ Merck. "Cancer during pregnancy". Merck Manual Home Health Handbook. Merck Sharp & Dohme. Archived from the original on 2015-03-28. Retrieved 2013-08-13.
  3. ↑ Merck. "High blood pressure during pregnancy". Merck Manual Home Health Handbook. Merck Sharp & Dohme. Archived from the original on 2015-03-02. Retrieved 2013-08-13.
  4. ↑ Merck. "Liver and gallbladder disorders during pregnancy". Merck Manual Home Health Handbook. Merck Sharpe & Dohme. Archived from the original on 2015-03-16. Retrieved 2013-08-13.
  5. ↑ Merck. "Heart disorders during pregnancy". Merck Manual Home Health Handbook. Merck Sharp & Dohme. Archived from the original on 2015-02-21. Retrieved 2013-08-13.
  6. ↑ Merck. "Kidney disorders during pregnancy". Merck Manual Home Health Handbook. Merck Sharp & Dohme. Archived from the original on 2015-02-21. Retrieved 2013-08-13.
  7. ↑ Merck. "Seizure disorders during pregnancy". Merck Manual Home Health Handbook. Merck Sharp & Dohme. Archived from the original on 2015-02-21. Retrieved 2013-08-13.
  8. ↑ Merck. "Liver and gallbladder disorders during pregnancy". Merck Manual Home Health Handbook. Merck Sharpe & Dohme. Archived from the original on 2015-03-16. Retrieved 2013-08-13.
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