Medical Illness’ in

Pregnancy

Dr Md Ridwanur Rahman

Professor of Medicine

Shaheed Suhrawardy Medical College

Dhaka 1207

THALIDOMIDE TRAGEDY IS A

TRAGEDY FOR THE

WOMANKIND

Quote

We can not use many effective drugs in

pregnancy not because they are unsafe, but

because there is not enough evidence of

safety

MEDICAL DISEASES WITH

PREGNANCY: Most medical conditions in this age group do

not result in serious morbidity, though many have the potential to do so

It is important that women receive good advice pre-pregnancy about the potential impact of their medical condition and

enter pregnancy with appropriate confidence about routine medication or specific management plans to alter treatment in the first trimester

National Center for Health Statistics,

July 2006

Medical Illness in Pregnancy: Changing

Trends in Maternal Age

These conditions make major contributions to maternal deaths

Condition 2003-5 2000-2 1997-9 Thromboembolism 41 30 35

Pre-eclampsia and

eclampsia

18 14 16

Cardiac Disease 48 44 35

Epilepsy 11 13 9

Asthma 4 5 5

Diabetes Mellitus 1 3 4

Total-named diseases 123 (42%) 109 (42%) 104 (43%)

TOTAL

Direct + Indirect

295 261 242

Systems approach

Neurologic

Cardiac

Pulmonary

Endocrine

Gastointestinal

Renal

Autoimmune

Hematologic

Musculoskeletal

Skin

Kaaja and Greer, JAMA 2006

Pregnancy and chronic disease

Pregnancy likely to unmask occult

chronic disease

Glucose intolerance

Renal dysfunction

Hypercoaguable states

Valvular heart disease

Cerebral aneurysm

Pregnancy as a “stress test for life”

Approach to Medical Illness in

Pregnancy

An understanding of the physiologic changes of pregnancy and how they affect disease

A basic knowledge of pregnancy specific illnesses

A strategy for evaluating drug safety and diagnostic imaging in

pregnancy

The State of Pregnancy

Hyperdynamic

Hypermetabolic

Diabetogenic

Hypervolemic

Hypercoagulable state

Immunity changes

Seizure disorders

Cerebrovascular Disorders

Migraines

Neurologic

Chronic Hypertension Heart Disease

Heart failure, Arrhythmias, MI

Valvular disease MS (SLE, rheumatic) MVP MR/TR AS

Congenital malformations Peripartum Cardiomyopathy

Cardiac

Asthma

Pneumonia

Tuberculosis

Autoimmune

Sarcoidosis

Pulmonary

Endocrine

Diabetes

Thyroid

Adrenal Insufficiency

Cushings

CAH

Pheochromocytoma

Pituitary Disorders

Gastrointestinal Ulcer Disease

Inflammatory Bowel Disease

Crohn’s vs Ulcerative Colitis

Cholecystitis

Cholestasis

Hepatitis

Hyperemesis Gravidarum

Appendicitis

Renal/Urinary

Infections

Glomerulonephritis

Stones

Renal Failure

Transplantation

Autoimmune

Multiple Sclerosis

SLE

RA

Scleroderma

Haematologic Anemia

Iron deficiency

Folic Acid deficiency

Sickle Cell

Thalassemia

Hemorrhagic Disorders

Gestational thrombocytopenia

ITP

Thromboembolism

Thromboembolism

VTE affects 1 in 1000 pregnancies

Risk of DVT equal throughout all trimesters and

postpartum, but PE more common postpartum

Hypercoagulable state (includes postpartum)

Virchow’s triad (circulatory stasis, vascular damage,

hypercoagulability)

Increase in Factor I, VII, VIII, IX, X

Decrease in protein S, fibrinolytic activity

Increased activation of platelets

Resistance to activated protein C

Anticoagulation dependent on thrombophilia,

personal history and family history

Sexually transmitted diseases

Syphilis:early stage of syphilis---placenta---fetus

Gonorrhea

Condyloma acuminata:rare intrauterus infection,mainly transvaginal infection

Cytomegalovirus(CMV)

Genital herpes

Chlamydia trachomatis(CT)

HIV

Retrovirus

Up to one-third may not know they are

infected

40-85% HIV infected infants born to

women whose HIV status unknown to

their provider

World-wide vertical transmission is an

increasingly large portion of people with

the virus

Treatment Antiretroviral therapy

Viral load at intervals

Min 3 months

Intrapartum/peripartum antiretrovirals

Intrapartum/intraoperative antibiotics

Cesarean delivery for viral loads greater than 1,000 copies

Appropriate counseling

Epidemiology of critical care in OB Medical complications during pregnancy leading to an

ICU admission

Dildy et al. Critical Care Obstetrics, 4th edition.

Category N (of 1354) Percentage

Hypertension 417 30.8

Hemorrhage 275 20.3

Pulmonary 176 13.0

Cardiac 95 7.0

Sepsis/Infection 90 6.7

CNS 44 3.2

Anesthesia 43 3.2

Epidemiology of critical care in OB

Pregnancy related maternal deaths in the US1

Koonin et al. MMWR 1997;56-17-36.

Cause of death % of all deaths PRMR*

Hemorrhage 28.8 2.6

Embolism 19.9 1.8

Hypertension 17.6 1.6

Infection 13.1 1.2

Cardiomyopathy 5.7 0.5

Anesthesia 2.5 0.2

Other/Unknow

n

12.8 1.2

Lee R, 2000

Prescribing in pregnancy

Do not start any medication unless clearly

indicated

Do not discontinue medicines that

successfully maintain the maternal

condition unless there are clear indications

to do so

Have a pregnancy medication reference

available

Favor older medicines with longer record

of use

Prescribing in pregnancy

Requires a balanced approach: Being over-cautious may deny a beneficial

therapy

Lack of due caution might harm babies as a consequence of drug exposure

Benefits of treatment need to be weighed against the risks of giving no medication For minor conditions, the risks almost always

outweigh the (often trivial) benefits

Causes of developmental disorders

• Unknown:- Spontaneous development disorders;

multigenetic conditions (65%)

• Genetic diseases:- (20%)

• Chromosomal disorders:- (5%)

• Anatomical factors:- (2%)

• Maternal conditions:- (4%)

• Chemical and physical agents:- Medicinal products;

drugs of abuse (especially alcohol); ionizing radiation;

hyperthermia; environmental chemicals (4%)

FDA Drug Categories

FDA category D/X drug exposure

Category D Category X

Methadone 496 (0.81%) Oral Contraceptive 1614 (2.64%)

Progesterone 445 (0.73%)

Emergency

Contraceptive 159 (0.26%)

Diazepam 188 (0.31%) Estradiol 80 (0.13%)

Paroxetine 125 (0.20%) Flurazepam 26 (0.04%)

Prednisolone 123 (0.20%) Clomifene 22 (0.04%)

Quinine 101 (0.16%) Contraceptive Patch 21 (0.03%)

Valproate 82 (0.13%) Cannabis 18 (0.03%)

Carbamazepine 77 (0.13%) Cocaine 12 (0.02%)

Propylthiouracil 52 (0.08%) Medroxyprogesterone 11 (0.02%)

Atenolol 49 (0.08%) Atorvastatin 10 (0.02%)

Drugs to avoid in pregnancy

ACE inhibitors: renal dysgenesis

Tetracycline: abnormalities of bone and teeth

Fluoroquinolones: abnl cartilage development

Systemic retinoids: CNS, craniofacial, CV defects

Warfarin: skeletal and CNS defects

Valproic acid: neural tube defects

NSAIDS: bleeding, premature closure of the ductus arteriosis

Live vaccines (MMR, oral polio, varicella, yellow fever): may cross placenta

Sciali, 2004 accessed from

www.reprotox.org

Limits of the FDA classification

Hard to remember

May be misleading

Up to 60% of category X drugs have no human

data

No information on degree of risk

A drug may end up in category X simply if it has

no utility in pregnancy

Rarely updated

Good References for Drug Prescribing

Briggs, Freeman, and Yaffe: Drugs in Pregnancy and Lactation, 2005.

Lee, Rosene-Montella, Barbour, Garner, Keely: Medical Care of the Pregnant Patient, 2000.

www.reprotox.org

www.motherisk.org

www.micromedix.com (reprorisk)

www.otispregnancy.org (free)

Hale, T: Medications and Mother’s Milk, 2004. Also www.ibreastfeeding.com

Conclusions Common medical problems are

commonly seen in pregnancy.

Treat mother 1st: Sick mom = Sick

fetus.

Quality & safety of prescribing in

pregnancy is a challenge

Solution requires co-ordination

Health policy, Clinical practice, Multi-

disciplinary