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Joanna Quist-Nelson
Obstetric Evidence Based Guidelines, 3rd Ed, 2017
UNIVERSAL SCREENING AND
RELATED INTERVENTIONS
Vaccines
• Influenza vaccinaLon for new mothers and
other close contacts of the newborn will reduce
risk of infecLon for the child who is unable to
receive vaccinaLon unLl 6 months of age.
• Through this process of “cocooning,” the
newborn is protected from the high morbidity
and mortality rates associated with influenza in
the first year of life [42].
UNIVERSAL SCREENING AND
RELATED INTERVENTIONS
Vaccines
• Hepa88s B vaccina8on should be offered to all
suscepLble women of reproducLve age in regions
with intermediate and high rates of endemicity
(where ≥2% of the populaLon is hepaLLs B surface
anLgen [HBsAg] posiLve).
• Perinatal transmission of hepaLLs B results in 90%
chance of chronic infecLon in the newborn, which
places the child at risk for future cirrhosis and
hepatocellular carcinoma.
• In regions of low prevalence, vaccinaLon should be
targeted to high-risk groups (Table 1.5).
UNIVERSAL SCREENING AND
RELATED INTERVENTIONS
Vaccines
• Tetanus vaccina8on should remain up-to-date in
reproducLve-age women, parLcularly in regions of the
world where maternal and neonatal tetanus is prevalent
[43].
Chronic Diseases
Diabetes
• The benefits of preconcepLon diabetes care have
been previously demonstrated [61,62], even in
teenagers [63].
• PreconcepLon care is also essenLal for
counseling of the woman with condiLons severe
enough to make a successful pregnancy
extremely unlikely.
SPECIFIC INDIVIDUAL ISSUES
Chronic Diseases
Diabetes
• The diabeLc woman with either ischemic heart
disease, untreated proliferaLve reLnopathy,
creaLnine clearance <50 mL/min, proteinuria >2
g/24 hours, creaLnine >2 mg/dL, uncontrolled
hypertension, or gastropathy should be told not
to get pregnant before the above condiLons can
be improved, and counseled regarding adopLon
if the condiLons cannot be improved [64].
SPECIFIC INDIVIDUAL ISSUES
Chronic Diseases
Diabetes
• The frequency of fetal/infant and maternal morbidity and
mortality is reduced in diabeLc women seeking
consultaLon in preparaLon for pregnancy, but
unfortunately only about one-third of these women
receive such consultaLon [65].
• The preconcepLon consultaLon affords the opportunity to
screen for vascular consequences of the diabetes, with
ophthalmologic, electrocardiogram (EKG), and renal
evalua8on via a 24-hour urine collec8on for total protein
and crea8nine clearance, and determine ancillary
pregnancy risks.
SPECIFIC INDIVIDUAL ISSUES
Chronic Diseases
Diabetes
• ProliferaLve reLnopathy should be treated with
laser before pregnancy.
• A thyroid-sImulaIng hormone (TSH) level should
be checked, as 40% of young women with type 1
diabetes have hypothyroidism.
• Of note, there is insufficient evidence to treat
subclinical hypothyroidism [66].
SPECIFIC INDIVIDUAL ISSUES
Chronic Diseases
Diabetes
• Diabetes evaluaLon should emphasize the
importance of Lght glycemic control, with
normalizaLon of the HgB A1c to at least <7%.
• To achieve euglycemia, diet, glucose monitoring,
and exercise are always stressed.
• If euglycemia is not achieved with these means,
oral hypoglycemic agents or insulins are u8lized,
and their regimens should be opLmized preconcep-
Lonally.
SPECIFIC INDIVIDUAL ISSUES
Chronic Diseases
Diabetes
• Of the oral hypoglycemic agents, glyburide and
glucophage can be used, and probably conLnued
during pregnancy.
• The original safety data available for glyburide
showed that it did not cross the placenta in
appreciable amounts [67], but recent data have
shown a 70% level in umbilical blood compared
with maternal blood [68].
SPECIFIC INDIVIDUAL ISSUES
Chronic Diseases
Diabetes
• The other oral hypoglycemic agents should not be
used for preconcepLon glycemic control, as there is
no sufficient evidence for their safety and efficacy in
pregnancy.
• A common insulin regimen currently used by
diabetologists is long-ac8ng (e.g., glargine) and
short-ac8ng (e.g., lispro).
• This is a safe and effecLve regimen in pregnancy,
too. Women compliant with insulin pumps should
conLnue this regimen.
SPECIFIC INDIVIDUAL ISSUES
Chronic Diseases
Diabetes
• If a woman has a history of gestaLonal diabetes,
appropriate postpartum diabetes screening
should be performed.
• InterconcepLon counseling and lifestyle
modificaLons may be beneficial for future
pregnancies [69].
SPECIFIC INDIVIDUAL ISSUES
Chronic Diseases
Hypertension
• Hypertension (see Chapter 1 in Maternal-Fetal
Evidence Based Guidelines) is associated with several
maternal [worsening hypertension; superimposed
preeclampsia; severe preeclampsia; eclampsia;
hemolysis, elevated liver enzyme levels, and a low
platelet count (HELLP) syndrome; cesarean delivery]
and fetal (growth restricLon; oligohydramnios;
placental abrupLon; PTB; perinatal death) risks in
pregnancy.
SPECIFIC INDIVIDUAL ISSUES
Chronic Diseases
Hypertension
• Serum crea8nine, 24-hour urine for total protein and
crea8nine clearance, EKG, and ophthalmologic exam are
suggested, especially in women with long-standing or
severe hypertension.
• It is important to idenLfy cardiovascular risk factors and
any reversible cause of hypertension, as well as assess for
target organ dam- age or cardiovascular disease.
• If hypertension is newly diagnosed and has not been
evaluated previously, a medical consult may be indicated
to assess for any of these factors.
SPECIFIC INDIVIDUAL ISSUES
Chronic Diseases
Hypertension
• Secondary hypertension, target organ damage (lec
ventricular dysfuncLon, reLnopathy, dyslipidemia,
microvascular disease, and prior stroke), maternal age
>40, previous pregnancy loss, systolic blood pressure ≥180
mmHg, or diastolic blood pressure ≥110 mmHg are
associated with higher risks in pregnancy.
• AbnormaliLes should be addressed and managed
appropriately. If, for example, serum creaLnine is >1.4 mg/
dL, the woman should be aware of increased risks in
pregnancy (pregnancy loss, reduced birth weight, PTB, and
accelerated deterioraLon of maternal renal disease).
SPECIFIC INDIVIDUAL ISSUES
Chronic Diseases
Hypertension
• Even mild renal disease (creaLnine 1.1–1.4 mg/dL)
with uncontrolled hypertension is associated with
tenfold higher risk of fetal loss.
• PreconcepLon prevenLon can be enormously
effecLve.
• Thirty minutes of exercise five 8mes per week in all
women with hypertension and weight reduc8on if
overweight are recommended.
SPECIFIC INDIVIDUAL ISSUES
Chronic Diseases
Hypertension
• RestricLon of sodium intake to the same <2.4 g
sodium daily intake recommended for essenLal
hypertension is beneficial in nonpregnant adults.
• If anLhypertensive medical therapy is necessary,
angiotensin-conver8ng enzyme (ACE) inhibitors and
angiotensin II (AII) receptor antagonists should be
discon8nued as they are associated with birth
defects, fetal growth restricLon, oligohydramnios,
neonatal renal failure, and neonatal death in
pregnancy.
SPECIFIC INDIVIDUAL ISSUES
Chronic Diseases
Hypertension
• All other anLhypertensive agents should be used
at the lowest effecLve dose and are probably
safe if started preconcepLonally and conLnued in
pregnancy.
SPECIFIC INDIVIDUAL ISSUES
Chronic Diseases
Seizure Disorders
• ConcepLon should be deferred unLl seizures are
well controlled on the minimum effecLve dose of
medicaLon (see Chapter 19 in Maternal-Fetal
Evidence Based Guidelines).
• Monotherapy is preferable.
• Lamotrigine has been reported to be the first-line
therapy for nonpregnant adults for parLal seizures
[70–72] and is associated with a low incidence of
major malformaLons ([73], but not in all studies [74].
SPECIFIC INDIVIDUAL ISSUES
Chronic Diseases
Seizure Disorders
• The best choice is the anLepilepLc drug (AED) that
best controls the seizures.
• The AEDs are usually U.S. Food and Drug
AdministraLon (FDA) category C (human risk
unknown, but none proven yet) except for the
following AEDs that are known potenLal teratogens:
carbamazepine, primidone, phenytoin, and
valproate (Table 1.8).
SPECIFIC INDIVIDUAL ISSUES
Chronic Diseases
Seizure Disorders
• These four AEDs should therefore be avoided if
possible, by using a different therapy beginning in
the preconcepLon period.
• Women who have been seizure-free for ≥2 years
with a normal electroencephalogram (EEG) may
be eligible to stop an8convulsant therapy afer
consul8ng with a neurologist [75].
SPECIFIC INDIVIDUAL ISSUES
Medica8ons/Teratogens
• Detailed discussion regarding prescribed and
over-the- counter medicaLons should occur at
the preconcepLon visit.
• The indicaLon, safety, effecLveness, and
necessity of each drug need to be reviewed.
Ocen, women and their doctors stop
efficacious and necessary medicaLons as soon
as the woman finds out she is pregnant,
compromising the health of both the woman
and her baby.
SPECIFIC INDIVIDUAL ISSUES
Medica8ons/Teratogens
• The vast majority of prescribed medica8ons
are safe in pregnancy, even in the rst
trimester.
• Only a few drugs, chemicals, infec- 8ons, or
radia8on are proven teratogens (Table 1.8)
[76,77].