This review discusses the effects of chronic hypertension on pregnancy, to clarify the terminology and criteria used to define and diagnose it during pregnancy, and to review the available evidence for treatment options. Chronic hypertension complicates pregnancy and is associated with several adverse outcomes, including premature birth, intrauterine growth restriction (IUGR), fetal demise, placental abruption, and cesarean delivery. An additional diagnostic complication may arise in women with hypertension who begin prenatal care after 20 weeks of gestation.Read More

Among the various physiologic alterations that occur in normal pregnancy, few are as striking as those affecting the urinary tract. Changes in the urinary tract during normal pregnancy are so marked that norms in the nonpregnant cannot be used for obstetric management. Awareness of all alterations is essential if kidney problems in pregnancy are to be suspected or detected and then handled correctly. Most women with mild to moderate renal disease tolerate pregnancy well and have a successful obstetric outcome without adverse effect on the natural history of the underlying renal lesion. Crucial determinants are renal functional status at conception, the presence or absence of hypertension, and the type of renal disease.Read More

The current guidelines to manage cardiovascular diseases affecting pregnancy, and preconception counseling are discussed. The new guidelines for antibiotic prophylaxis for infective endocarditis are also discussed. There is some controversy over the optimal approaches to clinical assessment and treatment of women with cardiac diseases. Management hinges on the severity of cardiac diseases, gestational age and evaluation of relative risks. Additional guidelines on the basis of consensus and expert opinion also are presented. Without accurate diagnosis and appropriate care, heart disease in pregnancy can be a significant cause of maternal mortality and morbidity.Read More

Thyroid disease is the second most common endocrine disease affecting women of reproductive age; obstetricians often care for patients who have been previously diagnosed with alterations in thyroid gland function. In addition both hyperthyroidism and hypothyroidism may initially manifest during pregnancy. The interactions between pregnancy and the thyroid gland are fascinating from at least three aspects: pregnancy induces increased thyroid-binding globulin, intimate relationship between maternal and fetal thyroid function, and a number of related abnormal pregnancy and thyroid conditions that at least appear to interact. The purpose of this document is to review the thyroid-related patho-physiologic changes created by pregnancy, and the maternal-fetal impact of thyroid disease.Read More

Roughly one out of every 100 pregnancies occurs in a woman with epilepsy. These pregnancies present a unique challenge to obstetricians and neurologists due to the interrelationship of the effects of epilepsy and pregnancy, the variable effects of anti-convulsant medications on mother and fetus, and the changes in pharmacokinetics of these medications during pregnancy. The obstetricians and neurologist should work together prior to conception and throughout the patient's pregnancy to determine the safest and most effective medical therapy. Furthermore, the pediatrician selected by the patient to care for her baby should be included in pre-pregnancy discussions to address the potential increase in congenital malformations, the potential for neonatal sedation with certain medications, and questions concerning breast-feeding. The purpose of this document is to provide the current information on this issue and to offer practical advice on managing patients.Read More

Maternal alcohol abuse is associated with impaired fetal growth; virtually all neonates with fetal alcohol syndrome (FAS) will exhibit significant growth restriction. The physicians should counsel patients presenting with drug or alcohol problems and refer them to an appropriate treatment resource when available. Physicians who detect the serious medical condition of addiction (drugs and/or alcohol) are obligated to intervene during pregnancy or Preconceptional counseling. On the one hand, no person has a right to use illegal drugs, and a pregnant woman has a moral obligation to avoid use of both illicit drugs and alcohol in order to safeguard the welfare of her fetus. On the other hand, effective intervention with respect to substance and alcohol abuse by a pregnant or a non-pregnant woman requires that a climate of respect and trust exist within the physician-patient relationship. Patients who begin to disclose behaviors that are stigmatized by society may be harmed if they feel that their trust is met with disrespect.Read More

Acute asthma attacks render both the mother and fetus vulnerable to progressive hypoxia and potentially disastrous results. Early studies of pregnant women with asthma revealed high rates of perinatal complications, including perinatal loss, prematurity, preeclampsia, and low birth-weight. Prospective studies performed in the last decade demonstrate essentially normal perinatal outcomes with modern management of asthma. Poor outcomes with some evidence of increased perinatal mortality and morbidity are also seen if the intensity of asthma therapy is decreased. Pregnant patients with asthma should be managed proactively to achieve a good perinatal outcome. Initial and ongoing assessment of the severity of an asthmatic woman's condition facilitates the stepwise addition of medication to optimize control of symptoms and prevent acute attacks. Educating patients is the key to their ability to use medication appropriately and initiate treatment before an acute disease process becomes critical.Read More

The perinatal complications associated with maternal tobacco use include preterm delivery, premature rupture of membranes, spontaneous abortion, ectopic pregnancy, low birth weight, intra-uterine growth restriction, placental abruption, placenta previa, still birth, and sudden infant death syndrome (SIDS). Smoking cessation and the resources available are also discussed. Screening for tobacco use can be done efficiently as a vital sign at every clinical visit. Tobacco control is one of the most rational, evidence-based policies in medicine. The Millennium Development Goals do not include an explicit target for reducing tobacco use, but this article explains how lower tobacco use could contribute to their achievement.Read More

When any fetal group factor inherited from the father is not possessed by the mother, antepartum or intrapartum fetal-maternal bleeding may stimulate an immune reaction by the mother. The term hemolytic disease of the fetus/newborn, for instance has replaced hemolytic disease of the newborn because modern diagnostic techniques now allows us to detect the disorder much earlier. To prevent the disease, routine postpartum use of Rhesus immune globulin (Rh I G) in Rh-negative patients was introduced in the United States over 40 years ago. A subsequent recommendation for routine antenatal use at 28 weeks' gestation was introduced 20 years later. Despite these efforts, a recent review of the 2001 birth certificates in the US by the Centers for Disease Control and Prevention indicates that Rh sensitization still affects 6.7 out of every 1,000 live births. Maternal immune reactions can also occur from blood product transfusion.Read More