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Update on Medical Disorders in Pregnancy an Issue of Obstetrics and Gynecology Clinics the Clinics Internal Medicine

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  Contents Foreword xv William F. Rayburn Preface xvii Judith U. Hibbard Pregestational Diabetes 143 Gabriella Pridjian The prevalence of preexisting diabetes in pregnancy is increasing largelybecause of an increase in type 2 diabetes. Outcomes of diabetic pregnan-cies for mother and newborn have improved greatly in recent decadesfrom advances in understanding the disease process, improved educa-tion, and new treatment modalities delivered in a team approach. Nauseaand vomiting from pregnancy and pregnancy-associated insulin resis-tance can make glycemic control a challenge. Care of women with preex-istingdiabetesdemandscarefulmonitoringinthepreconception,prenatal,and peripartum periods. Asthma in Pregnancy: Pathophysiology, Diagnosis and Management 159 Abbey J. Hardy-Fairbanks and Emily R. Baker  Asthma is a common, potentially serious, even life-threatening, chronicmedical condition seen amongst nearly all groups of patients, regardlessof ethnicity and socioeconomic circumstances. This article addressesthe group of pregnant women with symptomatic asthma as well as thosewhose asthma is asymptomatic as a result of good control. The incidence,the pathophysiologic changes of pregnancy, and the interplay betweenthese changes and asthma are reviewed in this article. The classificationof these patients and appropriate management strategies are discussed. Diagnosis and Management of Thyroid Disease in Pregnancy 173 Diana L. Fitzpatrick and Michelle A. Russell Thyroiddiseaseiscommon,affecting1%to2%ofpregnantwomen.Preg-nancymaymodifythecourseofthyroiddisease,andpregnancyoutcomescan depend on optimal management of thyroid disorders. Consequently,obstetric providers must be familiar with thyroid physiology and manage-ment of thyroid diseases in pregnancy. Following a brief overview of phy-siology, this article provides an in-depth review of diagnosis andmanagement of the spectrum of thyroid disease occurring in pregnancy.Recommendations for screening and treatment of hypo- and hyperthy-roidism are summarized. Specific attention is given to the limitations of current research and the status of ongoing work. Update on Medical Disorders in Pregnancy   Management of Renal Disease in Pregnancy 195 Tiina Podymow, Phyllis August, and Ayub Akbari  Although renal disease in pregnancy is uncommon, it poses considerablerisk to maternal and fetal health. This article discusses renal physiologyandassessmentofrenalfunctioninpregnancyandtheeffectofpregnancyon renal disease in patients with diabetes, lupus, chronic glomerulonephri-tis, polycystic kidney disease, and chronic pyelonephritis. Renal diseasesoccasionally present for the first time in pregnancy, and diagnoses of glo-merulonephritis, acute tubular necrosis, hemolytic uremic syndrome, andacute fatty liver of pregnancy are described. Finally, therapy of end-stagerenaldiseaseinpregnancy,dialysis,andrenaltransplantationarereviewed. Pregnancy in the RenalTransplant Recipient 211 Michelle A. Josephson and Dianne B. McKay March10th,1958,isthebirthdayofthefirstbabyborntoakidneytransplantrecipient.Thepregnancywenttotermandthebabywasdeliveredbycesar-ean section for fear that a vaginal birth could adversely affect the allograftkidney sitting in the iliac fossa. Undoubtedly, this pregnancy more than 50yearsagowas considered highrisk becauseof itspioneering nature. How-ever, given that the transplant recipient had received her kidney from heridenticaltwinsisterapproximately2yearsbeforeandwasnottakinganyim-munosuppressive medications, the pregnancy was associated with farfewer risks than most pregnancies in transplant recipients of today. Notonlyareimmunosuppressantsnowavailablethathavepotentialadverseaf-fects on the developing fetus but also many kidney transplant recipientshave kidney function that is suboptimal. Although thousands of womenwith kidney transplants have successfully delivered healthy babies, manynew issues must be considered during a transplant recipient’s pregnancycompared with 50 years ago. These issues are discussed in this article. Sickle Cell Disease in Pregnancy 223 Dennie T. Rogers and Robert Molokie The term sickle cell disease (SSD) encompasses several different sicklehemoglobinopathies. The ability to predict the clinical course of SSD dur-ing pregnancy is difficult. This article examines pregnancy-associatedcomplications in SSDand the management of sickle cell disorders in preg-nantwomen. Outcomes have improved for pregnant women withSSD andnowadays the majority can achieve a successful live birth. However, preg-nancy isstill associated with an increased incidence of morbidity and mor-tality. Optimal management during pregnancy should be directed atpreventing pain crises, chronic organ damage, optimization of fetal healthand minimizing early maternal mortality using a multidisciplinary team ap-proach and prompt, effective and safe relief of acute pain episodes. Abnormal Placentation, Angiogenic Factors, and the Pathogenesis of Preeclampsia 239 Michelle Silasi, Bruce Cohen, S. Ananth Karumanchi, and Sarosh Rana Preeclampsia is a common complication of pregnancy with potentiallydevastating consequences to both the mother and the baby.It is the Contents x  leading cause of maternal deaths in developing countries. In developedcountries it is the major cause of iatrogenic premature delivery and con-tributes significantly to increasing health care cost associated with prema-turity. There is currently no known treatment for preeclampsia; ultimatetreatment involves delivery of the placenta. Although there are severalrisk factors (such as multiple gestation or chronic hypertension), most pa-tients present with no obvious risk factors. The molecular pathogenesis of preeclampsia is just now being elucidated. It has been proposed that ab-normal placentation and an imbalance in angiogenic factors lead to theclinical findings and complications seen in preeclampsia. Preeclampsiais characterized by high levels of circulating antiangiogenic factors suchas soluble fms-like tyrosine kinase-1 and soluble endoglin, which inducematernal endothelial dysfunction. These soluble factors are altered notonly at the time of clinical disease but also several weeks before the onsetof clinical signs and symptoms. Many methods of prediction and surveil-lance have been proposed to identify women who will develop preeclamp-sia, but studies have been inconclusive. With the recent discovery of therole of angiogenic factors in preeclampsia, novel methods of predictionand diagnosis are being developed to aid obstetricians and midwives inclinical practice. This article discusses the role of angiogenic factors inthe pathogenesis, prediction, diagnosis, and possible treatment of preeclampsia. Update on Gestational Diabetes 255 Gabriella Pridjian and Tara D. Benjamin  As the rate of obesity increases in adolescent and adult women in theUnited States, practitioners of obstetrics see higher rates of gestational di-abetes. Recent clinical studies suggest that women with gestational dia-betes have impaired pancreatic beta-cell function and reduced beta-celladaptation resulting in insufficient insulin secretion to maintain normal gly-cemia. Despite recent evidence that even mild hyperglycemia is associ-ated with adverse pregnancy outcomes, controversies still exist inscreening, management, and treatment of gestational diabetes. Initialstudiesregardingglyburidefortreatmentofgestationaldiabetesareprom-ising. Overall, only about half of the women with gestational diabetes arescreened in the postpartum period, an ideal time for education and inter-vention, to decrease incidence of glucose intolerance and progression totype 2 diabetes. Cholestasis of Pregnancy 269 Bhuvan Pathak, Lili Sheibani, and Richard H. Lee Intrahepatic cholestasis (ICP) of pregnancy is a disease that is likely mul-tifactorial in etiology and has a prevalence that varies by geography andethnicity. The diagnosis is made when patients have a combination of pru-ritus and abnormal liver-function tests. It is associated with a high risk foradverse perinatal outcome, including preterm birth, meconium passage,and fetal death. As of yet, the cause for fetal death is unknown. Becausefetal deaths caused by ICP appear to occur predominantly after 37 weeks,it is suggested to offer delivery at approximately 37 weeks. Contents  xi  Ursodeoxycholic acid appears to be the most effective medication to im-prove maternal pruritus and liver-function tests; however, there is no med-ication to date that has been shown to reduce the risk for fetal death. Update on Peripartum Cardiomyopathy 283 Meredith O. Cruz, Joan Briller, and Judith U. Hibbard  Although multiple mechanisms have been postulated, peripartum cardio-myopathy (PPCM) continues to be a cardiomyopathy of unknown cause.Multiple risk factors exist and the clinical presentation does not allow dif-ferentiation among potential causes. Although specific diagnostic criteriaexist, PPCM remains a diagnosis of exclusion. Treatment modalities aredictated by the clinical state of the patient, and prognosis is dependenton recovery of function. Randomized controlled trials of novel therapies,such as bromocriptine, are needed to establish better treatment regimensto decrease morbidity and mortality. The creation of an international regis-try will be an important step to better define and treat PPCM. This articlediscusses the pathogenesis, risk factors, diagnosis, management, andprognosis of this condition. PregnancyAfter Bariatric Surgery 305 Michelle A. Kominiarek The incidence of obesity is increasing rapidly, and it affects a greater pro-portion of women than men. Unfortunately, obesity has a negative impacton women’s reproductive health, including increased adverse perinataloutcomes. Weight loss surgery, also known as bariatric surgery, is per-formed in many hospitals, and can allow for significant weight loss and im-provement in medical comorbidities such as diabetes and hypertension. A woman who becomes pregnant after bariatric surgery usually has an un-complicated pregnancy but requires special attention to some complica-tions that can occur after these procedures. This article reviews theperinatal outcomes and provides recommendations for care regardingthe unique issues that arise during a pregnancy after bariatric surgery. SelectedViral Infections in Pregnancy 321 Britta Panda, Alexander Panda, and Laura E. Riley Thisarticlereviewstheimpactofseasonalinfluenzaonpregnancywithpar-ticularemphasisonthe2009novelH1N1pandemic.Antiviraltherapyforin-fluenza, as well as recommendations and safety data on vaccination arediscussed. In addition, the impact of hepatitis A, B, and C in pregnancy isaddressedwithafocusonpreventionandtreatmentstrategiesforhepatitisB and C. Thromboprophylaxis in Pregnancy:Who and How? 333 Sarah M. Davis and D. Ware Branch Venous thrombosis and embolism (VTE) is one of the most common, seri-ous complications associated with pregnancy, and now ranks as a leading Contents xii
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