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Mental Health and Behavioral Disorders in Pregnancy

Key Points Mental health is fundamental to health. To the extent that maternal biopsychosocial exposures with negative impact on pregnancy outcomes can be diminished, eliminated, or replaced with positive factors, the risk of poor pregnancy outcome can be reduced. Major depression is a treatable illness that is the leading cause of disease burden among girls and women worldwide. The period prevalence of depression is 12.7% during…

Maternal and Perinatal Infection in Pregnancy: Bacterial

Key Points Overall, without screening and treatment, 85% of neonatal GBS infections are early in onset and result from transmission from a colonized mother. All pregnant women should be cultured for cervicovaginal GBS at 35 to 37 weeks’ gestation. Culture-positive patients should receive intrapartum antibiotic prophylaxis to prevent early-onset neonatal infection. Pregnant patients with GBS bacteriuria should be targeted for intrapartum prophylaxis. All pregnant women should…

Maternal and Perinatal Infection in Pregnancy: Viral

Key Points Rubella immunization and HBV and HIV infection screening is standard. HIV screening should be performed via an “opt out” approach, and in high prevalence areas, repeat screening in the third trimester should be considered. Varicella screening may be considered in women without a history of infection. Routine CMV screening is not recommended secondary to high seroprevalence. The ACOG and the CDC recommend seasonal influenza…

Maternal and Perinatal Infection: Chlamydia, Gonorrhea, and Syphilis in Pregnancy

Key Points All pregnant women younger than 25 years or those at increased risk should be screened for Chlamydia and gonorrhea during pregnancy. Women younger than 25 and those at high risk for sexually transmitted infections should be rescreened for Chlamydia during the third trimester. Syphilis screening should be performed at the first prenatal visit as well as early in the third trimester. Repeat testing should…

Skin Disease and Pregnancy

Key Points With the physiologic skin changes of pregnancy, no risks are incurred for the mother or fetus. The changes should be expected to resolve postpartum. Preexisting melanocytic nevi may show mild changes in pregnancy, but no increased risk for malignant transformation exists. Preexisting skin disorders are more likely to worsen than improve in pregnancy; atopic dermatitis (eczema) is the most common dermatosis in pregnancy. Prognosis…

Malignant Diseases and Pregnancy

Key Points Because many of the common complaints of pregnancy are also early symptoms of metastatic cancer, pregnant women with cancer are at risk for delays in diagnosis and therapeutic intervention. The safest time for most cancer therapies in pregnancy is in the second and third trimesters, thereby avoiding induction of teratogenic risks or miscarriage in the first trimester. For most malignancies diagnosed during the second…

Neurologic Disorders in Pregnancy

Key Points Epilepsy affects approximately 1% of the general population and is the most frequent neurologic complication of pregnancy. Prepregnancy counseling is imperative in the patient with epilepsy. Valproic acid has been associated with a significantly increased risk of major congenital malformations and adverse cognitive outcomes, including lower IQs and an increased risk of autism, when compared with other AEDs and with the general population. AEDs…

Gastrointestinal Disorders During Pregnancy

Key Points The differential diagnosis of GI symptoms and signs such as abdominal pain is particularly extensive during pregnancy. Aside from GI and other intraabdominal disorders incidental to pregnancy, the differential includes obstetric, gynecologic, and GI disorders related to pregnancy. Pregnancy can affect the clinical presentation, frequency, or severity of GI diseases. For example, GERD markedly increases in frequency, and peptic ulcer disease decreases in frequency…

Hepatic Disorders During Pregnancy

Key Points The differential of hepatobiliary conditions is extensive in pregnancy and includes pregnancy-related disorders in addition to disorders unrelated to pregnancy. Indeed, several clinical syndromes are unique to pregnancy, such as intrahepatic cholestasis of pregnancy and acute fatty liver of pregnancy. Pregnancy affects the normative values of serum parameters of liver function and pancreatic injury. During pregnancy, the serum level of albumin declines, and the…

Collagen Vascular Diseases in Pregnancy

Key Points SLE is the most common serious autoimmune disease that affects women of reproductive age. SLE disease activity at the onset of pregnancy is the most important determinant of the course of the disease in pregnancy. Women with SLE should be counseled to postpone pregnancy until a sustained remission for at least 6 months has been achieved. For women with lupus nephritis, moderate renal insufficiency…

Thromboembolic Disorders in Pregnancy

Key Points VTE is a leading cause of mortality and serious morbidity in pregnant women, with a prevalence of 1 per 1000 to 1 per 2000 pregnancies; the greatest risk of fatal PE occurs following CDs. Inherited and acquired thrombophilias account for most VTEs in pregnancy. VUS is the most common diagnostic modality used in the evaluation of patients with suspected DVT, with an overall sensitivity…

Hematologic Complications of Pregnancy

Key Points Four percent of pregnancies will be complicated by maternal platelet counts of less than 150,000/mm 3 . The vast majority of these patients have gestational thrombocytopenia with a benign course and need no intervention. Surgical bleeding occurs if the platelet count falls below 50,000/mm 3 , and spontaneous bleeding occurs if the platelet count falls below 20,000/mm 3 . Platelet counts below 30,000/mm 3…

Pituitary and Adrenal Disorders in Pregnancy

Key Points About 30% of prolactin-secreting macroadenomas enlarge significantly during pregnancy. Dopamine agonists can be used safely for the treatment of prolactinomas if stopped when pregnancy is diagnosed. In patients with acromegaly, the risks of gestational diabetes and hypertension are increased. Gonadotropins, gonadotropin-releasing hormone, and assisted reproductive technology have been used successfully to achieve pregnancy in women with hypopituitarism. Sheehan syndrome is very uncommon with modern…

Thyroid and Parathyroid Diseases in Pregnancy

Key Points Hyperthyroidism due to Graves disease needs to be differentiated in the first trimester of pregnancy from the syndrome of gestational thyrotoxicosis. Recent reports indicate increased risk for liver failure with the use of PTU; it is recommended that PTU be used in the first trimester of pregnancy and MMI after 13 weeks’ gestation. MMI is not indicated in the first trimester because of the…

Obesity in Pregnancy

Key Points Behavioral modification of diet or diet plus exercise can decrease excessive gestational weight gain in obese women. Weight gain in pregnancy should be based on pregravid BMI and should follow the Institute of Medicine recommendations. Obese women should be counseled as to the limitation of ultrasound in identifying structural anomalies. At the first prenatal visit, obese women should be screened for glucose intolerance. Antenatal…

Diabetes Mellitus Complicating Pregnancy

Key Points Pregnancy has been characterized as a diabetogenic state because of increased postprandial glucose levels in late gestation. Both hepatic and peripheral (tissue) insulin sensitivity are reduced in normal pregnancy. As a result, a progressive increase in insulin secretion follows a glucose challenge. In women with GDM, the hormonal milieu of pregnancy may represent an unmasking of a susceptibility to the development of type 2…

Renal Disease in Pregnancy

Key Points Asymptomatic bacteriuria complicates 5% to 7% of pregnancies. If left untreated, it will result in symptomatic urinary tract infections in 40% of women. Pyelonephritis complicates 1% to 2% of pregnancies and generally requires inpatient treatment. Women with glomerular disease can have successful pregnancies, but pregnancy loss rates increase greatly if the patient has preexisting hypertension. Creatinine clearance can decline 70% before significant increases are…

Respiratory Disease in Pregnancy

Key Points Pneumonia is the most common nonobstetric infectious cause of maternal mortality, and more than 40% of pneumonia cases are complicated by preterm delivery. Streptococcus pneumoniae is the most common bacterial pathogen associated with pneumonia during pregnancy. To treat pneumonia, empiric antibiotic coverage should be started that includes a third-generation cephalosporin and a macrolide, such as azithromycin, to cover atypical pathogens. If CA-MRSA is suspected,…

Heart Disease in Pregnancy

Key Points Hemodynamic changes in pregnancy may adversely affect maternal cardiac performance. Intercurrent events (e.g., infection) in pregnancy are usually the cause of decompensation. Women with heart disease in pregnancy frequently have unique psychosocial needs. Labor, delivery, and postpartum are periods of hemodynamic instability. The postpartum period can be characterized as a “perfect storm” of volume loading, tachycardia, and increased afterload; each of these may contribute…

Prolonged and Postterm Pregnancy

Key Points Ultrasonography, preferably done in the first trimester, is the most accurate method with which to establish the EDD. No gestational cutoff has been established by which to define a prolonged pregnancy in multiple gestations. The risk for stillbirth increases after 38 weeks in twins and after 35 weeks in triplets. Late-term and postterm pregnancies are associated with an increased risk for perinatal morbidity and…