Clinical Care for WomenMedical Conditions
All women with asthma should be counseled about the potential for their asthma control to worsen with pregnancy and the importance of achieving asthma control before a pregnancy through appropriate medical management and avoidance of triggers. Women with asthma who are planning to become pregnant or who could become pregnant should be treated with pharmacologic step therapy for their chronic asthma based on the American College of Allergy, Asthma, and Immunology–American College of Obstetricians and Gynecologists recommendations for the Pharmacologic Step Therapy of Chronic Asthma During Pregnancy. Women with poor control of their asthma should be encouraged to use effective birth control until symptom control is achieved.
Women of reproductive age with cardiovascular disease should be counseled about the risks that pregnancy presents to their health and the risks of the cardiac condition and any medications needed to treat the condition (e.g., warfarin) on pregnancy-related outcomes. Women who are considering or planning a pregnancy should be counseled to achieve optimum control of the condition before conception and should be offered a suitable contraceptive method to achieve optimum timing of the pregnancy. Women whose treatment regimen involves warfarin should be counseled about its teratogenic nature; whenever possible, the treatment should be changed to a less teratogenic anticoagulant before conception. Women with a congenital cardiac condition should be offered preconception genetic counseling.
Good diabetes management reduces the increase in prevalence of birth defects among infants of women with diabetes.
All women with diabetes mellitus should be counseled about the importance of diabetes mellitus control before considering pregnancy. Important counseling topics include maintaining optimal weight control, maximizing diabetes mellitus control, self-glucose monitoring, maintaining a regular exercise program, and ceasing tobacco, alcohol, and drug use, along with social support to assist during the pregnancy. In the months before pregnancy, these women should demonstrate as near-normal a glycosylated hemoglobin level as possible for the purpose of decreasing the rate of congenital anomalies. Testing to detect prediabetes and type 2 diabetes among asymptomatic women should be considered for adults who are overweight or obese (BMI ≥25 kg/m2) and who have one or more additional risk factors for diabetes, including a history of gestational diabetes mellitus. Women with gestational diabetes mellitus should be screened for type 2 diabetes 6 to 12 weeks postpartum, and then every 1 to 3 years.
All women with anorexia and bulimia should be counseled about the risks to fertility and future pregnancies. Women with these disorders should be encouraged to enter into treatment programs before pregnancy.
Women of reproductive age with chronic hypertension should be counseled about the risks associated with hypertension during pregnancy for both themselves and their offspring and the possible need to change the antihypertensive regimen when they are planning a pregnancy. Women with chronic hypertension should be assessed for ventricular hypertrophy, retinopathy, and renal disease before pregnancy. Angiotensin-converting enzyme inhibitors and angiotensin-receptor blockers are contraindicated during pregnancy; women who could become pregnant while taking these medications should be counseled about their adverse fetal effects. Women who are planning a pregnancy should discontinue these medications before pregnancy.
Women of reproductive age with lupus should be counseled about the risks associated with lupus during pregnancy for themselves and their offspring, the importance of optimizing disease control before pregnancy, the possible need to change the medication regimen close to conception or early during pregnancy, and the importance of specialized prenatal care once pregnant. Women whose treatment regimen involves cyclophosphamide should be advised of its teratogenic nature; whenever possible, the treatment should be changed to a safer regimen before conception, and the women should be offered contraception if they are not planning a pregnancy.
Maternal PKU management prevents babies from being born with PKU-related intellectual disability.
Women of reproductive age with PKU should be counseled about the importance of maintaining a low phenylalanine level during their childbearing years and should be encouraged to maintain a low phenylalanine diet, particularly when they are planning to become pregnant, to avoid adverse outcomes for the offspring. Women who do not desire a pregnancy should be encouraged to use contraception.
Women of reproductive age with bipolar disorder should be counseled that pregnancy is a time of substantial risk of relapse, particularly after discontinuation of ongoing mood-stabilizing maintenance treatment. A relapse prevention and management strategy for bipolar disorder should be outlined before the patient attempts conception. Women of reproductive age with bipolar disorder should be counseled regarding contraceptive options, which should include options that will prevent conception during bipolar episodes.
Depression and Anxiety
Providers should screen and be vigilant for depression and anxiety disorders among women of reproductive age because treating or controlling these conditions before pregnancy can help prevent negative pregnancy and family outcomes. Women of reproductive age with depressive and anxiety disorders who are planning a pregnancy or who could become pregnant should be informed about the potential risks of an untreated illness during pregnancy and about the risks and benefits of various treatments during pregnancy. Several studies have shown an increased risk for heart defects associated with taking selective serotonin-reuptake inhibitors (SSRIs) during early pregnancy. One recent study found that taking bupropion during pregnancy might increase the risk of certain heart defects. A number of studies have identified risks to the fetus and newborn associated with use of antidepressant medications.
Women of reproductive age with schizophrenia should be counseled, together with a partner or family member whenever possible, about the risks of pregnancy on their condition and the risks of their condition on pregnancy-related outcomes. They should be counseled about the importance of prenatal care, and a relapse prevention and management strategy of the illness should be outlined before the patient attempts conception.
Women of reproductive age with renal disease should be counseled about the likelihood of progression of renal disease during pregnancy and the increased risk of adverse pregnancy outcomes for themselves and their offspring, and the importance of achievement and maintenance of normal blood pressure before conception. Angiotensin-converting enzyme inhibitors and angiotensin-receptor blockers are contraindicated during pregnancy; women who could become pregnant while taking these medications should be counseled about their adverse fetal effects and should be offered contraception if they are not planning a pregnancy. Women who are planning a pregnancy should discontinue these medications before pregnancy in favor of a safer regimen, whenever possible. Women who do not desire pregnancy should be offered an appropriate method of contraception.
Women with known history of rheumatoid arthritis should be advised of the natural history of the disease during pregnancy and the probability of a flare after pregnancy. The most important task is to review the patient's medication use. Nonsteroidal anti-inflammatory drugs should be discontinued by 27 weeks of gestation. Methotrexate and leflunomide are extremely teratogenic and should be stopped by women planning a pregnancy.
Women of reproductive age with seizure disorders should be counseled about the risks of increased seizure frequency during pregnancy, the potential effects of seizures and anticonvulsant medications on pregnancy outcomes, and the need to plan their pregnancies with a health care provider well in advance of a planned conception. Women who take liver enzyme-inducing anticonvulsants should be counseled about the increased risk of hormonal contraceptive failure. Whenever possible, women of reproductive age should be placed on anticonvulsant monotherapy with the lowest effective dose to control seizures. Women who are planning a pregnancy should be fully evaluated for consideration of alteration or withdrawal of the anticonvulsant regimen before conception, and folic acid supplementation of 4 milligrams (mg) per day should be initiated for at least one month before conception through the end of the first trimester to prevent neural tube defects.
Providers might consider screening women of childbearing age for a personal or family history of venous thrombotic events or recurrent or severe adverse pregnancy outcomes. Women with a personal or family history suggestive of thrombophilia then might be offered counseling and testing for thrombophilias if they are contemplating pregnancy. Screening for thrombophilias with laboratory testing during routine care is not recommended. Women of reproductive age with a known genetic thrombophilia should be offered preconception genetic counseling to address the risk of the condition for their offspring. Women of reproductive age with thrombophilia whose treatment regimen involves warfarin should be counseled about its teratogenic nature; whenever possible, the treatment should be changed to a less teratogenic anticoagulant before conception. Switching women off teratogenic anticoagulants (i.e., warfarin) before pregnancy avoids harmful exposure to the fetus.
Women with hypothyroidism should be counseled about the risks of this condition for pregnancy outcomes and the importance of achieving optimal replacement therapy before conception. All women with symptoms of hypothyroidism should be screened for thyroid disease.
Adjusting levothyroxine dosage early during pregnancy protects proper neurological development of the fetus.
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