What diseases need special consideration during pregnancy?

Diabetes and some collagen vascular diseases like lupus and rheumatoid arthritis fall into this category. If you have one of these conditions, tell your gynecologist.

If you are diabetic, consult the internist or endocrinologist who is treating your diabetes as well as your gynecologist before you become pregnant and throughout your pregnancy. Get your blood sugar completely under control, close to 100 mg/dl, before the pregnancy begins. It was formerly thought that a normal blood sugar was 100-200 mg/dl and that diabetics should aim for the 150-200 range, within which they seemed to feel and function well. Today that level is considered far too high during pregnancy. Keeping blood sugar as close to normal as possible (a state called euglycemia) markedly reduces the risk of birth defects in the babies of diabetic women.

Hemoglobin Ai-C is a marker of long-term diabetes control, of whether your blood sugar stays in an appropriate range for a long time. If your hemoglobin Ai-C is normal, then it is reasonable to try to get pregnant; if it is elevated, you should wait until you are under better control.

What are the concerns for diseases like rheumatoid arthritis and lupus?

These diseases, which frequently affect young women, are commonly treated with steroids. There are two problems here: one is the impact of pregnancy on the disease itself; the second is steroid use during pregnancy.

Years ago, women with these diseases, particularly lupus, were counseled not to even think about getting pregnant. The pregnancy, in addition to being difficult, could make the disease worse. Recent studies have suggested that the risks are smaller than was formerly thought. If you are in reasonably good shape and your disease is under reasonable control, it is probably fine to become pregnant. Nevertheless, consult your internist and your gynecologist before you stop using contraception.

Your doctor will probably try to wean you from steroids during pregnancy. But even if you have to take them during a flare-up, their effect on the fetus will be minimal.

What about pregnancy and multiple sclerosis?

Multiple sclerosis has such a variable course that it is hard to predict during pregnancy, but the general view is that the disease will not harm the mother or the fetus and the pregnancy will not worsen the disease. Keep in close touch with your neurologist before and during your pregnancy.

Does pregnancy complicate asthma?

If you use inhalers to control your asthma, discuss this issue with your physician. The medications used to treat asthma are generally safe during pregnancy, but the physical conditions of pregnancy can worsen asthma. In the third trimester, when the baby pushes up against your diaphragm, you may feel short of breath even if you do not have asthma; there is less room for your lungs to expand, a situation that is aggravated by asthma.

Are there diseases that absolutely prohibit pregnancy?

There are only one or two very rare diseases that contraindicate pregnancy. One is a congenital heart disease called pulmonary hypertension that involves the blood vessels of the lungs. Another is Marfan’s syndrome, which is a connective tissue disorder. If you have one of these conditions, discuss the situation with your gynecologist and your internist.

Are there diseases for which your husband or sexual partner should be tested for before you try to become pregnant?

This question raises problems that may result from the genetic makeup of both the man and the woman. Sickle-cell anemia, most commonly seen in blacks, was formerly considered dangerous for pregnancy and still needs to be closely monitored. Perhaps as many as 10 percent of blacks of African descent have the genetic trait, but many have no clinical symptoms. Still, it is prudent to know whether or not you carry the trait. The disease involves a change of only one amino acid in the entire hemoglobin protein, the component of red blood cells that transports oxygen to body tissues. The alteration causes blood cells to become sickle shaped instead of round. These sickle-shaped cells are poor carriers of oxygen and may clog small blood vessels, interfering with circulation.

Tamika has sickle-cell anemia. When she became pregnant, she worried that her husband might carry the sickle trait. She knew that if he did, there would be a 50-percent chance that her baby would be born with sickle-cell anemia. Her husband was screened and did not have the trait, so her children will have the sickle trait, but not sickle-cell anemia.

The Tay-Sachs gene is carried by 3-4 percent of Jews of Central European ancestry and is also found in French Canadians. It causes degeneration of nerve cells within the brain and central nervous system. If you and your partner belong to one of these ethnic groups, think about being screened before becoming pregnant. The disease has symptoms only if the child inherits defective genes from both parents; people with only one defective gene are carriers and do not actually have the disease. Children of parents who are both carriers have a one-in-four chance of inheriting two defective genes and thus having the disease. A blood test before pregnancy occurs can determine whether you carry the defective gene. If both parents are carriers and you are pregnant, amniocentesis (a procedure for genetically screening the amniotic fluid surrounding the fetus in the uterus) can determine whether the fetus has the disease.

Another disease carried by 2-3 percent of Jews of Eastern European origin is Canavan disease, which results in neurological degeneration because of a defect in myelin (a protein that protects nerves and allows messages to be sent to and from the brain). For the child to have the disease the defective gene for Canavan disease must be inherited from both parents. Jewish couples or those with a family history of the disease can be screened for it.

Other genetic diseases for which testing is available include cystic fibrosis and certain blood diseases. Cystic fibrosis is a genetic disease in which abnormally thick mucus obstructs the pancreas and clogs the lungs, leading to chronic infections. It afflicts primarily Caucasians, of whom about 4 percent are carriers, but the disease appears only if defective genes are inherited from both parents. Physicians routinely offer screening for cystic fibrosis. If you have a family history of this disease, of hemophilia, or other genetic blood diseases, you should be tested.

Is it important to have certain immunizations before becoming pregnant?

Certain infectious diseases can have a negative impact on a pregnancy, so check into your immunity for them. If you get married in Connecticut, you will be tested for syphilis and German measles. Most states require this testing, but if you and your partner are not married, do get tested for these diseases if you decide to have a child. Syphilis is not very common, but it does exist and should be ruled out before you become pregnant. Children nowadays are routinely immunized against German measles, but it is worthwhile making sure that you either have had the disease or were immunized against it.

Chicken pox can be dangerous for pregnant women. Children seldom get very sick with it, though occasionally it has serious complications. Adults can become quite ill with chicken pox, but pregnant women get even sicker and sometimes have serious pneumonia. There is minimal danger to the fetus. If you have had chicken pox, you are safe from getting it again; if you are not sure, have a lab test called a varicella titer to see whether you are immune. There is a vaccine that will protect you when, for example, your toddler comes home from day care with chicken pox. If one of our pregnant patients who has not had chicken pox is exposed to it, we treat her aggressively with immunoglobulin (a protein in the blood that fights infections).

Immunizations usually become effective in about three months. If you need to be immunized, wait about three months after your shots before you try for a pregnancy.

What about human immunodeficiency virus testing?

The other big question nowadays is prenatal human immunodeficiency virus testing. I am one of many who believe that testing should be mandatory for everyone contemplating pregnancy. First of all, knowing that you are human immunodeficiency virus positive can guide you in your decision on whether to have a child. Second, if you do decide to have a child, certain medications can substantially reduce the risk that the fetus will develop human immunodeficiency virus.

My own feelings are that if you are human immunodeficiency virus positive, you should seriously consider not becoming pregnant. You may choose not to become a mother because you do not wish to leave your child an orphan. Or you may elect not to have a child because even though AZT (zizovudine), the primary anti-human immunodeficiency virus drug, can reduce the chances of infecting your unborn child, you do not want to take this risk at all.

How effective is AZT in preventing transmission of HIV to an unborn child?

Before the development of AZT, 25-30 percent of human immunodeficiency virus-positive mothers passed the disease on to the fetus. Today, aggressive therapy with AZT reduces that risk to about 8 percent. For this reason human immunodeficiency virus testing during pregnancy is mandatory in Connecticut and many other states.

The Centers for Disease Control report that from 1996 to 1997 the number of children under age 13 diagnosed with Acquired immunodeficiency syndrome declined 40 percent, reflecting the success of efforts to reduce transmission at birth through human immunodeficiency virus testing and AZT therapy for pregnant human immunodeficiency virus-infected women and their infants.

What about testing for STDs before pregnancy?

If you are planning pregnancy and think you are at risk for a sexually transmitted disease like chlamydia and gonorrhea, it is worthwhile to be tested. Unlike German measles, for example, these diseases do not cause birth defects, but they can increase the chance of premature labor. Testing is a simple matter of swabbing the cervix. Furthermore, these diseases can be treated.

If you have been in a monogamous relationship for a long time and were tested previously, there is no need to be retested. But if you have had several sexual partners, it is definitely desirable.

What about pregnancy and anorexia?

Women with anorexia often have difficulty becoming pregnant, because their body weight is so low that they stop ovulating. Pregnancy can cause significant psychological distress for women with bulimia or other problems with body image. Ideally, women gain 25-35 pounds during pregnancy, and women who are already conflicted about their bodies may find this healthy gain unacceptable.

Does obesity complicate pregnancy?

You should be in top physical shape when you become pregnant. Pregnancy makes great physical demands on your body, and labor and delivery are more strenuous than running a half-marathon. No serious runner would consider starting a long-distance race without training, and I encourage women to train during pregnancy. Being in shape includes being as close to your ideal body weight as you can manage.

Why is that important? First, I have said that you will gain a good deal of weight during pregnancy. If you are already 20 pounds overweight, you will be carrying 45 extra pounds or so when you deliver — and even 25 pounds is a lot of excess weight to be carrying around all day long. Second, the more overweight you are, the more you are at risk for high blood pressure or diabetes during pregnancy.

Many women just cannot shed those extra pounds. If you have been trying for years to lose 30 pounds, at some point you are simply going to have to say to yourself, “Overweight or not, now’s the time to try for a pregnancy.” If you really want a child and cannot manage to lose weight, the problem can be managed. But be realistic in your expectations. The weight may make you uncomfortable. You may need a cesarean section, a higher statistical risk for overweight women than for those of normal weight. While the procedure is not pleasant for either the patient or the physician, many women have had C-sections and gone on with their lives. On the other hand, some women who have weight problems do not gain significant additional weight during their pregnancies.

Danielle weighs 250 pounds despite her best efforts to control her weight. When she found herself pregnant, she worried about gaining another 35 pounds. I suggested she stick to a reasonable diet, exercise, and not think she was “eating for two.” As a result she didn’t gain weight at all, although her baby developed normally.

What nutritional guidelines should you follow if you are planning to become pregnant?

Calcium, iron, and folic acid are especially important during a pregnancy. Babies steal from their mothers, which is how they get formed, and the specific nutrients they steal are calcium and iron. Often I prescribe prenatal vitamins for women who are planning pregnancy. Most of these vitamins contain 1 mg of folic acid, extra iron, and extra calcium.

Most American women are calcium deprived. If you are planning to become pregnant, start making sure that your diet contains at least 1,000 mg of calcium, the recommendation for pregnant women.

If you tend to be anemic, pump yourself full of iron. Iron, taken as dietary supplements, can have one unfortunate side effect: constipation. And pregnancy often has the same effect. If you are anemic before pregnancy, decide to take iron, and become constipated, you are still better off than you would be if you were both constipated and anemic during your pregnancy.

Increase your folic acid intake. This substance is critical in preventing neural tube defects such as spina bifida or anencephaly. The neural tube is an embryonic structure that appears between the fifth and sixth weeks of pregnancy; normally it closes and forms the brain and spinal cord. If the tube does not close completely, spina bifida or anencephaly result. Spina bifida (“divided” spine) is a condition in which the vertebrae do not form over the back of the spinal cord, leaving it unprotected; the severity of the defect depends on the location of the opening. Infants with anencephaly, in which the head and brain do not develop completely, usually are stillborn or die shortly after birth.

The relevant research on these diseases came from Great Britain, where neural tube defects seem more common than in this country, where their incidence is somewhere between 1 in 500 births and 1 in 1,000 births. The Centers for Disease Control encourage women to take folic acid prenatally, since studies suggest that the incidence of neural tube defects can then be brought down significantly. The standard recommendation for folic acid supplements is 0.4 mg (400 mg) daily. Women at high risk for producing children with neural tube defects should take larger doses, 4 mg daily. If you have previously been pregnant with a fetus that had a neural tube defect, you are in the high-risk category. You are also at increased risk if you have a strong family history of this problem: for example, your sister has had two children with these defects.

Does pregnancy worsen depression or other psychological problems?

Women who have had psychological difficulties usually do well during pregnancy if they became pregnant because they want a child. If the pregnancy was unplanned or was entered into grudgingly (perhaps because someone else wants the child), then women who have been depressed may become more so. Some of the side effects of pregnancy can depress women with tendencies in that direction.

Sharon struggled with depression in her daily life. When she was about two months pregnant, she came for a checkup and burst into tears, weeping uncontrollably. She felt nauseated and vomited in the mornings, which although unpleasant is not unexpected during the first trimester. Unlike many women in the same situation, Sharon did not cope well at all with the nausea. The last straw came when her mother-in-law, who helped care for Sharon’s older child, got sick and couldn’t babysit. Sharon was not taking antidepressants or other medication for her emotional state.

I asked Sharon how I could help her. Basically, she said, she needed someone to watch her child so that she could nap during the afternoon (she was having difficulty sleeping at night). In my estimation she was on the brink of serious emotional difficulties, so I called her HMO and asked for home health care, describing her fragile state. The HMO refused, saying that if Sharon did get worse and needed hospitalization, they would think about skilled nursing care, but they could not possibly provide for home help unless she suffered a breakdown. Sharon continued to feel more and more depressed and anxious; I eventually did send her to the hospital, for which the HMO agreed to pay. It was a very expensive way to take care of Sharon’s problems.

Are women who have had problems with depression likely to suffer from postpartum depression?

Unfortunately, the answer is yes. No one knows why postpartum depression happens and who is at risk. Of the many theories, the one currently in favor stresses the changing levels of hormones. During pregnancy women have higher levels of steroids and estrogen, both natural antidepressants, which explains why most women feel pretty cheerful at this time. In fact, some women with depression actually feel better during pregnancy.

Once the child is born, all these hormones return to their prepregnancy levels and women can become severely depressed. If you have been treated for depression, even if you are totally off the medications, it is wise to stay in touch with your psychiatrist and be prepared for the possibility that you may be depressed after the birth. You may be perfectly fine, but if you should experience postpartum depression, you can get help quickly.

Try to be realistic about what will happen once your child is born. Of course he or she will be wonderful (maternal instinct takes care of that), but your wonderful child will still poop and pee and wake you at three in the morning. These stresses exist for every new mother, and if your hormones are not in balance and you are not getting a good night’s sleep, you can expect to be less than completely cheerful.

Can you take antidepressants if you are pregnant?

Most antidepressants currently in use, called selective serotonin reuptake inhibitors (selective serotonin reuptake inhibitors), are reasonably safe during pregnancy. Several studies show that seriously depressed women do better taking the medications than not taking them. selective serotonin reuptake inhibitors include Prozac and Zoloft.

What about over-the-counter drugs just before or during pregnancy?

Most over-the-counter drugs are fine. Tylenol is probably better as a painkiller than ibuprofen or naprosyn and has the best track record as far as safety is concerned. If you have heartburn, you can take Maalox, Mylanta, or Turns, which are great because they contain the calcium you need in increased quantity during pregnancy. If you have a cold, the ordinary tried-and-true antihistamines and decongestants, including Benadryl and Sudafed, are safe.

When should you stop using birth control if you want to get pregnant?

I encourage my patients on birth control pills to stop taking them about three months before they intend to become pregnant, because some women experience a slight delay in the return of ovulation after stopping the pill. My second reason for suggesting this buffer zone is that some studies show that women who conceive in the first cycle off birth control have a higher incidence of twins. So you might want to wait an extra cycle unless you are actively seeking twins.

With other forms of contraception, you can stop the month before you plan to become pregnant. If you use Depo-Provera, you may have to wait several months for your

menstrual periods to resume, though many women resume ovulating the month they stop taking their Depo shots.

Should you take special measures, like planning the time of intercourse, when you do want to become pregnant?

My advice is to relax, have fun, and enjoy your sex life and the freedom of the moment. Throw away your thermometer, and don’t sit and look at your watch. For many women, this is probably the first time they have not had to worry about birth control.

Having stopped your birth control methods, don’t be disappointed if you do not get pregnant immediately. Remember that your statistical odds of getting pregnant in any one month are only 15 percent. On the other hand, you may be one of the 15 percent — so you can’t plan on its taking you six months to conceive.

If you stop using contraception and do not conceive during that first month, don’t immediately conclude that you have an infertility problem. Try to maintain your perspective. It is far too early to get out the menstrual calendars, or to wake up at three in the morning and have sex because that seems to be the optimal moment. Try to avoid sex on demand, which lessens the enjoyment. Have fun!

If you don’t succeed in becoming pregnant, when should you seek help?

Years ago I saw patients who would try for as long as five years before investigating the problem. That is rare in this day and age. If you are in your mid-30s, about six months is an appropriate wait. Then give your gynecologist a call and you can start some simple testing to try to find out what is going on. If you are in your early 20s, you can try for a year before consulting your gynecologist.

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