Niharika Mehta

Respiratory disease in pregnancy

Many physiological and anatomical changes of pregnancy affect the respiratory system. These changes often affect the presentation and management of the various respiratory illnesses in pregnancy. This article focuses on several important respiratory issues in pregnancy. The management of asthma, one of the most common chronic illnesses in pregnancy, remains largely unchanged compared to the nonpregnant state. Infectious respiratory illness, including pneumonia and tuberculosis, are similarly managed in pregnancy with antibiotics, although special attention may be needed for antibiotic choices with more pregnancy safety data. When mechanical ventilation is necessary, consideration should be given to the maternal hemodynamics of pregnancy and fetal oxygenation. Maintaining maternal oxygen saturation above 95% is recommended to sustain optimal fetal oxygenation. Cigarette smoking has known risks in pregnancy, and current practice guidelines recommend offering cognitive and pharmacologic interventions to pregnant women to assist in smoking cessation.

Prescribing for the pregnant patient.

Prescribing in pregnancy can be challenging for providers facing insufficient information about drug safety, overestimation of the risk of medications by both the patient and the care provider, and increasing litigation costs. This article provides key concepts to consider when prescribing for a pregnant patient and offers practical advice for choosing the safest possible drug treatments. Key concepts to consider and practical advice for choosing the safest possible drug treatments.

Pharmacotherapy in Pregnancy and Lactation

Prescribing for patients who are pregnant and breastfeeding can be a challenge for clinicians facing insufficient information regarding medication safety, overestimation of perceived risk of medication both by patients and care providers, and increasing litigation costs. This article aims to guide the clinician in choosing the safest and most effective strategy when prescribing medications to patients who are pregnant and breastfeeding.

Skin disease in pregnancy: The approach of the obstetric medicine physician

This review presents the approach of the obstetric medicine physician to skin disease in pregnancy. It elaborates on common skin-related problems during gestation, such as pruritus, with or without eruption, and drug eruptions. An algorithmic approach to the differential diagnosis of pruritus in pregnancy is outlined. Also, the review focuses on how to diagnose promptly endocrinopathies presenting with skin manifestations in pregnancy, such as Addison disease, diabetes, and hyperthyroidism. The prompt diagnosis of endocrine disorders can help to optimize management and improve outcomes. Finally, the authors outline their approach to minimizing maternal and fetal risks associated with skin disease. The risks associated with obstetric cholestasis, pemphigoid gestationis, and impetigo herpetiformis are discussed. Prompt diagnosis helps to minimize the serious risks associated with certain infections. Preconception counseling and a multidisciplinary approach are crucial to preventing risks associated with rheumatic skin disease and genodermatoses. Challenging, real-life obstetric medicine cases are discussed.

Moyamoya disease in pregnancy and delivery planning: A case series and literature review

Moyamoya disease is a rare condition characterized by stenosis or occlusion of the intracranial internal carotid arteries leading to the development of fragile collateral vessels. Disruption of these vessels can lead to both ischemic and hemorrhagic strokes. As such, these patients are sensitive to changes in intracranial pressure and pose a challenge in pregnancy and delivery planning. Two cases of a parturients with moyamoya disease are presented, and the literature regarding safe method of delivery in similar patients is reviewed. The available evidence suggests that adequate anesthesia, and maintenance of hemodynamic status, takes precedence over the exact method of delivery in these patients. Cesarean delivery under epidural anesthesia can be a safe option for parturients with moyamoya disease, but an uncomplicated vaginal delivery, most often assisted with either vacuum or forceps, has also been frequently reported.

Prescribing in Pregnancy and Lactation

Ever since the thalidomide tragedy in the 1950s, drugs have increasingly been under scrutiny for teratogenensis. Both patients and clinicians are hesitant to use medications in pregnancy because of uncertainty about fetal effects. However, with advances in medical science, as we grow more and more dependent on pharmaceuticals for disease management and prevention, medication use in pregnancy often becomes necessary. An international survey found that 86% of the women studied took prescription medication during their pregnancy, receiving an average of 2.9 prescriptions. This pattern of medication use appeared to be almost universal and did not differ between poor and wealthy nations (1). Although this data did not include herbal, alternative, or over the counter medications, the use of these agents by pregnant women is also fairly common (2, 3). This chapter aims to provide some key principles to guide clinicians when prescribing for the pregnant patient with pulmonary disease. The Myth of the Placental Barrier Despite the widespread belief to the contrary, no ‘‘placental barrier’’ exists. The clinician should assume that the fetus will be exposed to almost any medication that is given to the mother. The most notable commonly prescribed exceptions that do not cross the placenta are glyburide, heparins, and insulin. For most other medications, drug levels in the fetus may be the same, lower or even higher than in the mother. Lipophilic drugs, drugs of a low molecular weight, and drugs that are nonionized at physiologic pH generally cross the placenta more efficiently than others.

Fontan circulation and implications for future reproduction

This article summarizes and critiques four recent publications looking at preconception counseling, pregnancy outcomes, and cardiac complications in women with history of Fontan circulation. The Fontan procedure is a palliative strategy for single-ventricle type congenital heart disease and involves passive flow of venous return into the pulmonary circulation, bypassing the ventricles. Pregnancy in these patients is not without risk and preconception counseling and contraception practices vary widely. High rates of miscarriage, prematurity, and small-for-gestational-age babies are reported. Cardiac complications include mainly arrhythmias. Whether long-term prognosis in these patients is affected by pregnancy is not yet known.