Counselling for women with medical disorders

Women with serious medical disorders require specific care and counselling prior to pregnancy. The aim is to provide seamless care from chronic disease state to early conception to delivery and back to long-term care. This has not been achieved within many traditional patterns of care. The aims of prepregnancy care in this context are outlined in Table 5.2.

It is important for women with certain medical problems that consideration is given to first trimester complications. Women with bleeding disorders will need admission plans in the event of miscarriage or ectopic pregnancy and clear plans for ultrasound assessment of pregnancy to try and prevent emergency admission. Hyperemesis can have more profound implications for women with diabetes making control at a critical time difficult to achieve and for women on maintenance medication such as steroids or other immunosuppressive treatment. Thromboembolic disorders can pose very specific risks in the first trimester as vomiting and hyperemesis can predispose to increased risks of thrombosis. Threshold for admission and assessment needs to be adjusted accordingly.

Medications should be prescribed pre-conceptually that are in general safe in the first trimester [13]. Some medications are important for long-term well-being and physicians may be reluctant to stop them to await conception.

Table 5.2 Issues that need to be considered when giving pre-conceptual advice to women with background medical conditions

Table 5.3 Drugs known to be teratogenic [13]


Vulnerable period Harm







Clear contact arrangements with medical team Medications consistent with safe use in pregnancy Or clear plan to change treatment in first trimester Clear plan in the event of first trimester complications Appropriate medication

High-quality anomaly scanning as appropriate Availability of perinatal care for late second trimester delivery, i.e. 25-28 weeks Appropriate medical and surgical backup Clear plan for disease flares or incidental complications Smooth transition to optimal treatment to meet long-term healthcare needs

Conception may only be achieved after unpredictable periods of time and many will choose to leave women with hypertension or renal compromise on angiotensin converting enzyme (ACE) inhibitors, with a view to cessation of treatment as early as possible in the first trimester [14]. The same arguments may apply to warfarin treatment in women at high risk of thromboembolism. It is clear that seamless care with medical clinics is necessary for such treatment plans and well-informed patients.

The importance of good control in the diabetic mother has been covered in Chapter 27. Prior to pregnancy assessment of co-morbidities such as retinal disease, renal function and blood pressure control all aid a smooth transition into pregnancy. The cause of renal compromise is best addressed prior to pregnancy, and in the presence of nephrotic syndrome a plan for thromboprophylaxis needs to be instituted.

Phenylketonuria (PKU) is a specific genetic condition where appropriate dietary treatment can influence disease expression. This will have implications for an infant of an affected mother. Mothers with rare conditions of this nature tend to be well informed and to have ready access to specialist advice.

Diabetes 2

Diabetes 2

Diabetes is a disease that affects the way your body uses food. Normally, your body converts sugars, starches and other foods into a form of sugar called glucose. Your body uses glucose for fuel. The cells receive the glucose through the bloodstream. They then use insulin a hormone made by the pancreas to absorb the glucose, convert it into energy, and either use it or store it for later use. Learn more...

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