Slide 5 Cystic Fibrosis Mental Illness

NEUROLOGIC DISORDERS AND PREGNANCY
A Woman With a Seizure Disorder

Causes:
head trauma or meningitis
unknown (idiopathic).
• pregnancy exists for women with seizures as long as the medication
they take is at the lowest dose possible and serum levels are
carefully monitored.
Therapeutic Management
• seizure medications -mildly teratogenic, (meet with their obstetrician

and primary care provider ) before pregnancy
• In the early months of pregnancy, - continue to
take their antiseizure medications despite the
nausea or vomiting
• The risk of adverse maternal or fetal outcome from
seizures during pregnancy, however, is greater
than the risk of teratogenicity from taking
anticonvulsant drugs .
• evaluation of serum drug levels before pregnancy
or early in pregnancy to establish that their
medication is being prescribed at a therapeutic
level .
Common drugs prescribed to control seizures are:
• Trimethadione (Tridione) (pregnancy risk category D)
• Valproic acid (sodium valproate and divalproex sodium)
(pregnancy risk category D)
• Carbamazepine (Tegretol) (pregnancy risk category C)
• Ethosuximide (Zarontin), a drug often used to control absence
seizures (pregnancy risk category C)
• Phenytoin sodium (Dilantin) (pregnancy risk category D).
• Dilantin can cause a fetal syndrome involving , cognitive impairment
and a peculiar facial proportion and Vit k Def. (competition for folic
acid binding sites).
• neural tube disorders as a result of this folic acid displacement.
• An ultrasound can rule out the possibility of this.
• prone to hemorrhagic disease of the newborn
because of decreased levels of vitamin K
coagulation factors at birth from phenytoin.
(vitamin K during labor or the last 4 weeks of
gestation.)
• Women who have been taking phenytoin (Dilantin)
may have developed chronic hypertension
( baseline blood pressure )should be established
early in pregnancy so that changes can be
interpreted correctly.
Myasthenia Gravis
• Autoimmune disorder
characterized by the presence of
an IgG antibody against
acetylcholine receptors in
striated muscle. (motor neurons)
• This causes failure of the striated
muscles to contract, particularly
those of the oropharyngeal,
facial, and extraocular groups
• Myasthenia gravis is treated with anticholinesterase drugs such as pyridostigmine
(Mestinon) or neostigmine (Prostigmin) and possibly a corticosteroid such as
prednisone.
• These medications may be continued during pregnancy, as the fetus will experience no
effects from these drugs
• smooth muscle is not affected by the disease,
labor should occur normally. Magnesium sulfate
should be avoided because it can diminish the
acetylcholine effect and therefore increase disease
symptoms.
• An infant born to a woman with myasthenia gravis
may demonstrate disease symptoms at birth
because of the transfer of antibodies.
Multiple sclerosis
• (MS) occurs predominantly in women of
childbearing age, usually between 20 and
40 years of age
• With MS, nerve fibers become
demyelinated and therefore lose
function.
symptoms
 Fatigue
 numbness
 blurred vision
 loss of coordination.
• ACTH or a corticosteroid is commonly given to strengthen nerve
conduction.
• These both can be administered safely during pregnancy.
• In contrast, cyclosporine
(Sandimmune), azathioprine
(Imuran), and cyclophosphamide
(Cytoxan)are not safe for use
during pregnancy.
• interferon has not been tested;
as such, it is classified as a
pregnancy category C drug.
• Women may continue with plasmapheresis
(withdrawal and replacement of plasma),
another treatment regimen, during
pregnancy as long as the volume of exchange
is well controlled.
• MS may actually improve with pregnancy
because of the increased circulating
corticosteroid levels.
• UTIs tend to occur as a poorly defined
consequence of the illness.
MUSCULOSKELETAL DISORDERS AND PREGNANCY
Scoliosis
• (lateral curvature of the spine) begins to be noticed first in girls
between 12 and 14 years of age-uncorrected -curvature progresses -
deformity, interfering with respiration and heart action because of chest
compression.
If a woman’s spine is extremely curved, spinal or epidural anesthesia
may be difficult to administer for pain management in labor.
Pelvic distortion
-can interfere with childbirth, especially at the pelvic inlet.
• If a woman’s pelvis is distorted, a cesarean birth may be necessary to
ensure a safe birth.
• Vaginal birth- plot the course of labor on a labor graph so an
unusually long first stage, suggesting cephalo-pelvic disproportion,
can be recognized.
ENDOCRINE DISORDERS AND PREGNANCY
A Woman With a Thyroid

Dysfunction
• As a normal effect of pregnancy,
the thyroid gland enlarges
(hypertrophies) slightly because
of increased vascularity and
blood flow.
• A woman with pre-existing
thyroid problems have difficulty
making this pregnancy transition.
Hypothyroidism
• This can lead to early spontaneous miscarriage.

 fatigue easily and tend to be obese;
 skin is dry (myxedema),
 little tolerance for cold
increased incidence of extreme nausea and vomiting
(hyperemesis gravidarum).
levothyroxine (Synthroid)
• needs to consult with her obstetrician and internist when she is
planning on becoming pregnant. (1 week past her missed menstrual
period).
• As a rule, her dose of levothyroxine will need to be increased as much
as 20% to 30% for the duration of the pregnancy to simulate the
increase that would normally occur in pregnancy
• separate thyroxine ingestion from any medication containing iron,
calcium, or soy products by about 4 hours to be sure that there is no
problem with the absorption of thyroxine
• After the pregnancy, dose is tapered back to the pre pregnancy level.
(hyperthyroidism)
Hyperthyroidism
• overproduction of thyroid
hormone, causes symptoms such
as:
• Rapid heart rate
• Exophthalmos (protruding
eyeballs)
• Heat intolerance
• Nervousness
• Heart palpitations
• Weight loss
• may develop heart failure during
pregnancy because her heart
rate, already high at the
beginning of pregnancy
• hypertension of pregnancy, fetal
growth restriction, and preterm
labor than the average woman.
• diagnosed by a nuclear medicine
imaging study involving the
radioactive uptake of 131I
subtype.
• This diagnostic procedure should not be used during
pregnancy because the fetal thyroid will also
incorporate this drug, possibly resulting in destruction
of the fetal thyroid.
• thioamides (methimazole [Tapazole] or
propylthiouracil [PTU])- which reduce thyroid activity-
teratogens.
• cross the placenta and can lead to congenital
hypothyroidism - enlarged thyroid gland (a goiter) in
the fetus-obstruct the airway and make resuscitation
difficult for the infant at birth.
• Methimazole is the preferred drug for pregnant
women as it appears to cross the placenta less
easily
• The infant may appear jittery, and tachypnea and
tachycardia may be present.
• An assay of fetal cord blood will reveal the level of
T4 and thyroid-stimulating hormone and the need
for therapy in the infant.
• Women receiving smaller or minimal doses of
antithyroid drugs may breastfeed, although
women receiving large doses of these drugs may
be advised not to breastfeed because these drugs
are excreted in breast milk .
Woman With Diabetes Mellitus
Woman With Diabetes Mellitus

• All women experience a number of changes in the glucose insulin
regulatory system as pregnancy progresses.
• Glomerular filtration is increased (slight glycosuria)
• All women appear to develop an insulin resistance as pregnancy
progresses- caused by the presence of hormone human placental
lactogen and high levels of cortisol, estrogen, progesterone and
cathecholamines.
• Continued use of glucose by the fetus may lead to hypoglycemia
(occur overnight)
• Greater risk for pregnancy induced hypertension and infection
(monilial infection)
Infants tend to be large (more than 10
lb)-
( inc. insulin the fetus to counteract
overload of glucose - increased
glucose adds subcutaneous fat
deposit.-Macrosomic infant-
cephalopelvic disproportion and
shoulder dystocia- necessary for CS.
• High incidence of Congenital
Anomaly esp. caudal regression
syndrome, spontaneous miscarriage
and stillbirth
Gestational Diabetes
• Become diabetic during pregnancy-usually at the midpoint of pregnancy
(insulin resistance)
• Symptoms fade at the completion of pregnancy but risk of developing
type 2 is high as 50 to 60%
Risk factor:
Obesity
Age over 25 yrs old
hx of large babies
hx of unexplained fetal or perinatal loss
Hx of congenital anomalies of previous pregnancies
Family history of DM
Population with high risk
Screening and
Diagnosis
ORAL GLUCOSE
CHALLENGE TEST
Protocol for the Evaluation of Diabetes
in Pregnant Filipino Woman 2019
• Glycosylated Hemoglobin- detect the degree of hyperglycemia
present. Measure amount of glucose attached to hemoglobin for the
past 4 to 6 weeks (not advisable in the Phil)
• Opthalmic examination, retinal changes, dot hemorrhage, macular
edema, proliferation retinopathy- blindness (laser therapy during
pregnancy)
• Urine culture-detect asymptomatic UTI
Therapeutic Management:
Insulin- short-acting insulin (regular) combined with intermediate type

self administered 30 minutes before breakfast 2:1 ratio (Intermediate to
regular) and before dinner 1:1 ratio.
Oral hypoglycemics not used- cross placenta,
teratogenic
• Insulin Pump Therapy- automatic pump with small gauge needle implanted
in SQ abdomen/thigh.
• Blood Glucose Monitoring-fingerstick technique- site of lancet puncture
Tests for Placental Function and Fetal Well
Being
Serum alpha protein at 15 to 17 weeks to assess for neural tube
defects
Ultrasound to detect gross abnormalities at 18 to 20 weeks.
Self monitor fetal well being- record movements in an hour. 10
movements/hr.(at night, L side)
Sonograms- determine fetal growth, amniotic fluid volume, placental
location and biparietal diameter at week 28 and 36 to 38
• Oligohydramnios, fetal growth restrictions or fetal
renal abnormality, hydramnios- gastrointestinal
malformation or poorly controlled disease.
• Lecithin-sphingomyelin ratio by amniocentesis- assess
fetal maturity. ( In diabetes complicated pregnancy-
ratio does not show maturity because synthesis of
phosphatidyl glycerol is delayed (compound that
stabilize surfactant)
Timing for Birth
Individualized
Glucose control
Maternal/fetal complications
Do not induce less than 40 weeks
Do not go beyond 40 weeks
DM – poorly controlled, induced labor 37-38 weeks AOG
Insulin- 38 weeks
Before 38 weeks- only with compelling reason (prevent RDS)
CANCER AND PREGNANCY
• If malignancy is diagnosed at 1st trimester of pregnancy, she and

partner will be asked to decide:
• To delay treatment to avoid teratogenic risk to fetus (but increase
woman’s risk)
• To abort pregnancy to allow chemotherapy/radiation to be initiated
• Choose chemotherapy/radiation which will cause birth abnormalities
to fetus
• As a rule: women can receive chemotherapy in the 2nd
or 3rd trimester without adverse fetal effects.
• Radiation puts fetus at risk throughout pregnancy if
fetus is directly exposed.
• Surgery to remove tumor can be completed during
pregnancy but fetus is at risk for anoxia during
anesthesia
• Cancer does not metastasize to the fetus- placenta
serves as barrier and fetus maybe capable of resisting
invasion of foreign cells.
• Melanoma is the only type of cancer that seems to
spread to fetus.
MENTAL ILLNESS AND
PREGNANCY
• Mental illness may precede or occur with pregnancy.

• Schizophrenia tends to have its highest incidence in adolescents and
young adults and so occurs in young pregnant women.
• Depression occurs almost four times more commonly in women than
in men, and often in young adults. It is the most common mental
illness seen in pregnant women.
• A woman with a psychiatric disorder should be cared for by both a
psychiatric care team and a prenatal care group to ensure that the
stress of pregnancy is not exacerbating the mental illness, and distorted
perceptions or depression do not complicate the pregnancy.
• Any psychotropic medication taken by a pregnant woman should be
evaluated for possible fetal harm
• Lithium- a mainstay of therapy for mood disorders such as bipolar
disorder (manic depression), and serotonin-reuptake inhibitors used to
counteract depression, are potentially teratogenic
• Mental illness may also occur in the postpartum period (postpartum
depression or psychosis

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NEUROLOGIC DISORDERS AND PREGNANCY

A Woman With a Seizure Disorder

• seizure medications -mildly teratogenic, (meet with their obstetrician

A Woman With a Thyroid

• This can lead to early spontaneous miscarriage.

Woman With Diabetes Mellitus

Insulin- short-acting insulin (regular) combined with intermediate type

• If malignancy is diagnosed at 1st trimester of pregnancy, she and

• Mental illness may precede or occur with pregnancy.

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