PROGRAVID: Preconception Risk Reduction

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Monday, June 29, 2009

EPILEPSY and PREGNANCY

Epilepsy and Pregnancy Increased Risks

	General Population	Women with Epilepsy
Major Malformations	2 to 3 Percent	4 to 8 Percent
Minor Malformations	5 to 10 Percent	10 to 15 Percent
Fetal Death	2 to 7 Percent	2 to 14 Percent

More than 90 percent of women with epilepsy will have normal, healthy infants. However, they are at greater risk for complications of pregnancy, labor and adverse pregnancy outcomes than women without epilepsy. Preconceptional counseling and coordination of care among all members of the health care team is key to treating women with epilepsy of reproductive age.

Conception

Fertility

Women with epilepsy have fewer children than women in general, with a fertility rate 25 to 33 percent lower than average. While personal choice and/or societal pressure may play some role in this disparity, research has indicated that women with epilepsy have a higher incidence of menstrual irregularities, polycystic ovarian disease and reproductive endocrine disorders. Any of these may reduce fertility.

Unplanned Pregnancies

Women with epilepsy taking certain anti-epileptic drugs (AEDs) may experience failure of hormonal birth control methods. Some of the medications [carbamazepine, oxcarbazepine, phenytoin, barbiturates (phenobarbital, mephobarbital, and primidone) and topiramate] may lower concentrations of estrogen, thus reducing effectiveness of the hormonal contraceptive.

Congenital Malformations

Major Malformations

Major malformations are defined as defects of medical, surgical or cosmetic importance. This type of anomaly, which will seriously affect a child’s life, occurs in 2 to 3 percent of all liveborn children. For women with epilepsy on one seizure medication, the incidence is estimated to be 4 to 8 percent and possibly greater for women with epilepsy taking more than one drug. Types of major malformations occurring most often in children of women with epilepsy are orofacial clefts, cardiac abnormalities and neural tube defects.

Folic acid supplementation (at a minimum dose of 0.4 mg daily) is especially important prior to conception and during pregnancy in women with epilepsy to lower the risk of neural tube defects in the offspring.

In general, AED polypharmacy and higher blood levels of AEDs are associated with the increased incidence of birth defects in infants born to women with epilepsy. A single AED at the lowest possible dose for efficacy is recommended whenever possible.

Minor Anomalies

The incidence of minor physical defects in infants born to women with epilepsy is approximately 15 percent. Features such as hypertelorism, epicanthal folds, shallow philtrum, distal digital hypoplasia, and simian creases are often present as a familial trait. Although the incidence is reported as 2 to 3 times greater in women with epilepsy, these may be present in infants whose mothers use other types of medication or have excessive alcohol intake during pregnancy. Many of these minor physical defects appear to be idiopathic in nature. These anomalies do not cause any serious problems and are primarily of cosmetic concern.

Other CNS Effects

A greater incidence of mental retardation and/or microcephaly has been reported in children of women with epilepsy, but these studies have been inconsistent and have not always been controlled for other possible contributing factors (such as inherent genetics, and the effects of maternal seizures or AEDs in utero).

However, developmental delays may be significant in terms of risk to infants of women with epilepsy. Factors other than the maternal epilepsy that are thought to be important are IQ scores in the mother and AED polypharmacy (particularly exposure to phenobarbital in utero).

Spontaneous Abortion

There is no increased risk of early fetal death (the not uncommon, spontaneous abortion within the first 20 weeks post-conception) in women with epilepsy. Late fetal loss (a stillbirth or spontaneous abortion after 20 weeks of pregnancy) shows an increased incidence in women with epilepsy, as much as twofold over the general population (2 to 7 percent of all pregnancies and 2 to 14 percent in women with epilepsy, depending on the study).

Anti-epileptic Medications

Concerns

As stated earlier, the risk for adverse effects on the fetus increases when maternal AED polypharmacy is present. All commonly used AEDs have been associated with congenital malformations. Some of the newer AEDs have not been used in large enough numbers to have meaningful data.

Valproic acid (with a risk of 1 to 2 percent), and to a lesser degree, carbamazepine (with a risk of 0.5 percent) have been associated with neural tube defects, specifically spina bifida. Folate supplementation used prior to conception and throughout the childbearing years may minimize this risk.

Many experts believe that trimethadione is contraindicated in women with epilepsy who might become pregnant because it has been associated with a high incidence of fetal loss and congenital malformations.

You may wish to encourage all pregnant women taking AEDs to register with the North American AED Pregnancy Registry housed at Massachusetts General Hospital, Harvard Medical School. The toll free number is (888) 233-2334.

Management

Uncontrolled seizures, particularly generalized tonic-clonic episodes, are hazardous during pregnancy and discontinuing AEDs may pose a greater risk for both mother and fetus than the possible adverse effects of the medication. Miscarriage, trauma related to falls, fetal hypoxia and acidosis are all possible sequelae of maternal seizures.

Status epilepticus carries a high mortality rate for mother and fetus, and generalized seizures occurring during labor can result in fetal bradycardia.

During pregnancy, one quarter to one third of women with epilepsy have an increase in seizure frequency despite continued use of AEDs. Decreased protein binding of AEDs, increased drug clearance, and increased maternal plasma volume during pregnancy may lower serum concentrations of AEDs, requiring more frequent laboratory assessments, and dosage adjustments.

Plasma levels of unbound AEDs should be monitored closely throughout pregnancy and for at least 8 weeks following delivery, as it is common for levels to rise in the postpartum period.

Pregnancy Complications

Other potential obstetrical problems seen more frequently in women with epilepys are hyperemesis, gravidarum, vaginal bleeding, and anemia. Difficulties during labor and delivery include premature labor, failure to progress, and an increased rate of cesarean sections.

Hemorrhagic Disorder of the Newborn

This is a unique hemorrhagic disease of the neonate that occurs in the first 24 hours of life. Maternal AEDs competitively inhibit vitamin K transport across the placenta and the infant has prolonged prothrombin and partial thromboplastin times. The risk can be reduced by maternal supplementation with oral vitamin K (at a dose of 10 mg/ day) during the last month of pregnancy. This specific neonatal disorder seems to be associated with exposure to AEDs in utero (phenobarbital, primidone, phenytoin, and perhaps others).

Risk of Seizures in the Child

There is a higher risk for women with epilepsy to have children with the condition than for men with epilepsy. Seizure type and age of onset also affect incidence of epilepsy in the child. It is encouraging to recognize that even for patients in the highest risk groups, the risk that an offspring will develop epilepsy is less than 10 percent. Also see Genetics.

REFERENCES

Holmes LB, Harvey EA, Coull BA, et al. The teratogenicity of anticonvulsant drugs. NEJM. 2001;344(15):1132-1138.
Yerby M. Treatment of epilepsy during pregnancy. In: Wyllie E, ed. The Treatment of Epilepsy, Second Edition. Baltimore: Williams & Wilkins; 1996:785-798.
Practice parameter: management issues for women with epilepsy (summary statement). Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 1998;51:944-8.
Seizure disorders in pregnancy. In: ACOG Educational Bulletin. Washington, DC: American College of Obstetricians and Gynecologists; 1996:231.

GENITAL HERPES and PREGNANCY

Most women with genital herpes give birth to healthy babies. However, if you suffer from genital herpes there is a very small risk that your baby will catch the infection and if she does the results can be serious, even fatal. That's why it is important to tell your midwife if you or your partner have ever had an outbreak of genital herpes or if you think you have any of the symptoms. Extra care can then be taken of you and your baby.

What is genital herpes?

Genital herpes is caused by the herpes simplex virus which also causes cold sores around and in the mouth. Genital herpes is usually caused by herpes simplex virus type 2 (HSV-2), while cold sores are usually caused by herpes simplex virus type 1 (HSV-1). However, genital herpes can also be caused by HSV-1. Once you have been infected with a herpes virus it stays in your body for life, only becoming active every now and again.

How might genital herpes affect my pregnancy?

If you had genital herpes before you became pregnant then the risk of your baby becoming infected is very low, even if you have an outbreak during your pregnancy or during labour. This is because your body has had time to develop antibodies to the herpes simplex virus and this immunity is passed on to your baby during pregnancy. Your baby will continue to be immune for up to three months after the birth.
If you catch genital herpes for the first time in the first or second trimester of your pregnancy, there is a slight risk that it will affect your developing baby. The infection has been linked to miscarriage, intrauterine growth retardation (IUGR), premature labour, microcephaly (where the baby's brain is underdeveloped) and hydrocephaly (where fluid builds up around the baby's brain) but this happens very rarely. Your doctor will probably refer you to a genitourinary medicine (GUM) clinic where you will be given a 5-day course of an oral antiviral medicine, usually acyclovir. The acyclovir will help to reduce your discomfort and speed up the healing or your sores. It is safe to use in pregnancy.
Your baby is at greater risk if you catch genital herpes for the first time in late pregnancy before you have had time to develop antibodies to the virus and to pass this immunity on to your baby. Your baby can catch the virus through direct contact with an active sore, which is weeping or inflamed, during birth. If a baby catches the infection at birth it is called neonatal herpes. About four in ten babies develop neonatal herpes when born vaginally to women with a first infection when they come to give birth.
In the UK, only one or two babies in 100,000 catch neonatal herpes, but it can be very serious and even fatal. Neonatal herpes can cause infection in a baby's skin, eyes or mouth and may damage the brain or other organs. If your baby does catch neonatal herpes, effective treatment with antiviral medicine for you and your baby can help prevent and minimise long term damage to your baby's health.

Will I need to have a caesarean?

If you suspect you have an active genital herpes infection in the last trimester of pregnancy it is vital that you tell your midwife or doctor. If you have never had herpes before then you will probably be advised to have a planned caesarean section, particularly if you have your first outbreak in the last six weeks of pregnancy. This is to minimise the risk of transmitting the virus to your baby.
If you want to go ahead with a vaginal delivery, then your obstetrician will try to avoid any invasive procedures such as ventouse or forceps and will give you intravenous acyclovir during labour and delivery as this may reduce the risk of your baby catching herpes. Your newborn baby will also be given acyclovir.
If it is not your first infection, you will probably be given acyclovir daily for the last four weeks of pregnancy. You will not be advised to have a caesarean as your baby will probably have immunity to the virus.

Can I breastfeed if I have herpes?

The herpes virus is not transmitted through breastmilk so having herpes shouldn't stop you from breastfeeding, providing you don't have any sores on your breasts. Make sure that sores elsewhere on your body are covered and wash your hands frequently and carefully. If you are taking acyclovir, it will be excreted in your breastmilk but is not thought to be harmful.

What are the symptoms of a genital herpes infection?

Symptoms vary a lot from person to person. What most people do find is that symptoms are usually worse, and last longer, the first time they have a herpes outbreak. Symptoms of a primary or first infection may include:
• painful sores over your genitals and buttocks
• itching
• stinging when passing urine
• vaginal discharge
• swollen glands in the groin area
• flu-like symptoms including fever, headache and muscle aches
A primary episode can last two to three weeks.
With a second or later infection you may get no symptoms at all or just a small area of irritation. If it is not your first outbreak, it will probably be over within three to five days.
Whether or not you have symptoms, it is important to remember that you are still contagious during a herpes recurrence. In fact, most infections occur when the person passing it on has no noticeable symptoms. This is why it is important to tell your midwife if you or your partner suspect you may have had a herpes outbreak in the past.

How can I avoid catching the virus while I am pregnant?

If your partner has genital herpes you need to be particularly careful when you are pregnant. As the virus can be transmitted without your partner knowing that he is having an outbreak there are no foolproof methods to avoid catching herpes. In fact, the virus is most infectious when, or just before, symptoms appear. You can catch herpes from penetrative and non-penetrative sex (vaginal or anal), from oral sex, and by sharing sex toys. Condoms may help to reduce the risk of catching herpes from your partner, or you may want to avoid sex altogether. You should also be aware that you can catch genital herpes from your partner if he has oral herpes and performs oral sex.

Who can help?

Talk to your GP or midwife or contact the Herpes Viruses Association for more information.

CHICKENPOX and PREGNANCY

Effects of Chicken Pox on the Pregnant Woman and her Unborn Child

Chicken pox is usually a benign, self-limited, viral infection caused by the varicella virus. However, chicken pox acquired during pregnancy causes an increase risk of complications to the mother and the infant. The time of infection, during early pregnancy or near delivery, determines the risk to mother and child.

Pregnant Women Exposed to Chicken Pox
Pregnant women who have a history of a previous chicken pox infection or who have been immunized have antibodies to the virus. These antibodies are transferred to the infant through the placenta throughout the pregnancy. Therefore, pregnant women who are immune and are exposed to someone with chicken pox do not need to worry about complications for themselves or their infant.

Testing for Immunity in Pregnancy
All women should be questioned about previous chicken pox infection or immunization at their first prenatal visit. Of those women who do not remember a past infection or immunization, 80% to 90% have antibodies and are considered immune. For this reason, testing for antibodies is controversial, but many practitioners obtain this test at the first prenatal visit.

Maternal Complications of Chicken Pox in Pregnancy
A primary chicken pox infection occurs in only 0.05% to 0.07% of pregnancies because most women of childbearing age have immunity to the varicella virus because of a previous infection or immunization. Women who do acquire chicken pox while pregnant, especially in the third trimester, are at a greater risk of developing varicella pneumonia. Varicella pneumonia is a potentially life-threatening infection of the lungs by the varicella virus.

Infant Complications of Chicken Pox in Early Pregnancy
Primary chicken pox infection in the first trimester of pregnancy, especially weeks 8 to 12, carries a 2.2% risk of congenital varicella syndrome, a syndrome of birth defects in the infant. The most common manifestation of congenital varicella syndrome is scarring of the skin. Other abnormalities that can occur include a smaller than normal head, eye problems, low birth weight, small limbs, and mental retardation.

Infant Complications of Chicken Pox in Late Pregnancy
If a woman acquires a primary chicken pox infection within 5 days before and 2 days after delivery, her newborn is at risk for disseminated varicella infection. Disseminated varicella infection occurs when the virus infects a newborn before the transfer of protective maternal antibodies. This overwhelming viral infection leads to death in 25% of cases.

Treatment of Pregnant Women with Chicken Pox
Women who acquire primary chicken pox during pregnancy should be treated with the antiviral drug acyclovir (Zovirax) which seems to be safe in pregnancy. Pregnant women with varicella pneumonia should be treated with IV acyclovir and be observed in the hospital. In addition women who are not immune to varicella, but are exposed may be treated with varicella-zoster immunoglobulin (VZIG), a substance that triggers an immune response against the varicella virus.

Treatment of Infants with Chicken Pox
Infants whose mothers develop varicella 5 days before delivery or 2 days following delivery should receive VZIG after birth. Infants who develop varicella during the first 2 weeks of life should be treated with IV acyclovir.

SMOKING and PREGNANCY

Smoking is a major public health problem. All smokers face an increased risk of lung cancer, other lung diseases, and cardiovascular and other disorders. Smoking during pregnancy can harm the health of both a woman and her unborn baby. Currently, at least 10 percent of women in the United States smoke during pregnancy. ⁽¹⁾
In the United States and in other industrialized countries, 18 percent of women smoke.⁽²⁾ This proportion is somewhat smaller in developing countries where only 8 percent of women smoke.⁽³⁾ Statistics from the United States are compelling. According to the U.S. Public Health Service ⁽⁴⁾ , if all pregnant women in this country stopped smoking, there would be an estimated:

11 percent reduction in stillbirths
5 percent reduction in newborn deaths

Cigarette smoke contains more than 2,500 chemicals. It is not known for certain which of these chemicals are harmful to the developing baby, but both nicotine and carbon monoxide play a role in causing adverse pregnancy outcomes.

How can smoking harm the newborn?
Smoking nearly doubles a woman's risk of having a low-birthweight baby. In 2004, 11.9 percent of babies born to smokers in the United States were of low birthweight (less than 5½ pounds), compared to 7.2 percent of babies of nonsmokers ⁽¹⁾. Low birthweight can result from poor growth before birth, preterm delivery or a combination of both. Smoking has long been known to slow fetal growth. Smoking also increases the risk of preterm delivery (before 37 weeks of gestation) ⁽⁵⁾. Premature and low-birthweight babies face an increased risk of serious health problems during the newborn period, chronic lifelong disabilities (such as cerebral palsy, mental retardation and learning problems), and even death.

The more a pregnant woman smokes, the greater her risk of having a low-birthweight baby. However, if a woman stops smoking even by the end of her second trimester of pregnancy, she is no more likely to have a low-birthweight baby than a woman who never smoked ⁽⁶⁾.
A recent study suggests that women who smoke anytime during the month before pregnancy to the end of the first trimester are more likely to have a baby with birth defects, particularly congenital heart defects ⁽⁷⁾. The risk of heart defects appears to increase with the number of cigarettes a woman smokes.

Can smoking cause pregnancy complications?
Smoking is associated with a number of pregnancy complications. Smoking cigarettes doubles a woman's risk of developing placental problems ⁽⁴⁾ . These include:

Placenta previa (a low-lying placenta that covers part or all of the opening of the uterus)
Placental abruption (in which the placenta peels away, partially or almost completely, from the uterine wall before delivery)

Both can result in heavy bleeding during delivery that can endanger mother and baby, although cesarean delivery can prevent most deaths.

Smoking in pregnancy increases a woman's risk of premature rupture of the membranes (PROM), when the sac that holds the baby inside the uterus breaks before completion of 37 weeks of pregnancy ⁽⁴⁾.(Usually, when it breaks, normal labor ensues within a few hours.) If the rupture occurs before 37 weeks of pregnancy, it often results in the birth of a premature baby.

Does smoking affect fertility?
Cigarette smoking can cause reproductive problems before a woman even becomes pregnant. Studies show that women who smoke may have more trouble conceiving than nonsmokers ⁽⁴⁾ . Studies suggest that fertility returns to normal after a woman stops smoking.

Does smoking during pregnancy cause other problems in babies or young children?
A 2003 study suggests that babies of mothers who smoke during pregnancy undergo withdrawal-like symptoms similar to those seen in babies of mothers who use some illicit drugs ⁽⁸⁾ . For example, babies of smokers appear to be more jittery and difficult to soothe than babies of nonsmokers.

Babies whose mothers smoked during pregnancy are up to three times as likely to die from sudden infant death syndrome (SIDS) as babies of nonsmokers ⁽⁵⁾ .

Studies suggest that babies of women who are regularly exposed to secondhand smoke during pregnancy may have reduced growth and may be more likely to be born with low birthweight ^(5). Pregnant women should avoid exposure to other people's smoke.

How can a woman stop smoking?
The March of Dimes recommends that women stop smoking before they become pregnant and do not smoke throughout pregnancy and after the baby is born. A woman's health care provider can refer her to a smoking-cessation program or suggest other ways to help her quit. The March of Dimes supports a 5- to 15-minute, 5-step counseling approach called “The 5 A's,” which is performed by the health care provider during routine prenatal visits. This approach has been shown to improve smoking cessation rates among pregnant women by at least 30 percent .

Studies suggest that certain factors make it more likely that a woman will be successful in her efforts to quit smoking during pregnancy. These include:

Attempting to quit in the past
Having a partner who doesn't smoke
Getting support from family or other important people in her life
Understanding the harmful effects of smoking

How does exposure to smoke after birth affect a baby?
It is important to stay smoke-free after the baby is born. Parents should refrain from smoking in the home and should ask visitors to do the same. Babies who are exposed to smoke suffer from more lower-respiratory illnesses (such as bronchitis and pneumonia) and ear infections than do other babies. Babies who are exposed to their parents' smoke after birth also may face an increased risk of asthma and SIDS.

Smoking harms a mother's health, too. Smokers have an increased risk of lung and other cancers, heart disease, stroke and emphysema (a potentially disabling and, sometimes, deadly lung condition). Quitting smoking makes parents healthier and better role models for their children.

Does the March of Dimes fund research on the risks of smoking during pregnancy?
The March of Dimes has long supported research on the risks of smoking during pregnancy. In the 1970s, March of Dimes-supported research suggested that nicotine and carbon monoxide reduce the supply of oxygen to the baby, perhaps explaining how these chemicals in cigarette smoke reduce fetal growth.

In 2002, a March of Dimes grantee published a study that may shed light on why some women who smoke cigarettes during pregnancy have low-birthweight babies and others do not ⁽¹⁰⁾ . The researcher reported that pregnant women who smoke are more likely to have a premature or low-birthweight baby if they have either of two common genetic traits (which influence the body's ability to dispose of certain chemicals). These findings could lead to better ways to identify and treat women at high risk of having a low-birthweight baby.

A current March of Dimes grantee is investigating whether smoking at a critical stage of embryonic palate development increases the risk of cleft lip/palate.

What resources are available for health care providers?

The American College of Obstetricians and Gynecologists provides information for health care providers to assist them as they help patients stop smoking.
Smoking Cessation for Pregnancy and Beyond is a free CME course for health care providers available from Dartmouth Medical School.

References

Martin, J.A., et al. Births: Final Data for 2004. National Vital Statistics Reports, volume 55, number 1, September 29, 2006.
Centers for Disease Control and Prevention (CDC). Smoking and Tobacco Fact Sheet: Women and Smoking. February 28, 2007.
World Health Organization (WHO). Women and the Tobacco Epidemic: Challenges for the 21st Century. 2001.
U.S. Department of Health and Human Services. The Health Consequences of Smoking: A Report of the Surgeon General, 2004. Centers for Disease Control and Prevention, Office on Smoking and Health, Atlanta Georgia, May 2004.
Centers for Disease Control and Prevention (CDC). What Do We Know About Tobacco Use and Pregnancy. June 11, 2007.
American College of Obstetricians and Gynecologists (ACOG). Smoking Cessation during Pregnancy. ACOG Committee Opinion, number 316, October 2005.
Malik, S., et al. Maternal Smoking and Congenital Heart Defects. Pediatrics, volume 121, number 4, April 2008, pages e810-e816.
Law, K.L., et al. Smoking During Pregnancy and Newborn Neurobehavior. Pediatrics, volume 111, number 6, June 2003, pages 1318-1323.
Centers for Disease Control and Prevention (CDC). Preventing Smoking During Pregnancy. November 2005.
Wang, X., et al. Maternal Cigarette Smoking, Metabolic Gene Polymorphism, and Infant Birth Weight. Journal of the American Medical Association, volume 287, number 2, January 9, 2002, pages 195-202.

ALCOHOL and PREGNANCY

Drinking alcohol during pregnancy can cause a wide range of physical and mental birth defects. The term “fetal alcohol spectrum disorders” (FASDs) is used to describe the many problems associated with exposure to alcohol before birth. Each year in the United States, up to 40,000 babies are born with FASDs ⁽¹⁾ .

Although many women are aware that heavy drinking during pregnancy can cause birth defects, many do not realize that moderate or even light drinking also may harm the fetus. In fact, no level of alcohol use during pregnancy has been proven safe. Therefore, the March of Dimes recommends that pregnant women do not drink any alcohol, including beer, wine, wine coolers and liquor, throughout their pregnancy and while nursing. In addition, because women often do not know they are pregnant for a few months, women who may be pregnant or those who are attempting to become pregnant should not drink alcohol.

Recent government surveys indicate that about 1 in 12 pregnant women drink during pregnancy ⁽²⁾ . About 1 in 30 pregnant women report binge drinking (five or more drinks on any one occasion) ⁽²⁾ . Women who binge drink or drink heavily greatly increase the risk of alcohol-related damage to their babies.

When a pregnant woman drinks, alcohol passes through the placenta to her fetus. In the fetus’s immature body, alcohol is broken down much more slowly than in an adult's body. As a result, the alcohol level of the baby's blood can be higher and remain elevated longer than the level in the mother's blood. This sometimes causes the baby to suffer lifelong damage.

What are the hazards of drinking alcohol during pregnancy?
Drinking alcohol during pregnancy can cause FASDs, with effects that range from mild to severe. These effects include mental retardation; learning, emotional and behavioral problems; and defects involving the heart, face and other organs. The most severe of these effects is fetal alcohol syndrome (FAS), a combination of physical and mental birth defects.

Drinking alcohol during pregnancy increases the risk for miscarriage and premature birth (before 37 completed weeks of pregnancy) ^{(3, 4)}. Studies also suggest that drinking during pregnancy may contribute to stillbirth. A 2008 Danish study found that women who binge drink three or more times during the first 16 weeks of pregnancy had a 56 percent greater risk for stillbirth than women who did not binge drink ⁽³⁾ . Another 2008 study found that women who had five or more drinks a week were 70 percent more likely to have a stillborn baby than non-drinking women ⁽⁵⁾ .

What is fetal alcohol syndrome (FAS)?
FAS is one of the most common known causes of mental retardation. It is the only cause that is entirely preventable. Studies by the Centers for Disease Control and Prevention (CDC) suggest that between 1,000 and 6,000 babies in the United States are born yearly with FAS ⁽⁶⁾ .

Babies with FAS are abnormally small at birth and usually do not catch up on growth as they get older. They have characteristic facial features, including small eyes, a thin upper lip and smooth skin in place of the normal groove between the nose and upper lip. Their organs, especially the heart, may not form properly. Many babies with FAS also have a brain that is small and abnormally formed. Most have some degree of mental disability. Many have poor coordination, a short attention span and emotional and behavioral problems.

The effects of FAS and other FASDs last a lifetime. Even if not mentally retarded, adolescents and adults with FAS and other FASDs are at risk for psychological and behavioral problems and criminal behavior ⁽²⁾ . They often find it difficult to keep a job and live independently ^{(2, 6)}.

What are other FASDs?
The CDC estimates that about three times the number of babies born with FAS are born with some, but not all, of the features of FAS ⁽²⁾ . These FASDs are referred to as alcohol-related birth defects (ARBDs) and alcohol-related neurodevelopmental disorders (ARNDs).

The term ARBDs describes physical birth defects that can occur in many organ systems, including the heart, liver, kidneys, eyes, ears and bones.
The term ARNDs describes learning and behavioral problems associated with prenatal exposure to alcohol. These problems can include learning disabilities; difficulties with attention, memory and problem solving; speech and language delays; hyperactivity; psychological disorders and poor school performance.

Children with ARBDs and ARNDs do not have the characteristic facial features associated with FAS ⁽¹⁾ .

In general, ARBDs are more likely to result from drinking alcohol during the first trimester, when organs are forming rapidly. Drinking at any stage of pregnancy can affect the brain, resulting in ARNDs, and can also affect growth.

An older term called fetal alcohol effects (FAEs) is sometimes used to describe alcohol-related damage that is less severe than FAS. The more specific diagnostic categories of ARBDs and ARNDs are now more frequently used.

How much alcohol is too much during pregnancy?
No level of drinking alcohol has been proven safe during pregnancy. According to the U.S. Surgeon General, the patterns of drinking that place a baby at greatest risk for FASDs are binge drinking and drinking seven or more drinks per week ⁽⁷⁾ . However, FASDs can occur in babies of women who drink less.

Researchers are taking a closer look at the more subtle effects of moderate and light drinking during pregnancy.

A 2002 study found that 14-year-old children whose mothers drank as little as one drink a week were significantly shorter and leaner and had a smaller head circumference (a possible indicator of brain size) than children of women who did not drink at all ⁽⁸⁾ .
A 2001 study found that 6- and 7-year-old children of mothers who had as little as one drink a week during pregnancy were more likely than children of non-drinkers to have behavior problems, such as aggressive and delinquent behaviors. These researchers found that children whose mothers drank any alcohol during pregnancy were more than three times as likely as unexposed children to demonstrate delinquent behaviors ⁽⁹⁾ .
A 2007 study suggested that female children of women who drank less than one drink a week were more likely to have behavioral and emotional problems at 4 and 8 years of age. The study also suggested similar effects in boys, but at higher levels of drinking ⁽¹⁰⁾ .
Other studies report behavioral and learning problems in children exposed to moderate drinking during pregnancy, including attention and memory problems, hyperactivity, impulsivity, poor social and communication skills, psychiatric problems (including mood disorders) and alcohol and drug use ⁽²⁾ .

Is there a cure for FASDs?
There is no cure for FASDs. However, a 2004 study found that early diagnosis (before 6 years of age) and being raised in a stable, nurturing environment can improve the long-term outlook for individuals with FASDs ⁽¹¹⁾ . Children who experienced these protective factors during their school years were two to four times more likely to avoid serious behavioral problems resulting in trouble with the law or confinement in a psychiatric institution.

If a pregnant woman has one or two drinks before she realizes she is pregnant, can it harm the baby?
It is unlikely that the occasional drink a woman takes before she realizes she is pregnant will harm her baby. The baby’s brain and other organs begin developing around the third week of pregnancy, however, and are vulnerable to damage in these early weeks. Because no amount of alcohol has been proven safe during pregnancy, a woman should stop drinking immediately if she even suspects she could be pregnant, and she should not drink alcohol if she is trying to become pregnant.

Is it safe to drink alcohol while breastfeeding?
Small amounts of alcohol do get into breastmilk and are passed on to the baby. One study found that breastfed babies of women who had one or more drinks a day were a little slower in acquiring motor skills (such as crawling and walking) than babies who had not been exposed to alcohol ⁽¹²⁾ . Large amounts of alcohol may interfere with ejection of milk from the breast.

For these reasons, the March of Dimes recommends that women not drink alcohol while they are breastfeeding. Similarly, the American Academy of Pediatrics (AAP) recommends that breastfeeding mothers not drink alcohol ⁽¹³⁾. However, according to the AAP, an occasional alcoholic drink probably doesn’t hurt the baby, but a mother who has a drink should wait at least 2 hours before breastfeeding her baby ⁽¹³⁾ .

Can heavy drinking by the father contribute to FASDs?
There is no proof that heavy drinking by the father can cause FASDs. But men can help their partner avoid alcohol by not drinking during their partner’s pregnancy.

Where can a woman get help to stop drinking alcohol?
Some women find it difficult to stop drinking. These organizations can help:

National Council on Alcoholism and Drug Dependence (NCADD), (800) NCA-CALL (622-2255)
Substance Abuse Treatment Facility Locator, (800) 622-HELP (4357)

Resources

The Fetal Alcohol Spectrum Disorders (FASD) Center for Excellence, (866) 786-7327
FASD Support Site
Fetal Alcohol Spectrum Disorders, U.S. Centers for Disease Control and Prevention

References

Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services. Fetal Alcohol Spectrum Disorders. 2007.
Centers for Disease Control and Prevention (CDC). Fetal Alcohol Spectrum Disorders. Updated 5/2/06.
Strandberg-Larsen, K., et al. Binge Drinking in Pregnancy and Risk of Fetal Death. Obstetrics and Gynecology, volume 111, number 3, March 2008, pages 602-609.
Sokol, R.J., et al. Extreme Prematurity: An Alcohol-Related Birth Defect. Alcoholism Clinical and Experimental Research, volume 31, number 6, June 2007, pages 1031-1037.
Aliyu, M.H., et al. Alcohol Consumption During Pregnancy and the Risk of Early Stillbirth among Singletons. Alcohol, volume 42, August 2008, pages 369-374.
Bertrand, J., et al., National Task Force on FAS/FAE. Fetal Alcohol Syndrome: Guidelines for Referral and Diagnosis. Atlanta, GA: Centers for Disease Control and Prevention, July 2004.
Surgeon General. Surgeon General’s Advisory on Alcohol Use in Pregnancy. February 21, 2005.
Day, N.L., et al. Prenatal Alcohol Exposure Predicts Continued Deficits in Offspring Size at 14 Years of Age. Alcoholism Clinical and Experimental Research, volume 26, number 10, 2002, pages 1584-1591.
Sood, B., et al. Prenatal Alcohol Exposure and Childhood Behavior at Age 6 to 7. Pediatrics, volume 108, number 2, August 2001, page e34.
Sayal, K., et al. Prenatal Alcohol Exposure and Gender Differences in Childhood Mental Health Problems: A Longitudinal Population-Based Study. Pediatrics, volume 119, number 2, February 2007, pages e426-434.
Streissguth, A.P., et al. Risk Factors for Adverse Life Outcomes in Fetal Alcohol Syndrome and Fetal Alcohol Effects. J Dev Behav Pediatr, volume 25, number 4, August 2004, pages 228-238.
Little, R.E., et al. Maternal Alcohol Use During Breast-Feeding and Infant Mental and Motor Development at One Year. New England Journal of Medicine, volume 321, number 7, August 17, 1989, pages 425-430.
American Academy of Pediatrics (AAP). AAP Policy Statement: Breastfeeding and the Use of Human Milk. Pediatrics, volume 115, number 2, February 2005, pages 496-506.

RUBELLA and PREGNANCY

(German measles)

This factsheet describes how a child can be affected when a woman has rubella (often called German Measles) while she is pregnant. It also talks about some of the ways that children affected by rubella can be helped, and tells you where to go for advice and support.

What is rubella?

Prior to immunisation, rubella was a common disease of childhood. It is caused by a virus which is spread in the air as droplets - by coughing and sneezing.

When someone has been in contact with the virus it takes two to three weeks to develop. When it does, they will generally feel unwell and off-colour for the first five days, with swollen glands, and a light temperature or a sore throat. If a rash develops, it will start on the face, and spread downwards over the body and limbs, and this may cause pain and discomfort in the limbs - especially in women. Some people have rubella, but show no symptoms at all.

What happens if a woman has rubella when she is pregnant?

Sometimes the mother will not pass the rubella onto the baby. However, if she has rubella in the early stages of her pregnancy then there is a greater chance of the virus passing through the cord to the developing baby.

A child affected by rubella during pregnancy will be said to have congenital rubella. Children born with congenital rubella will have the virus circulating in their bloodstream for up to 20 months after they are born. They will normally pose no risk to others, but anyone in direct contact with children with congenital rubella is advised to be screened and immunised as necessary.

About vaccination

Most women today choose to protect themselves from rubella by being immunised before they become pregnant, and this has greatly reduced the numbers of children affected. Even if a woman has already been immunised however, it is important that she has a blood test before becoming pregnant to ensure that she is still immune. The rubella vaccine is now given to children when they are between 12 and 15 months old. This is given in combination with the vaccinations for measles and mumps - called the MMR vaccination. Children receive a booster injection before they start school.

How can rubella affect the baby?

We do not fully understand how the baby is affected by the virus. The virus seems to affect the cells of parts of the baby's body that are being developed at the time of infection. Sometimes there is insufficient blood supply which can harm organs which have developed already. However, every child is different. Some children will appear to be unaffected, but they should be followed up during childhood, particularly for hearing loss. Anyone with congenital rubella should have regular health check-ups, including vision and hearing assessments throughout their life.

Where might the damage occur?

The stage of pregnancy when the rubella infection occurs is the most important factor determining what kind of harm, if any, occurs. Rubella in the first two months of pregnancy is likely to affect the baby and may cause a number of impairments. After 18 weeks gestation, although rubella infection may be passed on to the baby, the chances of the baby being affected may be minimal. The most commonly affected organs include the ears, the eyes, and the heart.

1. The eyes

The eyes develop during the early stages of pregnancy. Several things may happen:

Cataracts

Between three and seven weeks the eye lenses may be affected and become cloudy. A cloudy lens is called a cataract - sometimes people will use the term congenital cataracts. This means that the baby will have cloudy lens from birth. Again, the degree of cataract can vary enormously - from a small clouded area to the complete lens being affected. Sometimes one eye only will be affected- sometimes both.

Small eye

Sometimes the size of one or both eyes will be affected, although this is quite rare.

Colouring of the retina

Babies who are born with rubella have speckled colouring or pigment on the back of their eye, although this does not affect their sight.

Eye movement

The eyes may jump from side to side in a flickering movement. This eye condition is known as nystagmus.

Less common eye problems

There are several rare conditions which may affect the baby - optic atrophy, corneal haze, and glaucoma. If your child has these problems please ask your ophthalmologist (see below) for more information.

2. The heart

The heart is a complicated organ, and many different problems can be caused by the virus. These problems are best explained to you on an individual basis by your paediatrician in the hospital who will explain the difficulties your child is facing.

3. The ears

A common problem for babies affected by the rubella virus is hearing loss. This can vary considerably from mild to severe, and may affect one or both ears. The part of the ear which is damaged is the Corti. This is the inner ear or Cochlea which links the ear to the brain. The hearing loss is known as sensori neural.

The amount of hearing loss can vary a great deal, and hearing may deteriorate over a period of time.

4. Neurological problems

The rubella virus may or may not affect the child's brain, and difficulties can vary from mild to severe. If a child has any of these problems, then it is best to discuss these with a paediatrician who can offer individual advice.

Conditions that may occur:

Lethargy, irritability, learning difficulties, small head (microcephaly), large soft spot on the head, movement problems, poor balance and posture, lack of coordination seizures. Some children may have associated behaviour problems. Other rarer conditions have been associated with babies affected by rubella. If you notice anything out of the ordinary, it is best to discuss the situation with your health visitor or GP who can refer you to a paediatrician for specialist advice.

What support do children affected by rubella need?

Children who have been affected by Rubella may have to cope with an impairment of both sight and hearing, as well as other disabilities - although this will vary a great deal. Many children will have some sight and/or hearing however, and it is important to make as much use of these possible. The other senses - touch and smell in particular - must also be developed to the full.

The biggest challenges facing children affected by Rubella, will be to learn to communicate, to move around safely, and to find out about the world around them. It is vital that these children get specialist help which is geared towards their particular combination of abilities and impairments as soon as possible. Intensive one-to-one teaching developed for work with deafblind children for example, can help them to understand the human interaction that is the basis of communication. Children can learn various ways to communicate such as using symbols, objects of reference, sign language, and braille.

All children and adults affected by Rubella have the capacity to learn and achieve. But without the right kind of help, their mental and physical development may be slower because of lack of stimulation. Early intervention, with continuing intensive educational support is the key to a child's future development, although extra support may be needed throughout a person's lifetime.

FOLIC ACID and PREGNANCY

Having a healthy baby means making sure you're healthy, too. One of the most important things you can do to help prevent serious birth defects in your baby is to get enough folic acid every day — especially before conception and during early pregnancy.

What Is Folic Acid?

Folic acid, sometimes called folate, is a B vitamin (B9) found mostly in leafy green vegetables like kale and spinach, orange juice, and enriched grains. Repeated studies have shown that women who get 400 micrograms (0.4 milligrams) daily prior to conception and during early pregnancy reduce the risk that their baby will be born with a serious neural tube defect (a birth defect involving incomplete development of the brain and spinal cord) by up to 70%.

The most common neural tube defects are spina bifida (an incomplete closure of the spinal cord and spinal column), anencephaly (severe underdevelopment of the brain), and encephalocele (when brain tissue protrudes out to the skin from an abnormal opening in the skull). All of these defects occur during the first 28 days of pregnancy — usually before a woman even knows she's pregnant.

That's why it's so important for all women of childbearing age to get enough folic acid — not just those who are planning to become pregnant. Only 50% of pregnancies are planned, so any woman who could become pregnant should make sure she's getting enough folic acid.

Doctors and scientists still aren't completely sure why folic acid has such a profound effect on the prevention of neural tube defects, but they do know that this vitamin is crucial in the development of DNA. As a result, folic acid plays a large role in cell growth and development, as well as tissue formation.

Getting Enough Folic Acid

The Centers for Disease Control and Prevention (CDC) recommends that all women of childbearing age — and especially those who are planning a pregnancy — consume about 400 micrograms (0.4 milligrams) of folic acid every day. Adequate folic acid intake is very important before conception and at least 3 months afterward to potentially reduce the risk of having a fetus with a neural tube defect.

So, how can you make sure you're getting enough folic acid? In 1998, the U.S. Food and Drug Administration mandated that folic acid be added to enriched grain products — so you can boost your intake by looking for breakfast cereals, breads, pastas, and rice containing 100% of the recommended daily folic acid allowance. But for most women, eating fortified foods isn't enough. To reach the recommended daily level, you'll probably need a vitamin supplement.

During pregnancy, you require more of all of the essential nutrients than you did before you became pregnant. Although prenatal vitamins shouldn't replace a well-balanced diet, taking them can give your body — and, therefore, your baby — an added boost of vitamins and minerals. Some health care providers even recommend taking a folic acid supplement in addition to your regular prenatal vitamin. Talk to your doctor about your daily folic acid intake and ask whether he or she recommends a prescription supplement, an over-the-counter brand, or both.

Also talk to your doctor if you've already had a pregnancy that was affected by a neural tube defect. He or she may recommend that you increase your daily intake of folic acid (even before getting pregnant) to lower your risk of having another occurrence.

DIABETES and PREGNANCY

General Information About Diabetes

Diabetes and Pregnancy

Type 1 and Type 2 Diabetes and Pregnancy

Gestational Diabetes

Prevention of Problems

Diabetes is often detected in women during their childbearing years and can affect the health of both the mother and her unborn child. Poor control of diabetes in a woman who is pregnant increases the chances for birth defects and other problems for the baby. It might cause serious complications for the woman, also. Proper health care before and during pregnancy will help prevent birth defects and other poor outcomes, such as miscarriage or stillbirth.

What is diabetes?
Diabetes is a condition in which the body cannot use the sugars and starches (carbohydrates) it takes in as food to make energy. The body either makes too little insulin in the pancreas or cannot use the insulin it makes to change those sugars and starches into energy. As a result, the body collects extra sugar in the blood and gets rid of some sugar in the urine. The extra sugar in the blood can damage organs of the body, such as the heart, eyes, and kidneys, if it is allowed to collect in the body too long. The 3 most common types of diabetes are Type 1, Type 2, and gestational.

Type 1 diabetes is a condition in which the pancreas makes so little insulin that the body can’t use blood sugar for energy. Type 1 diabetes must be controlled with daily insulin shots.
Type 2 diabetes is a condition in which the body either makes too little insulin or can’t use the insulin it makes to use blood sugar for energy. Often Type 2 diabetes can be controlled through eating a proper diet and exercising regularly. Some people with Type 2 diabetes have to take diabetes pills or insulin or both.
Gestational diabetes is a type of diabetes that occurs in a pregnant woman who did not have diabetes before she was pregnant. Often gestational diabetes can be controlled through eating a proper diet and exercising regularly, but sometimes a woman with gestational diabetes must also take insulin shots. Usually gestational diabetes goes away after pregnancy, but sometimes it doesn’t. Also, many women who have had gestational diabetes develop Type 2 diabetes later in life.

What are some common problems caused by diabetes?
People with diabetes can get high blood pressure, kidney disease, nerve damage, heart disease, and blindness. Young women with diabetes might not have these problems yet. The damage caused by these problems often happen in people whose blood sugar has been out of control for years. Keeping blood sugar under control can help prevent the damage from happening.
People with diabetes can go into “diabetic coma” if their blood sugar is too high. They can also develop blood sugar that is too low (hypoglycemia) if they don’t get enough food, or they exercise too much without adjusting insulin or food. Both diabetic coma and hypoglycemia can be very serious, and even fatal, if not treated quickly. Closely watching blood sugar, being aware of the early signs and symptoms of blood sugar that is too high or too low, and treating those conditions early can prevent these problems from becoming too serious.

How does a person get diabetes?
We don’t know exactly how people get diabetes. However, it appears that both genetics and personal lifestyle play a role in who gets diabetes. Some people have diabetes that “runs” in the family. Lack of exercise, poor eating habits, and obesity seem to increase the risk of developing Type 2 diabetes in other people. In some, but not all cases, Type 2 diabetes can be controlled if people lose weight, eat right, and exercise regularly.

Can a person prevent problems from diabetes?
A person with diabetes who keeps her blood sugar as close to normal as possible has fewer problems than a person who does not keep his blood sugar in “tight control.” A woman with diabetes who can get pregnant should watch her blood sugar closely to prevent problems if she should get pregnant. To keep blood sugar in tight control, a person can manage her diabetes with a strict plan:

Eat healthy foods from personal diabetes meal plan
Exercise regularly
Monitor blood sugar often
Take medications on time, including insulin if ordered by the doctor.
Know how to adjust food intake, exercise, and insulin depending on the results of blood sugar tests
Control or treat low blood sugar and high blood sugar
Follow up with health care provider regularly

How does gestational diabetes differ from Type 1 or Type 2 diabetes?
Gestational diabetes happens in a woman who develops diabetes during pregnancy. Some women have more than one pregnancy affected by diabetes that disappears after the pregnancy ends. About half of women with gestational diabetes will develop Type 2 diabetes later.
If not controlled, gestational diabetes can cause the baby to grow extra large and lead to problems with delivery for the mother and the baby. Gestational diabetes might be controlled with diet and exercise, or it might take insulin as well as diet and exercise to get control.
Type 1 and Type 2 diabetes often are present before a woman gets pregnant. If not controlled before and during pregnancy, Type 1 and Type 2 diabetes can cause the baby to have birth defects and cause the mother to have problems (or her problems to worsen if they are already present), such as high blood pressure, kidney disease, nerve damage, heart disease, or blindness. Type 1 diabetes must be controlled with a balance of diet, exercise, and insulin. Type 2 diabetes might be controlled with diet and exercise, or it might take diabetes pills or insulin or both as well as diet and exercise to get control.

Will my baby have diabetes?
Babies born to mothers with diabetes do not come into the world with diabetes. However, if the mother’s diabetes was not controlled during pregnancy, the baby can very quickly develop low blood sugar after birth and must be watched very closely until his or her body adjusts the amount of insulin it makes.
Extra large babies are more likely to become obese and to develop Type 2 diabetes later in life. They especially need to develop healthy eating and regular exercise habits as they grow up to lessen the chance of obesity and Type 2 diabetes.

If the father of the developing baby has diabetes, does his diabetes affect the pregnancy?
Diabetes in the father does not affect the developing baby during pregnancy. However, depending on the type of diabetes the father has, the baby might have a greater chance of developing diabetes later in life.

What can happen to a woman with Type 1 or Type 2 diabetes who becomes pregnant?
Pregnancy is a time when a woman’s body goes through lots of changes as it nurtures a developing baby. All women need more nutrients, rest, and energy to grow the baby when they are pregnant. They also need to be physically active. When a woman with diabetes is pregnant, changes happen in her blood sugar, often quickly. If a woman with diabetes does not keep good control of her blood sugar, she might get some of the common problems of diabetes, or those problems might get worse if she already has them. Out of control blood sugar could lead to a woman having a miscarriage. Out of control blood sugar might also cause high blood pressure in a woman during pregnancy, and she will need extra visits to the doctor. High blood pressure during pregnancy might lead to a baby being born early and also could cause seizures or a stroke (a blood clot in the brain that can lead to brain damage) in the woman during labor and delivery. Sometimes, out of control blood sugar causes a woman to make extra large amounts of amniotic fluid around the baby which might lead to preterm (early) labor. Another problem common to a pregnant woman with uncontrolled diabetes is that her baby grows too large. Besides causing discomfort to the woman during the last few months of pregnancy, an extra large baby can lead to problems during delivery for both the mother and the baby.

What can happen to the baby of a woman with Type 1 or Type 2 diabetes during pregnancy?
Diabetes in a pregnant woman can cause the baby to have birth defects, miscarry, be born early and have a low birth weight, be stillborn, or grow extra large and have a hard delivery.
A woman who has Type 1 or Type 2 diabetes that is not tightly controlled has a higher chance of having a baby with a birth defect than does a woman without diabetes. The organs of the baby form during the first two months of pregnancy, often before a woman knows that she is pregnant. Out of control blood sugar can affect those organs while they are being formed and cause serious birth defects, such as those of the brain, spine, and heart, or can lead to miscarriage of the developing baby.
If the woman’s blood sugar remains out of control throughout the pregnancy, the baby likely will grow extra large. Out of control diabetes causes the baby’s blood sugar to be high. The baby makes more insulin and uses the extra calories or stores them as fat. The baby is “overfed” and grows extra large. Extra large babies can occur in women with any out of control diabetes, including Type 1, Type 2, and gestational. The extra large baby can cause problems during and after delivery. Nerve damage to the baby can happen from pressure on the baby’s shoulder during delivery. A newborn might have quickly changing blood sugars after delivery. A large baby born to a woman with diabetes might have a greater chance of being obese and/or developing Type 2 diabetes later in life.
If the woman with diabetes has problems that lead to a preterm birth, the baby might have breathing problems, heart problems, bleeding into the brain, intestinal problems, and vision problems. A woman with diabetes might have a baby born on time with low birth weight. A baby with low birth weight might have problems with eating, gaining weight, fighting off infections, and staying warm.

What can happen to a pregnant woman with gestational diabetes?
A pregnant woman who does not have diabetes can develop “gestational diabetes” later in pregnancy. A woman with gestational diabetes will need to watch her blood sugar closely and balance food intake, exercise, and, if needed, insulin shots to keep her blood sugar in control. If a woman with gestational diabetes does not keep her blood sugar in good control, she could have several problems. She might have an extra large baby, have high blood pressure, deliver too early, or need to have a cesarean section (an operation to get the baby out of the mother through her abdomen). The extra large baby might cause the woman to feel uncomfortable during the last months of pregnancy. Also, it could lead to problems for both the woman and the baby during delivery. When the baby is delivered surgically by a cesarean section (C-section), it takes longer for the woman to recover from childbirth. High blood pressure when a woman is pregnant might lead to an early delivery and could cause seizures or a stroke in the woman.
Sometimes gestational diabetes in women does not go away after delivery. These women have converted to Type 2 diabetes. A woman whose diabetes does not go away after delivery will need to manage her diabetes for the rest of her life.

What can happen to the baby of a woman with gestational diabetes?
A woman who has gestational diabetes has less chance of having a baby with a birth defect than does a woman with Type 1 or Type 2 diabetes. Since gestational diabetes develops later in pregnancy, the baby’s organs are already formed. If her blood sugar is not controlled, a woman with gestational diabetes still has a greater chance of having a stillborn baby than a woman who doesn’t have diabetes.
If the woman’s blood sugar remains out of control throughout the pregnancy, the baby likely will grow extra large. Out of control diabetes causes the baby’s blood sugar to be high. The baby makes more insulin and uses the extra calories or stores them as fat. The baby is “overfed” and grows extra large. Extra large babies can occur in women with any out of control diabetes, including Type 1, Type 2, and gestational.
The extra large baby can cause problems during and after delivery. Nerve damage to the baby can happen from pressure on the baby’s shoulder during delivery. A newborn might have quickly changing blood sugars after delivery. A large baby born to a woman with diabetes might have a greater chance of being obese and/or developing Type 2 diabetes later in life.
If the woman with diabetes has problems that lead to a preterm birth, the baby might have breathing problems, heart problems, bleeding into the brain, intestinal problems, and vision problems. A woman with diabetes might have a baby born on time with low birth weight. A baby with low birth weight might have problems with eating, gaining weight, fighting off infections, and staying warm.

Can a woman with diabetes prevent the problems to herself and to her baby during pregnancy?
If a woman with diabetes keeps her blood sugar in tight control before and during pregnancy, she can lessen her risk of having a baby with a birth defect to that of a woman who doesn’t have diabetes. Controlling her blood sugar also reduces the risk that a woman will develop common problems of diabetes, or that the problems will get worse during pregnancy. The baby is less likely to grow extra large during her pregnancy if a woman keeps her blood sugar in tight control.

How can a woman with diabetes who wants to get pregnant prevent problems to herself and her baby?

Plan the pregnancy. Unplanned pregnancies are more common among women with diabetes than among women who do not have diabetes. About 70% of women with diabetes don’t plan their pregnancies as compared to about 50% of women who don’t have diabetes. It is very important for a woman with diabetes to get her body ready before she becomes pregnant.
See her doctor. Her doctor needs to look at the effects that diabetes has had on her body already, talk with her about getting and keeping control of her blood sugar, change medications if needed, and plan for frequent follow-up. Her doctor will remind her about the usual steps to get ready for pregnancy, such as to take prenatal vitamins (with folic acid), stop smoking, avoid alcohol, eat right, exercise, and avoid stress.
Eat healthy foods from a meal plan made for her as a person with diabetes. If a woman is overweight, she might try to lose weight before getting pregnant as part of her plan to get her blood sugar in control. Talking with a dietitian can help her plan a good diet for a person with diabetes, especially if she plans to lose weight before she gets pregnant. A dietitian can also help her learn how to control her blood sugar while she is pregnant.
Exercise regularly. Exercise is another way to keep blood sugar under control. Exercise helps to balance food intake. A woman should begin a regular exercise plan before she gets pregnant and stick with the exercise plan both while she is pregnant and after the baby comes.
Monitor blood sugar often. Because pregnancy causes the body’s need for energy to change, blood sugar levels can change very quickly. A pregnant woman with diabetes needs to check her blood sugar more often, sometimes 6 to 8 times a day, which might be higher than when she is not pregnant. Checking blood sugar levels often can help a woman keep her blood sugar in control.
Take medications on time. If insulin is ordered by a doctor, a pregnant woman with diabetes should take it when it’s needed. She should know how to adjust food intake, exercise, and insulin, depending on the results of her blood sugar tests, to keep the blood sugar in the range of tight control. For more information, see the American Diabetes Association website at http://www.diabetes.org/type-1-diabetes/tight-control.jsp .
Control and treat low blood sugar quickly. Keeping tight blood sugar control can lead to a chance of low blood sugar at times. A pregnant woman with diabetes should have a ready source of carbohydrates, such as glucose tablets or gel, on hand at all times. It’s helpful to teach family members and close co-workers or friends how to help in case of a severe low blood sugar reaction.
Follow-up with the doctor regularly. A pregnant woman with diabetes needs to see her doctor more often than does a pregnant woman without diabetes. Together, the woman can work with her doctor to prevent or catch problems early. Although there are no guarantees, a woman with diabetes who gets and keeps her blood sugar in control is more likely to have a healthy pregnancy and a healthy baby.

CHRONIC HYPERTENSION and PREGNANCY

Chronic Hypertension and Pregnancy

Highlights

What is chronic hypertension?

If you had high blood pressure before you got pregnant, or if you're diagnosed with it before you reach 20 weeks, you have chronic hypertension. Up to 5 percent of women start their pregnancies with this condition. High blood pressure is defined as a reading of 140/90 or higher, even if just one of the numbers is higher. Severe chronic hypertension is 180/110 or higher.
Chronic hypertension isn't the only reason you might have high blood pressure during pregnancy. If you develop high blood pressure after 20 weeks of pregnancy, you'll be diagnosed with gestational hypertension. (If your blood pressure doesn't return to normal within 12 weeks after giving birth, your diagnosis changes to chronic hypertension.) If you develop hypertension after 20 weeks of pregnancy and have protein in your urine, you may have a condition called preeclampsia.

How does having chronic hypertension affect my pregnancy?

Having chronic hypertension significantly increases your risk of developing preeclampsia. Preeclampsia that develops in addition to your already existing chronic hypertension is called "superimposed preeclampsia." Up to 1 in 4 women with chronic hypertension and as many as half of women with severe chronic hypertension will develop superimposed preeclampsia during pregnancy.
Chronic hypertension also puts you at increased risk for a number of other pregnancy complications, including intrauterine growth restriction, preterm birth, placental abruption, and stillbirth. If your chronic hypertension is mild, your risk for these complications during pregnancy is not too much higher than it would be if you had normal blood pressure — that is, as long as you have no other existing medical problems, your hypertension doesn't get worse during pregnancy, and you don't develop superimposed preeclampsia. The more severe your hypertension, however, the higher your risk for these problems, and developing superimposed preeclampsia increases your risk even more. Your risk is also higher if you've had hypertension for a long time and it's done some damage to your cardiovascular system, kidneys, or other organs, or if your hypertension is a result of an underlying medical condition such as diabetes, kidney disease, or lupus.

How is chronic hypertension managed during pregnancy?

Ideally, before getting pregnant, you discussed your plans to conceive with the healthcare provider who manages your hypertension and let your pregnancy provider know about your hypertension at a preconception visit. Among other things, they might have changed your high blood pressure medication, because some antihypertensive drugs, such as ACE inhibitors, may raise the risk of birth defects when taken during pregnancy.
If that didn't happen before you got pregnant, call your provider right away and be sure to discuss any medications you're on. (If you don't have a pregnancy provider yet, call the provider who's been managing your hypertension.) Depending on your condition, you may be referred to a perinatologist (a high-risk specialist).
At your first visit with your pregnancy caregiver, be prepared to tell her everything you know about your hypertension — for instance, when it started, what tests or work-up procedures have been performed, and what medications you've taken in the past and are currently taking (if any). It's a good idea to arrange for a copy of your medical records to be sent ahead of time (or bring them with you) so your caregiver can review your blood pressure readings over time, as well as the results of lab tests and other evaluations.
If blood and urine tests relating to your hypertension haven't been done recently, she'll probably order a complete set now. And depending on your condition and what's been done in the past, she may order an EKG, an ultrasound of your kidneys, an eye exam, and possibly other tests If this is the first time you've been diagnosed with hypertension, then you'll have a complete work-up, including tests to rule out other conditions that may be causing your high blood pressure.
If you have severe hypertension, you'll need to continue taking blood pressure medication during your pregnancy. Your doctor may need to switch your usual medication to one that's safer for your baby, though, especially if you were on an ACE inhibitor-type medication. She may decide to hospitalize you for a few days so you can be monitored closely until your medication is adjusted and your blood pressure is under control. It's critically important to keep taking your medication, because severe uncontrolled hypertension can be life-threatening.
If you have mild chronic hypertension (without other complications, such as advanced diabetes or kidney disease), your caregiver may advise you to stop taking your blood pressure medication or to reduce your dose. Being off medication temporarily is unlikely to cause problems for you. If you're not currently taking blood pressure medication, your caregiver probably won't recommend starting it now. That's because pregnancy itself tends to lower your blood pressure at the end of the first trimester and keep it down throughout much of the second trimester. And if your pressure gets too low, it may actually reduce blood flow to the placenta in some cases. Plus, studies suggest that blood pressure medication won't lower your risk of developing pregnancy complications. That said, if your pressure starts to get too high, you'll be started on medication (or have your dose increased) to protect you from the serious consequences of severe hypertension.
Whether your hypertension is severe or mild, it's important to keep all of your prenatal appointments so your caregiver can monitor you and your baby and spot any developing problems, such as rising blood pressure, signs of preeclampsia, or poor fetal growth. You'll have more frequent prenatal visits and lab tests to monitor how you're doing. In addition to the usual second-trimester ultrasound, you'll have periodic ultrasounds in your third trimester to monitor your baby's growth and your amniotic fluid level, as well as regular fetal testing (nonstress tests or biophysical profiles) and possibly Doppler ultrasounds (to check blood flow to your baby).
If at any time during pregnancy your blood pressure gets too high, you'll be hospitalized until it's under control, and if you develop superimposed preeclampsia, you'll be hospitalized until you give birth. Depending on your condition and your baby's health, you may have to deliver early, even if your baby is premature.
You'll need to pay particular attention to your salt intake: Avoid the saltshaker, try to use fresh foods instead of prepared or processed ones, and check labels for sodium content. If you've never had nutritional counseling or are unclear about how to keep your salt intake within the limit recommended by your caregiver, ask her for a referral to a registered dietitian who can help devise a diet plan that works for you. She may also recommend cutting back on activity and avoiding aerobic exercise. If you smoke or drink alcohol, it's now even more important to stop, since they can both make your hypertension worse.

What warning signs should prompt a call to my caregiver?

Once your baby starts moving regularly, your caregiver may ask you to do "fetal kick counts," that is, to keep track of your baby's movements. (This is a good way to for you to monitor your baby's well-being between prenatal appointments.) Let your practitioner know immediately if you notice that your baby is less active than usual. Also call your caregiver right away if you have:

Any headache, but especially a severe, persistent, or pounding one
A pounding sensation in your chest or heart palpitations
Dizziness
Swelling in your face or puffiness around your eyes, more than slight swelling of your hands, or excessive or sudden swelling of your feet or ankles
Weight gain of more than 4 pounds in a week.
Vision changes, including double vision, blurriness, seeing spots or flashing lights, light sensitivity, or temporary loss of vision
Intense pain or tenderness in your upper abdomen
Nausea or vomiting (other than morning sickness in early pregnancy)

What will happen after I give birth?

With chronic hypertension, particularly if it's severe, you're at risk for complications as your cardiovascular system adjusts to all the changes in your body after you give birth — so after delivery, you'll be monitored very closely for at least 48 hours.

Also, since preeclampsia can develop after delivery, let your practitioner know immediately if you develop any symptoms of the disorder, even after you're discharged home. You'll start taking blood pressure medication again or have your dosage adjusted as necessary. Let your practitioner know if you plan to breastfeed, because that will affect her choice of blood pressure medication for you.

In addition to taking whatever medication is prescribed and seeing your primary care provider regularly, you'll need to take good care of yourself to reduce your risk of long-term complications from hypertension, such as heart or kidney disease and stroke.

Try to maintain a healthy lifestyle, paying particular attention to your diet and weight, avoiding tobacco, and limiting how much alcohol you drink. When your postpartum recovery is complete and your practitioner gives you the go-ahead to begin exercising, ask your doctor what kind of exercise regime is best for your individual situation, and stick to it.

HEPATITIS and PREGNANCY

The word 'hepatitis' means an infection or inflammation of the liver. If the liver becomes inflamed due to an infection with a virus it is called 'viral hepatitis'. However, the liver can also become inflamed through excessive alcohol intake or by taking certain medications or being exposed to certain chemicals.

Some viral hepatitis infections only cause a temporary dysfunction of the liver, while others can cause permanent liver damage (called 'cirrhosis'). In some cases, a small number of people with cirrhosis may eventually experience liver failure or liver cancer later in life. However, this will depend on the type of hepatitis involved.

There are 3 main types of viral hepatitis. These are:

Hepatitis A virus (HAV). Hepatitis A or 'hep A' is the most common type of hepatitis. It is transmitted by coming in contact with contaminated faeces (bowel motions) through water supplies, foods washed in contaminated water or eating utensils handled by the unwashed hands of an infected person. Some people become infected with the virus through occupational exposure by working with sewerage, handling the faeces of patients in hostels or hospitals or changing babies in childcare settings. Hepatitis A does not cause long term liver problems and there are vaccinations available if you feel you are at risk of coming in contact with the virus. Many people are vaccinated as a precaution before travelling overseas (especially to developing countries).

Hepatitis B virus (HBV). Hepatitis B or 'hep B' is transmitted by coming in contact with infected blood of another person. This can be through the sharing of injecting equipment, tattooing or body piercing with non-sterile equipment or occupational needle stick injuries.

It can also be transmitted through their saliva or having unprotected sex with an infected person. The hepatitis B virus can cause long term liver problems for some people. Vaccinations are now available to protect against hepatitis B and the vaccination of babies during the first 6 months after birth is now offered routinely in Australia. You can read more about this in Hepatitis B vaccination.

Hepatitis C virus (HCV). Hepatitis C or 'hep C' (previously known as 'non A - non B hepatitis') is transmitted by coming into contact with the blood of an infected person. Hepatitis C is not transmitted through saliva and very rarely through sexual contact. Infection with the hepatitis C virus can happen by sharing injecting equipment, tattooing or body piercing with non-sterile equipment or occupational needle stick injuries. At present there is no vaccine available to protect against hepatitis C.

In recent years there have been additional types of viral hepatitis identified. These are relatively rare so far but can include hepatitis E or 'HEV' (which is similar to hepatitis A), Hepatitis D (HDV) and hepatitis G (HGV). At present these types of hepatitis are not routinely tested for during pregnancy.

NOTE:

Be aware that even though all types of viral hepatitis infect and inflame the liver, not all hepatitis infections produce obvious physical signs. There are many people who are 'carriers' of a hepatitis virus, meaning they are infected with the virus and are capable of infecting others but are not aware they have the infection themselves. Also each type of hepatitis can be transmitted from one person to another in different ways.

Effects on the pregnancy

If a woman knows she has hepatitis or discovers she has it during her pregnancy, the most common concerns are how this will affect her pregnancy and her unborn baby.

In most cases the pregnancy itself will not affect the severity of the hepatitis infection for the woman, or the long term course of the hepatitis disease. (Unless it is found to be the rarer type of hepatitis E or 'HEV', which can become worse during pregnancy. This type of hepatitis is similar to hepatitis A.)

The unborn baby does not tend to have any health concerns if their mother has hepatitis. However, it is sometimes possible for the baby to become infected with the virus around the time of birth or during their early childhood years. Transmission of the virus during pregnancy does not usually happen, but the risk for this can be increased if the mother first becomes infected just before she conceives or during her pregnancy (this mainly relates to hepatitis C).
Most women with hepatitis will have a normal pregnancy, but the physical process of pregnancy can put added strain on a woman's liver. For a few women this may lead to complications or health concerns during pregnancy and can include:

Gallstones or 'cholelithiasis'. About 6% of women with hepatitis can develop gallstones (or 'cholelithiasis') during their pregnancy. This may present as abdominal pain and sometimes jaundice. Cholelithiasis may need to be treated with an operation to remove the gallstones if they do not pass naturally into the woman's bowel. The timing of this will depend on the severity of the condition, weighing up the risks of miscarriage or premature birth.

Cholestasis. A few women may be at increased risk of developing cholestasis of pregnancy. This condition is characterised by itching of the skin, especially the hands and feet. You can read more in cholestasis.

Acute fatty liver of pregnancy. Although rare, hepatitis can predispose a few women to a condition called 'acute fatty liver of pregnancy'. This is a life-threatening condition for the woman that may require delivering her babyprematurely and possible treatment for the woman in an intensive care facility. However, most women normally recover quickly after the baby is born. If a pregnant woman becomes very unwell before the birth of her baby, the baby may also be unwell and can in some cases be stillborn.

Pregnant women who have (or carry) the hepatitis virus require regular blood tests during their pregnancy to check the functioning of their liver. These are called 'Liver Function Tests' or 'LFT's'. Depending on the results of the tests, these may be done every few months, monthly or perhaps weekly if the levels appear to be rising. Be aware that it is normal for pregnant women to have increased alkaline phosphatase levels (3 to 4 times higher than normal) because the placenta creates alkaline phosphatase. However, ALT levels (or 'alanine aminotransferase serum') increase if the woman is ill from hepatitis or if liver damage is occurring. (The normal ALT range for women is 10 - 32 U/L.)

NOTE:Women with hepatitis should not be treated any differently by their healthcare professionals during the pregnancy, labour, birth or postnatal recovery. All caregivers handling blood products and performing medical procedures involving blood exposures treat every person in the same way. This is known as 'universal precautions' and means the caregiver will wear gloves when taking blood and gloves gowns and goggles or glasses when caring for women giving birth or having a Caesarean operation, regardless of whether they are positive for hepatitis or not. However, women who are infectious with hepatitis A do need to be isolated from other women and babies when being cared for in a hospital setting.

Support

Finding out you have hepatitis can come as quite a shock and bring up a range of emotionsYour caregiver should discuss at length the implications of having the virus and any effects on your pregnancy, family, relationships and overall health as well as any health concerns for your baby. Usually your close personal contacts (such as your partner) will need to be tested for the virus. But you are not obliged to tell other members of the family, friends or work colleagues and the results of your test should be kept confidential.
Obtaining up to date information and counselling with people who understand your situation can provide immediate and ongoing support. These are usually provided by volunteer and health department organisations that specialise in hepatitis. At present in Australia there is no central organisation that provides national services. Most are state based and funded and usually have local numbers in capital cities and toll free numbers for rural residents. Ask your caregiver about what is available in your area or use the phone book or a search of the Internet to locate these organisations.

Reviewed by Bambang Widjanarko Obstetrician & Gynecologist

Juni 2009