Clinical medicine (London, England)
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Asthma is the most common chronic disease to affect pregnant women and can have a significant effect on pregnancy outcomes, with increased rates of preterm birth, premature delivery and caesarean section observed if poorly controlled. Pregnancy can also influence asthma control. ⋯ The majority of asthma treatment can be continued as normal in pregnancy and there is emerging evidence of the safety of biologic medications also. This article aims to summarise the current evidence about asthma in pregnancy and guide the appropriate management of this population.
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Palpitations are common in pregnancy and warrant investigation. Palpitations may be caused by non-cardiac and cardiac causes. Patients with structural or functional abnormalities or inherited cardiovascular disease are more likely to develop arrhythmia, especially during pregnancy when the mother's body undergoes extensive physiological adaptations, which further contribute to an increased arrhythmia risk. ⋯ If the patient is stable, medical management is indicated, and early involvement of the pregnancy heart team can help facilitate appropriate treatment. In complex arrhythmia, consultation of an arrhythmia expert should be sought. Many anti-arrhythmics are safe in pregnancy, and it is important to reassure the pregnant patient of this.
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Pulmonary embolism (PE) is a significant cause of morbidity and mortality in pregnancy and the puerperium. In severe cases, it causes haemodynamic instability and can lead to cardiac arrest due to obstructive shock. Patients with acute PE can be risk stratified to guide their monitoring and treatment; this article focuses on intermediate- and high-risk PE. ⋯ Diagnostic imaging should not be delayed due to pregnancy. Low-molecular-weight heparin (LMWH) and unfractionated heparin (UFH) can be used during pregnancy and breastfeeding, and systemic thrombolysis can be used in obstetric patients, but there are significant bleeding risks and it should be reserved for high-risk PE with hypotension and shock. Although pregnancy and the puerperium are risk factors for PE, it is important to avoid early diagnostic closure, and to consider other causes for the patient's presentation.
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Unidentified obstructive sleep apnoea (OSA) can lead to unexpected perioperative complications, unplanned postoperative admissions and increased length of hospital stay. NICE (National Institute for Health and Care Excellence) recommends a rapid preoperative assessment for patients undergoing elective surgery. ⋯ Prevalence of OSA is high in presurgical patients identified through preoperative screening. A diagnosis of moderate to severe OSA impacts surgical decision and planned anaesthetic route. Prior awareness of the diagnosis may help clinicians to identify the at-risk group. Timely CPAP initiation to facilitate surgery remains a challenge and, despite low compliance, CPAP may reduce postoperative complications. A multidisciplinary team (MDT) approach and a dedicated CPAP pathway post-diagnosis may help the clinicians and patients.
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With a rising worldwide incidence of obesity, particularly in the young, bariatric surgery offers an effective method of meaningful and sustained weight loss. At present, most bariatric procedures are carried out in women and increasingly in younger age groups. In line with the fertility benefits associated with weight loss, pregnancy after bariatric surgery is now a very common scenario. ⋯ However, rates of stillbirth and small-for-gestational-age (SGA) babies are increased, suggesting that screening and supplementation of micronutrients is likely to be very important in this cohort. The risks and benefits that bariatric surgery may pose to pregnancy outcomes, both maternal and fetal, are largely dependent upon the degree of weight loss, weight stability upon entering pregnancy, surgical complications and the time interval between bariatric surgery and pregnancy. Ideally, preconception care would be more widely available, helping to assess and address micronutrient deficiencies and support preparation for pregnancy.