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    Trimester zero (Part 1 of 2)

    Pregnancy wellness begins before the positive pregnancy test.

     

    Pulmonary

    Asthma: Asthma complicates approximately 4%–8% of pregnancies.18 Women with poorly controlled asthma before pregnancy are more likely to experience worsening symptoms during pregnancy. The goal of treatment in pregnancy is to maintain adequate oxygenation of the fetus by preventing hypoxic episodes in the mother.19 Preconception care should focus on medically optimizing asthma control and identifying and reducing exposure to allergens.

    Asthma self-management skills— including self-monitoring with peak flow monitors, correct use of inhalers, and prompt handling of signs of worsening asthma—enhance asthma control. Inhaled corticosteroids are first-line controller therapy for persistent asthma during pregnancy.

    Gastrointestinal

    Inflammatory bowel disease: Inflammatory bowel disease (IBD) does not decrease fertility; however, fertility in patients with IBD is possibly affected by active disease, medications, and prior surgeries. Women with IBD experience worse obstetrical and pregnancy-related outcomes compared to the general population, even with disease remission.20

    The course of IBD during pregnancy is determined by how active the disease is at conception. Women in remission at conception are likely to remain in remission during pregnancy. In contrast, up to 70% of women with active disease at conception will have continued or worsening symptoms.21

    Stopping medications that are maintaining remission can induce relapse or flare. Methotrexate and diphenoxylate are contraindicated in pregnancy, whereas sulfasalazine, 5-aminosalicylates, and corticosteroids are considered safe. Many immunomodulators (ie, azathioprine and 6-mercaptopurine) and biologic agents (ie, infliximab) are safe during pregnancy but their use should be managed in coordination with MFM and an IBD specialist.

    Renal

    Lupus nephritis: Women with systemic lupus erythematosus (SLE) have better pregnancy prognoses if their disease has been quiescent for at least 6 months prior to pregnancy and they have normal or near-normal renal function. Active SLE at conception is a strong predictor of adverse maternal and obstetrical outcomes.

    Next: Recurrent pregnancy loss

    Disease flares with pregnancy are difficult to decouple from the physiologic changes of pregnancy and from preeclampsia. Most SLE medication can be continued during pregnancy, but these drugs should be reviewed prior to conception. Medications contraindicated in pregnancy include cyclophosphamide, mycophenolate, methotrexate, and leflunomide. Other SLE drugs that are reasonably safe for use during pregnancy (with certain limitations beyond the scope of this review) are nonsteroidal anti-inflammatory drugs, glucocorticoids, azathioprine, rituximab, belimumab, and some antihypertensive medications.

    The most important aspect of preconception counseling in cases of SLE is to determine whether pregnancy may present an unacceptably high maternal or fetal risk, and to optimize preconception disease status.

    References

    1. Johnson K, Posner SF, Biermann J, et al. Recommendations to improve preconception health and health care—United States. A report of the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care. MMWR Morb Mortal Wkly Rep. 2006;55(RR-6):1-23.

    2. Frayne DJ, Verbiest S, Chelmow D, et al. Health Care System Measures to Advance Preconception Wellness: Consensus Recommendations of the Clinical Workgroup of the National Preconception Health and Health Care Initiative. Obstet Gynecol. 2016;127(5):863-72.

    3. ACOG Practice Bulletin. Clinical Management Guidelines for Obstetrician-Gynecologists. Number 60, March 2005. Pregestational diabetes mellitus. Obstet Gynecol. 2005;105(3):675-85.

    4. Moos MK, Bangdiwala SI, Meibohm AR, Cefalo RC. The impact of a preconceptional health promotion program on intendedness of pregnancy. Am J Perinatol. 1996;13(2):103-8.

    5. Henshaw SK. Unintended pregnancy in the United States. Fam Plann Perspect. 1998;30(1):24-9, 46.

    6. Yoon P SM. The family history public health initiative Atlanta, GA: CDC; 2004.

    7. Dolan SM, Moore C. Linking family history in obstetric and pediatric care: assessing risk for genetic disease and birth defects. Pediatrics. 2007;120 Suppl 2:S66-70.

    8. JGDC. Jewish Genetic Disease Consortium. 2015 [cited 2015 November]; Available from: http://www.jewishgeneticdiseases.org/genetics-and-carrier-screening/

    9. Committee opinion no. 608: influenza vaccination during pregnancy. Obstet Gynecol. 2014;124(3):648-51.

    10. CDC. Pregnancy and Whooping Cough. 2016 [cited July 17, 2016]; Available from: https://www.cdc.gov/pertussis/pregnant/hcp/pregnant-patients.html

    11. Petersen EE, Polen KN, Meaney-Delman D, et al. Update: Interim Guidance for Health Care Providers Caring for Women of Reproductive Age with Possible Zika Virus Exposure – United States, 2016. MMWR Morb Mortal Wkly Rep. 2016;65(12):315-22.

    12. Simeone RM, Shapiro-Mendoza CK, Meaney-Delman D, et al. Possible Zika Virus Infection Among Pregnant Women - United States and Territories, May 2016. MMWR Morb Mortal Wkly Rep. 2016;65(20):514-9.

    13. Hadar E, Ashwal E, Hod M. The preconceptional period as an opportunity for prediction and prevention of noncommunicable disease. Best Pract Res Clin Obstet Gynaecol. 2015;29(1):54-62.

    14. SMFM Statement: benefit of antihypertensive therapy for mild-to-moderate chronic hypertension during pregnancy remains uncertain. Am J Obstet Gynecol. 2015;213(1):3-4.

    15. American College of O, Gynecologists, Task Force on Hypertension in P. Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists’ Task Force on Hypertension in Pregnancy. Obstet Gynecol. 2013;122(5):1122-31.

    16. Sibai BM, Anderson GD. Pregnancy outcome of intensive therapy in severe hypertension in first trimester. Obstet Gynecol. 1986;67(4):517-22.

    17. Canobbio MM, Warnes CA, Aboulhosn J, et al. Management of Pregnancy in Patients With Complex Congenital Heart Disease: A Scientific Statement for Healthcare Professionals From the American Heart Association. Circulation. 2017; Published ahead of print.

    18. Kwon HL, Belanger K, Bracken MB. Asthma prevalence among pregnant and childbearing-aged women in the United States: estimates from national health surveys. Ann Epidemiol. 2003;13(5):317-24.

    19. Dombrowski MP, Schatz M. ACOG practice bulletin: clinical management guidelines for obstetrician-gynecologists number 90, February 2008: asthma in pregnancy. Obstet Gynecol. 2008;111(2 Pt 1):457-64.

    20. Cornish J, Tan E, Teare J, et al. A metaanalysis on the influence of inflammatory bowel disease on pregnancy. Gut. 2007;56(6):830-7.

    21. Getahun D, Fassett MJ, Longstreth GF, et al. Association between maternal inflammatory bowel disease and adverse perinatal outcomes. J Perinatol. 2014;34(6):435-40.

    Yalda Afshar, MD, PhD
    Dr. Afshar is a Maternal-Fetal Medicine Fellow in the Department of Obstetrics and Gynecology, University of California, Los Angeles
    Christina S Han, MD
    Dr Han is an Associate at the Center for Fetal Medicine and Women’s Ultrasound, Los Angeles, Califoria and a Clinical Faculty in the ...

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