Australian Doctor 3rd November 2023 3rd Nov 23 | Page 44

pharmacist assistance to inform

shared decision-making .

Perform a baseline assessment of

the medical condition , so that any deterioration during pregnancy can be evaluated . This may require repeated imaging , blood tests , urine tests , cardiological or respiratory studies , or a range of other baseline investigations .

Providing information

The final step is a discussion with the

woman and her partner , if applicable , ( see figure 1 ) regarding the risks , benefits , and likely outcomes of pregnancy , given the particular medical situation . The author generally breaks this discussion into four parts ( see box 1 ). Often answering these questions and giving sound advice to women and their families will involve a literature

Box 1 . Issues to discuss with the woman and her partner

1 . What is the likely impact of pregnancy on the medical condition , and subsequent morbidity and mortality ?

2 . What is the likely impact of the medical condition on pregnancy , birth and neonatal outcomes , in the short and long term ?

3 . If after considering the risks and benefits , the woman wishes to try to conceive , how do we maximise the chance of good outcomes ?

4 . If natural conception is not possible , in this situation , is assisted fertility a reasonable choice , given the woman ’ s situation ?

woman and her partner will decide that a pregnancy is too risky . This can be associated with very significant grief , and may need multidisciplinary care , including the support of social workers or psychologists . For some women , motherhood defines womanhood , and there may be considerations relating to family expectations , cultural practices , religious background , and a sense of meaning and purpose that need to be resolved in coming to terms with not being able to have a baby . These need time and sensitivity .

APPROPRIATE CONTRACEPTION FOR WOMEN WITH MEDICAL ISSUES

DURING preconception care , espe-

affected by pregnancy with a real risk of maternal death ( such as , pulmonary hypertension , some congenital cardiac anomalies ), women who are taking medications that are not appropriate in pregnancy ( for example , women on medications such as statins , ACEIs , ARBs , bisphosphonates , mycophenolate , methotrexate , monoclonal antibodies , sodium valproate and other antiepileptic drugs , isotretinoin , tetracyclines , NSAIDs , warfarin ), or where pregnancy is inadvisable for psychosocial or other reasons .

PRECONCEPTION CARE FOR MEN

WHILE we focus on preconception

care for women , we tend to neglect the reproductive health and precon-

surgical issues , migraines , metabolic syndrome and thromboembolic disease . In some cases , specialist preconception advice may assist .

Specialist care may be required

Women with conditions such as the

ones listed in box 2 are likely to benefit from referral to a tertiary centre with expertise in obstetric medicine for preconception and pregnancy care . If in doubt , it is far better to refer unnecessarily than to have to care for a pregnant woman who did not have adequate preconception care . Many major centres now offer telemedicine , which makes these specialist services accessible to women throughout rural and regional Australia . Telemedicine services also offer the benefit of bet-

review , as the outcomes of pregnancy

cially in high-risk settings , adequate

ception care of men . A 2019 review

ter supporting GPs providing obstet-

in various medical conditions is con-

contraception is critical . Document

by Kothari et al outlines the impor-

ric services in regional and rural

stantly improving .

partner and family or key supports , as

contraception advice at each pre-

tant issues regarding men ’ s health

communities .

Helping women understand risk

Where there is significant risk of serious

adverse outcomes , such as the risk of maternal or perinatal mortality , or severe morbidity , it is good

they may end up caring for a baby without a mother . In addition , usual end of life planning , such as the preparation of wills , advanced health directives and appointment of health power of attorney is important .

To help people understand risk , it

conception visit for woman with medical disorders .

Many women who have chronic diseases fall pregnant without any preconception care . This means regular discussions about pregnancy planning , the need for preconception

and preconception care . 4

MANAGEMENT OF SIMPLE MEDICAL ISSUES BEFORE PREGNANCY

THERE is a range of common medical

PRE-PREGNANCY DISORDERS THAT NEED MANAGING DURING PREGNANCY

IN the absence of preconception

practice to write this information

can be helpful for the woman and her

care and pregnancy issues should be

issues that need to be well managed

care , all women with a background

down for women and their families

partner to speak with the range of spe-

a routine component of healthcare

before pregnancy to ensure the best

medical disorder who are found to

to process . Once they have had time

cialists who may be involved in their

appointments for all women of repro-

pregnancy and neonatal outcomes .

be pregnant need pregnancy assess-

to consider written information , it

care , such as anaesthetists , obstetri-

ductive age with chronic disease .

Optimise asthma management before

ment as early as possible . A baseline

is helpful to invite them back to dis-

cians , maternal-fetal medicine special-

There is also the problem of

pregnancy ( see figure 2 ). A common

assessment is required , along with

cuss the issues again and provide the opportunity for the woman , partner

ists , psychiatrists and neonatologists . If there is a high risk of the neonate

women with high-risk medical issues who accidentally find them-

problem is the cessation of inhaled corticosteroids at the beginning of

an urgent review of all medications . Some medication doses may need to

and family to ask questions .

requiring intensive care nursery sup-

selves pregnant , leading to diffi-

pregnancy . It is important to note

be increased ( for example , thyroid

There are several other important

port , a visit to the nursery to see what

cult decisions regarding termination

that inhaled corticosteroids should

replacement therapy , antiepileptic

considerations if pregnancy is likely to

this is like in real life can assist in

of pregnancy . To avoid this , it is

be continued throughout pregnancy .

drugs ). Early appropriate manage-

be very risky . It is important to reassure

decision-making .

important to advise all women with

There are now excellent guidelines

ment needs to be started .

women that whatever they decide , or whatever happens , the very best care will be provided regardless of how risky the situation is . This helps to avoid

If pregnancy is not possible or is inadvisable

In some situations , the woman ’ s

medical issues of the risks of pregnancy , and to have an appropriate contraception plan in place . This is particularly important for women

about the management of asthma before and during pregnancy . 5

Other issues that need attention before conception include hyperten-

Careful review and follow-up

At the beginning of pregnancy ,

determine a plan regarding review

shame and secrecy around conception .

medical issues will preclude natu-

who are recovering from hormo-

sion , thyroid disease , iron deficiency

and follow-up . This requires good

If there are concerns about the risk

ral conception , and assisted fertility

nally dependent cancers ( for exam-

anaemia , gut issues that may benefit

communication between all mem-

of maternal death or serious morbid-

is contraindicated in some situa-

ple , breast cancer ), those who have

from an endoscopy or colonoscopy

bers of the pregnancy care team ,

ity , it is important to try to involve the

tions . In some circumstances , the

diseases that would be adversely

before conception , dental issues ,

including the GP .

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