Figure 2 . Optimise asthma management before pregnancy . |
||||||
|
PAGE 44
Depending on the condition
, regular clinical review , regular
blood tests and regular repeat investigations may be needed
|
Box 2 . Examples of conditions where referral to a tertiary obstetric medicine centre may be advisable |
development of comprehensive clinical guidelines for management , easily obtainable through a search of the internet . Seek guidelines pub- |
include cardiomyopathy , thromboembolic disease ( see figure 4 ), intracerebral pathology , tumours ( see figure 5 ), haemorrhage , cerebral |
low threshold for further investigations , such as a Holter study , thyroid function tests and iron studies to investigate palpitations ; an FBC , |
|
to monitor the progress of the condition .
A good understanding of the changes in pregnancy physiology is required ( see figure 3 ), to determine when a condition is likely to be at risk of exacerbation ; this will determine the timing and frequency of clinical review .
Provide women with options for emergency contacts , should they ever be concerned . Communicate with them clearly so they are aware of symptoms that trigger the need for a more urgent clinical review .
In general , advise women that if they are worried in any way , it is preferable for them to be seen many times during pregnancy rather than them not presenting , while deteriorating in the absence of appropriate care .
Multidisciplinary team care
Women with complex medical disorders
requiring management during pregnancy have better outcomes in high volume centres with multidisciplinary care . Care requires the input of GPs , obstetricians , obstetric physicians ,
|
• Transplant recipients .
• Pulmonary hypertension .
• Cystic fibrosis .
• Chronic lung disease .
• Recent malignancy .
• Congenital cardiac disease .
• Cardiomyopathy .
• Valvular heart disease .
• Arrhythmias .
• Hypertriglyceridaemia and recurrent pancreatitis .
• Cirrhosis .
• Portal hypertension .
• Hepatic nodules .
• Pregestational diabetes .
• Chronic endocrine disorders .
• Previous early onset or severe pre-eclampsia .
• Previous intrauterine fetal death related to a medical condition .
• Antiphospholipid syndrome .
• Renal disease .
• Neurological disorders .
• Epilepsy .
• Autoimmune disorders .
• Haemoglobinopathies .
• Any other condition that is of concern .
|
lished by reputable state-based , national or international bodies . However , without significant clinical experience , following guidelines can be difficult , and so always seek advice if there is any doubt about what to do in a particular clinical situation . Most tertiary maternity hospitals in Australia have an obstetric physician or an obstetric medicine registrar on call who is available for phone advice . The Handbook of Obstetric Medicine provides an excellent resource . 6
Common symptoms arising during pregnancy
There are a range of symptoms that
are common in pregnancy . These include palpitations , shortness of breath , chest pain , headaches , dizziness , syncope , fatigue , numbness , itching , vomiting , back pain and abdominal pain .
sinus thrombosis and malignancy ( see figures 6 and 7 ).
It is important to note that almost all imaging and investigations that occur outside of pregnancy are indicated during pregnancy , if deemed necessary after a careful risk – benefit assessment .
Determining symptoms are pregnancy related is a diagnosis of exclusion
There are many physiological
changes of pregnancy that result in a range of symptoms . For example , hormonal changes impact on respiratory centres quite early in pregnancy , giving rise to a sense of shortness of breath . Increase in circulating blood volume and the physiological demands on the cardiovascular system can give rise to palpitations and shortness of breath . Ninety-five per cent of pregnant
There are many physiological changes of pregnancy that result in a range of symptoms .
|
echocardiogram , and consideration of exclusion of pulmonary embolus in women who present with shortness of breath ; and careful assessment of adequacy of pregnancy weight gain , abdominal symptoms including rectal bleeding , and indications for coeliac studies in women with iron deficiency anaemia ( see figure 8 ).
Always carefully consider women ’ s concerns about breast lumps , skin changes , weight loss , vaginal bleeding , fatigue and other pregnancy complaints . There are many reports of women with peripartum cardiomyopathy , serious arrhythmias , adenocarcinoma of the bowel , squamous cell carcinoma of the cervix and other serious medical conditions being missed because of lack of care or careful clinical history and examination , attributing symptoms to pregnancy , or failing to undertake appropriate tests and investigations because of pregnancy .
Medical symptoms can be a cry for help
It is important to note the increased
|
|
maternal-fetal medicine specialists , anaesthetists , neonatologists , social workers , midwives , nurse |
made for pregnant women who have medical disorders are often highly complex , and benefit from a |
While many of these symptoms can relate to the physiological changes in pregnancy , all new |
women will have a soft ejection systolic murmur at the left sternal edge , which is due to the increased |
risk of domestic violence during pregnancy . 7 In addition , pregnancy can be a time when mental health |
practitioners , lactation support , psychologists , physiotherapists , intensive care , Aboriginal and Torres Strait Islander healthcare workers ( where relevant ) and complex case co-ordinators . Co-ordination and communication across the |
multidisciplinary team .
MEDICAL DISORDERS THAT DEVELOP DURING PREGNANCY
THERE are a range of common med-
|
symptoms warrant a thorough history , examination , relevant investigations and exclusion of all differential diagnoses .
For cautionary tales regarding this issue , the reader is referred to the various maternal mortality
|
blood volume and increased cardiac output of pregnancy . 6 While pregnancy is a state of increased iron demand , attributing iron deficiency anaemia to pregnancy alone is fraught with risk . All symptoms that present during pregnancy need |
issues are unmasked or worsen and require additional management .
Have a very low threshold for suspicion for the role of domestic violence , previous trauma and mental health contributions to physical symptoms . Some women
|
team , including when women are |
ical disorders that arise during |
reports throughout Australia , where |
to be carefully evaluated . |
repeatedly present to hospital with |
transitioned into and out of hospi- |
pregnancy , including hypertensive |
inadequate assessment of these |
Determining that they are likely |
symptoms such as headaches , |
tal care , and into and out of com- |
disorders of pregnancy , gestational |
common symptoms resulted in |
to be physiological requires , at the |
abdominal pain and shortness |
munity-based care , is critical . The decisions that need to be |
diabetes and thromboembolism . These have all been subject to the |
missing life-threatening illness . Commonly missed diagnoses |
very least , a thorough history and physical examination . Have a very |
of breath , because of the safety afforded by inpatient admission . |