Australian Doctor 3rd November 2023 3rd Nov 23 | Page 47

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Table 1 . Definitions of the Australian categories for prescribing medicines in pregnancy

Figure 3 . The physiological and anatomical changes of pregnancy .

Source : Department of Health and Aged Care , TGA 8

Many of the symptoms of mental illness such as depression and anxiety overlap with the symptoms of pregnancy . Shortness of breath , palpitations , feeling hot , insomnia and fatigue all need to be properly explored to ensure there is no underlying medical condition contributing to them , but the role of mental health needs to be considered .

High quality perinatal mental health care can assist women in managing pregnancy symptoms , medical disorders of pregnancy , and chronic health conditions that predate pregnancy . Many women with chronic health issues have a background of poor mental health , or adverse childhood experiences ; consider these in the holistic care of women .

Blood test abnormalities that arise during pregnancy

Common blood test abnormalities that arise during pregnancy include low haemoglobin , falling platelet counts , abnormal LFTs and abnormal renal function tests . A high degree of suspicion for the onset of pre-eclampsia is required with abnormal blood tests .

Unless there is a clear reason for the blood test abnormality , conduct a detailed history , thorough clinical examination and further appropriate investigation .

There are some tests that are difficult to interpret during pregnancy , and therefore should not be done ( see box 3 ). Should these investigations be required , they need to be performed at least 6-8 weeks after

Box 3 . Difficult to interpret tests during pregnancy

• Alpha-fetoprotein ( elevated in the presence of a placenta , and always positive during pregnancy ).

• Ceruloplasmin .

• Protein S .

• Protein C .

• Renin .

• Aldosterone .

pregnancy , when pregnancy-related changes have mostly resolved .

Drugs in pregnancy

Drugs need to be carefully prescribed during pregnancy . The current ABCD rating ( see table 1 ) is for guidance only , and many category C drugs are used during pregnancy based on a careful risk – benefit assessment , and review of the more detailed literature . 8

Drugs that are commonly ceased but should generally be continued in pregnancy include asthma medications ( particularly inhaled LABAs and corticosteroids ) and hydroxychloroquine .

Specialist pharmacists , who can be contacted in each of Australia ’ s major maternity hospitals , can be an invaluable source of information regarding less common drugs prescribed during pregnancy .

There are several excellent resources to aid in decisions regarding the use of drugs in pregnancy , and the opinion of experienced clinicians should be readily sought .

Endocrine

• Increased levels of oestrogen and progesterone

• Increased T3 and T4

• Increased cortisol

• Increased prolactin

Radiation in pregnancy

Pregnant women are often denied routine radiological procedures as there is a fear regarding the risk to the fetus . It is common for women to be denied dental radiographs , limb radiographs or CT head imaging because of fear of radiation . All these routine types of radiography are associated with very low radiation exposure to the fetus in any trimester of pregnancy and should be performed when indicated . If these investigations would be considered to be indicated outside of pregnancy , they should be performed during pregnancy .

If a pregnant woman requires a chest X-ray at any point during her pregnancy , the radiation exposure is low , and the risks associated with undiagnosed and untreated cardiopulmonary disease are significant . Therefore , if a chest X-ray would be considered to be indicated outside of pregnancy , it should be performed during pregnancy .

MRI with gadolinium contrast should not be used during

Musculoskeletal

• Headache and neck pain

• Lower back pain

• Carpal tunnel syndrome

pregnancy , except with specialist review and a detailed risk – benefit assessment .

If there is a concern about pulmonary thromboembolism , appropriate imaging is required in any trimester of pregnancy . This includes either a ventilation / perfusion scan or CT pulmonary angiogram .

Imaging that causes higher radiation dose exposure directly involving the fetus , such as CT scans of the spine , abdomen or pelvis , angiography , and interventional radiology procedures , require a detailed specialist assessment of risk and benefit , a discussion with the patient , and careful documentation before proceeding .

Avoiding stigma and shame

Many women report that their pregnancy care experiences have resulted in shame . 9 Common issues that result in this experience are ‘ fat shaming ’, the shame that results from a diagnosis of gestational diabetes , and the sense that women have done something

Haematological

• Increased erythrocyte volume

• Increased leukocytes

• Increased risk of thromboembolism

wrong if they struggle with medical complications in pregnancy . Take great care to ensure communication is compassionate and shame sensitive , to ensure women continue to engage in much needed antenatal , peripartum and postnatal care .

Postpartum follow-up

All women who have developed medical disorders before or during pregnancy need a careful postpartum follow-up plan .

Careful review is required to ensure all pregnancy exacerbated issues resolve in the postpartum period , and if they do not resolve , appropriate further investigation is required ( see box 4 ).

Breastfeeding support

Many women who have been unwell during pregnancy have difficulty with breastfeeding initiation . Emergency caesarean section , neonatal intensive care admission , loss of opportunities for skin-to-skin contact , postpartum complications in mother and baby ,