Gestational trophoblastic tumor, a rare cancer in women, is a disease in which cancer (malignant) cells grow in the tissues that are formed following conception (the joining of sperm and egg).

Gestational trophoblastic tumors start inside the uterus, the hollow, muscular, pear-shaped organ where a baby grows. This type of cancer occurs in women during the years when they are able to have children. There are two types of gestational trophoblastic tumors: hydatidiform mole and choriocarcinoma.

If a patient has a hydatidiform mole (also called a molar pregnancy), the sperm and egg cells have joined without the development of a baby in the uterus. Instead, the tissue that is formed resembles grape-like cysts. Hydatidiform mole does not spread outside of the uterus to other parts of the body.

If a patient has a choriocarcinoma, the tumor may have started from a hydatidiform mole or from tissue that remains in the uterus following an abortion or delivery of a baby. Choriocarcinoma can spread from the uterus to other parts of the body. A very rare type of gestational trophoblastic tumor starts in the uterus where the placenta was attached. This type of cancer is called placental-site trophoblastic disease.

Gestational trophoblastic tumor is not always easy to find. In its early stages, it may look like a normal pregnancy. A doctor should be seen if the there is v.a.g.i.n.al bleeding (not menstrual bleeding) and if a woman is pregnant and the baby hasn't moved at the expected time.

If there are symptoms, a doctor may use several tests to see if the patient has a gestational trophoblastic tumor. An internal (pelvic) examination is usually the first of these tests. The doctor will feel for any lumps or strange feeling in the shape or size of the uterus. The doctor may then do an ultrasound, a test that uses sound waves to find tumors. A blood test will also be done to look for high levels of a 293 Pregnancy and Birth Sourcebook, Third Edition hormone called beta-hCG (beta human chorionic gonadotropin) which is present during normal pregnancy. If a woman is not pregnant and HCG is in the blood, it can be a sign of gestational trophoblastic tumor.

The chance of recovery (prognosis) and choice of treatment depend on the type of gestational trophoblastic tumor, whether it has spread to other places, and the patient's general state of health.

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Chapter 33.

For Women with Diabetes: Your Guide to Pregnancy You have type 1 or type 2 diabetes and you are pregnant or hoping to get pregnant soon. You can learn what to do to have a healthy baby. You can also learn how to take care of yourself and your diabetes before, during, and after your pregnancy.

Pregnancy and new motherhood are times of great excitement, worry, and change for any woman. If you have diabetes and are pregnant, your pregnancy is automatically considered a high-risk pregnancy. Women carrying twins-or more-or who are beyond a certain age are also considered to have high-risk pregnancies. High risk doesn't mean you'll have problems. Instead, high risk means you need to pay special attention to your health and you may need to see specialized doctors. Millions of high-risk pregnancies produce perfectly healthy babies without the mom's health being affected. Special care and attention are the keys.

Taking Care of Your Baby and Yourself Keeping your blood glucose as close to normal as possible before you get pregnant and during your pregnancy is the most important thing you can do to stay healthy and have a healthy baby. Your health care team can help you learn how to use meal planning, physical activity, Excerpted from "For Women with Diabetes: Your Guide to Pregnancy," by the National Inst.i.tute on Diabetes and Digestive and Kidney Diseases (NIDDK, www.niddk.nih.gov), February 2008.

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Pregnancy and Birth Sourcebook, Third Edition and medications to reach your blood glucose goals. Together, you'll create a plan for taking care of yourself and your diabetes.

Pregnancy causes a number of changes in your body, so you might need to make changes in the ways you manage your diabetes. Even if you've had diabetes for years, you may need changes in your meal plan, physical activity routine, and medications. In addition, your needs might change as you get closer to your delivery date.

High blood glucose levels before and during pregnancy can: * worsen your long-term diabetes complications, such as vision problems, heart disease, and kidney disease; * increase the chance of problems for your baby, such as being born too early, weighing too much or too little, and having low blood glucose or other health problems at birth; * increase the risk of your baby having birth defects; * increase the risk of losing your baby through miscarriage or stillbirth.

However, research has shown that when women with diabetes keep blood glucose levels under control before and during pregnancy, the risk of birth defects is about the same as in babies born to women who don't have diabetes.

Glucose in a pregnant woman's blood pa.s.ses through to the baby.

If your blood glucose level is too high during pregnancy, so is your baby's glucose level before birth.

Your Diabetes: Before and during Your Pregnancy As you know, in diabetes, blood glucose levels are above normal.

Whether you have type 1 or type 2 diabetes, you can manage your blood glucose levels and lower the risk of health problems.

A baby's brain, heart, kidneys, and lungs form during the first 8 weeks of pregnancy. High blood glucose levels are especially harmful during this early part of pregnancy. Yet many women don't realize they're pregnant until 5 or 6 weeks after conception. Ideally, you will work with your health care provider to get your blood glucose under control before you get pregnant.

If you're already pregnant, see your health care provider as soon as possible to make a plan for taking care of yourself and your baby.

Even if you learn you're pregnant later in your pregnancy, you can still do a lot for your baby's health and your own.

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For Women with Diabetes: Your Guide to Pregnancy Planning Ahead Before you get pregnant, talk with your health care team about your wish to have a baby. Your team can work with you to make sure your blood glucose levels are on target. If you have questions or worries, bring them up. If you're already pregnant, see your doctor right away.

Daily Blood Glucose Levels You'll check your blood glucose levels using a blood glucose meter several times a day. Most health care providers recommend testing at least four times a day. Ask your health care provider when you should check your blood glucose levels. Generally, you should check blood glucose levels at the following times: * fasting-when you wake up, before you eat or drink anything; * before each meal; * 1 hour after the start of a meal; * 2 hours after the start of a meal; * before bedtime; * in the middle of the night-for example, at 2 or 3 a.m.

The daily goals recommended by the American Diabetes a.s.sociation for most pregnant women are shown in Table 33.1. Write down the goals you and your health care team have chosen.

The A1C Test Another way to see whether you're meeting your goals is to have an A1C blood test. Results of the A1C test show your average blood glucose levels during the past 2 to 3 months.

Low Blood Glucose When you're pregnant, you're at increased risk of having low blood glucose, also called hypoglycemia. When blood glucose levels are too low, your body can't get the energy it needs. Usually hypoglycemia is mild and can easily be treated by eating or drinking something with carbohydrate. But left untreated, hypoglycemia can make you pa.s.s out.

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Pregnancy and Birth Sourcebook, Third Edition Although hypoglycemia can happen suddenly, it can usually be treated quickly, bringing your blood glucose level back to normal. Low blood glucose can be caused by: * meals or snacks that are too small, delayed, or skipped; * doses of insulin that are too high; * increased activity or exercise.

Low blood glucose also can be caused by drinking too much alcohol. However, women who are trying to get pregnant or who are already pregnant should avoid all alcoholic beverages.

Table 33.1. Blood Glucose Goals for Pregnant Women Recommended by the American Diabetes a.s.sociation Blood Glucose Goals for Pregnant Women Recommended by the American Diabetes a.s.sociation When Plasma Blood Glucose (mg/dL) Before meals and when you wake up 80 to 110 2 hours after the start of a meal Below 155 Source: American Diabetes a.s.sociation. Preconception care of women with diabetes. Diabetes Care. 2004;27(Supplement 1):S7678.

Table 33.2. Blood Glucose Goals Recommended by the American College of Obstetricians and Gynecologists Blood Glucose Goals Recommended by the American College of Obstetricians and Gynecologists When Plasma Blood Glucose (mg/dL) Fasting 105 or less Before meals 110 or less 1 hour after the start of a meal 155 or less 2 hours after the start of a meal 135 or less During the night Not less than 65 Source: American College of Obstetricians and Gynecologists (ACOG) Committee on Practice Bulletins. ACOG Practice Bulletin Number 60: Pregestational diabetes mellitus. Obstetrics and Gynecology. 2005;105(3):675685.

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For Women with Diabetes: Your Guide to Pregnancy Using Glucagon for Severe Low Blood Glucose If you have severe low blood glucose and pa.s.s out, you'll need help to bring your blood glucose level back to normal. Your health care team can teach your family members and friends how to give you an injection of glucagon, a hormone that raises blood glucose levels right away.

High Blood Glucose High blood glucose, also called hyperglycemia, can happen when you don't have enough insulin or when your body isn't able to use insulin correctly. High blood glucose can result from: * a mismatch between food and medication; * eating more food than usual; * being less active than usual; * illness; * stress.

In addition, if your blood glucose level is already high, physical activity can make it go even higher. Symptoms of high blood glucose include: * frequent urination; * thirst; * weight loss.

Talk with your health care provider about what to do when your blood glucose is too high-whether it happens once in a while or at the same time every day for several days in a row. Your provider might suggest a change in your insulin, meal plan, or physical activity routine.

Ketone Levels When your blood glucose is too high or if you're not eating enough, your body might make chemicals called ketones. Ketones are produced when your body doesn't have enough insulin and glucose can't be used for energy. Then the body uses fat instead of glucose for energy. Burning fat instead of glucose can be harmful to your health and your baby's health. Harmful ketones can pa.s.s from you to your baby. Your 299 Pregnancy and Birth Sourcebook, Third Edition health care provider can teach you how and when to test your urine or blood for ketones.

If ketones build up in your body, you can develop a condition called ketosis. Ketosis can quickly turn into diabetic ketoacidosis, which can be very dangerous. Symptoms of ketoacidosis are: * stomach pain; * frequent urination or frequent thirst, for a day or more; * fatigue; * nausea and vomiting; * muscle stiffness or aching; * feeling dazed or in shock; * rapid deep breathing; * breath that smells fruity.

Checking Your Urine or Blood Ketone Levels Your health care provider might recommend you test your urine or blood daily for ketones and also when your blood glucose is high, such as higher than 200 mg/dL.

You can prevent serious health problems by checking for ketones as recommended. Ask your health care team about when to check for ketones and what to do if you have them.

If you use an insulin infusion pump, your health care provider might also recommend that you test for ketones when your blood glucose level is unexpectedly high.

Your health care provider might teach you how to make changes in the amount of insulin you take or when you take it. Or your provider may prefer that you call for advice when you have ketones.

Checkups Pregnancy can make some diabetes-related health problems worse.

Your health care provider can talk with you about how pregnancy might affect any problems you had since before pregnancy. If you plan your pregnancy enough in advance, you may want to work with your health care provider to arrange for treatments, such as laser treatment for eye problems, before you get pregnant. Your diabetes-related health conditions can also affect your pregnancy.

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For Women with Diabetes: Your Guide to Pregnancy Have a complete checkup before you get pregnant or at the start of your pregnancy. Your doctor should check for: * high blood pressure, also called hypertension; * eye disease, also called diabetic retinopathy; * heart and blood vessel disease, also called cardiovascular disease; * nerve damage, also called diabetic neuropathy; * kidney disease, also called diabetic nephropathy; * thyroid disease.

You'll also get regular checkups throughout your pregnancy to check your blood pressure and average blood glucose levels and to monitor the protein in your urine.

Medications for Diabetes During pregnancy, the safest diabetes medication is insulin. Your health care team will work with you to make a personalized plan for your insulin routine. If you've been taking diabetes pills to control your blood glucose levels, you'll need to stop taking them. Researchers have not yet determined whether diabetes pills are safe for use throughout pregnancy. Instead, your health care team will show you how to take insulin.

If you're already taking insulin, you might need a change in the kind, the amount, and how or when you take it. The amount of insulin you take is likely to increase as you go through pregnancy because your body becomes less able to respond to the action of insulin, a condition called insulin resistance. Your insulin needs may double or even triple as you get closer to your delivery date. Insulin can be taken in several ways. Your health care team can help you decide which way is best for you.

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Chapter 34.

Epilepsy and Pregnancy What Is Epilepsy?

Epilepsy is a brain disorder in which cl.u.s.ters of nerve cells, or neurons, in the brain sometimes signal abnormally. Neurons normally generate electrochemical impulses that act on other neurons, glands, and muscles to produce human thoughts, feelings, and actions. In epilepsy, the normal pattern of neuronal activity becomes disturbed, causing strange sensations, emotions, and behavior, or sometimes convulsions, muscle spasms, and loss of consciousness. During a seizure, neurons may fire as many as 500 times a second, much faster than normal. In some people, this happens only occasionally; for others, it may happen up to hundreds of times a day.

More than 2 million people in the United States-about 1 in 100- have experienced an unprovoked seizure or been diagnosed with epilepsy. For about 80 percent of those diagnosed with epilepsy, seizures can be controlled with modern medicines and surgical techniques.

However, about 25 to 30 percent of people with epilepsy will continue to experience seizures even with the best available treatment. Doctors call this situation intractable epilepsy. Having a seizure does not necessarily mean that a person has epilepsy. Only when a person has had two or more seizures is he or she considered to have epilepsy.

From "Seizures and Epilepsy: Hope Through Research," by the National Inst.i.tute of Neurological Disorders and Stroke (NINDS, www.ninds.nih.gov), part of the National Inst.i.tutes of Health, March 23, 2009.

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Pregnancy and Birth Sourcebook, Third Edition Epilepsy is not contagious and is not caused by mental illness or mental r.e.t.a.r.dation. Some people with mental r.e.t.a.r.dation may experience seizures, but seizures do not necessarily mean the person has or will develop mental impairment. Many people with epilepsy have normal or above-average intelligence.

Seizures sometimes do cause brain damage, particularly if they are severe. However, most seizures do not seem to have a detrimental effect on the brain. Any changes that do occur are usually subtle, and it is often unclear whether these changes are caused by the seizures themselves or by the underlying problem that caused the seizures.

While epilepsy cannot currently be cured, for some people it does eventually go away. One study found that children with idiopathic epilepsy, or epilepsy with an unknown cause, had a 68 to 92 percent chance of becoming seizure-free by 20 years after their diagnosis. The odds of becoming seizure-free are not as good for adults or for children with severe epilepsy syndromes, but it is nonetheless possible that seizures may decrease or even stop over time. This is more likely if the epilepsy has been well-controlled by medication or if the person has had epilepsy surgery.

Eclampsia Eclampsia is a life-threatening condition that can develop in pregnant women. Its symptoms include sudden elevations of blood pressure and seizures. Pregnant women who develop unexpected seizures should be rushed to a hospital immediately. Eclampsia can be treated in a hospital setting and usually does not result in additional seizures or epilepsy once the pregnancy is over.

Pregnancy and Motherhood Women with epilepsy are often concerned about whether they can become pregnant and have a healthy child. This is usually possible.

While some seizure medications and some types of epilepsy may reduce a person's interest in s.e.xual activity, most people with epilepsy can become pregnant. Moreover, women with epilepsy have a 90 percent or better chance of having a normal, healthy baby, and the risk of birth defects is only about 4 to 6 percent. The risk that children of parents with epilepsy will develop epilepsy themselves is only about 5 percent unless the parent has a clearly hereditary form of the disorder.

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Epilepsy and Pregnancy Parents who are worried that their epilepsy may be hereditary may wish to consult a genetic counselor to determine what the risk might be. Amniocentesis and high-level ultrasound can be performed during pregnancy to ensure that the baby is developing normally, and a procedure called a maternal serum alpha-fetoprotein test can be used for prenatal diagnosis of many conditions if a problem is suspected.

There are several precautions women can take before and during pregnancy to reduce the risks a.s.sociated with pregnancy and delivery. Women who are thinking about becoming pregnant should talk with their doctors to learn any special risks a.s.sociated with their epilepsy and the medications they may be taking.

Some seizure medications, particularly valproate, trimethadione, and phenytoin, are known to increase the risk of having a child with birth defects such as cleft palate, heart problems, or finger and toe defects. For this reason, a woman's doctor may advise switching to other medications during pregnancy.

Whenever possible, a woman should allow her doctor enough time to properly change medications, including phasing in the new medications and checking to determine when blood levels are stabilized, before she tries to become pregnant. Women should also begin prenatal vitamin supplements-especially with folic acid, which may reduce the risk of some birth defects-well before pregnancy.

Women who discover that they are pregnant but have not already spoken with their doctor about ways to reduce the risks should do so as soon as possible. However, they should continue taking seizure medication as prescribed until that time to avoid preventable seizures.

Seizures during pregnancy can harm the developing baby or lead to miscarriage, particularly if the seizures are severe. Nevertheless, many women who have seizures during pregnancy have normal, healthy babies.

Women with epilepsy sometimes experience a change in their seizure frequency during pregnancy, even if they do not change medications. About 25 to 40 percent of women have an increase in their seizure frequency while they are pregnant, while other women may have fewer seizures during pregnancy. The frequency of seizures during pregnancy may be influenced by a variety of factors, including the woman's increased blood volume during pregnancy, which can dilute the effect of medication. Women should have their blood levels of seizure medications monitored closely during and after pregnancy, and the medication dosage should be adjusted accordingly.

Pregnant women with epilepsy should take prenatal vitamins and get plenty of sleep to avoid seizures caused by sleep deprivation. They 305 Pregnancy and Birth Sourcebook, Third Edition also should take vitamin K supplements after 34 weeks of pregnancy to reduce the risk of a blood-clotting disorder in infants called neonatal coagulopathy that can result from fetal exposure to epilepsy medications. Finally, they should get good prenatal care, avoid tobacco, caffeine, alcohol, and illegal drugs, and try to avoid stress.

Labor and delivery usually proceed normally for women with epilepsy, although there is a slightly increased risk of hemorrhage, eclampsia, premature labor, and cesarean section. Doctors can administer antiepileptic drugs intravenously and monitor blood levels of anticonvulsant medication during labor to reduce the risk that the labor will trigger a seizure. Babies sometimes have symptoms of withdrawal from the mother's seizure medication after they are born, but these problems wear off in a few weeks or months and usually do not cause serious or long-term effects. A mother's blood levels of anticonvulsant medication should be checked frequently after delivery as medication often needs to be decreased.

Epilepsy medications need not influence a woman's decision about breast-feeding her baby. Only minor amounts of epilepsy medications are secreted in breast milk, usually not enough to harm the baby and much less than the baby was exposed to in the womb. On rare occa-sions, the baby may become excessively drowsy or feed poorly, and these problems should be closely monitored. However, experts believe the benefits of breast-feeding outweigh the risks except in rare circ.u.mstances.

Women with epilepsy should be aware that some epilepsy medications can interfere with the effectiveness of oral contraceptives.

Women who wish to use oral contraceptives to prevent pregnancy should discuss this with their doctors, who may be able to prescribe a different kind of antiepileptic medication or suggest other ways of avoiding an unplanned pregnancy.

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Chapter 35.

Lupus and Pregnancy Twenty years ago, medical textbooks said that women with lupus should not get pregnant because of the risks to both the mother and unborn child. Today, most women with lupus can safely become pregnant. With proper medical care, you can decrease the risks a.s.sociated with pregnancy and deliver a normal, healthy baby.

To increase the chances of a happy outcome, however, you must carefully plan your pregnancy. Your disease should be under control or in remission before conception takes place. Getting pregnant when your disease is active could result in a miscarriage, a stillbirth, or serious complications for you. It is extremely important that your pregnancy be monitored by an obstetrician who is experienced in managing high-risk pregnancies and who can work closely with your primary doctor. Delivery should be planned at a hospital that can manage a high-risk patient and provide the specialized care you and your baby will need. Be aware that a v.a.g.i.n.al birth may not be possible. Very premature babies, babies showing signs of stress, and babies of mothers who are very ill will probably be delivered by cesarean section.

One problem that can affect a pregnant woman is the development of a lupus flare. In general, flares are not caused by pregnancy. Flares that do develop often occur during the first or second trimester or Excerpted from Lupus: A Patient Care Guide for Nurses and Other Health Lupus: A Patient Care Guide for Nurses and Other Health Professionals, 3rd Edition Professionals, 3rd Edition, National Inst.i.tute of Arthritis and Musculoskeletal and Skin Diseases. NIH Publication No. 06-4262, September 2006.

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Pregnancy and Birth Sourcebook, Third Edition during the first few months following delivery. Most flares are mild and easily treated with small doses of corticosteroids.

Another complication is pregnancy-induced hypertension. If you develop this serious condition, you will experience a sudden increase in blood pressure, protein in the urine, or both. Pregnancy-induced hypertension is a serious condition that requires immediate treatment, usually including delivery of the infant.

The most important question asked by pregnant women with lupus is, "Will my baby be okay?" In most cases, the answer is yes. Babies born to women with lupus have no greater chance of birth defects or mental r.e.t.a.r.dation than do babies born to women without lupus.

As your pregnancy progresses, the doctor will regularly check the baby's heartbeat and growth with sonograms. About 10 percent of lupus pregnancies end in unexpected miscarriages or stillbirths. Another 30 percent may result in premature birth of the infant. Although prematurity presents a danger to the baby, most problems can be successfully treated in a hospital that specializes in caring for premature newborns.

About 3 percent of babies born to mothers with lupus will have neonatal lupus. This lupus consists of a temporary rash and abnormal blood counts. Neonatal lupus usually disappears by the time the infant is 3 to 6 months old and does not recur. About one-half of babies with neonatal lupus are born with a heart condition called heart block. This condition is permanent, but it can be treated with a pace-maker.

Caring for Yourself * Keep all of your appointments with your primary doctor and your obstetrician.

* Get enough rest. Plan for a good night's sleep and rest periods throughout the day.