* Eat a sensible, well-balanced diet. Avoid excessive weight gain.

Have your obstetrician refer you to a registered diet.i.tian if necessary.

* Take your medications as prescribed. Your doctor may have you stop some medications and start or continue others.

* Don't smoke, and don't drink alcoholic beverages.

* Be sure your doctor or nurse reviews with you the normal body changes that occur during pregnancy. Some of these changes 308 Lupus and Pregnancy may be similar to those that occur with a lupus flare. Although it is up to the doctor to determine whether the changes are normal or represent the development of a flare, you must be familiar with them so that you can report them as soon as they occur.

* If you are not sure about a problem or begin to notice a change in the way you feel, talk to your doctor right away.

* Ask your doctor or nurse about partic.i.p.ating in childbirth preparation and parenting cla.s.ses. Although you have lupus, you have the same needs as any other new mother-to-be.

Planning Your Pregnancy You and your spouse or partner should talk to your doctor about the possibility of pregnancy. You and the doctor should be satisfied that your lupus condition is under good control or in remission. Your doctor should also review potential problems or complications that could arise during the pregnancy, their treatment, and outcomes for both you and the unborn child.

You should select an obstetrician who has experience in managing high-risk pregnancies. Additional experience in managing women with lupus is also good. The obstetrician should be a.s.sociated with a hospital that specializes in high-risk deliveries and has the facilities to care for newborns with special needs. It is a good idea to meet with the obstetrician before you become pregnant so that he or she has an opportunity to evaluate your overall condition before conception. This meeting also will give you the opportunity to decide if this obstetrician is right for you.

Check your health insurance plan. Make sure that it covers your health care needs and those of the baby and any problems that may arise.

Review your work and activities schedule. Be prepared to make changes if you are not feeling well or need more rest.

Consider your financial status. If you work outside the home, your pregnancy and motherhood could affect your ability to work.

Develop a plan for help at home during the pregnancy and after the baby is born. Motherhood can be overwhelming and tiring, and even more so for a woman with lupus. Although most women with lupus do well, some may become ill and find it difficult to care for their child.

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Chapter 36.

Sickle Cell Disease and Pregnancy Impact of Hydroxyurea on Pregnancy Women and men who are taking hydroxyurea should use contraceptive methods and discontinue the drug if they plan to conceive a child, since hydroxyurea has been shown to be teratogenic in animal models. However, it remains unclear whether the drug causes birth defects in humans. Approximately 55 cases of hydroxyurea use during pregnancy have been reported. Based on these cases, the risk of birth defects appears to be much lower than animal studies have suggested. A 2007 expert panel concluded that hydroxyurea probably does not cause short-term negative effects on offspring, but that there is not enough data to completely exclude risk.

Management of Pregnancy Prenatal Care The prenatal a.s.sessment visit serves to provide counseling and outline continued care for the duration of the pregnancy. The primary focus is to identify maternal risks for low birth weight, preterm delivery, and genetic risks for fetal abnormalities. At this time, the physician Excerpted from "The Management of Sickle Cell Disease," a publication by the Centers for Disease Control and Prevent (CDC, www.cdc.gov), and the National Heart, Lung and Blood Inst.i.tute (NHLBI, www.nhlbi.nih.gov), June 2002.

Revised by David A. Cooke, MD, FACP, April 29, 2009.

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Pregnancy and Birth Sourcebook, Third Edition reviews and discusses the behavior and social patterns that place the patient at risk for s.e.xually transmitted diseases, illicit drug use, alcohol and tobacco use, and physical abuse.

A history of previous cesarean section and uterine curettage should be obtained at prenatal evaluation because of the correlation of the occurrence of placenta previa in patients with previous uterine surgery. Adequate nutritional a.s.sessment and the avoidance of precipitating factors that cause painful events should be outlined with this initial visit as well as all subsequent visits. The patient's prepregnant weight, height, and optimal weight gain in pregnancy will be recorded.

Physical exam should also include determination of splenic size.

Initial comprehensive laboratory studies include complete blood count with a reticulocyte index, hemoglobin electroph.o.r.esis, serum iron, total iron binding capacity (TIBC), ferritin levels, liver function tests, urine examination and culture, electrolytes, blood urea nitro-gen (BUN), creatinine, blood type and group, red cell antibody screen, and measurement of antibodies to hepat.i.tis A, B, and C, as well as to HIV [human immunodeficiency virus]. Rubella antibody t.i.tre, tuber-culin skin test, Pap smear, cervical smear, and gonococcus culture and screening for other s.e.xually transmitted diseases, and bacterial vaginosis also should be performed.

Hepat.i.tis vaccine should be administered when appropriate for patients who are negative for hepat.i.tis B. If asymptomatic bacteri-uria is found, the patient should receive antibiotics in order to prevent urinary tract infection and pyelonephritis.

Return visits are recommended 2 weeks after the initial visit. Low-risk patients are scheduled for monthly visits until the second trimester, when they should be seen every two weeks; in the third trimester, they should be seen every week.

Recognition of Pregnancy-Induced Hypertension and Dia- betes For women with SCD, preeclampsia and severe anemia have been identified as risk factors for delivering infants that are small for their gestational age. The incidence of preeclampsia (defined as blood pressure >140/90 mmHg, proteinuria of >300 mg/2 hours, and pathologic edema), and eclampsia (seizures in addition to features of preeclampsia) in pregnant women with SCD was 15 percent. The mechanisms for the high incidence of hypertension in this patient population remain unclear; multiple factors such as placental ischemia and endot-helial injury have been implicated. Other known risk factors for 312 Sickle Cell Disease and Pregnancy preeclampsia, even in women without SCD, are nulliparity, a history of renal disease or hypertension, multiple gestation, and diabetes.

Pregnant women with SCD should be observed closely if blood pressure rises above 125/75 mmHg, if the systolic blood pressure increases by 30 mmHg, or diastolic blood pressure increases by 15 mmHg, in a.s.sociation with edema and proteinuria in the second trimester. Preeclampsia, which requires frequent monitoring, can be treated with bed rest at home or in the hospital, if needed.

If preeclampsia is worsening, delivery of the fetus may be required if the gestational age is greater than 32 weeks. Expedited delivery is recommended for uncontrolled hypertension.

Labor, Delivery, Postpartum Care, and Counseling Cardiac function can be compromised because of chronic hypoxemia and anemia. During labor, fetal monitoring is useful to detect fetal distress, which can trigger prompt delivery by cesarean section. If surgery appears imminent, simple transfusion or rapid exchange transfusion can be of benefit depending on the baseline hemoglobin levels. The postpartum patient may require transfusion if she has undergone extensive blood loss during parturition.

Venous thromboembolism can also complicate the postpartum course. To prevent this, early ambulation is initiated.

Counseling is also an important component of postpartum care.

Results of the screen for SCD in the infant should be made available to the mother and father, as well as to the pediatrician.

Contraception and plans for future pregnancies also should be discussed. If a woman is considering no future pregnancies, she can receive preliminary counseling about tubal ligation for permanent birth control.

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Chapter 37.

Thyroid Disease and Pregnancy What is thyroid disease?

The thyroid gland's production of thyroid hormones (T3 and T4) is triggered by thyroid-stimulating hormone (TSH), which is made by the pituitary gland. Thyroid disease is a disorder that results when the thyroid gland produces more or less thyroid hormone than the body needs. Too much thyroid hormone is called hyperthyroidism and can cause many of the body's functions to speed up. Too little thyroid hormone is called hypothyroidism, in which many of the body's functions slow down.

How does pregnancy normally affect thyroid function?

Two pregnancy-related hormones-human chorionic gonadotropin (hCG) and estrogen-cause increased thyroid hormone levels in the blood. Made by the placenta, hCG is similar to TSH and mildly stimulates the thyroid to produce more thyroid hormone. Increased estrogen produces higher levels of thyroid-binding globulin, a protein that transports thyroid hormone in the blood. These normal hormonal changes can sometimes make thyroid function tests during pregnancy difficult to interpret.

Excerpted from "Pregnancy and Thyroid Disease," by the National Inst.i.tute of Diabetes and Digestive and Kidney Diseases (NIDDK, www.niddk.nih.gov), part of the National Inst.i.tutes of Health, June 2008.

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Pregnancy and Birth Sourcebook, Third Edition Thyroid hormone is critical to normal development of the baby's brain and nervous system. During the first trimester, the fetus depends on the mother's supply of thyroid hormone, which it gets through the placenta. At 10 to 12 weeks, the baby's thyroid begins to function on its own. The baby gets its supply of iodine, which the thyroid gland uses to make thyroid hormone, through the mother's diet.

Women need more iodine when they are pregnant-about 250 micrograms (g) a day. In the United States, about 7 percent of pregnant women may not get enough iodine in their diet or through prenatal vitamins. Choosing iodized salt-salt supplemented with iodine-over plain salt is one way to ensure adequate intake.

The thyroid gland enlarges slightly in healthy women during pregnancy, but not enough to be detected by a physical exam. A noticeably enlarged gland can be a sign of thyroid disease and should be evaluated. Higher levels of thyroid hormone in the blood, increased thyroid size, and other symptoms common to both pregnancy and thyroid disorders-such as fatigue-can make thyroid problems hard to diagnose in pregnancy.

What causes hyperthyroidism in pregnancy?

Hyperthyroidism in pregnancy is usually caused by Graves disease and occurs in about one of every 500 pregnancies. Graves disease is an autoimmune disorder, which means the body's immune system makes antibodies that act against its own healthy cells and tissues.

In Graves disease, the immune system makes an antibody called thyroid stimulating immunoglobulin, sometimes called TSH receptor antibody, which mimics TSH and causes the thyroid to make too much thyroid hormone. Although Graves disease may first appear during pregnancy, a woman with preexisting Graves disease could actually see an improvement in her symptoms in her second and third trimesters. Remission of Graves disease in later pregnancy may result from the general suppression of the immune system that occurs during pregnancy. The disease usually worsens again in the first few months after delivery.

Rarely, hyperthyroidism in pregnancy is caused by hyperemesis gravidarum-severe nausea and vomiting that can lead to weight loss and dehydration. This extreme nausea and vomiting is believed to be triggered by high levels of hCG, which can also lead to temporary hyperthyroidism that usually resolves by the second half of pregnancy.

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Thyroid Disease and Pregnancy How does hyperthyroidism affect the mother and baby?

Uncontrolled hyperthyroidism during pregnancy can lead to: * congestive heart failure; * preeclampsia-a dangerous rise in blood pressure in late pregnancy; * thyroid storm-a sudden, severe worsening of symptoms; * miscarriage; * premature birth; and * low birthweight.

If a woman has Graves disease or was treated for Graves disease in the past, the thyroid-stimulating antibodies she produces may travel across the placenta to the baby's bloodstream and stimulate the fetal thyroid. If the mother is being treated with ant.i.thyroid drugs, hyperthyroidism in the baby is less likely because these drugs also cross the placenta. But if she was treated for Graves disease with surgery or radioactive iodine, both of which destroy all or part of the thyroid, she can still have antibodies in her blood even though her thyroid levels are normal. Women who received either of these treatments for Graves disease should inform their doctor so the baby can be monitored for thyroid-related problems later in the pregnancy.

Hyperthyroidism in a newborn can result in rapid heart rate that can lead to heart failure, poor weight gain, irritability, and sometimes an enlarged thyroid that can press against the windpipe and interfere with breathing. Women with Graves disease and their newborns should be closely monitored by their health care team.

What causes hypothyroidism in pregnancy?

Hypothyroidism in pregnancy is usually caused by Hashimoto disease and occurs in one to three of every 1,000 pregnancies. Like Graves disease, Hashimoto disease is an autoimmune disorder. In Hashimoto disease, the immune system makes antibodies that attack cells in the thyroid and interfere with their ability to produce thyroid hormones.

White blood cells also invade the thyroid and decrease thyroid hormone production.

Hypothyroidism in pregnancy can also result from existing hypothyroidism that is inadequately treated or from prior destruction or removal of the thyroid as a treatment for hyperthyroidism.

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Pregnancy and Birth Sourcebook, Third Edition How does hypothyroidism affect the mother and baby?

Some of the same problems caused by hyperthyroidism can occur in hypothyroidism. Uncontrolled hypothyroidism during pregnancy can lead to: * congestive heart failure; * preeclampsia; * anemia-a disorder in which the blood does not carry enough oxygen to the body's tissues; * miscarriage; * low birthweight; and * stillbirth.

Because thyroid hormones are crucial to fetal brain and nervous system development, uncontrolled hypothyroidism-especially during the first trimester-can lead to cognitive and developmental disabilities in the baby.

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Chapter 38.

Eating Disorders during Pregnancy Chapter Contents.Section 38.1-How Do Eating Disorders Impact Pregnancy? ........................................................... 320 Section 38.2-Pica ....................................................................... 323 319.

Pregnancy and Birth Sourcebook, Third Edition Section 38.1 How Do Eating Disorders Impact Pregnancy?

"Eating Disorders during Pregnancy," 2008 American Pregnancy a.s.sociation (www.americanpregnancy.org). Reprinted with permission.

Eating disorders affect approximately seven million American women each year and tend to peak during child-bearing years. Pregnancy is a time when body image concerns are more prevalent, and for those who are struggling with an eating disorder, the nine months of pregnancy can cause disorders to worsen.

Two of the most common types of eating disorders are anorexia and bulimia. Anorexia involves obsessive dieting or starvation to control weight gain. Bulimia involves binge eating and vomiting or using laxatives to rid the body of excess calories. Both types of eating disorders may negatively affect the reproductive process and pregnancy.

How Do Eating Disorders Affect Fertility?

Eating disorders, particularly anorexia, affect fertility by reducing your chances of conceiving. Most women with anorexia do not have menstrual cycles, and approximately 50% of women struggling with bulimia do not have normal menstrual cycles. The absence of menstruation is caused by reduced calorie intake, excessive exercise, and/ or psychological stress. If a woman is not having regular periods, getting pregnant can be difficult.

How Do Eating Disorders Affect Pregnancy?

Eating disorders affect pregnancy negatively in a number of ways.

The following complications are a.s.sociated with eating disorders during pregnancy: * premature labor; * low birth weight; 320.

Eating Disorders during Pregnancy * stillbirth or fetal death; * likelihood of cesarean birth; * delayed fetal growth; * respiratory problems; * gestational diabetes; * complications during labor; * depression; * miscarriage; * preeclampsia.

Women who are struggling with bulimia will often gain excess weight, which places them at risk for hypertension. Women with eating disorders have higher rates of postpartum depression and are more likely to have problems with breastfeeding.

The laxatives, diuretics, and other medications taken may be harmful to the developing baby. These substances take away nutrients and fluids before they are able to feed and nourish the baby. It is possible they may lead to fetal abnormalities as well, particularly if they are used on a regular basis.

Reproductive Recommendations for Women with Eating Disorders If you are struggling with an eating disorder, you have an increased risk of complications, and it is recommended that you try to resolve weight and behavior problems. The good news is that the majority of women with eating disorders can have healthy babies. Also, if you gain normal weight throughout your pregnancy, there should be no greater risk of complications.

Here are some suggested guidelines for women with eating disorders who are trying to conceive or have discovered that they are pregnant.

Prior to Pregnancy * Achieve and maintain a healthy weight.

* Avoid purging.

* Consult your health care provider for a pre-conception appointment.

321.

Pregnancy and Birth Sourcebook, Third Edition * Meet with a nutritionist and start a healthy pregnancy diet, which may include prenatal vitamins.

* Seek counseling to address your eating disorder and any underlying concerns; seek both individual and group therapy.

During Pregnancy * Schedule a prenatal visit early in your pregnancy and inform your health care provider that you have been struggling with an eating disorder.

* Strive for healthy weight gain.

* Eat well-balanced meals with all the appropriate nutrients.

* Find a nutritionist who can help you with healthy and appropriate eating.

* Avoid purging.

* Seek counseling to address your eating disorder and any underlying concerns; seek both individual and group therapy.

After Pregnancy * Continue counseling to improve physical and mental health.