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New Treatments for Medical Problems in Pregnancy

Epilepsy. You will see this in one percent of the population and in pregnancy, one-half of one percent of your population. About half get worse during pregnancy and there is no change in thirty percent. Do you have to manage their drug regimens any differently? There is usually an increased metabolism of drugs due to the dilantin induction of enzymes, so you have to increase the dosage as pregnancy progresses and as the placenta metabolizes more drug.

What therapies do you have available to you? The common ones are dilantin, Tegretol, phenobarb and valproate. There are no new studies on the newer drugs for epilepsy, which may be a better treatment; I hope they are. Please remember that dilantin side effects are nystagmus, ataxia and drowsiness and the common theme here is drowsiness in all of these drugs. This is one of the first things that you can talk to patients about. It gives you a real clue as to how they are going.

My next topic is lupus. Lupus is defined by a combination of signs and symptoms. This classification criteria was proposed - and they called it a classification criteria rather than a diagnostic criteria because it is still a clinical decision as to whether the patient.

Lupus changes over pregnancy. The way that you can monitor these changes are not necessarily using the same tests that you used for diagnosis. Complement level - C4 and C5 or total complement, is near and dear to my heart, since one of the first papers.

How does the pathophysiology of this autoimmune disease relate to and really affect the pregnancy and various organs? Let's start with the various organs. The antigen/antibody complexes that are formed from the autoimmune production of antibody and its combination with antigens in your own tissues causes renal, joint, skin and central nervous system.

Pregnancy on lupus - pregnancy on the disease - is it going to make the disease worse? In the past, the post partum flare seemed to occur, but that was before people common gave stress doses of steroids. There is an effect of the activity at conception on the behavior of the disease during pregnancy. The best candidate is a patient inactive at conception and six months prior.

Let's talk a little bit about the SSA antibody, since people talk about it. It is really more common in Sjögren's syndrome than lupus, but it does occur in lupus. If a patient has SSA, which is anti-Rowe, they have a risk of 1 in 20 for congenital heart block. That is a positive predictive value; 1 in 20 that if you've got the antibody, you'll get the disease only 1 in 20 times.

What are you going to do about this? Again, pre-conceptual counseling is very important, because you want to emphasize that remission at conception and for a period of time before that gives the patient the greatest likelihood of having a good outcome.

Depending on how high risk patients you want to take care of, you will put them on prednisone, usually with dermatologic or articular manifestations. They will be on levels somewhere between 20 and 40 mg and certainly levels of 30 mg are common in pregnancy with asthma and other abnormalities and there is no problem with that.

Let's talk about the fetus and recommendations. Early ultrasound dating, targeted ultrasound and fetal echocardiography. But remember that congenital heart block is usually just diagnosed by auscultation. It is possible that early evidence of congenital heart block can be picked up on fetal echocardiography as the heart block develops. It is reasonable to do this early in pregnancy, even though you don't suspect an actual congenital anomaly as we typically see it structurally. Repeat this ultrasound monthly in patients with SSA antibodies.

You don't want perforation to happen, but it is more common in pregnancy; twenty-five to thirty-five percent of cases versus ten to fifteen. The average time to operation in a perforated case is 16 hours versus 6 hours in nonperforated, so time makes a difference. Ultrasound in the non-pregnant patient has pretty good predictive value, but in pregnancy.

A transverse incision might be a nice compromise, because you can enlarge that and get to the other side, if you need to. This will also depend on how sure you are that there is nothing on the left side. There has been some discussion about whether to do a c-hyst. That certainly depends on perforation and the likelihood of leaving infected tissue behind.

Chemical dependency, or substance abuse, depending on what you want to call it, is our last topic. These are some disturbing thoughts - these patients are in trouble. Seventy percent of drug-dependent females were sexually abused. Eighty-three percent of drug-dependent women have parents who are drug dependent. Ninety percent of parents who abused their kids are drug abusers. So they can be classified as any number of patients who have problems. It is not all their fault. In the Tribune, they did a nice twin study that looked into what component.

Can you make a public health impact on the substance-abusing population? You can, because in pregnancy, the behavior pattern is different than a patient who walks in off the street and is chemically dependent. They cut down on their own; they usually make an effort to cut down. They are a captive audience already, if you can keep them, and they do seem to be motivated by the fetus and motivated by their condition and motivated by the attention they are getting about their health and the attention that is drawn to their health and the public exposure of their problem. We try to look at the addiction concept without a moralistic approach.

Why are these women so hard to take care of? They are hard to take care of because they are sick; they are anemic, they have difficult nutritional challenges, they have sexually transmitted diseases, they have hepatitis and fifty percent have a psychologic diagnosis. Of course, HIV is related to this population; fifty-one percent of HIV cases are related to IV drug use; thirty-six are heterosexual contact. Interestingly, the population characteristics and survival with AIDS is similar in females and males.