Contraception and preconception counseling in women with autoimmune disease

Appropriate contraception and preconception counseling are critical for women of reproductive age with systemic autoimmune diseases (AIDs) because clinical diagnosis, rheumatology medications, and disease activity may impact the safety or efficacy of certain contraceptives as well as the risk of adverse pregnancy outcomes. The presence of antiphospholipid (aPL) antibodies (anticardiolipin, anti-β2 glycoprotein I, and lupus anticoagulant) is the most important determinant of contraception choice, as women with these antibodies should not receive estrogen-containing contraceptives because of the increased risk of thrombosis. Prepregnancy counseling generally includes the assessment of preexisting disease-related organ damage, current disease activity, aPL antibodies, anti-Ro/SS-A and anti-La/SS-B antibodies, and medication safety in pregnancy. Quiescent AID for six months on pregnancy-compatible medications optimizes maternal and fetal/neonatal outcomes for most patients.     

High prevalence of post-partum depression in women with coeliac disease

AIM: To explore the prevalence of post-partumdepression(PPD) in coeliac disease(CD). METHODS: we performed a case-control study evaluating the prevalence of PPD in CD patients on gluten-free diet(GFD) compared to that of healthy subjects experiencing a recent delivery. All participants were interviewed about menstrual features, modality and outcome of delivery and were evaluated for PPD by Edinburgh Postnatal Depression Scale(EPDS). RESULTS: The study included 70 CD patients on GFD(group A) and 70 controls(group B). PPD was present in 47.1% of CD women and in 14.3% of controls(P 0.01; OR = 3.3). Mean EPDS score was higher in CD compared to the controls(mean score: group A 9.9 ± 5.9; group B 6.7 ± 3.7; P 0.01). A significant association was observed between PPD and menstrual disorders in CD(69.7% vs 18.9%; P 0.001; OR = 3.6). CONCLUSION: PPD is frequent in CD women on GFD, particularly in those with previous menstrual disorders. we suggest screening for PPD in CD for early detection and treatment of this condition.     

The preconception needs of women with severe mental illness: a consecutive clinical case series

Abstract

Introduction: Women with severe mental illness (SMI) are having babies at an increasing rate, but continue to face many challenges across the perinatal period. There is little research into the preconception needs of women with SMI and the aim of this study was to investigate the social circumstances, general health, mental health and reproductive health care needs in these at risk women.

Method: Women with SMI referred for specialist preconception counselling at a tertiary obstetric hospital in 2012 were eligible to participate. The data source was a semi-structured study-specific interview schedule with open-ended questions incorporated into the routine assessment protocol.

Results: In a one-year period, 23 women were referred to the service and 22 consented to data from the interview being pooled for the study. All women were taking at least one psychotropic medication at the time of referral. Overall, 40% (n?=?9) were aged at least 35 years, 36% (n?=?8) smoked cigarettes daily and over half (54.5% n?=?12) reported their body mass index as being in the overweight or obese range. Thematic analysis revealed the importance of maternal desire, and concerns relating to age and biological time pressure, the impact of the illness and medication on pregnancy and motherhood.

Conclusion: Our data indicate that preconception counselling should be routine in the care of women with SMI of reproductive age, and should take into account the potential centrality of motherhood in the woman’s rehabilitation, as well as the complex appraisals of risks, general health and support.     

Pregnancy in women with epilepsy

The aim of this study was to analyze the outcome of pregnancy and delivery in epileptic women. A retrospective review of the 41 pregnant women with epilepsy who delivered in the Department of Obstetrics and Perinatology of the University School of Medicine in Lublin over 7 years (1993-1999) was carried out. Women with epilepsy had more pregnancy complications including premature labor, anemia, hypertension, vaginal bleeding, urinary tract infection, nausea and vomiting. An increased risk of congenital malformations and intrauterine fetal growth retardation was observed. Women with epilepsy require more extensive pregnancy planning including neurologic and preconceptional care.     

Attitudes towards preconception care in Maltese women with type 1 diabetes mellitus

Introduction: The aim of this study was to assess the level of knowledge and awareness related to preconception care among Maltese women of reproductive age with type 1 diabetes mellitus (T1DM). Methods: Thirty-seven T1DM women, aged 12–30 years, were self-administered a questionnaire related to diabetes self-management and preconception care. The participants then underwent an educational intervention and re-took the same questionnaire. Results: Before the intervention, 26 participants (70%) claimed they did not have any knowledge about the preconception care of diabetes. Of the remaining 11 participants, the main reported source of information about diabetes care was the diabetologist (n = 8; 6.7%). The response rate was 70% (26 out of 37 participants completed the questionnaire after the educational intervention). Six of the participants who initially reported no preconception care knowledge claimed an increased awareness after the event. There was a statistically significant increase in the knowledge scores after the intervention. Conclusion: It is evident that there is a lack of awareness of the importance of pre-pregnancy planning to avoid pregnancy-related complications with diabetes. This emphasizes the need for more education and it is imperative for healthcare professionals to address these issues with adolescent female patients.     

Obstetric outcome in women with epilepsy

A comparison of 150 pregnancies in women with epilepsy and 150 pregnancies in matched nonepileptic control women showed similar rates of pregnancy-induced hypertension, albuminuria, premature contractions, premature labor, and bleeding in pregnancy. Duration of labor, blood loss at delivery, cesarean section rates, and vacuum extraction rates were also similar among epileptic and control groups. There were five perinatal deaths in the epileptic group and two in the control group. A fetal heart rate tracing during a maternal grand mal seizure showed bradycardia, reduced short-term and long-term variability, and late decelerations suggesting asphyxia. It is concluded that grand mal seizures during pregnancy should be avoided by the use of antiepileptic drugs. Women with epilepsy require antenatal neurological and obstetric follow-up during pregnancy.     

Management of post-partum hemorrhage in low-income countries

The provision of safe and effective delivery care for all women in poor countries remains elusive, resulting in a continuing burden of mortality in general and mortality from post-partum haemorrhage in particular. Deployment of a functional health system and effective linkage of the health system to communities are the necessary prerequisites for the provision of the life-saving technical interventions that will make a difference in individual cases. Sadly, two factors militate against progress: the mantra that 'we know what works' (resulting in some serious gaps in evidence for best practice in resource-poor settings) and a lack of large-scale investment in maternity services to counteract the degradation of infrastructure and depletion of human resources evident in many countries.     

Actively preparing for pregnancy is associated with healthier lifestyle of women during the preconception period

ObjectiveTo assess whether actively preparing for pregnancy by women is associated with lifestyle changes during the preconception period.Designretrospective cross-sectional study.Settingprimary care community midwifery practice in the Netherlands.Participantsconvenience sample of 283 women who received antenatal care.Measurements and findingsthe association between pregnancy preparation (defined as searching for information and/or consulting a healthcare provider) and preconception lifestyle changes (healthier diet, folic acid, alcohol and tobacco cessation) was measured and adjusted for age, body mass index and educational level. Almost 60% (n=160) of women acquired preconception information themselves and 25% (n=68) consulted a healthcare provider regarding their pregnancy wish. The former group was significantly more likely to quit drinking (adjusted OR 5.46 (95% CI 1.76–16.96)), improve their diet (adjusted OR 7.84 (95% CI 3.03–20.30)) and use folic acid (adjusted OR 3.90 (95% CI 2.00–7.62)) compared with women who did not prepare for pregnancy. Effect sizes were even larger for women who (also) consulted a healthcare provider with regard to folic acid use, healthier diet and smoking cessation.Key conclusionsgathering preconception information, either by women themselves or by means of a PCC consult, is associated with women positively changing lifestyles during the preconception period.Implications for practicewe recommend to not solely focus interventions on increasing the uptake of PCC consults, yet providing a suitable offer of preconception health information, which enables women to properly inform themselves.     

Ibuprofen versus acetaminophen as a post-partum analgesic for women with severe pre-eclampsia: randomized clinical study

Objective: To compare differences in blood pressure levels between patients with severe post-partum pre-eclampsia using ibuprofen or acetaminophen.

Methods: A randomized controlled trial was made in women with severe pre-eclampsia or superimposed pre-eclampsia after vaginal birth. The patient was randomly selected to receive either 400?mg of ibuprofen every 8?h or 1?g of acetaminophen every 6?h during the post-partum. The primary variable was systolic hypertension ≥150?mmHg and/or diastolic hypertension ≥100?mmHg after the first 24?h post-partum. Secondary variables were the arterial blood pressure readings at 24, 48, 72, and 96?h post-partum and maternal complications.

Results: A total of 113 patients were studied: 56 in the acetaminophen group and 57 in the ibuprofen group. With regard to the primary outcome, more cases were significantly hypertensive in the ibuprofen group (36/57; 63.1%) than in the acetaminophen group (16/56; 28.6%). Severe hypertension (≥160/110?mmHg) was not significantly different between the groups, 14.5% (acetaminophen) and 24.5% (ibuprofen). The levels of arterial blood pressure show a hammock-shaped curve independent of the drug used, however, is more noticeable with ibuprofen.

Conclusions: This study shows that ibuprofen significantly elevates blood pressure in women with severe pre-eclampsia during the post-partum period.     

Complications during pregnancy in women with epilepsy: population-based cohort study

Objective  To investigate whether women with epilepsy have an increased risk of complications during pregnancy and to explore the impact of antiepileptic drug (AED) use.
Design  Population-based cohort study.
Setting  Data from Medical Birth Registry of Norway based on all births in Norway 1999–2005.
Population  All births ( n  = 372 128) delivered in Norway, ensured through linkage with the National Population Registry run by Statistics Norway. All singleton births and the first child in multiple pregnancies were included, leaving 365 107 pregnancies for analyses.
Main outcome measures  Pre-eclampsia (mild and severe), gestational hypertension, eclampsia, vaginal bleeding (early and late) and preterm birth.
Results  We compared 2805 pregnancies in women with a current or past history of epilepsy (0.8%) and 362 302 pregnancies in women without a history of epilepsy. Women with epilepsy had an increased risk of mild pre-eclampsia, [odds ratio 1.3: 95% confidence interval (1.1–1.5)] and delivery before week 34 [1.2: (1.0–1.5)].
Antiepileptic drugs were used in 33.6% ( n  = 942) of the pregnant women with epilepsy. Compared to women without epilepsy, women with epilepsy and AED use had an increased risk of mild pre-eclampsia [1.8: (1.3–2.4)], gestational hypertension [1.5: (1.0–2.2)], vaginal bleeding late in pregnancy [1.9: (1.1–3.2)], and delivery before 34 weeks of gestation [1.5: (1.1–2.0)]. No significant increase in the risk of these complications was observed in women with epilepsy not using AED. These results remained unchanged after exclusion of multiple pregnancies.
Conclusion  Women with epilepsy have a low complication rate, but special attention should be paid to those using AED during pregnancy.     

Intrapartum analgesia and its association with post-partum back pain and headache in nulliparous women

BACKGROUND: The effect of intrapartum analgesia on post-partum maternal back and neck pain, headache and migraine, is uncertain. AIMS: To determine if nulliparous women having epidural analgesia during labour have a similar incidence of the above-mentioned post-partum symptoms compared with women managed using other forms of pain relief. METHODS: Secondary analysis of cohort data from a randomised trial in which nulliparous women intending to deliver vaginally were randomised to either epidural analgesia (EPI) or continuous midwifery support (CMS) at admission for delivery. Because of high cross-over rates, groups were initially defined by the randomised treatment allocation and the actual treatment received (CMS-CMS n = 185, EPI-CMS n = 117, EPI-EPI n = 376 and CMS-EPI n = 314). Univariate analysis showed no difference between groups, so final analysis was based on the actual treatment received. RESULTS: Six hundred and ninety women received epidural analgesia (EPIDURAL) and 302 received other methods of pain relief including CMS. Back pain was common before, during and after pregnancy, and risk factors for post-partum back pain at six months were back pain prior to pregnancy or at two months post-partum. Epidural analgesia, mode of delivery, spontaneous or induced labour, birthweight and back pain during pregnancy had no significant relationship with post-partum back pain at six months. Headache was significantly more common in the EPIDURAL group during pregnancy and at two months post-partum, but not at six months. Migraine was not associated with intrapartum analgesia. CONCLUSIONS: This analysis supports previous research suggesting that epidural analgesia is not a significant risk factor for persisting post-partum back pain, headache or migraine.     

Attitudes towards preconception sex selection: a representative survey from Germany

Within the next parliamentary term, the German government is expected to replace the current Embryo Protection Act with a new Human Reproductive Technology Act. Before introducing new legislation, policy makers may want to survey public attitudes towards novel applications of reproductive technology. In order to assess opinions and concerns about preconception sex selection for non-medical reasons, a social survey has been conducted in Germany. As a representative sample of the German population, 1005 men and women 18 years and older were asked whether or not preconception sex selection should be made available. Of the respondents, 32% held that sex selection should be strictly prohibited, be it for medical or non-medical reasons, and 54% accepted the use of preconception sex selection for medical purposes. Only a minority of 11% approved of the use of preconception sex selection for non-medical reasons. The widespread opposition to a freely available service for non-medical sex selection is based on several claims: 87% of respondents hold that 'children are a gift and deserve to be loved regardless of any characteristics such as beauty, intelligence or sex'; 79% argue that choosing the sex of children is 'playing God'; 76% are opposed because it is seen as 'unnatural'; 49% are afraid that it is 'skewing the natural sex ratio'; and 40% consider it to be 'sexist'.     

Associations of preconception Body Mass Index in women with PCOS and BMI and blood pressure of their offspring

Women with polycystic ovary syndrome (PCOS) have unfavorable metabolic profiles. Their offspring may be affected by such risks. The objective of the current study was to disclose associations between preconception health of these women and health of their offspring. 74 women diagnosed with PCOS according to the Rotterdam criteria were screened systematically before conception. Cardiovascular health of their offspring was assessed at 2.5–4 (n?=?42) or at 6–8?years of age (n?=?32). Multivariate linear regression analysis was performed with adjustments for potential confounders. In the primary analyses the association between preconception Body Mass index (BMI) and offspring BMI was evaluated. Secondly associations between preconception blood pressure, androgens, insulin-resistance (HOMA-IR), and LDL-cholesterol in women with PCOS and BMI and blood pressure of offspring were assessed. Results show that preconception BMI of women with PCOS was positively associated with sex- and age-adjusted BMI of their offspring at 6–8?years of age (β?=?0.55 (95% CI: 0.12 to 0.97), p?=?.012). No other significant associations were found. In conclusion, our data suggest that preconception BMI in PCOS is significantly associated with offspring BMI at 6–8?year of age. If this suggestion could be confirmed this may provide an opportunity for improving the future health of these children.     

Prenatal exposure to anti-epileptic drugs: the need for preconception counselling

There is accumulating evidence that prenatal exposure to antiepileptic drugs (AEDs) poses an increased risk to the fetus. There is robust evidence surrounding the incidence of major congenital malformations following exposure to some commonly prescribed AEDs, and growing evidence that prenatal exposure to certain AEDs is also associated with a reduction in cognitive functioning and an increase in neurodevelopmental disorders in childhood. This article discusses some of the findings in regards to pregnancy outcome after exposure to AEDs, the possible implications for the child and, given recent findings, the need for preconception counselling for women with epilepsy of childbearing potential.     

Abnormal pattern of luteinizing hormone pulsatility in women with epilepsy

Dysfunction of the hypothalamic-pituitary-ovarian axis in epileptic females has been suggested in the latest years. To further elucidate this issue, we assessed reproductive endocrine function in 10 normally cycling, drug-free epileptic women and in 5 normal controls, evaluating the basal hormonal profile and luteinizing hormone (LH) pulsatility in the midfollicular phase. Luteinizing hormone pulse frequency was significantly higher in epileptic women with a consequent reduction of the LH interpulse interval. We suggest that epilepsy may interfere with the functional activity of the gonadotropin-releasing hormone pulse generator. The pathogenetic mechanisms for this phenomenon may be the spreading of paroxysmal activity within the hypothalamic areas or, alternatively, a neurotransmitter dysfunction giving rise both to the seizure disorder and to the abnormal LH pulsatile pattern.