Pregnancy Planning with a Chronic Disease: A Step-by-Step Guide

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• Preconception Clinic Importance
• Effects of Disease on Pregnancy
• Effects of Pregnancy on Disease
• Medication Risk Assessment
• Fetal Malformation Risks
• Transient Baby Effects
• Breastfeeding Considerations
• Informed Decision Making

The Critical Role of a Preconception Clinic

For a woman with a chronic medical condition, the first and most crucial step in pregnancy planning is to seek specialized care. Dr. Marc Dommergues, MD, emphasizes the importance of a 'preconception clinic'. This is a dedicated consultation with an obstetrician who has specific expertise in the patient's type of disease. The process begins with a thorough review of the patient's complete medical history and data.

The outcome of this visit is comprehensive health information provided both verbally and as a detailed written record. This document empowers the patient to carefully consider her options, discuss them with her other doctors, and consult with her family, forming the foundation for all subsequent decisions.

Assessing the Effects of the Disease on Pregnancy

A primary objective of preconception counseling is to understand how an existing chronic disease might impact a pregnancy. This analysis is vital for anticipating potential complications and creating a proactive management plan. The most immediate concern for many patients, as noted by Dr. Dommergues, is often the medication they are taking.

It is critically dangerous to discontinue necessary medications out of fear without proper medical guidance. This is a key reason why the preconception meeting is so essential, as it provides a safe space to address these fears with evidence-based information.

Understanding the Effects of Pregnancy on the Disease

Pregnancy induces significant physiological changes that can alter the course of a chronic illness. Hormonal shifts, increased blood volume, and changes in immune function can cause a pre-existing condition to worsen, improve, or remain stable. Dr. Marc Dommergues, MD, stresses that this reverse relationship must be evaluated.

A specialist familiar with both the disease and obstetrics can forecast these potential changes and adjust treatment plans accordingly to maintain the mother's health throughout the gestational period.

Comprehensive Medication Risk Assessment

The safety of medications during pregnancy is a complex and paramount concern. Dr. Dommergues outlines that the assessment involves determining several types of potential effects on the fetus. The first step is to establish whether a drug carries a known risk of causing fetal malformations.

For many medications, the precise risks are not fully known. This is where collaboration with teratogen information services, which exist in many countries, becomes invaluable. These specialists have access to published data, unpublished data from pharmaceutical laboratories, and registries of clinical case reports, providing the most current risk profiles.

Evaluating Fetal Malformation Risks

When a medication is known to pose a teratogenic risk, the preconception clinic provides detailed information. Dr. Marc Dommergues, MD, explains that patients need to understand the rate of potential malformations, the specific types of anomalies that could occur, and how these might be identified through prenatal screening. This knowledge allows for informed decision-making about whether to continue, adjust, or change a medication regimen before conception occurs, thereby minimizing risk.

Managing Transient Effects on the Baby

Some medications may not cause permanent malformations but can have transient effects on a newborn's health. As Dr. Dommergues describes, psychotropic drugs or certain antiepileptics can cause a baby to be lethargic or sleepy for the first few days of life and may induce a withdrawal syndrome.

These conditions are typically temporary and can be managed effectively by pediatricians who are experienced in caring for neonates exposed to maternal medication. Foreknowledge of this possibility ensures the baby receives appropriate care immediately after delivery.

Navigating Breastfeeding Considerations

The decision to breastfeed while on medication is another critical topic addressed during preconception planning. Dr. Dommergues points out that if a drug is present in significant concentrations in breast milk, it may be passed to the infant. In some cases, choosing not to breastfeed may be the most reasonable option to avoid neonatal exposure.

Attitudes towards medication and breastfeeding can vary between countries and even among physicians, highlighting the need for early discussion to reach a comfortable and safe decision for the family.

The Power of Informed Decision Making

The ultimate goal of all these steps is to empower the patient. As Dr. Marc Dommergues, MD, concludes, having ample time to process detailed information, discuss it with a multidisciplinary medical team, and consult with family is invaluable. This thorough and collaborative approach to pregnancy planning for women with chronic diseases significantly increases the chances of a successful and healthy outcome for both mother and baby.

Full Transcript

Dr. Anton Titov, MD: Professor Dommergues, you specialize in planning the pregnancy for women with various chronic medical diseases. So if somebody has a medical condition that can complicate the pregnancy, what can a woman do to make sure that pregnancy planning is done properly and correctly, and that pregnancy is successful?

Dr. Marc Dommergues, MD: There are steps that are not specific at all. As usual, she should quit smoking and drinking. She should take folic acid tablets and do the usual blood tests such as HIV, etc.

But then, when it comes to someone who has a chronic disease, the first point is that the lady should discuss the pregnancy with the doctor who is usually in charge of her disease. It is also very important that she should see an obstetrician who is familiar with the type of disease she has. This is what we call a 'preconception clinic'.

In this preconception clinic, the first part is to learn about the history of the person, get all information and medical data, and then give information to the patient, first verbally and then as a written record that gives details that the patient can think about, discuss with her doctors, and discuss with her family. This enables her to have adequate health information.

Dr. Anton Titov, MD: So the information is the first step.

Dr. Marc Dommergues, MD: And there's a simple way of providing it. First, it's important to consider the effect the disease may have on pregnancy. Then we need to consider the effects that pregnancy may have on the disease.

Regarding the effect of the disease on pregnancy, probably the first question is the question of the medicines that a person is taking. It is a major fear for future pregnant women that they might take drugs that could harm babies. It is, of course, very dangerous to discontinue medications that you need to take, stopping them just out of fear. This is one of the reasons why a preconception meeting is extremely important.

To illustrate, drugs may have different types of effects on a fetus. The first type of effect is that medications may induce fetal malformations. Then it's important to know what is the rate of fetal malformations, what type of malformations, and how malformations can be identified. In some cases, we just do not know precise risks for a given drug to induce malformations.

It's important to exchange data on medications during pregnancy with specialists who concentrate on the effect of drugs on fetuses. Those experts exist in different countries. They can provide us with published data, but also with unpublished data that belongs to the laboratories or information from clinical cases that were reported to their centers.

Dr. Anton Titov, MD: So the first point to assess any medication used in pregnancy would be to establish whether those drugs have a risk of inducing fetal malformations or if medication has a long-term effect on the baby without inducing malformation.

Dr. Marc Dommergues, MD: Another type of effect a medication may have is that a drug interacts transiently with the baby's health. For instance, if you're taking psychotropic drugs or some antiepileptic drugs, the baby may be lazy and sleepy for a few days, and then may have withdrawal syndrome. Usually, this resolves spontaneously with baby care by pediatricians who are used to those babies being under the influence of medicines taken by their moms. But this is something that has to be considered.

Sometimes the question of breastfeeding must be taken into account. For example, it may be a reasonable choice to choose not to breastfeed if there's a significant concentration of drugs in the milk, which may then pass from the milk to the baby. This is often controversial. In different countries, physicians may have different opinions on what should be done.

Of course, the more time the future mother and family have to think about this, the better. Because it helps in making decisions. This was point number one: the medicines.