Start with the patient in mind

What is her condition and what are her concerns? It is remarkable how much patients have thought about the exact issues that their doctors think about, often long before and in different ways. Is she willing to consider pharmacologic treatment at all? What are her concerns about her condition? What is her need for certainty about the safety of a medication for her developing fetus? In today’s environment, ask what she already knows about her condition and possible treatments. Chances are, she has already checked out internet sites and may even have already made a decision about what she thinks her options are. The patient must have a role in deciding whether to take a medicine and which one to take.

Ensure the diagnosis is correct

Pregnancy is not a time to treat empirically, so a confident diagnosis of the patient’s problem is critical to selection of an appropriate therapy. It is surprising how often this is overlooked in the clinician’s zeal to “do something.” Patients who enter pregnancy with a chronic medical condition usually have had so much investigation that diagnostic testing, such as for rheumatoid arthritis, is not necessary. However, when the condition is of new onset or presents in a way that is different from manifestations the patient has previously experienced, determining the diagnosis is essential. Once a diagnosis is made, three major considerations merge in reaching a decision about treatment:

• how the pregnancy might affect the mother’s condition or illness
  
• how the pathophysiology of the condition might affect the pregnancy or the fetus
  
• what the treatment options are.

A good rule to keep in mind is that at the end of pregnancy, a healthy baby is best assured by a healthy mother.

In general, conditions that will adversely affect the mother or the fetus, such as progressive acute or chronic medical conditions, should be considered as potentially detrimental to the developing fetus and likely to require treatment. Many self-limited, symptomatic illnesses (e.g. tension headaches, viral upper respiratory infections) can be managed with simple, nonpharmacologic treatments. However, there are also conditions that the pregnant woman may tolerate reasonably well but which still place fetal well-being at risk, such as some thyroid disease, asthma and some viral illnesses. Young women can have remarkable tolerance to substantial physiologic and immune alteration, while their developing fetus may not.

Will pregnancy affect the mother’s medical condition?

Pregnancy itself can exacerbate some medical conditions, putting the pregnant woman at substantial risk. As stated above, the more healthy the mother, the greater the likelihood of a healthy fetus and infant. Conditions that worsen in pregnancy may place the mother at risk for morbidity and, in some cases, mortality. These are therefore likely to require pharmacologic intervention at some point. Examples include asthma, autoimmune conditions, congestive heart failure and cardiac arrhythmias. Unfortunately, for many such illnesses, it is not clear in advance which women will be adversely affected during pregnancy. For example, an uncomplicated first pregnancy in a woman with asthma is not necessarily reassurance that she will have a similar course in any subsequent pregnancy.

Will the medical condition affect the pregnancy and the fetus?

There are medical conditions that negatively affect pregnancy and fetal development, because of an effect on either maternal health or the fetus. These include some endocrine disorders, especially diabetes and thyroid disease, infections, and consequences of chronic conditions that manifest with episodic exacerbations. Examples of the latter include asthma and epilepsy, both of which can result in fetal hypoxia, even if the mother experiences no significant sequelae herself. Similarly, hypertension is usually asymptomatic in the mother, but its presence increases the risk of pre-eclampsia which may hamper fetal growth and development. Certain infections, even if mild in the mother, are well known to be associated with preterm labor.

It is not necessary to withhold medications from women who have self-limited conditions or those who have conditions that are not known to specifically adversely affect pregnancy. Here, understanding the patient’s preferences and needs will guide whether or not to intervene with a medicine. For example, maternal migraine headaches are not likely to cause the fetus direct harm. They can, however, so substantially interfere with the woman’s ability to carry out daily activities that she becomes depressed, sleep deprived and even poorly nourished – none of which are good for the fetus. Without a physician’s willingness to consider prescribing an effective intervention, she may take matters into her own hands and use over-the-counter remedies she presumes are safe but which have their own risks (e.g. acetaminophen hepatotoxicity), to say nothing of herbal treatment and dietary supplements. Herbal-based or “natural” products are not necessarily safer than traditional medicine – they have simply not been tested.

Whenever possible, it is prudent to have a plan for medical intervention should a patient with a medical illness worsen. Establishing such a plan well in advance is highly recommended – and it should be developed in partnership with the patient and any of her other healthcare providers, preferably before encountering an acute or emergency situation. A treatment plan can be simple, but should include the points in Box 30.1 including the diagnosis, what clinical changes will trigger starting pharmacologic treatment, and evidence that you and the patient have had frank discussions about her options and preferences.