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Physiological changes in pregnancy Dawn L. Adamson, Mandish K. Dhanjal, and Catherine Nelson-Piercy Print Publication Year: 2011 Published Online: Oct 2011 ISBN: 9780199574308 eISBN: 9780191726224 Item type: chapter

Publisher: Oxford University Press DOI: 10.1093/med/9780199574308.003.0013

Introduction - Physiological changes in the antenatal period - Physiological changes in the peripartum period - Physiological changes in the post-partum period - Conclusion

Benefits and risks of hormone replacement therapy J.C. Stevenson Print Publication Year: 2010 Published Online: May 2010 Publisher: Oxford University Press ISBN: 9780199204854 eISBN: 9780199570973 DOI: 10.1093/med/9780199204854.003.1420 Item type: chapter

Hormone replacement therapy (HRT) comprises oestrogen with or without progestogen. Benefits—HRT is the most effective treatment for the relief of menopausal symptoms and for the primary prevention of postmenopausal osteoporosis. There are also possible benefits for coronary heart disease, colorectal cancer, and neurocognitive function, but these are yet to be established. Risks—the main risk of HRT is perhaps a small increase in incidence of breast cancer, but this risk may be confined to women with a long exposure to certain oestrogen–progestogen combinations. There is a small increased risk of stroke if HRT is initiated in older women and a small increased risk of venous thromboembolism with oral therapy. Balance of benefits and risks—given appropriately, the benefits of HRT outweigh the risks. The choice and dose of therapeutic agents should be tailored to suit the individual case, but usually the therapy used should be the one that the patient finds most acceptable. Risks and benefits should be reviewed annually, but no limit on duration of treatment need be set.

Heart disease in pregnancy Catherine E.G. Head Print Publication Year: 2010 Published Online: 2013 ISBN: 9780199204854 eISBN: 9780199570973 Item type: chapter

Publisher: Oxford University Press DOI: 10.1093/med/9780199204854.003.1406_update_001

Pregnancy is a vasodilator state in which plasma volume and cardiac output increase such that many symptoms and signs of cardiac disease can occur physiologically. Page 1 of 5 PRINTED FROM OXFORD MEDICINE ONLINE (www.oxfordmedicine.com). © Oxford University Press, 2015. All Rights Reserved. Under the terms of the licence agreement, an individual user may print out a PDF of a single chapter of a title in Oxford Medicine Online for personal use (for details see Privacy Policy). date: 23 January 2017

Disproportionate symptoms or abnormal signs such as a diastolic murmur require investigation as usual; necessary radiological investigations should not be withheld as the risks to the fetus are generally low. Prepregnancy risk assessment—this is ideally based on data related to the specific cardiac abnormality, with prepregnancy functional status an important predictor of outcome. Issues of particular note are (1) pregnancy is high risk in pulmonary hypertension or severe left ventricular dysfunction—effective contraception and termination should be offered; (2) women at risk of aortic dissection are at increased risk during pregnancy—prepregnancy elective replacement of the aortic root should be considered if its diameter at its widest point is greater than 4.5 –5.0cm, depending on the underlying aetiology; ##-blockers and regular echo monitoring should continue through pregnancy. Delivery of the baby—vaginal delivery is recommended, other than in the presence of a dilated aortic root, aneurysm or dissection, or if the fetal INR is elevated. Low dose infusions of epidural anaesthesia and oxytoxic drugs are safe. Heart conditions arising in pregnancy Peripartum cardiomyopathy—this should be considered in any woman presenting peripartum with dyspnoea or tachycardia. Myocardial infarction—when occurring in pregnancy this may be due to coronary dissection: immediate angiography with percutaneous coronary intervention is the management of choice, but thrombolysis is not contraindicated. Pregnancy in women with known cardiac disorders Valve diseases and cardiomyopathies—(1) Symptomatic mitral stenosis—may be managed medically with diuretics, ##-blockade and maintenance of sinus rhythm; failing this, balloon valvuloplasty is usually successful. (2) Aortic stenosis—women with satisfactory prepregnancy haemodynamics are at low risk of problems in pregnancy. (3) Hypertrophic cardiomyopathy—patients generally tolerate pregnancy well. Congenital cardiac lesions—low-risk conditions include atrial septal defect, restrictive ventricular septal defect and corrected tetralogy of Fallot in the absence of severe pulmonary regurgitation or aortic root dilatation. All cases other than those at low risk should be managed by a multidisciplinary team in a specialist centre. Anticoagulation—the optimal anticoagulation management of a pregnant patient with a mechanical prosthetic valve is not known. Continued warfarin therapy carries the risk of warfarin embryopathy for the fetus, but switching to heparin increases the maternal risk of thromboembolism, although newer regimens using LMW heparin with monitoring of anti-Xa levels almost certainly perform better than historical regimens using unfractionated heparin.

Pre-pregnancy counselling Dawn L. Adamson, Mandish K. Dhanjal, and Catherine Nelson-Piercy Print Publication Year: 2011 Published Online: Oct 2011 ISBN: 9780199574308 eISBN: 9780191726224 Item type: chapter

Publisher: Oxford University Press DOI: 10.1093/med/9780199574308.003.0124

Pre-pregnancy counselling - Assessment of maternal cardiac risk - Assessment of fetal risk Preparation for pregnancy - Maternal age at pregnancy - Diversity and beliefs Page 2 of 5 PRINTED FROM OXFORD MEDICINE ONLINE (www.oxfordmedicine.com). © Oxford University Press, 2015. All Rights Reserved. Under the terms of the licence agreement, an individual user may print out a PDF of a single chapter of a title in Oxford Medicine Online for personal use (for details see Privacy Policy). date: 23 January 2017

Contraception Dawn L. Adamson, Mandish K. Dhanjal, and Catherine Nelson-Piercy Print Publication Year: 2011 Published Online: Oct 2011 ISBN: 9780199574308 eISBN: 9780191726224 Item type: chapter

Publisher: Oxford University Press DOI: 10.1093/med/9780199574308.003.0135

Introduction - Combined hormonal contraceptives - Progestogen-only contraceptives - Copper intrauterine contraceptive device (Copper IUD) - Sterilisation - Emergency contraception - Barrier methods - Termination of pregnancy - Specific cardiac conditions

Maternal cardiac disease Harini Narayan Print Publication Year: 2015 Published Online: Sep 2015 ISBN: 9780199673643 eISBN: 9780191800344 Item type: chapter

Publisher: Oxford University Press DOI: 10.1093/med/9780199673643.003.0004

Cardiac disease is a leading cause of maternal mortality and morbidity. Pregnancy carries increased risks for women with congenital heart disease. This chapter addresses the general principles of multidisciplinary management of pregnancies of women with congenital or acquired cardiac diseases including valvular and ischaemic heart disease, aortic dissection, cardiac arrhythmias, hypertrophic cardiomyopathy and the rare, but life threatening peripartum cardiomyopathy. The fact file for each condition outlines aetiopathology, symptomatology, de-novo presentation in pregnancy, impact of cardiac diseases on pregnancy and vice versa. Pre-pregnancy cardiology/obstetric assessment and counselling with risk stratification, review of medications, continued assessment of maternal cardiac status during pregnancy, anaesthetic input, fetal assessments, risk of fetal cardiac disease, and prognosis are discussed. Controversies in anticoagulant regimen for prosthetic heart valves are addressed. Care pathways incorporate guidance regarding appropriate referrals to tertiary centres, integrated management plans for antenatal care, labour, delivery, postnatal contraceptive advice and continued cardiology surveillance.

Pregnancy and Heart Disease Patrizia Presbitero, Giacomo G. Boccuzzi, Christianne J.M. Groot, and Jolien W. Roos-Hesselink Print Publication Year: 2009 Published Online: Aug 2009 Publisher: Oxford University Press ISBN: 9780199566990 eISBN: 9780199572854 DOI: 10.1093/med/9780199566990.003.033 Item type: chapter

Maternal neurological conditions Harini Narayan Print Publication Year: 2015 Published Online: Sep 2015 ISBN: 9780199673643 eISBN: 9780191800344 Item type: chapter

Publisher: Oxford University Press DOI: 10.1093/med/9780199673643.003.0010

Page 3 of 5 PRINTED FROM OXFORD MEDICINE ONLINE (www.oxfordmedicine.com). © Oxford University Press, 2015. All Rights Reserved. Under the terms of the licence agreement, an individual user may print out a PDF of a single chapter of a title in Oxford Medicine Online for personal use (for details see Privacy Policy). date: 23 January 2017

A wide range of neurological disorders including epilepsy, Bell’s palsy, idiopathic intracranial hypertension, multiple sclerosis, strokes, myasthenia gravis, Charcot-MarieTooth disease, myotonic and muscular dystrophy are covered here. The multidisciplinary management required in each high-risk pregnancy is presented in practical terms based on national guidelines, best practice evidence, and up-to-date literature. Information regarding epidemiology, risk factors, inheritance, pathophysiology, symptomatology, impact of pregnancy on the neurological condition and vice versa, is presented in a format suitable for use in busy clinical settings. Multidisciplinary integrated antenatal management embracing both primary care and hospital settings and essential investigations and assessments are incorporated in individualized care pathways, ranging from pre-pregnancy to postdelivery, including contraception. Medications and supplements are discussed. Essential documentation and communication of the key information for intrapartum and postnatal care, as well as the need to avoid unnecessary interventions, are highlighted. Patient information is provided for each condition.

Benefits and risks of oral contraception John Guillebaud Print Publication Year: 2010 Published Online: May 2010 Publisher: Oxford University Press ISBN: 9780199204854 eISBN: 9780199570973 DOI: 10.1093/med/9780199204854.003.1419 Item type: chapter

Efficacy of the ‘pill’ as an oral contraceptive—users of combined oral contraceptives (COC) must understand the importance of not lengthening the pill-free (contraception-deficient) time, and be appropriately advised if prescribed enzyme-inducing drugs. Noncontraceptive benefits of COC use—these include fewer disorders of the menstrual cycle and less risk of colorectal cancer and cancers of the ovary and endometrium, which may sometimes provide the principal indication for prescription. Risks of COC use—these include (1) cancer of the breast (possible cofactor) and of the cervix (probable cofactor, with impact reducible through cervical screening); (2) venous thromboembolism—the attributable risk with any formulation of COC is very small without a hereditary or acquired predisposition, including obesity and immobility; (3) vascular diseases—the attributable risk of both acute myocardial infarction and haemorrhagic stroke is negligible without an added arterial risk factor; migraine with aura is a specific thrombotic stroke risk factor and contraindicates use of any oestrogen-containing method of contraception. By 10 years all-cause mortality in past-users is indistinguishable from that in never-users of the COC. Progestogen-only pills—these have fewer contraindications than COC. Desogestrel 75 µ#g (Cerazette) blocks ovulation in 97% of cycles, hence it relies less than other progestogen-only pills on the cervical mucus effect and is a more effective option if COC is contraindicated.

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Medical problems prior to pregnancy Sabaratnam Arulkumaran Ippokratis Sarris (ed.) , Susan Bewley (ed.) , and Sangeeta Agnihotri (ed.) Print Publication Year: 2009 Published Online: Nov 2012 Publisher: Oxford University Press ISBN: 9780199218479 eISBN: 9780191753169 DOI: 10.1093/med/9780199218479.003.0007 Item type: chapter

Psychiatric disorders - Substance abuse - Illicit drug abuse - Chronic hypertension Endocrine causes of hypertension - Cardiac disease - Congenital heart disease - Valvular heart disease - Acquired heart disease - Respiratory disease - Granulomatous disease - Cystic fibrosis - Neurological disease - Epilepsy - Diabetes in pregnancy - Thyroid and pregnancy—1 - Thyroid and pregnancy—2 - Parathyroid disease - Other endocrine disorders - Renal disease - Specific renal diseases - Transfusion-dependent anaemias and thalassaemia - Sickle cell disease - Bleeding disorders - Systemic lupus erythematosus Neonatal lupus erythematosus and rheumatoid arthritis - Antiphospholipid antibodies and syndrome - Inflammatory bowel disease Covered elsewhere Platelet disorders (see Section 8.15)

Page 5 of 5 PRINTED FROM OXFORD MEDICINE ONLINE (www.oxfordmedicine.com). © Oxford University Press, 2015. All Rights Reserved. Under the terms of the licence agreement, an individual user may print out a PDF of a single chapter of a title in Oxford Medicine Online for personal use (for details see Privacy Policy). date: 23 January 2017