Infections To Look Out For During Pregnancy

Expectant mothers are more susceptible to various viral, bacterial and other types of infections compared to regular people. Being aware and taking precautions is significant in ensuring the health of mother and baby

Pregnant women are at increased risk of acquiring infections because of the lower immunity levels.According to Dr Teena Thomas, Consultant Obstetrician and Gynaecologist at Motherhood Hospitals, it is common for pregnant women to catch infections as their immunity is generally low. Urinary tract Infections and conditions such as bacterial vaginosis are quite common but with the right advice and medical treatment, these types of problems during pregnancy can to resolved, says Dr Thomas.

At Motherhood Hospitals, doctors strive to ensure that all expectant mothers get the best quality care and assistance. All the necessary diagnostic tests are carried out for early detection of any infection and timely treatment is given for the same.

There are different types of infections that might affect women in pregnancy. These can be categorised into

VIRAL INFECTIONS

Chicken Pox This infection is rarely seen in pregnant women, as most people get chicken pox in childhood and because of this become naturally immune to the virus. But in women who have never been affected, there are chances of getting it during pregnancy. If affected by the chicken pox (varicella) virus, pregnant women are at risk of contracting pneumonia. It can be dangerous for the newborn if the virus affects the expectant mother at the end of the 1st trimester or very close to the delivery. In the first trimester, there is a one per cent chance of the baby developing a serious condition called Varicella syndrome, a rare condition in infants that results in low birth weight and certain developmental/brain abnormalities and hence may require terminations. If the mother is diagnosed with chicken pox very near to the delivery time, then there is a risk of the baby also getting infected.

If the non-immune expectant mother is infected nearing delivery. She can be administered the varicella zoster immunoglobin as soon as possible to minimise the effect of the infection. The infected newborn should also be administered the same immunoglobin and effective treatment for the ailment needs to be given by a team of specialists.We have had mothers with chicken pox coming in to the hospital and with timely care and treatment both baby and mother came out of danger, said Dr Thomas.

Cytomegalovirus (CMV) It is a common virus, belonging to the Herpes virus family and many people get infected by it at some point in their lives. But it rarely causes any symptoms. While CMV infection is quite rare, it can be a cause of concern in pregnancy, as 1-4 in 100 babies can get infected by the virus through their mothers. It may cause flu-like symptoms in the pregnant woman. Most infected babies don’t have any problems but some may have congenital abnormalities including hearing loss, visual impairment and so on. The virus can be detected with a blood test and treated accordingly.

Hepatitis B (HBV) This virus is highly infectious and can be blood borne or sexually transmitted. It can cause liver problems later in life. Pregnant women who are infected by the virus can pass it on to the foetus. So babies at risk should be immunised at birth with HBV vaccine as this is 90-95 per cent effective in preventing the disease.

We screen expectant mothers for HBV as part of the antenatal care and if found positive, appropriate treatment is given, adds Dr Thomas.

Hepatitis C This virus is also passed on through the blood or sexually transmitted. If the mother passes on the infection to the newborn, medical assessment needs to be done and care is provided.
Herpes This viral infection can be of different kinds, most commonly oral herpes and genital herpes. Primary genital herpes is diagnosed by actively present blisters and ulcers in the vaginal area particularly dangerous for the baby and it can be passed on during a vaginal delivery. Normally, doctors advise a Caesarean section delivery to prevent transmission.
HIV A test for the virus is offered as part of antenatal care to all mothers. An HIV positive pregnant woman can pass on the infection to her baby. But constant monitoring and active treatment from 28 weeks of pregnancy, apart from an elective C-section can bring down the risk of transmission. Late booking patient’s treatments can also be commenced at 36 weeks in labour.After birth also the baby is monitored for some time to rule out transmission, says Dr Thomas.
Parvovirus This is rare type of virus but if there is primary infection during pregnancy, the expectant mother might have mild rash and fever. Some complications of Parvovirus include miscarriage or the fetal anaemia. There is a test to diagnose the infection and can be treated with medications and requires fetal monitoring.
Rubella It is a contagious infection caused by the Rubella virus which causes fever, rashes, sore throat and swollen glands. In India, rubella infection is very rare as it is part of the standard immunisation plan. But Primary Rubella affects the mother in the first half of pregnancy it can lead to serious complications in the baby including blindness and mental retardation. In the later part of the pregnancy, it can result in pre-term labour.

We had a young mother who was diagnosed with Rubella at 28 weeks of pregnancy through a test. She was monitored carefully by the hospital and all necessary care was taken. She went into preterm labour and birth and the baby weighed only 1.1 kg. But with good care in the NICU, the baby went home healthy, recalls Dr Thomas.

PARASITIC

Toxoplasmosis This is the most common parasitic infection seen during pregnancy and is caused by the parasite Toxoplasma gondii, found in cat faces. If the pregnant mother comes in contact with the parasite, by handling cat litter or eating raw contaminated food, there is a risk of passing it on to the foetus. The infection is dangerous in pregnancy as it can cause stillbirth, miscarriage and congenital abnormalities in the baby. Such infections can be easily prevented by taking necessary precautions but if the pregnant woman is found to be infected, antibiotic medications are administered till delivery.

BACTERIAL

Urinary tract infection (UTI) The most common infection in pregnancy, it is an infection of the urinary tract caused by bacteria which causes burning sensation, fever and chills.Most women are checked for UTIs during antenatal screening and treated accordingly, Asymptomatic bacteria (without symptoms) also needs to be treated. It can cause complications such as low birth weight and preterm labour .

Bacterial Vaginosis (BV) This is an infection caused by overgrowth of hormonal commensal bacteria of the vagina and is typically characterised by fishy odour in the vaginal discharge. BV in pregnancy can lead to complications such as preterm labour, miscarriage and premature rupture of the membrane and hence requires prompt treatment with Antibiotics.

Group B Streptococci This is a bacterial infection that is mostly asymptomatic but in some pregnancies, it can cause serious complications in the baby. It results in preterm labour and premature rupture of membrane.

All the three bacterial infections can be treated successfully with antibiotics.

Sexually Transmitted Diseases (STDs) There are a few common sexually transmitted diseases such as Gonorrhoea and Chlamydia that when present in a pregnant woman can cause problems. Complications include preterm labour, miscarriage & new-born infections. STDs should be diagnosed and detected early and treated with medications.

HOW TO PREVENT INFECTIONS

Sometimes a little bit of care and sound advice from the gynaecologist can go a long way in preventing harmful infections during pregnancy.

According to the Centers for Disease Control and Prevention, simple measures can prevent infection. These include

Washing your hands often especially after touching raw food and meat, using the bathroom, playing with children, touching dirt and soil
Avoid eating uncooked food and raw and processed meat.
Drink lots of water to prevent UTIs. (around 2.5 l/ day)
Stay away from animal droppings and cat litter.
Get checked for infections such as HIV, STDs and Hepatitis B
Make sure to get vaccinations
Healthy diet and lifestyle remains till date the key to prevent it.

Content Credits: Dr Teena Thomas (Obstetrics & Gynaecology)

CERVICAL CANCER

Introduction

Cervical cancer is one of the commonest causes of cancer-related deaths amongst women in developing countries. Every year in India, 122,844 women are diagnosed with Cervical cancer and about half of them die due to this fatal disease. Worldwide, Cervical cancer accounts for 500,000 new cases every year and India contributes nearly 25%.

Who are prone to Cervical cancer?

The median age of diagnosis for women is 48 years, and the majority of cases are diagnosed between 35 and 55 years when women are in the prime of their lives.

What causes Cervical cancer?

Long-term use of hormonal contraceptives, high parity, early initiation of sexual activity, multiple sex partners, tobacco smoking and co-infection with HIV, immunosuppression, low socio-economic status, poor hygiene and diet low in antioxidants increase the likelihood of developing Cervical cancer

There is a firm establishment of a causal relationship between persistent infection with high-risk Human PapillomaVirus (HPV) genotypes and Cervical cancer.

HPV infection occurs in a high percentage of sexually active women. Most of these infections clear spontaneously within months to a few years, a small proportion of persistent infection will progress to cancer.

Symptoms

The first symptom is abnormal vaginal bleeding, usually postcoital. Vaginal discomfort, malodorous discharge, and dysuria are common symptoms.

The tumor grows by extending upward to the endometrial cavity, downward to the vagina, and laterally to the pelvic wall, who can then present with constipation, hematuria, vaginal fistula.

How can it be prevented?

Primary prevention involves intervention for sexual and health care-seeking behavior or through mass immunization against high-risk HPV.

The objective of Cervical screening/secondary prevention is to prevent invasive Cervical cancer from developing by detecting and treating women with precancerous lesions, and the effectiveness is determined by reduction in incidence and mortality.

What is screening and how is it done in Cervical cancer patients?

There are 2 types of tests used for Cervical cancer screening.

The PAP test can find early cell changes and treat them before they become cancer. The Pap test can also find cervical cancer early when it’s easier to treat.

The HPV (Human Papilloma Virus) test finds certain infections that can lead to cell changes and cancer. HPV infections are very common.

American Cancer Society recommends all women should begin Cervical cancer screening at the age of 21 years. Women between 21 and 29 years should have a PAP test every 3 years. Women between the age of 30 and 65 should have both a PAP test and an HPV test every 5 years or a Pap test alone every 3 years.

Women over age 65 who have had regular and normal results should not be screened. Women who have been diagnosed with Cervical pre-cancer should continue to be screened.

Women post hysterectomy who have their cervix removed need not to be screened.

Women who have had the HPV vaccine should still follow the screening recommendations for their age group.

Cervical cancer vaccination

Two vaccines licensed globally are available in India; a quadrivalent vaccine (Gardasil ) and a bivalent vaccine (Cervarix )

The recommended age for initiation of vaccination is 9 12 years. A total of three doses at 0, 2 and 6 months are recommended with Gardasil or 0, 1 and 6 months with Cervarix .

Treatment

The treatment of Cervical cancer varies with the stage of the disease. For early invasive cancer, surgery is the treatment of choice. In more advanced cases, radiation combined with chemotherapy is the current standard of care.

Preterm labor – be on the alert By Dr. Beena Jeysingh

Preterm labor is when your body gets ready for birth too early in your pregnancy. It is premature if it starts earlier than 3 weeks of due date.

Risk factors are overweight or underweight at time of conception, hypertension, diabetes, smoking, alcohol, pregnancy induced hypertension, gestational diabetes, uterine abnormalities, previous history of preterm delivery, any severe maternal infection. Report to obstetrician if severe backache, cramping in lower abdomen, fluid leaking from vagina, vaginal bleeding.

Preterm birth is the most important single determinant of adverse infant outcome hence prevention and early detection is important.

By
Dr.Beena Jeysingh

Morning Sickness -don’t fear! By Dr. Beena Jeysingh

It is an uncomfortable feeling of just nausea or nausea with vomiting experienced in the early
weeks of pregnancy due to hormones. About 50 percent of pregnant women experience it.
Usually starts around 6weeks of pregnancy and disappears by end of 3months though rarely can
stay until end of pregnancy. Report to obstetrician if excess vomitting, less or dark color urine,
blood in vomitus. Management is by intake of frequent small feeds and in severe cases
medications to reduce vomiting.

By

Dr.Beena Jeysingh

Recurrent Pregnancy Loss by Dr. Sireesha Reddy

Recurrent Pregnancy Loss

Spontaneous pregnancy loss is a surprisingly common occurrence. Whereas approximately 15% of all clinically recognized pregnancies result in spontaneous loss, there are many more pregnancies that fail prior to being clinically recognized. Only 30% of all conceptions result in a live birth

Spontaneous pregnancy loss can be physically and emotionally taxing for couples, especially when faced with recurrent losses. Recurrent pregnancy loss (RPL), also referred to as recurrent miscarriage or habitual abortion, is historically defined as 3 consecutive pregnancy losses prior to 20 weeks from the last menstrual period. Based on the incidence of sporadic pregnancy loss, epidemiologic studies have revealed that 1% to 2% of women experience recurrent pregnancy loss.

CAUSES

Genetic Etiology

Approximately 2% to 4% of RPL is associated with a parental balanced structural chromosome rearrangement, most commonly balanced reciprocal or Robertsonian translocations.

Anatomical Abnormalities

Anatomic abnormalities account for 10% to 15% of cases of RPL and are generally thought to cause miscarriage by interrupting the vasculature of the lining of womb, prompting abnormal and inadequate placentation. Thus, those abnormalities that might interrupt the vascular supply of the lining of womb are thought to be potential causes of RPL. These include congenital uterine anomalies, intrauterine adhesions, and uterine fibroids or polyps.

The uterine septum is the congenital uterine anomaly most closely linked to RPL, with as much as a 76% risk of spontaneous pregnancy loss among affected patients. Other M?ªllerian anomalies, including unicornuate, didelphic, and bicornuate uteri have been associated with smaller increases in the risk for RPL.

The presence of intrauterine adhesions, sometimes associated with Asherman syndrome, may significantly impact placentation and result in early pregnancy loss. Intramural fibroids larger than 5 cm, as well as submucosal fibroids of any size, can cause RPL.

Infectious Causes

Certain infections, including Listeria monocytogenes, Toxoplasma gondii, rubella, herpes simplex virus (HSV), measles, cytomegalovirus, and coxsackieviruses, are known or suspected to play a role in sporadic spontaneous pregnancy loss. However, the role of infectious agents in recurrent loss is less clear. The most pertinent risk for RPL secondary to infection is chronic infection in an immunocompromised patient.

Endocrine Causes

Luteal phase defect (LPD), polycystic ovarian syndrome (PCOS), diabetes mellitus, thyroid disease, and hyper prolactinemia are among the endocrinologic disorders implicated in approximately 17% to 20% of RPL.

Poorly controlled type 1 diabetes mellitus is also associated with an increased risk of spontaneous abortion. Evaluation of endocrine disorders should include measurement of the thyroid-stimulating hormone (TSH) level. Other testing that might be indicated based on the patient’s presentation include insulin resistance testing, ovarian reserve testing, serum prolactin in the presence of irregular menses, antithyroid antibody testing. Therapy with insulin-sensitizing agents for the treatment of RPL that occurs in the presence of PCOS has recently gained popularity.

Thrombotic Etiologies

Both inherited and combined inherited/acquired thrombophilias are common, with more than 15% of the white population carrying an inherited thrombophilic mutation.

The potential association between RPL and heritable thrombophilias is based on the theory that impaired placental development and function secondary to venous and/or arterial thrombosis could lead to miscarriage. Evidence that the transfer of nutrition from the maternal blood to the fetal tissues depends on uterine blood flow, and thus may be affected by thrombotic events occurring there, suggests a role for thrombophilias in pregnancy losses regardless of gestational age.

Appropriate therapy for heritable or acquired thrombophilias should be initiated once the disorder is diagnosed. Therapy is disorder specific and includes

(1) Supplemental folic acid for those patients with hyperhomocysteinemia

(2) Prophylactic anticoagulation in cases of isolated defects with no personal or family history of thrombotic complications

(3) Therapeutic anticoagulation in cases of combined thrombophilic defects.

Environmental Etiologies

Because of its propensity to result in feelings of responsibility and guilt, patients are often particularly concerned about the possibility that environmental exposures may have caused their pregnancy losses.

Three particular exposures-smoking, alcohol, and caffeine-have gained particular attention, and merit special consideration given their widespread use and modifiable nature. Although maternal alcoholism (or frequent consumption of intoxicating amounts of alcohol) is consistently associated with higher rates of spontaneous pregnancy loss, a connection with more moderate ingestion remains tenuous. Studies linking moderate alcohol intake with pregnancy loss have shown an increase in risk when more than 3 drinks per week are consumed during the first trimester or more than 5 drinks per week are consumed throughout pregnancy. It seems logical that cigarette smoking could increase the risk of spontaneous abortion based on the ingestion of nicotine, a strong vasoconstrictor that is known to reduce uterine and placental blood flow. However, the link between smoking and pregnancy loss remains controversial, as some, but not all, studies have found an association. Although still not undisputed, there appears some evidence that caffeine, even in amounts as low as 3 to 5 cups of coffee per day, may increase the risk of spontaneous pregnancy loss with a dose-dependent response. The association of caffeine, alcohol, and nicotine intake with recurrent pregnancy loss is even weaker than their associations with sporadic loss.

Prognosis

Although the diagnosis of RPL can be quite devastating, it can be helpful for the physician and patient to keep in mind the relatively high likelihood that the next pregnancy will be successful. A particular individual’s prognosis will depend on both the underlying cause for pregnancy losses and the number of prior losses. Correction of endocrine disorders, APA, and anatomic anomalies enjoy the highest success rates, approximately 60% to 90%. Patients with a cytogenetic basis for loss experience a wide range of success (20% 80%) that depends on the type of abnormality present. Overall, the prognosis for RPL is encouraging. Even with the diagnosis of RPL and as many as 4 to 5 prior losses, a patient is more likely to carry her next pregnancy to term than to have another loss.

Dr. Sireesha Reddy | Know your doctor

Pregnancy Myths By Dr.Beena Jeysingh

Plethora of advices about Do s and Don’ts in pregnancy start flowing in from friends and relatives. Some frequently asked doubts.
Can I travel by flight during first and last trimester?
Yes, surely you can fly in any trimester of pregnancy but airlines limit the weeks of travel as they are worried in last trimester about labour during travel which will cause concern and inconvenience.

Does applying cocoa butter prevents stretch marks?
No, it may cause allergic reactions to sensitive skin.

Can I continue waxing, pedicure, manicure, dyeing hair?
Yes, you can continue enjoying them but a word of caution not to try any new products for fear of allergy and herbal stuff is preferable

Does walking start labour?
No, it makes you feel better but no activity can start labour

Can I drink coffee?
Yes, you can relax with one cup a day, it will not harm your baby

By
Dr.Beena Jeysingh

What is Urinary incontinence Dr. Rubina Shanawaz

Explore insights on urinary incontinence with Dr. Rubina Shanawaz - Motherhood Hospital India.

Do you involuntarily leek urine when you laugh hard or sneeze? To find a solution to this embarrassing situation, read on

Isn??t involuntary leakage of urine a part of having children & growing older??

Though it is caused by repeated childbirths, hormonal changes, there is a solution to this embarrassing predicament which more than 1 in 10 women suffer from but silently endure due to the stigma associated with this condition.

What is the medical term for this condition?

Involuntary leakage of urine during activities such as coughing, sneezing, lifting weights or laughing is referred to as Stress Urinary Incontinence (SUD) where urinary incontinence refers to inability to control urine & stress refers to its precipitating factor.

How common is Urinary incontinence?

Around 1 in 10 women suffer from varying degrees of involuntary leakage of urine. The commonest of these is Stress Urinary Incontinence. Most of the affected women don??t realize there are simple, effective treatment options available.

What causes such involuntary leakage?

The urinary bladder &urethra the tube which brings urine from the bladder to the exterior) are supported by pelvic floor muscles which contract during coughing, sneezing & exercise to prevent leakage. Weakness in these muscles or damage to the bladder neck support can result in leakage

What-is-Urinary-incontinence-by-Dr--Rubina2

This can be a result of:

Pregnancy & vaginal birth(as the same group of muscles support the uterus)
Obesity, Long standing cough/ Constipation
Lifting heavy weights over a long period of time

These can cause an increase in pressure in your abdomen & aggravate the stress on the pelvic floor leading to involuntary leakage.

Genetically Inherited factors:
Women with stress incontinence may also have problems with urinary Urge Incontinence (not able to control urine till reaching the restroom) or incontinence of feces/gas or prolapse (descent of uterus, felt as lump outside vagina). Do not feel embarrassed to mention these problems to your doctor. Pelvic floor problems are more common than depression(1 in 20 women) or hypertension (1 in 3 women)

What are my treatment options? These will depend on the severity of leakage & associated conditions Conservative options include General lifestyle changes:

Aim to drink 1.5 to 2 liters of water per day to pass urine 4 to 6 times/day
Maintaining a healthy lifestyle
High fiber diet to avoid constipation
Cutting out smoking

Pelvic floor exercises (PFC) The importance of these exercises cannot be over emphasized in mainly preventing and treating mild degrees of urinary incontinence. If practiced regularly and for 3 to 6 months at least, upto 75% of women show an improvement in leakage. It is important for all age groups of women right from first pregnancy and childbirth to post menopause. Surgical Options:- These range from daycare procedures like ??mid urethral sling suspension (suspending urethra with tape) to laparoscopic/open Burch colposuspension to bulking agents, depending on the individual patients?? severity of incontinence previous surgeries and other factors. By Dr. Rubina Shanawaz, MBBS, MS(OBG)

What should I expect from my first prenatal checkup?

When you suspect that you could be pregnant or if you have already got a positive pregnancy test at home, you must see your gynaecologist as soon as possible.

At this first visit, a detailed consultation with your doctor would take place. The aim is to understand details of your health, any problems that may be running in the family and any other issues which may put you or your baby at risk. This visit also gives you information regarding the do’s and don’ts during your pregnancy so as to protect your health and the baby’s health.

Be prepared for plenty of questions as this helps the doctor to get a clear idea of your health and your family’s health. If you have had any previous pregnancies, then detailed information of each pregnancy is sought by the doctor.

Examination:

Your examination at this visit would include general checkup including blood pressure, height and weight.

Information:

Now is the time to clear your doubts about your pregnancy and what to expect in the next nine months. There will be a lot of information to take in at this first visit.

Discussions and advice:

healthy eating
exercise
travelling and driving
your job
your lifestyle
sex
investigations that are recommended in pregnancy

Investigations:

If warranted, a test to confirm your pregnancy would be done.

Other than this, various tests would be recommended to ensure that you are in the pink of health. Early identification of any abnormalities and their treatment would reduce complications for you and the baby.

Tests would include

Hemoglobin level
Blood group
Blood sugar levels
Thyroid function
Testing for Rubella immunity
Tests for various infections like Syphilis, HIV, Hepatitis B
Complete Urine Examination
Ultrasound scan to confirm pregnancy location and your due date

Prescription:

You would be given a prescription for folic acid which is essential for preventing neural tube defects in the baby. Other vitamin supplements or a prenatal may be prescribed if needed.

What is Urogynaecology? By Dr. Rubina Shanawaz

Urogynaecology is a sub-specialty which integrates the complex and intricate specialities of Urology and Gynaecology, focusing on urinary problems and pelvic floor disorders in women. These problems arise due to the close anatomy of the urinary bladder and urethra with the uterus and vagina. Hence, these issues in women will have to be dealt with keeping in mind the effect of the urinary and reproductive systems on each other in order to ensure complete relief of symptoms.

When will I need to consult a urogynaecologist ?

Are you not able to laugh freely or cough hard for fear of leakage of urine?
Are you not able to travel as you wish due to very frequent visits to the toilet?
Do you have a dragging pain in your vagina and have difficulty passing urine or stools?
Do you feel your vagina has lost its tone after repeated vaginal childbirths?

If your answer to any of the above questions is a yes, you need to visit a urogynaecologist.

What are the common conditions encountered in this field?

Incontinenceandpelvic floor problemsare remarkably common but many women are reluctant to receive help because of the stigma associated with these conditions. There is no more distressing lesion than urinary incontinence. A constant dribbling of the repulsive urine soaking the clothes which cling wet and cold to the thighs, making the patient offensive to herself and her family and ostracizing her from society.

Although countless women are bothered by a loss of bladder control, bowel symptoms, and pelvic discomfort they are often not aware that these problems have a name, much less how common they really are. Pelvic floor conditions are more common than hypertension, depression, or diabetes. 1 in 3 adult women have hypertension; 1 in 20 adult women have depression;1 in 10 adult women have diabetes; and, more than 1 in 2 adult women suffer from pelvic floor dysfunction. Around 1 in 10 women suffer from varying degrees of involuntary leakage of urine (urinary incontinence). The most common of these is Stress Urinary Incontinence.

Stress Urinary Incontinence (SUI):

Stress Urinary Incontinence (SUI) is the involuntary leakage of urine during activities such as coughing, sneezing, lifting, laughing or exercising.SUI affects at least 10-20% of women, many of whom do not realize that there are simple,effective treatment options available.

Other common types of incontinence include

Over active bladder (OAB)

In this condition, there is increased frequency of urination or urge to get up to pass urine more than once at night. Mixed stress and urge incontinence, overflow incontinence, reflex and functional incontinence.

Prolapse:
This condition occurs when there is a descent of the pelvic organs usually asca result of repeated vaginal childbirths. This usually is a descent of the uterus and cervix along with the urinary bladder and rectum or descent of just urinary bladder or rectum alone.

Fistulas :
These occur when there is an inadvertent creation of a false passage between the urinary tract and an abdominal organ resulting in leakage of urine usually following surgery where there is already an anatomical distortion due to endometriosis/ PID/ previous surgeries/ tumours involving bladder wall.

Diagnostic tests and procedures performed include:

Specialty treatments available include:

Laparoscopic/ Abdominal / vaginal / urethral reconstruction
Behavioural modification
Botulinum toxin injections
Pelvic floor re-education
Pessary(for prolapse and incontinence)
Pubovaginal slings
Sacral nerve stimulation
Apical suspension procedures for prolapse

Dr. Rubina Shanawaz MBBS, MS(OBG)

Hypothyroidism in pregnancy

Thyroid hormones regulate metabolism’the way the body uses energy and affect nearly every organ in the body.Too little thyroid hormone is called hypothyroidism and can cause many of the body’s functions to slow down. Hypothyroidism affects between three and ten percent of adults, with incidence higher in women and the elderly.

Thyroid hormone plays a critical role during pregnancy both in the development of a healthy baby and in maintaining the health of the mother.

What is the thyroid?

The thyroid is a 2-inch-long, butterfly-shaped gland weighing 25-30 g in adults (it is slightly heavier in women). Located in the front of the neck below the larynx, or voice box, it has two lobes, one on either side of the windpipe. The thyroid gland produces, stores, and releases hormones into the bloodstream. The hormones then travel through the body and direct the activity of the body’s cells.

The thyroid gland makes two thyroid hormones, triiodothyronine (T3) and thyroxine (T4). T3 is the active hormone and is made from T4.Thyroid hormones affect metabolism, brain development, breathing, heart and nervous system functions, body temperature, muscle strength, skin dryness, menstrual cycles, weight, and cholesterol levels.

Thyroid hormone production is regulated by thyroid-stimulating hormone (TSH), which is made by the pituitary gland in the brain. When thyroid hormone levels in the blood are low, the pituitary releases more TSH. When thyroid hormone levels are high, the pituitary responds by decreasing TSH production.

Pregnancy

Thyroid hormone is critical to normal development of the baby’s brain and nervous system. During the first trimester, the fetus depends on the mother’s supply of thyroid hormone, which comes through the placenta. At around 12 weeks, the baby’s thyroid begins to function on its own.

The thyroid enlarges slightly in healthy women during pregnancy, but not enough to be detected by a physical exam. A noticeably enlarged thyroid can be a sign of thyroid disease and should be evaluated. Thyroid problems can be difficult to diagnose in pregnancy due to higher levels of thyroid hormone in the blood, increased thyroid size, fatigue, and other symptoms common to both pregnancy and thyroid disorders.

Two pregnancy-related hormones human chorionic gonadotropin (hCG) and estrogen cause increased thyroid hormone levels in the blood. Made by the placenta, hCG is similar to TSH and mildly stimulates the thyroid to produce more thyroid hormone. Increased estrogen produces higher levels of thyroid-binding globulin, also known as thyroxine-binding globulin, a protein that transports thyroid hormone in the blood. Overall, only 0.04% T4 and 0.5% T3 are free and functioning.

These normal hormonal changes can sometimes make thyroid function tests during pregnancy difficult to interpret.

What causes hypothyroidism in pregnancy?

Hypothyroidism in pregnancy is usually caused by Hashimoto’s disease and occurs in three to five out of every 1,000 pregnancies.2 Hashimoto’s disease is a form of chronic inflammation of the thyroid gland.

Hashimoto’s disease is an autoimmune disorder. In Hashimoto’s disease, the immune system attacks the thyroid, causing inflammation and interfering with its ability to produce thyroid hormones.

Hypothyroidism in pregnancy can also result from existing hypothyroidism that is inadequately treated or from prior destruction or removal of the thyroid as a treatment for hyperthyroidism.

How does hypothyroidism affect the mother and baby?

Uncontrolled hypothyroidism during pregnancy can lead to

preeclampsia
anemia’too few red blood cells in the body, which prevents the body from getting enough oxygen
miscarriage
low birth weight
stillbirth
congestive heart failure, rarely

Because thyroid hormones are crucial to fetal brain and nervous system development, uncontrolled hypothyroidism especially during the first trimester can affect the baby’s growth and brain development.

How is hypothyroidism in pregnancy diagnosed?

Hypothyroidism is diagnosed through a careful review of symptoms and measurement of TSH and T4 levels.

Symptoms of hypothyroidism in pregnancy include extreme fatigue, cold intolerance, muscle cramps, constipation, and problems with memory or concentration. High levels of TSH and low levels of free T4 generally indicate hypothyroidism. Because of normal pregnancy-related changes in thyroid function, test results must be interpreted with caution.

The TSH test can also identify subclinical hypothyroidism a mild form of hypothyroidism that has no apparent symptoms. Subclinical hypothyroidism occurs in 2 to 3 percent of pregnancies.2 Test results will show high levels of TSH and normal free T4.

If subclinical hypothyroidism is discovered during pregnancy, treatment is recommended to help ensure a healthy pregnancy.

How is hypothyroidism treated during pregnancy?

Hypothyroidism is treated with synthetic thyroid hormone called thyroxine a medication which is identical to the T4 made by the thyroid. Women with preexisting hypothyroidism will need to increase their pre-pregnancy dose of thyroxine to maintain normal thyroid function. Thyroid function should be checked every 6 to 8 weeks during pregnancy. Synthetic thyroxine is safe and necessary for the well-being of the fetus if the mother has hypothyroidism.

Dietary Supplements

Because the thyroid uses iodine to make thyroid hormone, iodine is an important mineral for a mother during pregnancy. During pregnancy, the baby gets iodine from the mother’s diet. Women need more iodine when they are pregnant about 250mcg a day.

However, people with autoimmune thyroid disease may be sensitive to harmful side effects from iodine. Taking iodine drops or eating foods containing large amounts of iodine’such as seaweed, pulse, or kelp may cause or worsen hyperthyroidism and hypothyroidism.To help ensure coordinated and safe care, people should discuss their use of dietary supplements with their health care provider.

To conclude, women with thyroid problems can have a healthy pregnancy and protect their fetuses health by learning about pregnancy’s effect on the thyroid, keeping current on their thyroid function testing, and taking the required medications.