What to expect when you're expecting (202 page)

The prognosis for both you and your baby will be best if you receive state-of-the-art medical care. You’ll likely have prenatal checkups more frequently than other pregnant patients—possibly every two to three weeks up to the 32nd week, and every week after that. Your care should take a team approach: Your obstetrician should be familiar with sickle cell disease and work closely with a hematologist who’s knowledgeable about sickle cell in pregnancy. Though it’s not certain whetherit’s a beneficial therapy or not, it’s possible that you’ll be given a blood transfusion at least once (usually in early labor or just prior to delivery) or even periodically throughout pregnancy.

As far as childbirth is concerned, you’re as likely as any other mother to have a vaginal delivery. Postpartum, you may be given antibiotics to prevent infection.

If both parents carry a gene for sickle cell anemia, the risk that their baby will inherit a form of the disease is increased. For that reason, your spouse should be tested for the trait early in your pregnancy (if he wasn’t before conception). If he turns out to be a carrier, you may want to see a genetic counselor and possibly undergo amniocentesis to see if your baby is affected.

“I was diagnosed as being hypothyroid when I was a teenager and am still taking thyroid pills. Is it safe to keep taking them while I’m pregnant?”

It’s not only safe to continue taking your medication, it’s vital to both your baby’s well-being and your own. One reason is that women with untreated hypothyroidism (a condition in which the thyroid gland does not produce adequate amounts of the hormone thyroxine) are more likely to miscarry. Another reason is that maternal thyroid hormones are necessary for early fetal brain development; babies who don’t get enough of these hormones in the first trimester can be born with neurological development problems and, possibly, deafness. (After the first trimester, the fetus makes its own thyroid hormones and is protected even if mom’s levels are low.) Low thyroid levels are also linked to maternal depression during pregnancy and postpartum—another compelling reason to continue your treatment.

Your dose, however, may need to be adjusted, since the body requires more thyroid hormone when it’s in baby-making mode. Check with your endocrinologist and your obstetrician to be sure your dose is appropriate now, but keep in mind that your levels will probably be monitored periodically during pregnancy and postpartum to see if your dose needs further adjustment. Be on the lookout, too, for signs that your thyroid level is too low or too high and report these to your practitioner (though many of those probably familiar symptoms of hypothyroidism, such as fatigue, constipation, and dry skin, are so similar to those of pregnancy that it’s often tough to tell which have you down, report them anyway).

Iodine deficiency, which is becoming more common among women of childbearing age in the United States because of reduced iodized salt consumption, can interfere with the production of thyroid hormone, so be sure you are getting adequate amounts of this trace mineral. It’s most commonly found in iodized salt and seafood.

“I have Graves disease. Is this a problem for my pregnancy?”

Graves disease is the most common form of hyperthyroidism, a condition in which the thyroid gland produces excessive amounts of thyroid hormones. Mild cases of hyperthyroidism sometimes improve during pregnancy because the pregnant body requires more thyroid hormone than usual. But moderate to severe hyperthyroidism is a different story. Left untreated, these conditions could lead to serious complications for both you and your baby, including miscarriage and preterm birth, so appropriate treatment is necessary. Happily, when the disease is treated properly during pregnancy, the outcome is likely to be good for both mother and baby.

During pregnancy, the treatment of choice is the antithyroid medication propylthiouracil (PTU) in the lowest effective dose. If a woman is allergic to PTU, methimazole (Tapazole) may be used. If neither drug can be used, then surgery to remove the thyroid gland may be needed, but it should be performed early in the second trimester to avoid the risk of miscarriage (in the first trimester) or preterm birth (in the late second and third trimester). Radioactive iodine is not safe to use during pregnancy, so it won’t be part of your treatment plan.

If you had surgery or radioactive iodine treatment for Graves before you became pregnant, you’ll need to continue your thyroid replacement therapy during pregnancy (which is not only safe but essential for your baby’s development).

Getting the Support You Need

Though it’s true that every expectant woman needs plenty of support, it’s also true that moms-to-be with a chronic condition could use even more. Even if you’ve had your condition for years, you know everything there is to know about it, and you’re an old pro at handling it, you’ll probably find that pregnancy changes the rules (including the ones you had memorized).

Enter, that extra support. No pregnant woman should ever have to go it alone, but as a pregnant woman with a chronic condition, you may want and need even more company. Among the kinds of support you’ll benefit from:

Medical support.
Just like every expectant mom, you’ll need to find (if you don’t already have one) a prenatal practitioner who can consult with you before you conceive (if possible), care for you during your pregnancy, and make that special delivery when the time comes. Unlike with a lot of other expectant moms, that practitioner won’t be the only member of your obstetrical team. You’ll also need to bring the doctor or doctors who care for your chronic condition on board. Your team of doctors will work together to ensure that you and baby are both well taken care of—that your baby’s best interests are represented in the care of your chronic condition, and your best interests are represented in the care of your baby. Communication will be a vital part of that teamwork—so make sure your doctors are all kept in the loop about tests, medications, and other care components.

All your doctors have lots of other patients, so it’s best not to assume that communication’s always taking place. If your chronic-care specialist prescribes a new medication, ask if it’s been okayed by your prenatal practitioner, and vice versa.

Emotional support.
Everyone needs somebody to lean on, but you may find you need plenty of somebodies. Somebody to vent to when you’re feeling resentful over your special diet (Easter eggs instead of chocolate bunnies?). To complain to about being stuck in a revolving door of medical procedures (six tests in three days?). To cry to when you’re feeling particularly anxious. To confide in, share with, unload on. To give you the emotional support every expectant mom craves—since you might crave a little more.

Your partner is a perfect source of this support, of course, especially because he sees what you’re going through and would do anything to help you. Your friends and relatives may lend a sympathetic ear when you need one, too, even if their own pregnancies were more “normal” and they can’t always relate. But you’ll probably find that no one quite gets it like another mom in the same situation—and that no one else gives you as much comfort, empathy, and satisfying support.

Depending on your chronic condition and where you live, you may be able to find a support group geared to expectant moms or new moms who are in the same or a similar boat as you. Or with a little help from your medical team, you might even be able to start one (even if it’s just a group of two—another mom you can have lunch with or chat with on the phone). Or reach out online, either on pregnancy message boards or chat rooms for those who have the same chronic condition. Not only will you find the emotional hand-holding you’re in the market for, but you’ll find practical support, too—advice, treatment tips, strategies, diet ideas, and other resources to help you cope with your important dual mission: caring for your chronic condition and nurturing your baby-to-be.

Physical support.
Again, there isn’t an expectant mom who doesn’t need it at some point in her pregnancy (probably at many points): someone to do the shopping when she’s too tired to move, to scrub the toilet so she doesn’t have to breathe in those fumes, to cook dinner when coming face-to-breast with uncooked chicken makes her heave. But for moms who are juggling the physical demands of pregnancy with the physical challenges of a chronic condition, there’s no such thing as too much help. Get it wherever you can, and don’t be shy about asking for it. Enlist your partner to pick up the slack (and the dry cleaning and groceries) that you don’t have the energy to pick up, but also look to friends, relatives, and, if you can afford it, paid household help.

I
F YOU’VE BEEN DIAGNOSED WITH A
complication or suspect that you’re having one, you’ll find symptoms and treatments in this chapter. If you’ve had a problem-free pregnancy so far, though, this need-to-know chapter is not for you (you don’t need to know any of it). Most women sail through pregnancy and childbirth without any complications. While information is definitely empowering when you need it, reading about all the things that could go wrong when they’re not going wrong is only going to stress you out—and for no good reason. Skip it, and save yourself some unneeded worry.

The following complications, though more common than some pregnancy complications, are still unlikely to be experienced by the average pregnant woman. So read this section only if you’ve been diagnosed with a complication or you’re experiencing symptoms that might indicate a complication. If you are diagnosed with one, use the discussion of the condition in this section as a general overview—so you have an idea of what you’re dealing with—but expect to receive more specific (and possibly different) advice from your practitioner.

What is it?
A miscarriage—known in medical speak as a spontaneous abortion—is the spontaneous expulsion of an embryo or fetus from the uterus before the fetus is able to live on the outside (in other words, the unplanned end of a pregnancy). Such a loss in the first trimester is referred to as an early miscarriage. Eighty percent of miscarriages occur in the first trimester. (A miscarriage that occurs between the end of the first trimester and week 20 is considered a late miscarriage; see
page 540
).

Types of Miscarriage

If you’ve experienced an early pregnancy loss, the sadness you’ll feel is the same no matter the cause or the official medical name. Still, it’s helpful to know about the different types of miscarriage so you’re familiar with the terms your practitioner might be using.

Chemical pregnancy.
A chemical pregnancy occurs when an egg is fertilized but fails to develop successfully or implant fully in the uterus. A woman may miss her period and suspect she is pregnant; she may even have a positive pregnancy test because her body has produced some low—but detectable—levels of the pregnancy hormone hCG, but in a chemical pregnancy, there will be no gestational sac or placenta on ultrasound examination.

Blighted ovum.
A blighted ovum (or anembryonic pregnancy) refers to a fertilized egg that attaches to the wall of the uterus, begins to develop a placenta (which produces hCG), but then fails to develop into an embryo. What is left behind is an empty gestational sac (which can be visualized on an ultrasound).

Missed miscarriage.
A missed miscarriage, which is very rare, is when the embryo or fetus dies but continues to stay in the uterus. Often, the only signs of a missed miscarriage are the loss of all pregnancy symptoms, and less commonly, a brownish discharge. Confirmation of the miscarriage occurs when an ultrasound shows no fetal heartbeat.

Incomplete miscarriage.
An incomplete miscarriage is when some of the tissue from the placenta stays inside the uterus and some is passed through the vagina via bleeding. With an incomplete miscarriage, a woman continues to cramp and bleed (sometimes heavily), her cervix remains dilated, pregnancy tests still come back positive (or blood hCG levels are still detectable and don’t fall as expected), and parts of the pregnancy are still visible on an ultrasound.

Threatened miscarriage.
When there is some vaginal bleeding but the cervix remains closed and the fetal heartbeat (as seen on ultrasound) is still detectable, it is considered a threatened miscarriage. Roughly half of those women with a threatened miscarriage go on to have a perfectly healthy pregnancy.

Early miscarriage is usually related to a chromosomal or other genetic defect in the embryo, but it can also be caused by hormonal and other factors. Most often, the cause can’t be identified.

How common is it?
Miscarriage is one of the most common complications of early pregnancy. It’s hard to know for sure, but researchers have estimated that over 40 percent of conceptions end in miscarriages. And well over half of those occur so early that pregnancy is not even suspected yet—meaning these miscarriages often go unnoticed, passing for a normal or sometimes heavier period. See the box above for more on the different types of early miscarriage.