Mayo Clinic Guide to a Healthy Pregnancy: From Doctors Who Are Parents, Too!

CHAPTER 29. Managing mom’s health concerns

In addition to caring for baby, pregnancy involves making sure mom stays healthy — both during pregnancy and afterward. Mom’s care can be more complicated if she enters pregnancy with existing medical issues. These issues could also increase the risk for problems after baby is born.

PRE-EXISTING HEALTH ISSUES

Women who have a health condition before becoming pregnant may receive different care during their pregnancies, depending on the condition. That’s because a pre-existing health condition can affect the outcome of a pregnancy. The good news is, with a doctor’s help and guidance, most problems can be managed in a way that’s safe for both you and your baby.

Asthma Asthma occurs when the main air passages of the lungs (bronchial tubes) become inflamed and constricted. Production of extra mucus can also further narrow the airways. This can lead to symptoms ranging from minor wheezing to severe difficulty breathing. Although asthma attacks can be life-threatening, asthma is a highly treatable condition. With the right care and medication, problems can be prevented during pregnancy.

Managing asthma If your asthma is well controlled during pregnancy, there’s little chance you and your baby will have an increased risk of health complications. In general, women with mild asthma have few difficulties during pregnancy, while women with severe asthma need to be followed more closely. Talk with your care provider about what steps to take. The medical profession has extensive experience with treating asthma during pregnancy. Most asthma medications can be safely used by pregnant women.

Left uncontrolled, asthma can cause problems for both you and your baby. If you experience low oxygen levels, oxygen to the fetus may decrease, possibly resulting in slowed fetal growth and even fetal brain damage. If you experience an attack, extra oxygen and inhaled medications (nebulizer treatments) are commonly used to increase oxygen levels and help open up lung airways.

To control your signs and symptoms, it’s important to continue taking medications as directed. Don’t stop any medication for asthma unless directed to do so by your care provider. For some pregnant women, asthma worsens in the second and third trimesters. In rare cases, it can worsen during labor.

Cancer Cancer in pregnancy is rare, and there’s no evidence that a woman’s risk of cancer increases during pregnancy. However, cancer can — and does — occur in women of childbearing age, even during pregnancy.

If you’re being treated for cancer or you have a history of it, you may be advised to delay becoming pregnant. Women diagnosed with breast cancer, for example, usually are encouraged to take steps to prevent pregnancy until after treatment is complete. Those who have had breast cancer in the past also may be advised to wait and see if there’s a recurrence before trying to conceive. In some cases, cancer treatment can affect fertility.

If you receive a diagnosis of breast cancer while you’re pregnant, the prognosis generally is the same as that of women with breast cancer who aren’t pregnant. However, it’s important that treatment begins right away. Treatment during pregnancy can improve your odds of survival and give you the opportunity to raise your child.

Managing cancer Your treatment will be based on several factors. These include the type of cancer, how advanced the cancer is (stage), what the best treatment would be and how far along you are in pregnancy. Various treatment options may be considered.

Chemotherapy, a common cancer treatment, is most dangerous during the first trimester of pregnancy. At that time, it has a risk of causing birth defects or miscarriage. In the second and third trimesters, chemotherapy may lower your baby’s birth weight. The degree of risk for causing other problems varies according to the medications used.

Radiation therapy might or might not affect your baby. It depends on the type of exposure, the location of the radiation site — the distance from the baby — the timing of the treatment, and the gestational age of the fetus. Radiation applied to your chest or abdominal area is more likely to affect the fetus than radiation applied to your head or a lower leg. The most vulnerable period for a fetus is between eight and 15 weeks of gestation. Depending on your circumstances, it may be best to postpone treatment, or delay it until the baby can be safely delivered.

Surgical procedures are often possible while you’re pregnant. If surgery is needed for cancer and it doesn’t involve the uterus, it’s probably best to do the surgery during the pregnancy rather than waiting until your baby is born. However, if surgery causes inflammation or infection in the abdomen, it increases the risk of preterm labor.

It’s not clear whether pregnancy directly affects the progression of cancer. However, in many cases it can complicate treatment or reduce treatment options. If you’ll be undergoing cancer treatment after delivery, talk with your health care team about measures to preserve your ability to have additional children, if that’s important to you. Techniques are available that help allow for future pregnancies.

Depression Depression is a serious mental health condition. It can interfere with the ability to eat, sleep, work, interact with others, care for yourself and others, and enjoy life. It may be a one-time problem, triggered by a stressful event such as the death of a loved one, or it may be a chronic condition. The illness often runs in families, which indicates that genetics may play a role. Experts think this genetic vulnerability, along with environmental factors such as stress, may trigger an imbalance in brain chemicals and result in depression.

Pregnancy can affect depression. During pregnancy, women go through many changes. For a woman with depression, pregnancy can trigger a wide range of emotions that can make coping more difficult. Changes in fluid volume during pregnancy and labor can also alter the effectiveness of antidepressant medications. In addition, women with histories of major depression can have repeated episodes of it during and after pregnancy. This is especially true if they decide to stop using their antidepressant medications during pregnancy. The good news is, with proper medical care, most women with depression have normal pregnancies.

Managing depression Treatment of depression is very important during pregnancy. If you don’t take proper care of depression during pregnancy, you may put your health — and your baby’s health — at risk. Although pregnancy doesn’t make depression worse, it often triggers a range of emotions that can make it more difficult to cope with depression. Untreated depression during pregnancy also may affect your baby’s well-being. Some studies associate signs and symptoms of maternal depression with preterm birth, lower birth weight and intrauterine growth restriction.

Depending on the medication you’re taking, your doctor may suggest switching to a different drug. That’s because some antidepressants are thought to be safer during pregnancy than others. Overall, the risk of birth defects and other problems for babies of mothers who take antidepressants during pregnancy is very low. Still, few medications have been proved safe without question during pregnancy and some types of antidepressants have been associated with health problems in babies.

During the last trimester of pregnancy, some doctors suggest tapering antidepressant doses until after birth to minimize newborn withdrawal symptoms, though it’s unclear whether this method can reduce harmful effects. Such an approach needs to be closely monitored. It may be unsafe for new mothers as they enter the postpartum period, in which risk of mood and anxiety problems is typically increased.

The decision to continue or change your antidepressant medication is up to you and your care provider. Follow your care provider’s advice on how to best manage depression during pregnancy.

Diabetes Diabetes affects the regulation of blood sugar (glucose), the body’s main source of energy. Foods you eat are broken down to glucose, which is stored in the liver and released into the bloodstream. Insulin, a hormone secreted by the pancreas, helps glucose enter your cells, especially muscle cells. In people with diabetes, this system doesn’t function normally.

There are two main types of diabetes, type 1 and type 2:

 Type 1. With this type, the insulin-producing cells in the pancreas are destroyed. The individual needs injections of insulin every day to survive.

 Type 2. With type 2, there’s limited insulin activity, mostly because the body has developed a resistance to insulin. When cells become resistant, they don’t take in sufficient insulin from the bloodstream. As a result, sugar stays in the bloodstream and accumulates there.

During pregnancy, some women develop a temporary condition known as gestational diabetes. It resembles type 2 diabetes, but usually goes away after the pregnancy ends. Women who develop gestational diabetes are at increased risk of diabetes later in life.

Managing diabetes There is no cure for diabetes. But blood sugar can be controlled with proper medication and lifestyle management, which includes eating right, maintaining a healthy weight and getting plenty of exercise. If you have diabetes and your blood sugar levels are kept under control before conception and during pregnancy, you’re likely to have a healthy pregnancy and give birth to a healthy baby. If your diabetes isn’t under control, you’re at higher risk of having a baby with a birth defect of the brain or spinal cord, heart or kidneys. The risk of miscarriage and stillbirth also increases significantly.

Poor control of your diabetes also puts you at increased risk of having a baby that weighs 10 pounds or more. That’s because when blood sugar becomes too high, the baby receives higher-than-normal levels of glucose and produces extra insulin to use the sugar and to store it as fat. The fat tends to accumulate and produce an infant that’s larger than normal — a medical condition known as macrosomia. Monitoring your baby’s growth during pregnancy can give advanced warning if the baby appears to be adversely affected by diabetes.

Insulin requirements tend to increase for pregnant women with diabetes because hormones from the placenta impair the normal response to insulin. In fact, some women may need two to three times their usual dose of insulin to control their blood sugar. Most women taking insulin before pregnancy will require multiple daily doses of insulin or an insulin pump. Frequent adjustments of insulin dosage will likely be needed throughout the pregnancy. Eating properly throughout pregnancy is an important part of diabetes care.

It’s important to work closely with your doctor to protect your health and the health of your baby.

Epilepsy Epilepsy is a seizure disorder that results from abnormal electrical activity in the brain. These abnormal signals may cause temporary changes in sensation, behavior, movement or consciousness. In some cases, seizures may have a known cause, such as a disease or an accident that affects the brain. In others, they may occur for no apparent reason.

Anti-epileptic drugs can eliminate or reduce the amount and intensity of seizures in the majority of people with epilepsy. The great majority of women with epilepsy who become pregnant will have successful pregnancies.

Managing epilepsy Even though some medications taken during pregnancy can affect the fetus, it’s important to continue treatment to control seizures. Seizures can injure the baby. Before you conceive, talk with your doctor about your treatment to ensure you receive the right medications to maximize safety for you and your baby.

Most women continue taking the same medications they used before becoming pregnant, because changing medications increases the risk of new seizures. Some anti-epileptic drugs affect the way the body uses folic acid, an important source of protection against birth defects. Therefore, your doctor may ask you to take a higher dose of folic acid with your medications.

Because your blood volume increases during pregnancy and your kidneys can remove medications faster, you may need to monitor blood levels more frequently and increase your medication dosage as your pregnancy progresses. Be sure to follow doctor’s orders.

Heart disease Heart disease can include a range of conditions, from coronary artery disease to congenital heart problems to valve disease. Although some conditions are more serious than others, all can affect how blood is moved around the body.

For the most part, women with heart disease who are pregnant can be monitored and managed in a manner so that mother and baby will do well. There are exceptions, however. So it’s always best to consult your doctor about the specifics of your condition before becoming pregnant and to work with the proper specialist during your pregnancy to manage your condition.

Managing heart disease Pregnancy can put additional stress on the heart and circulatory system. In fact, the workload on your heart increases as early as the first trimester of pregnancy. You’ll be closely monitored during pregnancy for possible worsening of your underlying condition. This may mean more frequent tests and exams. In addition, some of the normal changes accompanying pregnancy may be of special concern for you. Anemia, for example, poses greater risks for people with some types of heart conditions. Fluid retention needs to be monitored and managed carefully. Though common during pregnancy, it could also indicate worsening of the underlying heart problem.

During labor, you may require special evaluation, including cardiac monitoring. Pain relief medications are used, in part, to decrease stress on the mother’s circulation. Epidural or spinal anesthesia is commonly used. In addition, forceps or vacuum extractors are more likely to be used during a vaginal birth to minimize prolonged pushing, which also puts stress on the mother’s heart. Labor might even be avoided by having a C-section, but vaginal delivery is often preferred.

Hepatitis B Hepatitis B is a serious liver infection caused by the hepatitis B virus (HBV). The virus is transmitted by way of the blood and body fluids of someone who’s infected — similar to the way the human immunodeficiency virus (HIV) that causes AIDS is transmitted. But HBV is much more infectious than HIV.

Women with hepatitis B can pass the infection to their babies during childbirth. Newborn babies can also become infected with the virus from contact with an HBV-positive mother. In the United States, pregnant women who receive prenatal care are routinely screened for HBV.

Most people infected with HBV as adults recover fully. Infants and children are much more likely to develop a chronic infection.

Managing hepatitis B The greatest risk of hepatitis infection during pregnancy is that of infecting the baby with HBV. The risk of pregnancy complications and infection of your newborn appear to be related to the activity of your HBV disease. If your disease activity is high, you may be given medication to reduce the risk of complications to you and your baby. Your newborn can be given antibodies against the virus after birth.

Vaccination against HBV is a common, and in some states a mandatory, part of the series of immunizations given to children during infancy. The hepatitis B vaccination, which is administered as a series of shots, may be given to newborns as well as to premature infants. For optimal protection, an individual needs all of the shots in the series.

High blood pressure Blood pressure is the force with which flowing blood pushes against the walls of the arteries. When the pressure becomes too high, the condition is called high blood pressure (hypertension).

High blood pressure that develops before pregnancy can occur for various reasons. Genetic factors, diet and lifestyle are thought to play a role in the condition, but other chronic conditions also can account for its development.

Most women with high blood pressure can have healthy pregnancies. However, the condition does require close observation and careful management throughout the pregnancy. High blood pressure can worsen significantly, leading to problems for both the mother and the baby.

Managing high blood pressure If you have high blood pressure, it’s best to see your doctor before trying to become pregnant so that he or she can see if your condition is under control and review your medications. Some medications used to lower blood pressure are safe to take during pregnancy, but others, such as angiotensin-converting enzyme (ACE) inhibitors, can harm your baby. For that reason, your doctor may want to change the type or dosage of medications you take during pregnancy. Treatment is important during pregnancy.

Blood pressure usually changes as the body adapts to pregnancy. High blood pressure that existed before pregnancy can worsen during pregnancy, especially in the last trimester. In some cases, pregnancy can reveal previously unrecognized hypertension.

To monitor baby’s health and development, frequent visits and repeated ultrasounds will usually be done to assess fetal growth and monitor the baby’s well-being. In most cases, women with high blood pressure will need to deliver by their due dates to avoid complications.

Immune thrombocytopenic purpura Immune thrombocytopenic purpura (ITP) is a disease that results in an abnormally low number of platelets in the blood. Platelets are a type of blood cell essential to clotting, which stops bleeding from cuts or bruises. If the level of platelets becomes too low, bleeding can occur even after a minor injury or even through normal wear and tear. With ITP, the body destroys platelets due to a malfunction of the immune system.

Pregnancy itself doesn’t affect the course or severity of ITP. But the antibodies that can destroy platelets occasionally cross the placenta and can decrease the platelet count in your baby. Unfortunately, the baby’s platelet count can’t be predicted by your platelet count or even by the length of time you’ve had a low platelet level. The baby’s platelet count may be low even if yours is fine.

Managing ITP Because the risk of bleeding in the baby is very low, cesarean birth isn’t routine for this condition, unless you’ve had a pervious birth in which your child experienced complications related to low platelet counts. Efforts should be made to provide the baby with appropriate treatment at delivery with a team approach. If your platelet count is very low, medications may be given to try and raise your platelet count before your baby is born.

Inflammatory bowel disease Inflammatory bowel disease (IBD) is a chronic inflammation of the digestive tract. Ulcerative colitis and Crohn’s disease are the two most common forms of IBD. Both can cause repeated episodes of fever, diarrhea, rectal bleeding and abdominal pain. The exact cause of IBD is unknown. Heredity, environment and the immune system may play a role.

Although there’s no cure for ulcerative colitis or Crohn’s disease, medications and other treatments are available. IBD conditions can arise during pregnancy. But the diagnosis is more likely to be made before pregnancy.

Women whose IBD has affected their weight or nutritional condition may have difficulty getting pregnant or having a healthy pregnancy. Women with Crohn’s disease may be at increased risk of giving birth prematurely. However, if you have your disease under control before and during your pregnancy, you’re much more likely to have a healthy pregnancy and full-term delivery.

Managing IBD If you have IBD, pregnancy shouldn’t significantly affect your treatment. Most of the medications commonly used to treat IBD don’t harm the fetus. Improving your condition is likely to benefit both mother and baby, outweighing potential concern for a drug’s effect on the fetus.

However, some immunosuppressive medications used to treat certain cases of IBD might cause harm to the fetus. If you take one of these medications, discuss it with your doctor. Also discuss the use of anti-diarrheal medications, especially during the first trimester of pregnancy.

If you have Crohn’s disease and it was inactive before pregnancy, it’s likely to stay inactive while you’re pregnant. When it’s active, it’s likely to remain active or even worsen during pregnancy. With ulcerative colitis, about one-third of the women who become pregnant while the disease is in remission will experience a flare-up. If the colitis is active when you become pregnant, it’s likely to remain active or possibly worsen.

If diagnostic testing becomes necessary to deal with IBD during pregnancy, it’s likely that the procedures can be done safely. Extra precautions may be taken to minimize risk to the fetus.

Lupus Lupus can cause chronic inflammation of many organ systems. It can affect your skin, joints, kidneys, blood cells, heart and lungs. The disease commonly results in a rash and arthritis of varying severity. Several types of lupus exist. The most common type is systemic lupus erythematosus (SLE).

Lupus sometimes shows up for the first time during pregnancy or shortly after giving birth. Women who already have lupus may note an increase in symptoms during pregnancy — even if the condition hasn’t been active. If lupus is active at the start of pregnancy, there’s a much higher risk of it worsening during pregnancy.

Managing lupus If you have active lupus during your pregnancy, you’re at risk of problems, including the development of high blood pressure and preeclampsia. You may need to adjust the use of certain medications that could harm to your baby. Work closely with your doctor before and during your pregnancy to take proper care of your health and to protect that of your baby. Your pregnancy care team should be led by a specialist.

Phenylketonuria This is an inherited disease that affects how the body processes phenylalanine, one of the amino acid building blocks of proteins. Phenylalanine is found in milk, cheeses, eggs, meat, fish and other high-protein foods. If the level of phenylalanine in the bloodstream becomes too high, it can cause brain injury. A special diet low in phenylalanine can prevent or minimize brain damage in those with phenylketonuria (PKU).

Managing PKU If you have PKU and it’s been kept under control both before and during pregnancy, you can have a healthy baby. If your blood levels of phenylalanine aren’t well regulated, you could give birth to an infant with mild to severe mental retardation. Affected infants may also be born with an abnormally small head and congenital heart disease.

If you have a family history of the disease or were treated for PKU as a child, tell your doctor. Ideally, you’ll want to have your blood levels of phenylalanine measured before trying to conceive. If necessary, you can begin a special diet to help keep levels low and prevent birth defects.

During pregnancy, the dietary restrictions needed to keep down the levels of phenylalanine can be hard to manage. Your diet may be reviewed and adjusted if phenylalanine levels are too high.

Rheumatoid arthritis Rheumatoid arthritis causes chronic inflammation of the joints, most often the wrists, hands, feet and ankles. Problems can vary from occasional flares of pain to serious joint damage. The disease is most common in women between the ages of 20 and 50. Currently, there is no cure. The condition can be managed with proper medical treatment and self-care.

Managing rheumatoid arthritis If you have rheumatoid arthritis, it’s unlikely to affect your pregnancy. But the medications you may use to treat the condition may need to be adjusted. For example, aspirin and other anti-inflammatory medications generally aren’t recommended during pregnancy.

During your pregnancy you may experience some improvement with your rheumatoid arthritis. This may result from a change in your immune system while you’re carrying a child. However, almost all women who experience improvement during pregnancy will experience a relapse following delivery.

Sexually transmitted infections If sexually transmitted infections (STIs) aren’t diagnosed and treated, they can affect the health of a pregnant woman and her baby. Unfortunately, many STIs have mild signs and symptoms that may go unnoticed, and a woman may be unaware that she’s infected.

Chlamydia It is the most common bacterial STI in the United States. The majority of women who contract it have no signs or symptoms. If you have untreated chlamydia, you may face an increased risk of miscarriage and premature rupturing of the membranes surrounding your baby in the uterus. It’s also possible for you to spread chlamydia from your vaginal canal to your child during delivery. This can cause pneumonia or an eye infection in the child, which may lead to blindness.

Gonorrhea This highly contagious STI also has few recognizable signs and symptoms. Sometimes, there’s a slight increase in vaginal discharge. Gonorrhea, like chlamydia, can increase your risk of miscarriage and premature rupture of the membranes if the disease is left untreated. In addition, you can infect your infant during vaginal delivery. A baby who becomes infected can develop a severe eye infection. Because gonorrhea and chlamydia can go undetected in mothers and because these infections pose a serious risk to a newborn’s eyes, all newborns are given medication at birth to prevent development of eye infection.

Genital warts There are many kinds of genital warts, some invisible and some hard to miss. Genital warts can appear one month to several years after sexual contact with an infected person. They appear in the moist areas of the genitals and may look like small, flesh-colored bumps.

If you have genital warts, they can enlarge during pregnancy, causing increased itching and sometimes spotting. In severe cases, they may cause difficulty urinating, profuse bleeding or even obstruct the birth canal. Your doctor may remove these warts using one of several procedures, including medication or surgery. Most often, though, the warts don’t cause significant problems and it’s not necessary to have them removed. In extremely rare cases, an infant born to an infected mother may develop warts in the throat and voice box, which may require surgery to prevent obstruction of the airway.

The presence of warts isn’t a reason for a cesarean delivery, unless the warts are extremely large and could interfere with vaginal delivery of the infant.

Herpes Herpes is a contagious disease caused by the herpes simplex virus. The virus comes in two forms: herpes simplex virus type 1 (HSV-1) and type 2 (HSV-2). Type 1 causes cold sores around the mouth or nose, but it may also involve the genital area. Type 2 causes painful genital, and sometimes oral, blisters that rupture and become sores. Both types are passed on through direct contact with an infected person.

The initial (primary) infection may be obvious, with serious signs and symptoms lasting a week or more. After the initial outbreak, the virus remains dormant in infected areas, periodically reactivating. These episodes last about 10 days. They may start with tingling, itching or pain before sores become visible.

Antiviral drugs can help reduce the number of reactivations or shorten their duration. Sometimes, they’re used to help avoid recurrences in late pregnancy. If you have genital herpes, your baby potentially can become infected with the virus during delivery through the birth canal. The most serious risk for a newborn exists when the mother has her first (primary) herpes infection just before labor. A recurring episode of herpes at childbirth poses much less risk to the baby.

Preventing newborn herpes infection can be difficult. In the majority of newborn infections, the mother has no signs or symptoms suggesting herpes during labor or birth. Still, prevention is important because herpes infection can be life-threatening for a newborn. In addition, newborns who contract herpes can develop serious infections that damage the eyes, internal organs or brain, despite treatment with antiviral drugs.

If you’ve had genital herpes, your baby is unlikely to have a serious infection acquired at birth. Women who’ve had the disease develop antibodies that they pass to their babies and provide some temporary protection. Nevertheless, there’s a small risk. If sores are present, cesarean birth might lessen this very small risk of newborn infection and is the current standard of care in the United States.

HIV and AIDS Acquired immunodeficiency syndrome (AIDS) is a chronic, life-threatening condition caused by the human immunodeficiency virus (HIV). HIV is most commonly spread by sexual contact with an infected partner. It can also spread through infected blood and shared needles or syringes contaminated with the virus. Untreated women with HIV can pass the infection to their babies during pregnancy and delivery or through their breast milk.

Testing for HIV is now a routine part of prenatal care. If you feel you may have become infected during your pregnancy, consider having your HIV status tested again. Although a positive diagnosis can be devastating, treatments are available that can greatly improve a mother’s health and reduce the risk of passing on the infection to her baby. Drug treatments begun before or during pregnancy can benefit both mom and baby.

If you know you have HIV or AIDS, tell your doctor. A doctor who knows about your condition can monitor your health and help you to avoid procedures that could increase your baby’s exposure to your blood. The medical treatment you receive can greatly influence the risk of transmission of the infection to your baby. Your doctor can also make sure that your baby is promptly tested and treated for infection after birth. Early testing can make it possible for infants diagnosed with HIV to be treated with HIV-fighting drugs, which have been shown to slow the progression of the disease and improve survival rates.

Sickle cell disease Sickle cell disease is an inherited blood disease that often results in anemia, pain, frequent infections and damage to vital organs. It’s caused by a defective form of hemoglobin, a substance that enables red blood cells to carry oxygen from the lungs to parts of the body. In people with the disease, red blood cells change from healthy, round cells to crescent-shaped cells. These unusual cells can block blood flow through smaller blood vessels, causing pain.

Sickle cell disease typically is diagnosed in infancy with a screening test. In the United States, it most commonly affects blacks, Hispanics and American Indians. Women with sickle cell disease have a greater risk of developing serious pregnancy-related complications, such as pregnancy-induced high blood pressure. In addition, they have an increased risk of preterm labor and of delivering a low birth weight baby. During pregnancy, infections can occur more frequently and lead to painful sickle cell crises. These infections may include urinary tract infection, pneumonia and uterine infection.

Managing sickle cell disease Women with sickle cell disease may need to have a team of medical specialists involved in their prenatal care. They often are closely monitored for complications of the disease, such as seizures, congestive heart failure and severe anemia. Anemia is likely to be most severe during the final two months of pregnancy, and may require blood transfusions. If a mother-to-be has a sickle cell crisis or another complication, the baby’s health will likely be closely monitored.

Thyroid disease The thyroid is a butterfly-shaped gland located at the base of the neck, just below the Adam’s apple. The hormones it produces regulate your metabolism, which is related to everything from your heart rate to how quickly you burn calories. Problems can occur from too much or too little hormone production.

Hyperthyroidism When your thyroid gland produces too much of the hormone thyroxine, it can cause overactive thyroid disease known as hyperthyroidism. This can prompt your body’s metabolism to speed up, and it may lead to sudden weight loss, a rapid or irregular heartbeat, and nervousness or irritability.

Most pregnancies proceed normally in women with hyperthyroidism, but the disease can be difficult to control. In addition, some medications commonly used to treat hyperthyroidism may need to be avoided or readjusted during pregnancy or while breast-feeding. For example, radioactive iodine medications shouldn’t be used during pregnancy.

If you have hyperthyroidism or a history of the condition, review your medications with your doctor. He or she can monitor it throughout your pregnancy. Management of your condition is important for the health of both you and your baby. If you develop a fever or feel ill, contact your care provider immediately. Follow his or her instructions carefully and report signs and symptoms that return or worsen.

During pregnancy, hyperthyroidism sometimes worsens during the first trimester. It can improve during the second half of pregnancy. In some women, hyperthyroidism develops after birth (postpartum thyroiditis). It can cause excessive fatigue, nervousness and increased sensitivity to heat. Sometimes it’s mistaken for other problems, such as postpartum depression. Report such symptoms to your care provider.

Hypothyroidism Hypothyroidism is the opposite of hyperthyroidism; it occurs when the thyroid doesn’t produce enough hormones. When the thyroid is underactive, you may feel tired and sluggish. Left untreated, signs and symptoms can include increased sensitivity to cold, constipation, pale and dry skin, a puffy face, weight gain, a hoarse voice and depression. The signs and symptoms of hypothyroidism can easily be mistaken for pregnancy fatigue.

Women with hypothyroidism may have difficulty becoming pregnant. If they do become pregnant and their hypothyroidism is left untreated or undertreated, they have an increased risk of miscarriage, preeclampsia (pregnancy-induced high blood pressure), problems with the placenta and slowed growth for their babies. Proper thyroid hormone replacement is required for normal fetal growth and development.

If you have hypothyroidism, your dosage of replacement hormone will likely increase over the course of the pregnancy. Your care provider will likely check your thyroid levels throughout pregnancy, but it never hurts to remind your provider that you need to have the tests done.

Uterine fibroids Uterine fibroids are noncancerous tumors of the uterus that are common in women in their childbearing years. They can appear on the inside or outside lining of the uterus, or within its muscular wall. They usually develop from a single smooth muscle cell that continues to grow. Some can be as small as a pea. Others can grow as large as a grapefruit, or even bigger. Most cause no symptoms and are discovered only during a routine pelvic exam or during a prenatal ultrasound.

When symptoms do occur, they may include abnormally heavy or prolonged menstrual bleeding, abdominal or lower back pain, pain during sexual intercourse, difficult or more frequent urination, and pelvic pressure. Medication or surgery may be recommended prior to conception to shrink or remove fibroids that cause discomfort or could result in complications, including infertility.

Fibroids can sometimes increase the risk of miscarriage during the first and second trimesters or increase the likelihood of preterm labor. In some cases, they can also obstruct the birth canal, complicating labor and delivery. Rarely, uterine fibroids can interfere with the ability of a fertilized egg to implant on the uterine lining, making it difficult to become pregnant.

Managing uterine fibroids Fibroids can enlarge during pregnancy, possibly because of increased levels of estrogen in the body. Occasionally, larger fibroids bleed or lose their blood supply, resulting in pelvic or abdominal pain. If you experience pelvic or abdominal pain or abnormal bleeding, contact your doctor immediately. If the fibroids are painful, they can be treated with medications. During pregnancy, surgery for fibroids is generally avoided because it can lead to preterm delivery and extensive blood loss.

The vast majority of pregnancies involving uterine fibroids take place with little or no problems. Depending on the size and location of the fibroids, the fetus may be positioned abnormally at the time of delivery, possibly requiring the need for cesarean delivery. Fibroid removal generally is avoided during cesarean delivery because of bleeding risk (hemorrhage).

POSTPARTUM CONCERNS

After your child is born, you enter the postpartum period. It’s a transition time for you, both physically and emotionally. This section explains problems that can develop during the postpartum weeks.

Blood clots A blood clot inside an internal vein, called deep vein thrombosis (DVT), is one of the most serious potential complications following birth. Most often the clot develops in a leg and, if left untreated, a portion of the clot can break off and travel to your heart and lungs. There, it can obstruct blood flow, causing chest pain, shortness of breath and, in rare cases, even death.

The hormonal changes of pregnancy increase a new mom’s risk of developing DVT during or after pregnancy. That said, the condition is rare. However, your risk of developing DVT is about three to five times greater after a cesarean birth than after a vaginal birth. You’re at increased risk of developing DVT if you smoke, have a body mass index (BMI) of 30 or greater, are over age 35 or can’t walk after surgery as much as recommended. Studies indicate that many, if not most, people with DVT have a genetic predisposition for DVT formation.

Clotting often occurs in the legs but can also occur in the pelvic veins. Signs and symptoms of DVT include tenderness, pain or swelling in your leg, particularly around your calf. DVT typically appears within the first few days after delivery and is often detected in the hospital. It can, however, occur up to several weeks after you’ve been discharged. Although less common, blood clots may also develop during pregnancy.

Treatment If you have a blood clot, you’ll likely be given anticoagulant (“blood-thinning”) medication to help prevent the development of any more clots. Initially, this may require that you be admitted to a hospital to be monitored. Depending on whether DVT occurs before or after delivery, you may have to give yourself anticoagulant injections or take anticoagulant medications orally as a tablet.

Excessive bleeding Serious bleeding (hemorrhaging) after birth is not normal. It occurs in a small percentage of all births, and generally takes place during childbirth or within 24 hours of giving birth. Less commonly, bleeding can occur up to six weeks after childbirth.

A number of problems can cause serious bleeding after birth. Blood loss is most often caused by one of the following:

 Uterine atony. After you’ve given birth, your uterus must contract to control bleeding from where the placenta was attached. The reason your nurse periodically massages your abdomen after delivery is to encourage your uterus to contract. With uterine atony, the uterine muscle doesn’t contract well. The condition is slightly more likely to occur when the uterus has been stretched by a large baby or twins, if you’ve already had several babies, or if labor has been lengthy. To reduce the chance of atony, you may be given the medication oxytocin (Pitocin) after the baby is delivered. Other medications may also be given if atony occurs

 Retained placenta. If your placenta doesn’t expel on its own within 30 minutes after your baby is born, you can experience excessive bleeding. Even when the placenta does expel on its own, your doctor carefully examines it to make sure it’s intact. If tissue is missing, there’s a risk of bleeding.

 Tearing (lacerations). If your vagina or cervix tears during birth, excessive bleeding can result. Tearing might be caused by a large baby, a forceps- or vacuum-assisted birth, a baby that came through the birth canal too rapidly or an episiotomy that tears.

Other, less common, causes of postpartum bleeding include:

 Abnormal placental attachment. Very rarely, the placenta attaches to the uterine wall more deeply than it should. When this happens, the placenta doesn’t readily detach after birth. These abnormal placental attachments can cause severe bleeding.

 Uterine inversion. The uterus turns inside out after the baby is born and the placenta is removed. This is somewhat more likely when there’s abnormal attachment of the placenta.

 Uterine rupture. Rarely, the uterus can tear during pregnancy or labor. If this happens, the mother loses blood, and the baby’s oxygen supply is decreased.

Your risk of bleeding may be higher if you’ve had bleeding problems with past births. Your risk is also increased if you have a complication such as placenta previa, in which the placenta is located low in the uterus and may partly or completely cover the opening of the cervix.

In addition to blood loss, signs and symptoms of heavy postpartum bleeding include pale skin, chills, dizziness or fainting, clammy hands, nausea and vomiting and a racing heart. Excessive blood loss requires immediate action.

Treatment Your medical team can take several steps to respond to excessive bleeding, including massaging your uterus. They may also give you intravenous (IV) fluids and oxytocin. Oxytocin is a hormone that stimulates uterine contractions. Other treatments may include additional medications to stimulate contractions, surgical intervention and blood transfusions. Treatment depends on the cause and severity of the problem. Even in the most severe cases, hysterectomy may not be necessary.

Infection Infections can occasionally occur after delivery. The most common are:

Endometritis Endometritis is an inflammation and infection of the lining of the uterus (endometrium). The bacteria that cause the infection initially grow in the lining of the uterus but may extend beyond the lining of the uterus. The infection sometimes can spread to the ovarian and pelvic blood vessels.

Endometritis is one of the most common infections that occurs after childbirth. It can develop after a vaginal or cesarean birth, but it’s far more common after a cesarean delivery. A long labor or a long length of time between when your water breaks and delivery occurs can contribute to endometritis. Other factors that increase risk include smoking, diabetes and obesity.

Signs and symptoms can vary depending on the severity of the infection. They may include fever, an enlarged and tender uterus, abnormal or foul-smelling vaginal discharge, general abdominal discomfort, chills and a headache.

To diagnose the condition, your care provider may press on your lower abdomen and uterus to check for tenderness. If an infection is suspected, a pelvic exam, blood tests and urine tests may be done.

Treatment. Women with endometritis are commonly hospitalized and given intravenous (IV) antibiotics. Fluids are given either orally or intravenously. In mild cases, treatment may occur on an outpatient basis.

Antibiotics clear up most cases of endometritis. However, if the infection goes untreated, it can lead to other serious problems, including infertility and chronic pelvic pain. Contact your care provider if you develop signs or symptoms of endometritis.

Mastitis Mastitis is an infection that can occur when bacteria enter the breast while breast-feeding. Nipples may become cracked or sore from breast-feeding. This can happen if your baby isn’t well-positioned when feeding or latches on to the nipple instead of putting his or her lips and gums around the area surrounding the nipple (areola). Sometimes, bacteria can enter the breast without any signs of nipple problems.

Mastitis can affect one or both breasts. When a breast becomes infected, you’ll develop a fever and feel sick, like you have the flu. The breast may feel sore, hard and hot. It may swell and redden. Typically, the diagnosis is based on personal history and a physical examination with no further testing required. An ultrasound may be performed if your doctor suspects a breast abscess.

Treatment. Antibiotics are generally prescribed for mastitis. Because mastitis can be painful, you may be tempted to stop breast-feeding. It’s best to keep breast-feeding or breast pumping because doing so will help empty your breast and relieve pressure. The infection won’t spread to the milk your baby consumes, and the antibiotics you take won’t harm your baby, although you may notice a change in the color of your baby’s bowel movements.

Applying warm compresses to the infected breast several times a day can help. Acetaminophen or ibuprofen may be used to relieve fever and pain. Dry your breasts between feedings and compresses so that they can heal properly.

Post-cesarean wound infection Most cesarean incisions heal with no problem at all, but in some cases an incision can become infected. Wound infection rates following cesarean births vary. Your chances of developing wound infection after a cesarean birth are higher if you abuse alcohol or drugs or smoke, or if you have diabetes or are obese. Fat tissue tends to heal poorly.

If the skin on the sides of your incision becomes painful, red and swollen, it may be infected, especially if the wound is draining in any way. Wound infection can also cause fever. If you suspect your incision has become infected, contact your care provider.

Treatment. If your care provider confirms that you have an infection, he or she may need to open and drain the incision to release trapped bacteria. This is generally done as an office procedure.

Urinary tract infection After giving birth, you may not be able to completely empty your bladder. The remaining urine provides an ideal breeding ground for bacteria, which can cause an infection of your bladder, kidneys or urethra — the tube that transports urine from the bladder during urination. Urinary tract infections (UTIs) can occur after either vaginal or cesarean births. They’re a common complication during pregnancy and after birth. You’re at increased risk of developing a UTI if you have diabetes or if you keep a catheter in longer than normal after surgery.

With a urinary tract infection, you may have a frequent, almost panicky urge to urinate, pain while urinating, a fever and tenderness over the area of the bladder. If you experience any of these signs and symptoms, contact your care provider.

Treatment. Treating a urinary tract infection generally involves taking antibiotics, drinking plenty of fluids, emptying your bladder regularly and taking medication to relieve the fever.

Postpartum depression The birth of a baby can bring on many powerful emotions, including excitement, joy and even fear. But there’s another emotion many new moms experience: depression.

Within days of delivery, many new mothers experience a mild depression that’s often called the baby blues. The baby blues may last for a few hours or up to two weeks after delivery. However, some new mothers experience a more severe form of the baby blues called postpartum depression, which can occur from weeks to months after giving birth. Left untreated, postpartum depression can last for a year or longer.

There’s no clear cause of postpartum depression. A combination of body, mind and social interactions likely plays a role. The levels of the hormones estrogen and progesterone drop dramatically immediately after childbirth. In addition, changes occur in the body’s blood volume, blood pressure, immune system and metabolism. All of these changes can impact how a woman feels, both physically and emotionally.

Other factors that can contribute to postpartum depression and increase the risk in new mothers include:

 A personal or family history of depression

 An unsatisfying birth experience

 A problematic or high-risk pregnancy

 Postpartum pain or complications from delivery

 A baby with a high level of needs

 Exhaustion from caring for a new baby or multiple children

 Anxiety or unrealistic expectations about motherhood

 Stress from changes at home or work

 Feeling a loss of identity

 Lack of social support

 Relationship difficulties

Signs and symptoms Signs and symptoms of the baby blues or mild depression include episodes of anxiety, sadness, irritability, crying, headaches, exhaustion and feelings of unworthiness. Often, these signs and symptoms pass within a few days or weeks. In some cases, though, baby blues turn into postpartum depression.

With postpartum depression, the signs and symptoms of depression are more intense and can last longer. They include:

 Constant fatigue

 Changes in appetite

 Lack of joy in life

 A sense of emotional numbness or feeling trapped

 Withdrawal from family and friends

 Lack of concern for yourself or baby

 Severe insomnia

 Excessive concern for your baby

 Loss of sexual interest or sexual responsiveness

 A strong sense of failure or inadequacy

 Severe mood swings

 High expectations and an overly demanding attitude

 Difficulty making sense of things

If you’re feeling depressed after your baby’s birth, you may be reluctant or embarrassed to admit it. But it’s important to inform your care provider if you experience signs or symptoms of postpartum depression.

Treatment Your care provider most likely will want to review your signs and symptoms in person. Because a great number of women feel tired and overwhelmed after having a baby, he or she may use a depression-screening scale to distinguish a short-term case of the blues from a more severe form of depression.

Postpartum depression is a recognized and treatable medical problem. Treatment varies according to individual needs. It may include:

 Support groups

 Individual counseling or psychotherapy

 Antidepressant or other medications

If you experience depression following childbirth, you have an increased risk of depression after a subsequent pregnancy. In fact, postpartum depression is more common in second-time mothers. With early intervention and proper treatment, however, there is less of a chance for serious problems and a greater chance of a rapid recovery.

SELF-CARE FOR POSTPARTUM DEPRESSION

If you’re diagnosed with postpartum depression, or you think you may have the condition, it’s very important that you seek professional care. To help aid in your recovery, try these tips:

 Get a healthy amount of rest. Make a habit of resting while your baby sleeps.

 Eat properly. Emphasize grains, fruits and vegetables.

 Take part in physical activity every day.

 Stay connected with family and friends.

 Ask for occasional help with child care and household responsibilities from friends and family.

 Take some time for yourself. Get dressed, leave the house and visit a friend or run an errand.

 Talk with other mothers. Ask your care provider about groups for new moms in your community.

 Spend time alone with your partner.