Managing Chronic Disease and High-Risk Pregnancy: A Guide to Risks and Preparation

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• Pregnancy's Impact on Chronic Disease
• Acute Complications During Pregnancy
• Long-Term Disease Aggravation
• Pre-Pregnancy Preparation and Risk Reduction
• Genetic Counseling and Diagnostic Options
• Multidisciplinary Pregnancy Care Management

Pregnancy's Impact on Chronic Disease

Pregnancy significantly alters a woman's physiology, which can have profound effects on pre-existing chronic medical conditions. As Dr. Marc Dommergues, MD, explains, a central part of pre-pregnancy counseling involves discussing the specific impact of pregnancy on a woman's disease. This conversation is crucial for informed family planning, especially for women managing conditions like autoimmune disorders, diabetes, or renal failure. Understanding these potential changes allows patients and their healthcare teams to prepare adequately and mitigate risks.

Acute Complications During Pregnancy

Certain chronic diseases can lead to severe, acute complications triggered by the demands of pregnancy. Dr. Marc Dommergues, MD, highlights several critical examples. For a woman with pre-existing heart failure, the significant increase in blood volume during pregnancy can precipitate an episode of acute heart failure. Similarly, a history of venous thrombosis dramatically raises the risk of a life-threatening acute pulmonary embolism. Conditions like diabetes can become exceedingly difficult to control, leading to dangerous fluctuations in blood sugar. These acute events require immediate medical attention and underscore the necessity of specialized prenatal care.

Long-Term Disease Aggravation

Beyond immediate acute risks, pregnancy can also accelerate the progression of a chronic disease, leading to long-term health consequences. Dr. Marc Dommergues, MD, points to chronic renal failure as a prime example. The stress of pregnancy on the kidneys can decrease their survival time, potentially necessitating a kidney transplant earlier than otherwise planned. For diabetic patients, chronic eye complications (diabetic retinopathy) can become more severe in the long run due to the physiological changes of pregnancy. While these effects may not be immediately apparent, they are a vital part of the risk-benefit discussion.

Pre-Pregnancy Preparation and Risk Reduction

The most effective strategy for a safer pregnancy with a chronic disease is meticulous pre-pregnancy preparation. Dr. Marc Dommergues, MD, emphasizes that the first step is optimizing health *before* conception. This involves a collaborative effort with physicians managing the chronic condition. For diabetes, this means achieving perfect blood sugar control and treating any existing complications, like retinopathy, beforehand. For women with HIV, viral load must be suppressed using pregnancy-compatible antiretroviral therapy. For autoimmune diseases like lupus, the goal is to enter pregnancy when the disease is in a quiet, inactive state to minimize flares.

Genetic Counseling and Diagnostic Options

An essential component of pre-pregnancy planning for many chronic conditions is genetic counseling. Dr. Marc Dommergues, MD, notes that this process helps couples understand their specific risks of passing a condition to their offspring. Based on this assessment, families can explore their options. This may include deciding whether to pursue prenatal diagnosis through procedures like chorionic villus sampling (CVS) or amniocentesis. For some inheritable conditions, pre-implantation genetic diagnosis (PGD) may be an option, where embryos are screened before being implanted via IVF.

Multidisciplinary Pregnancy Care Management

Successful management of a high-risk pregnancy hinges on seamless, coordinated multidisciplinary care. As Dr. Marc Dommergues, MD, explains, the obstetrical team must be familiar with the patient's specific disease, and the disease specialist must be engaged and responsive throughout the pregnancy. He illustrates this with the example of epilepsy; an obstetrician must understand its symptoms to gain the patient's trust, while a neurologist must offer timely appointments rather than a follow-up in two years. Pregnancy is a short, dynamic process that demands fast answers and close collaboration between all specialists involved in the patient's care, a point Dr. Anton Titov, MD’s discussion with Dr. Marc Dommergues, MD, reinforces.

Full Transcript

Dr. Marc Dommergues, MD: Part 2 of the discussion we have with women who plan pregnancy is the impact of pregnancy on the disease. It may have an acute impact. For example, if you have heart failure, the blood volume will increase during pregnancy. This may cause acute heart failure.

If you've had a history of venous thrombosis, you may have an acute pulmonary embolism during pregnancy. This is a very acute complication. If you have diabetes, it might be difficult to balance due to pregnancy, etc.

Dr. Anton Titov, MD: So these are the acute events that need to be discussed, of course, according to each disease.

Dr. Marc Dommergues, MD: Pregnancy may aggravate the disease. For example, if you have substantial chronic renal failure, then it's likely that being pregnant will decrease the survival time of your kidney. Because of that, you may be transplanted earlier.

Or if you have chronic eye complication of diabetes, pregnancy may make it more severe in the long run. But usually, it's not in the short run.

Dr. Anton Titov, MD: So this was the first part of a pre-pregnancy clinic—information.

Dr. Marc Dommergues, MD: Then the second part will be: how can we decrease those risks we've been discussing? Once we have disclosed all these risks and possible complications of pregnancy, the question is how are we going to manage all health risks during pregnancy.

The first step is preparation for the pregnancy. For example, if you have diabetes, it is very important that chronic complications be treated beforehand, such as eye complications. It is very important that your blood sugar is perfectly controlled when you are going to become pregnant.

If you have HIV, it's very important that you can suppress the presence of HIV in your blood beforehand with drugs that are compatible with pregnancy. If you have an immunological disease, such as lupus erythematosus, it's better that the disease be quiet before you start the pregnancy.

All this the physicians who take care of the chronic disease can handle before pregnancy. Then there's the question of genetic counseling. Should we perform prenatal diagnosis or not? Should we perform a pre-implantation diagnosis? These are important issues.

Then comes the question of how to manage the pregnancy itself, depending on the type of disease a woman has. Whether it's a rare disease or a more common disease, I think it's important that the obstetrical team would be familiar with this disease, and that the specialist in charge of the disease, in the long run, would be familiarized with a pregnancy of a patient.

Just to make things very simple, if you discuss with a patient who has epilepsy and who is pregnant, if you as an obstetrician are not able to understand the symptoms of epilepsy, the patient will not trust you. On the other hand, if a neurologist tells you that "my next appointment will be in two years," it will be a problem during pregnancy, because pregnancy is something that is rather short.

We need fast answers to our questions on epilepsy during pregnancy.