Dr. Stefan Agewall,
Initiation of drug therapy during pregnancy often makes both the pregnant woman and the doctor concerned. During this session we heard four excellent presentations on this topic. The hall was crowded and unfortunately a lot of people could not enter due to lack of space. Dr. Cifkova discussed hypertension treatment during pregnancy. Non-pharmacological management (including close supervision and restriction of activities) should be considered for pregnant women with SBP 140–149mmHg or DBP 90–95mmHg. In the presence of gestational hypertension (with or without proteinuria) drug treatment is indicated at BP levels >140/90mmHg. SBP levels >170 or DBP >110mmHg should be considered an emergency requiring hospitalization. In non-severe hypertension, oral methyldopa, labetalol, calcium antagonists and (less frequently) b-blockers (not atenolol) are drugs of choice. As emergency treatment, intravenous labetalol, oral methyldopa and oral nifedipine are indicated. Intravenous hydralazine is no longer the drug of choice because of an excess of perinatal adverse effects. During pregnancy blood volume normally increases by 35% and cardiac output by 40 % and therefore it is easy to understand that women with heart failure may not tolerate a pregnancy. Patients with severe heart failure have a high mortality (8-35%) and morbidity risk (50%) during pregnancy. Dr Alonso pointed out that pregnancy should be discouraged in patients with severe heart failure, however if the patient still wants to go through with pregnancy, then a multi-disciplinary approach between several medical specialities is required to optimize the situation. Dr Wolbrette reported that atrial fibrillation is quite uncommon in pregnant women with structural normal hearts, despite the fact that the hormonal, hemodynamic and autonomic status during pregnancy theoretically may increase the risk of arrhythmia. In haemodynamically stable patients with structurally normal hearts, flecainide or ibutilide given intravenously to terminate recent onset AF may be considered, if arrhythmia conversion is mandatory and DCC considered inappropriate. DCC can be performed safely at all stages of pregnancy, and is recommended in patients who are haemodynamically unstable due to AF, and whenever the risk of ongoing AF is considered high, for the mother or for the foetus. For paroxysmal atrial fibrillation the “pill in the pocket” strategy may be used with flecainide. Dr Roos-Hesselink pointed out that pregnancy is a hypercoagulable condition with increased platelet adhesiveness. One out of 1000 women suffers from a thrombosis during pregnancy. This risk increases if the patients have other risk factors such as age above 35 years, obesity, diabetes mellitus, smoking, caesarean delivery or assisted fertilization. Pulmonary embolism is a leading cause of pregnancy-related maternal death in developed countries. Exposure of the foetus to ionizing radiation is a concern when investigating suspected PE during pregnancy. However, this concern is largely overcome by the hazards of missing a potentially fatal diagnosis. Analysis of D-dimer may be useful to exclude significant thrombosis, however an elevated value is more difficult to interpret since D-dimer normally increases during pregnancy and normalises 4-6 weeks after delivery. The standard therapy is treatment with low-molecular heparin for thrombosis and pulmonary embolism during pregnancy. Thrombolytic treatment is a relative contraindication during pregnancy but may be used in critical cases.
Drug therapy in pregnancy
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