Asthma: Asthma complicates approximately 4%–8% of pregnancies.18 Women with poorly controlled asthma before pregnancy are more likely to experience worsening symptoms during pregnancy. The goal of treatment in pregnancy is to maintain adequate oxygenation of the fetus by preventing hypoxic episodes in the mother.19 Preconception care should focus on medically optimizing asthma control and identifying and reducing exposure to allergens.
Asthma self-management skills— including self-monitoring with peak flow monitors, correct use of inhalers, and prompt handling of signs of worsening asthma—enhance asthma control. Inhaled corticosteroids are first-line controller therapy for persistent asthma during pregnancy.
Inflammatory bowel disease: Inflammatory bowel disease (IBD) does not decrease fertility; however, fertility in patients with IBD is possibly affected by active disease, medications, and prior surgeries. Women with IBD experience worse obstetrical and pregnancy-related outcomes compared to the general population, even with disease remission.20
The course of IBD during pregnancy is determined by how active the disease is at conception. Women in remission at conception are likely to remain in remission during pregnancy. In contrast, up to 70% of women with active disease at conception will have continued or worsening symptoms.21
Stopping medications that are maintaining remission can induce relapse or flare. Methotrexate and diphenoxylate are contraindicated in pregnancy, whereas sulfasalazine, 5-aminosalicylates, and corticosteroids are considered safe. Many immunomodulators (ie, azathioprine and 6-mercaptopurine) and biologic agents (ie, infliximab) are safe during pregnancy but their use should be managed in coordination with MFM and an IBD specialist.
Lupus nephritis: Women with systemic lupus erythematosus (SLE) have better pregnancy prognoses if their disease has been quiescent for at least 6 months prior to pregnancy and they have normal or near-normal renal function. Active SLE at conception is a strong predictor of adverse maternal and obstetrical outcomes.
Disease flares with pregnancy are difficult to decouple from the physiologic changes of pregnancy and from preeclampsia. Most SLE medication can be continued during pregnancy, but these drugs should be reviewed prior to conception. Medications contraindicated in pregnancy include cyclophosphamide, mycophenolate, methotrexate, and leflunomide. Other SLE drugs that are reasonably safe for use during pregnancy (with certain limitations beyond the scope of this review) are nonsteroidal anti-inflammatory drugs, glucocorticoids, azathioprine, rituximab, belimumab, and some antihypertensive medications.
The most important aspect of preconception counseling in cases of SLE is to determine whether pregnancy may present an unacceptably high maternal or fetal risk, and to optimize preconception disease status.
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