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LEARNING OBJECTIVES

  1. Discuss the increased maternal and fetal risks associated with multiple gestation and its management.

  2. Explain what characteristics and behaviors increase the risk for gestational diabetes, and describe the methods of managing gestational diabetes.

  3. Describe the diagnostic criteria and appropriate management of preeclampsia.

  4. Discuss management options for cancer diagnosed during pregnancy.

INTRODUCTION

Pregnancy and childbirth are expected to be times of great joy and happiness for the expectant mother and her loved ones. The development of effective contraception has allowed women the choice to delay pregnancy. Unfortunately, advancing maternal age at the time of first pregnancy is associated with increases in infertility, diabetes, and hypertension. Modern pharmacologic therapy is an essential part of managing many of these complications in order to minimize morbidity.

Multiple gestation pregnancies in particular are associated with increased morbidity. These multi-gestational pregnancies are associated with up to double the rates of maternal hospitalization, Cesarean delivery, preeclampsia, and preterm delivery. In addition, the worldwide obesity epidemic has had major ramifications for the mother and child. Marked increases in gestational diabetes have been observed with increasing maternal weight and age.1 Not only are the infants born to mothers with gestational diabetes larger at the time of delivery as compared to infants born to mothers without gestational diabetes, they also suffer short- and long-term metabolic consequences.2 Furthermore, the mother has lifelong increases in the risk of developing overt diabetes and cardiovascular diseases.2 Preeclampsia and eclampsia remain among the most common causes of maternal deaths. Recognition and appropriate management of preeclampsia can significantly decrease these losses.

The diagnosis of cancer during pregnancy can be especially traumatic to both the patient and her caregivers. Concerns for maternal mortality, as well as fetal morbidity and/or mortality from diagnostic and therapeutic interventions, can complicate the treatment process. Fortunately, most diagnostic and therapeutic procedures can be undertaken with relative safety if appropriate precautions are taken.

Patient Case (Part 1)

M.J. is a 34-year-old, G1P0 who presents at 10 weeks 0 days gestation with nausea, vomiting, and a 5-lb weight loss.

HPI: M.J. has a 3-year history of infertility. She underwent ovulation induction to conceive this pregnancy.

PMH: Negative for diabetes, gastroesophageal reflux disease, or thyroid disease.

Family history: Her family history is significant for her mother and maternal aunt having adult-onset diabetes mellitus (DM).

Allergies: She denies any known drug allergies.

Medications: Over-the-counter prenatal vitamins.

Physical examination: Temp = 37oC; BP 110/70; HR 69; otherwise unremarkable.

Laboratory values: Within normal limits.

Diagnostic tests: Office ultrasound reveals a twin gestation with a thin intervening membrane.

MULTIPLE GESTATIONS

The incidence of multiple gestations rose steadily in the late 1980s and 1990s, primarily because of increased use of assisted reproductive technology (ART). With the advent of more judicious use of in-vitro fertilization in regards to the number of embryos implanted with ...

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