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This book provides an overview of the physiology of pregnancy and the pathophysiology of common pregnancy complications. Using this information, options are discussed for the early detection and prevention of these complications.
Chapter 1 outlines the maternal adaptation to pregnancy, which enables the fetus to grow, mature and thrive without compromising maternal health. Chapter 2 describes the pregnancy course in healthy women, who develop a common pregnancy complication, such as a placental syndrome, preterm birth or gestational diabetes. These complications are often superimposed on a latent defect in the cardiovascular, renal, immunologic and/or metabolic functions. Chapters 3 and 4 discuss pregnancy in women with a chronic disease that often affects one of these functions. Finally, chapter 5 uses the information provided in the preceding chapters to discuss the options for early detection and/or prevention of common pregnancy complications.
The emphasis of this book is on the pathophysiology of a complicated pregnancy rather than on its management. It explains the sequence of events that characterizes the development of common pregnancy complications. This insight is expected to assist in the deceision making and counseling by midwives and obstetricians of pregnant women, who at increased risk of these complications.

Inhoudsopgave

Voorwerk

1. Maternal adaptation to pregnancy

Abstract
The first chapter of this book describes the most important maternal adaptations to pregnancy. In the following three chapters, that information is used as a reference for the pathophysiology of common pregnancy disorders, that may develop in seemingly healthy women (chap. 2), in women with a pre-existent chronic disorder that predisposes to these pregnancy complications (chap. 3) and in women with a preexistent chronic disorder that does not directly predispose to these pregnancy complications (chap. 4). Finally, chapter 5 discusses how the information on pathophysiology of pregnancy complications can be translated into strategies that enable early detection and/or prevention of these complications.
L. L. H. Peeters, P. W. de Leeuw, E. D. Post Uiterweer

2. Pathophysiology of pregnancy complications in healthy women

Abstract
During pregnancy, the expectant mother provides a new human life with the ideal conditions to grow, mature and develop to its maximum genetic potential. This extra effort requires adaptive changes in her system, initially her immune function, but after embryo implantation, also various other organs, particularly in the cardiovascular/renal systems and metabolism. Some adaptations only consist of a reset of a particular setpoint (e.g. blood pressure and osmolality), whereas others (e.g. cardiovascular and metabolic adaptations) require the utilization of some of the maternal ‘normal’ reserve capacity (described in chap. 1). Chapter 2 consists of two sections. The first section describes frequently observed pathophysiologic developments in pregnancy in seemingly healthy women resulting from maladaptation of the maternal hemodynamic-, renal-, immune- and metabolic functions. The impact is usually a disruption of pregnancy course and outcome, because of the development of a (1) Placental syndrome, (2) Spontaneous preterm birth, or (3) Gestational diabetes. The second section describes less common pathophysiologic events that primarily affect maternal wellbeing, in conjunction with (4) side-effects of placental hormones, (5) abnormal placental morphology or insertion site in the uterus, and (6) distressing mechanical effects, caused by the rapidly growing pregnant uterus.
L. L. H. Peeters, P. W. de Leeuw, E. D. Post Uiterweer

3. Preexistent chronic disorders, often directly affecting pregnancy

Abstract
The first two chapters describe the strategy in mammalian pregnancy in general and human pregnancy in particular, how to secure the survival of the species without compromising maternal health. The first chapter discusses the specific adaptive strategy that a pregnant woman utilizes to achieve this goal. She temporarily accommodates an immunologically different human being within her body and by supplying this new life with sufficient O2, nutrients and disposing of its metabolic waste products, enables it to grow and mature, in line with its genetic potential. She does this in a setting, that allows her to shield the infant from external stress factors, such as excessive heat, – cold and – physical forces and, last but not least, she provides the infant with the means to safely exit the maternal body to the outer world at a suitable time. Yet, even seemingly-healthy women may develop common pregnancy complications, such as early pregnancy loss, placental syndromes, preterm birth and gestational diabetes. These complications are often superimposed on a preexistent, often latent defect in the maternal cardiovascular system (sect. 3.1), renal function (sect. 3.2), metabolism (sect. 3.3), certain liver functions (sect. 3.4), or the immune – (sect. 3.5) and clotting systems (sect. 3.6). Such a defect limits a woman’s capacity to adapt to pregnancy and therefore, predisposes her to one of these pregnancy complications. This chapter describes the course and outcome of pregnancy in women with a chronic disorder affecting one of these six maternal functions and also, whether pregnancy will alter the course of her underlying chronic disorder.
L. L. H. Peeters, P. W. de Leeuw, E. D. Post Uiterweer

4. Preexistent chronic disorders, often indirectly affecting pregnancy

Abstract
This chapter describes the impact of chronic disorders that do not directly interfere with placental development and function, but often have an indirect negative effect on the course and outcome of pregnancy. The most important primary organs targeted by these disorders are lungs (sect. 4.1), GI-tract (sect. 4.2), liver (partly) (sect. 4.3), endocrine system (sect. 4.4) and blood (sect. 4.5). The final two sections describe the interaction of common psychiatric disorders with pregnancy (sect. 4.6) and the effect of pregnancy on the pharmacokinetics of frequently used medication (sect. 4.7). The adverse effects of these disorders on pregnancy are partly related to the impaired function of the chronically affected organs (such as reduced respiratory reserve capacity in women with severe asthma), and partly related to their negative effect on the cardiovascular and metabolic reserves normally available to accommodate pregnancy. These two features lower the threshold for activation of the stress response as detailed in Chaps. 1 and 2. Early activation of this stress response not only predisposes a pregnancy to preterm birth and/or placental dysfunction. It may also worsen the underlying chronic disorder and with it, indirectly amplify the stress response and its associated adverse effect on pregnancy. These inferences indicate that optimizing clinical management of the disorder prior to pregnancy can be expected to reduce the risk of these negative effects.
L. L. H. Peeters, P. W. de Leeuw, E. D. Post Uiterweer

5. Prevention & early detection of common pregnancy disorders

Abstract
The previous chapters provided an overview of the normal maternal adaptation to pregnancy. This information was then used as a reference to discuss the pathophysiology of common pregnancy disorders in seemingly healthy women and women with a preexistent chronic disorder. This final chapter summarizes the options to early identify in these two subgroups those women that are really at high risk to develop (one of) these complications, followed by a description of the options to prevent these complications to develop or at least, to minimize their clinical impact in case they do develop anyway.
L. L. H. Peeters, P. W. de Leeuw, E. D. Post Uiterweer

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