Antepartal & Intrapartal Management of Pregnancies With

Medical Complications: GDM and Heart Disease

By: Ernesto S. Uichanco, M.D.

University  of  the  Philippines-­‐Philippine  General  Hospital  Department  of  Obstetrics  &  Gynecology  
Sec=on  of  Maternal  –  Fetal  Medicine  
 
Management of Heart Disease In Pregnancy
 Heart Disease In Pregnancy:
Classification & Risk Factors

• Pa=ent  evalua=on  essen=al  for  op=mal  care  

• Clinical  assessment  &  work-­‐up  to  iden=fy:  
   -­‐  Abnormal  func=onal  capacity  
   -­‐  LeI  ventricular  dysfunc=on  
   -­‐  Valve  obstruc=on  
   -­‐  History  of  heart  failure/embolic  events  
• Counsel  regarding  risks  &  outcome  
• Consult  with  cardiologist  
 NEW YORK HEART ASSOCIATION FUNCTIONAL CLASSIFICATION OF
CARDIAC DISEASE

CLASS I No functional limitation of activity.

No symptoms of cardiac decompensation with activity.

CLASS II Mild amount of functional limitation.

Patients are asymptomatic at rest. Ordinary physical
activity results in symptoms.

CLASS III Marked limitation of most physical activity.

Asymptomatic at rest
Minimal physical activity results in symptoms.

CLASS IV Severe limitation of physical activity results in symptoms.

Patients may be symptomatic at rest/heart failure at any
point of pregnancy.

CLASS V If patient is on ionotropic support, ventilator,

assisted circulation or having
comprised renal or pulmonary function
necessitating dialysis/EMCO to maintain vital signs.
The criteria committee of the New York Heart Association, Nomenclature and criteria for
diagnosis of diseases of heart and great vessels, Edi 8, New York Association,1979.
 NEW  YORK  HEART  ASSOCIATION  FUNCTIONAL  CLASSIFICATION  OF  CARDIAC  DISEASE  

CLASS  IV                      Severe  limita<on  of  physical  ac<vity  results  in  symptoms.  
                                                       Pa<ents  may  be  symptoma<c  at  rest/heart  failure  at  any  point  of  
   pregnancy.  
 
CLASS    V                      If  pa<ent  is  on  ionotropic  support,  ven<lator,  assisted    circula<on  
   or  having  comprised  renal  or  pulmonary    func<on  necessita<ng    
   dialysis/EMCO  to  maintain  vital  signs.  
  Maternal mortality risk and cardiac disease

Group Cardiac disease Associated mortality risk

   I  Atrial  septal  defect*          <1%  
       Ventricular  septal  defect*  
 Patent  ductus  arteriosus*  
 Pulmonary/tricuspid  valve  disease  
 Corrected  tetralogy  of  Fallot    
 Bioprosthe<c  valve  
 Mitral  stenosis,  NYHA  Class  I,  II  
 II    Coarcta<on  of  aorta  without  valvular  involvement    5%  -­‐  15%  
 Uncorrected  tetralogy  of  Fallot    
 Marfan’s  syndrome  with  normal  aorta  
 Mechanical  prosthe<c  valve  
 Mitral  stenosis  with  atrial  fibrilla<on  or  NYHA  Class  III,  IV  
 Aor<c  stenosis    
 Previous  myocardial  infarc<on  
III    Pulmonary  hypertension—primary  or  secondary    25%  -­‐  50%  
 Coarcta<on  of  aorta  with  valvular  involvement  
 Marfan’s  syndrome  with  aor<c  involvement  
 Peripartum  cardiomyopathy    
*Uncomplicated  
   
 
 Heart Disease In Pregnancy: Maternal Risk Stratification

Predictors  of  complica=ons:  

• Prior  cardiac  events  
• NYHA  Func=onal  Class  III  or  IV  
• Lesions  classified  as  Group  II  or  III  
• LeI  heart  obstruc=on  (Mitral  /Aor=c  stenosis)    
• Significant  leI  ventricular  systolic  dysfunc=on  
Heart Disease In Pregnancy:
Complications
Grouping  of  Complica<ons  
•  Primary  Cardiac  Events:  Any  of  the  following-­‐
 Pulmonary  edema        
 Sustained  symptoma=c  Tachy-­‐/Bradycardia    
 (Requiring  treatment)      
 Cardiac  arrest  or  Cardiac  death      
•  Secondary  Cardiac  Events:      
 Decline  in  NYHA  Class  (>  2  classes)    
 Need  for  urgent  invasive  cardiac  procedures  
             (During  pregnancy/within  6  months  aIer  delivery)  
 Heart Disease In Pregnancy:
Complications

Grouping  of  Complica<ons  (Con=nued)  

•  Neonatal  Events:  Any  of  the  following-­‐    
 Premature  birth    SGA  birthweight  
 Resp.  Distress  Syndr  Intraventricular  Hemorr.
 Fetal  death      Neonatal  death      
•  Obstetric  Events:            
 Non-­‐cardiac  death          
 Pregnancy-­‐induced  hypertension    
 Post-­‐partum  hemorrhage  
 Heart Disease In Pregnancy: Complications

Maternal  Mortality        -­‐ Neonatal  Complica=ons  

restricted  to  the  ff.:    -­‐derive  from  the  ff.:  
• Pulmonary  hypertension   • Preterm  birth  
• Coronary  artery  disease   • Miscarriage  
• Cardiomyopathy   • Growth  restric=on  
• Endocardi=s  
• Sudden  arrhythmia  
Heart Disease In Pregnancy: Management
1.  Modify  antepartum  ac=vity  
2.  Treat  coexis=ng  medical  condi=ons  
3.  Collaborate  care  with  mul=ple  special=es  
4.  Conduct  labor  in  the  lateral  decubitus  posi=on  
5.  Request  for  epidural  anesthesia  
6.  Oxygenate  during  labor  &  delivery  
7.  Prudent  bacterial  endocardi=s  prophylaxis  
8.  Reserve  cesarean  delivery  for  obstetric  indica=ons  
9.  Implement  hemodynamic  monitoring  
10. Avoid  hypotension  &/or  hypovolemia  
 Heart Disease In Pregnancy: Management
1.  Modify  antepartum  ac=vity  
•  Objec=ve:  Minimize  factors  that  encroach    upon  limited  
circulatory  reserves  
•  Includes  avoiding  or  minimizing  the  following:  
     1.  Anxiety  
     2.  Sodium  &  water  reten=on  
     3.  Sudden,  strenuous  or  isometric  exercises  
     4.  Heat  &  humidity  
     5.  Anemia  
     6.  Infec=on  
     7.  Disturbances  in  cardiac  rhythm  &  conduc=on  
     8.  Thromboembolic    predisposi=on  
   
 Heart Disease In Pregnancy: Management

2.  Treat  coexis=ng  medical  condi=ons  

•  Condi=ons  op=mized  to  minimize  co-­‐morbidity  
•  Examples:  
   1.  Anemia  
   2.  Hypertension  
   3.  Thyroid  disease  
   4.  Condi=ons  requiring  an=coagula=on  
Heart Disease In Pregnancy: Management

3.  Collaborate  care  with  mul=ple  special=es  

 •  Pa=ents  are  very  complex  
•  S=ll  a  mul=disciplinary  challenge  
•  Involves  specialists  from:        
 -­‐  Obstetrics            
 -­‐  Maternal-­‐fetal  medicine      
 -­‐  Cardiology            
 -­‐  Anesthesiology  
 Heart Disease In Pregnancy: Management

4.  Conduct  labor  in  the  lateral  decubitus  posi=on  

  •  Circulatory  responses  -­‐  influenced  by  posture  
•  Hemodynamic  fluctua=ons  exaggerated  in  the  
 supine  posi=on  (Aorta  occluded  by  uterus  
 crea=ng  a  restricted  proximal  vascular  
 compartment  w/  intermiient  blood  expulsion)      
•  Lateral  decubitus  reduces  increment  in  CO  
•  Important  to  aienuate  fluctua=ons    
Heart Disease In Pregnancy: Management

5.  Request  for  epidural  anesthesia  

 
•  Spinal  anesthesia  avoided  to  minimize  hypotension  
w/  drop  in  preload  &  ↓  CO  
•  Minimizes  pain,  sympathe=c  stress,    oxygen  u=liza=on  
&  fluctua=ons  in  CO  
 Heart Disease In Pregnancy: Management

6.  Oxygenate  during  labor  &  delivery  

 
• Open  to  ques=on  –  no  evidence  of  benefit  
• Keep  maternal  PaO2  >  70  mmHg  
• Intui=vely  administered  during  labor  
 Heart Disease In Pregnancy: Management

7.  Prudent  bacterial  endocardi=s  prophylaxis  

 
• During  rou=ne  delivery  in  pa=ents  w/  cardiac  
 lesions  suscep=ble  to  infec=ve  endocardi=s  
• Includes:  Prosthe=c  heart  valves,  Previous  
endocardi=s,  Surgically  constructed  systemic  
pulmonary  shunts,  Complex  cyano=c  congenital  
heart  disease  
• Should  not  assume  that  delivery  will  be  
 uncomplicated  
 Heart Disease In Pregnancy: Management

7.  Prudent  bacterial  endocardi=s  prophylaxis  

 
Recommended   an=bio=c  regimen:  
• Ampicillin  2.0  g  &  Gentamicin  1.5  mg/kg  (IM/IV)      -­‐  
Within  30  min.  before  procedure  or  1-­‐2  hrs    
 before  an=cipated  delivery  
   Repeat:  Ampicillin  1.0  g  oral,  IM  or  IV  6  hrs  later  
• Vancomicin  1.0  g  IV                
 for  penicillin-­‐allergy    
 Heart Disease In Pregnancy: Management

8.  Reserve  cesarean  delivery  for  OB  indica=ons  

  •  Underscores  benefits  of  vaginal  delivery  
•  Opera=ve  delivery  is  associated  with:  
 More  blood  loss    Increased  pain  
 Prolonged  bed  rest    Wound  infec=on
   
•  CS  to  improve  maternal  &  fetal  prognosis  in  
 very  dangerous  clinical  selng  
•  Vaginal  delivery  –  avoid  Valsalva  maneuver  
 Heart Disease In Pregnancy: Management

9.  Implement  invasive  hemodynamic  monitoring  

 
•  Pulmonary  catheter  inserted  in  high-­‐risk  
•  Safety  &  u=lity  recently  ques=oned  
•  Helpful  in  Preload-­‐dependent  cardiac  lesions  (Cri=cal  
aor=c  stenosis  &  Pulmonary  hypertension)  
 Heart Disease In Pregnancy: Management

10.  Avoid  hypotension  

 &/or  hypovolemia  
 
•  During  labor  &  delivery  –  beneficial  for  most  
•  Methods:  Keep  pa=ent  on  the  ‘wet’  side    
 Avoid  hemorrhage    Replenish  blood  loss
 Avoid  spinal  anesthesia  Preload  prior  to  induc=on
 Avoid  supine  hypotension        
 Postpartum  uterine  massage  &  IV  oxytocin    
•     Systemic  arterial  pressure  monitored  
Heart Disease In Pregnancy: Management

Postpartum  Period  

Concerns:  
 1.  Measures  to  reduce  thromboembolism  
 2.  Breast  feeding  in  selected  pa=ents  
 3.  Review  contracep=ve  plans  
Diabetes Mellitus In Pregnancy
Common  Diagnos<c  Test  &  Criteria  for  GDM  
  Threshold by Time Interval
Plasma Glucose (mg/dl)

OGTT
Modified
Organization glucose Fasting 1-hour 2-hour 3-hour
load criteria

ADA* 100-g Carpenter ≥95 ≥180 ≥155 ≥140

& Coustan
75-g ≥95 ≥180 ≥155 -
NDDG or
ACOG* 100-g Carpenter ≥105 ≥190 ≥165 ≥145
& Coustan

WHO** 75-g WHO ≥126 - ≥140 -

*2  or  more  glucose  values  must  meet  threshold  
**1  or  more  glucose  values  must  meet  threshold  
Diabetes in Pregnancy: Surveillance

1.  Maternal  glucose  levels  

2.  Fetal  growth  
3.  Urinary  Ketones  
4.  Glycosylated  hemoglobin  
 Maternal Glucose Level Monitoring

•  Daily  Self-­‐monitoring  
•  Recommended  Glucose  Goals:  
 Fas$ng/pre-­‐meal  -­‐  <  95mg/dL  (5.3  mmol/L)  
 1  hr  post-­‐prandial  -­‐  <140mg/dL  (7.8mmol/L)  
 2  hr  post-­‐prandial  -­‐  <120mg/dL  (6.7mmol/L)  
   Mean  Plasma  Glucose  –  90  –  100  mg/dL  
 Fetal Growth Monitoring

Ultrasonographic  Measurements  

•  Es=mated  fetal  weight  /  Abdominal  circumference  

•  Every  2-­‐4  weeks  from  2nd  &  early  3rd  trimester  
•  Normal  growth  rates  →  Less  intense  management  
•  Excessive  growth  →  Lower  targets  of  glycemic  control  or    add  /
intensify  pharmacologic  therapy  
Diabetes in Pregnancy: Surveillance

Maternal  Ketones   Glycosylated  Hemoglobin  

Recommended  in:   Reflects  average  glucose  levels  for  
previous  8-­‐12  weeks  
 -­‐  Severe  hyperglycemia  
Used  to  assess  overall  control  in  
 -­‐  Weight  loss   each  trimester  
 -­‐  “Starva=on  ketosis”   Target:  5%-­‐6%  (average  glucose  of  
     90-­‐120  mg/dl)  
Urinary  vs  Finger  blood  
?  Data  to  determine  value  
?  Effec=veness  in  
improving  outcome    
 Treatment of Diabetes in Pregnancy

A.  Daily  Self-­‐monitoring  of  blood  glucose  

 (SMBG)  
B.  Standard  Nutri=onal  Management  &  
 Planned  Physical  Ac=vity  
C.  Intensive  Metabolic  Therapy  
 (Pharmacologic)        
 1.  Insulin
             2.  Oral  
an=hyperglycemic  drugs  
Standard Nutritional Management & Planned Physical Activity in GDM

•  Cornerstone  of  Treatment  

•  Food  Plan:  
 -­‐  To  fulfill  pregnancy  requirements  
       -­‐Achieve  glycemic  control  
 -­‐Complex  carbohydrates  preferred  
 –Modified  according  to  body  habitus,  
weight  gain  &  ac=vity        
•  Con=nued  postpartum  
 Exercise in GDM

•  Metabolic  benefit  –    ability  to  

 enhance  insulin  sensi=vity  
•  Ex.-­‐  Brisk  walking,  recumbent  cycling,  arm  cycle  
•  Regular  -­‐    3-­‐4X/week  
   dura=on  of  15-­‐30  minutes  
•  HR  maintained  between  130-­‐160bpm  
Intensive Metabolic Therapy
(Pharmacologic)

•  Applied  if  conserva=ve  therapy  fails  to  

 maintain  glycemic  goals  or  observa=on  
   of  excessive  fetal  growth  
•  Required  in  20-­‐60%  of  GDM  
•  Agents  used:  
   A.  Insulin  
   B.  Oral  An=hyperglycemic  drugs  
 Insulin Therapy

•  The  Gold  Standard  in  management  

•  50-­‐80%  effec=ve  in  achieving  established    
 glucose  control  
•  Administra=on  individualized  
•  Designed  to  mimic  physiologic  secre=on  of  
 endogenous  insulin  
 Insulin Therapy in GDM
•  Preferably  Human  Insulin  
•  Dose:  0.7  –  1.0  U/kbw/day  
   2/3  before  breakfast  &  1/3  before  supper  
•  Intermediate  ac=ng  /  Pre-­‐mixed  
•  Subcutaneous  route/Infusion  pump  
•  Main  Concern:  Blood  Glucose  Control  
 Oral Antihyperglycemic Agents
•  Prescribed  for  non-­‐pregnant  type  2  DM  
•  Being  developed  as  an  adjunct  to  
 conserva=ve  therapy  in  GDM    
•  Advantages:  ease  of  use,  noninvasive  &  
       cost-­‐effec=ve  
•  Evolu=on  of  acceptance  in  pregnancy:
   -­‐  2000-­‐  Langer,  et.,al.  –  compared  glyburide  
&  insulin    -­‐  similar  outcome  &  ability  to  
control    -­‐  2002  –  endorsed  by  N.  American  
Diabetes  in          Pregnancy  Study  
Group      -­‐  2005  –  endorsed  in  5th  Internat’l  
Workshop-­‐Conf.  on        
 Gesta=onal  Diabetes  (ADA)    
 Pharmacologic  Effects  of  Glyburide  &  Me^ormin  

Excreted Daily
Mechanism of Pregnancy Cross
in Breast Maintainance
Drug Action Category Placenta
Milk Dose

.75-12 mg/d
single daily
Glyburide ↑ Insulin
B No No dose with
(Euglucon) secretion
breakfast or as
2 divided doses

↓Hepatic 1500-1550mg/
Metformin Gluconeogenesis, d in 2 or 3
B Yes No
(Glucophage) ↑Insulin divided doses
sensitivity with meals
Selec<ve  Characteris<cs  of  Glyburide  &  Me^ormin  

Duration of Decrease in Decrease in

Half-life
Antidiabetic FPG (mg/ Hemoglobin Side Effects
Drug Time (h)
Action (h) dl) A1C (%)

Glyburide Hypoglycemia,
12-24 60-70 1.5-2 10
(Euglucon) weight gain

Metformin
6-12 60-70 1.5-2 6.2 GI symptoms
(Glucophage)
 Goals of Fetal Surveillance in GDM

Apply  tes=ng  when  appropriate  to:  

 a.  Decrease  neonatal  morbidity  &  mortality  
 b.  Facilitate  op=mal  =ming  of  delivery  

•  Screen  for  congenital  anomalies  

•  Detect  macrosomia  
•  Assess  fetal  status  &  well-­‐being  
Diabetes in Pregnancy: Summary of Recommendations for Fetal
Surveillance
•  U=lity  of  rou=ne  antenatal  tes=ng  in  
 uncomplicated  GDM  has  not  been  shown  
•  Diet-­‐controlled  GDM  w/  normal  glycemic  control    
 -­‐  not  at  risk  for  IUFD.  Tes=ng  not  ins=tuted  
     un=l  40  wks  AOG.  
       Fetal  kick  count  
star=ng  at  32  wks.AOG  
•  Insulin-­‐  or  medicine-­‐requiring  GDM  –  
     twice  weekly  BPS  &  NST  
•  Preexis=ng  DM  –  twice  weekly  BPS  &  NST  
•  Doppler  studies  -­‐  reserved  for  those  with  
 vascular  disease,  IUGR  or  hypertension  
Diabetes in Pregnancy: Maternal Surveillance

Complica=ons  an=cipated:  
•  Spontaneous  preterm  labor  &  delivery
     -­‐  cor=costeroids  not  withheld  
→  close        glucose  monitoring  &  
temporary          addi=on/
increase  in  insulin  
•  Hypertensive  disorders
         -­‐  closely  monitor  
BP  &  urinary  protein  
Blood Glucose Control During Labor

•  Last  insulin  dose  given  Subcut.  the  night  before  

   or  that  morning  
•  Monitor  glucose  levels  every  1-­‐4  hrs  
•  Give  short  ac=ng  insulin  by  IV  infusion  at    
   0.5-­‐1.0  U/hr  for  plasma  glucose  >120mg/dL  
•  Target  of  control  during  labor:  
   Plasma  glucose  –  80-­‐120mg/dL  
   Capillary  glucose  –  70-­‐110mg/dL  
•  Discon$nue  IV  insulin  immediately  prior  to  delivery  
Timing of Delivery in DM in Pregnancy

•  Poor  metabolic  control  –  

   early  delivery  once  fetal  pulmonary  
     maturity  is  documented    
•  Good  metabolic  control-­‐  
   close  fetal  monitoring  
   deliver  by  40  weeks  AOG  
 Manner of Delivery in DM in Pregnancy

•  <  4,000gms    Trial  of  Labor  

•  4,000-­‐4,499gms    Individualize  
•  >4,500gms      Cesarean  sec=on  
 Metabolic  Assessment  Recommended  AIer  GDM  
 
Time Test Purpose
Post-delivery (1-3 days) Fasting/random plasma Detect persistent, overt
glucose diabetes

Early Post-partum 75 g 2-h OGTT Post-partum

( 1st visit) classification

1 Year Post-partum 75 g 2-h OGTT Assess glucose

metabolism
Annually Fasting plasma glucose Assess glucose
metabolism
Tri-annually 75 g 2-h OGTT Assess glucose
metabolism
Pre-pregnancy 75 g 2-h OGTT Classify glucose
metabolism
 Diabetes in Pregnancy: Lessons Learned

•  Remember  -­‐  pa=ent  is  more  than  her  blood  sugar  

•  Do  not  underes=mate  pa=ent’s  insight  regarding  
 changes  to  improve  glucose  control  
•  Keep  insulin  program  simple  &  make  changes  
 based  on  paierns  
•  Enlist  the  support  of  the  pa=ent’s  family  
•  Avoid  hypoglycemic  reac=ons  
 Diabetes in Pregnancy: Lessons Learned

•  Work  closely  with  the  health  care  team  

•  When  glucose  control  is  poor,  it’s  oIen  the  diet  
•  Weekends  are  not  our  “friends”  
•  When  changing  insulin  regimen  –  just  1  at  a  =me  
•  Respond  aggressively  to  nausea,  vomi=ng  &  
 fever    
Thank You !!!