PREPARATION FOR PLANNED CONCEPTION IN WOMEN

WITH METABOLIC DISEASE (Hypertension, Preeclampsia,

Diabetes)

Persiapan Kehamilan pada Wanita dengan Penyakit Metabolik

(Hipertensi, Preeklampsia, Diabetes)

Julian Dewantiningrum
Bagian / KSM Obstetri dan Ginekologi
FK UNDIP / RSUP dr. Kariadi Semarang
Global estimates of common NCDs affecting pregnancy and
contributing to poor pregnancy outcomes

Anil Kapur. Links between maternal health and NCDs.

Best Practice & Research Clinical Obstetrics & Gynaecology 2015 ; 29(1) : 32-42,
 MDG :
Improving maternal
health and reducing
childhood mortality

Reduction of non-
communicable maternal
diseases (NCDs) and
exposures in pregnancy

Improve the future

health of women
and their offspring
A framework for healthcare interventions to address maternal morbidity

Preconception care

Intl J Gynecology & Obste, Volume: 141, Issue: S1, Pages: 61-68, First published: 23 May 2018, DOI: (10.1002/ijgo.12469)
PRECONCEPTION CARE
• Preconception care is an
approach to health promotion
and preventive medicine which
focuses on interventions that
identify and modify biomedical,
behavioural and social risks to a
woman’s health or pregnancy
outcome.
 Steel A, Lucke J, Adams J. The prevalence and nature of the use of
preconception services by women with chronic health conditions: an
integrative review. BMC Womens Health. 2015;15:14.
 METABOLIC DISEASE
• Medical illness in pregnancy can impact a women’s health for the rest
of her life, as well as the health of future pregnancy
• Chronic hypertension
• Previous preeclampsia
• Diabetes mellitus
Every woman with HT, previous PE and DM should be aware of the potential
effects of her disease and its treatment on herself, her pregnancy and her
offspring, should she conceive, as weel as opportunities for maximing a
health outcome.
GENERALLY PRECONCEPTION CARE
• All women who plan to conceive should
be taking a multivitamin include folic acid
at least 2 months before pregnancy.
• All women / couples should encouraged to
develop a reproductive life plan and
mental health.
• All women should routinely assessed and
counseled about BMI, weight control,
exercise, diet, tobacco, other exposures
and immunization status.
• Gynecology examination.
HYPERTENSION
• Prevalence
• Approximately 2 - 12,6 % of women of childbearing age have chronic
hypertension.
• Around 10 – 15% of pregnancies are complicated by hypertensive disorders.
• Rates of chronic hypertension complicating pregnancy are increasing.
IMPLICATIONS FOR THE WOMAN IF SHE
CONCEIVES
• Goal is to maintain good BP control on least medication.
• High risk for the development of preeclampsia / eclampsia.
• Risk exists for progression of renal disease if woman already has
chronic renal insufficiency.
IMPLICATIONS FOR PREGNANCY
OUTCOMES
• Spontaneous abortion
• Preeclampsia.
Women with mild hypertension (systolic pressure 140–159 mm Hg or diastolic pressure 90–109
mm Hg) should be counselled that their risk of preeclampsia is about 20%; the risk for women with
severe hypertension (systolic pressure > 160 or diastolic pressure > 110 mm Hg) is about 50%, and
the risk for women with target-organ damage or secondary hypertension is as high as 75%
• Fetal growth restriction
• Abruptio placentae
• Preterm birth (both spontaneous and indicated)
• Caesarean delivery
The incidence of these complications appears to be related to the duration and severity
of the hypertension and the presence of superimposed preeclampsia.
MEDICATIONS
• Methyldopa most widely used and studied but limited effectiveness
• Nifedipine less well studied but appears safe
• Thiazide diuretics, ACE inhibitors and angiotensin receptor blockers
contraindicated because teratogenicity risk
FAMILY PLANNING NEEDS
• A reproductive life plan should be encouraged.
• Women / couples need to be aware of potential for progression of
disease when choosing the optimal time to conceive.
• Estrogen containing contraceptives are not recommended (may
increase BP and increase risk of cardiovascular events).
• Progestin only methods are probably safe.
• Women taking potentially teratogenic drugs (example ACE inhibitors)
should be counseled about importance of using effective
contraception.
PRECONCEPTION CARE
• Prevent unplanned pregnancies.
• Discuss consequences of delayed childbearing.
• Coordinate with internist for controlling hypertension (target BP < 140/90
s/d < 160/110)
• Avoiding teratogenic medications.
• Control of BP via lifestyle and diet modification and antihypertensive
medications.
• Goal to prevent cardiovascular complications.
• Assess for etiology of hypertension and for evidence of end organ disease
(example renal dysfunction, retinopathy and ventricular hypertrophy).
PRECONCEPTION CARE
• Counsel on risk of poor pregnancy outcomes.
• Counsel on optimal time to conceive (once BP under control and
before the development of end organ disease)
• Counsel not to suddenly discontinue medication if conceives
• Encourage early into prenatal care
PRECONCEPTION CARE
• Laboratory investigations including a complete blood count, serum
creatinine level and hepatic transaminase levels, as well as 24-hour
urine collection to test protein and creatinine clearance.
• An electrocardiogram to detect left ventricular hypertrophy. If
hypertrophy is detected, obtaining an echocardiogram should be
considered.
• In patients with poorly controlled disease or known heart or kidney
disease, other evaluations for target-organ damage, such as
hypertensive retinopathy, could be considered before conception.
PRECONCEPTION CARE
• No evidence that medical management of HT during pregnancy
reduces pregnancy complications.
• Severe or complicated HT is more often associated with poor
pregnancy outcomes.
• No conclusive data on optimal antihypertensive medication to
choose.
PREVIOUS PREECLAMPSIA
• History of previous preeclampsia is a known risk factor for recurrence
in a future pregnancy.
• The results from relevant studies is difficult due to many confounding
variables in the patient selection and methodology used, which lead
to rates of recurrence varying from < 10% to 65%.
PREVIOUS PREECLAMPSIA
• Acute and long-term consequences for the mother and the offspring
including increased risk of chronic hypertension, cardiovascular
disease, stroke, and metabolic syndrome for the mother.
• Complications of prematurity for the neonate, along with increased
risk of hypertension, diabetes, and neurological impairment later in
their lives.
• Psychological consequences from experiencing preeclampsia,
especially in severe cases, also have been reported for the woman
and her family.
PRECONCEPTION CARE
 Risk factors can be
controlled preconception
↖︎ Determine any comorbidities
• obesity
• chronic hypertension
• diabetes
• autoimmune disease
• lifestyle
Perform a complete evaluation to assess baseline medical conditions.

• Identification type 2 DM, obesity, Seek secondary causes of

hypertension, autoimun and hypertension

renal disease. Investigate potential target

organ damage
• Identification family history of Detailed medical history
preeclampsia, type 2 DM, Family history
autoimun and renal disease.
• Asses physical examination,
especially basal blood pressure.
Chronic hypertension, diabetes mellitus,
• Laboratory marker : blood autoimun disease, thrombophilia, renal disease,
obesity
glucose, profil lipid and urin
DIABETES MELLITUS
• Definition :
Diabetes is a chronic, metabolic disease characterized by elevated
levels of blood glucose, which leads over time to serious damage to the
heart, blood vessels, eyes, kidneys and nerves.
IMPLICATION FOR THE WOMAN IF SHE
CONCEIVES
• Presence of vasculopathy, hypertension or poor glycemic control are
risk factors for the development of preeclampsia.
• Progression of pre-existing nephropathy is possible during pregnancy
• Progression of retinopathy is often accelerated in pregnancy
threatening vision.
• Increased risk of urinary tract infection (which is a risk factor for
diabetic birth and ketoacidosis)
IMPLICATION FOR PREGNANCY
OUTCOME
• Abortion
• Congenital anomalies related to glycemic control.
• Fetal growth disturbances (macrosomia and IUGR)
• IUFD
• Premature (spontaneous and indicated)
• Preeclampsia
• Polyhydramnios and PROM
• Perinatal mortality : respiratory distress, hypoglycemia, jaundice
Association between preconception FPG and adverse pregnancy outcomes.

Wei Y, Xu Q, Yang H, Yang Y, Wang L, et al. (2019) Preconception diabetes mellitus and adverse pregnancy outcomes in over 6.4 million women: A
population-based cohort study in China. PLOS Medicine 16(10): e1002926. https://doi.org/10.1371/journal.pmed.1002926
https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002926
Hanson MA, Gluckman PD, Ma RC, Matzen P, Biesma RG. Early life opportunities for prevention of diabetes
in low and middle income countries. BMC Public Health. 2012;23(12)10-25.
MEDICATION
• Limited data on oral hypoglycemics and pregnancy. Metformin and
glyburide are the most well studied.
• Statins : limited data on safety but theoretic concerns because of the
role of cholesterol in embryonic development.
• ACE inhibitors often prescribed to limit progression of nephropathy,
should be discontinued prior to conception (related wirh fetal anomaly
cardiovascular, CNS and renal).
• Recomendation : insulin for glycemic control. Some express concern that
optimal pregestational control can only be achieved with insulin.
Review current medication list for diabetes and switch from oral
hypoglycemics to insulin to achieve target blood glucose levels before
conception. Review other medications as well.
FAMILY PLANNING NEEDS
• A reproductive life plan should be encouraged.
• No specific contraindications to any contraceptive method in women
with diabetes who do not have end-organ dysfunction.
• Estrogen containing contraceptives shoud avoid in women with
evidence of vascular or other end organ dysfunction.
• Unplanned pregnancy occur in about one third of diabetes women.
• Discontinue contraception if stable glycemic control, maternal
diabetic complication and coexisting medical problems acceptable.
FAMILY PLANNING NEEDS
• Potential contraindicated to pregnancy
• Ischemic heart disease
• Active proliferative retinopathy
• Renal insufficiency
• Severe gastroenteropathy
PRECONCEPTION CARE
• Prevent unintended or unplanned pregnancies
• Discuss consequences of delayed childbearing.
• Educate about increased risk of congenital anomalies and the dramatic
benefits of tight glucose control; educate about other to both mother
and fetus.
• Educate the women / couple about the demanding prenatal regimen
used to identify any risks to maternal or fetal health as early as possible
• Educate and emphasize self-management skills with preset monitoring
targets
• Engage with endocrinologist in coordinated preconception care.
PRECONCEPTION CARE
• Consider substituting insulin for oral hypoglycemic.
• Adjust medication regimen to achieve optimal glycemia for embryonic
development.
• Goals : HbA1c < 6%, fasting blood glucose 60 – 90 mg/dl ; 1 hour pp <
140 mg/dl ; 2 hous pp < 120. HbA1c monitor every 1 – 2 months.
Normal achieved for 2 – 4 months.
• Goals achieved by home monitoring, multiple daily injections, close
supervision, education
• Counsel to postpone conception until optimal control is achieved and
stable.
PRECONCEPTION CARE
• Seek evidence of coronary artery disease (CAD) or cardiomyopathy
through history and physical exam (consider EKG in patients with
longstanding diabetes). If detected CAD, poses a 5 – 15 % risk of
maternal mortality.
• Individualize further workup based on findings of age, duration of
disease, family history, profil lipid, etc.
• Should take into consideration the likely progression of their disease
when choosing to conceive
• Folic acid 4 mg/day 1 months before pregnancy
PRECONCEPTION CARE
• Laboratory test : TSH, fT4
• In women with long standing diabetes screen for
• Proliferative retinopathy (may progress during pregnancy)
• Nephropathy using creatinine and protein excretion (may increase maternal
and fetal risks)
• EKG : CAD (may better tolerate pregnancy after revascularization)
• Urinary tract infection.
• Neuropathy abnormalities if indicated.
PRECONCEPTION CARE
• Testing to detect prediabetes and risk of DMG in asymptomatic
women should be considered in adults who are :
• Overweight or obese
• History of DMG
• Poor obstetrics outcome
• Family history of DM
• PCOS
• Increased maternal age
• Chronic hypertension
• History of cardiovascular disease
 Fig. 1

Clinical Epidemiology and Global Health 2019 7418-423DOI: (10.1016/j.cegh.2018.11.005)

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COUNSEL PARTNER
• Engage partner in achieving planned, healthy pregnancies with their partners.
• Partner should be encouraged to develop a reproductive life plan to guide decisions
about reproductive health.
• The CDC recommends that all men have a preventive care prior to conception to
promote physiologic and emotional wellness, manage chronic health conditions,
and educate men about the importance of avoiding sexually transmitted infections,
substances, and toxic exposures.
• Men should be made aware of factors that can lead to decreased fertility and how
to avoid them.
• Counsel men on the importance of supporting their partner in efforts to adopt a
healthy lifestyle, follow treatment plans for chronic conditions, and take responsible
steps to ensure planned, appropriately spaced pregnancies.
CONCLUSION
• Increase clinician awareness, one of the most intervention to decrease
maternal perinatal mortality and morbidity is early management of preparation
for planned conception in women with metabolic disease.
• Multidicipline approach with other specialities to manage during
preconception.
• Contraception is needed when chronic metabolic disease not be controlled yet.
• Education about implication for the women if she conceives and about
pregnancy outcome.
• Never easy to specify the best management during preconception in a woman
with metabolic disease. Each patient’s risk must be considered individually.
Thank you