Pregnancy With Internal Pregnancy With Internal Medical DiseasesMedical Diseases

Yinglin Liu( 刘颖琳 )MD&PhD, Department of Gyn & Obs

The 2nd Affiliated Hospital of Sun Yat-sen University

EmphasisEmphasis

Pregnancy complicated with:Heart Disease(HD)Viral HepatitisGestational diabetes mellitus(GDM)

Key pointsKey points

Clinical manifestation, diagnosis, and management

Influence between disease & pregnancy(mothers & fetuses)

Types of Heart DiseaseDiagnosis of early heart failure(HF)Maternal-fetal transmission of hepatitis B

virusDefinition of GDM

Part One Part One Cardiovascular DiseasesCardiovascular Diseases

Pregnancy complicated with Heart Disease

Incidence of pregnancies:1-4%

Death rate: 0.6%-2.7%

2nd leading cause of maternal mortality: 8.3%

Influence 0f Pregnancy on Influence 0f Pregnancy on Cardiovascular systemCardiovascular system

During Pregnancy(32-34wks)

During Labor

Puerperium (first 3 days)

Hemodynamic and respiratory Hemodynamic and respiratory change of normal pregnancychange of normal pregnancy

Blood volume: ￪ 25-50% 32-36wksCO: ￪ 30-50% 20-30wksHR: ￪ 10-25bpmVascular resistance: ↓ 40-50%O2 consumption: ￪ 15-30%Tidal volume: ￪ 40%

During laborDuring labor

First stage:

Each ut. Con. CO ↑24%

extrudes 500 ml CVP↑

blood to peripheral cir.

MAP ↑ 10%

(MAP: mean arterial pressure)

During laborDuring labor

Second stage:

Bearing down effort Pulmonary pressure ↑

Congenital heart dis.

Blood shunt(L→R) → Blood shunt(R→L)

During laborDuring labor

Third stage:

1. After placenta elimination→

placental cir. disappears 500ml blood evacuated u. contracts enter circulation

2. u. shrinks → intra-abd. pressure ↓ → blood accumulated in visera

PuerperiumPuerperium

First 3 daysRetension fluid go back to circulationUterus shrinks further

The types of Heart Disease The types of Heart Disease Complication PregnancyComplication Pregnancy

I. Congenital heart diseaseⅡ. Rheumatic heart diseaseⅢ. Cardiovascular disease of hypertensive

disorder complicating pregnancyⅣ. Peripartum cardiomyopathy,PPCMⅤ. Myocarditis

Congenital heart diseaseCongenital heart diseaseBlood shunt only from L to R / No blood shunt

Blood shunt from R to L

Noncyanotic CyanoticAtrial septal defect, ventricular septal defect, Patent ductus arteriosus

Pulmonary stenosis, Coartation of aorta, Marfan’s syndrom

Tetralogy of Fallot

Eisenmenger’s syndrom.

Withstand hemodynamic change of pregnancy and labor with small shunt

Pregnancy is contraindicated

With large L-to-R shunt: pulmonary artery hypertension ， right-left shunt ， cyanosis

Rheumatic heart diseaseRheumatic heart disease

• Mitral stenosis• Aortic stenosis• Mitral or aortic insufficiency And combinations of those above

Heart Disease of hypertensive Heart Disease of hypertensive disorder complicating pregnancydisorder complicating pregnancy

Heart burthen coronary artery spasm systemic arterial spasm retention of water and sodium viscosity of blood ↑ Contraction force weaken ↓

cardiac muscle ischemic hypoxia systemic arterial spasm

Peripartum cardiomyopathyPeripartum cardiomyopathy (PPCM)(PPCM)

Cause: unknown.(viral infection, genetic factors, autoimmunity, mal-nutrition, etc), no cardiac history before pregnancy.

Period: late trimester ~ 6 months after deliverySymptoms&signs(HF): dyspnea, palpitation, cough,

emptysis, orthopnea, chest pain, hepatomegaly, edema, organic embolism, dyspnea ， thoracalgia ， edema ， hepatomegaly ect

X-ray: dilatation of heart, pulmonary congestionEcho-CG, ECG: Heart chambers dilatation ,left

ventricular hypertrophy, S-T seg. abnormal T waveHF, pulmonary infarction or arrhythmia may cause death.

PPCM

50% recover 6 months postpartum– Recur in the successive pregnancy– Clinical Implications ： 10-30% of

fetal death– Therapy

Treatment for heart failureHeart transplantation

Myocarditis and SequelaesMyocarditis and Sequelaes Symptoms may occur after viral infection: enteric virus ，

Coxsackie virus ， Rubella virus ， cytomegalovirus History of respiratory tract or alimentary infection,

fatigue, palpitation, dyspnea, uncomfortable on anterior chest

Lab.test:CRP ￪ , SR ￪ , enzyme, Ab ￪ (3wks) Abnormal ECG Even heart failure after two-three weeks of infection Not cure with disease for six months——myocarditis

sequelae Acute myocarditis cured——keep on pregnancy

Influence of Heart Diseases Influence of Heart Diseases on Fetuseson Fetuses

Abortion, premature labour, fetal death, FGR(fetal growth retardation) and fetal distress , mortality

Drugs (digoxin) can pass through the placentas and is danger for the fetuses.

Genetic problem Increased caesarean section rate

Symptoms & signs of normal Symptoms & signs of normal pregnancy mimicking HDpregnancy mimicking HD

Symptoms Palpitation, dyspnea / orthopnea, easy fatigability,

dizziness, nocturnal cough

Signs Displacement of apex Sinus tachycardia S1 of apex / S2 on PV ￪ & split, systolic murmur,

third heart sound Prominent jugular venous pulsations

Diagnosis Diagnosis of Heart Diseaseof Heart Disease

HistorySypmtoms: physical dyspnea, emptysis, orthopnea,

palpitationSigns: ≥Ⅱ dia. mur. or≥ III sys. mur, dia. gallop

rhythm,pericardial friction rub,alternating pulse, cyanosis, clubbing of fingers, persistent neck vein distention

ECG: serious arrhythmia (auricular fibrillation or flutter, AVB), abnormal ST

X-ray: Cardiomegaly Echocardiography: movement and construction

Functional Classification of Functional Classification of Heart Disease Heart Disease –– subjective subjective

sym.sym.

Class I: NO limitation to normal active life

Class II: Slight limitation of physical activity

Class III: Marked limitation of physical activity

Class IV: Complete limitation of physical activity

Clinical Classification Clinical Classification –– objective detectionobjective detection

Class A: No evidence of cardiovascular diseas

Class B: minimal cardiovascular disease according to examination

Class C: Moderate cardiovascular disease Class D: Severe cardiovascular disease

According To The PatientsAccording To The Patients’’ Ability Ability To Cope With PregnancyTo Cope With Pregnancy

Conditions allowable for pregnancy: Cardiac function is I or II, slight typesConditions unsuitable for pregnancy : Severe types, class III or IV, history of HF,

pulmonary hypertension, R to L shunt, severe arrhythmia, active rheumatic HD, combined valvar HD, Bac.endocarditis, acute myocarditis, enlargement of heart.

>35ys, long history.

Common complicationCommon complication

Heart failureSubacute infective endocarditisHypoxia & CyanosisVenous & pulmonary embolism

Diagnosis Of The Early Diagnosis Of The Early Cardiac FailureCardiac Failure

1. Stuffy, palpitation, short-breath after slight physical activity, nocturnal cough;

2. HR>110 bpm at rest, R>20 times/min;

3. Paroxysmal nocturnal dyspnea/ Orthopnea may be the very early symptoms;

4. Persistent basilar rales, even after couph.

ManagementManagementI. Prepregnancy

II. During Pregnancy

1. Therapeutic abortion

2. Antenatal examination

3. Prevention of cardiac failure

Prevention of cardiac failurePrevention of cardiac failure• Quiet & rest(>10hrs/d)• Nutrition: pro.& Vit, sodium & fat. weigh gain<10kg,

limited salt intake: <4-5g after 16 weeks, fluid replacement limited in 500~1000ml/d ， drop velocity <60ml/h

• Therapy of inducement: prevention of URI.; correct anemia & arrhythmia; therapy of EPH-syn; multiple and small amounts （ 150~200ml ） blood transfused if needed

Therapy of cardiac failure: digoxin (0.25mg, Bid), 2~3d qd. Diuretics. Vessel dilating agents.

Cesaren section. Timing is important.• Observe

To choose suitable birth wayTo choose suitable birth way

Trial labour: class ~ of cardiac function, Ⅰ Ⅱmoderate fetal size, normal fetal position, cervical condition is good enough.

Cesaren section: class ~ of cardiac Ⅲ Ⅳfunction, large fetal size, obstetric condition is not so good.

Management During DeliveryManagement During Delivery

• 1st stage: sedatives; surveillance (BP, P,R,HR); O2; digitalis; antibiotics

• 2nd stage : Bearing down effort should be avoid -- episiotomy, elective forceps and vacuums extraction

• 3rd stage: Sand bag, Oxytocin (ergometrine should be avoid)

• Who has torpidity labor or cephalopelvic disproportion or grade heart function should undergo cesarean section

Management During Management During PuerperiumPuerperium

• Careful observation (first 3 days)• Antibiotics (7 days after labour)• Breast feeding should be avoid in some

patients(III or IV cardiac function) : natrii sulfas ， not estrogen• Contraception and sterilization (1 week

after labour)

Heart SurgeryHeart Surgery

• Should not be done during pregnancy • <12 weeks of gestation• Prevention of abortion & infection

Part Two Acute Viral Hepatitis

Physiological Changes of Physiological Changes of Liver During PregnancyLiver During Pregnancy

Blood flow, size

AST/ALP

ALP, fibrinogen↑, Coagulative factors ↑ ,

A/G

The Effect Of Pregnancy On The Effect Of Pregnancy On HepatitisHepatitis

• More nutrition is needed• Hyperemesis gravidarum • The liver burden (maternal & fetal metabolism). • Endocrine change (estrogen )• Hypertensive disorder complicating

pregnancy,ICP,AFLP• During labor Postpartum hemorrhage Maternal mortality rate elevated

The Effect Of Viral Hepatitis On The Effect Of Viral Hepatitis On Pregnancy: For Gravidas Pregnancy: For Gravidas

• Mortality ↑18.3%• Worsen pregnant reaction• Hypertensive disorder complicating

pregnancy↑ (Aldosterone)• Postpartum hemorrhage , DIC↑

(coagulative factors)

The Effect Of Viral Hepatitis The Effect Of Viral Hepatitis On Pregnancy: For FetusesOn Pregnancy: For Fetuses

Malformation

Abortion

Premature labor

Fetal demise / still birth

Fetal malfromation

Perinatal mortality ↑ 46 ‰

Perinatal transmission

Materno-Fetal Transmission Materno-Fetal Transmission (HBV)(HBV)

• Intrauterine infection (9.1%~36.7%)

Impaired placental barrier, penetrability , leakage

• During delivery (40%~60%)

Mother’s blood or vaginal secretion• Postpartum

Sweat, saliva & milk

DiagnosisDiagnosis

• History• Symptoms• Sign• Laboratory examination: HBsAg, HBeAg,

HBVDNA, HBc-IgM

HBsAg: Active HBV infection; may be acute or chronic

HBeAg: High infectivity, active viral replication

HBcAg: Active copying, undetectable in serum

Anti-HBcAg IgM: Acute HBV infection (newer and more sensitive assays may also be positive during reactivation of chronic infections)

HBV-DNA and DNA polymerase: Direct measure of infectivity or replicative state; becoming increasingly available

Anti-HBsAg: Immune to HBV; may be natural immunity or following vaccination

Anti-HBeAg: Low or no infectivity; need only be measured in chronic HBV

Differential DiagnosisDifferential Diagnosis

• Hyperemesis gravidarum: ketosurine(+)• Hypertensive disorder complicating

pregnancy: hypertension, proteinuria, edema, renal function . HELLP Syn.

• AFLP (Acute fatty liver of pregnancy)• Liver lesion caused by medicine:

wintermin, luminal, erythromycin, rimifon,

Viral hepatitis ICP Acute fatty liver of pregnancy

HELLP syndrome

Hyperemesis gravidarum

Drug induced hepatitis

onset All time Late Late Late Early All time

Inducement - - - PIH - Drug use

symptoms Gastrointestinal, jaundice

pruritus-jaundice

epigastric pain, vomiting, acute liver failure

epigastric pain, jaundice, bleeding

Prolonged vomiting

Jaundice and prutitus after drug intake

Lab findings Hepatitis virus positive

Cholic acid serum bilirubin urine bilirubin(-)

Hemolysis, coagulopathy, BPC

Water, salt and ph imbalance

acidophil

Hepatic disfunction

Light-severe light Acute and severe

severe light light

pathology Hepatocyte damage

Intrahepatic cholestasis

Fat filled in cytoplasm

ischemia light light

fetus Malformation,demise

distress death death light light

prognosis prolonged Recover after delivery

poor Recover after delivery

recover Recover

Management Of Hepatitis

• Slight type: nutrition & rest• Severe type:

Liver protection (glucagon-insulin-glucose)

Prevention & therapy of hepatic coma, DIC & renal failure

Obstetric Management Obstetric Management • 1st trimester : artificial abortion• 2nd / 3rd trimester: avoid operation & drug,

fetal surveillance, prevention of EPH-syndrome

• During labor: Vit K, fresh blood; avoid bleeding; oxytocin; antibiotics

serious case --- Cesarean section 24hrs after• Puerperium: antibiotics; Stop Breast feeding (

HBVDNA /HBeAg+ in milk) disuse estrogen

PreventionPrevention

Enhence peripartum health care: surveillance, nutrition, serological screening

Prophylaxis of HAV: -globulin 2~3 ml im. within 7 days

Prophylaxis of HCV: diminish nosocomial transmission. γ- globulin

HBV Immunoprophylaxis

• Active immunity: HB vac (vaccine) 30 μg im. (<24hr, 10 μg 1st, 6 th month)

• Passive immunity: HBIG 0.5ml im.(just born), 0.16ml/kg (1, 3 months)

• Combined immunity:

active immunity plus HBIG 0.5ml im.(<24hr after birth)

Part IIIPart III Diabetes Mellitus Diabetes Mellitus

Gestational Diabetes Gestational Diabetes Mellitus(GDM)Mellitus(GDM)

Definition: It is the first time for D.M. to be found just during pregnancy.

Diagnostic standard: ①At least two values are abnormal in OGTT

(oral glucose tolerance test). (5.6-10.3-8.6-6.7mmol/l)② Fasting plasma glucose ≥5.8 mmol/L (105mg/dl) twice.

Effects of Pregnancy on Effects of Pregnancy on DiabetesDiabetes

Placentas →E3, HPL,…↑→antagonize insulin:• Latent D.M. →apparent type• Situation → worse →coma• More and more insulin is needed to be used.

Effects of Diabetes on Effects of Diabetes on Pregnancy Pregnancy (Gravidas)(Gravidas)

1. Natural abortion ↑ 15%~30%.

2. EPH-syn. 3-5 times ↑

3. Infection ↑ (WBC function ↓)

4. Prolonged labor and postpartum hemorrhage

5. Hydramnios and macrosomia

6. Ketoacidosis

Effects of Diabetes on Effects of Diabetes on Pregnancy Pregnancy (Fetuses)(Fetuses)

1. Fetal macrosomia: 25%~40%.

2. FGR: 21%.

3. Premature labour: 10%~25%

4. Fetal malformation: 6%~8%

5. Perinatal death rate ↑

Effects of Diabetes on Effects of Diabetes on Pregnancy Pregnancy (Neonates)(Neonates)

1. Respiratory distress syndrome (RDS) : mothers Glu.↑→ fetuses → Insulin↑ → antagonize the glucocorticoid (promote synthesis of surfactant) →surfactant↓.

2. Neonatal hypoglycemia:

intrauterine Glu.↑→ fetuses’ Insulin↑ → after birth → no Glu. → hypoglycemia

Minor adverse health effects for offspring in GDM

Birth Wt (g) 3303±64 3649±51 3849±72 <0.01

Macrosomia(%) 8 36 47 <0.01

C-S 5 10 14 <0.01

Hypoglycemia 2 28 52 <0.01

Hypocalcemia 0 4 7 <0.01

Hyperbilirubinemia 15 23 21 <0.01

Polycythemia 0 7 11 <0.01

Cord C-Pep 1.18±0.1 2.07±0.12 2.98±0.22 <0.01

Cord Glu 100±3.6 103±2.9 114±5.5 <0.01

Normal GDM DM P

DiagnosisDiagnosis• History• Laboratory examination:Fasting blood sugar ≥5.8 mmol/L at least

twice can be diagnosed as D.M.Screening test— Glu.50g →1hr.plasma

glucose ≥7.8 mmol/L (140mg/dl).OGTT -- Glu.75g →0, 1, 2, 3hrs (5.6, 10.3,

8.6, 6.7 mmol/L ) 2 values↑→GDM; 1 values↑→GIGT

White grouping

class description

A Abnormal OGTT treat only by diet therapy

B Onset at age 20years or older and duration of less than 10 years

C Onset at age 10-19 years or duration of 10-19years

D Onset before 10 years of age, duration over 20 years, exudative retinopathy

E Calcification of pelvic cavity vasculopathy by X-ray

F Nephropathy

R proliferative retinopathy

RF proliferative retinopathy and Nephropathy

G Many pregnancy failure

H coronary heart disease

T Prior renal transplantation

ManagementManagement

Ⅰ. To Estimate the Patients’ Ability to Cope With Pregnancy:

Class D, F, R → artificial abortion

Ⅱ. Dietotherapy

Balance diet: supply = consumption

With adequate proportion of various components (pro., Glucose, fat, vit, mineral)

Standard of blood glucose controled

Time blood glucose

fasting blood glucose 3.3~5.6mmol/L

two hours after meal 4.4~6.7mmol/L

at night

Before three meals4.4~6.7mmol/L

3.3~5.8mmol/L

ManagementManagement

Ⅲ. Medicinal therapy• Oral heparopen→pass placenta→fetal damage.• Insulin is the only drug to be used in gravidas.

The dosage should be moderated according to the blood glucose.

32~33 weeks: dosage reach maximum

postpartum dosage: 1/2 ~ 1/3 of maximum

Ⅳ. Materno-fetal Surveillance

Management Management ( . Termination of Ⅴ( . Termination of Ⅴpregnancy)pregnancy)

TimingIf blood glucose remain normal, pregnancy

can be prolonged as long as usual.Cesaren section: blood glucose can’t be

controlled ideally, serious EPH-syn., severe infection, FGR, fetal distress. Stop insulin 3 hours before operation

Amnionic fluid should be detected the indexs of fetal maturity by amniocentesis

Management Management (During labour & (During labour & puerperium)puerperium)

• Blood glucose and electrolytic level must be kept normal. (Glucose 4g + 1 U.) Glucose monitoring: >5.6mmol/L (100mg/dL)

• Labour and fetal monitoring maintain in whole period(12hrs). Vaginal delivery– Control the whole course within 12 hours

• Epidural anesthesia• After labour, dose of Insulin 1/2(< 24 hrs)• Puerperium: prevention of postpartum hemorrhage

& infection. insulin requirements recover at progestation dose post partum1~2weeks

Low-dosage constant insulin infusion for the intrapartum period

blood-glucose (mg/100ml ）

Insulin dosage （ U/h ）

fluids （ 125ml/h ）

<100 0 5%dextrose/lactated Ringer’s solution

100~140 1.0 5%dextrose/lactated Ringer’s solution

141~180 1.5 Normal saline

181~220 2.0 Normal saline

>220 2.5 Normal saline

dilution is 25U regular insulin in 250ml normal saline, administerd intravenously

Management of NeonatesManagement of Neonates

Treat them as preterm infants!Prevention of hypoglycemia(<2.22mmol/L),

hypocalcemia, jaundice & RDS.

Feeding them with 25% Glucose solusion.

(beginning from 30 minutes after birth.)

Prognosis

tendency to recur next pregnancythe risk of type diabetes riseⅡdevelop obesity and typeⅡ diabetes easily in

adult

Key pointsKey points Clinical manifestation, diagnosis, and

management of Pregnancy With Internal Medical Diseases(HD, Viral Hepatitis, GDM)

Influence between disease & pregnancy(mothers & fetuses)

3 danger phases in pregnancy with HD Types of Heart Disease Diagnosis, prophylaxis/treatment of early HF Maternal-fetal transmission of hepatitis B virus Definition of GDM

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