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RISKY PREGNANCIES MANAGEMENT
GUIDELINE
RISKY PREGNANCIES MANAGEMENT
GUIDELINE
High-Risk Pregnancies Management Guideline
Republic of Turkey Ministry of Health
Public Health Agency of Turkey
Department of Women’s Health and Reproductive Health
Ankara, 2014
Ministry of Health Publication No: 926
This work was prepared and published by the Republic of
Turkey, Ministry of Health, Public Health Agency of
Turkey, Department of Women’s Health and Reproductive
Health. All rights of publication of this work belong to the
Public Health Agency of Turkey. No quotations can be
made without citing the source. This work cannot be
reproduced or published, even if partially. When quoting
from this work, the source should be cited as follows:
“Risky Pregnancies Management Guideline”, The Republic
of Turkey, Ministry of Health, Public Health Agency of
Turkey, Publication No, Place of Publication and Date of
Publication.
Free of charge. Not for commercial use.
Cover Design: Graphic Designer Umman SEZGİN
FOREWORD
As a multidimensional development indicator, maternal and infant
mortality rates are closely linked to the quality of reproductive health
services delivery. Complications during pregnancy, labour and
puerperium are leading causes of death and disability among women
of reproductive age in developing countries. According to the
estimations of World Health Organisation, each year about 287,000
maternal mortality cases occur. Millennium Development Goal 5 aims
at improving maternal health. It has been determined that countries
can attain this goal by reducing maternal mortality and by ensuring
universal access to reproductive health.
While in 2002 maternal mortality rate was 64 in one hundred
thousand live births, according to National Maternal Mortality Survey
conducted in 2005 it decreased to 28.5, and it was reduced to 15.4 in
2012 thanks to various programmes conducted. Turkey’s success in
reducing maternal mortality is highly appreciated by WHO, and it has
set an example for other countries. In achieving all these, besides
overall development in Turkey, strengthening prenatal, delivery and
postnatal care and emergency obstetric care and ensuring that delivery
takes place at hospital have made a significant contribution.
Maternal mortality due to any preventable reason cannot be accepted.
Our efforts to prevent maternal mortality will continue increasingly.
As is known, it becomes more challenging to go beyond what has
already been achieved in the field of maternal and infant mortality.
We have to do more than what has been done to date and we have to
do it with higher quality. To do so, we have to keep the knowledge
and skills of the health personnel at the highest level possible as well
as making up the deficiencies of medical equipment and infrastructure
in health institutions. Under the scope of “High-Risk Pregnancies
Prevention Programme”, High-Risk Pregnancies Management
Guideline has been prepared in order to deliver high-quality, standard
and safe services to manage highly risky conditions leading to
maternal mortality, and to achieve uniformity in practice. The
Guideline is composed of Management Guideline for Venous
Thromboembolism in Pregnancy, Pregnancy and Cardiovascular
Diseases Management Guideline, Management Guideline for
Pregnants with Epilepsy, Management Guideline for Pregnants with
Diabetes and Management Guideline for Pregnants with Asthma.
The Guideline encompasses actions and operations to be performed
during prenatal period, delivery and postnatal period, and it requires
coordination between primary care and other health institutions and a
multidisciplinary approach through relevant specialities.
High-Risk Pregnancies Management Guideline has been developed
by the Scientific Commission of the Ministry presented below, and it
has been finalized through the comments of relevant associations. In
the process of the development of the Guideline, evidence-based
medical practices have been taken into account, and it has been
developed by taking into consideration country-specific features. It
has been agreed that the guidelines will be updated minimum every
two years, and new management guidelines will be developed on the
basis of risks to be identified.
We would like to render our thanks to members of the Scientific
Commission who have contributed to the preparation of the guideline,
institutional staff working for the programme, associations and staff
working with devotion in the field in order to prevent maternal
mortality and healthcare staff who will be implementing these
guidelines.
These guidelines are not a set of fixed rules and do not form legal
standards of the services delivered to patient. In accordance with the
main principle of the law “there are no diseases but patients”, it is
recognized that the specific condition of each patient should be
considered within his/her specific circumstances.
Presidency of Public Health Agency of Turkey
Members of the Scientific Commission and the Agency staff
involved in the programmes are presented below in alphabetical
order by their surname.
Scientific Commission for
High-Risk Pregnancies
Management Guideline
Prof. Dr. Nazlı ATAK
Prof. Dr. Sinan AYDOĞDU
Prof. Dr. Cengiz BEYAN
Prof. Dr. Yahya BÜYÜKAŞIK
Assoc. Prof. Dr. Zeki ÇATAV
Prof. Dr. Selçuk DAĞDELEN
Assoc.
Prof.
Dr.
Nuri
DANIŞMAN
Prof. Dr. Özgür DEREN
Specialist Deniz ERDEM
Dietician Şeniz ILGAZ
Assoc.
Prof.
Dr.
Ömer
KANDEMİR
Prof. Dr. Gül KARAKAYA
Prof. Dr. Faik Acar KOÇ
Assoc. Prof. Dr. Gülnihal
KUTLU
Prof. Dr. Tamer MUNGAN
Prof. Dr. Dilşat MUNGAN
Specialist Veli Dündar ONGUN
Prof. Dr. Necla ÖZER
Assoc.
Prof.
Dr.
Ferit
SARAÇOĞLU
Prof. Dr. Serap SAYGI
Prof. Dr. Mehmet Zeki TANER
Prof. Dr. Ahmet TEMİZHAN
Prof. Dr. Yusuf ÜSTÜN
Prof. Dr. Filiz Bilgin YANIK
Prof. Dr. İlhan YETKİN
Programme Officers of PHAT
Department of Women’s Health
and Reproductive Health
Nurse Hacer BOZTOK
Nurse Meltem KARAMAN
Dr. Zübeyde ÖZKAN ALTUNAY
Specialist Sema SANİSOĞLU
Department Head
Specialist Bekir KESKİNKILIÇ
Deputy President of PHAT
Prof. Dr. Seçil ÖZKAN
President of PHAT
Relevant Associations Sharing Their Comments
Turkish Society of Obstetrics and Gynaecology
Turkish Perinatal Society
Turkish Chapter of International League Against Epilepsy
Turkish Neonatology Society
Turkish Thoracic Society
Turkish Society of Cardiology
Turkish Society of Hematology
Turkish Society of Maternal Fetal Medicine and Perinatology
The Turkish Diabetes Foundation
The Society of Endocrinology and Metabolism of Turkey
Turkish National Society of Allergy and Clinical Immunology
Turkish Respiratory Society
Publication Commission
Assistant Prof. Dr. Hasan IRMAK
Deputy President of PHAT
Assoc. Prof. Dr. Nazan YARDIM
PHAT, Department Head,
Department of Obesity, Diabetes
and Metabolic Diseases,
Dr. Kanuni KEKLİK
PHAT, Department Head,
Department of Community Care
Services,
Specialist M. Bahadır SUCAKLI
PHAT, Department Head,
Department of Early WarningResponse and Field Epidemiology,
Publication Coordinators
Specialist Bekir KESKİNKILIÇ
Deputy President of PHAT
Specialist Sema SANİSOĞLU
PHAT, Department Head,
Department of Community Care
Services,
Dr. Zübeyde ÖZKAN ALTUNAY PHAT, Department of Community
Care Services,
Nurse Hacer BOZTOK (Editing)
PHAT, Department of
Women’s Health and Reproductive Health
i
TABLE OF CONTENTS
MANAGEMENT GUIDELINE FOR VENOUS
THROMBOEMBOLISM IN
PREGNANCY………………………………………………...1
MANAGEMENT GUIDELINE FOR PREGNANCY AND
CARDIOVASCULAR DISEASES
…………………………………………………………………..23
DIABETIC PREGNANCY MANAGEMENT GUIDELINE
………………………………46
EPILEPTIC PREGNANCY MANAGEMENT
GUIDELINE……………………………….…59
MANAGEMENT GUIDELINE FOR PREGNANTS WITH
ASTHMA……………………………………..65
ii
iii
MANAGEMENT GUIDELINE FOR VENOUS
THROMBOEMBOLISM IN PREGNANCY
iv
A-PRECONCEPTION THROMBOPROPHYLAXIS
Pregnancy is an independent risk factor for deep vein thrombosis
and pulmonary embolism. Pregnant women carry 5-6 times more
risk of venous thromboembolism (VTE) compared to nonpregnant women in the same age group. About 1 out of every 1000
births is complicated by venous thrombosis, and 1 out of every
1000 women suffers from thrombosis in the postpartum period.
Thus venous thromboembolic diseases are among the leading
causes of maternal mortality and morbidity. Furthermore, venous
thromboemlism incidence is 2-4 times higher in caesarean section
delivery compared to vaginal delivery.
Risk factors assessments concerning thromboembolism should
begin with the monitoring of women in age group 15-49. Women
with thromboembolism should receive counselling from healthcare
staff before conception. Importance of regular follow-up and
counselling should be underlined. If there is no intention of
conception, patient should be referred to Family Planning Clinic.
 During counselling, information should be provided about the
following: effect of thromboembolism on pregnancy, effect of
pregnancy on thromboembolism and effects of medications
used to treat thromboembolism on pregnancy, whether there is
a need to change medicines, potion, and drug interactions.
 Follow-up in prenatal period, during pregnancy and in
postpartum period should be conducted by specialists
experienced in haemostasis and gestation (in line with
principles specified in Table 2).
 Pregnancy should be planned. Change of medication change
should be made minimum 6 weeks prior to the planned
pregnancy. Individuals with high risk of thrombosis should be
2


monitored through pregnancy test every month, and
medication should be changed when the test result is positive.
In order to minimize malformations likely to occur in baby,
folic acid supplement should be initiated 3 months prior to
conception, and should continue until the end of 10th week of
pregnancy.
All pregnants should be subject to risk factors assessment in
line with Table 1 against VTE in pregnancy period or in early
pregnancy period. This assessment should be repeated when
the pregnant is hospitalized for any reason or when
accompanying problems develop. While assessing risk factors,
routine hereditary thrombophilia screening should not be
conducted in asymptomatic cases.
3
Table-1: Risk Factors
Timing
Preexisting
Factors
A- Previous venous thromboembolism
B- Thrombophilia
1- Hereditary
 Antithrombin deficiency
 Protein C deficiency
 Protein S deficiency
 Factor V Leiden
 Protrombin gene G20210A
2- Acquired
 Antiphospholipid syndrome
 Persistent recurrent abortus
 Persistent medium/high titre
anticardiolipin antibodies or
β2 glikoprotein1 antibodies
 Medical disorders (for instance; heart or
lung disorders, SLE, cancer,
inflammatory diseases such as inflammatory
bowel disease or inflammatory polartropathy,
nephritic
syndrome-proteinuira
>3gr/day,
sickle cell anaemia,
diseases requiring
intravenous medicine
 Above the age of 35
 Obesity prior to pregnancy or during early
pregnancy
(BMI>30kg/m2)
4










Obstetric
New on-set
/temporary
Reversible





Parity ≥3
Smoking
Apparent varicose veins (symptomatic
and/or on knee or phlebitis, with oedema
and/or
skin changes)
Paraplegia
Multiple pregnancy, assisted reproductive techniques
Preeclampsia
Caesarean section
Postpartum bleeding requiring transfusion (>1lt)
Prolonged labour, labour through intervention
Surgical intervention during pregnancy or p
puerperality (appendectomy, postnatal sterilisation
Hyperemesis, dehydration
Ovarian hyperstimulation syndrome (OHSS)
Hospitalisation or immobilisation
(3-day and/or longer bed rest)
Systemic infection (requiring hospitalization or use of antibiotics)
(for instance; pneumonia, pyelonephritis, postnatal wound infection)
Long-distance travel (> 4 hours)
B- PRENATAL CARE AND THROMBOPROPHYLAXIS
 All pregnants should be subject to risk factors assessment
against VTE during early pregnancy.
 Pregnant woman should be informed that thrombophilia risk
normally increasing with pregnancy will increase further due
to the risks she carries, and possible developments should be
explained to the pregnant.
5
o
 As long as treatment is not contraindicated, every pregnant
whose symptoms and findings support VTE should be treated
with low molecular weight heparin or classic heparin
(LMWH/AFH) until the diagnosis has been discarded through
objective tests.
 Consider administering DMAH/AFH ON pregnants with 3 or
more of risk factors demonstrated in Table 1 (except for
previous VTE or thrombophilia) or with continuing risk factor.
 Consider continuing with prophylactic LMWH/AFH minimum
for 7 days following delivery in pregnants with 2 or more of
risk factors demonstrated in Table 1 (except for previous
VTE or thrombophilia) or with continuing risk factor.
 It should be explained to the pregnant woman taking
LMWH/AFH during prenatal period that when they have
vaginal bleeding or when labour starts, they should not take
LMWH /AFH doses until the causes of bleeding are
understood.
 If there are clinical suspicions about deep vein thrombosis
(DVT), compression duplex ultrasound scan should be
carried out.
1. If ultrasound scan is negative and clinical suspicion
is weak, stop anticoagulant therapy.
2. If ultrasound scan is negative but there are strong
suspicions, continue with anticoagulant, and
ultrasound scan should be repeated within one week.
If D-dimer level is negative it can be considered
sufficient to stop anticoagulant.
Thromborophylaxis in Pregnants with Previous VTE and/or
6
Thrombophilia:
 Action is taken in line with Table 2.
 Counselling about the impacts of warfarin on baby should be
provided to pregnant receiving warfarin therapy.
 If pregnancy is not planned, stop warfarin right after pregnancy
is confirmed and begin LMWH /AFH. Begin LMWH /AFH
immediately for pregnants not receiving warfarin.
 In
pregnants
with
thrombosis
accompanied
by
antiphospholipid
syndrome
LMWH
and
antenatal
thromproplaxis should be administered. It was shown that
aspirin at low doses improved the course of pregnancy in
pregnants with antiphospholipid syndrome and thus should be
recommended for all pregnant with antiphospholipid
syndrome. In patients with no previous miscarriage or
thrombosis which cannot be attributed to antiphospholipid
syndrome, in the presence of antiphospholipid antibodies,
LMWH or low-dose aspirin is not needed.
 D-dimer test should not be used for acute VTE diagnosis
during pregnancy.
 Begin thromboprophylaxis in prenatal period upon seeing
intrauterine gestational sac in early pregnancy period.
When a Woman with Mechanic Cardiac Valve and Thus Using
Warfarin Gets Pregnant:
 It is recommended that in the first 12 weeks, the adjusted dose
of LMWH /AFH (twice a day subcutaneous) be administered
with anti Xa control; as of week 13, begin warfarin and when
labour gets closer, again LMWH /AFH and prophylaxis are
administered.
7
 It can be used during the length of pregnancy including the
first 12 weeks in pregnants with old-type valve and that
underwent thromboembolism previously.
 75-100 mg/day aspirin therapy can be added to anticoagulant
therapy in pregnants with prosthetic valve and in those found
to be highly risky in terms of thromboembolism.
Table-2: Tromboprophylaxis in pregnants with previous VTE
and/or thrombophilia
Risk
Groups
Previous VTE
and/or trombophilia
Very high 
VTE occurred while
taking warfarin for a long time

Antithrombin
deficiency

Previous VTE
and antiphospholipid
syndrome
8
Prophylaxis
Specialities
to
plan
pregnancy
management
Antenatal high
prophylactic dose
LMWH and
postnatal
LMWH /warfarin
for minimum
6 weeks
Perinatologist
High






Moderate

Previous recurrent
or idiopathic
VTE,
Previous
oestrogen associated
(medicine or pregnancy)
VTE,
Previous VTE together with
thrombophilia,
Previous VTE together with
VTE history in family
Asymptomatic
thrombophilia (combined
defects, homozygous
Factor V Leiden,
homozygous
protrombin gene
G20210A)
Pregnants meeting
antiphospholipid
syndrome criteria
Previous single case of
VTE accompanying temporary
risk factors
without thrombophilia,
family history or other risk factors
Asymptomatic
thrombophilia
(except for antithrombin
deficiency, combined
defects,
homozygous Factor V
Leiden, homozygous
protrombin gene
G20210A)
9
Recommend antenatal
prophylactic
LMWH and
postnatal
prophylactic
LMWH for
six weeks
Perinatologist
Consider antenatal
LMWH (not
recommended
routinely),
Recommend
postnatal
prophylactic
LMWH for six weeks
Recommend
postnatal
prophylactic
LMWH for seven days
(or 6 weeks if there is
family history or
other risk factors)
Obstetrician
and
Gynaecologist
C- THROMBOPROHYLAXIS DURING LABOUR PAIN
AND LABOUR
 Risk factors should be assessed at the admission of pregnant
who has not been followed up previously and for whom there
is no management plan; medications required and their doses
should be organized by specialists experienced in haemostasis
and gestation (in line with principles set in Table 2).
 Pregnancy related prothombotic changes in coagulation system
are at their maximum right after delivery. Thus in pregnants
taking LMWH/AFH at therapeutic or high prophylactic
dose, one day before induction, heparin dose should be
reduced to thromprohylaxis dose and if appropriate should be
continued during labour and delivery. If labour is planned,
before labour, and if regional anaesthesia is going to be used,
then at the beginning of labour pain, use of LMWH/AFH
should stop minimum 12-24 hours in advance in line with the
features of anticoagulation that is preferred.
 If regional anaesthesia techniques are going to be used in
order to reduce the risk of hematom; regional anaesthesia
techniques should not be used before at least 12 hours have
passed from last LMWH /AFH prophylactic dose and before at
least 24 hours have passed from last therapeutic dose.
 LMWH/AFH should not be used for 4 hours following the
application of spinal anaesthesia or epidural catheter. After last
injection, cannula should not be removed for 10-12 hours.
 Pregnants taking LMWH/AFH during prenatal period and
with possibility of caesarean section should take
10
LMWH/AFH thromprophilactic dose one day before labour;
however, operation should be performed before the pregnant
takes the morning dose.
D-POSTPARTUM CARE AND THROMBOPROPHYLAXIS
 First thromboprophilactic LMWH/AFH dose should be
administered as soon as possible after making sure that there is
no postpartum haemorrhage and no regional analgesia has been
used.
 In the case of regional analgesia, thromboprophilactic
DMAH/AFH dose should be administered 4 hours after postoperative/epidural catheter. If epidural catheter is kept after
labour for postpartum analgesia, the catheter should be
removed 10-12 hours after the administration of LMWH/AFH
dose, and once it has been removed no LMWH/AFH dose
should be administered at least for 4 hours.
 In the case of puerperants taking LMWH/AFH in prenatal
period and having caesarean section, thromboprophilactic
LMWH/AFH dose should be administered 4 hours after postoperative/epidural catheter.
 Even if risk factors against VTE have been assessed during
pregnancy, risk factors should be reassessed in postpartum
period. While assessing the risk factors, routine hereditary
thrombophilia screening should not be conducted in
asymptomatic cases.
 In the case of pregnant women with 3 or more of the risk
factors (except for previous VTE or thrombophilia) indicated
in Table 1 or with continuing risk factor, thromboprophilactic
11





LMWH/AFH therapy should continue for 6 weeks in the
postpartum period.
In the case of pregnant women with 2 or more of the risk
factors (except for previous VTE or thrombophilia) indicated
in Table 1 or with continuing risk factor, consider
thromboprophilactic DMAH/AFH therapy for at least 7 days in
the postpartum period.
In the case of puerperants with additional extended risk factors
(lasting longer than 7 days after delivery) (for instance, in the
case of long hospitalization or wound infections)
thrombophilia should be extended for up to 6 weeks or until
additional risk factors disappear.
In the case of pregnant women with thrombosis accompanied
by antiphospholipid syndrome, LMWH and postnatal
thromboprophylaxis should be administered. Especially in the
case of pregnant women with other risk factors, suffering from
antiphopholipid syndrome with repeated miscarriages, there is
no need for 6-week LMWH therapy in the postpartum period,
and it is appropriate to apply a therapy of minimum 3-5 days.
Regardless of the mode of delivery, LMWH/AFH or warfarin
and thromboprophylaxis and haematology consultation should
be recommended for minimum 6 weeks in the postpartum
period for all puerperants with previous VTE history.
All puerperants with known hereditary or acquired
thrombophilia should be recommended to take LMWH/AFH
for minimum 7 days in the postpartum period even if they have
not taken thromboprophylaxis during prenatal period. If there
is family history or any other risk factor, thromboprophylaxis
should be extended for up to 6 weeks.
12
 LMWH and thromboprophylaxis should be administered to all
women undergoing emergency caesarean section for 7 days in
the post-operative period. If there exists one or more risk
factors following elective caesarean section (such as above the
age of 35, BMI >30) LMWH and thromboprophylaxis should
be administered for 7 days.
 All peurperants with morbid obesity (BMI > 40 kg/m2) should
be considered for prophylactic LMWH/AFH administration for
7 days in postpartum period.
E- MEDICATIONS USED FOR THROMBOPROPHYLAXIS
MEDICATIONS USED IN PRENATAL AND POSTNATAL
PERIOD
LMWH: It is the first option for postpartum thromboprophylaxis.
LMWH is as effective as unfractionated heparin and more reliable
than it. It is safe to use in breastfeeding women. Recommended
doses per kilogram for low molecule weight heparin are
administered in line with Table 3.
Table 3: Recommended doses for low molecule weight heparin
Weight
(kg)
< 50
Enoxaparin
Dalteparin
Tinzaparin
20 mg/day
2500 u/ day
3500 u/ day
50–90
40 mg/ day
5000 u/ day
4500 u/ day
91–130
60 mg/ day *
7500 u/ day *
7000 u/ day *
131–170
80 mg/ day *
10 000 u/ day *
9000 u/ day *
> 170
0.6 mg/kg/ day * 75 u/kg/ day *
13
75 u/kg/ day *
High prophilactic dose
50-90 kg
40 mg for 12 hours5000 u for 12 hours 4500 u for 12 hours
Therapeutic dose
Antenatal 1 mg/kg/12 hours 100 u/kg/12 hours
175 u/kg/day
Postnatal
175 u/kg/day
1.5 mg/kg/day
200 u/kg/day
* Can be prescribed by dividing into two doses.
Unfractionated heparin: It has shorter half-life compared to
LMWH, and its effect can be completely neutralised with
protamine sulphate. In pregnants with high risk of thrombosis or
under the risk of bleeding, unfractional heparin can be used, if
needed, during labour, labour process. Unfractionated heparin
increases the risk of heparin associated thrombocytopenia. It is safe
to use in breastfeeding women.
Heparin related thrombocytopenia: Even if risk changes
according to the form used, all heparin preparations have the
risk of heparin related thrombocytopenia. Thus regardless of
its type, thrombocyte counts should be monitored closely on
the 5th-14th days following the start of the use of medication
in all patients taking heparin.
Warfarin: Its use during pregnancy is limited to situations where
use of heparin is not appropriate. As it penetrates placenta, risk of
congenital anomaly is high. Thus, a characteristic warfarin
embryopathy of 5% is observed in exposure in the period between
the 6th and 12th weeks of pregnancy. It depends on the dose, and it
is more likely to be seen among pregnants taking more than 5 gr of
warfarin per day.
Other complications associated with warfarin therapy during
pregnancy: Spontaneous abortion, stillbirth, neurological problems
in baby, fetal and maternal bleeding.
14
Warfarin can be used safely in postpartum and breastfeeding
periods through close monitoring of coagulation.
If antithrombotic therapy with warfarin is to continue in postpartum
period, it is appropriate to conduct LMWH thromboprophylaxis for
5-7 days additionally after delivery until the blood level adequate
for warfarin is reached.
Other anticoagulants: In the presence of heparin associated
reactions, fondaparinux and parenteral thrombin inhibitors can be
used in a limited manner. Use of oral direct thrombin inhibitors and
oral factor Xa inhibitors should be avoided. Fondaparinux, oral
direct thrombin inhibitors and oral factor Xa inhibitors should not
be used in breastfeeding women.
Patients using LMWH during pregnancy or postpartum period
for acute VTE therapy: If the weight of the patient is not
extraordinary (such as below 50 kg or above 90 kg) and if there
exist no other accompying factors (such as renal failure, recurrent
VTE) routine measurement of anti-factor Xa activity is not
recommended. As long as unfractionated heparin (AFH) is not
administered, it is not required to count have routine thrombocyte
count. Thrombocyte count should be monitored closely in
pregnants taking AFH at therapeutic dose.
F-LMWH/AFH CONTRAINDICATIONS
Once bleeding and clotting risk assessment has been conducted
carefully, LMWH/AFT use should be avoided in patients under the
risk of bleeding, or therapy should stop or be postponed.
Risk factors for bleeding:
15
1. Women with active bleeding in prenatal and postpartum
periods
2. Women with risk of severe bleeding (such as placenta
previa)
3. Women with bleeding diathesis (such as Von Willebrand,
haemophilia or acquired caogulopathy)
4. Women with thrombocytopenia (thrombocyte count less
than 75,000)
5. Women who have undergone acute stroke in the last 4
weeks
6. Women with severe kidney dysfunction
(GFR<30
2
ml/minute/1.73 m )
7. Women with severe liver dysfunction
(those with
prothrombin time above normal limits)
8. Women with uncontrolled hypertension (systolic blood
pressure ≥200mmHg and diastolic blood pressure
≥120mmHg)
G-ELASTIC COMPRESSION STOCKINGS
Studies supporting the use of elastic compression stocking is
limited.
If swelling continues, use of graduated elastic
compression stockings for two years following acute event should
be recommended in order to reduce the risk of post-thrombotic
syndrome risk. Furthermore, it is believed that its proper use during
pregnancy and postpartum period will be useful in the presence of
the following conditions:
 Pregnants/puerperants who are hospitalised for whom
anticoagulan therapy is contraindicated,
16
 Pregnants/puerperants hospitalised following caesarean section
(in addition to LMWH/AFH therapy) and considered to be
in high risk group for VTE (with previous VET history or with
more than 3 risk factors)
 Outpatients with previous VTE history (in addition to
LMWH/AFH therapy)
 Pregnants/puerperants that are to travel for more than 4 hours
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Bates SM, Greer IA, Middeldorp S, Veenstra DL,
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Thrombosis, 9th ed: American College of Chest Physicians
Evidence-Based Clinical Practice Guidelines. Chest. 2012
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2. Royal College of Obstetricians and Gynaecologists (RCOG).
Thromboprophylaxis during pregnancy, labour and after
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and Gynaecologists (RCOG); 2004 Jan. 13 p. (Guideline; no.
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3. Royal College of Obstetricians and Gynaecologists (RCOG).
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Obstetricians and Gynaecologists (RCOG); 2009 Nov. 35 p.
(Green-top guideline; no. 37a).
4. Royal College of Obstetricians and Gynaecologists (RCOG).
Thromboembolic disease in pregnancy and the puerperium:
acute management. London (UK): Royal College of
17
Obstetricians and Gynaecologists (RCOG); 2007 Feb. 17 p.
(Green-top guideline; no. 28).
18
FLOWCHART-1: PLANNING OF TREATMENT IN THE PREGNANT WITH VENOUS
THROMBOSIS
19
FLOWCHART-2: ANTENATAL ASSESSMENT FOR THROMBOPROPHYLAXIS IN PREGNANCY
GEBELİKTE VENÖZ TROMBOPROFİLAKSİ İÇİN ANTENATALDEĞERLENDİRME
20
FLOWCHART-3: POSTNATAL ASSESSMENT FOR VENOUS THROMBOPROPHYLAXIS
TROMBOPROFİLAKSİ İÇİN POSTNATAL
21
PREGNANCY AND CARDIOVASCULAR
DISEASES MANAGEMENT GUIDELINE
22
A-
GENERAL INFORMATION
In the follow-up of 15-49 ages, the treatment and counseling
service should start long before the conception for the women with
suspicion of cardiac disease. Counseling services should be
provided to the women with congenital heart defect, long QT
syndrome, cardiomyopathy, aortic disease or genetic formation
disorders. If there is no intention to get pregnant, the woman should
be referred to a family planning clinic. Barrier (condom) methods
and levonorgestrel releasing intrauterine devices are the safest and
most effective birth control methods for the women with cyanotic
congenital heart disease and pulmonary vascular disease.
 Each woman with the known or suspected congenital or
acquired cardiovascular diseases should be subjected to risk
assessment and should receive counseling service before the
conception.
 Women with critical congenital heart disease should be
monitored jointly by a perinatologist and cardiologist.
 Functional capacity, findings of examination, resting
electrocardiogram, echocardiography should be checked in
patients planning to get pregnant.
 For the women using medicine due to a known cardiac disease,
which medicines are inconvenient, and which of them should
be discontinued and/or changed during the pregnancy should
be determined in advance. If necessary, the woman should be
subjected to a risk assessment before getting pregnant in order
to utilize the other treatment options, and the treatment should
be reviewed.
 Hemodynamic problems can be observed in future phases of
pregnancy. This information should be shared and a follow-up
plan should be discussed with the patient (and her husband if
possible).
23
 In the presence of followings, it should be stated that
pregnancy poses risk for the mother and the unborn baby, and
therefore termination of the pregnancy should be discussed.
The safest period for elective pregnancy termination is the first
three months.
o Severe left ventricular dysfunction (ejection fraction
<30%, NYHA class III-IV )
o History of peripartum cardiomyopathy leaving residue
dysfunction in the left ventricle
o Cyanotic congenital heart disease
o Pulmonary hypertension
o Severe mitral stenosis
o Severe aortic stenosis
o Marfan syndrome with aortic root dilatation (>45 mm)
o Bicuspid aortic valve where aorta diameter enlarges
(>50 mm)
o Severe coarctation of aorta
 It should be ensured that women with cardiac diseases should
deliver at hospital.
 An experienced team should decide the method and place of
delivery.
 It should be planned that delivery takes place at a centre where
multidisciplinary approach can be followed. Vaginal delivery
is preferred with individual delivery plan. Vaginal delivery by
using epidural anesthesia, and selectively, instrumental
delivery should be considered for the patients with severe
hypertension. Caesarean section should be considered for the
aortic disease where the aorta diameter enlarges more than 45
mm or which occur due to the obstetric requirements, in case
of the severe aortic stenosis; in case of women who will
deliver early while receiving the treatment of oral
24
anticoagulant treatment, and in case of the pregnants with
Eisenmenger syndrome or severe heart failure.
BIN WHICH
SUSPECTED?
CASES
CARDIAC
DISEASE
IS
Cardiovascular Risk Criteria for the Pregnants
History:
 Dyspnoea
 Chest pain
 Tachycardia
 Cough
 Haemoptysis
 Syncope
Background:
 Hypertension
 Taking antihypertensive medicine before conception
 History of Acute Rheumatic Fever
 History of congenital heart disease
 History of acquired heart disease
Family History:
 History of sudden death in the family
 History of congenital heart disease in the family
 Coronary artery disease at early age in the family
Blood Pressure:
 Systolic > 140 mmHg
 Diastolic > 90 mmHg
Physical Examination:
 Cyanosis
 Nail clubbing
 Fine crackles in the lung
 Pathological heart sound
25
(additional sound/murmur)
CCARDIOVASCULAR
DIAGNOSIS
TREATMENT METHODS DURING PREGNANCY
AND
 Cardiovascular diagnosis during pregnancy: It is based on
patient history, clinical research, electrocardiography,
echocardiography
(including
transesophageal
echocardiography) and exercise test (until reaching 80% of
foreseen heart rate).
 Echocardiography: Each female patient having unexplained
and recent cardiovascular symptoms and findings should have
echocardiography scan.
 Radiation: Exposure to radiation should be avoided. Survivals
without any abnormality or death are the most likely results for
those who take doses of more than 50 m Gray within the first
14 days after the impregnation. Fetal risk increases for those
who continue taking 50 mGray even after the first two weeks.
 MRI: Although magnetic resonance imaging without
gadolinium is safe, there are limited numbers of data.
 CT: Computerized tomography is not recommended due to
high dose of radiation.
Checking the Fetus: Fetal ultrasound scan is carried out in
order to check fetus in the families with cardiac diseases. We
can make the diagnosis of congenital formation disorders in
heart as early as the 13th week.
 Interventions: Unless it is an absolute necessity, interventions
for the mother should be avoided during the pregnancy. It is
preferable to postpone the percutaneous coronary intervention
for a date after the fourth month of pregnancy. Heart surgery
having the purpose of rescuing mother’s life is performed
between 13th and 28th weeks in the best possible way.
26
However, delivery rather than surgery should be taken into
consideration after the 28th week.
1- MONITORING OF HEART FAILURE AND
CARDIOMYOPATHY (CMP) DURING PREGNANCY
1.1 PREPREGNANCY
 The women with congenital or acquired CMP should be
subjected to risk assessment before the conception, and should
be provided with individual counseling by the experts. If there
is no intention to get pregnant, the woman should be referred
to a family planning clinic.
 The women with congenital CMP should be provided with
counseling about genetics.
1.2 PREGNANCY
It should be monitored by a multidisciplinary team at the
specialized centers.
In addition to routine pregnant follow-ups and tests for the
pregnants with heart failure, the cardiological follow-up should
be carried out:
 Once a month until 28th week for the patients with mild heart
failure,
 Biweekly for the patients with moderate-severe heart failure
 Once a week starting from the 28th week until the labour.
Checking the pregnant woman suspected of heart failure:
 Shortness of breath is a common problem during pregnancy.
Heart failure can be encountered, too. Severe dyspnoea,
orthopnea, paroxysmal nocturnal dyspnoea, severe or
27
incremental peripheral oedema are signs of heart failure. In the
event of heart failure findings (crepitant rale in the lungs,
S3/S4 gallop, severity >3/6 murmur), she is referred to a
cardiologist for diagnosis and for checking in terms of the
continuity of pregnancy.
 Peripartum CMP occurs suddenly in the last month of
pregnancy or within the first five months postpartum. As there
is an inclination towards thrombophilia and an increase in the
thromboembolic events during pregnancy, anticoagulant
treatment should begin especially for the peripartum CMP
patients.
 First 48 hours postpartum are of the highest-risk in severe
valve diseases in terms of hemodynamic changes.
Heart Failure Treatment during Pregnancy:
Treatment of the pregnants with heart failure should be carried out
by cardiologists.
 Physical treatment and salt intake of the patient should be
limited.
 ACE inhibitors and angiotensin II receptor blockers should be
discontinued.
 Special attention should be paid to the occurrence of heart
failure, sudden death and arrhythmia during the pregnancy in
the patients with hypertrophic CMP. The patients with mildsevere left ventricular outflow tract obstruction should be
monitored by cardiologists, and beta blockers should be
considered for treatment. When beta blockers are not tolerated,
verapamil can be used alternatively.
Emergency Management
In pregnants with heart failure, the risk of acute decompensation
increases in the second trimester of pregnancy.
28
 The pregnants with acute decompensated heart failure should
be referred to tertiary care services immediately.
 The patient is placed in a half sitting position, vascular access
is established, and a catheter is inserted for urine tracking.
 If hypoxemia is detected, oxygen should be administered.
 If ıntravenous dıuretıc (20-40 mg of (20-40 mg bolus
furosemide), systolic blood pressure >110 mmHg; İ.V. nitrat
(i.e nitroglycerin may be started as 10–20 mg/mn and be
increased to 200 mg/mn), if inotropic drugs are needed in the
case of hypoperfusion or resistant heart failure; dopamine,
dobutamin and levosimendan can be used
1.3 DELIVERY
Delivery should take place at the hospital as monitorization is
required during pregnancy and early postnatal period. Labour
induction, management and postpartum observation require that
experienced cardiologists, perinatologists, anesthesiologist and
neonatologists supervise collectively in centers with intensive care
units.
1.4 POSTPARTUM PERIOD
The pregnant should be encouraged to continue breastfeeding
despite taking medicine. However, breastfeeding is not
recommended for the patients with peripartum CMP.
 Some ACE inhibitors (benazepril, captopril, enalapril) are
tested in detail, and using them in mothers is safe for infants.
 As an indicator of kidney dysfunction, body weight of the
infant should be monitored during the first 4 weeks.
2- FOLLOW-UP OF VALVE DISEASES IN
PREGNANCY
29
2.1 PREPREGNANCY
 Patients with valvular heart disease background should be
certainly examined by a cardiologist before conception and
checked for the severity of valve disease.
 The women with critical heart disease should be monitored
jointly by an experienced perinatologist and cardiologist. It
should be kept in mind that there could be deteriorations in
hemodynamic status of those pregnants with valve stenosis
(mitral stenosis, aortic stenosis) especially depending on the
increase in the volume of intravascular area in future
gestational weeks. The severity of valve failure should be
certainly determined before conception. It should be taken into
consideration that the course of valve failure is better than
valve stenosis.
2.2 PREGNANCY
 It should be kept in mind that a decrease in the effort capacity
and an increase in the symptoms can be observed in the
pregnants with valve diseases as of the second trimester
especially, depending on the increase of intravascular volume.
Effort capacity and symptoms of shortness of breath should be
checked especially in the examinations of the pregnants with
mitral and aortic stenosis. The patients with an increase in their
complaints should be referred to the division of cardiology.
 The patients who are not checked for valve disease before
conception but have the symptoms of shortness of breath,
tachycardia, chest pain, syncope and decrease in effort capacity
should be definitely examined in detail. The patients with
suspicion of valve disease should be referred to the division of
cardiology.
30
 It should be known that mild systolic murmur can be heard
especially in the apical area of the patients whose examination
revealed that she does not have severe valve disease or who is
considered to be normal in preconception assessment. As long
as there is no increase in their complaints, the follow-ups of
those patients should continue.
 As it is necessary to administer anticoagulants to the pregnants
with mechanical prosthetic valve diseases, cardiologist,
perinatologist and the patient jointly decide which medicine
should be chosen. INR follow-ups of the patients using
warfarin oral should be carried out under the control of a
cardiologist. The pregnants using low molecular weight
heparin should be monitored at better equipped centers where
anti actor Xa levels are measured.
 The patients whose symptoms and findings have progressed
significantly during pregnancy should be referred to a better
equipped centre by taking valve disease complications into
consideration.
When a Women with Mechanical Cardiac Valve and
Consequently Using Warfarin Gets Pregnant:
 It is recommended that she is administered the adjusted dose
LMWH/AFH (twice a day, subcutaneous) for the first 12
weeks with the control of anti Xa; proceeds with warfarin, and
administered prophylaxis with LMWH/AFH again towards the
end of pregnancy.
 It can be administered to the pregnants with old type of valve,
who had thromboembolism previously, during the entire
course of pregnancy including the first 12 weeks.
31
 75-100 mg/day aspirin treatment can be added to the
anticoagulant treatment of the pregnants with prosthetic valve
having high risk of thromboembolism.
2.3 DELIVERY
 Patients diagnosed with critical valve disease during pregnancy
should deliver in the centers having cardiology department,
perinatalogy and intensive care units.
 Caesarean section should be considered for the aortic disease
where the aorta diameter enlarges more than 45 mm or which
occur due to the obstetric requirements, in case of the severe
aortic stenosis; in case of women who will deliver early while
receiving the treatment of oral anticoagulant treatment, and in
case of the pregnants with Eisenmenger syndrome or severe
heart failure.
 For the pregnants with mild-severe valve disease, the method
of delivery is determined in line with the recommendations of
cardiology and perinatalogy departments. As symptoms can
appear in these patients during the labour depending on the
hypervolemia, it should be kept in mind that it is harmful to
load intravascular area more than necessary.
2.4 POSTPARTUM PERIOD
 Medicines of the patients with a known valve disease or who
need to use anticoagulants should be adjusted under the control
of a cardiologist.
 It is recommended that penicillin prophylaxy should continue
during and after pregnancy in the pregnants with rheumatic
heart disease.
32
 The first 48 hours following delivery are the most risky period
for the critical valve patients in terms of hemodynamic
changes.
3- OTHER CARDIOVASCULAR DISEASES
3.1 CONGENITAL HEART DISEASE (CHD) AND
PULMONARY HYPERTENSION
3.1.1. HIGH RISK CONDITIONS:
The pregnants with CHD who have the functional capacity of class
III-IV or the functional capacity of whom has declined according to
the functional classification of “New York Heart Association”
(NYHA) are considered to be high risk patients in following
conditions:
a. Pulmonary Hypertension: In order to prevent hypoxia and
acidosis, and the development of heart failure and hypotension,
the pregnant should be monitored in the centers having
experienced cardiology teams.
b. Patients with Eisenmenger's Syndrome: The pregnancy of
the patients with Eisenmenger’s Syndrome, peripartum
mortality rate of which is high, must be terminated. This
procedure is highly risky. If the patient insists on continuing
the pregnancy, she should be referred to a more experienced
and equipped centre.
c. Cyanotic Heart Disease without Pulmonary Hypertension:
In the event of hypoxemia (oxygen saturation is 80%) in
mother, conception of the mother is contraindicated. If the
pregnancy continues, the pregnant should be closely monitored
at the experienced centers during pregnancy.
33
d. Severe Left Ventricular Outflow Tract Obstruction: The
pregnancy is contraindicated for the patients with severe left
ventricular outflow tract obstruction.
3.1.2. SPECIFIC CONGENITAL HEART DEFECTS:
a. Atrial septal defect (ASD): Pregnancy is tolerated well by
most of the patients with ASD. Contraindications of pregnancy
in these patients are eisenmenger and pulmonary hypertension.
The follow-up should be carried out by relevant centers.
b. Ventricular Septal Defect (VSD): Developing with PH, VSD
is a high risk condition for pregnancy. However, small
perimembranous VSD can be tolerated in pregnancy.
c. Atrioventricular (AV) septal defect: Cases of ventricular
dysfunction and PH are considered to be of high risk for the
pregnancy. These pregnants should be closely monitored at the
experienced centers.
d. Coarctation of aorta: In case of non-operated coarctation of
aorta and residual hypertension following the repair, the risk of
miscarriage and aorta and cerebral artery aneurysm rupture has
increased. These pregnants should be closely monitored at the
experienced centers.
e. Pulmonary Stenosis (PS) and pulmonic regurgitation (PR):
All of the pregnants with PS and PR should be referred to
experienced centers where they are subjected to the required
test for right ventricular functions.
f. Tetralogy of Fallot: Surgical repair is necessary for the
women with unrepaired tetralogy of fallot. They should be
referred to experienced centers where thromboembolism,
34
endocarditis, heart failure and obstetrical complications, which
can develop during pregnancy, can be diagnosed and treated.
g. Epstein Anomaly: The pregnancy is well-tolerated for the
patients with Epstein anomaly who do not have cyanosis and
heart failure. However, the risk of premature birth and fetal
mortality has dramatically increased in the patients with
tricuspid insufficiency and right heart failure. The pregnant
follow-ups should be carried out at experienced centers.
h. Large artery transposition and corrected transposition:
The follow-ups of the pregnancies with these diseases,
especially the right ventricle functions, should be carried out at
experienced centers.
i. Fontan Circulation: If the fontan circulation cycle is not at
optimum level, the pregnants should be referred to experienced
centers in order to monitor the heart failure and arrhythmia.
3.2 CORONARY ARTERY DISEASE
The pregnant previously diagnosed with coroner artery
disease: The pregnants without clinical heart failure and residual
ischemia can plan a pregnancy. The pregnants with coronary artery
disease should be monitored at experienced centers.
Actions to be taken before conception:
 Detailed Anamnesis: Chest pain, shortness of breath,
functional capacity, previous myocardial infarction and
revascularization history should be checked.
 Physical Examination: Blood pressure, heart rate, additional
sound, murmur, heart failure findings should be checked.
35
 It should be asked which medicines are used (Acetylsalicylic
acid B-Blocker can be used safely. ACE inhibitors, angiotensin
receptor blockers, rennin inhibitors should be discontinued.)
 ECG scan should be carried out.
 The pregnant should be referred for the expert review
(Evaluation of LV functions, effort test or residual ischemia
analysis through exercise echocardiography).
EMERGENCY MANAGEMENT
Actions to be taken for the pregnant presenting with Acute
Coronary Syndrome Clinic: ECK and vital signs (pulse, blood
pressure) should be checked immediately.

In case of hemodynamic
disturbance: The pregnant should be immediately referred to
a better equipped centre (preferably, to a centre with fullfledged Percutaneous Coronary Intervention (PCI)).
 In case of ST Elevation/Left Bundle Branch Block: Nonenteric coated acetylsalicylic acid should be administered. The
pregnant should be immediately referred to a centre with fullfledged percutaneous coronary intervention.
 ST depression in ECG: The pregnant should be immediately
referred to a better equipped centre (preferably, to a centre
with PCI).
 There is no change in ECG: If rapid troponin test can be
carried out, then troponin should be checked.
o If positive, the pregnant should be immediately referred
to a better equipped centre (preferably, to a centre with
PCI).
o If negative, the pregnant should be referred for the expert
review.
o If rapid troponin test is not available, the pregnant should
be immediately referred for the expert review.
36
3.3ARYTHMIA
The pregnant and women in reproductive age group are at higher
risk of arrhythmia. Arrhythmia frequently reappears during the
gestation period of women having chronic supraventricular and
ventricular tachycardia. Deterioration of hemodynamics poses a
risk for the health of infant and baby.
Approach to the pregnant diagnosed with tachyarrhythmia:
During pregnancy, sinus tachycardia or arterial or ventricular
ectopic pulses are frequently observed. These conditions are
generally associated with benign prognosis. In case of
supraventricular and ventricular tachycardia:
1. When tachycardia is detected, vital signs of the pregnant
should be checked, and her hemodynamic condition should
be evaluated.
2. Treatment of the tachycardia causing hemodynamic
disturbance is emergency cardioversion during pregnancy.
3. If the vagal manoeuvres fail, paroxysmal supraventricular
tachycardia (SVT), which does not cause hemodynamic
disturbance, adenosine and IV metoprolol can be used.
4. For the long-term treatment of SVT, oral digoxin or
metoprolol/ propranolol are recommended.
5. Atenolol should not be used for any kind of cardiac
arrhythmia.
Approach to the pregnant diagnosed with bradyarrytmia: The
pregnants can have sinus bradyarrytmia arising from lying on their
backs. In this case, the mother should lie on her left side. In case of
severe bradyarrytmia causing symptoms, the pregnant should be
immediately referred to a better equipped centre.
3.4 INFECTIVE ENDOCARDITIS PROPHYLAXIS
37
With the current changes in the guidelines, same measures taken
for the non-pregnant patients are applied. Endocarditis prophylaxis
is recommended for patients whose risk of developing only
endocarditis is still at maximum level (e.g. dental surgery).
Antibiotic prophylaxis is recommended during vaginal delivery or
caesarean section.
D- FREQUENTLY USED MEDICINES DURING
PREGNANCY
Use of cardiovascular (CV) drug becomes obligatory in some
cases. Physicians should make prudent choices by taking typical
characteristics and potential adverse effects of the drug into
consideration. Most frequently used CV drugs and their effects
during pregnancy are summarized in the table below.
When administering drug to the pregnant, its FDA category should
be known. Classification ranges from A (the safest) to X (the unknown). Following
categories are used for gestational and breastfeeding periods:
 Category B: Although studies on reproductive system in
animals do not show any fetal risks controlled studies on
the pregnant women have not been conducted. Furthermore,
the adverse effect which was determined in the studies on
the reproductive system of animals was not confirmed by
controlled studies on women.
 Category C: Although animal studies have revealed that
they had negative effects on fetus, controlled studies on
women or any study on women and animals have not been
conducted. The medicines which have more potential
benefits than potential risks should be used.
 Category D: Although there is evidence of fetal risk the
benefits of using it in the pregnant women are accepted
despite this risk (e.g. treatment of life-threatening
disorders).
38
 Category X: Based on the experiences on animals or
human, it has been demonstrated that there are
abnormalities in fetus. There are evidences of risk both in
human and animal studies. The risk of using it in pregnant
women exceeds any potential benefits. It is not
recommended that pregnant or fertile women take it.
Group of
medicine
Medicines
FDA
category
Possible adverse
effects
Getting
into
placenta
Getting
into breast
milk
(fetal
doses)
ACE-inhibitors
Captopril
Benazepril
Enalapril
Lisinopril
Perindopril
Ramipril
Silazopril
Teratogenicity (renal
or tubular dysplasia,
fetal hypocalvaria,
etc.) Fetotoxicity
(anuria-related
oligohydramnios and
induced pulmonary
hypoplasia, extremity
contractures,
D
persistent PDA,
defects of skull
ossification,
intrauterine growth
retardation, anemia,
intrauterine fetal
death, premature and
severe neonatal
hypotension)
Angiotensin II Receptor Blockers
39
Yes
It gets into
(maximum
1.6%)
Losartan
Valsartan
Olmesartan
Irbesartan
Candesartan
D
Teratogenicity (renal
or tubular dysplasia,
fetal hypocalvaria,
etc.) Fetotoxicity
(anuria-related
oligohydramnios and
induced pulmonary
hypoplasia, extremity
contractures,
persistent PDA,
defects of skull
ossification,
intrauterine growth
retardation, anemia,
intrauterine fetal
death, premature and
severe neonatal
hypotension)
Unknown
C
(D for
Atenolol)
Bradycardia and
hypoglycaemia in
fetus. [hypospadias
with Atenolol (in the
first three months); in
fetus: birth defects,
low birth weight (in
the second and third
months), intrauterine
growth retardation and
decrease in placenta
weight for those with
ISA negative]
Yes
Beta-Blockers
Propranolol
Bisoprolol
Nebivolol
Carvedilol
Atenolol*
Calcium Channel Blockers
Amlodipin
Even though the
Isradipine
experience is limited,
C
Nifedipine
they are wellDiltiazem
tolerated. Isradipine
40
Yes
Unknown
It gets into
It gets into
Verapamil
may induce potential
synergism
hypotension with
magnesium sulphate.
It may be related to a
more severe
hypotension risk and
fetal hypoperfusion in
intravenous use.
Diuretics
(As they are characterized by gestational hypertension hypovolemia, it is not
convenient to use them.)
It is wellFurosemid
C
tolerated,
Hidroklorotia
B
milk
zid
B
production
Oligohydramnios
Yes
Indapamid
may
decrease.
Aldosterone Antagonists
Spiranolacto
n
Statines
Atorvastatin
Fluvastatin
Pravastatin
Rosuvastatin
Simvastatin
D
X
Teratogenicity (cleft
palate, first 3 months),
Fetotoxicity
(antiandrogen effects)
Yes
It gets into
(maximum
1.2 %)
milk
production
may
decrease.
Unknown, using them
during pregnancy is
considered as
contraindication.
There is risk of
congenital anomaly.
Yes
Unknown
Fibrates
41
Fenofibrates
Gemfibrozil
Bile Resins
Colestipol,
Cholestyrami
ne
C
Unknown
C
They can disturb the
absorption of fat
soluble vitamins (e.g.
Vitamin K), cerebral
haemorrhage (in
newborn).
Yes
Unknown
Yes
It gets into
– it lowers
the level of
fat soluble
vitamins.
Antiaritmics
There is no notified
teratogenicity; the
level of serum should
not be trusted
Hypothyroidism (9%),
hyperthyroidism,
goitre, bradycardia,
growth retardation,
premature delivery.
C
Amiodarone
D
Lidocaine
C
Meksiletin
C
Fetal bradycardia,
acidosis, central
system toxicity.
Fetal bradycardia
Propafenone
C
Unknown
Yes
Sotalol
B
Bradycardia and
hypoglycaemia in
fetus (limited
experience).
Yes
It gets into
Quinidine
C
Thrombopenia,
premature delivery,
VIII. nerve toxicity
Yes
It gets into
They do not have any
known teratogenic
Yes
It gets into
(without
Anticoagulative agents
Aspirin
B
(Low dose)
42
Yes
It gets into
Digoxin
Yes
Yes
Yes
It gets into
It gets into
It gets into
It is
transferred
Heparin
B
Lowmolecularweight
heparin
(Enoxaparin,
etc.)
B
Clopidogrel
C
Ticlopidine
C
Warfarin
X
(Accordin
g to ESC,
D)
Vasodilator agents
Isosorbit
dinitrat
B
Nitroglycerin
e
Hydralazine
C
Methyldopa
B
effects (broad data
series)
Long-term
administration,
continuous
administration,
osteoporosis and
thrombocytopenia.
Long-term
administration, rarely
osteoporosis, less
thrombocytopenia
when compared to UF
heparin.
There is no
information on using
it during pregnancy.
There is no
information on using
it during pregnancy.
Embryopathy in the
first 3 months,
bleeding if used late.
No adverse effect has
been observed in
animals. The effects in
human are unknown.
Adverse effect in
mother: symptoms
similar to those of the
lupus, fetal
tachyarrhythmia.
Mild neonatal
43
any
problem)
No
It does not
get into.
No
It does not
get into.
Unknown
Unknown
Unknown
Unknown
Yes
It gets into
(maximum
10%);
Metabolite
is well
tolerated.
Unknown
Unknown
Yes
It gets into
(maximum
1%)
Yes
It gets into.
hypotension.
Pulmonary Hypertension Medicines
Teratogenic effects in
animals are
Bosentan
X
demonstrated. There is
no data on human.
It is reported that there
is no problem in using
Iloprost
C
it during pregnancy.
There is not sufficient
data.
It is reported that there
is no problem in using
Sildenafil
B
it during pregnancy.
There is not sufficient
data.
Yes
Unknown
Unknown
Unknown
Unknown
Unknown
REFERENCES:
1- ESC Guidelines on the management of cardiovascular diseases
during pregnancy: the Task Force on the Management of
Cardiovascular Diseases during Pregnancy of the European
Society of Cardiology (ESC). Eur Heart J. 2011 Dec;32(24):314797.
2- Gebelik ve Kalp Hastalıkları Video Konferans;
http://www.tkd.tv.tr/FormVideo.aspx?category=3
44
45
MANAGEMENT GUIDELINE for PREGNANT
WOMEN with DIABETES
46
PREPREGNANCY
For 15-49 age follow-up, the importance of monitoring diabetic
pregnant women before conception and providing them with
counseling services should be emphasized, and cases should be
assessed in accordance with risk groups. If there is no intention to
get pregnant, the woman should be referred to a family planning
clinic.
1) In case of women with body-mass index ≥ 25 kg/m2, if they
belong to any of the below-mentioned risk groups, their
Fasting Plasma Glucose (FPG) should be checked once a year
(They should not be diagnosed through glucometer)
 Diabetes in immediate family
 Those who have delivered a big baby or previously
diagnosed with Gestational Diabetes Mellitus (GDM),
 Hypertensive (Blood Pressure ≥140/90 mmHg),
 Dyslipidemics
(HDLcholesterol
≤35mg/dl
or
triglyceride≥250 mg/dl),
 Previous Impaired Fasting Glucose (IGT) or Impaired
Glucose Tolerance (IGT),
 Polycystic Ovarian Syndrome (PCOS),
 Bad obstetric history,
 Intrauterine death history,
 Clinic disease or findings on insulin resistance (acanthosis
nigricans),
 Coronary, peripheric or cerebral vascular disease,
 Born with low birth weight,
 Sedentary lifestyle or little physical activity,
 Dietary habits with high-saturated fat and low-fiber foods,
 Schizophrenic patients and those who use atypical
antipsychotics and other diabetogenic medicine (steroid,
etc.).
47
2) If there is history of diabetes in the family of the women with
body-mass index ≥ 25 kg/m2 or they are diagnosed with
diabetes mellitus, they should be checked biennially.
3) Fasting Plasma Glucose level <100 mg/dl should be
considered “normal”. If this figure is between 100 and 200, it
should be considered “impaired”. If it is ≥126 mg/dl, it
should be considered “diabetic”. The required interventions
should be made according to general medical rules.
4) Counseling services should be provided for those whose
Fasting Plasma Glucose is determined as impaired fasting
glucose between 100-125 mg/dl. It should be ensured that
obese people lose weight.
5) The people with Fasting Plasma Glucose≥126 mg/dl should
be referred to an endocrinologist (if not available, they should
be referred to an internist). If they intend to get pregnant, they
should be referred to a perinatologist (if not available, they
should be referred to an obstetrician and gynaecologist).
THE PREGNANT WITH PREGESTATIONAL DIABETES
Prepregnancy Follow-up;
All pregnant women with diabetes should be informed about
possible metabolic problems.
 The pregnant women should be recommended to receive help
from medical personnel before conception. If not available,
they should be referred to endocrinologist (if not, to an
internist) and perinatologist (if not, obstetrician and
gynecologist). Counseling should be provided about the
requirements of planned pregnancy, the importance of
48









glycemic control and cessation of medicines which might have
embryotoxic and teratogenetic effects.
In such conditions as bad blood glucose regulation; patients
with HbA1C ≥ 7%, patients with unstable fasting and
postprandial blood glucose, patients using oral antidiabetic,
patients suffering from diabetes for more than five years
should see an endocrinologist.
Subsequent follow-ups should be conducted in accordance
with the recommendation of a specialist.
The pregnancy should be certainly planned and glycemic
control should be carried out (A1C≤ 6.5% (preferably %6.0≤)
APG ≤95 mg/dl, postprandial 1st and 2nd hours, ≤120 mg/dl, it
can be tolerated up to 140 mg/dl).
0.4 mg/day of folic acid should be administered three months
before the conception, and it should be used throughout the
first trimester of pregnancy.
Embryopathy medicines should be ceased before conception or
replaced with nonteratogenic medicines (ACE inhibitors,
thiazide-type diuretics, angiotensin II receptor blockers (ARB)
and statines).
The patients using oral antidiabetic medicine should proceed
with prepregnancy insulin.
Diabetic women who want to get pregnant should be examined
by ophthalmologist before conception.
Diabetic women who want to get pregnant should be scanned
for nephropathia. If microalbuminuria or apparent
nephropathia is determined, optimal glycemic control and
blood pressure control should be carried out in order to prevent
complications in mother and fetus and to delay the progression
of nephropathia.
Maternal diabetes is not a risk factor for aneuploidy. Down
syndrome diagnosis and scan should be carried out in the same
way as with general population. However, it should be kept in
49
mind that the tests carried out in the second trimester should be
adjusted as the serum α-fetoprotein (AFP) and unconjugated
estriol (uE3) levels are low.
 Type 1 and Type 2 diabetes should also be diagnosed
Pregnancy follow-up:
The pregnants in the high-risk group (*brittle diabetes, those who
suffer from diabetes for more than five years, those with 7% and
above HbA1C level, those who have bad obstetric history) should
be examined by an endocrinologist and perinatologist if possible.
---------------------------* Diabetic pregnants for whom unexpected hypoglycaemia is
observed when insulin dose is increased by two units and
unexpected hyperglycaemia is observed when insulin dose is
decreased by two units.
In addition to the routine follow-up and tests of diabetic
pregnant:
First follow-up:
 Perform it within the first 6-8 weeks.
 Carry out the following procedures and tests, or ensure that
they are carried out.
o Carry out an ultrasound scan to check whether the fetus is
alive and to determine the gestational age. Analyze it in
terms of genital pathologies.
o Measure the level of HbA1C1.
o Check the thyroid functions.
o Retinal evaluation should be conducted by an
ophthalmologist.
1
HbA1c≤ %6.5 (preferably %6.0)
50
o Ensure that the renal evaluation2 is conducted.
o Have ECG scan.
o Have urine culture test and inform patient about the
complications of diabetes and diet, exercise, medication,
and train the patient on self-glucose monitoring.
 Ensure that patients with poor feeding, HbA1C3 level ≥ %7,
TSH ≥2.5 mU/l, retinopathy, kidney dysfunction and
proteinuira, coronary artery disease are examined by an
endocrinologist and perinatologist if possible.
Second follow-up:
 Perform it within the 11-14th gestational week.
 Conduct the glycemic check 3,4. If cannot be checked, ensure
that it is evaluated by an endocrinologist.
 Refer them to a perinatologist in order to carry out the
ultrasonographic evaluation and the first trimester screen test
of fetus.
Third follow-up:
 Perform it within the 16-18th gestational week.
 Carry out fetal anomaly screening, or ensure that it is carried
out.
 Carry out the following test, or ensure that they are carried.
2
RENAL EVALUATION
 Microalbumin/creatinin levels in spot urine are checked.
 This figure
‹30 µg/mg
normal
30-300 µg/mg microalbuminuria
>300 µg/mg
macroalbuminuria
3
HbA1C≤ 6.5% (preferably 6.0%)
4
GLYCEMIC CONTROL
 Premeal blood glucose 60-100 mg/dl
 1st and 2nd hour, preferably ≤120 mg/dl (It can be tolarable up
to 140 mg/dl)(It should be counted as of the first bite)
51
o Carry out the glycemic check.
o Carry out HbA1C measurement.
o Carry out triple test.
 Carry out the retina control check those with retinopathy, or
ensure that it is carried out.
 Carry out renal evaluation for those with nephropathy, or
ensure that it is carried out.
Fourth follow-up:
 Perform it within the 22-24th gestational week.
 Ensure that perinatologist carries out an expanded cardiac
screening in addition to fetal anomaly screening.
 Carry out glycemic control, or ensure that it is carried out.
Fifth follow-up:
 Perform it within the 28th week.
 Evaluate pregnancy through USG.
 Carry out glycemic check, or ensure that it is carried out.
 Measure HbA1C.
 Carry out the retina check for those with retinopathy, or ensure
that it is carried out.
 Carry out renal evaluation for those with nephropathy, or
ensure that it is carried out.
Sixth follow-up:
 Perform it within the 32nd gestational week.
 Carry out the following procedures and tests, or ensure that
they are carried out.
o Carry out glycemic check, or ensure that it is carried out.
o Check the fetal growth and amniotic fluid volume through
USG. Carry out fetal doppler if available
52
o Carry out fetal monitorization5
Seventh follow-up:
 Conduct it within the 34th gestational week.
 Carry out glycemic check.
 Carry out fetal monitorization.
Eight follow-up:
 Perform it within the 36th gestational week.
 Carry out the following procedures and tests, or ensure that
they are carried out.
o Carry out glycemic check.
o Carry out fetal monitorization.
o Measure HbA1C.
o Carry out the retina check for those with retinopathy, or
ensure that it is carried out.
o Carry out renal evaluation for those with nephropathy, or
ensure that it is carried out.
Ninth follow-up:
 Perform it within the 37th gestational week.
 Carry out glycemic check.
 Carry out fetal monitorization.
Tenth follow-up:
 Perform it within the 38th gestational week.
 Carry out glycemic check.
 Carry out fetal monitorization
5
Fetal Monitorization
 Fetal movement counting
 NST
 Biophysical profile
53
 Carry out USG for fetal weight estimation.
 Ensure that patients with suboptimal glycemic check and/or the
pregnants with additional disease (hypertension, nephropathy,
retinopathy, preeclampsia, Intrauterine Growth Retardation)
should be evaluated by a perinatologist in order to determine
delivery method and time.
Eleventh follow-up:
 Perform it within the 39th gestational week.
 Recommend labour induction for the pregnant women whose
estimated fetal weight is below 4000 grams.
 Inform the pregnant women whose estimated fetal growth is
above 4000 grams and fetal abdominal circumference is above
360 mm about delivery risks. Determine the delivery method
after evaluation.
 Take into consideration not only USG but also clinical findings
and pelvic examination finding when evaluating fetal weight
through USG in these weeks as it can cause mistakes.
GESTATIONAL DIABETES MELLITUS (GDM)
 All pregnants should undergo “Glucose Screening Test”
between the 24 - 28th weeks.
 OGTT should be applied to the pregnant women having
Fasting Plasma Glucose levels between 100-126 in the first
application week of gestation.
Available Screening Tests:
1- 50 grams glucose screening test
o Fasting and postprandial states do not make any
difference for the test. It can be applied when the
pregnant presents herself to hospital.
54
o
50 grams of glucose is melted in 100-200 cc of water.
After squeezing half lemon, it is drunk in one sip. 60
minutes later, plasma glucose is measured.
o The pregnants, whose 50 grams glucose screening test
results are above APG ≥140 mg/dl, should take Oral
Glucose Tolerance Test (OGTT) with 100 grams of
glucose into an empty stomach in another day.
o The pregnants, whose 50 grams glucose screening test
results are APG ≥180 mg/dl, are considered diabetic.
It is not necessary for those patients to take OGTT.
o If the results reveal that standard limits are exceeded
in at least two of the below-stated hours in 100 grams
of OGTT, they are diagnosed with GDM:
 APG ≥95 mg/dl,
 1st hour ≥180 mg/dl,
 2nd hour ≥155 mg/dl,
 3rd hour ≥140 mg/dl
o In the event that only one of the levels is high in 100
grams of OGTT, it is considered as impaired glucose
tolerance (IGT) and the patient is referred to an
endocrinologist (if not available, the patient should be
referred to an internist.)
2- 75 grams Oral Glucose Tolerance Test
o Following at least 8 hours (ideally 10 hours) of night
fasting, preprandial blood glucose of the pregnant is
checked before drinking 75 grams of oral glucose.
o 75 grams of glucose is melted in 100-200 cc of water.
After squeezing half lemon, it is drunk in one sip. 60
minutes and 120 minutes later, plasma glucose is
measured.
o If the results reveal that standard limits are exceeded
in at least one of the below-stated hours in 75 grams
of OGTT, they are diagnosed with GDM:
55
 APG≥92
 1st hour ≥180 mg/dl,
 2nd hour ≥153 mg/dl,
 During the loading tests, the patient should be in sitting
position, should not perform any activities, should not eat and
smoke. The patients, who cannot tolerate glucose and vomit,
should be tested again.
 There is no need for additional follow-ups apart from routine
pregnancy follow-up for the patients with GDM, whose
glucose level runs its course only with diet therapy and who do
not have any complications (macrosomia, preeclampsia,
growth retardation, poly/oligohydramnios, etc.).
 The patients with GDM, who use insulin, should be considered
high-risk patients, and the protocols used for gestational
diabetic patients should be followed.
LABOUR PAIN AND LABOUR IN PREGNANTS WITH
DIABETES
The moment when labour is induced, insulin resistance disappears
in the patients with pregestational diabetes and gestational diabetes.
 When the labour is induced, administer infusion equivalent to
5-7.5 grams of glucose per hour and administer 1-1.5 units of
insulin infusion per hour to the patients (GDM and
pregestational diabetes) who have used insulin during
pregnancy. Put 5 units of regular insulin into 500 cc 5%
dextrose, and administer at least 100 cc per hour. Rate of
infusion and the amount of insulin to be added into liquid
should be adjusted according to blood glucose.
 Continue using insulin liquid until oral intake begins.
 During labour pain, avoid maternal hyperglycemia and keep
the intrapartum glucose at the level of 70-110 mg/dl.
 During labour pain, measure capillary glucose per hour.
56
POSTNATAL FOLLOW-UP OF THE PREGNANTS WITH
DIABETES
 Monitor in accordance with the Postnatal Care Management
Guideline.
 Encourage the mother to breastfeed early and frequently.
Gestational Diabetes Mellitus;
 Keep the patients with GDM at hospital at least for 24 hours
even though there is no complication.
 Measure fasting and postprandial blood glucose for 24 hours
and 48 hours following vaginal delivery and caesarean section
respectively. The required treatment should be applied to the
patients with high levels of course.
 The patients whose results are normal should take two-hourOGTT with 75 grams of glucose between 6th and 8th weeks
following delivery
 The patients having high levels in 75 grams of OGTT should
be referred to an endocrinologist (if not available, the patient
should be referred to an internist.)
APG<100 mg/dL and
OGTT 2.st PG<140 mg/dL
APG<100 mg/dL and
OGTT 2.st PG 140-199 mg/dL
APG 100-125 mg/dL and
OGTT 2.st PG<140 mg/dL
APG 100-125 mg/dL and
OGTT 2.st 140-199 mg/dL
APG≥126 mg/dL and
OGTT 2.st PG≥200 mg/dL
57
Normal
Isolated IGT
Isolated IFG
IGT+IFG
Apparent Diabetes
 Inform the individuals about the risk of developing type 2
diabetes in the subsequent pregnancies and in the upcoming
years. Underline the importance of exercise, weight control
and long-term follow-up. Lay emphasis on complying with the
recommendations of type 2 diabetes screening and diabetes
prevention. It is also important to note that they should be
monitored again when they plan to get pregnant.
Pregestational Diabetes;
 Readjust the treatment by taking preconceptional insulin
dosages into consideration.
 At the end of postpartum period (in the 6th week), they should
consult to an internist.
58
EPILEPTIC PREGNANT MANAGEMENT
GUIDELINE
59
Preconception
1) In the follow up of women of 15–49 years of age, epileptic
women should absolutely get counselling from the health
personnel before becoming pregnant. Within the scope of
counselling, information should be provided about the effect of
pregnancy on epilepsy, how the drugs used for epilepsy affect
pregnancy, whether it is necessary to change medications and
the dose and interference of medications. The importance of
regular follow-up and counselling should be emphasized. If
there is no demand for pregnancy, the woman should be
referred to a Family Planning Clinic.
2) In the preconception period, the opinions of a neurologist and a
gynecologist should be received and the follow-ups in the
preconception period, during pregnancy and postconception
period should be conducted by these branches.
3) Pregnancy should absolutely be planned. Programs of
medication change should be completed at least 6 months
before the patient becomes pregnant. Monotherapy should be
preferred and antiepileptic drugs should be recommended at
the lowest dose possible.
4) 3 months before the patient becomes pregnant, a daily
supplement of folic acid of 400 mcg should be initiated to
minimize the malformations that may befall the infant and this
supplement should be continued till the end of the tenth
gestational week.
5) Antiepileptic drug should definitely be managed by a
neurologist. The dose and active ingredient of the drug should
not be changed without consulting the neurologist. The drugs
60
used in epilepsy treatment and their side effects are indicated
in the table below.
6) Carbamazepine and Lamotrigine which pose lower risks are
preferably used according to the type of seizure. Phenytoin and
Valproate can only be used when their use is absolutely
necessary at the appropriate dosage and by receiving the
consent of the patient.
Drug
Potential side effects
Valproate
Spina bifida aperta,
Cardiovascular complications,
urogenital malformations, skeletal
disorders, mental retardation
Phenytoin
Congenital heart disease, urogenital
defect, face fissures, dysmorphic face,
distal phalangeal hypoplasia
Carbamazepine Neural tube defect, heart defect,
hypospadias, knee dislocation,
Inguinal hernia
Lamotrigine
Cleft palate
Levetiracetam Limited study
Zonisamide
Limited study
FDA
category
D
D
D
C
C
C
PRENATAL CARE
1)
First follow-up:

Do the first follow-up in 6th-8th gestational weeks.

Monitor the pregnant in line with Prenatal Care
Management Guideline.
61

If preconception counselling has not been received,
provide the patient with counselling.
 Right after the determination of the pregnancy, make
sure that a neurologist controls the patient.
2) Second follow-up:
 Do the second follow-up in 11th–13+6 day gestational weeks.
 Monitor the pregnant in line with Prenatal Care
Management Guideline.
 In addition to the medical examination and other
examinations that are in line with the guideline, the
patient should be assessed by a perinatologist if possible.
(measurement of NT (nucal translucency) through
ultrasound and early anomaly screening)
3) Third follow-up:
 Do the third follow-up in the 16th gestational week.
 Monitor the pregnant in line with Prenatal Care
Management Guideline.
 In addition to the medical examination and other
examinations that are in line with the guideline; the level
of α-fetoprotein is measured by looking at the MoM
value. Triple-quadruple screen tests can also be used to
that end. Refer the pregnants with a high level of αfetoprotein to the perinatologists.
4) Fourth follow-up:
 Do the fourth follow-up in 18-22nd weeks.
 Monitor the pregnant in line with Prenatal Care
Management Guideline.
 In addition to the medical examination and other
examinations that are in line with the guideline; a general
anomaly screening should be conducted and especially
the development of heart should be well assessed and if
possible recommend an echocardiography for the patient.
 Make sure that a perinatologist controls the patient.
62
 Hold a consultation with a neurologist about the drug, blood
level and the overall situation.
5) Fifth follow-up:
 Do the fifth follow-up in 24-28th weeks.
 Monitor the pregnant in line with Prenatal Care
Management Guideline.
6) Sixth follow-up:
 Do the sixth follow-up in 32-34th weeks.
 Monitor the pregnant in line with Prenatal Care
Management Guideline.
7) Seventh follow-up:
 Do the seventh follow-up in 36-38th weeks.
 Monitor the pregnant in line with Prenatal Care
Management Guideline.
 Hold a consultation with a neurologist about the drug, blood
level and the overall situation.
 Make sure that the delivery is conducted at hospital.
 The gynecologist determines the mode of delivery
according to obstetric indications.
EMERGENCY MANAGEMENT
No matter in what week of pregnancy the pregnant is, if she has
seizures, she should be assessed by a neurologist. If you see a status
table that includes generalized tonic clonic seizures (Having 2
seizures within 5 minutes with ongoing loss of consciousness), the
patient should be referred immediately after having performed the
following interventions:
 Airway of the patient is opened.
 Respiration is ensured. The patient is administered
oxygen.
63
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
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



The circulatory system is stabilized.
Vascular access is established, fluid is administered and
blood glucose level of the baby is measured and if there
is hypoglycemia, this problem is addressed.
Diazepam or midazolam should be the first choice.
Diazem of 10 mg IV should be administered in such a
way as to finish within 5-10 minutes.
Midazolam of 0.05- 0.1 mg/kg IV should be injected
slowly. If the seizure is continuing, 10 minutes after the
first injection same dose of diazepam or midazolam IV
should be injected slowly (If it is injected fast, there is
the possibility of exitus due to respiratory depression.)
Although
the
seizure
stops
as
soon
as
diazepam/Midazolam IV is injected, you should proceed
with the phenytoin step.
Pehnytoin is added into normal saline of 100-150 cc at a
dose of 18-20 mg/kg (4-6 ampoules on average) within
3-45 minutes (level of 50 mg per minute should not be
exceeded).
The pregnant is monitored during infusion for
arrhythmia. If arrhythmia develops, the medication is
discontinued immediately. If necessary, antiaritmic
medication is administered and consultation is demanded
of a cardiologist.
While all of these procedures are being conducted,
consultation is demanded of the neurologist.
In this case, contact is made with 112 and the pregnant is
referred by being accompanied by a doctor.
POSTNATAL CARE
64
 The puerperant should be monitored in line with Postnatal
Care Management Guideline.
 The mother should proceed with breastfeeding despite using
medication.
 The puerperant should be seen by a neurologist in the
postpartum 1-3rd weeks for a change of dose and
medication.
65
MANAGEMENT GUIDELINE FOR PREGNANTS
WITH ASTHMA
66
GENERAL INFORMATION
Asthma is a common and chronic inflammatory disease. The cause
of the disease is unclear and it is characterized by airway
inflammation, bronchial hyperactivity and diffuse reversible airway
obstruction. The said inflammation causes stertorous respiration,
shortness of breath, feeling of pain in the chest and cough in the
form of repetitive attacks especially at night and/or in the morning.
The symptoms are accompanied by airway obstruction that gets
better by itself or through treatment. Due to the existing
inflammation, hypersensitivity occurs in airways against certain
stimuli.
Asthma prevalence is between 2-17% in different countries of the
world. This rate is 8-11 % in women of fertility age. In adults in
our country the rate is 2-6%. Although the number of asthmarelated deaths decreases gradually, there is an increase in its
prevalence and morbidity.
Asthma is seen in around 4-8% of all pregnancies. These two
conditions affect the course of each other. The effect of pregnancy
on asthma is changeable, in one third of the phenomena asthma
deteriorates, in another one third it gets better and in the last one
third there is no change in the course of asthma. Taking asthma
under control through an appropriate treatment is very important in
terms of pregnancy complications and fetal risks. In pregnants with
asthma who also have allergic rhinitis, the symptoms of rhinitis
may increase especially in the third trimestre. In this case nasal
steroid can be included in the treatment. Mild and moderate asthma
under control does not pose an important risk against maternal and
infant health. However, asthma that is not under control and severe
asthma may cause increased prematurity, preeclampsia, low birth
weight, fetal growth restriction, the obligation to have caesarean
section and other perinatal complications. The main purpose of
67
asthma treatment during pregnancy is to make sure that the fetus
gets enough oxygen by preventing asthma attacks. The principles
of asthma treatment to be administered during pregnancy are no
different from those that are valid in the normal period. This
process is composed of training the patient, avoiding triggers and
pharmacological treatment.
Preconception
1)
In the follow up of women of 15–49 years of age, women
with asthma should absolutely get counselling from the
health personnel before becoming pregnant. Within the scope
of counselling; information should be provided about the
effect of asthma on pregnancy, the effect of pregnancy on
asthma, how the drugs used for asthma affect pregnancy,
whether it is necessary to change medications and the dose
and interference of medications. The importance of regular
follow-up and counselling should be emphasized. If there is
no demand for pregnancy, the woman should be referred to a
Family Planning Clinic.
2) In the preconception period, the opinions of a pulmonologist
and a gynecologist should be received and the follow-ups in
the preconception period, during pregnancy and
postconception period should be conducted by these
branches.
3) The pregnancy should be planned when the asthma is under
control.
4) The medication should not be discontinued. The medications
should definitely be managed by a pulmonologist. The dose
and active ingredient of the medications should not be
changed without consulting the pulmonologist.
68
PREGNANCY
It is safer for a pregnant with asthma to use asthma
medications during pregnancy when compared to risks that
may be caused by uncontrolled asthma and attacks that may
develop when the patient is not treated.
Pregnants with asthma should be monitored in line with the
prenatal care management guideline. And in addition to these
follow-ups regarding asthma;
 The pregnant with asthma should be informed of the fact
that asthma medications are safe and that if she uses her
medications regularly, she will have a healthy pregnancy
and that otherwise, uncontrolled asthma may do more
damage to the fetus.
 The main purpose of asthma treatment during pregnancy is
to prevent hypoxic attacks in the mother to make sure that
the fetus is oxygenated to a sufficient extent.
 Asthma is assessed through symptoms and respiratory
function tests. The follow-up of the pregnant whose
asthma is under control should be assessed by a
pulmonologist every trimestre including once before the
delivery. Then, a decision is made on whether the disease
is under control and the medication is adjusted
accordingly.
 Patients whose asthma is not under control or patients with
severe asthma should be followed up more frequently as
they carry an increased risk in terms of pregnancy
complications.
 Pharmacological treatment is administered in the form of
step treatment. The control level is determined in line with
the frequency of symptoms and SFT finding and the doses
of medications can be increased or decreased.
69






The principles of maintenance treatment and attack
treatment in pregnants with asthma are no different than
non-pregnant patients.
Asthma medications are divided into two groups as control
drugs (inhale steroids, long-acting agonists, LTRA,
teophylline) and those used to eliminate symptoms
(salbutamol, terbutalin). For a pregnant with asthma the
first choice is inhale corticosteroids from the group of
control drugs and among them preferably budesonides
(pregnancy category B). If asthma is not under control or
if the pregnant has severe asthma, other control drugs can
be included in the treatment as in the case of non pregnant
asthma patients.
The recommended saving treatment for pregnants with
asthma is inhale salbutomol or terbutalin. (Pregnancy
categories C).
In order to take asthma under control in pregnants with
asthma, triggers like cigarette smoke, allergens and
irritants should be avoided as well as administering
pharmacological treatment as in the case of all asthma
patients.
Initiating immunotherapy during pregnancy is not
recommended. Immunotherapy initiated before pregnancy
can be sustained.
The main purpose of asthma treatment during pregnancy
should be taking asthma under control. Patient whose
asthma has been taken under control through treatment
should make sure that the treatment is sustained during
pregnancy. Patients who are not under control (Table 1)
should be referred to a pulmonologist.
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ASSESSMENT OF ASTHMA CONTROL
Features
Controlled
Partially Controlled Uncontrolled
(All of the
following)
Symptoms seen during None (Two or
More than two
Partially
day
less / a week
/a week
controlled
asthma with
three or more
Limitation of activity None
Any of them
features
Symptoms seen at night None
Any of them
/waking up
Need of immediate
treatment
None (Two
or less/ a week
More than two
/a week
Lung
Functions
(PEF or
FEV1)
Normal
< %80 The best
function value that is
estimated or known
(if it is known)
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ATTACK TREAMENT
The initial treatment for attack in pregnants with asthma is not
different from the treatment of non-pregnant patients.
TREATMENT DOSE
EXPLANATION
Nasal O2
5-6 Lt/min
In such a way as to retain O2
saturation above 95%.
Salbutamol
dose inhaler or
nebula
4-8 puff
It can be administered every
20 minutes within the first 1
hour.
1-2 nebula
Prednisolone
4060mg/day
IV or oral
If there is no improvement
after the first dose of 40 mg,
additional dose can be
administered two hours later.
(20-40mg)
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Constant external fetal monitorization ( >24th week of
pregnancy)
DELIVERY MANAGEMENT
Asthma medications should not be discontinued during
delivery.
Before delivery and for the ensuing 24 hours, steroid should be
administered on the pregnant that has been using systemic
steroid for the past 4 weeks.
In vaginal delivery for a pregnant with asthma; pain control,
control of breathing and stress reduction become more important.
Especially in pregnants describing asthma attacks that are triggered
by exercise, cold air, hyperventilation and stress; pain and
tachypnea may trigger bronchoconstriction.
Analgesia methods that could be used include:
 Systemic opioids: It prevents the formation of mucosal
inflammation as well as having analgesic effect. However, it
should be kept in mind that it could cause maternal and fetal
respiratory depression if administered in high doses.
 Paracervical block: Effective in the 1st and 2nd phase of
delivery.
 Pudental nerve block: Effective in the 1st and 2nd phase of
delivery.
 Lumbar sympathetic block: Effective only in the 1st phase.
 Epidural and spinal anaesthesia: Ensures analgesia without
sedation and fetal depression. Constant pain control is possible.
It reduces hyperventilation stimuli. Unlike other analgesia
methods, in continuous epidural analgesia, sensorial block can
be ensured for caesarean section if necessary. General or
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regional anaesthesia is conducted according to obstetric and
respiratory situation of the patient in caesarean section. In the
perioperative period, the most common cause of bronchospas
is endotracheal intubation.
In asthma patients, regional anaesthesia should be the first choice.
The most important disadvantage of regional anaesthesia is the risk
of high thoracic motor block and respiratory distress. In the block
that may go up to T-8 maximum, the risk is minimal.
POSTNATAL
Asthma treatment should be continued in the puerperium. In
general, small amounts of asthma medication are transferred to the
breast milk. However, during breastfeeding asthma medications
(prednisone, teophylline, antihistamines, inhale corticosteroids and
beta2agonists) are not contraindicated.
Oral contraceptives used for contraception does not interact with
medications used for asthma maintenance treatment.
REFERENCES:
1- Türk Toraks Derneği, Astım Tanı ve Tedavi Rehberi 2010
2- McCallister JW. Asthma in pregnancy: management
strategies. Curr Opin Pulm Med. 2013 Jan;19(1):13-7
3- Rocklin RE. Asthma, asthma medications and their effects
on maternal/fetal outcomes during pregnancy. Reprod
Toxicol. 2011 Sep;32(2):189-97.
4- Mendola P, Laughon SK, Männistö TI, Leishear K, Reddy
UM, Chen Z, Zhang J. Obstetric complications among US
women with asthma. Am J Obstet Gynecol. 2013
Feb;208(2):127.e1-8
5- Virchow JC.Semin Respir Crit Care Med 2012;33:630-644
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6- Kurt E, et al. Prevalence and risk factors of allergies in
Turkey (PARFAIT): results of a multicentre cross-sectional
study in adults. Eur Respr J 2009;33:724-33).
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