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Gestational Diabetes Mellitus. Dr. Hema Divakar. Director, Divakar’s Hospital for Women, Bangalore. Secretary General, ICOG Former Vice president FOGSI Lots of publication on Diabetes in pregnancy. Gestational Diabetes Mellitus. Diagnosed first time in pregnancy May not last after.

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Dr. Hema Divakar

Director,

Divakar’s Hospital for Women, Bangalore.

Secretary General, ICOG

Former Vice president FOGSI

Lots of publication on Diabetes in pregnancy


Gestational diabetes mellitus1
Gestational Diabetes Mellitus

  • Diagnosed first time in pregnancy

  • May not last after


Incidence
incidence

  • West

  • India


Diabetes

  • The rate of GDM in Asian women is

    5–10 times higher than in white women1

1.Reece EA et al.Lancet. 2009; 373: 1789–1797.

2. Sela HY et al.Expert Rev of Obstet Gynecol. 2009;4(5):547-554.


Screening
Screening

  • Universal

  • Selective ----- high risk


Tests
tests

  • GCT

  • OGTT

  • C&C

  • NDDG

  • DIPSI


WHEN

  • Booking

  • 24 wks

  • Late ?


What next
WHAT NEXT

  • DIET

  • INSULIN

  • SURVIELLENCE

  • Delivery

  • POSTPARTUM CARE


Diabetic mothers are at higher risk for caesarean section

Women with diabetes have a less satisfactory pregnancy outcome compared with the general population and they have a 2.5-fold greater risk of a perinatal mortality.

Dunne F, Brydon P, Smith K, et al.Diabet Med. 2003 Sep;20(9):734-8.

de Valk HW, van Nieuwaal NH, Visser GH.Rev Diabet Stud. 2006 Fall; 3(3): 134–142


Gestational Diabetes

The reported incidence of macrosomia (>4000 g) in women with

GDM varies between 16% and 29%, as against to 10% rate

in women without GDM 1

1. Sela HY et al.Expert Rev of Obstet Gynecol. 2009;4(5):547-554.


Interval period
INTERVAL PERIOD

  • Preconceptional

  • HbA1 C

  • Cong malformations


High caesarean births: Obesity to Blame?

Pre-eclampsia

Gestational diabetes

Thromboembolic disorders

Caesarean sections

Obesity

Low apgar scores

Macrosomia

Galtier-Dereure F, Boegner C, Bringer J. Am J ClinNutr. 2000;71(5 Suppl):1242S-8S.

Stagnation of induced labor

http://www.cdc.gov/reproductivehealth/maternalinfanthealth/PregComplications.htm


Case one previous end trimester loss
CASE ONE - Previous end trimester loss

  • 3.85 kg RDS neonatal death36 wks IUD - large baby


This time she reports to you at 8 wks gestation
This time she reports to you at 8 wks gestation

  • You would (1) Do a clinical examination inclusive of PV(2) Ultrasound examination(3) First trimester biochemical tests(4) Any other investigations(5) Nothing now - will see later



Fetal surveillance
Fetal Surveillance

Fetal age established by CRL scan

11 – 14 wks – NT scan

Anomalies ruled out

in Targeted scan


There is no increase in birth defects in offspring of diabetic fathers

prediabetic women and women who develop gestational diabetes after the first trimester,

suggesting that glysemic control during embryogenesis is the main factor in the genesis of diabetes-associated birth defects.


Evidence
Evidence diabetic fathers

  • Major congenital malformations

  • Preconception programme

  • Enhanced control

  • 1.2% Vs 10.9 %

    -Kitzmiller/ Gavin - JAMA 1991


Preconceptional folic acid
Preconceptional folic acid diabetic fathers

  • RCT

  • Significant reduction in NTD

  • MRC vitamin study research group Lancet 1991


Prospective studies
Prospective studies diabetic fathers

  • NEng J

  • Obst/gynecol

  • Spontaneous abortions

  • Study group 7%

  • Control group 24 %

  • Control of blood glucose/ HbA1C prepregnancy and in first trimester


Conclusion
Conclusion diabetic fathers

GDM is an entity mandating universal screening & meticulous follow-up to yield optimal outcome

Early diagnosis of gestational diabetes mellitus (GDM) is a prerequisite to reducing fetal and neonatal complications of GDM


Take home
Take Home diabetic fathers

  • importance preconceptional counselling

  • and care during interval period and advice.


Interventions during pregnancy monitoring screening
Interventions during pregnancy:Monitoring/Screening diabetic fathers

  • Weighing pregnant women

  • Early OGTT

  • Early screening for vascular disease

  • Anomaly screening

  • High risk model of care with regular screening for preeclampsia –early urinary protein estimation and baseline blood pressure measurement


Peripartum diabetic fathers

Cesarean delivery

Failed vaginal birth after cesarean delivery

Operative morbidities

1) Anesthesia complications

2) Postpartum endometritis

3) Wound breakdown

4) Postpartum thrombophlebitis


Management at cesarean delivery
Management at diabetic fathers cesarean delivery


2 case two previous mid trimester loss
(2) CASE TWO diabetic fathers Previous mid trimester loss

  • History and documentation –

  • very clearly suggestive of cervical incompetance


Present pregnancy she presents at six weeks
Present pregnancy - she presents at six weeks diabetic fathers

You would

  • (1) Complete bed rest

  • (2) Progesterone support

  • (3) Cervical length assesment by scan

  • (4) Post her for cerclage

  • (5)Give tocolytics

  • (6) Give longterm antibiotics


Short cervix
Short cervix diabetic fathers


Managing first trimester safely in boh cases

Managing first trimester safely in BOH cases diabetic fathers

Moderator

Dr. Hema Divakar

Hon. Sec. ICOG

President KSOGA- Karnataka


Pleasure to introduce to you
Pleasure to Introduce to you diabetic fathers

  • R Dutta Ahmed              

  • Dr Surender kumar

  • Dr Abha Rani Sinha        

  • Dr Ramesh Ganapathy        

  • Dr Manpreet J Tehalia

  • Dr Smiti Nanda                  


So much new knowledge diabetic fathers

Technological Advances


Abnormal cervical appearance
Abnormal cervical appearance diabetic fathers

  • Shortening

  • Funneling

  • Dilatation of cervical canal.

Dynamic event serial scans required


Cervical length normal values
Cervical length – normal values diabetic fathers

  • 2.5 cms to 4.5cms

  • Ethnic difference seen in length varies with gestational age of pregnancy

  • Shortening seen from 30 wks onwards


Transvaginal usg of cervix
Transvaginal USG of cervix diabetic fathers

  • Closer to cervix

  • Higher resolution

  • Bladder should be empty

  • Distended bladder can elongate cx close the dilated OS


Etiology
Etiology diabetic fathers

  • Congenital disorders (congenital mullerian duct abnormalities)

  • DES exposure in utero.

  • Connective tissue disorder (Ehlers-Danlos syndrome)

  • Surgical trauma (conization, repeated cervical dilatation associated with termination of pregnancies)

  • Idiopathic (most)


Anatomical causes
ANATOMICAL CAUSES diabetic fathers

3% De Cherny 10% Hafer

Septum } RPL rate reduced

Aschermans } from 77.4% to 18.2%

AJOG 2000

Hickok.

Highlights the role of laprohysteroscopic surgery.


Many uncertainties wrt uterine anomalies diabetic fathers

  • incidence: 1.8% - 37.6%

  • ? Higher incidence associated with late miscarraiges

  • Recent evidence suggests high rates of miscarriage & PTB in untreated cases

  • But – open surgery associated with risk of infertility & scar rupture during pregnancy

  • - hysteroscopic surgery averts the above risks

  • ?Role for HSG

  • Patient discomfort

  • Risk of infection

  • Radiation exposure

  • No more sensitive than 2D ultrasound in skilled hands.

  • ? A new role for 3D ultrasound


Cervical length preterm labor
Cervical length & Preterm Labor diabetic fathers

  • < 20 mm – 100% PPV

  • > 30 mm – 100% NPV

Majority of women with short cervix and funneling may not have preterm labor


  • Cervical weakness diabetic fathers

  • Diagnosis based on history of late miscarriage, preceded by SROM

  • or painless cervical dilatation.

  • But

  • Over-diagnosed

  • No satisfactory test to identify women in the non-pregnant state

  • TVS might be useful: but ultrasound-indicated cerclage has not been shown to improve perinatal survival

  • MRC/RCOG trial of elective cervical cerclage - small benefit



Take home1
Take Home women with previous failed transvaginal cerclage.

  • Some situations are simple and straightforward and need specific action

  • Also the importance of clear documentation of previous loss


3 case three previous four early pregnancy losses
(3) CASE three women with previous failed transvaginal cerclage.Previous four early pregnancy losses

  • FHeart documented in all cases at around 7 to 8 weeks By 9-10 weeks - no cardiac activity


Recurrent first trimester loss
Recurrent first women with previous failed transvaginal cerclage.trimester loss

  • 3 or more 1 % of couples

  • 2 or more 3 % of couples


Pre -Embryonic loss - (less than 6 weeks) women with previous failed transvaginal cerclage.

Embryonic loss - (6 – 8 weeks)

FP + FH ?

>8 weeks FH + - APLA / Anatomic

but lost later others


Apla syndrome
APLA syndrome women with previous failed transvaginal cerclage.

  • Investigations

  • Aspirin heparin treatment

  • Adjuvant therapies if any

  • Prognosis


Lab tests to confirm
Lab. Tests to confirm women with previous failed transvaginal cerclage.

  • Lupus Anticoagulant – aptt

  • aCL – medium or high titer IgG

    normal RPL

  • LA 1 – 2 % 16 %

  • aCL 2 - 4 % 20 % - Am J obg 1991


  • Primary Antiphospholipid Syndrome women with previous failed transvaginal cerclage.

  • Diagnosis

  • 2 positive tests at least 6 weeks apart for either LA and/or aPL (IgG and/or IgM class

  • NB test results

  • the dilute Russell’s viper venom time (dRVVT) is more sensitive and specific than either

  • aPTT or the KCL.

  • aPL are detected using standardised ELISA, but considerable

  • inter-laboratory variation due temporal fluctuation of a

  • PL titres in individual patients; transient positive result due

  • to infections; suboptimal sample collection; lack of

  • standardisation of lab tests.


Informative investigations in RPL women with previous failed transvaginal cerclage.

  • Karyotype of couple

  • 2. Cytogenetic analysis of POC in all couples with a h/o RSM in the next pregnancy if that fails

  • 3. Pelvic ultrasound to assess uterine anatomy and ovarian morphology

  • 4. Screening for APS

  • 5. Screening for bacterial vaginosis


Non-informative investigations in RPL women with previous failed transvaginal cerclage.

  • Routine screening for thyroid antibodies

  • 2. Routine HLA typing of couple

  • 3. Routine screening for occult diabetes and thyroid

  • disease with OGTT or TFTs

  • 4. TORCH screening

  • 5. Routine thrombophilia screen


Early pregnancy support
Early pregnancy support women with previous failed transvaginal cerclage.

  • Progesterone

    Oral Depo Pessaries

  • Alleynesterol

  • hCG

  • Bed Rest

  • Low dose aspirin


6 trials meta analysis – women with previous failed transvaginal cerclage.

Exogenous Progesterone does not improve pregnancy outcome

? Lack of controlled trials

? Lack of Progesterone receptors


Micronised natural progesterone women with previous failed transvaginal cerclage.

logical support in LPD

Immunomodulation


Current concepts about implantation women with previous failed transvaginal cerclage.

Why did your mother reject you?

PIBF


Depot progesterone 17 ohc
Depot progesterone women with previous failed transvaginal cerclage.(17 OHC)

Improvement in Pregnancy outcome not statistically significant

-Resendus et al

Questionable efficacy

- Vytiska Binstorfer


Allylestrenol – women with previous failed transvaginal cerclage.

Associated with congenital anomalies like

- club foot

- Hypospadias

Teratogenic

Contraindicated in Pregnancy

(Lewis 2000)


Current therapy
Current therapy women with previous failed transvaginal cerclage.

  • Empirical

  • Limited controlled prospective data

  • Directed at

  • Coagulation Mechanisms

  • Immunologic mechanisms

  • OR

  • Both


Systematic review of therapeutic trials women with previous failed transvaginal cerclage.Cochrane controlled trials registerRCT / quasi RCT : total of 10 trials

  • 3 trials : Aspirin alone –

  • no significant reduction in pregnancy loss RR 1.05

  • 5 trials : Prednisolone + Aspirin – No significant reduction in pregnancy loss RR 0. 85

  • BUT – significant increase in prematurity RR 4.83

  • 2 trials : Heparin + Aspirin –

    significant reduction in

    pregnancy loss RR 0.46


Update on management 2001 june
Update on management : 2001 June women with previous failed transvaginal cerclage.

  • Sub cut. Heparin + LDA : Std. Rx

  • Prednisolone: High risk of maternal / fetal complications

  • IVIG : important additional Rx in those who failed with Heparin + LDA

  • H/O previous thrombosis : full therapeutic

    anti-coagulation


Frequency of factors associated with recurrent loss
Frequency of factors associated with recurrent Loss women with previous failed transvaginal cerclage.

Chromosomal 3.5 %

Anatomical 1.6 %

Infection 0.5 %

Endocrine 20 %

Immunological 20 %

Idiopathic 43 %


50 % - no reason ! women with previous failed transvaginal cerclage.

Role of TLC & psychotherapy

Has to be taken more seriously


  • Unexplained RPL women with previous failed transvaginal cerclage.

  • Excellent prognosis (75%) with:

  • Supportive care

  • Dedicated early pregnancy assessment unit

  • NB:

  • data is from non-randomised studies

  • prognosis worsens with increasing maternal age

  • prognosis worsens with increasing

  • number of previous miscarriages


% women with previous failed transvaginal cerclage.

%

%

%


What do you mean by tlc
What do you mean by TLC ? women with previous failed transvaginal cerclage.

Care provided in a specialized , dedicated clinic

  • Psychological support

  • Ample opportunity to discuss concerns

  • Close monitoring, including USG during the first trimester of pregnancy

  • Appropriate reassurance

  • Staff should be caring , helpful and never dismissive(Li T.C. Hum. Repod.1998)


Some cautionary issues in the management of RPL women with previous failed transvaginal cerclage.

  • Accepting blame / taking credit

  • 2. Excellent prognosis where no abnormality is detected

  • 3. The need to practice evidence-based medicine


THANKS women with previous failed transvaginal cerclage.


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