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Diabetes in pregnancy. Naghshineh.E MD. GDM versus overt DM. do not have overt vasculopathy do not have increased risk of congenital malformations. Conditions more common in GDM:. Macrosomia Preeclampsia(daily low dose ASA) Hydramnios Stillbirth Neonatal morbidity (RDS)

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diabetes in pregnancy

Diabetes in pregnancy

Naghshineh.E MD

gdm versus overt dm
GDM versus overt DM
  • do not have overt vasculopathy
  • do not have increased risk of congenital malformations

diabetes in pregnancy

conditions more common in gdm
Conditions more common in GDM:
  • Macrosomia
  • Preeclampsia(daily low dose ASA)
  • Hydramnios
  • Stillbirth
  • Neonatal morbidity (RDS)
  • Strict glycemic control:

-exacerbation of diabetic retinopathy

-may impair fetal growth

-not teratogenic in humans

diabetes in pregnancy

management of pregnancy
Management of pregnancy
  • Glucose monitoring &control
  • Antenatal fetal testing(NST,BPP,CST):

-GDM control with insulin or oral HGA:

usually initiated at 32wks weekly,

from 36 wks until delivery twice per week

-GDM control with nutritional therapy :

Not ante partum fetal surveillance

  • IUFD:3 per 1000 pregnancy (excluding congenital malformations)

diabetes in pregnancy

management of pregnancy1
Management of pregnancy
  • Assessment of fetal growth:

-induction of labor

-scheduled c/s

-not optimal glycemiccontrol

---EFW≥4800 gr → 50% chance FW≥4500 gr

---sono 28-32 wks, repeat 3-4 wks ,last 38 wk

or---single sono at 36 wks

---not recommended in GDM with nutritional therapy

diabetes in pregnancy

management of pregnancy2
Management of pregnancy
  • PTL:16%
  • Choice for tocolytic therapy :

Nifedipin Or Indometacin

  • Avoid Beta-adrenergic receptor :

severe hyperglycemia

  • Ante natal glucocorticoid:

hyperglycemia 12 hrs after first dose,

last 5 days

diabetes in pregnancy

timing of delivery
Timing of delivery

-Benefits of induction:

  • Avoidance of late stillbirth
  • Avoidance of delivery-related complications

-Disadvantage of induction:

  • c/s in failed induction
  • tachysystole
  • neonatal morbidity in<39 wks

diabetes in pregnancy

timing of delivery1
Timing of delivery
  • GDM euglycemicwith nutritional therapy:

induction of labor at 40 wks

  • GDM medically managed (ins or OHGA):

induction of labor at 39 wks

  • ACOG recommended:

c/s in DM :EFW≥4500 gr

c/s in non DM: EFW≥5000 gr

diabetes in pregnancy

management of labor
Management of labor
  • Cervical ripening agents are safe
  • Fallow labor progress closely
  • Operative vaginal delivery: only if fetal vertex has descended normally
  • Higher risk of shoulder dystocia & brachial plexus injury

diabetes in pregnancy

labor delivery
Labor & delivery
  • avoid maternal hyperglycemia : risk of fetal acidosis & neonatal hypoglycemia
  • insulin requirement usually decrease during labor
  • Glucose is important for optimal myometrial function
  • GDM euglycemicwith nutritional therapy:

rarely require insulin during labor (2%)

  • GDM medically managed (Ins or OHGA): may need insulin infusion during labor (3.5%)

diabetes in pregnancy

labor delivery1
Labor & delivery
  • Poorly controlled DM: Diabetic fetopathy( prolonged hypoglycemia secondary to pancreatic hyperplasia & hyperinsulinemia)
  • Maternal normoglycemia can not prevent neonatal hypoglycemia

diabetes in pregnancy

labor delivery2
Labor & delivery
  • Intrapartum glucose target:70-110
  • Check BS every 2-4 hrs during latent phase ,1-2 hrs during active phase of labor
  • Begin insulin infusion if BS>120
  • Check BS every 1 hour during insulin infusion
  • GDM euglycemic with nutritional diet & exercise:

BS on admission, every 4-6 hours

diabetes in pregnancy

labor delivery3
Labor & delivery
  • Mild hyperglycemia is less morbid than hypoglycemia
  • BS<50, BS>180:treated promptly
  • Protocols:

1-N/S infusion, when BS<70: DW5%

2-DW5%(100-125 ml/h)+Ins(0.5-1u/h)

3-Rotating fluids(N/S,DW5%,LR)

diabetes in pregnancy

cesarian delivery
Cesarian delivery
  • Procedure scheduled early in morning
  • NPO & Ins or OHGA withheld morning of surgery
  • Delay surgery until afternoon: 1/3 morning NPH +DW5% (avoid ketosis)
  • BS monitor & control with regular insulin
  • Hypoglycemia: wound infection, metabolic complications, neonatal hypoglycemia

diabetes in pregnancy

gdm postpartum management
GDM Postpartum management
  • Check FBS,BS (2hpp):

24 h after NVD & 48h after c/s

  • Relaxed BS level:140-160 during first24-48 h
  • If FBS<126: follow up
  • If FBS>126: monitoring and therapy
  • Postpartum depression is more common
  • follow up 6-8 wks later: GTT,75 gr,2 hr

diabetes in pregnancy

overt dm postpartum management
Overt DM Postpartum management
  • DM-I:

-1/2-2/3 (NPH+ Reg) prepartum

  • DM-II:

-no medication first 24-48 hours

-Ins 0.6 u/kg post partum weight

-Metformin, glyburide (safe breastfeeding)

-Metformin prefer in obese DM patients

diabetes in pregnancy

after hospital discharge
After hospital discharge
  • Hb A1C<7%
  • FBS<120
  • BS 2hpp<170

diabetes in pregnancy

overt dm
Overt DM
  • Insulin requirement:

-early rise 3-7 wks

-decline 7-15 wks

-rise during reminder of pregnancy

-if insulin fall after 35 wks>5-10%:R/O placental insufficiency, fetal wellbeing tests ,not indication of delivery

diabetes in pregnancy

overt dm1
Overt DM
  • Screening for aneuploidy:

-first trimester & ultrasound markers not affected by maternal DM

-Second trimester (QT):Decreased AFP & uE3 ,must be adjusted

  • MSAFP:NTD(2%)
  • Anomaly scan:18 wks
  • Fetal echocardiogram ?

(50% ,conotruncal &VSD)

diabetes in pregnancy

overt dm2
Overt DM
  • Timing for delivery:
  • Well controled:38+4 wks
  • With vascular disease:37 wks

diabetes in pregnancy

contraception
Contraception
  • Any type is acceptable
  • Progestin-only pills, DMPA, levonogestrol IUD : increased risk of developing DM-II ?
  • Copper IUD

diabetes in pregnancy

slide22

Towards a safe motherhood

diabetes in pregnancy

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