Diabetes in pregnancy
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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

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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


Diabetes in pregnancy

Towards a safe motherhood

diabetes in pregnancy


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