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Diabetes Mellitus. It is a syndrome characterized by disturbance of carbohydrates, fats, proteins, minerals and water caused by absolute or relative deficiency or decreased sensitivity of insulin either congenital or acquired. Incidence. Second commonest medical disorder in pregnancy.
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Diabetes Mellitus It is a syndrome characterized by disturbance of carbohydrates, fats, proteins, minerals and water caused by absolute or relative deficiency or decreased sensitivity of insulin either congenital or acquired.
Incidence • Second commonest medical disorder in pregnancy. • Generally the incidence is reported to be 1%.
Classification of Diabetes Complicating Pregnancy (A.C.O.G May 1986)
Gestational Diabetes WHO: Diabetes in pregnancy when fasting glucose >7.9mmol or > 11 mmol/L 2hours after a 75 gm glucose load. Gestational Diabetes: Meets the WHO criteria for diabetes during pregnancy but reverting to normal after puerperium
Potential Diabetes Risk of developing diabetes at some age in woman’s life. • Strong family H/O diabetes • A child with birth weight of 4kg or more • A stillborn child with pancreatic islet cell hyperplasia or other congenital anomalies • Maternal weight > 90 kg. • Previous unexplained IUD or early neonatal death or recurrent abortion.
Pregnancy & Carbohydrate Metabolism • Pregnancy is diabetogenic. • Pregnancy alters carbohydrates metabolism but adaptation occurs and there is no effect on mother and fetus, as insulin secretion also increases. • When there is abnormal maternal response, there is increased fetal risk. • Decreased sensitivity to insulin with increasing gestation due to cortisole, estrogen, progesterone, hPL and degradation of insulin by placenta.
Pregnancy & Carbohydrate Metabolism (Contd.) • Early pregnancy: fasting serum insulin and Peak after glucose intake are equal to non-pregnant state. • Late pregnancy levels are higher at 28 weeks. • There is tendency to post parendial hypoglycaemia. • For normal glucose homeostasis more insulin is to be secreted adequate reserve of cell. • Pregnancy can reveal a tendency to carbohydrate in tolerance 30% • Maternal age parity and genetics also has its effects.
Effects of Pregnancy on Diabetes • Lowered renal threshold for glucose. • Increase in Progesterone, H.P.L, cortisole, placental insulinase and insulin antibodies. • Insulin requirement increases steadily. • Control is difficult. • Increased tendency of acidosis ketosis • Increased risk of complications such as nephropathy and retinopathy
Effect of Diabetes on Pregnancy • Infertility • Spontaneous abortions • Infection • Candidiasis • Pre-eclampsia • Polyhydramnios • Pre-term labour • Macrosomia • Sudden intrauterine death • Perinatal death • Post-partum hemorrhage • Congenital malformations
Management Aims • To maintain euglycaemia and prevent complications. • To deliver at appropriate time. • Intensive neonatal care.
Diet Control • 30 – 30k cal/kg body weight for the non-obese patients • 25k cal/kg body weight for obese patients CHO 50 – 55% Proteins 15 – 20% Fat 20 – 30%
Antenatal Management • Early booking. • Ultrasound in early pregnancy and at 20 weeks for anomaly scan. • Fortnight visits to estimate maternal complications and assess fetal well-being • After 24 weeks monthly ultrasound for fetal growth. • In last trimaster fetal kick count, CTG and biophysical profile. • Late pregnancy admission to hospital to plan delivery.
Medical Management • Insulin therapy (maintain glucose between 4 – 6 mmol/L). • Insulin requirement increases steadily. • Never use oral hypoglycaemics. • Self monitoring with glucometer. • Patients education regarding insulin injections, symptoms of hypoglycaemia, urine testing, dietary advice and to report immediately if any complication occurs.
Admissions To The Hospital If: • Inadequate control of Diabetes. • Condition is newly diagnosed. • An intercurrent Infection. • Any medical or obstetric complication.
Obstetric Management • Plan normal delivery if every thing is OK • Induction and augmentation. • Omit morning insulin. • IV insulin therapy. • Monitor uterine contractions and fetal heart rate and CTG • Adequate analgesia. • Maintain partogram. • Second stage shortened by ventous or forceps. • Supervised by the senior. • Watch for diabetic ketoacidosis.
Neonatal Management • Nursery care. • Blood glucose estimation. • Treatment of hypoglycaemia, hypocalcaemia and jaundice.
Neonatal Complications • Hypoglycaemia • Hypocalcaemia • Hypomagnecaemia • Hyperbilirubinaemia • Polycythemia • Respiratory distress syndrome • Cardimyopathy • Late inherent diabetes mellitus
Maternal hyperglycaemia & hyperacidaemia Fetal hyperglycaemia & hyperacidaemia Fetal pancreatic hyperplasia Fetal hyperinsulinaemia Macrosomia Organomegaly Neonatal hypoglycaemia Increased erythropoisis Decreased surfactant
Post-Natal Management • Blood glucose level after delivery. • Insulin requirement decreases. • Prevention of wound infection. • Breast feeding. • Post-natal checkup after 6 weeks. • Contraceptive advice.
