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
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 • Universal • Selective ----- high risk
tests • GCT • OGTT • C&C • NDDG • DIPSI
WHEN • Booking • 24 wks • Late ?
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 • 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 • 3.85 kg RDS neonatal death36 wks IUD - large baby
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
Would you institute any treatment at this stage ? • Would you advice pregnancy termination if glycosylated Hb is 9.5 ?
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 • Major congenital malformations • Preconception programme • Enhanced control • 1.2% Vs 10.9 % -Kitzmiller/ Gavin - JAMA 1991
Preconceptional folic acid • RCT • Significant reduction in NTD • MRC vitamin study research group Lancet 1991
Prospective studies • NEng J • Obst/gynecol • Spontaneous abortions • Study group 7% • Control group 24 % • Control of blood glucose/ HbA1C prepregnancy and in first trimester
Conclusion 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 • importance preconceptional counselling • and care during interval period and advice.
Interventions during pregnancy:Monitoring/Screening • 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 Cesarean delivery Failed vaginal birth after cesarean delivery Operative morbidities 1) Anesthesia complications 2) Postpartum endometritis 3) Wound breakdown 4) Postpartum thrombophlebitis
(2) CASE TWOPrevious mid trimester loss • History and documentation – • very clearly suggestive of cervical incompetance
Present pregnancy - she presents at six weeks 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
Managing first trimester safely in BOH cases Moderator Dr. Hema Divakar Hon. Sec. ICOG President KSOGA- Karnataka
Pleasure to Introduce to you • R Dutta Ahmed • Dr Surender kumar • Dr Abha Rani Sinha • Dr Ramesh Ganapathy • Dr Manpreet J Tehalia • Dr Smiti Nanda
So much new knowledge Technological Advances
Abnormal cervical appearance • Shortening • Funneling • Dilatation of cervical canal. Dynamic event serial scans required
Cervical length – normal values • 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 • Closer to cervix • Higher resolution • Bladder should be empty • Distended bladder can elongate cx close the dilated OS
Etiology • 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 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 • 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 • < 20 mm – 100% PPV • > 30 mm – 100% NPV Majority of women with short cervix and funneling may not have preterm labor
Cervical weakness • 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
Transabdominal cerclage: (for short and scarred cervix in women with previous failed transvaginal cerclage. • No controlled trials • Potential benefits must be weighed against high risks of operative complications
Take Home • Some situations are simple and straightforward and need specific action • Also the importance of clear documentation of previous loss
(3) CASE threePrevious 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 • 3 or more 1 % of couples • 2 or more 3 % of couples
Pre -Embryonic loss - (less than 6 weeks) Embryonic loss - (6 – 8 weeks) FP + FH ? >8 weeks FH + - APLA / Anatomic but lost later others
APLA syndrome • Investigations • Aspirin heparin treatment • Adjuvant therapies if any • Prognosis
Lab. Tests to confirm • 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 • 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 • 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 • 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