DIABETES IN PREGNANCY

1. DIABETES IN PREGNANCY www.anaesthesia.co.in Email: anaesthesia.co.in@gmail.com

2. DIABETES IN PREGNANCY Definition Classification Pathophysiology Diagnostic criteria Effect of pregnancy on diabetes Effect of diabetes on pregnancy Indication of caesarian section Management Complications

3. Definition Clinical syndrome characterized by deficiency of insulin or insensitivity to insulin

4. Etiological classification Type Ia- immune mediated beta cell destruction Type Ib-idiopathic beta cell destruction Type II-insulin secretory defect with insulin resistance Type III-other cause A-genetic deficiency in beta cell fn B-genetic deficiency in insulin action C-ds of exocrine pancreas D-endocrinopathies E-drug induced F-infection G- Uncommon forms stiff man’s syndrome Anti - insulin receptor antibody H- Other genetic syndrome associated with Diabetes Mellitus Type IV- Gestational Diabetes

5. Diagnostic criteria for Gestational DM Screening Test (24-26 wks): 50gm oral glucose load(one hour) >140 mg% 3 Hour oral glucose test is perfomed

6. 3 Hour 100gm oral glucose test (GTT) is done after overnight fast of 10 hours Fasting >/= 95mg/dL 1 Hour >/= 180 mg/dL 2 Hour >/= 155 mg/dL 3 Hour >/= 140 mg/dL At least two of the four values must be abnormal to diagnose gestational diabetes

7. Diagnostic criteria of DM prior to pregnancy • Symptoms of diabetes Polyurea Polydypsia Unexpected weight loss 2. Fasting plasma glucose > 126 mg/dl 3. 2 Hour plasma glucose >/= 200mg/dl after taking 75 gm glucose load

8. Classification of diabetes complicating Pregnancy (ACOG classification)

10. Pathophysiology Lack of Insulin Increased Catabolism Hyperglycemia Increased secretion: Glucagon Cortisol Catecholamines Growth Hormone Fatigue Wasting Weight loss Glycogenolysis gluconeogenesis lipolysis Vulvitis Glycosuria Glycosuria Polyuria Polydypsia Osmotic Diuresis Hyperketonemia Tachycardia Hypertension Salt and Water depletion Peripheral vasodilatation Hyperventillation Acidosis(DKA) HPL, PROLACTIN,ESTROGEN & PROGESTERONE- DIABETOGENIC

11. Effect of pregnancy on diabetes • First trimester - hyperemesis  hypoglycemia& ketosis • Second trimester - Inc. in counter regulatory hormone  placental lactogen, placental GH, cortisol, progesterone progressive peripheral resistance to insulin at receptor& post receptor site inc requirement of insulin • dec. renal threshold glycosuria • Third trimester - inc.level of placental hormone  inc. need of insulin • During labor - inc. consumption of carbohydrate by uterine activity reduces the insulin need

12. Stress &pain of labor -may also cause fluctuation in B/S. • inc. blood sugar careful monitoring of B/S level becomes mandatory • B/S return to near normal following delivery but may take 2 months before normal glucose tolerance is restored

13. Effect of Diabetes on PregnancyMaternal Effect • Abortion • PIH & Pre-ecclampsia • Renal infection & vaginal moniliaisis • Hydramnios in 20% • Ketosis & coma  Death

14. Effect of maternal diabetes on fetus • Miscarriages • Frequency directly related to degree of maternal glycemic control. • Up to 44% with poorly controlled DM (HbA1C >12). • Preterm Delivery • Increase birth Defects (1-2%) • CNS and CVS, renal and GI abnormalities • caudal regression syndrome.

15. - Macrosomia - Defined as birthweight above 90th % or >4000 grams. Occurs in 15-45% of diabetic pregnancies, a 4-fold increase over normal. Carries many morbidities including birth trauma, RDS, neonatal jaundice and severe hypoglycemia. Growth Restriction growth restriction is fairly common among Type 1 diabetic mothers. Best predictor is presence of maternal vascular disease

16. Effect of diabetes on fetus Big baby Prolnged labour Hydramnios Abnormal presentation Risk of amniotic fluid embolism 25-30% increase in CS rate Anaesthetic risk & risk of post-op intection

17. Polycythemia • Hyperglycemia stimulates fetal erythropoeitin production. • Can lead to tissue ischemia and infarction. • Hypoglycemia • “overshoot” mechanism. • Baby is used to having lots of maternal glucose so it makes lots of insulin. When born, maternal glucose is no longer available but insulin remains high  hypoglycemia. • Can lead to seizures, coma and brain damage.

18. Postnatal hyperbilirubinemia • Occurs in appox. 25%, double that of normal. • Thought to be due in large part to polycythemia. • Respiratory distress syndrome • 5-6 fold increased frequency. • May be due to a delay in lung maturation or simply due to the increased frequency of preterm deliveries.

19. Polyhydramnios • Amniotic fluid volume >2000 mL • Increased risk of placental abruption and preterm labor.

20. Fetal Fetal distress before start of labour Shoulder dystocia Macrosomia Abnormal fetal presentation Malpresentation Maternal Indication of Casearean Section • Pregnancy complicated with • PIH • Severe vaginal moniliasis • Unfavourable cervix • Proliferative retinopathy • Diabetic Retinopathy

21. Manangement Diet • Provide adequate maternal &fetal nutrition • Restricted fat & cholesterol • Inc. dietary fiber • 3 meal & 1-3 snacks , last snack being taken at bed time • Desirable wt. gain 200-450 gm / week until full term • Total wt gain 10-13 kg during normal & diabetic pregnancy is recommended • Calorie intake 25-35 kcal/kg Monitoring • Self monitoring of B/S – 4 times/day • Daily urine ketones testing when B/S >200mg% or pt is unable to eat.

22. INSULIN • Gold standard • Does not cross placenta • Pt on oral hypoglycemic should be changed to insulin • GDM on diet control will require insulin if fasting glucose >95mg% or pp>130 mg% • Started with 0.5-0.8 u/kg/day in three divided doses with regular insulin

23. ORAL AGENTS • Transplacental passage • Teratogenic • Prolonged hypoglycemia • SECOND GEN. SULFONYL UREA (glyburide) - Does not cross placenta, achieve satisfactory glucose control

24. Acute DKA Hyperosmolar Hyperglycemic non-ketotic coma (HHNC) Hypoglycemia Chronic Microvascular (Atherosclerosis) Coronary Cerebrovascular Peripheral Vascular Macrovascular: Retinopathy Nephropathy Neuropathic: Autonomic Peripheral neuropathic Complications:

25. Polyurea, polydypsea anorexia nausea vomiting abdominal pain Confusion coma Shock hyperventilation smell of ketones Plasma glucose>300 mg% ph<7.3 Hco3 < 15 meq/l Anion gap- increased Osmolarity 310-330 mom/l Ketonuria ketonemia DKA M/C during II& III trimester Type I Clinical Features Lab Findings

26. treatment • i.v line • O2 by F/M • Asses level of glucose& electrolyte • Replacement of flui • Average fluid deficit 3-5 L • 1-2 L in first hr- isotonic N saline • 500 ml/hr • Insulin therapy • Initial bolus 10-20 Uregular insulin • Infusion 10U/hr • Glucose administration– 5% dextrose • K administration– after 3-4 hr of insulin therapy 10-20 meq/hr • Bicarbonate– if arterial ph <7.1 • S. Hco3 <5 meq/l

27. HHNC(Hyperosmolar hyperglycemic non ketotic coma) • Type II • S/S– • thirst • Polyurea • Malaise • Lab finding • Plasma glucose > 600 mg% • Ph >/= 7.3 • Hco3 > 20 • Osmolality > 330 mosm/ l • Treament • 0.95% NS 15-20 ml/hr • 0.15 u/kg i.v bolus regular insulin • O.1 u/kg/hr infusion • K replacement

28. HYPOGLYCEMIA • Term pregnancy-- < 35 mg% • Preterm pregnancy-- <25 mg% • S/S of rapidly decreasing blood glucose • Sweating • Inc. heart rate • Tremor • Nervousness • IrritabitityWeakness • Tingling • SS of constantly low bl glucose • Headache • Visual disturbances • Mental dullness • ConfusionAmnesia • seizure

29. Treatment • Unconscious- • 100ml of 25% dextrose i.v. • Or 0.5- 1mg glucagon i.m/ s.c • Conscious • Liquid carbohydrate

30. Anaesthetic management Preoperative evaluation • History • Family h/o DM • H/O obesity • Previous h/o large birth wt. of baby • h/o drug intake • Thiazide diuretic • Beta blocker • Phenytoin • Steroid

31. Anaesthetic management H/O • Fatigue • Polyurea • Polydypsea • Palpitation • Headache • Inc RR • Wasting • Wt loss • Diminution of vission • Tingling • numbness

32. Anaesthetic management Examination • PR • BP • Temp • Joint mobility • Bed side test for autonomic function

33. Anaesthetic management Investigation • B/S—fasting,pp • S. electrolyte • Urine--- albumin,sugar,ketone • Blood urea, s.creatinine • ECG • X ray chest

34. Anaesthetic management Monitoring • NIBP • Pulse Rate • SPO2 • ECG • Urine Output • Blood Sugar • Temperature- If autonomic dysfunction

35. Anaesthetic management Preop. Advise • NPO • pt to be taken as first case in OT • Fasting B/S,Urine sugar ,ketone, S. electrolytes • Aspiration prophylaxis • Continue insulin

36. Anaesthetic management Choice of Anaesthesia Depends on status of mother and fetus • Regional anaesthesia: If no evidence of peripheral neuropathy • Epidural labour analgesia: Decreased Pain Decreased plasma catecholamine level Improved uteroplacental circulation Minimises the need for GA in event of CS

37. GA Premedication– aspiration prophylaxis • Ranitidine/metoclopramide Induction –RSI Difficult intubation trolly • Ketamine not used(hyperglycemia) Maintenance– inhalation agent (ether& trilene causes hyperglycemia) Fluid – NS Reversal – neostigmine/atropine

38. Glycemic control Therapeutic objective for plasma glucose level • Fasting-- 60 – 90 mg/dl • Before breakfast 60 – 105 mg/dl • After meal • 1 hr < 130 – 140 mg/dl • 2hr < 120 mg/dl • Early morning 60 – 90 mg/dl

39. Low dose constant insulin infusion for intrapartum maternal Glycemic management • 1. withhold a.m insulin • 2. start glucose infusion– 5% dextrose 125 ml/hr ( 6.25 g glucose/hr) • Begin regular insulin infusion 0.5 U/hr(25 U Iin 250 ml NS) • Monitor glucose every 1 – 2 hr • Adjust insulin infusion

40. Plasma capillary infusion rate fluid glucose ( U/hr) (125ml/hr) <80 insulin off D5/RL 80-120 0.5 D5/RL 101- 140 1.0 D5/RL 141-180 1.5 NS 181-220 2.0 NS <220 2.5

41. Tight control regimen • Aim– B/S 80 – 120 mg% • Improve fetal outcome prevent infection better wound healing neurologic outcome in pt with focal/global ischemia

42. Tight control 1 • Evening before surgery– do B/S– start i.v D5 @ 50 ml/hr/70 kg Piggy back 50 U insulin + 250 ml NS(0.2 U/ml) Insulin U/ ml glucosemg%/100 Measure B/S 4 hrly On day of sx Start another i.v line for non dextrose containing sn Start above setup M Measure B/S at start & 2 hrly for 24 hr Aim B/S 80-120 mg%

43. TIGHT CONTROL II • Same as Tight controle I • Protocol-- obtain a feed back mechanical pancreas & set controle for desired plasma glucose • Regimen– 2 i.v drip insulin fluid

44. REFERENCES • Shnider and Levinsons Anesthesia for Obstetrics Pheladelphia 2001 • Obstetric Anesthesia– Principles & practice David H Chestnut, 3rd edition • Anesthesia & Co-existing Disease 5th edition • Millers Anesthesia 6th edition • Text book of obstetirc DC dutta • Clinical Obstetics the Fetus& mother 3rd ed. • Current Obstetric & Gynaecologic diagnosis & treatment 9th ed.

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