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DIABETES IN PREGNANCY. BY DR. SHUMAILA ZIA. DIABETES IN PREGNANCY. INCIDENCE -- 3—4/1000 pregnancy. CARBOHYDRATE METABOLISM DURING PREGNANCY:. Increased tissue resistance to insulin. Normally glucose level stays constant b/w 4-4.5 mmol/l except after meals.

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diabetes in pregnancy

DIABETES IN PREGNANCY

BY

DR. SHUMAILA ZIA

diabetes in pregnancy1
DIABETES IN PREGNANCY

INCIDENCE -- 3—4/1000 pregnancy.

carbohydrate metabolism during pregnancy
CARBOHYDRATE METABOLISM DURING PREGNANCY:
  • Increased tissue resistance to insulin.
  • Normally glucose level stays constant b/w 4-4.5 mmol/l except after meals.
  • With increasing insulin resistance, homeostasis can only be maintained by doubling insulin secretion from the end of 1st to 3rd trimester b/c insulin resistance increases with gestation.
  • Exact etiology unknown, most probably b/c of increased production of preg. associated hormones or free cortisol, like HPL (Human placental lactogen) most important.
influence of pregnancy on cho met
INFLUENCE OF PREGNANCY ON CHO MET.
  • Increased insulin resistance –increased production of insulin by pancreas (hyperplasia/ hypertrophy)
  • Adequate insulin production may become inadequate to meet increased demand during pregnancy –gestational DM
  • Abnormally high tissue insulin resistance.

2. Known diabetic controlled on diet may need insulin

3. Medicine dependent need enhanced medication.

cho derangements in pregnancy
CHO. DERANGEMENTS IN PREGNANCY
  • Established DM:

- Type- 1----IDDM (more common in peg.)

- Type- 2----NIDDM

2. Gestational DM:

- Appear in preg. mostly disappear after preg.

3. Impaired Glucose tolerance:

- CHO metabolism altered

- Some develop frank DM in later half

- So, should be managed as DM

white s classification
White’s classification

Class D

Insulin-treated diabetic

Onset under age 10

Duration more than 20 years

Background retinopathy

Class F

Diabetic nephropathy

Class H

Cardiac disease

Class R

Proliferative retinopathy

Class A1

Abnormal glucose tolerance test with normal fasting capillary (95 mg/dl) and postprandial (120 mg/dl) glucose levels Controlled with diet alone

Class A2

Abnormal glucose tolerance test with abnormal fasting or postprandial glucose levels Treated with diet and insulin

Class B

Insulin-treated diabetic

Onset over age 20 years

Duration less than 10 years

No vascular disease or retinopathy

Class C

Insulin-treated diabetic

Onset between ages 10 and 20 years

Duration between 10 and 20 years

Background retinopathy

effects of dm on pregnancy
EFFECTS OF DM ON PREGNANCY
  • Fetal glucose level follows maternal one closely until facilitated diffusion saturated or maternal glucose reaches 11-13mmol/l then fetus dose not follow—Fetal protective mechanism
  • Insulin appear in fetal circulation at 10-12 wk.
  • In maternal DM, fetus has hyperinsulinemia- acting as growth promoting hormone-- fetal macrosomia
  • F. hyperinsulinemia rather than F. hyperglycemia is responsible for adverse effects.
adverse fetal effect of dm
ADVERSE FETAL EFFECT OF DM.
  • Congenital Malformation:

4—10 times higher than normal.

Exact mechanism of teratogenicity not known.

Said to be directly related to conc. Of glucose at time of organogenesis.

So, in known diabetics ---more chance of

Cong. abnormality.

adverse fetal effect of dm cont
ADVERSE FETAL EFFECT OF DM. Cont--
  • Structural abnormalities:

CVS, Skeletal, CNS, GIT.

  • Fetal caudal regression syndrome:

Abnormality of vertebrae below T10.

  • Sacral agenesis: missing sacrum.
  • Dislocation of hips.
  • Talipes.
  • Spina bifida.
  • Renal anomalies.
  • Urinary or fecal incontinence.
cong an of infants of diabetic mother
Cong. An. of infants of diabetic mother
  • Skeletal and central nervous system

Caudal regression syndrome

Neural tube defects

Microcephaly

  • Cardiac

Transposition of the great vessels

Ventricular septal defects

Coarctation of the aorta

defects or patent ductus arteriosus

Atrial septal defects

Cardiomegaly

  • Renal
  • Hydronephrosis
  • Renal agenesis
  • Urethral duplication
  • Gastrointestinal
  • Duodenal atresia
  • Anorectal atresia
  • Small left colon syndrome
  • Other
  • Single umbilical artery
adverse fetal effect of dm cont1
ADVERSE FETAL EFFECT OF DM. Cont--

2.Spontaneous miscarriage:

Due to cong. Anomalies.

3.Fetal macrosomia:

- Due to f. hyperinsulinaemia. body wt 4kg.

- f. macrosomia----large for dates.

- Prolonged obstructed labour.

- Shoulder dystosia.

4.IUGR:

- placental function compromised.

- poor prognosis.

adverse fetal effect of dm cont2
ADVERSE FETAL EFFECT OF DM. Cont--

5. Polyhydramnios:

- fetal. polyuria—osmotic diuresis.

- premature labour.

- malpresentation.

6.Pre-eclempsia:

- perinatal mortality double.

7.RDS:

- diabetes delays production of surfactant.

8. Unexplained intrauterine death.

9. Perinatal mortality:

- 5times higher.

management
MANAGEMENT.
  • INITIAL MANAGEMENT:

A:known diabetic:

- Pre-pregnancy care

- Early booking --- optimal control

--- USG

B:Gestational diabetes:

- Many women go unrecognized

&diagnosed after poor obs. Outcome.

effects of pregnancy on dm
EFFECTS OF PREGNANCY ON DM

CONTROL More difficult

RETINOPATHY Proliferative retinopathy may progress so careful ophthalmic assessment.

NEPHROPATHY

  • No permanent deterioration in renal function.
  • Fetal outcome good if preclampsia does not supervene & glucose control good.
  • End stage renal disease – termination of pregnancy.
initial management cont
INITIAL MANAGEMENT Cont--

SCREENING:

a. Clinical Features:

cheap way of screening.

women at high risk of gest. D.M.

*diabetes in 1st degree relatives.

*maternal obesity. Wt.90kg.

*persistent glycosuria.

* previous hx. of large baby.

*previous hx. of unexplained still birth.

*previous birth of cong. malformed baby.

*polyhydramnios /macrosomia in current

preg.

initial management cont1
INITIAL MANAGEMENT Cont--

b. Random glucose test.

cut of value 6.4 mmol/l with in 2 hr&

5.8mmol/l after 2 hrs of meal-----OGTT.

c. Fasting glucose test.

cut of value 4.8mmol/l-----OGTT.

d. Glucose challenge test: At 28wks.

50g glucose given.

1hr later blood taken--if >7.8mmol/l-OGTT.

diagnostic test
DIAGNOSTIC TEST.
  • Oral glucose tolerance test.

Gold standard investigation.

If screening test is +v

O’SULLIVAN METHOD.

- after an overnight fast >8hrs.

- a fasting blood sample taken.

- Give 100g glucose in 250ml water.

- Take blood sample ½ hrly for next 3 hrs.

slide19

Abnormal results:

if values exceeds this:

fasting= 5.0mmol/l

1hr = 9.2mmol/l

2hr = 8.1mmol/l

3hr = 6.9mmol/l

ii further management
II. Further Management.
  • Medical management.
  • Obstetrical management.

MEDICAL MANAGEMENT:

combined care –obstetrician + endocrinologist.

a) TREATMENT MODLITIES:

- diet.

- diet + insulin.

slide22

1. Diet:

Three meals and three snacks

30-35 Kcal/Kg ideal body weight

No more than 10-12 Kg weight gain

50% of energy carbohydrates (unrefined), 30% fat and 20% proteins

Review diet history to identify major areas of reduction of caloric intake

Insulin: see later

Alert the patients and relatives about the possibility of hypoglycemia and measures to counteract

2 insulin therapy
2.INSULIN THERAPY.
  • Tm of choice - does not cross placenta.

- Short acting.

- Long acting.

  • Insulin regimen:
  • four times daily regimen;

- short acting insulin---3 times after meal.

- long acting---------------at night.

2 insulin therapy cont
2.INSULIN THERAPY Cont--

BIPHASIC REGIMEN:

  • Fixed combination of medium & short acting

insulin 70:30 is given in 2DD dosage.

  • One before breakfast and other before dinner
  • 2/3rd of daily dose before breakfast.2/3-p.insulin+1/3-NPH.
  • 1/3rd in evening.1/2+ 1/2. p.insulin+NPH.
dosage schedule
DOSAGE SCHEDULE
  • In insulin dependent, adjust dose especially in later half of pregnancy
  • If started during preg. Initially start 6 hourly short acting 6 units/dose but at night long acting 10 units

For biphasic regimen start 20units/day

  • In NIDDM control on diet, start insulin if

Pre-prandial glucose persistantly > 6mmol/l

other formulas to control diabetes
OTHER FORMULAS TO CONTROL DIABETES.

1.wt× 0.7------6_15 wks. Wt× 0.8 ---15_25wks

wt×0.9 ---25_35wks. Wt×1 u----36-40 wks.

2.wt/2. total dose.

3. Sliding scale.

4. BSL -5/20= single dose.

5. Mean of all readings of bld sugar profile/5.

monitoring
MONITORING
  • Objective is to maintain

- Fasting glucose------< 5.5 mmol/l

- P P ---------------------<7.5 mmol/l

a. Blood glucose level:

- In U K ---- test 4 times (3 pre-meal & 1 at bed time)

- In U S A – after meal measurements also taken

b/c it correlate better with fetal wt.

- Pre-breakfast high measurement may be due to

rebound phenomenon after nocturnal hypoglycemia

slide28

b. HbA1C (glycosilated Hb.):

Glucose irreversibly bound to Hb.

- Indicates previous 2 months glucose control

- Repeat monthly basis

- For good control should be <8%.

obstetrical management
OBSTETRICAL MANAGEMENT
  • ANTENETAL CARE:
  • -1ST trimester : - good glucose control &

- USG

- 2nd trimester: - USG at 18-20 wk.(cong. An.)

- USG at 20-22wk.(cardiac An.)

- 3rd trimester: - Care for

. Polyhydramnios . PIH

. F. macrosomia . IUD

. Pre-term labour

slide30

2. DELIVERY:

a) Time of Delivery:

- Well controlled DM --- 39-40 weeks

- Uncontrolled DM ----- 38 weeks

b) Mode of Delivery:

- Vaginal delivery is mode of choice

- Low threshold for C- section

slide31

c) Management During Labour:

*Insulin therapy: Give I/V insulin 1 unit/h if,

. Labour established

. Induction of labour

. Elective C-section

Dilute insulin 20 U (0.2ml) in 19.8 ml N/S . Infuse 1 ml (1 U)/ hour. Measure glucose 1 hourly

Aim: Maintain glucose between 4.5-5.5 mmol/l

Give also 10% D/W in other I/ V line @ 1L/8 hourly

slide32

* OBSTETRIC Mx:- Induction of labour – as usual

- good pain relief

- avoid milking of U cord

- Early clamping of U cord

- call neonatologist

slide33

2. VISIT FREQUENCY:

-Fortnightly from 24-32 wk. followed by weekly

3. FETAL SURVEILLANCE:

a) USG: - AC– good indicator of fetal wt. so,

- AC+ AFI from 24 weeks , fortnightly

b) CTG: - 2-3 times/week from 36 weeks onward

c) Doppler:

d) Biophysical Profile:

slide34

POST PARTUM CARE

  • CARE OF THE MOTHER
      • Fall in insulin requirement in the puerperium.
  • CARE OF THE BABY
  • RESPIRATORY SYSTEM
      • Resp distress syndrome
      • Transient tachypnoea of the newborn
  • HYPOGLYCAEMIA
      • Blood glucose checked at 2,4,6& 12 hours of age.
      • If <1.4mmol/l at 4 hours, I/v 10% dextrose.
      • Start feeding by 2 hours & continue at 3-4 hours interval.
  • HYPERBILI RUBINAEMIA
      • Vit K 1mg Inj.
      • Phenobarbitone 2.5-5mg /kg daily
      • Phototherapy
      • Exchange transfusion
newborn maanagement
NEWBORN MAANAGEMENT
  • SERIALLY ASSESS CAPILLARY GLUCOSE OF THE NEONATE ESPECIALLY IN THE FIRST 12 HOURS. REPLACE GLUCOSE IF THE GLUCOSE LEVEL IS LESS THAN 45 MG/DL
  • IF THE HEMATOCRIT VALUE EXCEEDS 70, EXCHANGE TRANSFUSION
  • SERIALLY MONITOR BILIRUBIN LEVEL.
contraception
CONTRACEPTION
  • Estrogen containing allowed with need for tight control unless vascular disease
  • Progestin only allowed
  • IUCD allowed increased method failure
  • Barrier methods allowed
  • Sterilization should be considered especially women with contraindications to pregnancy (proliferative retinopathy, cardiopathy, nephropathy, gastropathy and other vascular lesions)
don t forget
DON’T FORGET
  • OGTT at 6 weeks to confirm disappearance of impaired glucose tolerance
summary
SUMMARY
  • DM is a common and serious problem for the mother and fetus
  • Prompt management of preexisting DM should start BEFORE pregnancy
  • Insulin dosage schemes differ but the therapeutic aim is the same
  • GDM should be sought in all pregnant women with few exceptions