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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DR. SHUMAILA ZIA
INCIDENCE -- 3—4/1000 pregnancy.
2. Known diabetic controlled on diet may need insulin
3. Medicine dependent need enhanced medication.
- 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
Onset under age 10
Duration more than 20 years
Abnormal glucose tolerance test with normal fasting capillary (95 mg/dl) and postprandial (120 mg/dl) glucose levels Controlled with diet alone
Abnormal glucose tolerance test with abnormal fasting or postprandial glucose levels Treated with diet and insulin
Onset over age 20 years
Duration less than 10 years
No vascular disease or retinopathy
Onset between ages 10 and 20 years
Duration between 10 and 20 years
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
CVS, Skeletal, CNS, GIT.
Abnormality of vertebrae below T10.
Caudal regression syndrome
Neural tube defects
Transposition of the great vessels
Ventricular septal defects
Coarctation of the aorta
defects or patent ductus arteriosus
Atrial septal defects
Due to cong. Anomalies.
- Due to f. hyperinsulinaemia. body wt 4kg.
- f. macrosomia----large for dates.
- Prolonged obstructed labour.
- Shoulder dystosia.
- placental function compromised.
- poor prognosis.
- fetal. polyuria—osmotic diuresis.
- premature labour.
- perinatal mortality double.
- diabetes delays production of surfactant.
8. Unexplained intrauterine death.
9. Perinatal mortality:
- 5times higher.
- Pre-pregnancy care
- Early booking --- optimal control
- Many women go unrecognized
&diagnosed after poor obs. Outcome.
CONTROL More difficult
RETINOPATHY Proliferative retinopathy may progress so careful ophthalmic assessment.
a. Clinical Features:
cheap way of screening.
women at high risk of gest. D.M.
*diabetes in 1st degree relatives.
*maternal obesity. Wt.90kg.
* previous hx. of large baby.
*previous hx. of unexplained still birth.
*previous birth of cong. malformed baby.
*polyhydramnios /macrosomia in current
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.
Gold standard investigation.
If screening test is +v
- 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.
if values exceeds this:
1hr = 9.2mmol/l
2hr = 8.1mmol/l
3hr = 6.9mmol/l
combined care –obstetrician + endocrinologist.
a) TREATMENT MODLITIES:
- diet + insulin.
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
- Short acting.
- Long acting.
- short acting insulin---3 times after meal.
- long acting---------------at night.
insulin 70:30 is given in 2DD dosage.
For biphasic regimen start 20units/day
Pre-prandial glucose persistantly > 6mmol/l
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.
- 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
Glucose irreversibly bound to Hb.
- Indicates previous 2 months glucose control
- Repeat monthly basis
- For good control should be <8%.
- 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
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
*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
- good pain relief
- avoid milking of U cord
- Early clamping of U cord
- call neonatologist
-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
d) Biophysical Profile: