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Diabetes in pregnancySupervised via:
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Diabetes in pregnancy
Pre-existing diabetes Gestational diabetes
Pre-existing diabetesIDDM
(Type1)
NIDDM
(Type2)True GDM
Preexisting diabetes in pregnancy
Type 1 DM ( IDDM)
Type 2 DM (NIDDM)
Preexisting DM in pregnancyEffect of pregnancy on pre-existing DM
• Increase requirement for insulin doses
• Nephropathy , autonomic neuropathy may deteriorate
• Progress in diabetic retinopathy Hypoglycemia
• Diabetic ketoacidosis
Preexisting DM In PregnancyEffect of preexisting DM on pregnancy
(1) Maternal
1. increase risk of miscarriage
2. increase risk of preclampsia
3. increase risk of infeaction eg vaginal candidiasis, UTI, endometrial or wound infection
Preexisting DM in Pregnancy(2) Fetal
1. increase risk of congenital abnormalities
sacral agenesis, congenital heart disease,
neural tube defects
Hba1c level Risk
normal not increased
<8% 5%
>10% 25 %
Preexisting DM in Pregnancy2. Perinatal mortality (excluding
congenital abnormality ) 2 fold increased
3. Increase risk of sudden unexplained intrauterine fetal death.
Complications of pregnancy in pre-existing DMMaternal:
Increase insulin requirment’
Hypoglycemia
Infection
Ketoacidosis
Deterioration in retinopathy’
Increased proteinuria+edema
Miscarriage
Polyhydramnio
Preeclampsia
Increased caesarean rate
Fetal:
Congenital abnormalities
Increased neonatal and perinatal mortality
Macrosomia
Late stillbirth
Neonatal hypoglycemia
Polycythemia
Shoulder dystocia
jaundice
Maternal hyperglycemia
|
Fetal hyperglycemia
|
Fetal pancreatic beta-cell hyperplasia
|
Fetal hyperinsulinaemia
|
Macrosomia,organomegaly, polycythaemia, hypoglycemia, RDS
Management Aim
Achieve maternal near normoglycemic level to prevent adverse perinatal
outcomes
DietLow-carbohydrate diet , high fibre with
caloric restriction
Frequent small snacks may be needed between meals
Avoid starvation
Insulin3 pre-meal short acting insulin
(actrapid) +/- intermediate-acting insulin (protophane) as it allows maximum flexibility
Target blood glucose:
fasting < 5mmol/L
2 hr <7 mmol/L
Oral Hypoglycemic agents Implicated as teratogeneic in animal
studies esp first generation sulfonyureas
In humans, scattered case reports of congenital abnormality
Risk of congenital abnormality related to maternal glycemic control rather than mode of the anti-DM agents
Oral hypoglycemic agentsFor Type 2 DM patients,
to stop oral hypoglycemic agents and change to insulin
Reassure that the risk of congenital abnormality due to drug is small
Oral hypoglycemic agents Biguanides ( metformin)
Commonly used in Polycystic Ovarian Disease (PCOD) to treat insulin resistance and normalize reproductive function
Not teratogeneic
Reduce first trimester miscarriage
10X reduce gestational diabetes
Oral hypoglycemic agentsSulfonylureas1st generation drug increase risk of
neonatal hypoglycemia2nd generation drug (Glyburide) no
such effect and other morbidities . 4%-20% patients failed to achieve
glucose control with maximum dose of drugIncrease risk of preeclampsia and need
for phototherapy
Insulin Analogues 1. rapid-acting insulin analogs
(lispro)
majority of evidence showed that it does not cross placenta, and has no adverse maternal or fetal effects
Insulin Analogues2. Long acting analogs
glargine
Not well studied systemically
MonitoringRegular home glucose monitoring with
h’stix
Insulin may be need to be adjusted as gestation advances
Hba1c monitoring
Fetal monitoring with USG
Refer ophthamologist
DeliveryTiming and mode of delivery
individualised
Intrapartum insulin infusion with glucose monitoring
no contraindication for Breast feeding either with insulin or oral hypoglycemic agents
Pre-conception Counselling Allows for optimisation of diabetic control prior to
conception, and assessment of the presence of complications like hypertension, nephropathy, and retinopathy
Should counsel that good control and lower hba1c lower the risk of congenital abnormalities and improve outcome
If necessary, proliferative retinopathy may be treated with photocoagulation prior to conception
Contraindications to pregnancy only :ischemic heart dx, untreated proliferative retinopathy, severe renal impairment(creatinine>250 mmol/L)
Gestational diabetesDefinition
Carbohydate intolerance of variable severity first recognised during the present pregnancy.
This includes women with preexisting but previously unrecognised diabetes
Gestational diabetes Screening and diagnosis
In general, the test is performed btn 24-28 wk
because at this point in gestation the diabetogenic effect of pregnancy is manifest and there is sufficient time remaining in pregnancy for therapy to exert its effect
Gestational diabetes Screening and diagnosis
In general, risk factor includes:1. age>25y2. BMI > 253. previous GDM4. Family hx of DM in 1st degree relative5. previous macrosomic baby (<4 kg)6. polyhydramnio7. large for date baby in current pregnancy8. previous unexplained stillbirth
Gestational diabetesScreening
Fasting / random glucose/ glucose challenge test(50gm)
Diagnosis
Glucose challenge test
(75gm/100gm ?)
Gestational diabetes Diagnosis
WHO criteria 1998,
75 gm glucose
fasting 2 hr (mmol/L)
Impaired fasting glucose 6.1-6.9
IGT <or =7 and 7.8-11
DM >or = 7 or > or=11.1
Gestational diabetesIncidence
2-9%
more common in Asian and Indian women
In developed countries, increasing trend because of epidemic of obesity
Gestational diabetesClinical significance of GDM
1. High incidence of macrosomia, and adverse pregnancy outcomes,
2. A significant proportion(30%) identified as GDM in fact have DM before pregnancy
Gestational diabetesWomen with glucose intolerance just
above normal range are at low risk for pregnancy complications, those with more severe glucose intolerance approaching the criteria of diabetes are at risk of neonatal complications
Fetal complicationsMacrosomia (>4 kg)
risk is 16-29% as compared to 10% in control
Increase in caesarean delivery, instrumental deliveries ( forceps/vacuum), birth trauma, such as brachial plexus injuries , clavicular fractures
Increase in neonatal hypoglycemia (24% ), hyperbilirubinemia, hypocalcemia, polycythemia
Children are at risk of type 2 DM and obesity in life
Maternal complications Increase risk of hypertensive disorders
Increase risk of caesarean and intrumental deliveries
Increased Risk (40-60%) of developing type 2 DM within10-15 yr.
Gestational diabetes
Management Management similar as preexisting DM
Need for glucose monitoring
Start with Diet control
Commence insulin for poor control
Delivery plan individualised
Gestational diabetesIn view of risk of developing type 2 DM
the woman should be screened annually for DM on yearly basis.
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