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Diabetes in Pregnancy
Introduction
• Affects up to 3% of all pregnancies
• 90% due to gestational diabetes
• Perinatal mortality around 2-5%
Pathophysiology• Normal pregnancy:• glucose homeostasisis affected by increased
estrogen, progesterone &HPL which lead to B cell hyperplasia and increased insulin secretion. Lower maternal fasting glucose levels.
• Increased: glycogen deposition, fatty acids, triglycerides & ketones
• Decreased: circulating amino acids
• Maternal response is to increase protein catabolism and accelerate renal gluconeogenesis
Pathophysiology• Normal pregnancy:• lipids become an important fuel as pregnancy advances, fat
storage increases.
• With the rise of HPL, lipolysis is stimulated in adipose tissue. The release of glycerol and fatty acids reduces both maternal glucose and amino acid utilization and sparing them for the fetus
• This action of HPL is responsible for the “diabetogenic state of pregnancy”along with increased cortisol. Estrogen and progesterone.
• Fetal glucose level is similar to the mothers by facilitated diffusion, insulin dose not cross the placenta. Persistant elevated levels of glucose will stimulate the pancreas resulting in β-cell hyperplasia and fetal hyperinsulinemia
Maternal classification and risk assessment
Modified white classification of pregnant diabetic women
class
Onset age duration
Vascular dis Insulin need
A1 Any any 0 0
A2 any Any 0 +
B >20 <10 0 +
C 10-19 10-19 0 +
D <10 >20 + +
F Any Any + +
R Any Any + +
T Any Any + +
H any Any + +
Gestational diabetes
Pre-gestational diabetes
Effect of pre-existing diabetes on pregnancy
Pre-eclampsia and eclampsia Diabetic ketoacidosis Worsening pre-existing nephropathy Worsening pre-existing retinopathy Infection: genital > monilial Polyhydramnios/ oligohydramnios Cesarean delivery Post partum hemorrhage mortlaity
Fetal Morbidity and Mortality
1-miscarriage2-teratogenecity , drug related3- Congenital Malformation
Caudal regressionNeural tube defectCVS
4- Macrosomia / IUGR5-Fetal Death
Diabetes Mellitus and Gestational Diabetes
Summery of Management Options1- Pre-Pregnancy Explain general risks and management of
diabetes in pregnancy Evaluate any additional risks with appropriate
specialist referral (e.g. renal, ophthalmologic) Optimize blood glucose control Discuss effective contraception until good glucose
control (avoid estrogen containing-preparations with vascular disease)
Folate supplementation(4-5 mg daily) for at least 2 months before or during first trimester
B- prenatal
1- Detection of Diabetes in Pregnancy
2- Treatment of the Insulin-Dependent Patient
3- Fetal Surveillance
4- Management of Gestational Diabetes
Pregnancy is diabetogenic1. Occurrence of GDM2. Unmasking latent DM3. Worsening of existing DM4. Shift of GTT upward5. Need of more insulin in
pregnancy6. Need of less insulin after
labour7. High female to male ratio
Now we screen all gravid womenAt bookingAt 28 weeks
High risk patientsPositive family history (mother, father,
siblings)Maternal obesity (BMI > 30 kg/m2, trunkal
obesity)Aged gravidaPoor obstetric historyPersistent glycosuria MacrosomiaHydramnios
Screening for DM
high risk patients should undergo glucose testing
A fasting plasma glucose level >125mg/dL or a casual plasma glucose >200 mg/dL meets the threshold for the diagnosis of diabetes
In the absence of this degree of hyperglycemia, evaluation for gestational diabetes mellitus in women with average or high-risk characteristics is by glucose tolerance test .
Risk assessment
Methods of screening
Method Sensitivit
y
Specifici
ty
Family history
Random glucose
Glucose load
(WHO)
Glycated Hb
50 %
40 %
79 %
40 %
66 %
90 %
83 %
90 %
Fasting and 2 hours postprandial venous plasma sugar during
pregnancy.
Border line indicates glucose tolerance test.
125-200 mg/dl.100-125 mg/dl
Diabetic>200 mg/ dl.>125 mg/ dl
Not diabetic< 145mg/ dl.<100 mg/dl
Result2h postprandial
Fasting
50-g oral glucose challenge
The screening test for GDM, a 50-g oral glucose challenge, may be performed in the fasting or fed state. Sensitivity is improved if the test is performed in the fasting state .
A plasma value above one hour after is commonly used as a threshold for performing a 3-hour OGTT.
If initial screening is negative, repeat testing is performed at 24 to 28 weeks.
130 - 140 mg/dl
3 hour Oral glucose tolerance test
Prerequisites:- Normal diet for 3 days before the test.- No diuretics 10 days before.- At least 10 hours fast.- Test is done in the morning at rest.
Giving 75 gm (100 gm by other authors) glucose in 250 ml water orally
Criteria for glucose tolerance test:The maximum blood glucose values during pregnancy:- fasting 90 mg/ dl, - one hour 165 mg/dl,- 2 hours 145 mg/dl, - 3 hours 125 mg/dl.If any 2 or more of these values are elevated, the patient is considered to have an impaired glucose tolerance test.
Team care
The patient is the most important member of the team by her compliance
The patient
Control of diabetes in pregnancy
Diet Exercise
Insulin
Antenatal careRegular visitsTight glucose control
Pre-meal glucometery
Diet and insulinMedical conditionComplications
MedicalObstetric
Fetal assessmentMaturityWellbeing
Initial visit1. Careful dating
2. White’s staging
3. Obstetric history
4. Funduscopy **
5. Blood pressure
6. Urinalysis & culture **
7. HbA1c **
3- Fetal Surveillance
Ultrasound scan
CTG
Biophysical Profile
Starting 32 week gestation, weekly
Diet control25-35 kcal/kg ideal wt
50% carbohydrate20% protein30% fat Adjust for work
3 meals and 3 snacksTest for sugar before mealsArtificial sweeteners, high-fiber, low
salt diet
What worsen diabetes
1. Infection
2. Lack of exercise
3. Drugs
4. Stress of life
5. Smoking
Your aim is not weight reduction, but proper glycemic control
Proper weight gain is 1 Ib/mo in first half & 1 Ib/wk in second half
Exercise for diabeticsAdvantage
Exercising muscle utilizes glucose without insulin
Synergistic with insulin
Improves metabolic control
Improve the mood and well-being
DisadvantageExercise-induced
hypoglycemiaVigorous exercise
worsen metabolic control precipitates lactic acidosis
Strenuous exercise diverts blood to the muscles; it can cause IUGR
Regular exercise improves the outcome of pregnancy in diabetics but strenuous one disproves it
Contraindication for exercise in pregnant diabetics
MedicalCVS diseases
Retinopathy
Nephropathy
ObstetricPIH
Over distended uterus
History of premature labour
Insulin therapyHuman insulin (Actrapid, Initard 1/1,
Mixatard 2/1)Intermittent dosing
Twice daily doses (Lewis) Before breakfast 2/3 dose (NPH: Regular 2:1)Before dinner 1/3 dose (NPH: Regular is 1:1)
Thrice daily doses (Jovanovic) Before breakfast 2/3 dose (NPH: Regular 2:1)Before lunch 1/6 dose (Regular)Before dinner 1/6 dose (NPH)
Continuous insulin infusion pump (CII pump)
Daily dosage is calculated according to gestational age, severity of diabetes and actual body weight.
2- Prenatal Screen for gestational diabetes ideally in all
pregnancies ( controversy over which test and whether just at 24-28 weeks): OGTT is diagnostic test
Regular capillary glucose series Avoid oral hypoglycemic agent Appropriate diet Amend insulin regimen to keep capillary
glucose values as normal as possible Instruct partners/relatives in glucagon use for
hypoglycemic attacks
2- Prenatal Baseline renal and possibly cardiac function Randomized trials of low dose aspirin in women
with vascular disease are awaited Regular ophthalmologic review Monitor for hypertensive disease Fetal surveilance - Normality -Growth -Well-being(NST,BPS) -
Umbilical artery blood flow Gestational diabetics: initially try to control with
diet rather than insulin; otherwise, as for established diabetics
Vaginal Spontaneous or inducedShoulder dystocia develops at lower birth
weights
Caesarean sectionPlanned Urgent
Neonatologist should be available
DeliveryInduction of labor at 38 weeks, as PNM
starts to increase steadily afterward, for IDDM and GDM on treatment
If GDM on diet control with no complication allow till term
Timing of delivery depends on
Mother FetusVascular diseaseGlycemic controlObstetric history
MaturityEFWBPP
Intrapartum careTwo infusion sets
G.I.K. 10% glucose + 10 I.U insulin + 10 mmol K
1-2 hourly blood sugar check and infusion adjustment according to level
keep the blood sugar 90-120 mg/dlCTG during labor & delivery
Post-partum careReadjust the dose of insulinEncourage breast feedingReassess the glycemic statusGive a suitable contraceptiveWeight reduction to delay
NIDDMFollow-up for NIDDM
Hypoglycemia
Respiratory Distress Syndrome
Hypocalcemia
Hypomagnesemia
Jaundice
Requiring admission to nursery for monitoring and Rx