DIABETIC PARTURIENTDr.CHANDRA PRAKASH

Prof. &HOD DEPARTMENT OF ANAESTHESIOLOGY

Dr.PARVEEN SKP. G IIYr

MNR MEDICAL COLLEGE

ClassificationClassification

Pregestational diabetesPregestational diabetes

Type 1 DMType 1 DM

Type 2 DMType 2 DM

Secondary DMSecondary DM Gestational diabetes Gestational diabetes

DefinitionDefinition

Gestational diabetes (GDM) is defined as glucose Gestational diabetes (GDM) is defined as glucose intolerance of variable degree with onset or first intolerance of variable degree with onset or first recognition during the present pregnancy. recognition during the present pregnancy.

Pregestational diabetes precedes the diagnosis of pregnancy.

Gestational diabetes and impaired glucose tolerance (IGT) in pregnancy affects

between of all pregnancies and both have been associated with pregnancy

complications.

2-3%

EPIDEMIOLOGY

The prevalence of gestational diabetes { GDM} in india varied from 3.8 to 21% in different parts of the country,depending on the geographical locations and diagnostic methods used.

GDM is found to be more prevalent in urban areas than in rural areas.

Normal hepatic glucose metabolism represents a balance between insulin and counter-regulatory hormones

Counterregulatory hormones are glucagon, cortisol, epinephrine and growth hormone

Insulin also an important anabolic regulator of lipids and amino acids

Progressive resistance to insulin at receptor and postreceptor level due to increase in counterregulatory hormones (placental lactogen and growth hormone, cortisol and progesterone) in third trimester

Placental lactogen most plausible cause Placental lactogen has growth hormone like activity Gestational diabetes results when a patient can’t mount

a sufficient compensatory insulin response during pregnancy

In patients with pregestational diabetes, the therapeutic dose of insulin increases progressively during pregnancy

At term, the requirement is 1 U/kg compared to 0.7 U/kg before pregnancy

Type I diabetes: insulin requirements decrease with onset of first stage of labor

Insulin requirements increase during second stage of labor

After delivery, insulin requirements decrease markedly and return to normal within several weeks of delivery

Before discovery of insulin (1921), pregnancies were rare in diabetic patients

Despite improved obstetric and medical care, maternal mortality remains ten times higher in diabetic than non diabetic patients

Major complications of DM

ACUTE : Diabetic ketoacidosis Hyperosmolar hyperglycaemic nonketotic coma Hypoglycaemia

CHRONIC : Macrovascular(atherosclerosis) coronary cerebrovascular peripheral vascular Microscopic retinopathy nephropathy Neuropathy Autonomic Somatic

DKA: 8%-9% of diabetic pregnancies One case report of DKA with gestational diabetes Perinatal mortality as high as 30%-70% with DKA Occurs most commonly during second and third trimester Associated with ᵦ-adrenergic therapy, emesis, decreased caloric

intake, poor medical management, patient non-compliance and infection (3.2 higher in type I than non-diabetic)

ᵦ -adrenergic agents used to treat preterm labor and corticosteroids for fetal lung maturity can precipitate DKA during pregnancy

Fetal heart rate patterns consistent with fetal distress during DKA Probably related to decreased placental perfusion secondary to

acidosis HHNC: Rare during pregnancy, one case report

Hypoglycemia: Significant risk during pregnancy for patients with

pregestational type I diabetes. Occurs in approx 33%-71% of patients. (or 3-15 times greater than for non pregnant type I

diabetics) 73% of episodes of hypoglycemia occur before 16 weeks

gestation. Risk increases with tight glucose control. Counter regulatory responses to hypoglycemia impaired

after intensive insulin therapy in both pregnant and non-pregnant patients.

Relationship between pregnancy and development of macrovascular complications unknown.

Patients with pregestational type I diabetes have higher systolic and diastolic pressures during pregnancy.

PIH three times more common. MI occurs during diabetic pregnancies but is a rare

complication. Pregnancy may accelerate the progression of proliferative

retinopathy. In contrast, pregnancy doesn’t accelerate the development of

diabetic nephropathy. It is unclear whether pregnancy accelerate progression of

somatic or autonomic neuropathy.

Both pregestational and gestational diabetes associated with increased incidence of PIH, polyhdramnios and cesarean delivery

CS rate increased 3-10 fold in patients with pregestational diabetes

1.5 times with gestational diabetes Pregestational diabetes associated with 2-3

fold increase in incidence of preterm labor and delivery

FETAL COMPLICATIONS OF MATERNAL DM DURING PREGNANCY AND PUERPERIUM

Macrosomial/large for gestational age -shoulder dystocia -birth injury/trauma Structural malformatins CNS: anencephaly,encephalocele meningomyelocele,spina bifida,holoprosencephaly CARDIAC : Transposition of great vessels,VSD, situs inversus,single ventricle, hypoplastic ventricle SKELETAL : caudal regression RENAL : agenesis, multicystic dysplasia GASTROINTESTINAL : anal/rectal atresia,small left colon PULMONARY : hypoplasia AFTER BIRTH IUD/Neonatal death Neonatal respiratory distress syndrome Neonatal hypoglycaemia Neonatal hyperbilirubinaemia Glucose intolerance Possible impairment of cognitive development

Fetal macrosomia well known complication of both pregestational and gestational diabetes

Fetal macrosomia (4000 gms vs. 4500 gms depending on definition)

9%-25% incidence with pregestational diabetes 4-6 fold increase when compared to non-diabetic Macrosomia results in increased incidence of shoulder

dystocia and birth trauma Mechanism probably anabolic response in fetus

secondary to hyperinsulinemia from hyperglycemia

Increased risk of fetal anomalies with pregestational diabetes

Incidence 6% to 18% which is 7-10 times higher than non-diabetics

Cardiovascular anomalies most common followed by CNS anomalies.

3%-8% with gestational diabetes Ten fold decreased incidence of malformations with

strict glycemic control

Higher perinatal mortality rate with pregestational > gestational diabetes

Intrauterine fetal death accounts for 40% of perinatal fetal deaths

68% of stillbirths occur between 36-40 weeks gestation

Risk factors: fetal macrosomia and recurrent episodes of hypoxia from reduced placental perfusion

Now congenital anomalies have emerged as leading cause of perinatal mortality

Cardiac: transposition, VSD, situs inversus, single ventricle, hypoplastic left ventricle

CNS: anencephaly, encephalocele, meningomyelocele, spina bifida

Skeletal: Caudal regression syndrome Renal: Agenesis, multicystic kidney GI: anal/rectal atresia Pulmonary hypoplasia

Caudal regression syndrome

Caudal regression syndrome

Intrauterine/neonatal death Respiratory distress syndrome Neonatal hypoglycemia: occurs in 5%-12%

cases of pregestational and gestational diabetics

(6-16 fold increase in incidence when compared to nondiabetics)

Neonatal hyperbilirubinemia: 2-5 fold increase

Gestational Diabetes associated with advanced maternal age, obesity, family history of diabetes, prior stillbirth, neonatal death, fetal malformation or macrosomia.

1 hr glucose tolerance test with cut off of 140 mg/dl.

Patients with +ve screen undergo a 100 g 3-hr glucose tolerance test.

Glycosylated hemoglobin: 4.1% to 5.9% in pregnant nondiabetic.

1. Symptoms of DM plus casual plasma glucose concentration ≥ 200 mg/dL. Casual is defined as any time of day without regard to time since last meal. The classic symptoms of DM include polyuria polydipsia, and unexplained weight loss.

or

2. Fasting plasma glucose (FPG) ≥ 126 mg/dL. Fasting is defined as no caloric intake for at least 8 hours.

or

3. Two-hour postload plasma glucose (2hPG) ≥ 200 mg/dL during an oral glucose tolerance test (OGTT). This test should be performed as described by the World Health Organization, using a glucose load containing the equivalent of 75 g of anhydrous glucose dissolved in water.

• In the absence of unequivocal hyperglycemia with acute metabolic decompensation, these criteria should be confirmed by repeat testing on a different day.

• The Third measurement (OGTT) is not recommended for routine clinical use.• Normal fasting glucose = FPG < 110 mg/dL.• Normal glucose tolerance = 2hPG < 140 mg/dL.• Impaired fasting glucose = FPG ≥ 110 and < 126 mg/dL.• Impaired glucose tolerance = 2hPG ≥ 140 and < 200 mg/dL.

_________________________________________________________________________________

From American Diabetes Association Expert Committee on the Diagnosis and Classification of Diabetes Mellitus.Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care 1997; 20:1183-97.

Whom to screen ?Whom to screen ?

Risk stratification based on certain variablesRisk stratification based on certain variables

Low risk : no screeningLow risk : no screening

Average risk: at 24-28 weeksAverage risk: at 24-28 weeks

High risk : as soon as possibleHigh risk : as soon as possible

Essentially all Indian women have to be Essentially all Indian women have to be screened for gestational diabetes mellitusscreened for gestational diabetes mellitus

as they belong to a high risk ethnicityas they belong to a high risk ethnicity

How to screen?How to screen?

Oral glucose tolerance Oral glucose tolerance

test ( OGTT) with 100 gm test ( OGTT) with 100 gm glucoseglucose

FastingFasting 95 mg/dl95 mg/dl

1-h1-h 180 mg/dl180 mg/dl

2-h2-h 155 mg/dl155 mg/dl

3-h3-h 140 mg/dl140 mg/dl

• Overnight fast of at least 8 hours

• At least 3 days of unrestricted diet and unlimited physical activity

• > 2 values must be abnormal

CLARITY IN CATEGORIZING ABNORMAL CLARITY IN CATEGORIZING ABNORMAL GLUCOSE TOLERENCE IN PREGNANCYGLUCOSE TOLERENCE IN PREGNANCY 2h plasma glucose in2h plasma glucose in pregnancy outside pregnancypregnancy outside pregnancy

>200mg/dl Diabetes Diabetes

>140-199mg/dl GDM IGT

120-139mg/dl Gestational glucose intolerance

-

<120mg/dl Normal Normal

Urine glucose monitoring is not useful in gestational Urine glucose monitoring is not useful in gestational diabetes mellitusdiabetes mellitus

Urine ketone monitoring may be useful in detecting Urine ketone monitoring may be useful in detecting insufficient caloric or carbohydrate intake in women insufficient caloric or carbohydrate intake in women treated with calorie restrictiontreated with calorie restriction

Urine monitoring

Daily self-monitoring of blood glucose (SMBG) appears to be superior to intermittent office

monitoring of plasma glucose.

Monitoring

For women treated with insulin, preprandial monitoring is postprandial monitoring. However, the success of

either approach depends on the glycemic targets that are set and achieved.

Monitoring

superior superior toto

Glycosylated haemoglobin (Hb A1(

It is normally accounts for 5-6% of the total haemoglobin mass. A value over 10% indicates poor diabetes control in the previous 4-8 weeks.

If this is detected early in pregnancy, there is a high risk of congenital anomalies .

If this is detected in late pregnancy it indicates increased incidence of macrosomia and neonatal morbidity and mortality.

Monitoring

Assessment for asymmetric fetal growth by ultrasonography,

particularly in early third trimester, may aid in identifying fetuses that can benefit from maternal insulin therapy

Monitoring

Maternal surveillance should include blood pressure and urine protein monitoring to detect hypertensive

disorders.

Monitoring

ManagementManagement

Clinical parameters: checked at each visitClinical parameters: checked at each visit

medicationsmedications pre-pregnancy weight pre-pregnancy weight weight gainweight gain edemaedema pallorpallor blood pressure blood pressure Fundal height Fundal height

Patient educationPatient education

Cornerstone in GDM managementCornerstone in GDM management

1) Preconceptional counselling 2) Medical nutrional therapy 3) Drugs- Oral hypoglycaemics, Insulin therapy 4) Fetal monitering 5) Timing of delivery 6) managemant during labour & delivery 7) glycaemic management during labour 8)Post-partum followup 9) Longterm risk-followup 10) Immediate management of neonate 11) Anaesthetic implications

Preconception counsellingPreconception counselling

Diabetic mother : glycemic control with insulin/SMBGDiabetic mother : glycemic control with insulin/SMBG Target: HbA1c < 7% Target: HbA1c < 7%

Folic acid supplementation: 5 mg/day Folic acid supplementation: 5 mg/day

Ensure no transmissible diseases: HBsAg, HIV, rubellaEnsure no transmissible diseases: HBsAg, HIV, rubella

Try and achieve normal body weight: diet/exerciseTry and achieve normal body weight: diet/exercise

Stop drugs : ?oral hypoglycemic drugs, ACE inhibitors, Stop drugs : ?oral hypoglycemic drugs, ACE inhibitors, beta blockersbeta blockers

Medical nutrition therapyMedical nutrition therapy

Promote nutrition necessary for maternal and fetal healthPromote nutrition necessary for maternal and fetal health

Adequate energy levels for appropriate gestational weight Adequate energy levels for appropriate gestational weight

gain,gain,

Achievement and maintenance of normoglycemiaAchievement and maintenance of normoglycemia

Absence of ketones Absence of ketones

Regular aerobic exercisesRegular aerobic exercises

Medical nutrition therapyMedical nutrition therapy

Approximately 30 kcal/kg of ideal body weightApproximately 30 kcal/kg of ideal body weight

> 40-45% should be carbohydrates> 40-45% should be carbohydrates

6-7 meals daily( 3 meals , 3-4 snacks). Bed time snack to prevent 6-7 meals daily( 3 meals , 3-4 snacks). Bed time snack to prevent ketosis ketosis

Calories guided by fetal well being/maternal weight gain/blood Calories guided by fetal well being/maternal weight gain/blood sugars/ ketonessugars/ ketones

Energy requirements during the first 6 months of lactation Energy requirements during the first 6 months of lactation require an additional 200 calories above the pregnancy meal require an additional 200 calories above the pregnancy meal plan.plan.

Self monitored blood glucoseSelf monitored blood glucose

4 times/day minimum, fasting and 1 to 2 4 times/day minimum, fasting and 1 to 2 hours after start of mealshours after start of meals

Maintain log bookMaintain log book

Use a memory meterUse a memory meter

Calibrate the glucometer frequentlyCalibrate the glucometer frequently

GDM

Failure to maintain glycemic targets

INSULIN THERAPY

Medical nutrition therapy

insulin therapy is recommended when medical nutrition therapy fails to maintain self-monitored glucose at the

following levels:Fasting whole blood glucose <95 mg/dL Fasting plasma glucose <105 mg/dL or1-hour postprandial whole blood glucose <140 mg/dL 1-hour postprandial plasma glucose <155 mg/dL or2-hour postprandial whole blood glucose <120 mg/dL 2-hour postprandial plasma glucose <135 mg/dL

insulin therapy

GOAL Self-blood glucose monitoring combined

with aggressive insulin therapy has made the maintenance of maternal

normoglycemia (fasting and premeal glucose between

50-80mg/dl and 1 hour postprandial glucose <140mg/dl)

Insulin therapy …..cont.

Insulin

Preparations Onset (hr) Peak (hr) Duration (hr)

Short-Acting Class•Regular 0.5-1 2-4 4-8•Lispro* 0.25 1 2-4•Aspart* 0.25 1 2-4

Intermediate Class•NPH 1-4 6-10 12-20•Lente 2-4 6-12 12-20

Long-Acting Class•Ultralente 3-5 10-16 18-24•Glargine* 2 None 24

*Insulin analogs

Insulin therapy …..cont.

Twice daily ( before breakfast and before dinner) injections of a combination of short

and intermediate acting insulins are usually sufficient to control most patients

otherwise a subcutaneous insulin pump is used.

The total first dose of insulin is calculated according to the patient’s weight as follow:

Insulin therapy …..cont.

In the first trimester .......... weight x In the first trimester .......... weight x

0.70.7

In the second trimester........ weight x In the second trimester........ weight x

0.80.8

In the third trimester........... weight x In the third trimester........... weight x

0.90.9

If the total dose of insulin is less than 50 units/ day, it is given in a single morning dose with the ratio: Short acting (regular or Actrapid)/Intermediate (NPH or Monotard) = 1 : 2

In higher doses, As a general rule, the amount of intermediate-acting insulin will exceed the short-acting component by a 2:1 ratio. Patients usually receive two thirds their total dose with breakfast and the remaining third in the evening as a combined dose with dinner

Suggested Flow Chart Suggested Flow Chart For GD TreatmentFor GD Treatment

In patients who are not well controlled, a brief period of hospitalization is often necessary for the initiation of therapy. Individual adjustments to the regimens

implemented can then be made.

3-Hospitalisation

Fetal monitoringFetal monitoring

Baseline ultrasound : fetal sizeBaseline ultrasound : fetal size At 18-22 weeks: major malformationsAt 18-22 weeks: major malformations

fetal echocardiogramfetal echocardiogram 26 weeks onwards: growth and liquor volume26 weeks onwards: growth and liquor volume III trimester: frequent USG for accelerated growthIII trimester: frequent USG for accelerated growth

( abdominal: head circumference) ( abdominal: head circumference)

Timing of deliveryTiming of delivery

Small risk of late IUD even with good controlSmall risk of late IUD even with good control Delivery at 38 weeksDelivery at 38 weeks Beyond 38 weeks, increased risk of IUD without an Beyond 38 weeks, increased risk of IUD without an

increase in RDSincrease in RDS Vaginal delivery: preferredVaginal delivery: preferred Caesarian section only for routine obstetric indicationCaesarian section only for routine obstetric indication just GDM is not an indication !just GDM is not an indication ! Unfavorable condition of the cervix is a problemUnfavorable condition of the cervix is a problem 4500 grams, cesarean delivery may reduce the likelihood of 4500 grams, cesarean delivery may reduce the likelihood of

brachial plexus injury in the infant (ACOG)brachial plexus injury in the infant (ACOG)

Management of labor and deliveryManagement of labor and delivery

Maternal hyperglycemia in labor: fetal hyperinsulinemia, Maternal hyperglycemia in labor: fetal hyperinsulinemia,

worsen fetal acidosisworsen fetal acidosis Maintain sugars: 80-120 mg/dl (capillary: 70-110mg/dl )Maintain sugars: 80-120 mg/dl (capillary: 70-110mg/dl ) Feed patient the routine GDM diet Feed patient the routine GDM diet Maintain basal glucose requirementsMaintain basal glucose requirements Monitor sugars 1-4 hrly intervals during labourMonitor sugars 1-4 hrly intervals during labour Give insulin only if sugars more than 120 mg/dlGive insulin only if sugars more than 120 mg/dl

Glycemic management during labourGlycemic management during labour

Later stages of labour: start dextrose to maintain basal Later stages of labour: start dextrose to maintain basal nutritional requirements: 150-200 ml/hr of 5% dextrose nutritional requirements: 150-200 ml/hr of 5% dextrose

Elective LSCS: check FBS, if in target no insulin, start Elective LSCS: check FBS, if in target no insulin, start dextrose dripdextrose drip

Continue hourly SMBGContinue hourly SMBG Post delivery keep patients on dextrose-normal saline till Post delivery keep patients on dextrose-normal saline till

fedfed No insulin unless sugars more than normal ( No insulin unless sugars more than normal ( not GDM not GDM

targets ! )targets ! )

Glycemic targetsGlycemic targets

Fasting venous plasma < 95 mg/dlFasting venous plasma < 95 mg/dl 2 hour postprandial <120 mg/dl2 hour postprandial <120 mg/dl 1 hour postprandial <130 mg/dl (140)1 hour postprandial <130 mg/dl (140)

Pre-meal and bedtime: 60 to 95 mg/dlPre-meal and bedtime: 60 to 95 mg/dl

If diet therapy fails to maintain these targets > 2 times/week, start insulin

These are venous plasma targets, not glucometer targets

Why these tight glycemic targets?Why these tight glycemic targets?

Prospective study in type1 patients with pregnancyProspective study in type1 patients with pregnancy

FBSFBS MacrosomiaMacrosomia

>105 mg/dl>105 mg/dl 28.6 %28.6 %

95-105 95-105 10%10%

<95 mg/dl <95 mg/dl 3%3%

Post partum follow upPost partum follow up : :

Check blood sugars before dischargeCheck blood sugars before discharge

Breast feeding: helps in weight lossBreast feeding: helps in weight loss

Lifestyle modification: exercise, weight reductionLifestyle modification: exercise, weight reduction

OGTT at 6-12 weeks postpartum: classify patients into OGTT at 6-12 weeks postpartum: classify patients into normal/impaired glucose tolerance and diabetesnormal/impaired glucose tolerance and diabetes

Preconception counseling for next pregnancyPreconception counseling for next pregnancy

Increased risk of cardiovascular disease,future diabetes and dyslipidemia

Immediate management of neonateImmediate management of neonate

Hypoglycemia : 50 % of macrosomic infants Hypoglycemia : 50 % of macrosomic infants 5–15 % optimally controlled GDM5–15 % optimally controlled GDM

Starts when the cord is clamped Starts when the cord is clamped

Exaggerated insulin release secondary to pancreatic ß-cell Exaggerated insulin release secondary to pancreatic ß-cell hyperplasiahyperplasia

Increased risk : blood glucose during labor and delivery Increased risk : blood glucose during labor and delivery exceeds 90 mg/dlexceeds 90 mg/dl

Anticipate and treat hypoglycemia in the infant

Management of neonateManagement of neonate

Hypoglycemia <40 mg/dl Hypoglycemia <40 mg/dl

Encourage early breast feeding Encourage early breast feeding

If symptomatic give a bolus of 2- 4 cc/kg, IV, 10% dextroseIf symptomatic give a bolus of 2- 4 cc/kg, IV, 10% dextrose

Check after 30 minutes, start feedsCheck after 30 minutes, start feeds

IV dextrose : 6-8 mg/kg/min infusionIV dextrose : 6-8 mg/kg/min infusion

Check for calcium, if seizure/irritability/RDSCheck for calcium, if seizure/irritability/RDS

Examine infant for other congenital abnormalitiesExamine infant for other congenital abnormalities

Long term risk: offspringLong term risk: offspring

Increased risk of obesity and abnormalIncreased risk of obesity and abnormal

glucose toleranceglucose tolerance

Due to changes in fetal islet cell function Due to changes in fetal islet cell function

Encourage breast feeding: less chance of obesity in later Encourage breast feeding: less chance of obesity in later lifelife

Lifestyle modificationLifestyle modification

Anaesthetic implicationsAnaesthetic implications AIMS:AIMS:Avoid hypoglycaemiaAvoid hypoglycaemiaAvoid hyperglycaemiaAvoid hyperglycaemiaMinimise electrolyte dysfunctionMinimise electrolyte dysfunctionPrevention of lipolysis and proteolysisPrevention of lipolysis and proteolysis

?Tight glycaemic control??Tight glycaemic control?

Effects of AnaesthesiaEffects of Anaesthesia

There is no evidence that anaesthetic There is no evidence that anaesthetic technique affects mortality or morbiditytechnique affects mortality or morbidity

Regional techniques have some Regional techniques have some advantage in obtunding the stress advantage in obtunding the stress response, decreasing blood loss, and response, decreasing blood loss, and decreasing thrombo-embolic complicationsdecreasing thrombo-embolic complications

Hence they are the prefered over general Hence they are the prefered over general anaesthesia.anaesthesia.

Potential for hypotension during regional;:noninvasive testing for autonomic dysfunction may be useful.

In nonpregnant diabetic patients, corrected QT interval correlates with severity of autonomic neuropathy.

Autonomic dysfunction: more frequent blood pressure monitoring and more vigorous IV hydration before and during regional.

Gastroparesis is a manifestation of autonomic neuropathy in diabetic patients.

Consider preanesthetic administration of metoclopramide. Autonomic neuropathy also associated with decreased cough

reflex threshold and increased incidence of obstructive sleep apnea.

Neonatal acidosis not a problem during spinal or epidural anesthesia provided maternal glycemic control satisfactory.

Aggressive volume expansion with non dextrose containing solution.

Treat hypotension aggressively with ephedrine Some diabetic parturients have chronic uteroplacental

insufficiency; epidural may be preferable in these patients compared to spinal due to slower onset of sympathetic blockade.

Perioperative peripheral nerve injuries reported after administration of anesthesia in nonpregnant diabetic patients .

These nerve injuries may represent either unrecognized preanesthetic neurologic deficits or a propensity of nerve injury because of latent peripheral nerve disease

Proper perioperative positioning and padding of extremities important

Preanesthetic neuro exam may be helpful Diabetic stiff joint syndrome in type I diabetics has been described

as a cause of difficult direct laryngoscopy and intubation Associated with nonfamilial short stature, joint contractures and

tight skin Limited movement of atlantooccipital joint Screening for stiff joint syndrome by looking for prayer sign Some have suggested phalangeal visualization on an ink print of

palm

Inability to approximate the palmer surfaces of the phalangeal joints (prayer sign) despite maximal effort, secondary to diabetic stiff-joint syndrome. (From Hogan K, Rusy D, Springman SR. Difficult laryngoscopy and diabetes mellitus. Anesth Analg 1988; 67:1162-5.)

Besides difficult laryngoscopy and intubation, these patients can have noncompliant epidural space.

One case report in a pregnant patient with pregestational diabetes and diabetic scleroderma of anterior spinal artery syndrome after administration of epidural anesthesia for cesarean section

Cause of vascular compression could have resulted from preexisting microvascular disease, stiff epidural space because of connective tissue disease or administration of large volume (35 ml) of local anesthetic

ConclusionConclusion

Gestational diabetes is a common problem in India.Gestational diabetes is a common problem in India.

Risk stratification and screening is essential in all Indian Risk stratification and screening is essential in all Indian pregnant women.pregnant women.

Tight glycemic targets are required for optimal maternal Tight glycemic targets are required for optimal maternal and fetal outcome.and fetal outcome.

Patient education is essential to meet these targets.Patient education is essential to meet these targets.

Long term follow up of the mother and baby is essential .Long term follow up of the mother and baby is essential .

                                                                                                               

                

17 pound baby born to Brazilian diabetic mother Courtesy: MSNBC News ServicesJan. 24, 2005

Wissler RN. Endocrine Disorders in Principles and Practice of Anesthesia, Editor David Chestnut, Elsevier Mosby, PA.

Indian Journal of Anaesthesia vol54/issue5/sep-oct2010.

PLASMA GLUCOSE AND INSULIN iv FLUID

Drip rate : 16 to 20 drops per minute. Maternal capillary blood glucose to be checked by glucometer every 1hr and drip rate adjusted.

Plasma glucose at time of onset of labour

Insulin IV fluid

<70mg/dl 5% DNS-100ml/hr

90-120mg/dl NS-100ml/hr

120-140mg/dl NS-100ml/hr plus

4 units of Reg.insulin

140-180mg/dl NS-100ml/hr plus

6 units of Reg.insulin

>180mg/dl NS-100ml/hr plus

8 units of Reg.insulin

INTRAOPERATIVE INSULIN REGIMEN

Blood glucose level (mMol/L) Rate/hour (units)

Fluid infusion: 10% dextrose(1L) with 20 mmol potassium.insulin infusion: 50U of actropid in 50 ml of 0.9% sodium chloride in a syringe driver.

0-3 0U, call docter immediately

3.1-6 1U

6.1-9 2U

9.1-12 3U

12.1-15 4U repeat after 30 min,call docter if rising

>15 6U, call docter immediately