Diabetes in pregnancy
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Transcript of Diabetes in pregnancy
Diabetes in pregnancy
Naghshineh.E MD
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do not have overt vasculopathy do not have increased risk of congenital
malformations
GDM versus overt DM
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Macrosomia Preeclampsia(daily low dose ASA) Hydramnios Stillbirth Neonatal morbidity (RDS)
Strict glycemic control:-exacerbation of diabetic retinopathy-may impair fetal growth-not teratogenic in humans
Conditions more common in GDM:
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Glucose monitoring &control
Antenatal fetal testing(NST,BPP,CST):-GDM control with insulin or oral HGA:usually initiated at 32wks weekly, from 36 wks until delivery twice per week -GDM control with nutritional therapy :Not ante partum fetal surveillance
IUFD:3 per 1000 pregnancy (excluding congenital malformations)
Management of pregnancy
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Assessment of fetal growth:-induction of labor-scheduled c/s-not optimal glycemic control
---EFW≥4800 gr → 50% chance FW≥4500 gr ---sono 28-32 wks, repeat 3-4 wks ,last 38 wkor---single sono at 36 wks---not recommended in GDM with nutritional
therapy
Management of pregnancy
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PTL:16% Choice for tocolytic therapy : Nifedipin Or Indometacin Avoid Beta-adrenergic receptor : severe hyperglycemia Ante natal glucocorticoid : hyperglycemia 12 hrs after first dose, last 5 days
Management of pregnancy
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-Benefits of induction: Avoidance of late stillbirth Avoidance of delivery-related complications
-Disadvantage of induction: c/s in failed induction tachysystole neonatal morbidity in<39 wks
Timing of delivery
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GDM euglycemic with nutritional therapy: induction of labor at 40 wks GDM medically managed (ins or OHGA): induction of labor at 39 wks
ACOG recommended: c/s in DM :EFW≥4500 gr c/s in non DM: EFW≥5000 gr
Timing of delivery
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Cervical ripening agents are safe Fallow labor progress closely
Operative vaginal delivery: only if fetal vertex has descended normally
Higher risk of shoulder dystocia & brachial plexus injury
Management of labor
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avoid maternal hyperglycemia : risk of fetal acidosis & neonatal hypoglycemia
insulin requirement usually decrease during labor
Glucose is important for optimal myometrial function
GDM euglycemic with nutritional therapy: rarely require insulin during labor (2%) GDM medically managed (Ins or OHGA): may
need insulin infusion during labor (3.5%)
Labor & delivery
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Poorly controlled DM: Diabetic fetopathy ( prolonged hypoglycemia secondary to pancreatic hyperplasia & hyperinsulinemia)
Maternal normoglycemia can not prevent neonatal hypoglycemia
Labor & delivery
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Intrapartum glucose target:70-110 Check BS every 2-4 hrs during latent
phase ,1-2 hrs during active phase of labor Begin insulin infusion if BS>120 Check BS every 1 hour during insulin
infusion
GDM euglycemic with nutritional diet & exercise:
BS on admission, every 4-6 hours
Labor & delivery
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Mild hyperglycemia is less morbid than hypoglycemia
BS<50, BS>180:treated promptly
Protocols: 1-N/S infusion, when BS<70: DW5% 2-DW5%(100-125 ml/h)+Ins(0.5-1u/h) 3-Rotating fluids(N/S,DW5%,LR)
Labor & delivery
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Procedure scheduled early in morning NPO & Ins or OHGA withheld morning of
surgery Delay surgery until afternoon: 1/3 morning
NPH +DW5% (avoid ketosis) BS monitor & control with regular insulin
Hypoglycemia: wound infection, metabolic complications, neonatal hypoglycemia
Cesarian delivery
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Check FBS,BS (2hpp): 24 h after NVD & 48h after c/s Relaxed BS level:140-160 during first24-48 h
If FBS<126: follow up If FBS>126: monitoring and therapy
Postpartum depression is more common follow up 6-8 wks later: GTT,75 gr,2 hr
GDM Postpartum management
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DM-I: -1/2-2/3 (NPH+ Reg) prepartum
DM-II: -no medication first 24-48 hours -Ins 0.6 u/kg post partum weight -Metformin, glyburide (safe breastfeeding) -Metformin prefer in obese DM patients
Overt DM Postpartum management
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Hb A1C<7% FBS<120 BS 2hpp<170
After hospital discharge
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Insulin requirement:-early rise 3-7 wks-decline 7-15 wks-rise during reminder of pregnancy-if insulin fall after 35 wks>5-10%:R/O
placental insufficiency, fetal wellbeing tests ,not indication of delivery
Overt DM
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Screening for aneuploidy:-first trimester & ultrasound markers not
affected by maternal DM-Second trimester (QT):Decreased AFP & uE3
,must be adjusted MSAFP:NTD(2%) Anomaly scan:18 wks Fetal echocardiogram ? (50% ,conotruncal &VSD)
Overt DM
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Timing for delivery:- Well controled:38+4 wks- With vascular disease:37 wks
Overt DM
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Any type is acceptable Progestin-only pills, DMPA, levonogestrol
IUD : increased risk of developing DM-II ? Copper IUD
Contraception
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Towards a safe motherhood