Diabetes mellitus in pregnancy
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Transcript of Diabetes mellitus in pregnancy
DIABETES MELLITUS IN PREGNANCY
Kusuma Neela Bolla, M.Sc,M.B.A
Asst.proof, S.D.M.S.M.Kalasala, Vijayawada.
CLASSIFICATION OF DIABETES IN PREGNANCY
DEFINITIONSDiabetes Mellitus in Pregnancy falls into 2
categories:
1. Gestational Diabetes Mellitus (GDM) – Any degree of glucose intolerance with onset or first recognition during pregnancy. Does not exclude possibility that unrecognised glucose intolerance may have been present before onset of pregnancy.
2. Pre-gestational Diabetes Mellitus – diagnosed when the woman has diabetes before pregnancy.
WHITE’S CLASSIFICATION OF DIABETES DURING PREGNANCY
CLASS DEFINITIONA1 Diet controlled gestational DMA2 GDM requiring insulinB Pre-existing DM without complications. Dur:<10yrs.
Onset: >20yrsC Pre-existing DM without complications. Dur:10-19yrs,
Onset:<10-19yrsD Pre-existing DM. Dur:>20yrs. Onset:<10yrsF Pre-existing DM with NephropathyR Pre-existing DM with retinopathyT Pre-existing DM with post op renal transplant statusH Pre-existing DM with heart diseases
GESTATIONAL DIABETES MELLITUS (GDM)
Physiology Pregnancy ↑ HPL + cortisol (insulin antagonists) Mother relative insulin resistance esp 3rd trimester Maternal pancreas ↑ insulin to maintain
carbohydrate metabolism ↓ FPG Carbohydrate intake ↑ glucose than non-pregnant
lady
Glucose crosses placenta by facilitated diffusion and the fetal blood glucose level closely follows the maternal level
Therefore, fetal glucose levels therefore is normally maintained within normal limits, as in mother.
Modified Penderson Theory: Impact of Maternal Hyperglycaemia During Pregnancy
MATERNAL PLACENTA FOETAL
↓ Insulin release
↓ glucose utilisation
Hyperglycaemia Hyperglycaemia
↑ Insulin(hyperinsulinaemia)
Birth weight ↑
↑ Lipid & ↑ Glycogen? Altered structure
and/or function
GDM IN FIRST TRIMESTER Women found to have fasting
hyperglycaemia or abnormal glucose intolerance in the first trimester might have pre-existing diabetes
Should be treated as women with glucose intolerance before pregnancy
First trimester hyperglycaemia high risk of congenital abnormalities in foetus
SCREENING FOR GDM Women with high risk of GDM:
BMI >30kg/m2
First degree relative with Diabetes Personal history of GDM Previous macrosomic baby ≥4.5kg Family origin with high diabetes prevalance
(South Asian, African-Caribbean, Middle-Eastern) *Previous poor obstetrics outcomes usually
associated with diabetes
TESTS FOR DIAGNOSIS OF GDMNon challenge blood glucose test: Fasting glucose test 2 hr post prandial test Random glucose testScreening glucose challenge testOral glucose tolerance test
PRE-GESTATIONAL DIABETES
TYPE 1 AND TYPE 2 DIABETES Pre-conception care is essential If untreated in first few weeks gestation,
associated with: Spontaneous abortions Birth defects
If untreated during 2nd or 3rd trimester, associated with: Foetal macrosomia and metabolic abnormalities Birth injury Maternal hypertension and pre-eclampsia Future diabetes and/or obesity in child
PRE-PREGNANCY COUNSELLING To assess suitability for pregnancy To look for complications of diabetes,
evaluate and treat complications prior to onset of pregnancy
To achieve optimal control prior to and during very early pregnancy
To provide an opportunity for pre-pregnancy advice and folate supplements
MEDICAL ASSESSMENT IN PRE-CONCEPTION CARE Duration and type of diabetes Medical history and current medical
management plan Chronic diabetes complications:
Retinopathy Nephropathy Neuropathy
Co-morbid conditions (in addition to diabetic complications) Hypertension (ideal blood pressure <120/80) Coronary Artery Disease Hyper- or Hypothyroidism Other auto-immune disease
PREVENTING RETINOPATHY PROGRESSION
Rapid normalization of blood glucose during pregnancy can trigger retinopathy progression
Retinal status should stabilized prior to conception
Reassess retinal status each trimester (more frequently if retinopathy is present)
RECOMMENDATIONS Plan pregnancies Attain a pre-conception HbA1c of < 7% If planning pregnancy:
Needs retinal screening prior to conception Screen for diabetic retinopathy and coronary
heart disease Discontinue oral hypoglycaemic agents and
attain glycaemic targets using insulin, if possible Replace ACEI and ARBs to other hypertensives
that are safe to take in pregnancy Stop statins
POSSIBLE CONTRA-INDICATIONS TO PREGNANCY Ischaemic Heart Disease Active, unrelated proliferative retinopathy Renal insufficiency Severe Gastroparesis
Inability or unwillingness to use Insulin
RISKS TO MOTHER WITH GESTATIONAL DIABETES Increased risk of Caesarian Section Pre-eclampsia (2-4 x esp with co-existing
microalbuminuria/frank nephropathy) Polyhydramnios Pre-term labour Post-Partum Haemorrhage Temporary worsening of renal function Progression of retinopathy ↑ incidence of infection, severe
hyperglycaemia/hypoglycaemia, DKA In future:
Recurrent GDM Pregnancies Risk of developing T2DM (50% in 5 - 10 years)
POTENTIAL COMPLICATIONS IN INFANTS OF MOTHERS WITH DIABETES
Intra-uterine demise Spontaneous
abortions Stillbirth (10-30%)
Congenital malformations Neural tube defects Cardiac defects Caudal Regression
syndrome (rare)
POTENTIAL COMPLICATIONS IN INFANTS OF MOTHERS WITH DIABETES Macrosomia Visceromegaly
Cardiac enlargement Hepatic enlargement
Respiratory Distress Syndrome
Asphyxia Birth injury
Shoulder Dystocia Erb’s Palsy Diaphragmatic
paralysis Facial paralysis
MACROSOMIA
POTENTIAL COMPLICATIONS IN INFANTS OF MOTHERS WITH DIABETES Metabolic complications
Hypoglycaemia (high insulin production in immediate neonatal period due to recent foetal hyperglycaemia) Mothers encouraged to breastfeed ASAP; monitor
baby’s blood glucose; formula-fed or glucose infusion prn
Hypocalcaemia, magnesium deficiency apnoeic episodes and fits
Polycythaemia hyperbilirubinaemia jaundice Partial exchange transfusion
Management: Obstetrics Nuchal Traslucency Scan Detailed US for foetal anomalies Foetal echocardiography Serial growth scan Monitor foetal well-being (doppler US & CTG) Aim: vaginal delivery between 38 – 40 weeks 50% Ceasarian section because of
macrosomia, pre-eclampsia and failed induction of labour
Management: preterm labour & polyhydramnios Difficult Tocolytics (e.g. ritodrine, salbutamol) are
diabetogenic I/M steroid for foetal lung maturation
destabilize diabetic control I/V insulin / glucose infusion if required to
ensure normoglycaemia
Management: Intrapartum Induced/Spontaneous labour sliding scale
of insulin to maintain normoglycaemia Test maternal blood glucose hourly Continuous foetal monitoring advised Foetal scalp blood sampling if CTG abnormal
Management: Post-delivery Insulin requirements return to pre-pregnant
levels If GDM, stop insulin OGTT 6/52 post-delivery to ensure diabetes
has resolved