Postnatal and Preconceptual Counseling Ecwg Kuantan 2013

7/27/2019 Postnatal and Preconceptual Counseling Ecwg Kuantan 2013

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DR MOHD SUKARNO SAUD

KKB KOTA BAHRU KELANTAN

East coastworking groupGDM inpregnancy


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Introduction Evidence of impairment of insulin secretion and

action with the of diagnosis of gestational diabetes.

The dysglysecemia defect may persist with the risk of16-20 % at 3 to 6 months post partum .

A proper follow up programmed is outlined in thismanual to detect this group of patient so that

intervention can be given early to prevent the onsetof overt diabetes.


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Committee recommendation for postpartum

follow up of gestational diabetes mother

1.At delivery-Mother-Mother with GDM ,insulin therapy should be discontinued immediately

postpartum

-Blood sugar monitoring should be discontinued once blood glucosereturns to normal level (4-7 mmol/l)

-Baby-Neonate should be nursed at the mothers bedside unless admission to

intensive care is necessary

Early breast feeding (within 1 hours) should be encouragedBaby of GDM/Diabetic mother should be admitted to SCN forobservation and assessment by neonatalogist esp if mother needinsulin antenataly.

Following delivery, neonatal blood glucose concentration fall quickly thenrises and stabilized by approximately 2-3 hours of birth.


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At Discharge

-for mother

Make sure all postnatal plan written in the POSTNATAL planform

Low risk mother -GDM on diet/insulin- OGTT at

6/52High risk mother (tyep1 and type 2 dm with and without

comorbidities)

6/52 reviewed at OG clinic/PPC

-for babyContinue breast feeding and neonatal care

Breast feeding has been shown to reduce the risk of obesityand type 2 Diabetes in later life in infants of mother with

GDM


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Appendix 2

POST NATAL PLAN FORM (to be created and inserted at the last page in the antenatal book)

POST NATAL PLANEx: Repeat MOGTT 6/52 to get date at local clinic

2)

3)

4)

NO Name IC/RN Address No contact Appt. date for

MOGTT

Appt. date to review

result

Result plan

Fasting 2nd Hour

1.

2.

3

4.

5.

6.

Appendix 3: MOGTT RECORD BOOK - (need to keep in Health centre: Pre pregnancy clinic)


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Subsequent Follow up for GDM

motherThe increase risk of developing T2DM in the

future should be emphasized and education

in the post natal period should incorporateadvice on :

-Diet

-Physical activity-Weight reduction/healthy weight

maintenance

-Other life style intervention


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Risk factors for developing T2DMPre-pregnancy overweight/obesityHigh blood glucose level at diagnosis of

GDMHigh insulin requirement during pregnancyEarly gestation at diagnosis of GDM

The need of insulin treatment duringpregnancyPreterm deliveryAn abnormal postpartum OGTT


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MANAGEMENT AFTER OGTT Normal OGTT- repeat OGTT/2HPP every 3 years.weight

loss and and physical activity as needed

IGT/IF-Yearly assessment by OGTT /2HPP (Preferred)

Life style intrevention should be emphasis including dietand moderate physical activity.This can reduce risk ofT2DM by as much as 40-60%.weight management is thebest strategy to prevent T2DM therefore woman should be

encouraged to achieve and maintain a healthy bodyweight.physical activity should be encouraged as this willreduce insulin resistance.

Breast feeding should be supported and encouraged


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At 6-8 weeks post partum

A 75 g OGTT using WHO criteria performed at

6 weeks postpartumDIABETES

Fasting plasma glucose > Or 7.0 mmol/l

2-H Plasma Glucose > Or 11.1 mmol/l

Impaired Glucose Tolerance(IGT)

Fasting Plasma Glucose -

2 H plasma Glucose 7.8mmol/l -11.1 mmol/l

Impaired Fasting Glucose (IFG)

Fasting Plasma Glucose 6.1-6.9 mmol/l

2 h Plasma Glucose


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pec c recommen a on orpatient with pre-gestational

diabetes General advice- mothers with diabetes should be offered an opportunity for skin to skin contact with their babies

immediately after delivery .Paternal support is encouraged Early and frequent feeding should be encouraged to avoid neonatal hypoglycemia and to stimulate lactation

TYPE 1 DIABETESPost partum insulin regime (similar to the pre-pregnancy dose of insulin) should be

prescribed prior to delivery if possible and this should commence immediately following

the third stage of labour.Blood sugar monitoring should be performed in the post partum period and insulin regime

adjusted by by physcian/endoncrinologist to maintain blood glucose between 4-7mmol/l.

Close contact with the diabetes team is essential in the postpartum period to allow forassessment of glycemic control and adjustment of insulin dose.

Multi disciplinary (obstetrician /physcian and dietian) management must be reemphasized.

Women should be advised regarding risk of hypoglycemia while breast feeding and shouldbe encouraged to monitor blood sugar levels closely to allow for correct insulin doseadjustment.

Mother may require less insulin due to the calories expended with the breast feeding andmay require a carbohydrate snack before or during breast feeding.

Medication which were discontinue for safety reasons in the preconception period orantenatal period should continue to be avoided during lactation


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Type 2 Diabetes

Following delivery women with T2DM may be switched from insulin therapy toOHA .

Careful consideration of the type of agent is needed in the lactating mother.Glipizide Glyburide,Metformine and Acarbose are considered compatiblewith breast feeding.

Blood sugar monitoring should be done in post partum period and insulinregime adjusted by physician/endocrinologist to maintain blood sugar between4-7 mmol/l.

Close contact with the diabetes team is essential in the postpartum periodperiod to allow for assessment of glycaemic control and adjustment of insulindose.

Multidisciplinary team (obstetrician/physcian,dietician) management must beemphasized.

Breast feeding should be actively encouraged in women with preexistingdiabetes ,not only for the proven benefit offered to the general population butalso for the protective effects against type 2 diabetes in the offspring in laterlife.

Medications which were discontinued for safety reasons in the preconceptual

or antenatal period should continue to be avoided during lactation.


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DR MOHD SUKARNO SAUD

KKB KOTA BHARU KELANTAN


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Is Pre-pregnacy counseling improved out come

for mother with pre-gestational Diabetes ?

. A study by Murphy et al in women with type 2 diabetesshowed significant improvements that helped to reduce overall adverse

outcomes8.

For women with type 2 diabetes, the congenital malformation rate fell

from 12.3 to 4.4%,

perinatal mortality fell from 6.2 to 0.9%, and any serious adverseoutcome fell from 16.4 to 5.3%, whereas in

all these subcategories, there was very little change for women with type

1 diabetes. The importance of the reported study is

that it shows that access to pre-pregnancy counseling and care doesindeed reduce adverse pregnancy outcomes by approximately 80%8.


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Optimal timing of pregnancy

Optimally compliant and informed patient

Optimized therapeutics

Planned pregnancy

CARE PLAN


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Desired outcome:

Well informed patient

Where risks identified and risk reduction

strategized.Periconception optimization of disease

and therapeutics

Planned conception


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ADVICE AND CARE PLAN FOR PREGESTATIONAL

Discussion with the patient about future plan for pcontraceptive advise,

Educate the patient about the effect of diabetic

on pregnancy and pregnancy on diabetic.Women with diabetes who wish to conceive shoul

of the need to establish good glycaemic control

to conception with the aim of HbA1c


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ADVICE AND CARE PLAN FOR PREGESTATIONAL

Screening for complications of diabetes for allwomen who plan to get pregnant9

Substituted the medications with known

teratogenic effects with appropriate medication prito conception9.(ACEI,ARB,Statin,Fibrate,Diuretic) Prescribing high dose folic acid (5mg)

as part of pre-pregnancy care to prevent neural tube

( )


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OHA medication (metformin / glibenclamide) can be continue

however insulin therapy has to be started in order to achieve

glycemic controlAim to change to total insulin treatment before conception

in type 2 Diabetes .

Optimized control in type 1 Diabetes.

Offering dietary advice to women with diabetes whoare planning to become pregnant9.Offering effective family planning methoduntil the optimum glycaemic controlled achieved .In the presence ofvascular complications of diabetes

or other contraindications, the combined oestrogen-progestogenpill should be avoided and other methods discussed (WHO MEC).

Advice and care plan (cont)

GENERAL EDUCATION FOR PREGESTATIONAL


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The need for assessment and treatment of any

complications of diabetes prior to conception

and during pregnancy.

The increase risk of congenital defects,

neonatal morbidity and perinatal mortalityassociated with diabetes and pregnancy10,12.

The risk of possible transient exacerbation of

pre-existing retinopathy9

or nephropathy.The risk of hypoglycaemia and of

hypoglycaemia unawareness in pregnancy13

GENERAL EDUCATION FOR PREGESTATIONALDIABETES DURING PRECONCEPTION PERIOD


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The following capillary glucose targets are

recommended in the pre-conception period:Fasting 4.0 6.0 mmol/LRBS: 4.0 8.0 mmol/L6HbA1c levels should be < 6.5%9.

Follow-up of patients are individualized andhypoglycaemia should be avoided.Expected glycaemic targets should be discussed with thewomen and realistic individualized goals should be

agreedHbA1c care does indeed reduce adverse pregnancyoutcomes by approximately 80%8.levels should be measured 3 monthly during the pre-conception period6


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:AND MANAGEMENT IN THE

PRECONCEPTION PERIOD Preexisting complications of diabetes need to be

evaluated as complications may accelerate and alterthe outcome of the pregnancy

In the presence of advanced complications of diabetes

Specialist advice should be sought from anendocrinologist ,to evaluate the individualized risk of

pregnancy in that patient


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Retinal assessment in the preconception period: Presence of any retinopathy on fundus camera examination

should be referred to ophthalmologist The risk of advancement of retinopathy should be discussed. Renal assessment in the preconception period Women should be offered microalbminuria/albuminuria

assessment serum creatinine and e-GFR assessment . If serum creatinine is abnormal or e-GFR is less than 45 mmol/l

the patient should be referred to nephrologists. Assessment of autonomic neuropathy in the preconception

period Gastroparesis,urinary retention, hypoglycemia unawareness or

orthostatic hypotension may seriously complicate themanagement of diabetes in pregnancy.


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Cardiovascular assessment in the preconception period Hypertensive women with diabetes who are contemplating

pregnancy or who are at risk of becoming pregnant should beprescribed antihypertensive medication appropriate to

pregnancy. Specifically ,ACE inhibitors should be avoided wherepossible in this group. ECG should be done for those women age > 35 (Diabetic Care

2008).Pre-existing or suspected coronary artery disease warrantscardiology review before conception

Thyroid assessment in the preconception period Thyroid function should be measure in patient with type 1Diabetes at initial physical assessment as both hypothyri0dismand hyperthyroidism can adversely affect pregnancy outcome ifleft untreated


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Diabetic women with HbA1c >10% and

impaired renal function with serum creatinine >0.2mmol/l ( 180 umol/l )are advice not to get pregnant


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Preconception Advice and care for

previous GDM and IGT patients Achieving and maintaining and ideal body weight (BMI 18-27 kg/m2) Healthy lifestyle which include diet and physical activity Assessment of self care ability should be undertaken and any

shortcoming addressed.

The need to stop medication with teratogenic effect and possible needof insulin prior to conception The necessity of commencing folic acid ( 5 mg) as part of pre-

pregnancy care to prevent neural tube defect. Important of early booking should and unplanned pregnancy

occurred.

For IGT patient advice for good control by diet and monitor their bloodglucose 3-6 months before conception

For previous GDM mother or having risk factors of GDM repeat OGTTat once to asses the glycaemic control.


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General advice in preconception period-general education

Safety of medicationHealth promotion

Dietary advice

Physical activityeducation

Yes No

Continue NCD folloow upDM surveilance

CONFIRM DIABETES-Counseling

-off contraception-start folic-target bsp

-preexistinjg complioationassessment

H/O GDM orwith risk factors

GDMRepeat OGTT at once

to asses theglycaemiac control

IGT-optimized glucosecontrol 3-6 monthsBefore conception

Pregestational Diabetes,Previous GDM and IGT

Plan For Pregnancy

T1 DM-Advice SMBG

-OPTIMIZED CONTROL-HBA1C

Type 2DM-Change to insulin

-For SMBG-Optimized control

-Hba1c


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Postnatal and Preconceptual Counseling Ecwg Kuantan 2013

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