Pre Pregnancy Counseling in Diabetic Patients(DR TASNEEM)

8/6/2019 Pre Pregnancy Counseling in Diabetic Patients(DR TASNEEM)

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Dr.Dr. TasneemTasneem AkhterAkhter

Consultant Ob. &Consultant Ob. & GynaeGynaeK.F.H AlK.F.H Al bahabaha

&&

Dr. ArishDr. Arish MahmoodMahmood

Pre PregnancyPre PregnancyCounseling in DiabeticCounseling in Diabetic

PatientsPatients


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When maternal diabetes precedesWhen maternal diabetes precedespregnancy it is associated with increasedpregnancy it is associated with increased

risk of miscarriages congenitalrisk of miscarriages congenitalmalformations accelerated fetal growth,malformations accelerated fetal growth,late still birth, RDs, neonatallate still birth, RDs, neonatalhypoglycemia, long term health problemhypoglycemia, long term health problem

for child.for child.


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Principals for management ofPrincipals for management of

pregnancy associated with diabetespregnancy associated with diabetes Principals for management for diabeticPrincipals for management for diabetic

pregnancy start before conception to thepregnancy start before conception to the

time of delivery.time of delivery. The need for goodThe need for good glycemicglycemic control based oncontrol based on

evidence that hyperglycemia is associatedevidence that hyperglycemia is associatedwith fetal and maternal complication.with fetal and maternal complication.

To achieveTo achieve glycemicglycemic control required tocontrol required tominimize complication associate withminimize complication associate withdiabetesdiabetes


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Role of pre pregnancy clinicRole of pre pregnancy clinic

When women attend preWhen women attend pre--pregnancy clinicpregnancy clinicoutcome of pregnancy is improvedoutcome of pregnancy is improved

Many complications can be avoided ifMany complications can be avoided ifglucose control is optimized beforeglucose control is optimized beforeconception.conception.

Pre pregnancy counseling is beneficial andPre pregnancy counseling is beneficial andcost effective and should be encouraged.cost effective and should be encouraged.


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Benefits of preBenefits of pre conceptionalconceptional

diabetesdiabetes Minimize maternal fetal andMinimize maternal fetal and perinatalperinatal

complications.complications.

Diabetic care and education must beginDiabetic care and education must begin

before conception bybefore conception by mutimuti --disciplinarydisciplinaryteam includingteam including DialectologistDialectologist

DiabeticDiabetic physcianphyscian..

DieticianDietician

Diabetic educatorsDiabetic educators

Social workersSocial workers


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Cont..Cont..

Purpose of this team isPurpose of this team is

Risk assessmentRisk assessment

health promotionhealth promotion

InterventionsInterventions

Out line effective team work strategies toOut line effective team work strategies toimplement plans before and during earlyimplement plans before and during early

pregnancypregnancy


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Specific Goal of treatmentSpecific Goal of treatment

Pre pregnancy clinics provide an opportunityPre pregnancy clinics provide an opportunityforfor glycemicglycemic control to be intensivelycontrol to be intensivelymanaged.managed.

To lower HbA1c to optimal level duringTo lower HbA1c to optimal level duringembryogenesis and organogenesis.embryogenesis and organogenesis.

Decrease the diabetic related complications inDecrease the diabetic related complications in

all stages of pregnancy.all stages of pregnancy. Use of anUse of an appropriate diet plan.appropriate diet plan.

SelfSelf--monitoring of blood glucose (SMBGmonitoring of blood glucose (SMBG))


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Specific Goal of treatment (cont.)Specific Goal of treatment (cont.)

SelfSelf--administration of insulin and selfadministration of insulin and self--adjustment of insulin dosesadjustment of insulin doses

Treatment of hypoglycemia (patient andTreatment of hypoglycemia (patient andfamily members)family members)

Incorporation of physical activityIncorporation of physical activity

Development of techniques to reduceDevelopment of techniques to reducestress.stress.


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INITIAL VISITINITIAL VISIT

1.1.Medical and obstetricalMedical and obstetricalhistoryhistory

2.2.PhysicalPhysical examinationexamination

3.3.LaboratoryLaboratory evaluationevaluation

4.4.Management planManagement plan


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Medical and obstetrical historyMedical and obstetrical history

Duration and type of diabetesDuration and type of diabetes (type 1 or(type 1 ortype 2)type 2)

Acute complicationsAcute complications,, including history ofincluding history ofinfections,infections, ketoketo--acidosisacidosis, and hypoglycemia, and hypoglycemia

Chronic complicationsChronic complications, including, includingretinopathy, nephropathy, hypertension,retinopathy, nephropathy, hypertension,

atherosclerotic vascular disease, andatherosclerotic vascular disease, andautonomic and peripheral neuropathyautonomic and peripheral neuropathy


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Medical and obstetricalMedical and obstetrical

historyhistory Diabetes managementDiabetes management, including insulin, including insulin

regimen, prior or current use of oral glucoseregimen, prior or current use of oral glucose--lowering agents, SMBG regimens and results,lowering agents, SMBG regimens and results,

medical nutrition therapy, and physical activitymedical nutrition therapy, and physical activity Associated medical conditions andAssociated medical conditions and

medicationsmedications, thyroid disease in particular for, thyroid disease in particular forpatients with type 1 diabetespatients with type 1 diabetes

Menstrual/pregnancy historyMenstrual/pregnancy history;;contraceptive usecontraceptive use


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Physical examinationPhysical examination

Blood pressureBlood pressure measurementmeasurement

Dilated retinalDilated retinal exam.exam.by anby an

ophthalmologist.ophthalmologist. CardiovascularCardiovascular exam.exam.for evidence offor evidence of

cardiac or peripheral vascular diseasecardiac or peripheral vascular disease..

Neurological

Neurological exam

.exam

.,, includingincludingexamination for signs of autonomicexamination for signs of autonomic

neuropathyneuropathy


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Laboratory evaluationLaboratory evaluation

HbHb A1C test.A1C test.

Micro albumin urea.Micro albumin urea.

SerumSerum creatininecreatinine and urinary excretion ofand urinary excretion oftotaltotal protein.protein.

GFRGFR


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Screening for diabeticScreening for diabetic

complications and cocomplications and co--morbiditiesmorbiditiesDiabetic retinopathiesDiabetic retinopathies

Micro and macro vascularMicro and macro vascular

complicationscomplicationsDiabetic nephropathiesDiabetic nephropathies

Diabetic neuropathiesDiabetic neuropathies

Autonomic neuropathiesAutonomic neuropathies


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0

5

10

15

20

25

30

4.6-7.6 7.7-8.6 8.7-9.9 10-10.5


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PREGNANCY RELATED COMPLICATIONPREGNANCY RELATED COMPLICATIONIN WOMEN WITH AND WITHOUTIN WOMEN WITH AND WITHOUT

PREGESTATIONAL DIABETESPREGESTATIONAL DIABETESCOMPLICATIONS DIABETIC

PERCENTAGENON DIABETICPERCENTAGE

1. GESTATIONAL HYPERTENTION 28 9

2. PRE-TERM BIRTH 28 5

3. MACROSOMIA 45 13

4. FETAL-GROW

TH RIS

TRI

CTI

ONS

5 10

5. STILL BIRTHS 1 .4

6. PERINATAL DEATHS 1.7 .6


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Management planManagement plan

Counseling

Counseling1.1. About About the risk and prevention ofthe risk and prevention of congenitalcongenital

anomaliesanomalies

2.2. FetalFetal and neonatal complications of maternaland neonatal complications of maternal

diabetesdiabetes3.3. EEffectsffects of pregnancy on maternal diabeticof pregnancy on maternal diabetic

complicationscomplications

4.4. RRisksisks of obstetrical complications that occurof obstetrical complications that occur

with increased frequency in diabeticwith increased frequency in diabeticpregnanciespregnancies

5.5. TheThe need for effective contraception untilneed for effective contraception untilglycemiaglycemia isis wellwell--controlledcontrolled


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CONGENETAL MALFORMATIONCONGENETAL MALFORMATIONWI

TH OVERT DIAMET

IE

SWITH OVERT D

IAMET

IE

SANOMALIES RATIOOF

INCIDENCE

1. CAUDAL REGRESSION 252

2. SITUSINVERSUS 84

3. SPINA BIFIDA, HYDROCEPHALY AND OTHR CNS DEFECTS 2

4. CARDIC ANOMALIES 4

5. RECTAL ATRESIA

6. RENAL ANOMALIES

3

5


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MANAGEMENT PLANMANAGEMENT PLAN (cont.)(cont.)

SelectionSelection ofof antianti--hyperglycemic therapy (insulin)hyperglycemic therapy (insulin) Education of women how to achieve a goodEducation of women how to achieve a good

glycemicglycemic control.control.A Long acting basal insulin injection at night withA Long acting basal insulin injection at night with

short acting bolus insulin injection with each meal.short acting bolus insulin injection with each meal. Insulin regime selected to achieve following goalsInsulin regime selected to achieve following goals

Capillary plasma glucose before meal 3.9 to 5.6Capillary plasma glucose before meal 3.9 to 5.6 mmolmmol/L/L Capillary plasma glucose 2 hour after meal less than 7.8Capillary plasma glucose 2 hour after meal less than 7.8

mmolmmol/L/L Monitor HbA1C level at 4 weeks intervalMonitor HbA1C level at 4 weeks interval


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High doses of folic acid supplementsHigh doses of folic acid supplements

Stop harmful drugs such ACE inhibitorsStop harmful drugs such ACE inhibitors

Assessment of diabetic complication.Assessment of diabetic complication.Aspirin and heparin should consider forAspirin and heparin should consider for

those with risk of prethose with risk of pre--eclempsiaeclempsia andand

thrombophiliathrombophilia


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THANKSTHANKS

Pre Pregnancy Counseling in Diabetic Patients(DR TASNEEM)

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