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    Diabetes in Pregnancy My Notes PDF

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    001mahwish

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    Diabetes in Pregnancy My Notes PDF

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    001mahwish
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    Diabetes in Pregnancy My Notes(PDF)

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    Diabetes in Pregnancy My Notes PDF

    Uploaded by

    001mahwish

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    © All Rights Reserved
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    of 5

    DIABETES IN PREGNANCY

    Pregnancy is a diabetogenic state


    ü State of insulin resistance is due to;
    1. Insulin antagonists:
    o á Oestrogen o á Cortisol
    o á Progesterone o á Prolactin
    o á HPL (Human placental lactogen)
    2. Increased body weight, increased calorie intake.
    3. Increased lipolysis and altered carbohydrate metabolism to fulfil nutritional demands of the growing
    foetus.
    ü Changes in Insulin resistance occur to have enough glucose for transport across the placenta to ensure
    normal fetal growth and development.
    ü Transfer of glucose across the placenta stimulates fetal pancreatic insulin secretion and insulin acts as an
    essential growth hormone.
    ü Now, If resistance to maternal insulin action becomes too pronounced, maternal hyperglycemia occurs and
    gestational diabetes mellitus (GDM) is diagnosed
    ü As period of gestation increases – Insulin Resistance also increases

    Risk Factors for GDM:


    1. BMI > 30Kg/m2
    2. Family History of DM (In Parents/siblings)
    3. Previous GDM
    4. Previous Macrosomic Baby ≥ 4.5kg
    5. Minority ethnic family origin with high prevalence of DM

    ü Screening and diagnosis


    1. Internationally: Screening is done @ 24 – 28 weeks
    ( At booking- only if patient is high risk)
    2. In India: Screening is done at the time of booking or at 1st ANC visit
    (if Negative Repeated @ 24 – 28 weeks)
    2 STEP APPROACH

    o Step 1: Glucose challenge test (GCT)

    Patient given 50g glucose

    RBS after 1hr

    <140mg/dl >140mg/dl

    No further test needed Do confirmatory test , OGTT

    o Step 2: Oral Glucose tolerance test (OGTT)


    § Overnight fasting of 8 hours
    § Patient is given 100 gm glucose
    â
    § RBS checked after 1hr, 2 hr, 3hr
    o Carpenter / Coustan Criteria is used for diagnosing GDM. Normal values are less than following (in
    mg/dl):
    § Fasting – 95
    § 1 hour – 180
    § 2 hour – 155
    § 3 hour – 140

    1 STEP APPROACH

    1. As per Diabetes in Pregnancy Study Group of India (DIPSI)

    2. As per WHO / International Association of Diabetes and Pregnancy Study Groups (IADPSG)

    MOSTLY THIS 1 STEP APPROACH (WHO/ IADPSG) IS FOLLOWED FOR ALL PRACTICAL PURPOSES
    Congenital malformation in babies of diabetic females
    1ST Trimester HbA1C levels: (BEST PREDICTOR)
    ü < 6.5%: No greater risk of malformation than non-diabetic
    mothers
    ü 6.5% - 8.5%: 5% Risk of malformation
    ü >10 %: 22% Risk of malformation

    o IOC to predict anomaly risk – HBA1C


    o IOC to detect anomaly – level 2 scan at 18-20wk
    o Mc system involved – CVS ( Mc anomaly VSD , most specific anomay -TGA)
    o 2nd MC system, involved – CNS ( mc anomaly – anencephaly , most specific
    anomaly – caudal regression syndrome )
    o Overall most specific anomaly – caudal regression syndrome

    COMPLICATIONS OF DIABTES IN PREGNANCY-

    FETAL COMPLICATIONS
    1st TM -
    • Spontaneous abortion (25%) – in uncontrolled sugar
    • Congenital malformation(11%)
    nd
    2 TM -
    • Hydramnios
    • Preterm birth
    • Intra-uterine death
    rd
    3 TM -
    • LGA , Shoulder dystocia, birth injuries
    • Neonatal hypoglycemia, hypocalcemia , polycythemia.

    MATERNAL COMPLICATIONS
    • Pre-eclampsia (aspirin prophylaxis given)
    • Prolonged labor *No risk of congenital malformation occur with GDM
    • Obstructed labor *Except diabetic retinopathy long-term course of diabetes does
    • Caesarean section not appear to be affected by pregnancy.
    • Uterine atony
    • Post-partum hemorrhage

    MANAGEMENT
    DOC in Diabetes in pregnancy: INSULIN

    1. Maintain a good glycaemic control

    Diet and Exercise:

    o High protein / low carbohydrate diet


    o Atleast 30 min of mild to moderate exercise daily
    o Ideal BMI: ≤ 27 Kg/m2

    Glucose monitoring:

    o Atleast 4 times a day:


    o Measure FBS and 1 or 2 hr post meals
    o Aim: Fasting < 95, 1 h PP < 140, 2h PP < 120
    § HBA1C ≤ 6% ( since level of HBA1C is reduced in pregnancy)

    2. Maternal surveillance:

    OVERT DIABETES -

    1ST TRIMESTER -

    o Start Folic Acid 4mg/d till 13 weeks.


    o Start ecospirin 75-100mg , daily
    o Stop drugs mother has been taking already ( ACE inhibitors , AT antagonist , statins )

    o Measure HBA1C (1st trimester)


    o Renal Function Test
    o Retinal Scan (Repeated at 28 weeks)
    o Joint DM – ANC consultation, every 1-2 weekly - Measure BP at every visit as there is 2 x á risk of
    pre-eclampsia
    o Aneuploidy screening (Level 1 Scan @11-13th Weeks +Dual Marker (PAPPA + Beta- HCG)

    2ND TRIMESTER –
    o Level II scan & fetal echo
    o S.AFP
    rd
    3 TRIMESTER –
    o Intermittent BPP , CTG & DFMC ( Starting from 32-34wk)
    o 4 weekly scan from 28 weeks onwards

    GESTATIONAL DIABETES
    o Regular maternal surveillance , besides that a Fetal growth scan should be performed at 28-30
    weeks gestation & repeated at 34-36 weeks gestation.

    DELIVERY -

    • Watch out for Shoulder Dystocia (esp. in macrosomic baby > 4.5 kg)

    • Overall Vaginal delivery is always preferred.

    • If Mother has GDM / overt Diabetes + Macrosomic Baby (> 4.5 Kg): Ceasarean Section is Preferred

    POSTPARTUM MANAGEMENT
    1. Breastfeed the baby within 30 min of delivery
    2. Evaluated for immediate hypoglycemia (<45 mg/dL) within first hour of birth and at 4 hours interval using
    glucometer till four stable readings glucose values are achieved (≥45 mg/dL).
    3. Reduce dosage of insulin / metformin post-delivery according to sugar levels
    4. Measure OGTT , 6 – 13 weeks postpartum
    5. If > 13 weeks postpartum measure HBA1C- if its high refer to endocrinologist

    v DRUGS USED IN DIABETES IN PREGNANCY


    o Insulin is the drug of first choice and Metformin can be considered after 20 weeks of gestation for medical
    management of GDM
    o If the woman's blood sugar is not controlled with the maximum dose of metformin (2 gm/day) and MNT,
    Insulin is to be added
    o Actrapid or Mixtard Iinsulin given in pregnancy. (30:70)
    o 1st Trimester - .7 unit /kg 2nd Trimester - .8 unit /kg 3rd Trimester - .9 unit /kg At Term - 1 unit/kg
    o Based on sugar levels –
    2hr PPBS Insulin used
    120-160 4U
    160-200 6U
    >200 8U

    q q q

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