Post on 07-Apr-2018
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