Diabetes in Pregnancy Prof N Palaniappan

Chennai

Panelists

•Dr Dilshath

•Dr Ambigai Meena

•Dr Meena

•Dr Chitra

Case 1• Mrs G 32 yrs primi referred to the AN OPD with

leaking pv for 3 hrs • AN care with a local doctor• Past h/o

» Md 1 yr

» Mother diabetic

» 2 doses TT given

» Fe & ca tablets taken regularly

» Anomaly scan at 21 wks – no anomalies

» HIV, HbsAg, VDRL negative

• O/E Pt GC Fair• Vitals stable• At Ut 34 wks, relaxed• Cephalic, FH good• Clear Liquor leaking P/V, HVS taken• P/V cx 1.5cm long, soft, posterior

– Os 1 cm dilated– Memb absent– Cephalic above the brim

What will you do?

• Induce labour – If so with What?

• Give Tocolysis and steroids – If so with what?

• Give antibiotics – If so with what?

• Investigate – What?

• Random blood Sugar - 261

• USG – Baby wt 2.8kg Ut 32 wks

• AC falls above 95th percentile

• Cleft lip and cleft palate seen

• Heart normal

• Liquor 8 cms

• Placenta - Anterior

What will you do?????

• Steroid cover

• FBS/PPBS next day

• LSCS

Prognosis Explained

• Cleft lip, cleft palate explained

• Other anomalies – not ruled out, explained

• Salvagability explained

• Steroids given and T. Erythromycin 250mg 1 qid

LSCS done after 48 Hrs

• Baby – 2.9kg, Macrosomic Plethoric, Grunting +, Cleft lip, Palate +

• Admitted to NICU

Baby MotherHad RDS Wound Infection

Needed C pap Ventilation Sugar followed up

Needed 1 dose of Surfactant Very High

Discharged on 14th day of life Rx with Actrapid Insulin * 3 days

Wound Resuturing done

• Mother followed up – With what???

• Baby to undergo surgery for Cleft lip/Palate at later date

Moral of the Story

• Diabetes needs to be screened at needed time

• Treated vigorously

Case 2

• Mrs X 24 year old, family h/o diabetes, 10 weeks primi referred

• So far AN history – nil significant

• Routine investigations – normal

• How would you screen her for diabetes?

Spot Test

• Irrespective of fasting

• At about 20-22 wks of Pregnancy

• 50 gms of glucose

• 1 hr spot value 140, 130

• increases sensitivity from 80% to 90%

Diagnosing DM

• WHO currently recommends OGTT with 75gms

• Fasting >= 126

• 2hrs >= 140

How do you screen for Chromosomal anomalies?

Screening for Chromosomal Anomalies

• Downs syndrome does not increase with DM

• Triple screening less accurate as both MSAFP and UE3 are lower in diabetic pregnancies

• I Trimester screening mandatory – NT + PAPPA+B Hcg for Congenital anomalies

• DM confirmed with OGTT

• No chromosomal anomalies

• How would you treat her?

Drug Therapy in DM

• Insulin

• OHA ….????

• Patient was put on human insulin

• Six value sugars done

• Insulin dose titrated as per need

• 20 weeks anomaly scan and 24 weeks fetal echo done

• What is the role of HbA1C?

HbA1C – Rule of 8

• HbA1c of 8% equals average glucose of 180 mg/dl

• Each 1% up or down increases or decreases the average glucose by 30mg/dl

• 1 unit of rapid acting insulin will reduce glucose by 30mg/dl

• When will you want to deliver her?

• What antepartum fetal surveillance would you do?

AP Fetal Surveillance

• Unexplained still birth > 30% after 36 wks in type 2 DM

• NST – Bi weekly

• BPP – Bi weekly

• Doppler – Umbilical artery Doppler can be used selectively

Timing of Delivery

• Well controlled GDM – Not later than 40wks

• IDDM without Vasculopathy – Not later than 40wks

• Pts with Vasculopathy – 38.5 wks

Any special precautions during labour and delivery?

Labour & Delivery

• NPO after midnight• Usual bedtime dose is given• 5u of short acting Insulin with

500ml of 5% Dex on the day of surgery / Delivery

• Hourly glucose levels• RA is preferred in LSCS• Anticipate shoulder dystocia

and PPH

What Postpartum Follow up?

Usually sugars return to normal range immediately after delivery but may not be the case always as in– Pre existing type2DM that was identified as

GDM– Those with islet cell antigen that will progress

to type 1DM– Unexpected rise of sugars postpartum

Postpartum Glucose Testing

• Till now no standard, Universally accepted recommendation

• Followed up in 3 discrete phases – After Delivery– Early Postpartum– Long term

Recommendations at the V International workshop conference on GDM 2007

– Metzger BR, Buchanan TA, Coustan DR etal

Time Test PurposePost delivery (1-3d) Fasting or Random Plasma

glucoseDetect Persistent, overt diabetics

Early Postpartum 75g-2h OGTT Postpartum classifications of glucose metabolism

Annually FPG Assess glucose metabolism

Tri annually 75g 2h OGTT Assess glucose metabolism

Pre Pregnancy 75g 2h OGTT Classify glucose metabolism

Future risk of Cardiovascular Disease

• GDM pts have high prevalence of CVD • Carpenter MW, Gestational diabetes, pregnancy

hypertension and late vascular disease. Diabetes care 2007:30:5246-5250

• They experience – More Obesity– More insulin resistance– More chronic HT– Metabolic Syndrome

• But conclusive evidence is on further research

What contraception would you advice?

Contraception

• Barrier methods

• LNG IUD>cu IUD – risk weighed

• OCP

CASE 3

• Mrs. S 34yr old md for 6 years, IT professional treated for primary infertility-3 yrs

• Known Diabetic for the last 3 yrs on T.Pioglitazone 1 OD ,

• she had regular periods and was diagnosed as PCOS .

• Had 3 cycles of OI, IUI, sugars raised, HbA1C 7-8 but conceived spontaneously on the 4 th cycle

• Had spontaneous miscarriage at 8 weeks and D & C done

What advice would you give?

• Abstinence

• Contraception

• Treat overt diabetes

• Start folic acid

• Was started on T. Glimulin and

H. Insulin 6 units

• 3 cycles of OCP’s for PCOS

• Folic acid

• Weight reduction

• Diet control

• 6 months later patient was started on

• T. Glycomet 500mg 1 BD

• Ovulation induction with Letrozole , IUI

• Sugars 95, 125

• HbA1C – 5.5

Patient conceived on the 3 rd cycle of IUI

• On regular Ante natal visits • Patient was on T. Glycomet 500mg 1 BD

– FBS- 90-100 – PPBS- 120 -130 – Hba1c 5-5.5 – TVS- at 6 weeks + 3 days corresponded to 5

wks + 5 days

• Would you change to insulin?

• Would metformin cause teratogenicity?

Why not OHA in pregnancy

• From educated guess to accepted practice

• ISSUES – Congenital anomalies

BUT NO STUDIES – Fetal compromise – Fetal hypoglycaemic episodes

Evidence

• IN 2000, Langer ‘O etal NEJM- compared

• Glyburide & insulin

• And swung the use of glyburide in Pregnancies & subsequently approved

What is the Evidence for metformin ?

MIG Trail – Metformin in Gestational Diabetes trail

METFORMIN – BIGUANIDES

• Acts only in the presence of insulin

• Improves insulin sensitivity at the cellular level

• Does not stimulate insulin secretion

• Does not cause hypoglycaemia • Does not stimulate the fetal

pancreas to oversecrete insulin

• Although crosses the placenta it is a class B drug

• Dose – 500mg start & can go upto 2000mg/day

• Caution • Renal disease • Vit B 12 deficiency • Lactic acidosis

• Metformin use in pregnancy is not contraindicated

• Glycemic control over the 2 trimester is not adequate and hence is the only reason to add insulin after 1 trimester

• No teratogenicity • Glueck GJ etal , fertility sterility 2002 ,77, 520-525

Should PCO patients remain on metformin

throughout Pregnancy?Yes. They can continue Metformin

Class B drug

» Glueck GJ etal. Metformin therapy throughout pregnancy reduces the development of GDM in women with PCOS. Fertil steril-2002;77;520-525

• Patient was continued on metformin 500mg 1BD.

• Regular ante natal check up with FBS,PPBS& Hba1c

How many USG s ????When &

For what

• 1 trimester screening for down’s syndrome with NT, PAPP – A & beta HCG - screen negative –risk calculated was 1:5000

• Anomaly scan at 19 wks –normal • Fetal echo at 24 wks –normal

• At 22wks + 5 days • FBS- 98 • PPBS- 162 • Hba1c – 5.3

• Along with metformin, human insulin 30/70 4 units in the morning

• At 24 wks + 5 days with insulin and glycomet

• Sugars were 89, 128

ALL IS WELL

• Pt underwent elective LSCS at 37 weeks 5 days

• Baby 3. 4 kg

• Post partum follow up done

Awaiting Success

– Winston Churchill

To improve is to change; to be perfect is to change

often.

Sugar – The KillerBut

Medicine heals doubts as well as diseases

Karl Marx May 5th 1818