Diabetes Mellitus in pregnancy " Gestational diabetes mellitus''
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Transcript of Diabetes Mellitus in pregnancy " Gestational diabetes mellitus''
Diabetes in Pregnancy
Presented by :Nassr Saif ALBarhi
SULTANTE OF OMAN
OUTLINE:
Case scenario. Definition of GDM. Classification. Diagnosis. Management. Antepartum care
A 24 years old Omani lady, G4P1A2 at 23+2 wks of gestation. LMP: 27/10/2013. EDD by date:3/8/2014 , by scan: 29/7/2014.
k/c/o Type I DM on insulin in 2012.
Hypothyroidism on thyroxin 50mcg OD.
Presented to the OPD with Reflow 15.8 mmol admitted for glycemic and VPG control.
Also, she admitted for abnormal scan finding as fetus found to have ascites for further investigations.
She complain of polyphagia, morning nausea and burning sensation during voiding but she denied any polydepsia, vomiting, fever, vaginal discharge or labiality of mood.
Past ObsH
1st pregnancy>> abortion at 12weeks GA, no D&C. 2nd pregnancy>> Abortion at 3 months GA, D&C done. 3rd pregnancy>> FT LSCS for fetal distress , Diagnosed
as DM and IOL. -----
This is Spontaneous pregnancy:During this pregnancy had admissions for Blood sugar control and insulin adjustment last was 2/4/2014.Was offered Insulin pump but patient not keen for that.
Menstrual Hx: regular, 5/21days, small amount, mild pain, no intramenstrual
bleeding, LMP : 27/10/2013. EDD by date: 3\8\2014 PMH:
apart from OBS Hx, unremarkable Allergy:
nil Family Hx:
Her husband is 1st cousin of her father. Strong Family Hx of DM and HTN in first degree relatives
Social HX: Not smoker or alcohol consumer
General examination:
Looks well, comfortable, obese, afebrile, alert and cooperative not in distress.
There no pallor , jaundice, dehydration BP: 110/69.
Physical examination:
Abdominal examinations: Inspection:
The abdomen is distended. Umbilical is inverted scars Striae gravidarum. Linea nigra No visible veins No obvious masses. No change in skin colour. Normal hair distribution.
Palpation:
Abdomen is soft, not tender, uterus is relax and no contraction. FSH=29 cm. Fundal occuping by breach, supin: right side, cephalic presentation. FHR= 130.
Other systems are normal
Investigations: Hb: 11.9, platelet normal LDH, LFT, coagulation, and electrolytes normal
VPG at the day of admission:
Pre breakfast
Post breakfast
Post lunchPost dinner
55.65.710.7
Gestational diabetes
Introduction Diabetes mellitus refers to a chronic disorder of metabolism that
due to an absolute or relative lack of insulin.
It is characterized by hyperglycaemia in postprandial or fasting state or both.
GDM is defined as glucose intolerance of variable degree with onset or first recognition during the present pregnancy.
Reports show a rate of 3% to 8% of gestational diabetes mellitus (GDM).
Traditional classification :
Type 1 – IDDM – Juvenile diabetes
Type 2 – NIDDM – Maturity onset diabetes
Type 3 – Gestational diabetes.
Classification of diabetes
Type 1. Immune mediated & idiopathic B cell dysfunction.
Type 2. DM of adult onset due to insulin resistance & relative insulin deficiency, or from a secretory defect.
Type 3.Specific types of diabetes 1.Genetic defect of B cell function 2.Genetic defect in insulin action 3. Diseases of exocrine pancreas.
Type 4. Gestational diabetes
New classification
Classification of diabetes
why glucose Intolerance in pregnancy??
Risk factors:
Maternal age > 25 years Obesity. Family history of diabetes in a first-
degree relative. Previous large baby. Previous still birth, or a child with a birth
defect Polyhydramnios. Previous pregnancy with GDM.
Diagnosis
All women should be screened for GDM between 24-28 weeks of gestation.
Women with multiple risk factors!?
OGCT Method: oral glucose screening test
(OGST) or OGCT
Need no preparation: not fasting A 50 gm glucose is giving in glass of water Venous plasma glucose taking before the
test and after 1 hr.
Results: <7.8 mmol/L = no GDM ≥7.8-10.3 mmol/L = further investigation
with OGTT ≥10.3 mmol/L= GDM
How to do?
150 to 200gm CHO diet to be given for 3 days
before doing OGTT.
Overnight fasting
75 gm glucose giving in 300 ml of water
Venous plasma glucose taking before the test
and after 2hr.
OGTT
OGTT on 75 mg oral glucose load
GDM FBS ≥ 5.5 mmol/L 2 PPBS ≥ 7.8mmol/L
ORAL GLUCOSE TOLERANCE TEST
WHO criteria for the 2-hour OGTT
Whole blood venous
(mmol/L)
Whole blood capillary (mmol/L)
Plasma venous
(mmol/L)
Plasma capillary (mmol/L)
Fasting=>6.1=>6.1=>7.0=>7.02 hours=>6.7=>7.8=>7.8>=8.9
At booking (14 weeks) if at high risk: Family history of DM Previous GD Obesity Previous still birth Macrosomia Congenital malformation multiparty
When to do OGTT?
Done in day care unit or in the ward Patient on diet or insulin
4 venous sampling are collected: Fasting… 2 hr post breakfast 2 hr post break lunch. 2 hr post break dinner.
Venous plasma glucose profile
Management
Diet providing 30 kcal/kg –normal pregnant, 24 kcal/kg – over wt pregnancy women . Postprandial hyperglycemia - decreased by CHO
restricted, low glycemic index diets & small frequent meals
Increase Exercise improve blood sugar control 30 minutes a day recommended by NICE
guidelinies
Diet and Exercise
If already on medication, generally switch to insulin therapy: continuing glyburide or metformin controversial teratogenicity unknown for other oral anti-
hyperglycemics
Tight glycemic control Diet management first line therapy Post-prandial blood glucose values seem to be the most
effective at determining thelikelihood of macrosomia or other adverse pregnancy outcomes
Aim for Fasting Plasma Glucose (PG) 3.5-5.9 mmol/L 1-hour post prandial PG ≤7.8 mmol/L 2-hour post prandial PG ≤7 mmol/L
Management of DM in pregnancy
If blood glucose not well controlled, initiate insulin therapy.
ƒInsulin dosage may need to be adjusted in T2 due to increased demand and increased insulin resistance
Insulin requirement- 0.6, 0.7 & 0.8 units / kg /day- 1st, 2nd & 3rd trimesters
Given as 2 injections/day (some require 3- 4 injections)
Insulin therapy
2/3rd am 1/3rd pm
2/3rd N 1/3rd R ½N ½R
Available insulin preparations
TypeOnsetPeak (hours)Duration (hours)
Rapid
Lispro*
Aspart*
Glulisine
< 15 min
< 15 min
1 – 2
1 – 2
3 – 4
3 – 4
Short
regular insulin0.5 – 0.7 hour2 – 4 5 – 8
Intermediate
NPH(neutral protamine hagedorn)
Lente
1 – 2 hours
1 – 2 hours
6 – 12
6 – 12
18 – 24
18 – 24
Long acting
Ultralente
Glargine*
4 – 6 hours
2 – 4 hours
16 – 18
peakless
20 – 36
18 – 24
TARGETS OF GLYCEMIC CONTROL
FASTING POST B.F. POSTLUNCH
PREDINNER
POSTDINNER
876543210
MM/L
V.P.G PROFILECut values
Pre: 5.5
Post: 8.0
Monitor as for normal pregnancy plus initial 24-hr urine protein and creatinine clearance
Retinal exam, HbA1C
HbA1C: >8.5% of pre-pregnancy value associated with increased risk of spontaneous abortion and congenital malformations.
Increased fetal surveillance (BPP, NST)
Management of DM in pregnancy
Why DM in pregnancy is a concern??
1. Maternal complications.
2. Fetal complications.
Preterm labour.
Increase incidence of pre-eclampsia.
Polyhydramnios - AFI >240mm .
Macrosomia >4000gm .
Poorly controlled DM- subfertility, miscarriage, congenital anomalies, UTI.
Shoulder dystocia Perinatal mortalityPerinatal mortality
Complications of Diabetes
Maternal Complications•Obstetric:
• Hypertension/preeclampsia (especially if pre-existing nephropathy/proteinuria)•PolyhydramniosDiabetic
Emergencies• Hypoglycemia
•Ketoacidosis •Diabetic coma
Diabetic Emergencies
• Hypoglycemia •Ketoacidosis •Diabetic comaEnd-organ involvement or deterioration
(occur in DM1 and DM2, not in GDM) •Retinopathy •Nephropathy
End-organ involvement or deterioration
(occur in DM1 and DM2, not in GDM) •Retinopathy •Nephropathy
•Other•Pyelonephritis/UTI
•Increased incidence of spontaneous abortion (in DM1 and DM2, not in GDM)
•Other•Pyelonephritis/UTI
•Increased incidence of spontaneous abortion (in DM1 and DM2, not in GDM)
Fetal ComplicationsGrowth Abnormalities
• Macrosomia: maternal hyperglycemia leads to fetalhyperinsulinism resulting in accelerated anabolism
( •IUGR :)due to placental vascular insufficiency
Growth Abnormalities• Macrosomia: maternal hyperglycemia leads to fetal
hyperinsulinism resulting in accelerated anabolism
( •IUGR :)due to placental vascular insufficiency
Delayed Organ Maturity •Fetal lung immaturity
Delayed Organ Maturity •Fetal lung immaturity
Congenital Anomalies (occur in DM1 and DM2, not in GDM)
• 2-7x increased risk of cardiac (VSD), NTD, GU (cystic kidneys), GI (anal atresia), and MSK (sacral
agenesis) anomalies due to hyperglycemia
Fetal Complications•Labour and Delivery
•Preterm labour/prematurity:•Preterm labour is associated with poor glycemic control •Increased incidence of stillbirth•Birth trauma: due to macrosomia, can lead to difficult vaginal delivery and shoulder dystocia
•Labour and Delivery•Preterm labour/prematurity:•Preterm labour is associated with poor glycemic control •Increased incidence of stillbirth•Birth trauma: due to macrosomia, can lead to difficult vaginal delivery and shoulder dystocia
•Neonatal•Hypoglycemia: due to pancreatic hyperplasia and excess insulin secretion in the neonate•Hyperbilirubinemia and jaundice: due to prematurity and polycythemia•Hypocalcemia: exact pathophysiology not understood, may be related to functional hypoparathyroidism•Polycythemia: hyperglycemia stimulates fetal erythropoietin production
•Neonatal•Hypoglycemia: due to pancreatic hyperplasia and excess insulin secretion in the neonate•Hyperbilirubinemia and jaundice: due to prematurity and polycythemia•Hypocalcemia: exact pathophysiology not understood, may be related to functional hypoparathyroidism•Polycythemia: hyperglycemia stimulates fetal erythropoietin production
Antepartum Care
Goals Minimize/eliminate the risk of fetal death Early detection of fetal compromise Prevent unnecessary premature delivery
Fetal Surveillance
Frequent ANC Confirm viability & Gestational Age by early
scan Detailed anomaly scan ( 18-20 wks) Fetal echo cardiogram ( 24 weeks) Growth scans ( after 30 wks) BPP & Doppler ( after 34 wks)
FETAL SURVEILLANCE
Monthly VPG profile HbA1c once every 3 monthes FBS & PPBS every visit
ASSESSMENT OF GLYCEMIC
CONTROL
Timing and mode of delivery
Patient well controlled on diet only to be delivered by 40 weeks.
GDM well controlled to be delivered at 38 weeks.
NICE guidelines recommends that pregnant women with diabetes be offered elective birth after 38 completed weeks gestation
Timing of Delivery
o Spontaneouso Induced – PG/ARM/Syntocino Caesarean section
Mode of delivery
Hourly reflos – keep Blood Sugar ( 5-8 mmols) < 5 mmols – start 5% dextrose > 8 mmol - I.V insulin pump –1unit/hr & titrate
Continous CTG.
Watch for progress of labour
Anticipate & prepare for shoulder dystocia
Spontaneous
labour
Continue regular dose of insulin till the time of induction.
Reflo 4 hourly initially and 1-2 hourly in established labour.
Continue infusion of regular insulin in 5% dextrose at rate of .5 to 2 U of insulin/ hr and insulin dosage adjusted accordingly to maintain plasma glucose level (5-8 mmol)
Induction of labour
For Elective Cesarean
Omit the morning dose of insulin. Check Fasting Reflo
If Reflo <=4 mmol start 5% Dextrose at 125ml\hours
If Reflo >=8 mmol start insulin infustion as per sliding scale.
Postpartum period
Patient with GDM: stop the insulin and FBS and PPBS post-delivery.
Pre existing diabetics: start pre-pregnancy dose of insulin\oral hypoglycemic agents.
Patient with GDM are advised to do OGTT at 6 WEEKS POSTPARTUM.
Evaluation of glycemic control HbA1c – gives control 2-3 months If high – control diabetes before conception Evaluation of B.P Evaluation of retinal status Evaluation of renal function Change to Insulin prior to / when pregnancy is
diagnosed.
Planning next pregnancy
1. Pubmed
2. Uptodate.com
3. Hacker/Moore,2010 essentials of Obstetrics & Gynecology,saunders, fifth edition.
4. Obstetrics Guidelines,.SQUH, 20\1\2014.
5. Obstetrics Guidelines, University of Illinois at Chicago, Sept 2008
6. Pathophysiology of Gestational Diabetes Mellitus: The Past, the Present and the Future,Mohammed Chyad Al Noaemi1 and Mohammed Helmy Faris Shalayel2 1Al-Yarmouk College, Khartoum,2National College for Medical and Technical Studies, Khartoum,Sudan
References:
THANK YOU