Management of diabetes during pregnancy

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Management of diabetes during pregnancy

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  • Management of Diabetes during pregnancy Prof . Aboubakr Elnashar Benha university, Egypt Aboubakr Elnashar
  • Diabetes during pregnancy: 1. Gestational diabetes mellitus (GDM). 2. Pregestational diabetes: type 1 diabetes mellitus (T1DM) type 2 diabetes mellitus (T2DM). Aboubakr Elnashar
  • Preconception care 1. Educate 2. Encorage 3. Review 4. Assess Antenatal care Screening & Diagnosis M: G control Assess F: Wt Wellbeing Cong mal Delivery Intrapartum care Monitor Blood glucose Postpartum care Aboubakr Elnashar
  • A. Pre-Conception Care I. Health education: 1. Risks of DM can be reduced but not eliminated. 2. Avoidance of unplanned pregnancy: HbA1C 10%: Don't allow HbA1C 6.1%: allow 3. Hypoglycaemia awareness. 4. Pregnancy-related nausea/vomiting & their effect on glycaemic control. 5. Frequent appointments during ANC. Aboubakr Elnashar
  • Risks Miscarriage Cong malformation Stillbirth Macrosomia (>4 kg or birth wt centile >90) Sh dystocia: B trauma Res distress Neonatal hypoglycemia and poor feeding Hypoglycemia D Ketoacidosis Induction of labour or CS PET Worsening of Retinal and renal dis Aboubakr Elnashar
  • II. Encourage patient to: 1. Dietary restrictions 2. Exercises 3. Reduce wt if BMI 27 4. Self-monitoring by glucometer monthly HbA1C ketone strips. Aboubakr Elnashar
  • III. Review, replace& offer mediations: 1. Discontinue: a. Hypoglycaemic agents except: Metformin Glibenclamide (Daonil). b. Anti-hypertensive agents e.g. angiotensin-converting enzyme inhibitors (ACE) (Captopril)* angiotensin-II receptor antagonists )angiotensin ii receptor blocker) (ARB) (Candesartan, eprosartan, irbesartan, losartan, olmesartan, telmisartan, and valsartan ( Diovan c. Anti- cholesterol e.g Statin (Levacor, Zocor, Pravachol, Lipitor, Crestor( 2. Give: Folic Acid (5 mg OD) *Captopril (Category D): oligohydramnios, pulmonary hypoplasia, IUGR Aboubakr Elnashar
  • Safety of medications before and during pregnancy Metformin: safe Rapid-acting insulin analogues(aspart, lispro): safe long-acting insulin analogues (ultrlent, glargine) : Evidence is limited. Isophane (NPH) insulin: first-choice long-acting insulin during pregnancy. Aboubakr Elnashar
  • IV. Assess: 1. Retina 2. Renal function: refer to Nephrologist if (i) Microalbuminuria 2 gm /d (ii) Creatinine 120 M mol/L=1.25 mg 1mg=88.4 M mol/L 3. Thyroid status: D.M. Type I Aboubakr Elnashar
  • B. Antenatal care I. Screening Who? All pregnant women. When: At booking At 24-28 w How? FBS: 90 > mg/dl Aboubakr Elnashar
  • FBG: High sensitivity (81%) Good specificity (76%) with a cut off of 86 mg/dl (4.8 mmol/l) (Perucchini et al, 1999) Easier Cheaper More acceptable Can be applied to all pregnant women More than once during pregnancy. Suitable for screening Aboubakr Elnashar
  • II. Diagnosis The 75 g WHO OGTT Fasting venous & capillary blood glucose are similar. After a meal or a glucose challenge, capillary are higher than venous levels. It is not necessary for both values to be abnormal No need for GTT FBS 125 mg/dl or Random venous plasma glucose 200 mg/dl if confirmed on a subsequent day Plasma glucose Mg/dl Fasting 100 2-h 145 Aboubakr Elnashar
  • Recommendations of International Association of Diabetes and Pregnancy Study Groups (IADPSG) 2010 1-step 75-g OGTT screening at-risk individuals during 1st ANV. Aboubakr Elnashar
  • 1. Diabetic Centre 2. ANC clinic: /1-2 w Objective: Medical TT: M: Glycemic control Retinal and renal assessment Obstetric TT: F: wellbeing Wt Cong malformation Delivery Aboubakr Elnashar
  • Medical treatment Goals achieving normoglycemia preventing postprandial glucose excursions optimizing compliance Aboubakr Elnashar
  • I. Glycemic control Objective: These targets are the same for type 1, type 2 and gestational diabetes). {1. Outcomes (birth-weight and neonatal hypoglycaemia) correlate better with postprandial than with preprandial glucose levels. 2. Postprandial targets: better improvements in maternal HbA1Clevels}. Capillary blood glucose Mg/dl(mmol/L) Fasting 30 kg/m2: 25 Kcal/kg Aboubakr Elnashar
  • Carbohydrates 40% Protein 30%, Fat 30% (Garner, 1995). Concentrated sweets & added sugars: eliminated. Complex CHO with high fiber contents: preferable {slower glucose rise after ingestion} The classic food pyramid model: Recommends that carbohydrates such as bread, cereal, rice, and pasta comprise the majority of the meal, is now antiquated. It has been replaced with a new meal planning target that emphasizes more vegetables and whole grains Aboubakr Elnashar
  • 2. Exercise Reduce insulin requirement by as much as 50%. Effect appears after 4 w. 1h after mealtimes. For 20-30 min Upper extremity or lower extremity ms excerises while recumbent do not increase uterine contractions (Durak et al, 1990 ;de Veciana and Mason, 2000). Gentle aerobic exercise Walking (Homko et al, 1998). Aboubakr Elnashar
  • 3. Insulin Types NICE: glulisine, glargine and detemir. are avoided during pregnancy. Lispro and Aspart benefits: 1. fewer hypoglycaemic episodes 2. better control Aboubakr Elnashar
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  • Regular insulin: inappropriate for use during pregnancy. {cannot control the postprandial spike in blood glucose adequately unless it is administered 6090 min before the onset of the meal} Aboubakr Elnashar
  • Calculation of insulin dose: 1. Initial insulin dose: TDD 2. Adjustments acc to a. meal and blood glucose diaries b. results of point-of-care Hb A1c measurements. Aboubakr Elnashar
  • 4. Oral hypoglycaemic agents: Sulphonylureas, chlorpropamide, tolbutamide: Not recommended for use in pregnancy. 1. crossed the placenta & stimulated fetal insulin secretion: fetal macrosomia & hyperinsulinaemic hypoglycaemia and seizures in neonates. 2. Major congenital malformations in animals (Greene, 2000) Aboubakr Elnashar
  • Metformin and Glibenclamide= glyburide(Daonil) Safe (NICE, 2008). Metformin PCOS: Decrease 1st T abortion & G DM Cross placenta, but no increase in cong malformation an alternative to insulin therapy in pregnant women with type 2 diabetes Glibenclamide Cross placenta in small amounts New oral hypoglycemic: Nateglinide (Starlix) Very few data Aboubakr Elnashar
  • Hypoglycaemia blood glucose of 125 mg/dl: 2-4 u IV regular insulin and assess the coming hour. -< 75mg/dl: 10% dextrose infusion and assess after 15 min. Women with GDM controlled with insulin should be instructed to stop insulin use once labor starts, and then reevaluate their glycemic control with frequent SMBG testing in the postpartum period. Aboubakr Elnashar
  • IV dextrose and insulin: -Indication: Type 1 diabetes BG not maintained between 75& 125 mg/d. -Strength of solution: (1 u/ ml) (50 u insulin in 50 ml 5% dextrose) -Rate: if blood glucose 0-70 mg/dl= 0.5 u/h 71-140 mg/dl= 1 u/h 141-215 mg/dl= 2 u/h Aboubakr Elnashar
  • D. Postpartum care I. Breast feeding: Encouraged {Reduces the insulin requirement by 25% Breast- feed babies have a much lower risk of developing DM} Glyburide and metformin are secreted into breast milk and should not be used during lactation in women with T2DM. Breastfeeding can cause life-threatening hypoglycemia for lactating women on insulin, especially those with T1DM. Women who are both breastfeeding and on a form of basal insulin must either decrease their basal rate during lactation or eat a carbohydrate-containingAboubakr Elnashar
  • II. Glycemic control Insulin-treated pre-existing diabetes: Reduce insulin (30-50%) Self-monitor blood glucose to establish correct dose {Risk of hypoglycaemia, especially while breastfeeding} To have food available before or during breastfeeding. Once women with type 1 diabetes are eating normally, s.c. insulin should be recommenced at either the pre- pregnancy dose or at a 25% lower dose if the women intends to breast-feed, Aboubakr Elnashar
  • Type 2 diabetes: Resume or continue taking metformin and glibenclamide Not to take any other oral hypoglycaemic agents while breastfeeding. Aboubakr Elnashar
  • Gestational diabetes: Stop hypoglycaemic medication