Seminar 5 - DM in pregnancy

8/9/2019 Seminar 5 - DM in pregnancy

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Medical Complications in Pregnancy:

DIABETES MELLITUS

MUHAMMAD ZULHILMI BIN ABU BAKAR


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1. Type 1(IDDM)

2. Type 2(NIDDM)

3. Gestational diabetes

4. Others -genetic defects in insulin processing or action

-endocrinopathies

-drugs

-exocrine pancreatic defects

-genetic syndromes associated with dm


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E

ither type 1(iddm) or type 2(niddm)Type 1 occurs in younger age group and end

organ complications is likely to be

more.Hence they to have increased maternal

and obs risks

Type 2 usually occurs in obese patients and

have less maternal and obs compared to type

1


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Pregnancy alters carbohydrate in such away more glucose is made

available to the fetus

What cause the diabetogenic state?

Elevated placental hormones such asestrogens,progesterone,prolactin,human placental lactogen.

Plasma cortisol also rises during pregnancy.

Cause contrainsulin effect and state of insulin resistance

Further aggravated by increase body weight and increase caloric

intake during pregnancy Gestational diabetes develops when the pancreas ,despite the

production of insulin cannot overcome the effect of thesecounter regulatory hormones

In contrast pregestational diabetes becomes worse duringpregnancy


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1. Historical factors Age>30 years

Previous gdm

Family history of dm

Bad obs history

History of macrosomia

Prev. fetal anomalies

History of recurrent abortions or unexplained stillbirth

Drug history-steroids,tocolytic drug

2. Clinical factor in the present pregnancy Congenital fetal anomalies

Pre-eclampsia

Obesity>90 kg

Recurrent uti,vaginal candidiasis

Presence of glycosuria on more than 2 occasions


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Gdm is asymptomaticasymptomatic ,hence we need screening test to detect

gdm

1. Universal screening(all pregnant women)

2. Selective screening(presence of risk factors for gdm)

for universal screening do the glucose challenge testNo special preparation is needed for this test

50 grams of oral glucose is given between 24 to 28 weeks pog

Blood glucose is determined 1 hours later.

A plasma glucose level of > 7.8 is considered significant to perform

comfirmation diagnostic test.

Selective screening-oral glucose tolerance test 75 grams of oral glucose is given

Only 2 reading are taken-fasting glucose level and 2 hour post glucose

The diagnosis of dm is made when fasting glucose level are 7.8 and or 2

hour level of >11.1

If the 2 hours levels are between 7.8 and 11.1,the patient is said to have

impaired glucose tolerance test and should be treated as gdm.


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1. Pre-eclampsia

2. Recurrent infection-vaginal candidiasis,uti

3. Retinopathy

4. Nephropathy

5. Neuropathy

6. Micro/macroangiopathy

7. Polyhydramniospprom, cord prolapse,8. ketoacidosis

9. Increased instrumental and CS rates

10. Study shows that after gdm,40-60%of

women develop type 2 dm within 10years


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1. Miscarriage

2. Congenital anomalies(4 fold)-sacral

agenesis,ntd,cardiac and renal anomalies

3. Macrosomia

4. Respiratory distress syndrome

5. Hypoglycemia-result of hyperplasia of beta

cell

6. SIUD

7. Prematurity

8. Malpresentation

9. Shoulder dystocia.

10. polycythemic -jaundice


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1. Blood sugar level-weekly assessment is

required.useful in deciding wether to start

insulin or adjusting insulin dosage

2. Urine microscopy and culture-to excludeuti(bacteriuria)

3. HbA1c-done in first trimester.it gives

retrospective assessment 12 weeks

ago.high HbA1c at the end of firsttrimester indicates sugar control was poor

during organogenesis period.

4. Maternal serum AFP-done between 16 to

20 weeks pog


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5. Diagnostic imaging-gestational age, fetal

abnormalies, fetal growth, liquor volume .

6. Doppler of umbilical artery-done in cases of

diabetic vasculopathy


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Antenatal management

Plasma glucose level should be maitained between 4-6mmol/L

Early dating and scan to exclude fetal abnormalities

Diet control should be attempted first.if fail,insulinshould be started.

Admission-poor blood sugarcontrol,PIH,polyhydramnios.bsp should be monitored

Timing for delivery-if on insulin,38 weeks,if on diet

control,can prolonged to term Mode of delivery-lscs if macrosomia

baby,malpresentation,evidence of fetal compromise

Check BP

Fetal growth chart

Monitor closely with continuos ctg


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Oral hypoglycemic drug are generally not

recommended as it can cause teratogenic effect

towards fetus and can cross placenta causing

hypoglycemia

Diet therapy Total calories advised is 24-30 kcal/kg of the

present body weight.In obese diabetic pt.

24kcal/kg is adviced

The calories should be distributed between 3meals and 3 snacks

Dietery control decrease postprandial glucose

level and it also improve insulin action.

Blood glucose level and weight gain can be used

to formulate a meal plan


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Exercise

Light exercise help by lowering fatty acid

Contracting muscle help stimulate glucose

transport hence decrease blood sugar Better done after meals

Exercise involving the muscle of upper part of

the body is sufficient to lower down glucose

level.


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Insulin regimes

15% required insulin therapy

Insulin is indicated in all pregestational diabetes

and poorly controlled gdm The popular regimes use a mixture of short

acting and medium acting insulin


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Pre-pregnancy counsellingThis play an important roles for

pregestational diabetes in order to prevent

early pregnancy loss and congenital

anomalies.Complete assessment of diabetic status

should be done to find out wether she fit to

go through pregnancy.HbA1c can be done to

evaluate blood glucose control 12 weeks ago.Those with oral hypoglycemic should be

switched to insulin theraphy.


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15% of pt. with positive gct will have gdm

15% percent of GDM will required insulin

15% of GDM will have macrosomia

15% of GDM will have impaired gtt after

delivery

Seminar 5 - DM in pregnancy

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