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DR FARAH DEEBA NASRULLAH ASST PROF DEPT OF OBGYN UNIT II CHK/DUHS • Pregnancy is a state of insulin resistance & relative glucose intolerance • This is due to placental production of anti-insulin hormones : hPL, cotisol, and glucagon • FBS • Postprandial glucose ↑ ↑ • Insulin production ↑ ↑ 2 folds in N women • Insulin requirements ↑ ↑ in diabetic women • renal threshold for glucose glycosuria Pregnancy may be complicated by diabetes in two distinct forms: Gestational diabetes mellitus (GDM) is defined as glucose intolerance of varying severity with onset or first recognition during pregnancy. This constitutes 90% of women with pregnancies complicated by diabetes. The most important perinatal complication in this group is macrosomia with resulting birth trauma. More than 50% women ultimately develop diabetes in the next 20 years and majority of them are obese. Pre-gestational diabetes is diabetes that antedates pregnancy. Pregnancies complicated by pregestational diabetes, type-1 or type-2, carry an additional risk to both mother and fetus beyond the effects on fetal growth and congenital anomalies. • Pregestational diabetes: A woman with known diabetes who conceives while on treatment with diet, oral hypoglycemic agents or insulin. Type 1 DM, Type 2 DM, Secondary DM • Gestational diabetes mellitus is defined as glucose intolerance of variable degree with onset or first recognition during pregnancy. Risk Factors for gestational diabetes screening 1. Strong family history of diabetes 2. History of birth to large infants (>4 kg; 8 lbs 13 oz) 3. History of recurrent fetal loss 4. Persistent glycosuria 5. Age > 25 years 6. Past history of glucose intolerance or diabetes in a previous pregnancy Obesity; overweight women (>15% of non-pregnant ideal body weight) 8. Ethnic group with a high prevalence of diabetes (e.g. Pima Indians, Asians, Hispanic) 9. History of stillbirth, unexplained neonatal death, congenital malformations, prematurity. 10. History of pre-eclampsia or polyhydraminos 11. Chronic hypertension 12. Recurrent severe candidiasis or urinary tract infection 13. History of traumatic delivery with an associated neurological disorder in the baby Risk Assessment Low risk: no screening Average risk: at 24-28 weeks High risk: as soon as possible Screening is usually initiated b/w24th and 28th weeks of pregnancy or earlier in the presence of risk factors . Low risk for GDM • • • • • • Age <25 years normal BMI before pregnancy Ethnic group with a low prevalence of GDM No H/O diabetes in first-degree relatives No H/O abnormal glucose tolerance No H/O obstetric complication • • • • • HIGH RISK FOR GDM Marked obesity Prior GDM Glycosuria Strong family history Ethnic group with high diabetes prevalence Screening test Glucose Challenge Test (GCT): best screening test for gestational diabetes. It includes measurement of plasma glucose 1 hour after ingesting 50 g of glucose without dietary preparation between 24-28 weeks of gestation. cut-off value > 140 mg/dl identifies 80% women with GDM cut-off value > 130 mg/dl identifies 90% women with GDM Women with elevated GCT values require a diagnostic test (OGTT) Oral Glucose Tolerance Test (OGTT): After an overnight fast measurement of plasma glucose after ingesting 100 g of glucose. Timing of National Carpenter and measurement Diabetes Data Coustan (CC) Group (1979) 1982 Fasting 105 mg/dl 95 mg/dl 1 hour 190 mg/dl 180 mg/dl 2 hour 165 mg/dl 155 mg/dl 3 hour 145 mg/dl 140 mg/dl • Women in whom the criteria of DM are met in pregnancy include a gp of diabetics who were undiagnosed before pregnancy • FBS > 7 mmol/L on 2 occasions • Or • RBS > 11.1 mmol/L on 2 occasions • Borderline cases GTT DM is Dx if FBS > 7 mmol/L or 2 hrs > 11.1 mmol/L • Impaired glucose tolerance 2hrs G 8-11 mmol/L with a N FBS Effects of GDM on the fetus Congenital abnormalities Neonatal hypoglycemia Macrosmia (big baby syndrome > 4 Kg or >8 lb 13 oz) Jaundice Polycythemia / hyperviscosity syndrome Hypocalcemia, hypomagnesemia Birth trauma (due to macrosmia and shoulder dystocia) Prematurity Hyaline membrane disease Apnea and bradycardia The risk of fetal anomalies is not increased in GDM patients. However, the risks of unexplained still births (during the last 4-8 weeks of gestation) are similar to pre-gestational diabetes. Effects of GDM on neonates Hypoglycemia Hypocalcemia Hyperbilirubinemia RDS Cardiac Hypertrophy Long term effects on cognitive development Macrosomic infant Macrosomia (large for gestational age or big baby syndrome) (birth weight >90% percentile for gestational age) persistent maternal hyperglycemia leadS to fetal hyperglycemia and prolonged fetal hyperinsulinism. This stimulates excessive somatic growth mediated by insulin-like growth factors (IGFs). Macrosomia affects all organs except the brain. • Cardiac (most common): transposition of great vessels, Ventricular septal defect, Atrial septal defect • Central nervous system (7.2%): spina bifida, Anencephaly, hydrocephalus • Skeletal: cleft lip/palate, caudal regression syndrome • Genitourinary tract: ureteric duplication • Gastrointestinal: anorectal atresia • Renal agenesis, Duplex ureters, Cystic Kidney • Situs inversus Poor glycemic control at time of conception: risk Caudal regression syndrome factor (abnormal development of lower spine) Effects of GDM on the mother Pre-eclampsia: 10-25% of all pregnant women with GDM Infections: high incidence of chorioamnionitis and postpartum endometritis Postpartum bleeding: caused by uterine overdistension Cesarian section more common due to fetal macrosmia and cephalo-pelvic disproportion Weight gain Hypertension Miscarriages Third trimester fetal deaths Long term risk of type-2 diabetes mellitus Effect of pregnancy on diabetes More insulin is necessary to achieve metabolic control Progression of retinopathy: esp. severe proliferative retinopathy Progression of nephropathy: especially if renal failure + Increased risk of Coronary artery disease, and a high risk of maternal death in post MI patients Cardiomyopathy Instruct mother about maternal and fetal complications Medical Nutrition therapy Glycemic monitoring: teach mother about self monitored blood glucose measurement and glycemic targets Pre-conception counseling Fetal monitoring: ultrasound Planning on delivery Long term risks Glycemic control targets Tight glycemic control can reduce fetal risk. But, strict glycemic control p increaseds risk of hypoglycemic events and the fetus at risk of being small-forgestational age. American Diabetes Association Recommendations: Fasting whole blood <95 mg/dl glucose 1 hr postprandial blood glucose <140 mg/dl 2 hr postprandial blood glucose <120 mg/dl in type-1 patients with pregnancy Fasting blood sugar Macrosomia >105 mg/dl 28.6 % 95-105 10% <95 mg/dl 3% 4 times/day minimum, fasting and 1 to 2 hours after start of meals Maintain record Calibrate the glucometer frequently Medical Nutrition and Exercise therapy provide necessary nutrients for mother and fetus to ensure adequate gestational weight gain control glucose levels prevent starvation ketosis aerobic exercise, exercise that does not stress the trunk Current weight in Daily caloric Recommended relation to ideal intake pregnancy body weight (kcal/kg) weight gain (kg) <80-90% 36-40 28-40 80-120% (ideal) 30 25-35 120-150% 24 15-25 >150% 12-18 15-25 • Approximately 30 kcal/kg of ideal body weight • > 40-45% should be carbohydrates • 6-7 meals daily (3 meals, 3-4 snacks). Bed time snack to prevent ketosis • Calories guided by fetal well being/maternal weight gain/blood sugars/ ketones • Energy requirements during the first 6 months of lactation require an additional 200 calories above the pregnancy meal plan Insulin in GDM Insulin used if fasting blood glucose >105 mg/dl or 1 hr postprandial blood glucose >120 mg / dl on a diet Use basal bolus regime or pre-mixed insulin Short acting insulins (e.g. Lispro and Aspart) can be used to achieve postprandial control Insulin requirements increase by 50% from 20-24 weeks to 30-32 weeks, after which insulin needs often stabilize. Oral Hypoglycemic agents Glyburide is a clinically effective alternative to insulin in GDM (Langer et al. 2000) Metformin may be effective in GDM (Ratner et al., 2008; Coustan, 2007) Preconception counseling All women with pre-existing type-1 or type-2 diabetes, when planning on pregnancy, should receive pre-conception counseling so that they understand the importance of achieving near-normal blood glucose before conception to reduce the risk of congenital malformations and spontaneous miscarriage. Assess maternal and fetal risk Mother should learn self-administration of insulin and regular monitoring of blood glucose. Target: HbA1c < 7% Emphasize diet and exercise Folic acid supplementation: 5 mg/day Ensure no transmissible diseases: HBsAg, HIV, rubella Try and achieve normal body weight: diet/exercise Stop drugs: oral hypoglycemic drugs, ACE inhibitors, beta blockers and potentially teratogenic drugs Medications Pre-pregnancy weight Weight gain Edema Pallor Thyroid enlargement Blood pressure Fundal height Laboratory parameters to be monitored at antenatal visit Hemoglobin Blood Sugar HbA1C Urine microscopy and albumin Baseline ultrasound : fetal size Ultrasound evaluation of neural tube defects and other congenital malformations should begin by 15-21 weeks of At 18-22 weeks: fetal anatomic survey, major malformations At 20-22 weeks: fetal echocardiogram for cardiac defects — At 26 weeks onwards: ultrasound to evaluate fetal growth and amniotic fluid volume Third trimester: Fetal surveillance to reduce risk of still birth: include non-stress test, biophysical profile, maternal monitoring of fetal activity, frequent USG for accelerated growth abdominal: head circumference Small risk of late intra-uterine death even with good glycemic control Delivery usually at 38 weeks Beyond 38 weeks, increased risk of intrauterine death without an increase in RDS Management of labor and delivery Vaginal delivery: preferred Cesarian section only for routine obstetric indication GDM alone is not an indication ! > 4.5 Kg fetus: Cesarean delivery may reduce the likelihood of brachial plexus injury in the infant Unfavorable condition of the cervix is a problem Maintain euglycemia during labor Maternal hyperglycemia in labor: fetal hyperinsulinemia and worsen fetal acidosis Maintain sugars: 80-120 mg/dl (capillary: 70-110mg/dl ) Feed patient the routine GDM diet Maintain basal glucose requirements Monitor sugars 1-4 hrly intervals during labour Give insulin only if blood sugar >120 mg/dl GLYCEMIC MANAGEMENT DURING LABOUR Later stages of labour: start dextrose to maintain basal nutritional requirements: 150-200 ml/hr of 5% dextrose Elective Cesarian section: check fasting blood sugar; if within target range no insulin is needed; start dextrose drip Continue hourly self monitored blood glucose Post delivery keep patients on dextrose-normal saline till fed No insulin unless sugars more than normal ( not GDM targets ! ) Post partum follow up Check blood sugars before discharge Breast feeding: helps in weight loss Lifestyle modification: exercise, weight reduction Oral glucose tolerance test at 6-12 weeks postpartum: classify patients into normal/impaired glucose tolerance and diabetes Preconception counseling for next pregnancy Increased risk of cardiovascular disease,future diabetes and dyslipidemia Immediate management of neonate Hypoglycemia: 50 % of macrosomic infants 5–15 % optimally controlled GDM Starts when the cord is clamped Exaggerated insulin release secondary to pancreatic ß-cell hyperplasia Increased risk: blood glucose during labor and delivery exceeds 90 mg/dl Anticipate and treat hypoglycemia in the infant Hypoglycemia <40 mg/dl Encourage early breast feeding If symptomatic give a bolus of 2- 4 ml/kg, IV, 10% dextrose Check after 30 minutes, start feeding IV dextrose : 6-8 mg/kg/min infusion Check for calcium, if seizure/irritability/RDS Examine infant for other congenital abnormalities Increased risk of obesity and abnormal glucose tolerance due to changes in fetal islet cell function Encourage breast feeding: less chance of obesity in later life Lifestyle modification Conclusion Gestational diabetes is a common problem in worldwide Risk stratification and screening is essential in all pregnant women, particularly those from ethnicities with increased risk Tight glycemic targets are required for optimal maternal and fetal outcome Patient education is essential to meet targets Long term follow up of the mother and baby is essential ####################################################