Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Diabetes in Pregnancy Classification Pregestational diabetes Type 1 DM Type 2 DM Secondary DM Gestational diabetes Definition Gestational diabetes (GDM) is defined as glucose intolerance of variable degree with onset or first recognition during the present pregnancy. Pregestational diabetes precedes the diagnosis of pregnancy. Magnitude of problem: GDM GDM varies worldwide and among different racial and ethnic groups within a country Variability is partly because of the different criteria and screening regimens Whom to screen ? Risk stratification based on certain variables Low risk : no screening Average risk: at 24-28 weeks High risk : as soon as possible Low risk for GDM To satisfy all these criteria Age <25 years Weight normal before pregnancy Member of an ethnic group with a low prevalence of GDM No known diabetes in first-degree relatives No history of abnormal glucose tolerance No history of poor obstetric outcome Intermediate risk At least one of the criteria in the list High risk Marked obesity Prior GDM Glycosuria Strong family history Screening and Diagnosis of GDM in the U.S. Use the 50 g oral glucose challenge with BS taken 1 hour later Screen all pregnant women @ 24-28 weeks Test earlier in selected patients Threshold of 130 mg/dL or greater How to screen? Oral glucose tolerance test ( OGTT) with 100 gm glucose Fasting 95 mg/dl 1-h 180 mg/dl 2-h 155 mg/dl 3-h 140 mg/dl • Overnight fast of at least 8 hours • At least 3 days of unrestricted diet and unlimited physical activity • > 2 values must be abnormal Urine monitoring Urine glucose monitoring is not useful in gestational diabetes mellitus Urine ketone monitoring may be useful in detecting insufficient caloric or carbohydrate intake in women treated with calorie restriction Problems of GDM: fetal Increases the risk of fetal macrosomia Neonatal hypoglycemia Jaundice Polycythemia Hypocalcemia, hypomagnesemia Birth trauma Prematurity Problems: fetal Cardiac( including great vessel anomalies) : most common Central nervous system: 7.2% Skeletal: cleft lip/palate, caudal regression syndrome Genitourinary tract: ureteric duplication Gastrointestinal : anorectal atresia Poor glycemic control at time of conception: risk factor Caudal regression syndrome Caudal regression syndrome Problems of GDM: maternal Weight gain Maternal hypertensive disorders Miscarriages Third trimester fetal deaths Cesarean delivery (due fetal growth disorders) Long term risk of type 2 diabetes mellitus Pregnancy in diabetic mother: risks Progression of retinopathy: esp. severe proliferative retinopathy Progression of nephropathy: especially if renal failure + Coronary artery disease: Post MI patients: high risk of maternal death Management Preconception counselling Diabetic mother : glycemic control with insulin/SMBG Target: HbA1c < 7% 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 Clinical parameters: checked at each visit medications pre-pregnancy weight weight gain edema pallor blood pressure Fundal height Patient education Cornerstone in GDM management Maternal complication Fetal complication Medical Nutrition therapy Glycemic monitoring: SMBG and targets Fetal monitoring: ultrasound Planning on delivery Long term risks Glycemic targets Fasting venous plasma < 95 mg/dl 2 hour postprandial <120 mg/dl 1 hour postprandial <130 mg/dl (140) Pre-meal and bedtime: 60 to 95 mg/dl If diet therapy fails to maintain these targets > 2 times/week, start insulin These are venous plasma targets, not glucometer targets Why these tight glycemic targets? Prospective study in type1 patients with pregnancy FBS Macrosomia >105 mg/dl 95-105 <95 mg/dl 28.6 % 10% 3% GDM Medical nutrition therapy Failure to maintain glycemic targets INSULIN THERAPY Medical nutrition therapy Promote nutrition necessary for maternal and fetal health Adequate energy levels for appropriate gestational weight gain, Achievement and maintenance of normoglycemia Absence of ketones Regular aerobic exercises Medical nutrition therapy 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. Self monitored blood glucose 4 times/day minimum, fasting and 1 to 2 hours after start of meals Maintain log book Use a memory meter Calibrate the glucometer frequently Fetal monitoring Baseline ultrasound : fetal size At 18-22 weeks: major malformations fetal echocardiogram 26 weeks onwards: growth and liquor volume III trimester: frequent USG for accelerated growth ( abdominal: head circumference) Timing of delivery Small risk of late IUD even with good control Delivery at 38 weeks Beyond 38 weeks, increased risk of IUD without an increase in RDS Vaginal delivery: preferred Caesarian section only for routine obstetric indication just GDM is not an indication ! Unfavorable condition of the cervix is a problem 4500 grams, cesarean delivery may reduce the likelihood of brachial plexus injury in the infant (ACOG) Management of labor and delivery Maternal hyperglycemia in labor: fetal hyperinsulinemia, 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 sugars more than 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 LSCS: check FBS, if in target no insulin, start dextrose drip Continue hourly SMBG 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 OGTT 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 Management of neonate Hypoglycemia <40 mg/dl Encourage early breast feeding If symptomatic give a bolus of 2- 4 cc/kg, IV, 10% dextrose Check after 30 minutes, start feeds IV dextrose : 6-8 mg/kg/min infusion Check for calcium, if seizure/irritability/RDS Examine infant for other congenital abnormalities Long term risk: offspring 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 Risk stratification and screening is essential in all pregnant women Tight glycemic targets are required for optimal maternal and fetal outcome Patient education is essential to meet these targets Long term follow up of the mother and baby is essential 17 pound baby born to Brazilian diabetic mother Courtesy: MSNBC News Services Jan. 24, 2005 thank you