1 Diabetes mellitus in pregnancy - PowerPoint Presentation

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Diabetes mellitus in pregnancy

Dr Sume Percival Chisha

Registrar, OBGY- UTH

9

th

July, 2014.

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Definition

Fasting venous plasma glucose

≥ 8.0mmol/l and 11.0mmol/L 2 hours after a 75g oral glucose load; or one of these plus symptoms and signs (polydipsia, polyuria, weight loss)

Impaired glucose tolerance (IGT) is present if fasting level is <8.0 mmol/L but rises to 8.0-10.9mmol/L 2 hours after 75g load

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IGT/DM must be suspected in all women with;

Significant glycosuria on 2 occasions antenatally or in a single fasting urine sample

Positive family history of diabetes(parents or siblings), h/o latent diabetes during previous illness

Previous big babies (4KG or >)

Previous unexplained perinatal births diabetes in previous pregnancy

polyhydramnios or recurrent vaginal candidiasis in current pregnancy

Age over 30

Obesity

Persistent glycosuria

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Classification

Chemical or asymptomatic- GTT is abnormal but the patient has no clinical evidence of DM

Latent DM- under conditions of stress GTT is abnormal but it reverts to normal when stress is removed .When pregnancy is the cause of stress it is known as

gestational DM

Frank DM-abnormal

GTT associated with signs and symptoms of DM

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Classification

White’s classification of DM in pregnancy

A

1

: gestational diabetes not requiring insulin

A

2

: gestational diabetes requiring insulin

B: onset at ≥20 years of age or duration of <10 years

C: onset at 10 to 19 years of age or duration of ≥20 years or any onset or duration but with background

retinopathy

or hypertension only

F: nephropathy

(>

500

mg

proteinuria

per day at <20 weeks of pregnancy)

H:

arteriosclerotic

heart

disease

,

clinically evident

R: proliferative diabetic retinopathy or vitreous

hemorrhage

T: history of renal transplant

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Routine screening recommended because

About 30% of gestational diabetes have none of the above risk factors

Not all women with IGT or even diabetes have persistent glycosuria

Glycosuria can be found in the urine of up to 50% of all pregnant women at some time

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Selective or comprehensive screening can be undertaken by:

Random blood glucose estimation at booking and at 28-32 weeks.Further investigation is required for levels

≥6.4 mmo/L within 2 hours of the last meal or 5.8≥ mmo/l more than 2 hours after it

Estimation of blood glucose concentration fasting and 2 hours after a 50 g glucose load.An oral 75 g glucose tolerance (GTT) is indicated if fasting and/or the 2-hour levels exceed 5 and 7 mmol/L respectively

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Effects of pregnancy on diabetes

Pregnancy is diabetogenic therefore sugar control is difficult

Insulin effect is antagonised by combined effect of HPL ,oestrogen,progesterone,free cortisol and degradation of the insulin by the placenta

Dose of insulin therefore increase as pregnancy advances

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Other causes of insulin resistance

Normal glucose homeostasis maintained by increased insulin production

Loss of glucose to the fetus

Degradation by insulinase enzyme

Growth hormone- like effect of human chorionic somatomamotrophin increases insulin resistance

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Hormonal effects of glucose metabolism

Oestradiol –

increase in insulin secretion

Decreased gluconeogenesis

Progesterone

Increase insulin

Decreased glucagon secretion

HPL

Increased blood glucose

Blocks effects of oestradiol and progesterone

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Complications

Maternal

During pregnancy

Abortion if uncontrolled

Infection especially UTI

PE risk (25%)

Polyhydramnios(25-50%)

Maternal distress due to oversized baby or hydramnios

Retinopathy,nephropathy ,and neuropathy may be worsened

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During labour there is increased risk of;

Risk of prolongation of labour due to big baby

Shoulder dystocia

Perineal injuries

Postpartum haemorrhage

Operative interference

Pueperium

Puerperal sepsis

Failing lactation

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Foetal hazards

Foetal macrosomia

Results from maternal hyperglycaemia , with similar rise in fetus causing fetal hyperinsulinism

Causes hypoglycaemia, excessive lipogenesis

Congenital malformation(6-8%).Increased risk of cardiovascular and neural tube defects

Sudden unexpected fetal death –increase risk during the last 4-6 weeks of pregnancy

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Neonatal problems include

Birth

trauma,

hypomagnesaemia,

hypoglycaemia,

Hypocalcaemia and tetany

Polcythaemia, hyperbilirubinaemia

jaundice,

Hyaline membrane disease

infection

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management

Prepregnancy counselling allows:

General advice ,eg about tight diabetic control(particulary around conception and in the early weeks of pregnancy)

Planning for pregnancy (including early booking for antenatal care)

Review of diet

Examination of optic fundi

Establishment of good blood glucose control

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Antenatal care for pre-existing diabetics should be jointly between obstetrician ,physician ,dietician

Organise high fibre diet with correct calorific intake and CHO content

Blood glucose profile 2/3 times per week maintaining pre and post-prandial levels of <5.0 and <7.0 mmol/L respectively

Regular urinalysis

Regular glycosylated haemoglobin estimation

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Insulin best use combined soluble and intermediate-acting insulins mornings and evening or intermittent soluble insulin with each meal (three times per day) and an intermediate insulin in the evening

Dose of insulin is

0.7iu/kgBwt in first trimester

0.8iu/kgBwt in second trimester

0.9-1kgBwt in third trimester

Maternal health is also monitored carefully paying attention to weight,optic fundi,blood pressure and renal function

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Fetal welfare should be monitored carefully:

Baseline scan to confirm GA and at 20/40 to exclude major anomalies

Continue with serial scans for reduced and,particulary excess fetal growth

Asses fetal well being regulary from 28/40

If macrosomia arises check ultrasound for cardiac enlargement

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Admission to hospital is indicated if:

Good glucose control cannot be achieved as an outpatient

Severe HTN or PE develop

Weight gain is excessive

Renal function deteriorates

Fetal well being causes concern

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Gestational diabetes

If IGT is discovered during pregnancy ,carry out glucose profile

Treatment is indicated for glucose level

≥5.8mmo/l

Dietary control should be attempted initially.If this is not successful then insulin should be prescribed

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Labour and delivery

When DM is well controlled and pregnancy uncomplicated vaginal delivery between 38 and 49 weeks should be anticipated

Missed meal and usual insulin dose

During labour close control of blood glucose is achieved by continous infusion of soluble insulin ( usually 50 units in 50 mi normal saline),and a separate infusion of 5% dextrose with (10 mmol in 500ml) added.The dextrose infusion should run at constant rate of 100ml/hour

Regular sugar monitoring and keep levels at between 5-7 mmol/L

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If syntocinon is needed use normal saline

If elective C/S is planned ,careful control needed before,during and afterwards until woman can eat and drink normally

If preterm labour supervenes and beta sympathomimetics and steroids are needed , cover these by insulins

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Postnatal care

Insulin sensitivity goes down after delivery of placenta.Dose of insulin goes down so monitoring needed

Hypoglycemia common in neonate- treat promptly

Breast feeding is encouranged