DR EBUNU EN CONSULTANT OBSTETRICIAN AND GYANECOLOGIST ZONAL MDGHE PreTest Management of women with diabetes mellitus in pregnancy 1 Joint care with midwives obstetricians and diabetic physicians is not necessary ID: 1046090
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1. DIABETIC MELLILUS IN PREGNANCY: CONTEMPORARY MANAGEMENT.DR EBUNU E.NCONSULTANT OBSTETRICIAN AND GYANECOLOGISTZONAL MD.GHE.
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3. Pre-TestManagement of women with diabetes mellitus in pregnancy:1) Joint care with midwives, obstetricians and diabetic physicians is not necessary.2) fetal wt of 4 kg and > should have c/s.3) Dietary advice is not important.4) Home blood glucose monitoring and clinic HbAIc is important.5) Fundoscopy at regular intervals is not necessary6) Patient should continue her anti-diabetic drugs.7) Scans for growth and liquor volume is not part of the management.8) All patients should be allowed to come in spontaneous labour.9) Increasing insulin dose is part of the management.10) Corticosteroids are naturally diabetogenic
4. Introduction In 1921 Banting and Best discovered insulin.Fertility was restored MM improved remarkably.PM remained highFetal macrosoma, and IUFD were the causes.Early delivery & C/S were the antidote.Late IUFD was still a problem.1930 White classification.
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6. IncidenceMost common endocrine disorder in preg.Affects 2–3 % of all pregnancies1.5% in Lagos ( Abudu et al )0.7/1000 in Ibadan (Oladokun et al)90% are cases of GDM .on the increase due to obesity10% are pre-gestational DM
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22. ScreeningNo consensusFBS, 2HPP, (75g OGTT). RBS 50g glucose oral challenge, 1 hr glucose 140 mg/dl.Poor screening tools:Urinalysis, HbA1c, FructosamineUniversal or selectiveTiming of screening
23. Selective Screening: Certain risk factors at early pregIf normal test are found in an early screening, follow up test should be performed at 24 – 28 weeks gestation Universal Screening: Advocated by ACOGSCREENING contd.
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32. DIAGNOSISSymptoms & Signs: polydypsia, polyuria, polyphagia.WHO Criteria: 75 g OGTT2006 WHO Diabetes criteriaConditionFasting glucose2 hour glucosemmol/l(mg/dl)mmol/l(mg/dl)Normal<6.1 (<110)<7.8 (<140)Impaired fasting glycaemia≥ 6.1(≥110) & <7.0(<126)<7.8 (<140)Impaired glucose tolerance<7.0 (<126)≥7.8 (≥140)Diabetes mellitus≥7.0 (≥126)≥11.1 (≥200)A single abnormal value in symptomatic patient.
33. Management AIMSEducating the individualEuglycemiaEarly detection and treatment of medical problemsPrevent obstetric complicationsOptimal timing and appropriate mode of deliveryFamily planningAppropriate.
34. Management GDM MUITIDISCIPLINARY; Education, Diet, ExerciseMEDICAL ;Insulin,oral hypoglycemic agents ?OBSTETRICS;Ante-partumIntra-partumPost-partum
35. Preconception carePre-gestational DM/Counseling.Aim to achieve euglycemia congenital anomalies in infants of diabetic is related to the presence of hyperglycemia early in gestation.HgbAic level monitoring (< 6.5%) a reflection of the patients degree of glycaemic control during the preceding 4-8weeks
36. HgbAic levels > 10% indicates the most significant risk of developing malformation.Fetal embryopathy may occur in patients with normal HgbAic levels.Assess patients general medical status;presence of retinopathy, nephropathy,hypertention,and ischaemic heart disease must be assessed
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42. INSULIN THERAPYUse of human insulin for pregnant diabetics and diabetics considering pregnancy [ADA recom]Insulin need increase through out gestation from approx 0.7U/Kg/day from 6-18wks to 0.8U/Kg/day during wks 18-26wks to 0.9U/Kg during wks 26-36 to 1.0U/Kg during wks 36-41.
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45. REGIMENADJUSTED TO SPECIFIC NEEDSTwo injection regimen: 2/3rds of total daily dose – am (2:1 ratio of lente to regular insulin)1/3rd-pm (1:1 ratio of lente to regular insulin)Three injection regimenFour injection regimenContinuous sub cut insulin regimen
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47. Recommended levelsTherapeutic objectives:Fasting levels (60-90mg/dl)before lunch, dinner or bedtime snack levels (60-105 mg/dL).after meals 1hr levels (130-140mg/dL)2hr levels (≤ 120mg/dL)
48. Insulin Analogues1. rapid-acting insulin analogs (lispro) Cat B concerns about teratogenesis, antibodies formation, growth-promoting properties majority of evidence showed that it does not cross placenta, and has no adverse maternal or fetal effects
49. Insulin Analogues2. Long acting analogs glargineCat C drugNot well studied systemically
50. SupervisionHospitalization may be required in early gestation.To provide intensive education and counseling , and to improve glycemic control.Consencious out patient care frequent visits and phone calls is essential to ensure optimal glucose controlHospitalization is recom for patients whose glycemic control is poor:Constantly exceed 200 mg/dl or those who experience significant hypoglycemic episodes
51. Oral Hypoglycemic agents teratogenic in animal studies esp first generation sulfonyureasIn humans, scattered case reports of congenital abnormalityRisk of congenital abnormality related to maternal glycemic control rather than mode of the anti-DM agents
52. Oral hypoglycemic agentsSulfonylureas1st generation drug increase risk of neonatal hypoglycemia2nd generation drug (Glyburide) no such effect and other morbidities . Cat C drug4%-20% patients failed to achieve glucose control with maximum dose of drugIncrease risk of preeclampsia and need for phototherapy Langer, N Eng Med J , 2000Kremer, Am J Obst Gynaecol, 2004Chmait, J Perinatol ,2004Langer, Am J Obst Gynaecol, 2005
53. Oral hypoglycemic agentsBiguanides ( metformin)Cat B drug used in PCOD to treat insulin resistance and normalize reprod fxn.Not teratogeneicReduce first trimester miscarriage10X reduce gestational diabetesGlueck, Fertil Steril 2002Reece, Curr Opin Endocrinol Diabetes, 2006Hague, BMJ, 2003Glueck, Human Reprod, 2004
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55. ANTEPARTUM CAREMonitoring of BP, proteinuria and development of non-dependent oedema is imperative.Since 25% of diabetic patients develop pre-eclampsia.Early booking/datingOphthalmologic, cardiac, renal fxn should be assessed at the initial visit.Reassessed during gestation as indicatedUrine M/C/S is recommendedEvery trimester; so that asymptomatic bacteriuria can be treated in a timely fashion
56. FETAL ASSESMENT Maternal serum AFP should be carried outAt 16-20wks gestation; normal levels are lower in diabetic patients when compared to non diabeticsSonogram at 18-20wksTo check for fetal anomalies.Fetal echocardiogram at 20-22wks.Serial sonogramsBecause of the risk of both macrosomia and IUGR
57. FETAL ASSESSMENT contd……Non-stress test, Biophysical profile and CST. Maternal monitoring of fetal activity (fetal kick chart).A useful means of fetal surveillance.Doppler USSUseful in detecting changes in vascular resistance that may precede fetal compromise.
58. Timing of delivery based on both maternal and fetal risk factors.Present recommendations.Delivery should be delayed till term or onset of spontaneous labour:As long as good metabolic control and adequate antenatal surveillance are maintainedInduction of labour is advised (38–40 weeks).When diabetes is well controlled and pregnancy is uncomplicated, usually at 38 weeks.
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60. DeliveryOptions: Spontaneous labour,Induction of Labour, Caesarean Section.Preterm labour:Tocolytic therapy with b-sympathomimetic drugs should be avoided (may worsen control and cause ketoacidosis) if absolutely necessary can be covered by appropriate insulin infusions!Corticosteroids to promote lung maturation:Caution should however be exercised.
61. Are We Still Awake??
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73. Post partumBreast feeding encouragedAdditional 500 kcal/dayContraceptionBarrierLow dose OCPMini-pillsIUCDSterilization-VasculopathyOGTT 6-12 weeks later, OGTT yearly60-70% recurrence of GDM
74. Gestational diabetesNo consensus for 4 decades!
75. Gestational diabetesShould all pregnant women be screened or only those with risk factors?Is it safe to screen all?Which screening test and which diagnostic test are the most reliable?Which cut-off values should we use?What are the risk for mothers and babies and can treatment improve outcome?What is the connection between gestational diabetes and type 2 DM?Is it physiological or pathological ?
76. Diabetes and PregnancyConclusionPreexisting DM in pregnancyGood glucose control is important for decreasing morbiditiesInsulin is still the gold standard of tx in pregnancyIncreasing evidence for clincial effectiveness for treatment with oral hypoglycemic agents
77. Diabetes and pregnancyconclusion(2) Gestational diabetes no consensusThe morbidities increases as glucose level approaching the diagnosis as DMPossible that treatment improves outcomesOverlap with preexisting DM, esp type2Long term implication for health of the mother and baby
78. THANK YOU FOR KEEPING AWAKE!
79. Post-TestManagement of women with diabetes mellitus in pregnancy:1) Joint care with midwives, obstetricians and diabetic physicians is not necessary.2) fetal wt of 4 kg and > should have c/s.3) Dietary advice is not important.4) Home blood glucose monitoring and clinic HbAIc is important.5) Fundoscopy at regular intervals is not necessary6) Patient should continue her anti-diabetic drugs.7) Scans for growth and liquor volume is not part of the management.8) All patients should be allowed to come in spontaneous labour.9) Increasing insulin dose is part of the management.10) Corticosteroids are naturally diabetogenic