Diabetes In Preg

Diabetes in Pregnancy – Dr. Queishi

Venous Plasma Glucose (m.mol/l)

Introduction o Endocrine disorder-genetic heterogeneity o Clinical syndrome characterized by deficiency or Insensitivity to Insulin o 5% of general population o 1% pregnancy o Types o Type I IDDM o Type II NIDDM

Fasting

2 hr post-prandial

Normal

<6.2

< 7.8

Impaired glucose tolerance

< 7.0

7.8-11.1

Diabetes

>7.8

>11.1

GTT using 100 gm - National Diabetes Data Group(1979) Timing of measurement

Plasma glucose (m.mol/l)

Fasting

5.3

Challenges of caring for diabetes in pregnancy o To enhance preconceptual glucose control o To reduce risk of congenital malformation o Adequately screen pregnant women

1

Classification Priscilla White’s Classification Class Onset

Fasting Plasma Glucose

2 hr postPrandial Glucose

<5.3 mmol/l

<6.6 m.mol/l Diet

A2

Gestational

>5.3(5.8) mmol/l

>6.6 m.mol/l Insulin

o o o o o o

Class Age of Onset

Duration (yrs)

Vascular Dx

Therapy

B

>20

<10

None

Insulin

C

10-19

10-19

None

Insulin

D

<10

>20

Benign Retionpathy

Insulin

F

Any

Any

Nephropathy

Insulin

R

Any

Any

Proliferative Retinopathy

Insulin

H

Any

Any

Heart

Insulin

Pregnancy is a Diabetogenic state due to the effects of cortisol and human placental lactogen Pregnancy

Poor glycogen reserves

Increased fat absorption Increased fat metabolism

These effects will clinicaltodiabetes and Loss of aggravate sugar in established Tendency may reveal impaired glucose tolerance. urine ketosis WHO-75 GMS GLUCOSE TOLERANCE TEST

2 hour

9.1

3 hour

8.0

Screening o 2 or more episodes of glycosuria on routine testing

Gestational

Relatively high blood sugar

10.5

Therapy

A1

Anti-insulin action of hormones

Hour

Diabetes in a first degree relative Maternal weight of > 85 kgs(90) Body mass index 30 Previous baby >4.5kg (4) Previous unexplained perinatal death, still birth or repeated abortions Previous congenital abnormality

Screening for diabetes in pregnancy o No single test perfect. o Blood estimation needed o Random blood test - if >5.8 more than 2 hrs after a meal or >6.2 within 2 hrs of a meal then do full GTT o GTT ideal - expensive o

Mini –GTT, 50gm bottle of Lucozade after 1 hr glucose level >7.8 m.mol

Effect of pregnancy on diabetes o Control is more difficult. o nephropathy unaffected but untreated retinopathy significantly worsens. o Can be treated by laser coagulation Effect of Diabetes on Pregnancy o Increased abortion o Increased perinatal loss-especially at term o Increased congenital abnormality o Macrosomia o Fetal lung maturity may be delayed o Increased pregnancy complications o Pre-eclampsia (x4) o Polyhydramnios o Infections-UTI, Candidal Vaginitis/vulvitis o Pre-term labour x2 (superimposed PE) o PPH

Clinical scenario o A known diabetic who is pregnant o Ideally should have been seen at the diabetic clinic/prepregnancy clinic. o Optimal control prior to conception o Glycosylated Haemoglobin HbA 1c reflects control over previous 10 weeks. o Usually control can be achieved by converting to insulin o Oral hypoglycemic’s changed to insulin o During pregnancy insulin preferred o High doses of oral hypoglycemic’s teratogenic Glycosylated Haemoglobin (Hb A 1c) o Glucose influences the slow glycosylation of Haemoglobin during the life cycle of the RBC so that high Hb A 1 level reflects a high average Plasma Glucose concentration o Diabetics averages 6% o 20% in newly diagnosed diabetics o Values above 10% viewed with concern o High level associated with congenital abnormalities –such as caudal regression syndrome o Others-situs inversus, spina bifida, duplex ureter Antenatal management o Physician and obstetrician management o Maintain blood sugar with a mean 24 hr profile of <5mmol/l o Blood sugar levels of < 8 m.mol/l o Serial blood sugars o F(3.3-5),pre-meal 3.3-5.8,p.p 1 hr 5.5-6.7, 2 to 6 am 3.36.7 o 3-4 doses of soluble insulin o Dietician input, family support, social worker o 30-35 kcal/kg ideal wt given as 3 meals + 3 snacks o 55% CHO,20% protein,25% fat, <10% saturated fat o Regular fetal monitoring-serial U/S –doppler blood flows BPS

<5.5

Fluids (125ml/h)

0

D5 lactated ringer

5.5-7.7

1.0

D5 lactated ringer

7.8-10

1.5

Normal saline

10.1-12.2

2.0

Normal saline

>12.2

2.5

Normal saline

…cont’d o Measure blood sugars levels 2 hourly o ARM/Syntocinon o C/section performed for obstetric indications o Insulin requirements reduce quickly and day after delivery pre-pregnancy dose may be started o Mother can breastfeed and this is encouraged to keep the blood sugars in control Neonatal complications o Congenital abnormalities (5-10%) - Cardiac, musculoskeletal, NTD o Macrosomia- Birth asphyxia, birth injury-brachial nerve palsy o RDS o Hypoglycemia o Polycythemia o Hyperbilirubinemia o Cardicac hypertrophy o Inheritance of diabetes (1-3% incidence) WHO eligibility criteria for Contraception Methods in Diabetes 1 Use method in any circumstances 2 Generally use the method 3 Use of method not usually recommended unless other more appropriate methods are not available or not acceptable 4 Method not to be used Lngiud

Cuiud impl nt

d mpa

pop

cic

Labour and delivery o Induced at term to avoid unexplained fetal death o Optimal blood sugars o Omit morning dose of insulin o Dextrose infusion 5 units Insulin per 500 mls o Or use infusion pump Low dose insulin during labour-using the Infusion pump dilution is 25 units of or regular insulin in 250 ml of n saline with 25 mls flushed through the i/v line

Insulin dosage (U/h)

coc

Macrosomia o Increased blood glucose levels –placental transfer of glucose o High blood sugar levels in the fetus o Acts as growth hormone o Increase in all organs o Results in macrosomic baby if blood sugars are not controlled.

Blood glucose

Hx of G D

1

1

1

1

1

1

1

Pre-existing

2

2

2

2

2

1

2

Nephro/ neuro/retin opathy

3/4

3/4

2

3

2

1

2

>20 years duration

3/4

3/4

2

3

2

1

2