Diabetes Melitus In Pregnancy

DIABETES MELITUS IN PREGNANCY.

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DR S.A. OKOGBENIN CONSULTANT : IRRUA SPECIALIST TEACHING HOSP. LECTURER :AMBROSE ALLI UNIVERSITY

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Introduction • Definition: metabolic disorder – Abnormality in carbohydrate metabolism – Relative or absolute insulin lack.

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20th century witness remarkable outcome. Before this life expectancy was short Survivors had infertility. Those who got pregnant had disastrous outcome. MM=30-60%, PM=60%. 3

Introduction cont. • • • •

In 1921 banting and best discovered insulin. Fertility was restored MM improved remarkably. PM remained high – Fetal macrosoma, and IUFD were the causes. – Early delivery & C/S were the antidote. – Late IUFD was still a problem.

• 1930 White classification. 4

Introduction cont. • 1930 White classification, fetal risk was proportional to severity of mat diabetes,this permitted individualized timing of delivery and perinatal survival =85%. • TODAY, refinement in management has reduced PM to near that of normal pregnancy, except for cong. abnormality. 5

Classifications • Type 1: Insulin dependent – Immune mediated in genetically susceptible persons. – Predisposition is permissive rather than causal. – Abnormality in Chromosome 6 – Monozygotic twins =50% – Low vertical transmission. 6

Classifications • Type 2, non insulin dependent. – FAMILIAL – Monozygotic twins=100% – Older, obese and less severe.

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Classification in pregnancy • Overt D.M Chronic ,10% Type 1 or type2

.Gestational 90%

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Classification in pregnancy • Gest. DM. 90%. • Overt DM, chronic,10% .Type 1or • Carbohydrate intolerance of varying severity with type 2

onset or first recognition in preg. • Change in glucose metabolism • Type 2 unmasked in preg. • In 20yrs 50% will develop diabetes 9

White classification

Class A1 A2 B C D F R H

Onset GEST GEST >20Yr 10-19 <10 any any any

FBS <105 >105 <10yr 10-19 >20 any any any

2HPP THER >120 >120 B. Reti Neph P.reti heart 10

Pregnancy&cho metabolism • • • • •

Reduced insulin sensitivity. Increased fasting insulin Increased diabetogenic hormones Increased insulinase In diabetics, insulin requirement increases in preg. 11

Pregnancy effects on DM • More difficult to control • Proliferative retinopathy may worsen but the course of background retinopathy and nephropathy does not change,instead it is nephropathy assoc with HT and proteinuria that worsen pregnancy outcome. • No other long term effect of preg on DM. 12

Effect of DM on Pregnancy • • • • • • •

Spont.abortion Cong. Abnormality Fetal death Macrosoma Perinatal mortality Preterm delivery polyhydramnios 13

Effect of DM on preg. • Infections • PIH.

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DIAGNOSIS • SYMPTOMS & SIGNS • SCREENING – No consensus – FBS,2HPP. RBS – 50% glucose oral challenge, 1hr glucose 140mg/dl. 130mg/dl – Universal or selective. – Timing of screening. 15

Diagnosis cont. • 75g glucose OGTT (WHO) • 100g OGTT (ACOG) 3hr monitoring

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Management • • • • • • • • •

Prepregnancy clinic Combined management Early booking and dating More frequent visits Admit for stabilization Dietary contol Mild exercise Use insulin not oral hypoglyceamics Various insulin regime(Post prandial survillance 17

Management cont • • • • • • • • •

Alpha fetoprotein USS at 20 weeks Value of antenatal testing. Timing& mode of delivery Insulin management in labour. Avoid prolong labour 1-2hourly glucose measurement. Intraprtum monitoring. SHOULDER DYSTOCIA 18

Post partum • • • • •

Titrate insulin OGTT 6-12 WEEKS LATER OGTT 3YEARLY. 60-70% reccurrence.of GDM CONTRACEPTION

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NEONATE • • • • • • • • •

MACROSOMIA RDS Hypoglycaemia Hypocalaemia Hyperbilirubin Polycytaemia Perinatal mortality=2-4%( cong abn,unexp IUFD) cardiac hypertrophy. 1-3% inheritance. 20