Management Of Diabetes In Pregnancy
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Treatment of diabetes in preg Aim of management Principles of management Preconception care
Aim of management – to reduce perinatal and maternal morbidity and mortality. • Principle of management • • • • •
To achieve glycaemic control before conception Prevent obst complication by good antenatal care. Early detection and prompt Rx of medical problems Careful timing and appropriate mode of delivery Intensive neonatal care
• Preconception care • • •
Good control before pregnancy/treatment Prevent congenital anomalies – folate Counsel couples – about DM in preg, insulin therapy, hypoglycaemia, weight/ dietry advise.
•
Manage complications that can deteriorate – blood pressure control, retinopathy, nephropathy, ischaemic heart disease.
•
Counsel on contraception.
• Antenatal management •
Team management – obstetrican, physician, dietician etc
•
Main objective – mean 24hr glucose profile of 5mmol/l
•
Antenatal complications
• • • • • • •
Infections Miscarriages IUGR Macrosomia Hydramnios Premature labour Preeclampsia
Medical complications
•
macrosomia (25-40%) AC > 36cm; IUGR (PE); fundal height measurement; USS – 2-4weekly (DM = from 24weeks GA, while in IGT and GDM from 28weeks)
keto-acidosis, hypoglycaemia, visual deterioration, gaustattory vomiting, ischaemic heart disease.
• Obstetric management. • • •
Encourage early booking History – UTI, candidiasis Clinical examination – BP , polyhydramnios
•
•
Investigations – urinalysi, urinem/c/s, HVS for candidiasis, FBC, E,U&C, blood sugar profile twice weekly Early viability scan/dating
• Antenatal monitoring •
See more frequently – 2 weekly until 28 weeks of gestation, thereafter weekly until delivery
•
Morphology scan at 20weeks –
Neural tube defects, cardiac defects (transposition of great vessels most common major cardiac anomaly), renal
Fetal growth assessment –
•
Antenatal fetal monitoring
• • • •
High risk of fetal hypoxia and IUFD Fetal kick chart Auscultation Continuous fetal monitoring – ideally daily • Biophysical profile – weekly or twice weekly • Doppler uss. IGT – does not require intensive monitoring unless there are other problems Admit patient for stabilization of blood sugar if necessary.
Dietary management Aim – to control blood glucose level Caloric intake 30-35 cal/kg/day
•
Distribution
• Carbohydrate – 50% • Fat – 30% • Protein – 20% Avoid concentrated or refined sugars
Medical management • Stop all oral hypoglycaemic drugs – less reliable in action and cross placenta barrier.
• • •
Patient should have a glucometer for home glucose monitoring Good control – assess 2-3 times weekly Poor control – 6 times daily ( before meals and snacks)
•
Insulin therapy
• •
Soluble insulin Long acting PZI (lente)
Mixture of insulin – soluble and intermediate acting insulin Daily insulin requirement – 0.71.0units/kg body weight.
• Dose – 2/3 of total daily for • • • •
morning and 1/3 for evening Morning dose – 2/3 intermediate insulin and 1/3 soluble insulin Evening dose – ½ intermediate insulin and ½ soluble insulin Dose adjustment + 4units Aim – blood glucose of 4-6mmol/l
• Monitoring response to therapy • •
Clinical – hydramnios, macrosomia, hypoglycaemia Glycosylated haemoglobin monthly – well controlled = < 8.0% (Normal – 6.0%), poorly controlled = > 11.0%
• Side effects of insulin therapy • •
Lipoatrophy Hypoglycaemia
Intrapartum management •
Timing of delivery
• •
Optimal diabetic control – 39-40weeks Poorly controlled – early delivery, if before 34weeks use steroids (dexamethasone 12mg 12hourly x 2 doses)
•
Mode of delivery
•
Spontaneous vag delivery – primary goal Indications for c/s – fetal weight > 4.5kg, previous history of shoulder dystocia, previous c/s, other contraindication to vag delivery.
•
•
Management in labour
• • • •
Set up two IVF line Capillary blood glucose hourly Aim to maintain blood glucose level between 4-6mmol/l Only soluble insulin should be used
•
Insulin administration
•
Ideally use insulin pump
By preventing hyperglycemia during labour, ketoacidosis is prevented and the incidence of
• • • • •
Set up 10% dextrose water – 100ml/hr (10g/hr). Set up insulin pump at 1.0units/hour = 4-6 mmol/l Blood glucose > 6mmol/l – double insulin (2.0unit/hr) Blood glucose < 4mmol/l – ½ insulin dose (0.5unit/hr) ½ insulin infusion rate after delivery
•
Where insulin pump is not available
• •
Set up 5% dextrose water Administer insulin as follows on table below
•
Second regimen
• •
5% D/W S.C insulin 1unit hourly
•
Other management in labour
• • •
Monitor labour on partogram Adequate analgesia – hyperglycaemia Continuous fetal monitoring – fetal distress and perinatal mortality
Table for insulin therapy Capillary blood glucose (mmol/l)
Soluble insulin in 500ml of infusion
Time (hrs) for infusion (rate in drops per minute)
Supplementary s.c dose insulin given 6 hourly
< 2.0 2.0-3.9 4.0-7.9 8.0-11.9 12.0-15.9 > 16.0
Nil Nil 6 units 6 units 6 units Call physician
2 hrs (84dpm) 6 hrs (28dpm) 6 hrs (28) 6 hrs (28) 6 hrs (28) Call physician
0 0 0 6 units 10 units
•
Labour should be managed by experienced obstetrician. (duration should
•
Give insulin as stated above
be less than 12hrs)
•
Puerperal management
•
Availability of neonatal services and neonatologist to attend delivery. Poor progress in labour – do c/s
• • •
•
Induction of labour
•
Morning/breakfast insulin should not be given in the antenatal ward Admit to labour ward at 6.00am Capillary glucose hourly from 6.00am – starting with fasting blood glucose. Do ARM and set up oxytocin drip on one arm Set up 5% D/W on the second line Give S.C insulin 8units stat dose Commence insulin titration as in the table.
Readjust insulin dose Pre-gestational DM – ½ dose GDM – give only if blood glucose demands control Discontinue hourly glucose estimation Four point test – fasting, pre-breakfast, pre-lunch and 21.00hrs Encourage breast feeding Food supplementation after breastfeeding Do OGTT at 6weeks post partum and at 3 months after delivery Refer to the diabetic clinic if either of above result is positive Contraception – at 6 weeks
•
• • • • • •
•
Patient for caesarean delivery
• •
First on the operation list If blood glucose is > 6mmol/l – postspone surgery Do capillary blood glucose hourly from
•
• • • • • • •
Somogyi effect • Somogyi effect is a state of rebound reactive hyperglycemia, that occurs in diabetes on long acting insulin, following a period of relative unrecognised nocturnal hypoglycemia, which stimulates the release of hyperglycemic agents – adrenaline, noradrenaline, cortisol, glucagon and growth hormone (which produces the hyperglycemia the next morning). The patient suffers nightmares and night sweats. • Documenting hypoglycemia between 1.00-5.00am is diagnostic of this phenomenon • Treatment is to decrease the amount of long acting insulin the patient takes before super or at bedtime.
Dawn phenomenon
Aim of management – to reduce perinatal and maternal morbidity and mortality. • Principle of management • • • • •
To achieve glycaemic control before conception Prevent obst complication by good antenatal care. Early detection and prompt Rx of medical problems Careful timing and appropriate mode of delivery Intensive neonatal care
• Preconception care • • •
Good control before pregnancy/treatment Prevent congenital anomalies – folate Counsel couples – about DM in preg, insulin therapy, hypoglycaemia, weight/ dietry advise.
•
Manage complications that can deteriorate – blood pressure control, retinopathy, nephropathy, ischaemic heart disease.
•
Counsel on contraception.
• Antenatal management •
Team management – obstetrican, physician, dietician etc
•
Main objective – mean 24hr glucose profile of 5mmol/l
•
Antenatal complications
• • • • • • •
Infections Miscarriages IUGR Macrosomia Hydramnios Premature labour Preeclampsia
Medical complications
•
macrosomia (25-40%) AC > 36cm; IUGR (PE); fundal height measurement; USS – 2-4weekly (DM = from 24weeks GA, while in IGT and GDM from 28weeks)
keto-acidosis, hypoglycaemia, visual deterioration, gaustattory vomiting, ischaemic heart disease.
• Obstetric management. • • •
Encourage early booking History – UTI, candidiasis Clinical examination – BP , polyhydramnios
•
•
Investigations – urinalysi, urinem/c/s, HVS for candidiasis, FBC, E,U&C, blood sugar profile twice weekly Early viability scan/dating
• Antenatal monitoring •
See more frequently – 2 weekly until 28 weeks of gestation, thereafter weekly until delivery
•
Morphology scan at 20weeks –
Neural tube defects, cardiac defects (transposition of great vessels most common major cardiac anomaly), renal
Fetal growth assessment –
•
Antenatal fetal monitoring
• • • •
High risk of fetal hypoxia and IUFD Fetal kick chart Auscultation Continuous fetal monitoring – ideally daily • Biophysical profile – weekly or twice weekly • Doppler uss. IGT – does not require intensive monitoring unless there are other problems Admit patient for stabilization of blood sugar if necessary.
Dietary management Aim – to control blood glucose level Caloric intake 30-35 cal/kg/day
•
Distribution
• Carbohydrate – 50% • Fat – 30% • Protein – 20% Avoid concentrated or refined sugars
Medical management • Stop all oral hypoglycaemic drugs – less reliable in action and cross placenta barrier.
• • •
Patient should have a glucometer for home glucose monitoring Good control – assess 2-3 times weekly Poor control – 6 times daily ( before meals and snacks)
•
Insulin therapy
• •
Soluble insulin Long acting PZI (lente)
Mixture of insulin – soluble and intermediate acting insulin Daily insulin requirement – 0.71.0units/kg body weight.
• Dose – 2/3 of total daily for • • • •
morning and 1/3 for evening Morning dose – 2/3 intermediate insulin and 1/3 soluble insulin Evening dose – ½ intermediate insulin and ½ soluble insulin Dose adjustment + 4units Aim – blood glucose of 4-6mmol/l
• Monitoring response to therapy • •
Clinical – hydramnios, macrosomia, hypoglycaemia Glycosylated haemoglobin monthly – well controlled = < 8.0% (Normal – 6.0%), poorly controlled = > 11.0%
• Side effects of insulin therapy • •
Lipoatrophy Hypoglycaemia
Intrapartum management •
Timing of delivery
• •
Optimal diabetic control – 39-40weeks Poorly controlled – early delivery, if before 34weeks use steroids (dexamethasone 12mg 12hourly x 2 doses)
•
Mode of delivery
•
Spontaneous vag delivery – primary goal Indications for c/s – fetal weight > 4.5kg, previous history of shoulder dystocia, previous c/s, other contraindication to vag delivery.
•
•
Management in labour
• • • •
Set up two IVF line Capillary blood glucose hourly Aim to maintain blood glucose level between 4-6mmol/l Only soluble insulin should be used
•
Insulin administration
•
Ideally use insulin pump
By preventing hyperglycemia during labour, ketoacidosis is prevented and the incidence of
• • • • •
Set up 10% dextrose water – 100ml/hr (10g/hr). Set up insulin pump at 1.0units/hour = 4-6 mmol/l Blood glucose > 6mmol/l – double insulin (2.0unit/hr) Blood glucose < 4mmol/l – ½ insulin dose (0.5unit/hr) ½ insulin infusion rate after delivery
•
Where insulin pump is not available
• •
Set up 5% dextrose water Administer insulin as follows on table below
•
Second regimen
• •
5% D/W S.C insulin 1unit hourly
•
Other management in labour
• • •
Monitor labour on partogram Adequate analgesia – hyperglycaemia Continuous fetal monitoring – fetal distress and perinatal mortality
Table for insulin therapy Capillary blood glucose (mmol/l)
Soluble insulin in 500ml of infusion
Time (hrs) for infusion (rate in drops per minute)
Supplementary s.c dose insulin given 6 hourly
< 2.0 2.0-3.9 4.0-7.9 8.0-11.9 12.0-15.9 > 16.0
Nil Nil 6 units 6 units 6 units Call physician
2 hrs (84dpm) 6 hrs (28dpm) 6 hrs (28) 6 hrs (28) 6 hrs (28) Call physician
0 0 0 6 units 10 units
•
Labour should be managed by experienced obstetrician. (duration should
•
Give insulin as stated above
be less than 12hrs)
•
Puerperal management
•
Availability of neonatal services and neonatologist to attend delivery. Poor progress in labour – do c/s
• • •
•
Induction of labour
•
Morning/breakfast insulin should not be given in the antenatal ward Admit to labour ward at 6.00am Capillary glucose hourly from 6.00am – starting with fasting blood glucose. Do ARM and set up oxytocin drip on one arm Set up 5% D/W on the second line Give S.C insulin 8units stat dose Commence insulin titration as in the table.
Readjust insulin dose Pre-gestational DM – ½ dose GDM – give only if blood glucose demands control Discontinue hourly glucose estimation Four point test – fasting, pre-breakfast, pre-lunch and 21.00hrs Encourage breast feeding Food supplementation after breastfeeding Do OGTT at 6weeks post partum and at 3 months after delivery Refer to the diabetic clinic if either of above result is positive Contraception – at 6 weeks
•
• • • • • •
•
Patient for caesarean delivery
• •
First on the operation list If blood glucose is > 6mmol/l – postspone surgery Do capillary blood glucose hourly from
•
• • • • • • •
Somogyi effect • Somogyi effect is a state of rebound reactive hyperglycemia, that occurs in diabetes on long acting insulin, following a period of relative unrecognised nocturnal hypoglycemia, which stimulates the release of hyperglycemic agents – adrenaline, noradrenaline, cortisol, glucagon and growth hormone (which produces the hyperglycemia the next morning). The patient suffers nightmares and night sweats. • Documenting hypoglycemia between 1.00-5.00am is diagnostic of this phenomenon • Treatment is to decrease the amount of long acting insulin the patient takes before super or at bedtime.
Dawn phenomenon
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