Diabetes  &  Pregnancy
Epidemiology  <ul><li>Most common medical complication of Pregnancy </li></ul><ul><li>affects 2-3% of pregnancies </li></u...
CHO Metabolism <ul><li>Effects of Pregnancy </li></ul><ul><ul><li>mild fasting hypoglycemia; postprandial hyperglycemia </...
Glucose Metabolism <ul><li>Normal pregnancy : Diabetogenic state </li></ul><ul><ul><li>increase in pc BG </li></ul></ul><u...
Type I Diabetes <ul><li>Abrupt onset </li></ul><ul><li>usually young age </li></ul><ul><li>occasionally occurs in 30’s or ...
Type 2 DM <ul><li>Abnormalities of insulin sensitive tissues </li></ul><ul><ul><li>decreased skeletal muscle and hepatic s...
Diagnosis of Diabetes Non Pregnant <ul><li>Fasting plasma BG >7.0mmol/l </li></ul><ul><li>Casual plasma BG >11.1mmol/l Imp...
Classification and Risk Assessment <ul><li>Class DM onset Duration  Vascular Dis   Insulin Need </li></ul><ul><li>Gestatio...
Gestational Diabetes <ul><li>Definition </li></ul><ul><ul><ul><li>CHO intolerance of variable severity first diagnosed in ...
Gestational Diabetes <ul><li>Screening </li></ul><ul><ul><li>PC 50/Trutol </li></ul></ul><ul><ul><li>1 hr after 50g load o...
Gestational Diabetes <ul><li>Screening </li></ul><ul><ul><li>24-28 weeks routine </li></ul></ul><ul><ul><li>no need to fas...
Gestational Diabetes <ul><li>Diagnosis  OGTT </li></ul><ul><li>2 or more values greater than or equal to above cutoffs  di...
Gestational Diabetes <ul><li>Maternal Risks </li></ul><ul><li>birth trauma </li></ul><ul><li>operative delivery </li></ul>...
Gestational Diabetes
Gestational Diabetes <ul><li>Fetal Risks </li></ul><ul><li>no increase  in congenital anomalies </li></ul><ul><li>increase...
Gestational Diabetes <ul><li>Management </li></ul><ul><ul><li>goal is to optimize BG levels to minimize risk of adverse pe...
Gestational Diabetes <ul><li>Management : Diet </li></ul><ul><li>patients without fasting hyperglycemia </li></ul><ul><li>...
Gestational Diabetes <ul><li>Diet : general principles </li></ul><ul><li>55% CHO  25% Protein 20% fat </li></ul><ul><li>No...
Gestational Diabetes <ul><li>If persistent hyperglycemia after one week of diet control proceed to insulin </li></ul><ul><...
Gestational Diabetes <ul><li>If fasting hyperglycemia start with NPH  hs  </li></ul><ul><li>initial dose 6-8 U  </li></ul>...
Gestational Diabetes <ul><li>Intrapartum management </li></ul><ul><li>check bg hourly  </li></ul><ul><li>maintain BG 4-6mm...
Gestational Diabetes <ul><li>Postpartum </li></ul><ul><li>often will not require insulin </li></ul><ul><li>if fasting hype...
Gestational Diabetes <ul><li>Neonatal Risks </li></ul><ul><li>hypoglycemia  50% in macrosomic     5-15% if N BG control in...
Preexisting Diabetes <ul><li>Preconception Counselling </li></ul><ul><li>risk of NTD ~1-2% </li></ul><ul><li>Folic Acid 1-...
Preexisting Diabetes <ul><li>Normoglycemia prior to conception  </li></ul><ul><li>ideally HBA1C 6% or less </li></ul><ul><...
<ul><li>Assess for end organ disease </li></ul><ul><ul><li>assess for nephropathy - inc risk of PIH </li></ul></ul><ul><ul...
Preexisting Diabetes <ul><li>Maternal Risks </li></ul><ul><ul><li>PIH /PET </li></ul></ul><ul><ul><li>polyhydramnios </li>...
Prexisting Diabetes
Preexisting Diabetes <ul><li>Fetal Risks </li></ul><ul><li>congenital anomalies 3X inc risk </li></ul><ul><li>unexplained ...
Preexisting Diabetes <ul><li>Neonatal Risks  </li></ul><ul><li>hypoglycemia </li></ul><ul><li>hypocalcemia </li></ul><ul><...
Preexisting Diabetes <ul><li>Congenital anomalies </li></ul><ul><li>3x the general population risk  </li></ul><ul><li>appr...
<ul><li>CVS </li></ul><ul><ul><li>ASD/VSD,coarctation,transposition, </li></ul></ul><ul><ul><li>cardiomegaly </li></ul></u...
Preexisting Diabetes <ul><li>Maternal Surveillance </li></ul><ul><li>Blood pressure  </li></ul><ul><li>renal function * </...
Preexisting Diabetes <ul><li>Fetal Surveillance </li></ul><ul><li>U/S for dating/viability ~ 8 weeks </li></ul><ul><li>Fet...
<ul><li>Multidose Insulin </li></ul><ul><li>breakfast 25% H  </li></ul><ul><li>lunch  15% H </li></ul><ul><li>supper 25% H...
Insulin Therapy <ul><li>onset (h)  peak  duration </li></ul><ul><li>insulin analogs    .25 0.5-1.5 6-8 </li></ul><ul><li>r...
Insulin Therapy <ul><li>Insulin Pump </li></ul><ul><ul><li>Allows insulin release close to physiologic  </li></ul></ul><ul...
Peripartum Management <ul><li>Withhold subcutaneous insulin from onset of labour or induction </li></ul><ul><li>IV D10 @50...
Peripartum Management <ul><li>insulin rate usually based on BG and pre-delivery insulin requirement </li></ul><ul><li>eg. ...
Peripartum Management <ul><li>Following delivery </li></ul><ul><ul><li>stop insulin infusion  </li></ul></ul><ul><ul><li>b...
Oral Hypoglycemic agents  <ul><li>Traditionally not recommended in pregnancy </li></ul><ul><li>Recent RCT of oral glyburid...
Oral Hypoglycemic agents  <ul><li>Glyburide  Insulin </li></ul><ul><li>Achieved N BG 82% 88% </li></ul><ul><li>LGA infants...
Fetal Surveillance  <ul><li>Goals </li></ul><ul><ul><li>Minimize/eliminate the risk of fetal death </li></ul></ul><ul><ul>...
Fetal Surveillance  <ul><li>Gestational Diabetic Diet controlled </li></ul><ul><ul><li>Can start fetal surveillance at ter...
Timing of Delivery  <ul><li>GDM  Diet controlled </li></ul><ul><ul><li>Same as non diabetic  </li></ul></ul><ul><ul><li>Of...
Mode of Delivery <ul><li>Macrosomic infants of diabetic mothers have higher rates of shoulder dystocia than non diabetic m...
Diabetic Ketoacidosis <ul><li>5-10%  of pregnant Type 1 pts </li></ul><ul><li>Risk factors </li></ul><ul><ul><li>New onset...
Diabetic Ketoacidosis <ul><li>Management </li></ul><ul><ul><li>ABC’s and ABG </li></ul></ul><ul><ul><ul><li>Assess BG, ket...
Diabetic Ketoacidosis <ul><ul><li>Rehydration isotonic NaCl </li></ul></ul><ul><ul><ul><li>1L in 1 st  hour  </li></ul></u...
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Diabetes+and+Pregnancy

  1. 1. Diabetes & Pregnancy
  2. 2. Epidemiology <ul><li>Most common medical complication of Pregnancy </li></ul><ul><li>affects 2-3% of pregnancies </li></ul><ul><ul><li>Gestational DM 90% </li></ul></ul><ul><ul><li>Preexisting DM 10% </li></ul></ul>
  3. 3. CHO Metabolism <ul><li>Effects of Pregnancy </li></ul><ul><ul><li>mild fasting hypoglycemia; postprandial hyperglycemia </li></ul></ul><ul><ul><li>due to inc plasma volume in early gestation and inc fetal glucose utilization as pregnancy advances </li></ul></ul><ul><ul><li>progressive increase in tissue resistance to insulin </li></ul></ul><ul><ul><li>increase insulin secretion to maintain euglycemia </li></ul></ul><ul><ul><li>suppressed glucagon response </li></ul></ul><ul><ul><li>inc prolactin, cortisol </li></ul></ul><ul><ul><li>HPL has GH like effects </li></ul></ul>
  4. 4. Glucose Metabolism <ul><li>Normal pregnancy : Diabetogenic state </li></ul><ul><ul><li>increase in pc BG </li></ul></ul><ul><ul><li>insulin resistance </li></ul></ul><ul><ul><li>Early Pregnancy </li></ul></ul><ul><ul><ul><li>Anabolic state </li></ul></ul></ul><ul><ul><ul><ul><li>increase in maternal fat stores </li></ul></ul></ul></ul><ul><ul><ul><ul><li>decreased FFA concentration </li></ul></ul></ul></ul><ul><ul><ul><ul><li>decrease in insulin requirements </li></ul></ul></ul></ul>
  5. 5. Type I Diabetes <ul><li>Abrupt onset </li></ul><ul><li>usually young age </li></ul><ul><li>occasionally occurs in 30’s or 40’s </li></ul><ul><li>lifelong requiremnent for insulin replacement </li></ul><ul><li>may have genetic predisposition for islet cell ab </li></ul><ul><li>concordance in MZ twins for dev of DM is 33% </li></ul><ul><li>suggests other factors also imp (environmental) </li></ul>
  6. 6. Type 2 DM <ul><li>Abnormalities of insulin sensitive tissues </li></ul><ul><ul><li>decreased skeletal muscle and hepatic sensitivity to insulin </li></ul></ul><ul><ul><li>abnormal B cell response </li></ul></ul><ul><ul><ul><li>inadequate response for a given degree of glycemia </li></ul></ul></ul><ul><ul><ul><li>usually older </li></ul></ul></ul><ul><ul><ul><li>increased BMI </li></ul></ul></ul><ul><ul><ul><li>insidious onset </li></ul></ul></ul><ul><ul><ul><li>strong genetic component </li></ul></ul></ul><ul><ul><ul><ul><li>MZ twin data lifetime risk 58-100% </li></ul></ul></ul></ul>
  7. 7. Diagnosis of Diabetes Non Pregnant <ul><li>Fasting plasma BG >7.0mmol/l </li></ul><ul><li>Casual plasma BG >11.1mmol/l Impaired Fasting Glucose </li></ul><ul><li>FPG 6.1-7.0 mmol/l Impaired Glucose Tolerance </li></ul><ul><li>normal FPG </li></ul><ul><li>2 h 75gOGTT test with BG 7.8-11.1 mmol/l </li></ul><ul><li>Canadian Diabetes Association 1998 </li></ul>
  8. 8. Classification and Risk Assessment <ul><li>Class DM onset Duration Vascular Dis Insulin Need </li></ul><ul><li>Gestational Dm </li></ul><ul><li>A1 Any Any - - </li></ul><ul><li>A2 Any Any - + </li></ul><ul><li>Pregestational DM </li></ul><ul><li>B >20 <10 - + </li></ul><ul><li>C 10-19 10-19 - + </li></ul><ul><li>D <10 >20 + + </li></ul><ul><li>F Any Any + + </li></ul><ul><li>R Any Any + + </li></ul><ul><li>T Any Any + + </li></ul><ul><li>H Any Any + + </li></ul>
  9. 9. Gestational Diabetes <ul><li>Definition </li></ul><ul><ul><ul><li>CHO intolerance of variable severity first diagnosed in Pregnancy </li></ul></ul></ul><ul><li>Prevalence 2-4% </li></ul><ul><li>Risk Factors </li></ul><ul><ul><ul><li>maternal age >25 </li></ul></ul></ul><ul><ul><ul><li>Family history </li></ul></ul></ul><ul><ul><ul><li>glucosuria </li></ul></ul></ul><ul><ul><ul><li>prior macrosomia </li></ul></ul></ul><ul><ul><ul><li>previous unexplained stillbirth </li></ul></ul></ul><ul><ul><ul><li>ethnic group: Hispanic, Black, First Nations </li></ul></ul></ul>
  10. 10. Gestational Diabetes <ul><li>Screening </li></ul><ul><ul><li>PC 50/Trutol </li></ul></ul><ul><ul><li>1 hr after 50g load of glucose </li></ul></ul><ul><ul><li>>7.8mmol/l abnormal* </li></ul></ul><ul><ul><li>15% of patients screen positive * value > 10.3 diagnostic of GDM (no OGTT needed) </li></ul></ul>
  11. 11. Gestational Diabetes <ul><li>Screening </li></ul><ul><ul><li>24-28 weeks routine </li></ul></ul><ul><ul><li>no need to fast </li></ul></ul><ul><ul><li>screen at 1st prenatal visit if hx of previous GDM </li></ul></ul><ul><ul><li>screen earlier (12-24 weeks ) if risk factors </li></ul></ul>
  12. 12. Gestational Diabetes <ul><li>Diagnosis OGTT </li></ul><ul><li>2 or more values greater than or equal to above cutoffs diagnostic of GDM </li></ul><ul><li>single abnormal value indicates CHO intolerance </li></ul>Fasting 5.3 1h 10.6 2h 9.2 3h 8.1 Fasting 5.3 1h 10.6 2h 8.9 3 H 2H
  13. 13. Gestational Diabetes <ul><li>Maternal Risks </li></ul><ul><li>birth trauma </li></ul><ul><li>operative delivery </li></ul><ul><li>50% lifetime risk in developing Type II DM </li></ul><ul><li>recurrence risk of GDM is 30-50% </li></ul>
  14. 14. Gestational Diabetes
  15. 15. Gestational Diabetes <ul><li>Fetal Risks </li></ul><ul><li>no increase in congenital anomalies </li></ul><ul><li>increased risk of stillbirth if fasting+ pc hyperglycemia </li></ul><ul><li>macrosomia </li></ul><ul><li>birth trauma-shoulder dystocia and related complications </li></ul>
  16. 16. Gestational Diabetes <ul><li>Management </li></ul><ul><ul><li>goal is to optimize BG levels to minimize risk of adverse perinatal outcomes </li></ul></ul><ul><ul><li>diet </li></ul></ul><ul><ul><li>exercise </li></ul></ul><ul><ul><li>insulin therapy </li></ul></ul>
  17. 17. Gestational Diabetes <ul><li>Management : Diet </li></ul><ul><li>patients without fasting hyperglycemia </li></ul><ul><li>average 8000-9000 kj/day. </li></ul><ul><li>BMI>27 -- 25 kcal/kg/ideal body weight/d </li></ul><ul><li>BMI 20-26 -- 30 “ </li></ul><ul><li>BMI<20 -- 38 “ </li></ul>
  18. 18. Gestational Diabetes <ul><li>Diet : general principles </li></ul><ul><li>55% CHO 25% Protein 20% fat </li></ul><ul><li>Normal weight gain 10-12 kg </li></ul><ul><li>avoid ketosis </li></ul><ul><li>liberal exercise program to optimize BG control </li></ul>
  19. 19. Gestational Diabetes <ul><li>If persistent hyperglycemia after one week of diet control proceed to insulin </li></ul><ul><li>6-14 weeks 0.5u/kg/day </li></ul><ul><li>14-26 weeks 0.7u/kg/day </li></ul><ul><li>26-36 weeks 0.9u/kg/day </li></ul><ul><li>36-40weeks 1 u /kg/day </li></ul>
  20. 20. Gestational Diabetes <ul><li>If fasting hyperglycemia start with NPH hs </li></ul><ul><li>initial dose 6-8 U </li></ul><ul><li>if only pc hyperglycemia use humalog 2-4u ac the specific meal </li></ul><ul><li>adjust 2u/time 1 formula /time </li></ul><ul><li>BG target ac <5.3 2 h pc <6.7 </li></ul>
  21. 21. Gestational Diabetes <ul><li>Intrapartum management </li></ul><ul><li>check bg hourly </li></ul><ul><li>maintain BG 4-6mmol/L </li></ul>
  22. 22. Gestational Diabetes <ul><li>Postpartum </li></ul><ul><li>often will not require insulin </li></ul><ul><li>if fasting hyperglycemia - more likely to develop persistent Diabetes </li></ul><ul><li>6 weeks post partum 75g OGTT </li></ul><ul><li>yearly fasting BG </li></ul><ul><li>emphasize importance of maintaining N weight, exercise </li></ul>
  23. 23. Gestational Diabetes <ul><li>Neonatal Risks </li></ul><ul><li>hypoglycemia 50% in macrosomic 5-15% if N BG control in Pgy </li></ul><ul><li>Hyperbilirubinemia </li></ul><ul><li>polycythemia </li></ul><ul><li>hypocalcemia </li></ul><ul><li>hypomagnesiumia </li></ul>
  24. 24. Preexisting Diabetes <ul><li>Preconception Counselling </li></ul><ul><li>risk of NTD ~1-2% </li></ul><ul><li>Folic Acid 1-4 mg /day </li></ul><ul><li>BG 3.5-5.3 prior to meals </li></ul><ul><li>switch to MDI regimen (insulin ac meals and HS) </li></ul><ul><li>keep track of cycles </li></ul>
  25. 25. Preexisting Diabetes <ul><li>Normoglycemia prior to conception </li></ul><ul><li>ideally HBA1C 6% or less </li></ul><ul><li>Team approach </li></ul><ul><li>glucose monitoring qid </li></ul><ul><li>ACE contraindicated : should be D/C at conception or use Diltiazem instead </li></ul><ul><li>baseline HBA1C, 24h urine for protein Cr Cl , opthalmology review </li></ul><ul><li>switch from OHA to insulin </li></ul>
  26. 26. <ul><li>Assess for end organ disease </li></ul><ul><ul><li>assess for nephropathy - inc risk of PIH </li></ul></ul><ul><ul><li>Assess and treat retinopathy - may progress </li></ul></ul><ul><ul><li>assess for neuropathy </li></ul></ul><ul><ul><ul><li>generally remains stable during pregnancy </li></ul></ul></ul><ul><ul><li>assess and treat vasculopathy </li></ul></ul><ul><ul><ul><li>CAD is a relative C/I for pregnancy </li></ul></ul></ul>Preexisting Diabetes
  27. 27. Preexisting Diabetes <ul><li>Maternal Risks </li></ul><ul><ul><li>PIH /PET </li></ul></ul><ul><ul><li>polyhydramnios </li></ul></ul><ul><ul><li>preterm labour </li></ul></ul><ul><ul><li>operative delivery ~50% </li></ul></ul><ul><ul><li>birth trauma </li></ul></ul><ul><ul><li>infection </li></ul></ul><ul><ul><li>increase in insulin requirements </li></ul></ul><ul><ul><li>DKA </li></ul></ul>
  28. 28. Prexisting Diabetes
  29. 29. Preexisting Diabetes <ul><li>Fetal Risks </li></ul><ul><li>congenital anomalies 3X inc risk </li></ul><ul><li>unexplained stillbirth </li></ul><ul><li>shoulder dystocia </li></ul><ul><li>macrosomia </li></ul><ul><li>IUGR </li></ul>
  30. 30. Preexisting Diabetes <ul><li>Neonatal Risks </li></ul><ul><li>hypoglycemia </li></ul><ul><li>hypocalcemia </li></ul><ul><li>hyperbilirubinemia/polycythemia </li></ul><ul><li>idiopathic RDS </li></ul><ul><li>delayed lung maturity </li></ul><ul><li>prematurity </li></ul><ul><li>predisposition to diabetes </li></ul>
  31. 31. Preexisting Diabetes <ul><li>Congenital anomalies </li></ul><ul><li>3x the general population risk </li></ul><ul><li>approaches the gen pop risk (2-3%) if optimal control in periconception period </li></ul><ul><li>related to glycemic control during embryogenesis </li></ul>
  32. 32. <ul><li>CVS </li></ul><ul><ul><li>ASD/VSD,coarctation,transposition, </li></ul></ul><ul><ul><li>cardiomegaly </li></ul></ul><ul><li>CNS </li></ul><ul><ul><li>anencephaly, NTD, microcephaly </li></ul></ul><ul><li>GI </li></ul><ul><ul><li>duodenal atresia, anorectal atresia, situs inversus </li></ul></ul><ul><li>GU </li></ul><ul><ul><li>renal agenesis </li></ul></ul><ul><ul><li>Polycystic kidneys </li></ul></ul><ul><li>MSK </li></ul><ul><ul><li>caudal regression </li></ul></ul><ul><ul><li>siren </li></ul></ul>Congenital anomalies
  33. 33. Preexisting Diabetes <ul><li>Maternal Surveillance </li></ul><ul><li>Blood pressure </li></ul><ul><li>renal function * </li></ul><ul><li>urine culture ** </li></ul><ul><li>thyroid function </li></ul><ul><li>BG control HB A1C* </li></ul><ul><li> * q trimester </li></ul><ul><li> ** monthly </li></ul>
  34. 34. Preexisting Diabetes <ul><li>Fetal Surveillance </li></ul><ul><li>U/S for dating/viability ~ 8 weeks </li></ul><ul><li>Fetal anomaly detection </li></ul><ul><ul><li>nuchal translucency 11-14w </li></ul></ul><ul><ul><li>maternal serum screen </li></ul></ul><ul><ul><li>anatomy survey 18-20 w </li></ul></ul><ul><ul><li>Fetal echo 22 w </li></ul></ul>
  35. 35. <ul><li>Multidose Insulin </li></ul><ul><li>breakfast 25% H </li></ul><ul><li>lunch 15% H </li></ul><ul><li>supper 25% H </li></ul><ul><li>hs 35% NPH </li></ul><ul><li>indicates insulin as a % of total daily dose </li></ul>Gabbe Obstet Gynecol 2003
  36. 36. Insulin Therapy <ul><li>onset (h) peak duration </li></ul><ul><li>insulin analogs .25 0.5-1.5 6-8 </li></ul><ul><li>rapid acting 0.5 2-4 8-12 </li></ul><ul><li>intermediate 1-1.5 4-8 12-18 </li></ul>
  37. 37. Insulin Therapy <ul><li>Insulin Pump </li></ul><ul><ul><li>Allows insulin release close to physiologic </li></ul></ul><ul><ul><li>Use short acting insulin </li></ul></ul><ul><ul><li>50-60% of total dose is basal rate </li></ul></ul><ul><ul><li>40-50% given as boluses </li></ul></ul><ul><ul><li>Potential complications </li></ul></ul><ul><ul><ul><li>Pump failure </li></ul></ul></ul><ul><ul><ul><li>Infection </li></ul></ul></ul><ul><ul><ul><li>Increased risk of DKA if above happens </li></ul></ul></ul>
  38. 38. Peripartum Management <ul><li>Withhold subcutaneous insulin from onset of labour or induction </li></ul><ul><li>IV D10 @50cc/h </li></ul><ul><li>IV short acting insulin in NS usually starting at 0.5-1u/h* *10cc insulin in 100 cc NS(1U=10cc) </li></ul>
  39. 39. Peripartum Management <ul><li>insulin rate usually based on BG and pre-delivery insulin requirement </li></ul><ul><li>eg. For each 75-100 total units /24h of pre-delivery insulin, 1 unit per hour needed </li></ul><ul><li>measure capillary BG hourly VPG q2-3h </li></ul><ul><li>target: 4-6mmol/L </li></ul>
  40. 40. Peripartum Management <ul><li>Following delivery </li></ul><ul><ul><li>stop insulin infusion </li></ul></ul><ul><ul><li>begin sub Q insulin </li></ul></ul><ul><ul><li>resume previous MDI schedule at 1/2 -2/3 the pre pregnancy dose </li></ul></ul><ul><ul><li>maintain IV D5W @50cc/h until oral feeds tolerated </li></ul></ul>
  41. 41. Oral Hypoglycemic agents <ul><li>Traditionally not recommended in pregnancy </li></ul><ul><li>Recent RCT of oral glyburide vs insulin for GDM </li></ul><ul><li>440 patients </li></ul><ul><li>BG measured 7x daily </li></ul><ul><li>Treatment started after 11 weeks gestation </li></ul>Langer NEJM 2000
  42. 42. Oral Hypoglycemic agents <ul><li>Glyburide Insulin </li></ul><ul><li>Achieved N BG 82% 88% </li></ul><ul><li>LGA infants 12% 13% </li></ul><ul><li>Macrosomia 7 4 </li></ul><ul><li>C Section 23 24 </li></ul><ul><li>Hypoglycemia 9 6 </li></ul><ul><li>Preeclampsia 6 6 </li></ul><ul><li>Anomalies 2 2 </li></ul>Langer NEJM 2000
  43. 43. Fetal Surveillance <ul><li>Goals </li></ul><ul><ul><li>Minimize/eliminate the risk of fetal death </li></ul></ul><ul><ul><li>Early detection of fetal compromise </li></ul></ul><ul><ul><li>Prevent unnecessary premature delivery </li></ul></ul><ul><li>Main benefit is the NPV of these tests </li></ul><ul><ul><li>Provides reassurance that fetus with a N test unlikely to die in utero </li></ul></ul><ul><ul><li>Allow prolongation of pregnancy – fetal maturation </li></ul></ul>
  44. 44. Fetal Surveillance <ul><li>Gestational Diabetic Diet controlled </li></ul><ul><ul><li>Can start fetal surveillance at term (40 weeks) </li></ul></ul><ul><li>GDM on insulin/Type II DM/ Type I DM </li></ul><ul><ul><li>Start weekly BPP from 32 weeks </li></ul></ul><ul><ul><li>Consider earlier testing if </li></ul></ul><ul><ul><ul><li>suboptimal control </li></ul></ul></ul><ul><ul><ul><li>Hypertension </li></ul></ul></ul><ul><ul><ul><li>vasculopathy </li></ul></ul></ul>
  45. 45. Timing of Delivery <ul><li>GDM Diet controlled </li></ul><ul><ul><li>Same as non diabetic </li></ul></ul><ul><ul><li>Offer induction at 41 weeks if undelivered </li></ul></ul><ul><ul><li>GDM on Insulin/Type II/Type I </li></ul></ul><ul><ul><li>If suboptimal control deliver following confirmation of lung maturity if <39 weeks </li></ul></ul><ul><ul><li>Otherwise deliver by 40 weeks </li></ul></ul><ul><ul><li>Generally do not allow to go postterm </li></ul></ul>
  46. 46. Mode of Delivery <ul><li>Macrosomic infants of diabetic mothers have higher rates of shoulder dystocia than non diabetic mothers </li></ul><ul><li>Ultrasound estimates of fetal weight become significantly inaccurate after 4000g </li></ul><ul><li>Reasonable to recommend C/S delivery if EFW is >4500g </li></ul>
  47. 47. Diabetic Ketoacidosis <ul><li>5-10% of pregnant Type 1 pts </li></ul><ul><li>Risk factors </li></ul><ul><ul><li>New onset DM </li></ul></ul><ul><ul><li>Infection </li></ul></ul><ul><ul><li>Insulin pump failue </li></ul></ul><ul><ul><li>Steroids </li></ul></ul><ul><ul><li>B mimetics </li></ul></ul><ul><li>Fetal mortality 10% </li></ul>
  48. 48. Diabetic Ketoacidosis <ul><li>Management </li></ul><ul><ul><li>ABC’s and ABG </li></ul></ul><ul><ul><ul><li>Assess BG, ketones electrolytes </li></ul></ul></ul><ul><ul><li>Insulin </li></ul></ul><ul><ul><ul><li>.2-.4U/Kg loading and 2-10U/h maintenance </li></ul></ul></ul><ul><ul><li>Begin 5% dextrose when BG is 14 mmol/l </li></ul></ul><ul><ul><li>When potassium is N range begin 20mEq/h </li></ul></ul><ul><ul><li>Rehydration isotonic NaCl </li></ul></ul><ul><ul><ul><li>1L in 1 st hour </li></ul></ul></ul><ul><ul><ul><li>.5-1l/h over 2-4h </li></ul></ul></ul><ul><ul><ul><li>250cc/h until 80% replaced </li></ul></ul></ul><ul><ul><ul><li>Replace Bicarb and phosphate as needed </li></ul></ul></ul>
  49. 49. Diabetic Ketoacidosis <ul><ul><li>Rehydration isotonic NaCl </li></ul></ul><ul><ul><ul><li>1L in 1 st hour </li></ul></ul></ul><ul><ul><ul><li>.5-1l/h over 2-4h </li></ul></ul></ul><ul><ul><ul><li>250cc/h until 80% replaced </li></ul></ul></ul><ul><ul><li>Replace Bicarb and phosphate as needed </li></ul></ul>
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