Diabetes In Pregnancy


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Diabetes In Pregnancy

  1. 1. Diabetes in Pregnancy
  2. 2. Diabetes in Pregnancy <ul><li>Epidemiology </li></ul><ul><li>Classification </li></ul><ul><li>Pathophysiology </li></ul><ul><li>Morbidity </li></ul><ul><ul><li>Fetal </li></ul></ul><ul><ul><li>Maternal </li></ul></ul><ul><li>Diagnosis </li></ul><ul><li>Treatment and Management </li></ul><ul><li>References </li></ul>
  3. 3. Epidemiology <ul><li>4-6% of pregnancies in the U.S are complicated by DM, accounting for 50-150 thousand babies per year. </li></ul><ul><ul><li>88% GDM, 8% Type II DM, 4% Type 1 DM </li></ul></ul><ul><li>Prevalence also varies by race </li></ul><ul><ul><li>1.5-2% in Caucasians, 5-8% in Hispanic, Asian and African Americans, and up to 15% in some SW Native American groups. </li></ul></ul>
  4. 4. Classification
  5. 5. Pathophysiology <ul><li>Normal pregnancy is characterized by: </li></ul><ul><ul><li>Mild fasting hypoglycemia </li></ul></ul><ul><ul><li>Postprandial hyperglycemia </li></ul></ul><ul><ul><li>Hyperinsulinemia </li></ul></ul><ul><li>Due to peripheral insulin resistance which ensures an adequate supply of glucose for the baby. </li></ul>
  6. 6. Pathophysiology <ul><li>Human Placental Lactogen (HPL) </li></ul><ul><ul><li>Produced by syncytiotrophoblasts of placenta. </li></ul></ul><ul><ul><li>Acts to promote lipolysis  increased FFA and to decrease maternal glucose uptake and gluconeogenesis. “Anti-insulin” </li></ul></ul><ul><li>Estrogen and Progesterone </li></ul><ul><ul><li>Interfere with insulin-glucose relationship. </li></ul></ul><ul><li>Insulinase </li></ul><ul><ul><li>Placental product that may play a minor role. </li></ul></ul>
  7. 7. A Vicious Cycle???
  8. 8. Fetal Morbidity <ul><li>Miscarriages </li></ul><ul><ul><li>Frequency directly related to degree of maternal glycemic control. </li></ul></ul><ul><ul><li>Up to 44% with poorly controlled DM (HbA 1 C >12). </li></ul></ul><ul><li>Preterm Delivery </li></ul><ul><ul><li>Increase in both spontaneous and indicated preterm labor (<35 wks). </li></ul></ul>
  9. 9. Fetal Morbidity <ul><li>Birth Defects </li></ul><ul><ul><li>1-2% risk among the general population. </li></ul></ul><ul><ul><li>4-8 fold increased risk among preexisting diabetics. </li></ul></ul><ul><ul><li>Most common defects are CNS and CV, but also an increase in renal and GI abnormalities. </li></ul></ul><ul><ul><li>Up to a 600 fold increase in caudal regression syndrome. </li></ul></ul>
  10. 10. Fetal Morbidity <ul><li>Macrosomia </li></ul><ul><ul><li>Defined as birthweight above 90 th % or >4000 grams. </li></ul></ul><ul><ul><li>Occurs in 15-45% of diabetic pregnancies, a 4-fold increase over normal. </li></ul></ul><ul><ul><li>Carries many morbidities including birth trauma, RDS, neonatal jaundice and severe hypoglycemia. </li></ul></ul>
  11. 11. Fetal Morbidity <ul><li>Growth Restriction </li></ul><ul><ul><li>Although we typically associate maternal DM with macrosomia, growth restriction is fairly common among Type 1 diabetic mothers. </li></ul></ul><ul><ul><li>Best predictor is presence of maternal vascular disease. </li></ul></ul>
  12. 12. Fetal Morbidity
  13. 13. Fetal Morbidity <ul><li>Polycythemia </li></ul><ul><ul><li>Hyperglycemia stimulates fetal erythropoeitin production. </li></ul></ul><ul><ul><li>Can lead to tissue ischemia and infarction. </li></ul></ul><ul><li>Hypoglycemia </li></ul><ul><ul><li>Think of as an “overshoot” mechanism. </li></ul></ul><ul><ul><li>Baby is used to having lots of maternal glucose so it makes lots of insulin. When born, maternal glucose is no longer available but insulin remains high  hypoglycemia. </li></ul></ul><ul><ul><li>Can lead to seizures, coma and brain damage. </li></ul></ul>
  14. 14. Fetal Morbidity <ul><li>Postnatal hyperbilirubinemia </li></ul><ul><ul><li>Occurs in appox. 25%, double that of normal. </li></ul></ul><ul><ul><li>Thought to be due in large part to polycythemia. </li></ul></ul><ul><li>Respiratory distress syndrome </li></ul><ul><ul><li>5-6 fold increased frequency. </li></ul></ul><ul><ul><li>May be due to a delay in lung maturation or simply due to the increased frequency of preterm deliveries. </li></ul></ul>
  15. 15. Fetal Morbidity <ul><li>Polyhydramnios </li></ul><ul><ul><li>Amniotic fluid volume >2000 mL. </li></ul></ul><ul><ul><li>Occurs in 10% of diabetics. </li></ul></ul><ul><ul><li>Increased risk of placental abruption and preterm labor. </li></ul></ul>
  16. 16. Maternal Morbidity <ul><li>Increased risk of DKA due to increasingly resistant DM. </li></ul><ul><li>Increased incidence of UTI due to glucose-rich urine and urinary stasis. </li></ul><ul><ul><li>Glucosuria is a normal finding of pregnancy but may be much higher in diabetics. </li></ul></ul><ul><li>Diabetic retinopathy </li></ul><ul><li>Diabetic nephropathy </li></ul>
  17. 17. Maternal Morbidity <ul><li>Diabetic neuropathy </li></ul><ul><li>Preeclampsia </li></ul><ul><ul><li>2-fold increase </li></ul></ul>
  18. 18. Diagnosis <ul><li>Glucose Challenge Test (24-28 wks) </li></ul><ul><ul><li>50 gram glucose load with blood level 1 hour later. </li></ul></ul><ul><ul><li>Does NOT require fasting state. </li></ul></ul><ul><ul><li>Normal finding is <140 mg/dl. </li></ul></ul><ul><ul><li>If >140, need to do a 3 hour glucose tolerance test. </li></ul></ul>
  19. 19. Diagnosis <ul><li>Glucose Tolerance Test </li></ul><ul><ul><li>Draw a fasting glucose level (normal<95). </li></ul></ul><ul><ul><li>Give 100 gram glucose load with glucose levels drawn after 1, 2 and 3 hours. </li></ul></ul><ul><ul><li>Normal levels vary widely depending on who you ask but should be in the following ranges: </li></ul></ul><ul><ul><ul><li>1 hr:<180 2 hr:<155 3 hr:<140 </li></ul></ul></ul><ul><ul><li>2 or more abnormal values = GDM. </li></ul></ul>
  20. 20. Treatment and Management <ul><li>Obviously the main goal is to maintain good glycemic control. </li></ul><ul><ul><li>Typically controlled with insulin but oral hypoglycemic agents like glyburide are also showing promise. </li></ul></ul>
  21. 21. Treatment and Management <ul><li>Obstetrical management </li></ul><ul><ul><li>Serial US to trend fetal growth, AFI and fetal anatomy </li></ul></ul><ul><ul><li>Fetal well-being monitored with kick counts, NSTs, BPPs </li></ul></ul><ul><li>Postpartum, 95% of GDM mothers return to normal glucose tolerance, and require no further insulin. </li></ul><ul><ul><li>Glucose tolerance screen 2-4 mo. postpartum to detect those that remain diabetic. </li></ul></ul>
  22. 22. References <ul><li>www.acog.org </li></ul><ul><li>Current Obstetric & Gynecologic Diagnosis & Treatment (2003) </li></ul><ul><li>Williams Obstetrics (2005) </li></ul>