Diabetes In Pregnancy
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Diabetes In Pregnancy

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    Diabetes In Pregnancy Diabetes In Pregnancy Presentation Transcript

    • DIABETES IN PREGNANCY
      Margarita isabel amoroso-artes, m.d.department of obstetrics & gynecologydavao medical center
    • OBJECTIVES
      Discuss and define Diabetes in pregnancy
      Discuss clinical considerations and recommendations
    • References
      William’s Obstetrics
      Greasy & Resnik’s Maternal-Fetal Medicine 6th edition
      ACOG Compendium 2008
    • DIABETES
      IMPAIRED GLUCOSE TOLERANCE
    • HOW IS DIABETES IN PREGNANCY CLASSIFIED?
    • CLASSIFICATION
      PREGESTATIONAL OR OVERT
      GESTATIONAL
    • ETIOLOGICAL CLASSIFICATION
    • OVERT DIABETES IN PREGNANCY
      HIGH PLASMA GLUCOSE LEVELS
      GLUCOSURIA
      KETOACIDOSIS
      RANDOM PLASMA GLUCOSE >200 MG/DL PLUS POLYDIPSIA, POLYURIA AND UNEXPLAINED WEIGHT LOSS OR A FASTING GLUCOSE EXCEEDING 125 MG/DL
    • HOW SHOULD SCREENING FOR GDM BE ACCOMPLISHED?
    • ALL PREGNANT PATIENTS
      CLINICAL RISK FACTORS ASSOCIATED WITH INCREASED LIKELIHOOD OF GDM
      AGE
      ETHNICITY
      OBESITY
      FAMILY HISTORY
      PAST OBSTETRIC HISTORY
    • LOW RISK MEETS ALL THE CRITERIA:
      AGE YOUNGER THAN 25 YEARS
      NOT A MEMBER OF AN ETHNIC GROUP (HISPANIC, AFRICAN, NATIVE AMERICAN, SOUTH OR EAST ASIAN, PACIFIC ISLANDS ANCESTRY)
      BODY MASS INDEX OF 25 OR LESS
      NO PREVIOUS HX OF ABNORMAL GLUCOSE TOLERANCE
      NO PREVIOUS HX OF ADVERSE OBSTETRIC OUTCOME ASSO. W/ GDM
      NO KNOWN DIABETES IN FIRST DEGREE RELATIVE
    • SCREENING TEST: 50 GM ORAL GLUCOSE CHALLENGE TEST
      USE HISTORIC RISK FACTORS TO IDENTIFY THE INDIVIDUALS WHO MAY HAVE SUCH A LOW RISK FOR GDM THAT GLUCOSE CHALLENGE TESTING MAY NOT BE WORTHWHILE
      THERE MAY BE GROUPS AT SUCH HIGH RISK FOR GDM THAT IT MAY BE MORE CONVENIENT AND COST EFFECTIVE TO PROCEED DIRECTLY TO THE DIAGNOSTIC GTT WITHOUT OBTAINING THE SCREENING TEST
    • AT WHAT GESTATIONAL AGE SHOULD LABORATORY SCREENING BE PERFORMED?
    • PREVALENCE OF GDM INCREASES W/ ADVANCING GESTATION
      50 GM, 1 HOUR ORAL GLUCOSE CHALLENGE TEST AT 24-28 WEEKS AGE OF GESTATION
      INSULIN RESISTANCE INCREASES AS PREGNANCY PROGRESSES- TESTING LATER IN PREGNANCY WILL YIELD HIGHER ABNORMAL TESTS
    • PX WITH HX OF GDM PREVIOUS PREGNANCY 30 TO 35% LIKELIHOOD OF RECURRENCE IN SUBSEQUENT PREGNANCY
      PXS WITH HX OF GDM SHOULD BE TESTED IN BETWEEN PREGNANCIES TO DETECT PREEXISTING DIABETES
    • HOW IS LABORATORY SCREENING ACCOMPLISHED?
    • 50 GM, 1 HOUR GLUCOSE CHALLENGE TEST
      PURE GLUCOSE LOAD OF 50 GM IN 150 ML OF FLUID
      GLUCOSE POLYMER SOLUTIONS
      ( FEWER GI SYMPTOMS)
      SENSITIVITY: 80-90%
      THE SCREENING TEST MAY BE ADMINISTERED WITHOUT REGARD TO THE TIME ELAPSED SINCE THE LAST MEAL
    • IS THERE AN APPROPRIATE THRESHOLD VALUE FOR THE LABORATORY SCREENING TEST?
    • AMERICAN DIABETES ASSOCIATION:
      PAST: 140 MG/CL
      CURRENT: 130 MG/DL
      SENSITIVITY: 79%
      SPECIFICITY: 97%
      ** EITHER THRESHOLD IS STILL ACCEPTABLE***
    • HOW IS GDM DIAGNOSED?
    • DIAGNOSTIC TEST SPECIFIC: 100 GM, 3 HOUR ORAL GTT
      POSTIVE DIAGNOSIS REQUIRES 2 OR MORE THRESHOLDS BE MET OR EXCEEDED
      PXS W/ ONLY ONE ABNORMAL VALUE HAVE INCREASED RISK FOR MACROSOMIC INFANT AND OTHER MORBIDITIES
      PXS SHOULD REMAIN SEATED DURING THE TEST
    • INSTRUCTED TO FOLLOW AN UNRESTRICTED DIET CONSUMING AT LEAST 150 GM OF CHO PER DAY FOR AT LEAST 3 DAYS PRIOR THE TEST TO AVOID CHO DEPLETION WHICH COULD CAUSE SPURIOUSLY HIGH VALUES ON THE GTT
    • DIAGNOSTIC CRITERIA FOR GDM
    • HOW SHOULD BLOOD GLUCOSE BE MONITORED IN A WOMAN W/ GDM?
    • CAPILLARY GLUCOSE MONITORING
      Frequency & timing should be individualized
      Postprandial have the strongest correlation w/ fetal growth
      Typical glucose monitoring:
      Rising in the morning
      1 or 2 hrs after breakfast
      Before & after lunch
      Before dinner
      Bedtime
    • Target Capillary Glucose Levels
      Fasting plasma glucose level of 90 to 99 mg/dL (5.0 to 5.5 mmol/L)
      and
      1 hour postprandial plasma glucose level <140 mg/dL (<7.8 mmol/L)
      or
      2 hour postprandial plasma glucose level < 120 to 127 mg/dL (<6.7 to 7,1 mmol/L)
    • Target Plasma Glucose Values:
      Preprandially: 65 to 95 mg/dL
      Postprandially: 130 to 140 mg/dL
    • POSTPRANDIAL GLUCOSE VALUES APPEAR TO BE MOST EFFECTIVE AT DETERMINING THE LIKELIHOOD OF MACROSOMIA AND OTHER ADVERSE PREGNANCY OUTCOMES IN PATIENTS WITH GDM
    • Recommended Glucose Goal
    • IS THERE A ROLE FOR DIET THERAPY IN THE TREATMENT OF GDM?
    • YES
      NUTRITIONAL INTERVENTION SHOULD BE STARTED
      PXS DELIVER FEWER MACROSOMIC INFANTS
      AMERICAN DIABETES ASSOCIATION: OVESE WOMEN (BMI > 30): MODERATE CALORIC RESTRICTION (30-33%)
      SUPPLEMENTARY DIETARY FIBER MAY IMPROVE GLYCEMIC CONTROL
    • IS THERE A ROLE FOR ORAL ANTIDIABETIC AGENTS IN THE TREATMENT OF GDM?
    • ORAL ANTIDIABETIC AGENTS CONTRAINDICATED
      EARLY GENERATION SULFONYLUREAS CROSSES THE PLACENTA STIMULATE FETAL PANCREASE FETAL HYPERINSULINEMIA AND TERATOGENIC
    • Principles of insulin therapy
    • Goal of exogenous insulin therapy during pregnancy: postprandial blood glucose excursions maintained w/in a relatively narrow range (70 to 120 mg/dL)
      As pregnancy progresses increasing fetal demand for glucose results in lower fasting & between meal blood glucose levels increasing risk of symptomatic hypoglycemia
    • Period of maximal fetal growth velocity & fat accretion occurs at 33.5 wks gestation
      Delay in therapy by 33-34 wks AOG would miss maximal glycemic intervention effective in modulation fetal growth
      Allow a 1 to 2 week trial of dietary management
    • Insulin regiment used should be individualized accordin to the patient’s profile
      Short acting insulin (4 to 8 units to start) before meals
      If > 10 units of short acting insulin is needed before the noon meal add 6 to 8 doses of NPH before breakfast
      Doses are scaled up as necessary
    • INTRAPARTUM GLYCEMIC MGT
      Maternal hyperglycemia perinatal asphyxia & neonatal hypoglycemia
      Strict maternal euglycemia does not guarantee newborn metabolic stability in infants w/ macrosomia
      Use of combined insulin & glucose infusion durinnglabor maintains maternal plasma glucose level in narrow range (80 – 110 mg/dL)
      -- reduces incidence of neonatal hypoglycemia
    • Typical infusion rates
      5% Dextrose in Ringer’s lactate at 100 ml/hour AND
      Lispro or aspart insulin at 0.5 to 1 units per hour
      CBG monitored q hourly
      For patients with diet controlled GDM avoiding dextrose in all IV fluids during labor maintains excellent glucose control
    • For CS
      Procedure should be performed early in the day to avoid prolonged fasting
      Night before surgery:
      instructed to take full dose of NPH or glyburide
      No morning insulin or glyburide should be taken
    • Postpartum Metabolic Mgt
      In the Recovery Room & after delivery
      Insulin subcutaneously
      Insulin dose required after delivery typically 30 to 50% of the preprandial doses required during pregnancy just before delivery
    • IS FETAL ASSESSMENT INDICATED IN PREGNANCIES COMPLICATED BY GDM?
    • Antepartumfetal testing recommended
      3rd trimester Goal mgt: prevent stillbirth adn asphyxia while optimizing the opportunity for safe vaginal delivery
      Monitoring fetal growth to determine proper timing & route of delivery and testing for fetal well being at frequent intervals
    • Fetal movement counting
    • When and how should deliveries be accomplished in patients with GDM?
    • Timing of delivery should minimize neonatal morbidity & mortality while maximizing the likelihood of vaginal delivery
      Optimal time for delivery: 38.5 to 40 weeks
      Labor or Cesarean?
      ACOG recommended primary cesarean for diabetic gravidas with EFW greater than 4500 gm to reduce risk of shoulder dystocia
    • Indications for delivery in diabetic pregnancy
    • Confirmation of fetal maturity before termination of pregnancy
    • Should women with a history of GDM be screened postpartum?
    • Women w/ a history of GDM are at increased risk developing diabetes (generally type 2) later in life
    • What are the fetal effects of GDM?
    • Fetal Effects
      Abortion
      Preterm Delivery
      Malformations
      Unexplained Fetal Demise
      Hydramnios
    • Fetal Death
      In pregnancies not receiving optimal care
      After 36 wks gestation in pxs w/
      Vascular disease
      Poor glycemic control
      Hydramnios
      Fetalmacrosomia
      Preeclampsia
      Chronic hypoxia as likely cause of fetal death
    • Neonatal Effects
      Respiratory distress
      Hypoglycemia
      Hypocalcemia
      Hyperbilirubienmia
      Cardiac Hypertrophy
      Long Term Cognitive Development
      Inheritance of Diabetes
      Altered Fetal Growth
    • What are the Maternal Effects
    • Diabetic Nephropathy
      Diabetic Retinopathy
      Diabetic Neuropathy
      Preeclampsia
      Ketoacidosis
      Infections