DIABETES COMPLICATING PREGNANCY

DIABETES COMPLICATING PREGNANCY Dr. P. Meenambal M.D.,D.G.O.,

DIABETES COMPLICATING PREGNANCY
Prior to Advent of Insulin – preg – rare
M.M.R. – 30%: PNMR – 70%
With insulin M.M.R. – Nil - PNMR – 3-5%
Classification – PGDM - 4-15/ 1000 preg. GDM – 5-50/1000 preg. (NDDG)
Incidence – 2-3% of all preg.
Gestational diabetes – is carbohydrate intolerance of variable severity recognised for the first time during preg.

EFFECT OF PREG. ON DIABETES
Diabetogenic – unmask diabetes
Hyperinsulinaemia
Insulin Resistance
Insulin antagonist E,P, HPL, Cortisol Somatotrophin Insulinase
Intermittent eating mother and continuous eating fetus.
Fasting Stage – Accelerated starvation
Fed Stage – Facilitated anabolism.

Complication
I Trimester
a) Spontaneous abortion
b) Fetal anomaly 3-5 fold, cardiac, renal, neural
II Trimester – PIH 10-20%
Hydramnios – 15-20%
Keto acidosis,Nephropathy,Retinopathy
III Trimester
- preterm labour
- infection
- unexplained IUD
Labour – Operative delivery
PPH, injury
Puerperium – Subinvolution
- Infection
- Lactation failure

Diagnosis : From History & Confirm by Screening Test
I Historical Suspect
a. Genetic suspects –
family H/O diabetes
b. Obstetric suspects
large baby
unexplained fetal or neonatal death
baby with congenital anomaly.
poly hydramnios
PIH
Traumatic delivery
Recurrent abortion
GDM in previous preg.
Recurrent infection – UTI moniliasis
Ch. hypertension
mat age > 30
Clinical Suspects
Obesity > 15% of normal wt.
Hypertension
Vasculopathy
III Screening Tests

Tests
Fresh urine every AN visit second fasting specimen (too insensitive)
Random Blood Sugar – Simple, reliable > 100 mg – 2 hr GTT. (Fasting 100, PP-145)
Glucose challenge test – 50 gm oral – at 24-28 wks. 1 hr later – Bl. sugar > 140/dl full G.T.T.
Oral G.T.T. – (gold std)
ACOG – 100 gm
WHO – 75 gm

METHODS OF SCREENING
1. Universal Screening
2. Selective screening
Selective Screening - Majority of diabetes may be missed because risk factor are present in only 30% of those who develop glucose intolerance during preg.
Universal Screening – In population with low prevalence is ( 0.5 – 1%) is not cost effective better to do in high risk population

RISK ASSESSMENT AND TIMING OF SCREENING OF gDM
Low RISK : Call the following
Member of ethnic group with low prevalence of gDM
No known diabetes first degree relative
Age less than 25
Wt – normal before preg
Wt – normal at Birth
No H/o abnormal glucose metabolism
Blood glucose screening not routinely required

AVERAGE RISK :
one or more of the following
Member of ethnic group of high prevalence
Diabetes in first degree relative
Age ≥ 25
Over weight before preg
Wt high at birth
Blood glucose 24 – 28wks one or 2 step procedure

HIGH RISK :
Marked obesity
Strong family H/O type II D.M
Previous H/O gDM impaired glucose metabolism or glucosuria
Glucose testing as soon as possible

IV International workshop conference on g DM and American Diabetic association recommend assessment of risk of gDM should be performed in first visit
Low risk – 10% of overall population
Average risk – 24-34 wks
High - first visit
- 26-30 wks

No ideal screening test available to diabetes
Glucosuria / less sensitive
Random blood sugar – poor screening test
Fasting blood sugar – simple low specificity ( -16%)
Hb,Ac – not useful

Normal Impaired Diabetes
Fasting <105 mg 145 >145 mg
2 hrs <165 >165 >200
Current Recommendations
An visit
24-28 wk – gl. challenge test
Rpt at 32-34 wks
If positive 3 hr GTT with 100 mg. (glu. level > 140 mg)
HbAIC - <6

Management
a) Management of diabetes in preg.
Diet - Insulin
Exercise - Trt. of complications
b) Management of preg. in diabetes
Maternal Surveillance
Foetal surveillance
Intranatal management
Post partum care

Goal of antenatal care
To achieve metabolic control similar to normal preg. pt
Fasting
P.P.
Avoid iatrogenic prematurity
Detecting fetal distress well before IUD.
To avoid any maternal complications.
Pt. education – to understand the disease and to achieve satisfactory homeostasis.
Preconceptual counseling.
Team approach .

Management
Preconception Counseling
Blood sugar (80-105)
Hb AIC - <6
Self monitoring of glucose.
Folic acid 4 mg / day.

Management
I Trimester
Bl. sugar monitoring
HbAIC – 8 PNMR Increase,
10-12 % Cong. anamoly.
Fetal CRL - > 6days – congenital anamolies
Continue folic acid
Insulin
Sometimes admitted to stabilise the dose of insulin.
Meal plan.
MSAFP (Maternal Serum Alpha Fetoprotein)
Targeted scan – 18 – 20 weeks
Fundus

DIET
50-60% Carbohydrate – avoid simple sugars – include complex sugar and dietary fibre.
12-20% protein
<10% saturated fat upto 10% poly unsaturated fat.
Restrict Cholesterol.
Avoid alcohol, non sucrose sweetness.

Exercise
Use of upper body muscle -little stress on trunk.
It permits cardiovascular workout without fear of fetal distress.
It reduces blood glucose.

Insulin
Human insulin
Start insulin if fasting blood sugar >105 mg/dl.
Hospitalise to titre the dose.
Educate woman on self admn.and glucometer usage.
Total dose divided into 2/3 – NPH
1/3 – Shortactive
Monitor – postprandial gluc.
Prophylactic insulin – decrease macrosomia related complications.
Monitor – Intensified approach-7
Conventional management

Management
II Trimester
Urine – Sug., Alb., Deposits
Weight
B.P.
MSAFP – 16-20 wks
Targeted scan – 18-20 wks
Fundus

Management
III Trimester
Fetal surveillance from 32 wks.
Weekly visit to monitor blood sugar.
Serial U/S at 3-4 wks interval.
Evaluate for PIH.
Kick chart
NST
Biophysical profile
Blood sugar profile atleast 4 –
Fasting, Prelunch, pre dinner, 10 pm.

Hospitalise
Poorly controlled diabetes.
Those with hypertension.
I.D.D.M. admitted at 34 weeks until delivery to avoid unexplained still birth.

Intranatal Care
Well equipped neonatal intensive care centre.
Adequate intrapartum monitoring
LS Ratio >2 deliver
Vaginal delivery
Vx
< 4 kg
No fetal distress

Intranatal Care
Induction planned
Morning preferred.
DNS
Insulin drip
Bl. sugar monitoring 70-40
To avoid hyperglycemia.
Prophylactic antibiotic.
Place of cortisone, preterm labour no  symphothomemetic.
IUGR

Protocol for management of diabetes in labour
10% dextrose sol. at constant rate of 100 ml per hour. Do not alter this.
Human actrapid insulin 6 units in normal saline 60 ml. (1 unit/10ml)
Insulin infusion at 10 ml/hr i.e. 1unit/hr if initial bl.gluc. is
4-6mmol/litre.
if less than 4mmol – 5ml/hr ie. 0.5u/hr.
Bl. gluc. more than 6mmol, 20 ml/hr i.e. 2 unit/hr .
Check Bl.glucose hourly in other arm.
Halve the insulin infusion after delivery.

Caesarean
Obst. indication.
Preferably early morning.
DNS, insulin drip.
Regional.
Adequate incision.
Prophylactic antibiotic.

Puerperium
Insulin requirement decreases.
Contraception
No single method appropriate for diabetes.
Barrier
OCP (triphasic pill)
Low dose pill
Progesterone only pill
IUCD
Permanent.

Breast Feeding
Encouraged
Small snacks with milk before feeding to avoid hypoglycaemia.

Place of MTP
- HbsA1c > 8
- Advanced diabetes
- Anamolies

Key points for clinical practice 20 Point plan – 10 Medical - 10 Obst .
Medical points
Prepregnancy counsel.
Early AN Booking.
Advise Bl. glucose series twice weekly using glucometer.
Use human insulin.
Frequent A.N. visit (every 2 wk. till 32 wks then weekly )
Provide glucagon
Check retina
Aim for outpatient care
IV insulin glucose infusion in labour.
Reduce insulin to prepregnancy after delivery.

Key points for clinical practise
Obst. practice points
Early U/S dating scan.
Anamoly u/s at 19 wks.
Fetal growth (head & AC) at alternate visit.
Weekly or twice weekly biophysical profile from 36 wks.
Deliver at 273 days (39 completed weeks.)
Aim for vaginal delivery.
Montinuous FH monitoring in labour.
Ensure adequate analgesia in labour.
Do not admit the baby routinely to sp.care baby unit.
Encourage breast feeding.

Thank You !

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DIABETES COMPLICATING PREGNANCY

by sakthi ganesh

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