Pregestational DM Mgmt in Pregnancy

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  • Pregestational DM Mgmt in Pregnancy

    1. 1. Management of the Pregnant Pregestational Diabetic Patient Sarah McCormick MSIII Kansas City University of Medicine and Biosciences
    2. 2. Physiology of Disease <ul><ul><li>Maternal insulin doesn’t cross placenta, glucose does </li></ul></ul><ul><ul><ul><li>Extra Insulin enters fetal blood stream  Fetal liver is immature  produces more insulin, but not enough </li></ul></ul></ul><ul><ul><ul><li>Insulin is a Growth Hormone  Macrosomia </li></ul></ul></ul><ul><ul><li>HPL from placenta antagonizes insulin </li></ul></ul><ul><ul><ul><li>Diabetes can worsen with pregnancy </li></ul></ul></ul><ul><ul><ul><li>Higher amounts of Insulin needed to control </li></ul></ul></ul><ul><ul><li>Vascular disease in DM mom  decrease blood supply to fetus  uteroplacental insufficiency and decreased fetal growth </li></ul></ul><ul><ul><li>Hyperinsulinemia and Hyperglycemia in fetus consumes more O2  hypoxemia/acidosis </li></ul></ul>
    3. 3. Adverse Outsomes of DM In Pregnancy <ul><li>To Fetus </li></ul><ul><li>Macrosomia (insulin is a growth hormone) </li></ul><ul><li>Traumatic Delivery </li></ul><ul><li>Shoulder Dystocia </li></ul><ul><li>Erb’s Palsey </li></ul><ul><li>Delayed Organ Maturity </li></ul><ul><li>Pulmonary </li></ul><ul><li>Hepatic </li></ul><ul><li>Neurologic </li></ul><ul><li>Pituitary/Thyroid Axis </li></ul><ul><li>Congenital Malformations ( 3-4x increase esp. high 1 st trimester HbA1c)) </li></ul><ul><li>Cardiovascular Defects* </li></ul><ul><li>Neural Tube Defects* </li></ul><ul><li>Caudal Regression Syndrome </li></ul><ul><li>Situs Inversus </li></ul><ul><li>Duplex Renal Ureter </li></ul><ul><li>IUGR </li></ul><ul><li>Uteroplacental insufficienty (with vascular disease) </li></ul><ul><li>Death </li></ul>To Mother Obstetric Complications Polyhydraminos (increased fetal urination?) Preeclampsia Miscarriage Infection Postpartum Hemorrhage Increased C/S Preterm labor Diabetic Emergencies Hypoglycemia Ketoacidosis Diabetic Coma Vascular/End organ damage Cardiac Renal Opthalmic Peripheral Vascular Neurologic Peripheral Neuropathy GI
    4. 4. First Prenatal Visit <ul><li>Ideally, First 6-10 wks of pregnancy </li></ul><ul><li>Complete Medical, Surgical, Family, Social, Menstrual, Contraceptive and Obstetrical Hx </li></ul><ul><ul><ul><li>LMP, regularity of cycle </li></ul></ul></ul><ul><ul><ul><li>OCP use </li></ul></ul></ul><ul><ul><ul><li>current pregnancy symptoms, prior pregnancies and outcomes, hx of abortions, mode of delivery, length of labor in each stage, birth weight, and complications </li></ul></ul></ul><ul><li>Complete PE including Pap, Bimanual Exam, and Fundal Height </li></ul>
    5. 5. First Prenatal Visit Tests <ul><ul><li>H and H </li></ul></ul><ul><ul><li>Blood Type and Screen </li></ul></ul><ul><ul><li>RPR </li></ul></ul><ul><ul><li>Rubella Ab screen </li></ul></ul><ul><ul><li>HbsAg </li></ul></ul><ul><ul><li>G&C culture, Pap </li></ul></ul><ul><ul><li>PPD </li></ul></ul><ul><ul><li>UA and Cx </li></ul></ul><ul><ul><li>VZV titer if no exposure hx </li></ul></ul><ul><ul><li>Offer HIV, Nuchal Translucency, and Serum Screen </li></ul></ul>
    6. 6. Pregestational Diabetic Initial Visit Tests <ul><li>In addition to the routine prenatal tests: </li></ul><ul><ul><ul><li>EKG </li></ul></ul></ul><ul><ul><ul><li>Dating sonogram </li></ul></ul></ul><ul><ul><ul><li>24 hour urine collection (protein and CrCl) </li></ul></ul></ul><ul><ul><ul><li>HbA1C- repeat every 4-6 wks </li></ul></ul></ul><ul><ul><ul><li>Eye exam (opthamology) </li></ul></ul></ul><ul><ul><ul><li>TSH, T4 free </li></ul></ul></ul>
    7. 7. Counseling in First Visit <ul><li>Stress importance of tight glycemic control </li></ul><ul><ul><li>Especially in first trimester </li></ul></ul><ul><ul><li>Best if counseled prior to pregnancy </li></ul></ul><ul><ul><li>Decrease incidence of adverse outcomes </li></ul></ul><ul><ul><li>Insulin pumps-best </li></ul></ul><ul><ul><li>increased frequency of self monitoring of glucose (4-8x qd) </li></ul></ul><ul><ul><li>Normal 2,200 Cal +300 Cal. ADA Diet - 30-45g carbs breakfast, 45-60g carbs lunch/dinner, and 15g carb snacks </li></ul></ul><ul><ul><li>HBA1c ideally <6-6.5, sharp increase in major malformations and spontaneous abortions at >8.5 </li></ul></ul><ul><ul><li>Exercise-decreases insulin amount needed to decrease glucose </li></ul></ul><ul><ul><li>Important to include medical team in care </li></ul></ul><ul><ul><ul><li>Endocrine, nutrition, PCP </li></ul></ul></ul><ul><ul><li>Review risks if not reviewed prior to Pregnancy </li></ul></ul>
    8. 8. Management at First Visit <ul><li>Take off ACE/ARBS –best if off prior to pregnancy </li></ul><ul><li>Maintain BP- 110-129/ 65-79 </li></ul><ul><li>Oral hypoglycemics /Insulin </li></ul><ul><ul><li>Oral hypoglycemics contraindicted </li></ul></ul><ul><ul><li>Insulin does not cross placenta </li></ul></ul><ul><ul><li>Insulin TX- NPH (longer acting) qhs and qam, Lispro/humalog (shorter acting) prior to meals </li></ul></ul><ul><ul><li>Lantes (Glargine)-not effective in pregnancy </li></ul></ul><ul><ul><ul><li>Change insulin dosage less then or equal to 20% a day </li></ul></ul></ul><ul><ul><ul><li>Wait 24hrs between dosage changes to evaluate the response </li></ul></ul></ul><ul><ul><ul><li>Target Glucose Levels </li></ul></ul></ul><ul><ul><ul><ul><li>AM-70-90 </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Postmeals 100-130 </li></ul></ul></ul></ul>
    9. 9. First Trimester Visits <ul><li>Typically, every 4 weeks </li></ul><ul><ul><li>Weight changes, BP, edema, Fundal Height, Urine Dip </li></ul></ul><ul><ul><li>Add extra visits for PGD mom to review glucose levels </li></ul></ul><ul><ul><li>Glucose control </li></ul></ul><ul><ul><li>Urine Ketones if sick or any glucose >200 </li></ul></ul><ul><ul><li>Nephropathy- 1x trimester serum creatinine, quantitative 24hr urine </li></ul></ul>
    10. 10. Second Trimester Visits <ul><li>12-24 wks gestation </li></ul><ul><li>Q2-4wks (increase if complications) </li></ul><ul><ul><ul><li>Weight changes, BP, edema, Fundal Height, Urine Dip </li></ul></ul></ul><ul><ul><ul><li>Triple Screen- Maternal Serum Alpha Fetoprotein (15-18wks), B-hcg, Estradiol (add inhibin A for Quad screen) </li></ul></ul></ul><ul><ul><ul><ul><li>alpha fetoprotein and Estradiol are reduced in diabetic mothers </li></ul></ul></ul></ul><ul><ul><ul><li>Screening Ultrasound and Fetal Echocardiogram (18-20 wks)-anatomy, fluid, placenta, GA </li></ul></ul></ul><ul><ul><ul><li>Amniocentesis with AMA( >35yo) </li></ul></ul></ul><ul><ul><ul><li>12wks- begin Doppler US-heart rate </li></ul></ul></ul><ul><ul><ul><li>Urine Ketones if sick or any glucose >200 </li></ul></ul></ul><ul><ul><ul><li>Nephropathy- 1x trimester serum creatinine, quantitative 24hr urine </li></ul></ul></ul>
    11. 11. Third Trimester Visits <ul><li>>24 weeks </li></ul><ul><li>Q1-2wks to 36wks then q1wk </li></ul><ul><li>Bleeding? Contractions? ROM? </li></ul><ul><ul><li>Weight changes, BP, edema, Fundal Height, Urine Dip </li></ul></ul><ul><li>Nephropathy- 1x trimester serum creatinine, quantitative 24hr urine </li></ul><ul><li>Urine Ketones if sick or any glucose >200 </li></ul><ul><li>Strep. Agalactiae at 35-37wks </li></ul><ul><li>Rhogam at 28-30wks (if mom is RH negative) </li></ul><ul><li>Glucose monitoring </li></ul><ul><li>Increased HPL at third trimester </li></ul><ul><li>28 & 38wks- US for fetal growth assessment </li></ul><ul><li>32wks (26wks if complications)-BPP, NST once a week </li></ul><ul><li>36wks-BPP, NST twice a week </li></ul><ul><li>37 weeks fetal lung maturity testing </li></ul>
    12. 12. Delivery Time? <ul><ul><li>Tocolysis-Nifidipine or Indocin Sulfate </li></ul></ul><ul><li>Delay delivery long enough to give glucocorticoids for lung maturity </li></ul><ul><ul><li>Monitor blood glucose 12 hrs after 1 st dose, 24hrs after 2 nd dose </li></ul></ul><ul><li>Ideal Delivery 37-39 wks poor control no later than 40 wks </li></ul><ul><ul><li>Earlier delivery if poor glucose control, nonreassuring fetal test, worsening HTN, worsening renal disease, poor fetal growth </li></ul></ul><ul><li>Macrosomia>4500g  C/S </li></ul><ul><ul><li>Increased shoulder dystocia </li></ul></ul><ul><ul><li>Fetus of DM mom’s have larger disproportion of fetal head to shoulder width </li></ul></ul><ul><ul><li>Not advised for macrosomia of non-DM moms </li></ul></ul>
    13. 13. Labor and Delivery <ul><li>Epidural/Spinal Anesthesia lowers maternal pH </li></ul><ul><li>Inductions and C/S schedule in AM </li></ul><ul><ul><li>Fasting patient </li></ul></ul><ul><ul><li>Easier control </li></ul></ul><ul><li>Very important to monitor fetus and mother closely </li></ul><ul><ul><li>Abnormal fetal heart rates increased </li></ul></ul><ul><li>Strict blood glucose control </li></ul><ul><ul><li>Hourly monitoring </li></ul></ul><ul><ul><li>IV Dextrose /Insulin drip at 100-120mg/dl </li></ul></ul><ul><ul><li>If Glucose >120 increase insulin. </li></ul></ul><ul><ul><li>If Glucose 80-100 Dextrose infusion </li></ul></ul>
    14. 14. Postpartum <ul><li>Insulin requirements drop significantly after delivery </li></ul><ul><ul><li>Type 2 DM may go off insulin if needed </li></ul></ul><ul><ul><li>Type 1 DM NEVER go off insulin </li></ul></ul><ul><li>Calorie requirements drop </li></ul><ul><ul><li>25Cal/kg/day in non-breastfeeding patient </li></ul></ul><ul><ul><li>27Cal/kg/day in breastfeeding patient </li></ul></ul><ul><li>If breastfeeding do not resume oral hypoglycemics </li></ul><ul><li>Renal dz- 24hr urine at 6wks postpartum </li></ul><ul><li>Opthamology exam 12-14wks postpartum </li></ul><ul><li>6-8wks diabetes care transferred to back to PCP or endocrinologist </li></ul>
    15. 15. References <ul><li>UpToDate </li></ul><ul><li>Boards and Wards </li></ul><ul><li>Blueprints Obstetrics and Gynecology </li></ul>

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