:Facts every Doctor should Know about pre-conceptional care

1. iabetes Mellitus & Gestational
iabetes in Pregnancy
:Facts every Doctor should Know
about pre-conceptional care
DR. SHARDA JAIN
Dr. Jyoti Agarwal
…Caring hearts, healing hands

2. We taste life twice ,in the moments
when we see & treat patients
& in retrospection
when we present …..
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us…..

3. DIABETES AND PREGNANCY
OVERT DIABETES
GESTATIONAL DIABETES
Women diabetic before the onset of pregnancy
Diabetes first detected in course of pregnancy

4. GESTATIONAL DIABETES
•Defined as glucose intolerance first diagnosed during
pregnancy .
•Most commonly, it resolves post –pregnancy but
identifies women at higher risk of developing
Type 2 Diabetes.
• However ,increasing numbers of those first diagnosed
during pregnancy have pre-existing, undiagnosed type 2
or, rarely ,type 1 diabetes.

5. DIABETES AND PREGNANCY : ES GUIDELINES
GESTATIONAL DIABETES
Universal Testing for overt diabetes in non – diabetic
women at first prenatal visit
Diagnosis Fasting Glucose Random Glucose HbA1c
Overt Diabetes ≥ 126 mg/dL ≥ 200 mg/dL ≥ 6.5 %
Gestational
Diabetes
92-125 mg/dL NA NA

6. GESTATIONAL DIABETES
• Diagnosis is usually made with a glucose tolerance test (GTT)
at -28 weeks
• Aim to achieve Euglycaemia initially with diet, but ,if necessary ,
with metformin and/or insulin.
• Additional risk factor for gestational diabetes mellitus (GDM)
include obesity, maternal age, and ethnicity(especially south East
Asian including INDIA)

7. ADVERSE OUTCOMES DUE D.M.IN
PREGNANCY
•FETAL
• Premature delivery
• Congenital abnormality (most commonly, congenital heart disease an
neural tube disorders)
• Macrosomia
• Shoulder dystocia
• Stillbirth
•MATERNAL
• Increased risks of pre-eclampsia
• Increased C/S.Rate

8. PATHOPHYSIOLOGY

9. GESTATIONAL DIABETES -
PATHOPHYSIOLOGY
• Insulin resistance emerging in the 2nd trimester of pregnancy
– Progesterone
– Cortisol
– Human placental lactogen
– Prolactin and estrogen also contribute
• Some pts. cannot balance insulin needs and develop GDM
• Placental insulinase enzyme and obesity

11. DIABETES AND PREGNANCY : ES GUIDELINES
PRECONCEPTION COUNSELLING TO ALL DIABETIC WOMEN
•Sufficient glycemic control
•Assessment of comorbidities
•Discontinuing unsafe medications
•Smoking cessation

12. PRECONCEPTION CARE FOR
KNOWN D.M. PATIENTS
•Optimize blood glucose control and achieve
a EUGLYCAEMIC state .this will reduce the
risk of CONGENITAL Abnormalities
•Contraception should be discontinued
when good control is achieved
•Prescribe folic acid (5mg)

13. PRECONCEPTIONAL EUGLYCEMIA
Achieve blood glucose and
HbA1c close to normal
• FETAL MALFORMATIONS
• SPONTANEOUS ABORTIONS
• PERINATAL MORTALITY
Maternal Hyperglycemia in
first few wks of pregnancy

14. PRECONCEPTION CARE OF WOMEN WITH DIABETES
Achieve blood glucose and HbA1c close to normal

15. Diabetes and Pregnancy : ES Guidelines on
Insulin therapy
Multiple daily doses of insulin or,
Continuous sc insulin infusion
Split-dose, premixed
insulin therapy
1.More likely to achieve target levels
2.Flexibility
vs

16. FOLIC ACID SUPPLEMENTATION
1. Start 3 months before conceiving
2. 5 mg daily dose
↓ RISK OF NEURAL TUBE DEFECTS

17. PRECONCEPTION CARE OF WOMEN WITH DIABETES
FIRST TREAT RETINOPATHY
CONCEIVE ONLY WHEN IT IS
STABILIZED
DETAILED OCULAR ASSESSMENTRETINOPATHY PRESENT
PATIENT COUNSELLING
FOR RISK OF WORSENING
Retinopathy needing therapy
OCULAR CARE

18. Post-pregnancy assessment within 3
months after delivery
Women with Established Retinopathy
Ocular assessment every trimester
PRECONCEPTION CARE OF WOMEN WITH DIABETES
OCULAR CARE

19. Then, periodically as indicated
Women with No Retinopathy
Ocular assessment soon after conception
PRECONCEPTION CARE OF WOMEN WITH DIABETES
OCULAR CARE

20. Irreversible worsening
Renal dysfunction
in Type 1 DM
↑ Risk of Adverse Maternal & Fetal
outcomes (e.g. preeclampsia)
Mild Preconceptional
Renal dysfunction
Mod-Severe Preconceptional
Renal dysfunction
Reversible worsening
PRECONCEPTION CARE OF WOMEN WITH DIABETES
RENAL FUNCTION

21. ↑ Risk of Adverse outcomes
(e.g. preeclampsia)
Satisfactory BP Control <130/80 mm Hg
Preconceptional Uncontrolled HTN
PRECONCEPTION CARE OF WOMEN WITH DIABETES
Management of
Hypertension

22. SAFER ALTERNATIVES :
1.Methyldopa
2.Labetalol
3. Diltiazem
4.Clonidine
5. Prazosin
ACE Inhibitors or
Angiotensin-receptor
blockers
PRECONCEPTION CARE OF WOMEN WITH DIABETES
Management of
Hypertension

23. If vascular risk factors present
Screen for CAD before conceiving
PRECONCEPTION CARE OF WOMEN WITH DIABETES
Elevated Vascular Risk

24. 1. Dyslipidemia seldom poses threat during pregnancy
2. Unproven safety of statins, fibrates and niacin during pregnancy
DO NOT use Statins
DO NOT use Fibrates or Niacin
Bile acid-binding resins may be used to treat hypercholestrolemia
PRECONCEPTION CARE OF WOMEN WITH DIABETES
MANAGEMENT OF
DYSLIPIDEMIA

25. • ↓ Fertility
• ↑ Risk of spontaneous abortion
• ↑ Risk of Impaired fetal brain
development Hypothyroidism
Autoimmune thyroid Type 1 DM
Uncontrolled Hypothyroidism
Hypothyroidism
PRECONCEPTION CARE OF WOMEN WITH DIABETES
Thyroid function
assessment

26. ANTENATAL CARE
•Arrange care in a multidisciplinary environment,
with diabetologist obstetricians, and dieticians
•Care is intensive, with frequent contact throughout
pregnancy
•An early dating scan
•Screen for fetal abnormality, with particular
emphasis on neural tube defects (NTDs)and
congenital heart disease

27. ANTENATAL CARE
• Insulin is the most common hypo-glycaemic drug,
• although oral hypo-glycaemics [Metformin ]can be
safely used
• Women are encouraged to test their own blood
glucose with home monitors 3-4 times daily ,with
manipulation of insulin requirements according to
changing requirements

28. •Dietary control is essential .1800 calories Diet is
recommended
•Aspirin administration may help to prevent
pre-eclampisa
•Nephropathy and retinopathy, both of which can
progress, must be assessed
•Hypertension should be treated and pre-eclampsia
promptly diagnosed
ANTENATAL CARE

29. • In view of the risk of macrosomia and late
intrauterine fetal death (IUFD), FETAL SURVEILLANCE
-usually with serial ultrasound, is indicated.
• There is no proven benefit of particular regime for
assessment of fetal well-being in third trimester.
FETAL SURVEILLANCE

30. EUGLYCAEMIC CONTROL
• Women are encouraged to test their own blood
glucose with home monitors 3- 4 times daily with
manipulation of insulin requirements according to
changing requirements
• Care should be taken to maintain glycaemic control—
2hrs PP<120 mg
• Administration of antenatal steroids become
necessary sometimes to promote fetal maturity.

31. DELIVERY
• NICE guidelines recommend delivery at38 weeks to prevents late IUFD
• Shoulder dystocia is particular risk for the infants of diabetic mothers,
particularly with fetal macrosomia
• C/S rates-- higher in diabetic pregnancies
• Neonatal hypo-glycaemia is directly related to maternal blood glucose
control in labour ;hence ,blood glucose must be controlled in labour . This
is often with a glucose and insuling infusion for pre-gestanations
diabitics
• Maternal insulin requirements return promptly to their pre-pregnancy
levels immediately post –delivery.

32. NEONATAL IMPLICATIONS
• Prematurity rates are high ,Which , in association with a
specific effect of fetal hypernsulinaemia on the maturation
of fetal lungs results in respiratory distress syndrome
• Fetal hyperinsulinaemia result in neonatal hypoglycaemia
which normalizes within a few days of age
• Early infant feeding and blood glucose testing are
mandatory

33. NEONATAL IMPLICATIONS
• Polycythaemia , hyperbilirubinemia ,hypocalcaemia, and
hypomagnesaemia are also present but ,if well
controlled,are not usually clinically significant
• Macrosomia can result in birth trauma
• Hypertrophic cardiomyopathy is recognized but uncommon
• The risk of type 1 diabetes in later life is 1.3% if the mother
has type 1 diabetes, 6.1% if the father has type 1 diabetes.

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