5. Case Summery…
9/7/2023
Pre-gestational diabetes
5
GVII,PVI (V alive,II SB), amenorhic for 9month
LNMP unknown, no ANC followup
Refered from HGH with diagnosis of known type 1
dm(40M &20E) + 2previous cs scar + polyhydramnious.
After she presented there for ANC followup
6. Case Summery…
9/7/2023
Pre-gestational diabetes
6
She had followup for DM at Haromaya Hospital
She had 2 previous CD at this hospital,the 1st was 5
years back for unknown indication
The 2nd was 3 years back for indication of big baby
No danger sighn during pregnancy
No self or family hx of HTN,cardiac or renal disease
11. Investigation
DATE RFT LFT U/A U/S
18/02/15 WBC-6800
HCT -29%
HG-9.6
PLT – 184000
BG & RH – AB
+ve
PICT – NR
VDRL – NR
HBsAg –
negative
CRE – 0.51 GPT – 24
GOT – 43
RBS=78
GLU +2
PROT -
+2
Ketone -
ve
Cephalic
Fhb+ve
AGA –
34WK
EFW –2.8kg
AFI – 27cm
Gbm,Ft,Fbm
No GCA seen
Index – 3rd
TMP with
polyhydramn
ios
9/7/2023
11
12. Medical side Evaluation
9/7/2023
Pre-gestational diabetes
12
History and asst was the same
Plan
To do HgA1c
To put her on mixed insulin NPH/Regular
• MORNING 26/14
• EVENING 13/7
• To put her on modified sliding scale 180-200=1iu
201-249=2iu
250-299=3iu
300-349=4iu
>350=5iu
13. 9/7/2023
Pre-gestational diabetes
13
With 3 week stay in the ward
Preprandial 1x and post prandial 2x done daily
With RBS
Min=48mg/dl
Max=497 mg/dl
Mean=249mg/dl
14. Medical side Re-evaluation
9/7/2023
Pre-gestational diabetes
14
On 05/03/15
Hx & asst was the same
Mixed insulin NPH/RI
Morning 32/18
Evening 14/8
Premeal RI 10 iu if
postprandial Rbs>200
10/03/15
Mixed insulin NPH/RI
Morning 32/16
Evening 12/12
Premeal RI 10 iu if
postprandial Rbs>200
15. 9/7/2023
Pre-gestational diabetes 15
US on 18/02/15
SIUP
Cephalic
FHB +ve
Placenta Fundal
SDP 10cm
AGA 34wk+4d
EFW 2.8kg
GBM,FT & FBM seen
No GCA seen
3rd TMP +
Polyhydramnious
US on 24/02/15
SIUP
Cephalic
FHB+ve
Placenta Fundal
AFI 32cm
AGA 35wk + 4d
EFW 3.5kg
GBM,FT,& FBM seen
No GCA seen
3rd TMP +
Polyhydramnious
US on 08/03/15
SIUP
Cephalic FHB+ve
Placenta fundal
SDP 9cm
AGA 35wk+5d
EFW 4.1kg
GBM,FT,FBM seen
3rd TMP +
F.Macrosomia +
Polyhydramnious
16. On 09/03/15 @ 4:30pm
9/7/2023
Pre-gestational diabetes
16
Subjectively no new compliant
Objectively P/E GA: well looking
V/S BP:118/74, PR:80, RR: 20, T:37
ABD= FHB-ve
GUS= no bleeding
CNS=COTPP
19. CS Done on 12/03/15
9/7/2023
Pre-gestational diabetes
19
Indication:2cs scar + IUFD
Outcome: 5kg GIII macerated male neonate
Plan
To follow Rbs Q 6hrs & put on sliding scale
To star pre pregnancy insulin
Insert interval IUCD after 6weeks
Link to medical side before discharge
23. Introduction
9/7/2023
Pre-gestational diabetes
23
3-5% of pregnancies are complicated by DM
Pre insulin era – Pregnancy in diabetic women was
uncommon and was likely to be accompanied by fetal
mortality and risk for maternal death as well.
Perinatal mortality has reduced from 65% to 25% as result
of improved maternal glycemic control
24. Introduction Con…
9/7/2023
Pre-gestational diabetes
24
Diabetes in pregnant women may be
Pregestational or Gestational
GDM accounts for 88% of DM in pregnancy,
Type 2 comprises 8 %, and
Type 1 diabetes makes up the remaining 4 %
The prevalence of both gestational and type 2 diabetes is
increasing,
increasing prevalence of obesity.
25. Diagnosis
9/7/2023
Pre-gestational diabetes
25
RBS >200 mg/dL plus classic signs and symptoms
FBS >125 mg/dL
HbA1c atleast 6.5%
plasma glucose level >200 mg/dL measured 2 hours
after a 75 g oral glucose load
26. How dose diabetes affect pregnancy?
9/7/2023
Pre-gestational diabetes
26
• Women with type 1 and type 2 diabetes have an
increased risk of adverse pregnancy outcomes,
including
Miscarriage
Fetal congenital anomaly and
Perinatal death
In our case:-IUFD
• Studies suggest that, type 2 diabetes have higher
mortality rates than for type1 reasons being:
An older age,
More parous, and
More obese group
30. 9/7/2023
Pre-gestational diabetes 30
The frequency of major congenital malformations in newborns of
women with pregestational diabetes stratified by hemoglobin A1c levels at
first
prenatal visit
32. Unexplained Fetal Demise
9/7/2023
Pre-gestational diabetes
32
The risk of fetal death is three to four times higher in
women with pregestational diabetes
These stillbirths are “unexplained” because common
factors such as
obvious placental insufficiency,
placental abruption,
fetal-growth restriction, or
oligohydramnios are not identified
33. 9/7/2023
Pre-gestational diabetes
33
These unexplained stillbirths are associated with
poor glycemic control= Like in our Pt
Salvesen and colleagues analyzed fetal blood samples and reported that mean
umbilical venous blood
pH was lower in diabetic pregnancies and was significantly related to fetal insulin
levels.
Such findings support the hypothesis that hyperglycemia-mediated chronic
aberrations in oxygen and fetal metabolite transport may underlie these
unexplained fetal deaths
34. Respiratory Distress Syndrome
9/7/2023
Pre-gestational diabetes
34
Gestational age rather than overt diabetes is likely
the most significant factor associated with RDS
in one analysis of 19,399 very-low-birthweight
neonates delivered between 24 and 33 weeks’ gestation, rates of
respiratory
distress syndrome in newborns of diabetic mothers were not higher
compared with
rates in neonates of nondiabetic mothers
35. Hypoglycemia
9/7/2023
Pre-gestational diabetes
35
This is attributed to hyperplasia of the fetal β-islet
cells
induced by chronic maternal hyperglycemia
Frequent blood glucose measurements in the
newborn and
active early feeding practices can prevent these
complications.
36. In a retrospective study in Denmark, pregnancy
complications in pregestational DM mother shows:
9/7/2023
Pre-gestational diabetes
36
38. Proposed Classification System for Diabetes in
Pregnancy
9/7/2023
Pre-gestational diabetes
38
Gestational Diabetes:diagnosed during pregnancy that is not
clearly overt
Type 2 Diabetes: diabetes from inadequate insulin secreation in
the face of increased insulin resistance
a) Without vascular complication
b) With vascular complication
Type 1 Diabetes: diabetes resulting from beta cell
destruction,leading to absolute insulin deficiency
a) Without vascular complication
b) With vascular complication
39. Preconceptional care
9/7/2023
Pre-gestational diabetes
39
Diabetic women should be encouraged to have
preconception counseling.
Discussions regarding fetal and maternal effects of
diabetes,
Importance of maintaining euglycemic control
before pregnancy,
Conversion of women on oral agents to insulin prior
to conception.
Stop drugs : oral hypoglycemic drugs, ACE inhibitors,
ARBs, beta blockers, Statins
40. Preconceptional care Con…
9/7/2023
Pre-gestational diabetes
40
Glycemic control goals during the preconception
period include:
Pre-prandial blood sugar levels 70-100mg/dl,
2-hr post-prandial levels 100-120mg/dl
Mean daily glucose concentration of <110mg/dl
HgbA1c <6.5 %
If glycemic control is inadequate:
Recommend contraception use until Hgb A1c goal is
reached
41. Preconceptional care Con…
9/7/2023
Pre-gestational diabetes
41
Direct correlation between HgbA1C and risk of
congenital anomalies.
HgbA1C <7 no increased risk
7 – 8.9% -- 5 - 10%
9 – 10.9% -- 10 - 20%
> 11% -- > 20%
In our case:- HgbA1C= not done
Most anomalies in 1st trimester lethal and result in
miscarriage
42. Preconceptional care Con…
9/7/2023
Pre-gestational diabetes
42
Examinations for vasculopathy on selected women
including retinal exam by an ophthalmologist, a 24-hr
urine for protein and creatinine clearance, and ECG.
40% of type 1 diabetic women have thyroid
dysfunction
Diabetic women are at high risk for neural tube
defects, begin 4 mg of folic acid before conception.
43. Preconceptional care Con…
9/7/2023
Pre-gestational diabetes
43
Systematic review to evaluate the effectiveness &
safety of pre-pregnancy care in improving the rate of
congenital malformations & perinatal mortality for
women with overt DM
21 studies, 3088 women, were included. Meta-analysis
suggested:- Pre-pregnancy care for women with type 1 or
type 2 DM is effective in improving rates of congenital
malformations, perinatal mortality and in reducing maternal
HbA1C in the 1st TMP
44. First OB Visit
9/7/2023
Pre-gestational diabetes
44
Nutrition counseling
Hgb A1c to assess prepregnancy control and assist in
counseling
RFT- serum creatinine and 24-hour urine for protein
Eye examination if not completed in the last 6months
ECG—for those with diabetes >5 years or co-morbid
conditions
Prescribe insulin therapy
Type 1 DM: TSH
45. Subsequent OB visits
9/7/2023
Pre-gestational diabetes
45
q 2 wks in the 1st and 2nd TM to evaluate blood sugars
MSAFP screening test at 16-18wks gestation.
Weekly visits after 28-30 weeks
Targeted ultrasound at 18-20 weeks
U/S for fluid and growth every 4-6 weeks from 24-28
Hgb A1c each trimester
Antenatal fetal testing q week beginning at 32 wks with
NST, BPP, modified BPP.
46. Fetal surveillance
9/7/2023
Pre-gestational diabetes
46
No data or randomized trials to make an evidenced-
based recommendation as to which pregnancies
complicated by diabetes should undergo
Fetal surveillance,
When to start,
What test to order, or
How often to perform it.
ACOG suggested antepartum monitoring using fetal
movement counting, BPP, NST, and/or contraction
stress test at "appropriate intervals," with initiation of
testing generally at 32 to 34 weeks of gestation.
47. Dietary management
9/7/2023
Pre-gestational diabetes
47
Caloric recommendations are based on the patient’s
pre-pregnancy weight:
35-40 kcal/kg for the underweight patient
30-35 kcal/kg for the average weight patient
25 kcal/kg for the overweight patient.
40-50% carbohydrates, 20-30% fats, & 20-30%
protein.
10% at breakfast; 30% at lunch; 30% at dinner; and
up to 30% for snacks, especially a bedtime snack to
reduce nocturnal hypoglycemia.
48. Insulin
9/7/2023
Pre-gestational diabetes
48
Total dose
0.7-0.8 unit/kg /d first trimester
0.8-1.0 unit/kg/d second trimester
0.9-1.2 unit/kg/d third trimester
Total dose
50-66% intermediate or long acting insulin
33-50% short acting insulin before meals
50. Oral hypoglycemic agents
9/7/2023
Pre-gestational diabetes
50
Sulfonylureas
Reduce insulin resistance and improve insulin secretion and
action
Early generation meds associated with fetal anomalies
(crossed placenta) and maternal hypoglycemia
Glyburide (2nd generation) compared with insulin among
GDM not diet controlled
Pregnancy outcomes similar
Cesarean delivery
Preeclampsia
Macrosomia
Neonatal hypoglycemia
Metformin acceptable alternative, although RCT’s less robust
51. Oral anti-diabetic agents for women
with pre-existing DM/impaired
glucose tolerance or previous GDM
9/7/2023
Pre-gestational diabetes
51
A U T H O R S ’ C O N C L U S I O N S
Little evidence is available evaluating the use of oral
anti-diabetic agents in women with DM, IGT or
previous GDM planning a pregnancy or pregnant
women with pre-existing DM.
Current guidelines recommend the use of insulin in
women with pre-existing DM, with the use of oral
anti-diabetic agents considered on an individual basis.
52. Self-monitored
Capillary Blood
Glucose Goals
In our case:- all are high
Women should be advised to
monitor their blood sugars at least
4 x/day: fasting (AM) and post-
prandial (breakfast, lunch,
dinner).
Women using continuous
subcutaneous insulin infusion
should be monitored with 7x/day
blood sugars (fasting both pre-
and post-prandial for all 3 meals).
52
9/7/2023
Pre-gestational diabetes
53. Delivery
9/7/2023
Pre-gestational diabetes
53
Optimal timing of delivery relies on balancing the
risk of intrauterine fetal death with the risks of
preterm birth.
It can be allowed to progress to 38 – 39 wks of GA
as long as antenatal testing remains reassuring
But expectant management beyond 40 wks is not
recommended.
54. Delivery…
9/7/2023
Pre-gestational diabetes
54
Early delivery (at GA of 37wks) may be indicated in some
patients with
vasculopathy
nephropathy
poor glucose control
a prior stillbirth after confirmation of fetal pulmonary maturity
Delivery between 34wks+0d and 36wks+6 d is reserved
for
failure of in-hospital glycemic control
abnormal fetal testing.
55. 9/7/2023
Pre-gestational diabetes
55
A 2011 NIH workshop, “Timing of Indicated Late Preterm and Early
Term Births,” echoed these recommendations. For women with
pregestational diabetes without vascular disease whose diabetes was
well controlled, the workshop experts recommended delivery at ≥39
weeks. For those with pregestational diabetes and vascular disease,
they suggested that delivery at 37 to 39 weeks was appropriate, and
that delivery as early as 34 weeks could be considered on an
individualized basis among patients with poor glycemic control.
56. Effect of elective delivery at or near term, as compared to
expectant , in diabetic pregnant women, on maternal and
perinatal mortality and morbidity.
9/7/2023
Pre-gestational diabetes
56
A U T H O R S ’ C O N C L U S I O N S
Results of the RCT comparing elective delivery with
expectant management at term in pregnant women
with insulin-requiring diabetes show that induction
of labour reduces the risk of macrosomia.
The risk of maternal or neonatal morbidity was not
different between groups.
There might be little advantage in delaying delivery
beyond 38-39 weeks and induction of labour might be
a reasonable option for these women.
57. Intrapartum Management
9/7/2023
Pre-gestational diabetes
57
Patient is kept NPO after midnight.
Usual dose of intermediate-acting insulin is given at
bedtime.
Withhold morning (AM) insulin injection.
Begin and continue glucose infusion (5% dextrose in
water) at 100 – 150 mL/hr.
Add 10 U of regular insulin to 1000 mL of solution
containing 5% dextrose.
58. 9/7/2023
Pre-gestational diabetes
58
Begin infusion of regular insulin if capillary glucose
is greater than 80 mg/dL.
Use fluid without dextrose if capillary glucose is
greater than 180 mg/dL.
Begin oxytocin as needed.
Monitor maternal glucose levels hourly. Adjust
insulin infusion
Intrapartum Management
60. Post partum management
9/7/2023
Pre-gestational diabetes
60
Type 1 - One third to one half of ante-partum daily
dose.
Type 2 - Pre pregnancy insulin regimen, or diet
controlled, or oral hypoglycemics can be restarted.
Ensure adequate follow-up, these patients need to be
referred to an endocrinologist.
61. Postpartum Care
9/7/2023
Pre-gestational diabetes
61
Breastfeeding should be encouraged
Postpartum depression is more common in women
with diabetes than in nondiabetic .
Ophthalmologic follow-up during the first year
postpartum is advised
since retinopathy can be aggravated anytime during
pregnancy or postpartum
62. WHO medical eligibility for contraceptive
use: Endocrine conditions
9/7/2023
Pre-gestational diabetes
62
65. References
9/7/2023
Pre-gestational diabetes
65
1. Gabbe 8th edition
2. Up to date 20
3. Williams obstetrics 25th edition
4. ACOG PRACTICE BULLETIN CLINICAL MANAGEMENT
GUIDELINES FOR OBSTETRICIAN–GYNECOLOGISTS NUMBER 6,
DECEMBER 2018
5. Cochrane Database of Systematic Reviews 2001, Issue 2. Art. No.:
CD001997. DOI: 10.1002/14651858.CD001997.
6. Management of diabetes and its complications from preconception to
the postnatal period…..RCOG 2015
7. MANAGEMENT PROTOCOL ON SELECTED OBSTETRICS
TOPICS…FDRE MOH 2020
Infertility : Amenorrhea in 50%
Insulin-1922
This dramatic improvement in perinatal outcome can be largely attributed to clinical efforts to establish improved maternal glycemic control both before conception and during gestation
In one US study, 2/3rd of pregestational DM was type 2
In the absence of special preconceptional diabetes management, spontaneous abortions occur in 7%-17% of diabetic pregnancies and major malformations occur in 7%-13%.
Maternal deaths increased by 10-fold
result from ketoacidosis, hypertension, preeclampsia, and pyelonephritis
A meta-analysis of 33 cohort studies comparing maternal and fetal outcomes in women with type 1 versus type 2 diabetes found that women with type 2 diabetes had better glycemic profiles than women with type 1 diabetes, but that outcomes such as congenital anomalies, stillbirth, and neonatal mortality were equivalent in both groups.
In fact, women with type 2 diabetes had a higher perinatal mortality risk than women with type 1 diabetes.
Excessive stillbirth rates in pregnancies complicated by diabetes have been linked to chronic intrauterine hypoxia.
Extramedullary hematopoiesis, frequently observed in stillborn IDMs, supports chronic intrauterine hypoxia as a likely cause of these intrauterine fetal deaths.
Macrosomia appears to be the most frequent fetal complication, affecting 10%- 33% of infants, depending on the definition used for macrosomia. 50% in GDM and 40% in overt diabetes.
Macrosomia increases the risk of birth trauma and has been associated with a long-term risk of obesity in offspring.
*Single criteria required for diagnosis: age of onset, duration, or vascular disease.
†When diagnosed during pregnancy: 500mg or more proteinuria per 24 hours measured before 20 weeks’ gestation.
Class A1 diabetes mellitus includes those women who have demonstrated carbohydrate intolerance during an oral glucose tolerance test (GTT); however, their fasting and postprandial glucose levels are maintained within physiologic range by dietary regulation alone.
Class A2 includes gestational diabetic women who require insulin or oral hypoglycemic therapy in response to repetitive elevations of fasting or postpartum glucose levels following dietary intervention.
Class R diabetes designates women with proliferative retinopathy, representing neovascularization or growth of new retinal capillaries. These vessels may cause vitreous hemorrhage with scarring and retinal detachment, resulting in vision loss.
Class F describes the 5% to 10% of pregnant patients with underlying renal disease. This includes those with reduced creatinine clearance or proteinuria of at least 300 mg in 24 hours measured during the first 20 weeks of gestation.
Class H diabetes refers to the presence of diabetes of any duration associated with ischemic myocardial disease.
A Hgb A1c level of approximately 5-6%, is associated with a fetal malformation rate close to that observed in normal pregnancies (2-3%), whereas a Hgb A1c concentration near 10% is associated with a fetal anomaly rate of 20-25%. (ACOG, 2005)Complex cardiac defects, renal abnormalities, CNS and skeletal abnormalities are the most common. Diabetes also increases the risk of fetal demise, preterm birth, polyhydramnios, altered fetal growth (IUGR or macrosomia) and neonatal RDS, hypoglycemia, hypocalcemia, hyperbilirubinemia, and cardiac hypertrophy.(Cunningham et al., 2010; HAPO, 2008) Glycemic control can reduce the risk for most if not all of these complications.
Glycosylated hemoglobin measurement, which expresses an average of circulating glucose for the past 8 to 12 weeks, is useful to assess early metabolic control. This duration may be lower in pregnancy b/c the half life of RBC less than 120 days in pregnancy due to increased production of RBC. That is why we determine HgbA1C every 4-6 weeks or atleast at each trimester.
If this is detected early in pregnancy, there is a high risk of congenital anomalies .
In late pregnancy it indicates increased incidence of macrosomia and neonatal morbidity and mortality
HbA1c levels should be measured monthly during the pre-conception period.
● Woman with an HbA1c level above the target level should be strongly advised to avoid
conception (√).
High dose folic acid supplementation (5mg daily) is advised for at least three months before conception, to be continued until 12 weeks gestational age.
Although low dose aspirin therapy does not reduce the rate of preeclampsia in the overall group of women with type 1 diabetes [14], it is less clear whether this therapy might benefit a subgroup of patients with diabetes-related vascular disease (hypertension, nephropathy). While controversial, some perinatologists recommend use of daily low dose aspirin (81 mg) for prevention of preeclampsia in women with diabetes-related vascular disease.
Subsequent visits should occur every 2 weeks in the first and second trimester to evaluate blood sugars with more frequent evaluation in those women with poor control or requiring multiple insulin adjustments. Weekly visits should occur after 28-30 weeks.
More frequent evaluation is necessary in those with poor control or requiring multiple insulin adjustments.
Patients with IUGR, hypertension, diabetic vasculopathy or history of IUFD may warrant earlier and more frequent testing.
MSAFP screening test should be performed between 16 and 18 weeks gestation because of the increased risk of neural tube defects. A lower threshold for the upper limit of normal MSAFP, 1.5 multiples of the median, thus may be preferable in pregnancies complicated by diabetes mellitus in order to help detect spina bifida and other major malformations that are increased in this population.
ACOG recommends antepartum fetal testing for pregnancies complicated by pregestational diabetes.
Intrauterine fetal demise is now a rare complication of diabetic pregnancy, primarily due to achievement of good glycemic control. The fetus of the diabetic mother is at risk for hypoxia primarily from two mechanisms: (1) fetal hyperglycemia and hyperinsulinemia increase fetal oxygen consumption, which may induce fetal hypoxemia and acidosis if the oxygen needs of the fetus are not met, and (2) maternal vasculopathy and hyperglycemia can lead to reduced uteroplacental perfusion, which may be associated with reduced fetal growth
At least one study, however, has questioned the reassurance provided by a normal amniotic fluid volume in diabetic pregnancies, finding that the NST, but not the amniotic fluid index, was predictive of a nonreassuring fetal heart rate tracing in labor requiring cesarean delivery
The nonstress test (NST) remains the preferred primary method to assess antepartum fetal well-being in the patient with diabetes mellitus.
Exercise
All women should follow a program of moderate exercise (30 minutes of walking at least 5 times per week) as part of the treatment plan, barring any medical or obstetrical contraindication to this level of physical activity.
Diabetes in pregnancy has traditionally been treated with the recombinant human insulins, including short-acting regular and medium-acting NPH.
Semisynthetic human insulin preparations and newer insulin analogs are preferred for use during pregnancy. Insulin lispro and insulin aspart are rapid-acting insulin preparations that have replaced regular insulin.
Insulin lispro appears to be safe for use during pregnancy and is a category B drug.
During the night, glucose levels should not decrease to less than 60 mg/dL. Mean capillary glucose levels should be maintained at an average of 100 mg/dL with a glycosylated hemoglobin A1C (Hb A1C) concentration no higher than 6%.
Short- or rapid-acting insulins (short-acting regular insulin, insulin lispro, and insulin aspart) are administered before meals to reduce glucose elevations associated with eating.
Longer acting insulins are used to restrain hepatic glucose production between meals and in the fasting state.
Intermediate-acting insulin usually is given before breakfast with a rapid- or short-acting insulin and before the evening meal or at bedtime. Bedtime dosing is preferred because an injection given with the evening meal may increase the risks of nocturnal hypoglycemia.
In a study published in 2008, Hod et al randomized 412 patients with 322 pregnancies in women with type 1 diabetes to treatment either with aspart and NPH or humulin regular insulin and NPH preconceptionally or in the first trimester.
Although not a primary end point, women in both groups experienced similar rates of fetal loss, perinatal mortality, and congenital anomalies, and had comparable short-tem neonatal outcomes.
Maternal glycemic control was markedly improved in patients receiving aspart as compared with regular insulin, and the number of hypoglycemic episodes was lower.
There was no difference in hemoglobin A1c levels during pregnancy between the 2 groups.
The use of oral agents for control of type 2 diabetes mellitus during pregnancy should be limited and individualized until data regarding the safety and efficacy of these drugs become available.
Oral Hypoglycemic Agents in women with pregestational diabetes is not recommended except in rare circumstances when used as an adjunct to improve insulin sensitivity or in patients who refuse insulin treatment despite counseling.
Additionally, women with impaired glucose tolerance or gestational diabetes in a previous pregnancy represent a group of women with relative insulin resistance, and are at risk of developing type 2 diabetes mellitus. Appropriate management of these women is unclear.
There were no data from randomised controlled trials evaluating the use of oral anti-diabetic agents for women with pre-existing diabetes mellitus, impaired glucose tolerance or previous gestational diabetes pre-conceptionally or for pregnant women with pre-existing diabetes that was able to be included in this review.
There is no strong evidence of benefit from strict versus moderate to strict glucose targets.
There are two potential hazards from strict glycemic control: hypoglycemia and worsening of diabetic retinopathy
The study was too small to assess the effect on perinatal mortality.
Ind.Of L. @38 w Vs expectant mx:
- similar LUSCS rate, but
- reduced macrosomia and shoulder dystocia in elective ind.of l
A 2011 NIH workshop, “Timing of Indicated Late Preterm and Early Term Births,” echoed these recommendations [79]. For women with pregestational diabetes without vascular disease whose diabetes was well controlled, the workshop experts recommended delivery at ≥39 weeks. For those with pregestational diabetes and vascular disease, they suggested that delivery at 37 to 39 weeks was appropriate, and that delivery as early as 34 weeks could be considered on an individualized basis among patients with poor glycemic control.
Insulin requirements decrease rapidly after delivery.
• GDM - No therapy required. If the need arises, use of oral hypoglycemic agents can normalize the blood glucose concentration. Medical follow-up of these patients must be more intense as they are more likely to remain or progress to overt diabetes.
Pregnancy is characterized by increased insulin resistance and reduced sensitivity to insulin action.
The increase in insulin resistance is largely the result of a mixture of placental hormones, including human placental lactogen, progesterone, prolactin, placental growth hormone, and cortisol.
More recently, tumor necrosis factor α and leptin have been implicated as contributors to the insulin resistant state of pregnancy
Increasing evidence suggests that breast-feeding may give the offspring protection from type 2 diabetes as well as a decreased likelihood of developing obesity in childhood and young adulthood. Most recently, the Nurses Health Study found that the duration of breast-feeding was inversely associated with the risk of type 2 diabetes in two large cohorts of women.
1: A condition for which there is no restriction for the use of the contraceptive method. 2: A condition where the advantages of using the method generally outweigh the theoretical or proven risks. 3: A condition where the theoretical or proven risks usually outweigh the advantages of using the method. 4: A condition which represents an unacceptable health risk if the contraceptive method is used. COC: low-dose combined oral contraceptive; CIC: combined injectable contraceptives; P: combined patch; R: combined vaginal ring; POP: progestogen-only pill; DMPA: depot medroxyprogesterone acetate; NET-EN: norethisterone enantate; LNG: levonorgestrel; ETG: etonogestrel; ECP: emergency contraceptive pill; Cu-IUD: copper intrauterine device; LNG-IUD: levonorgestrel-releasing IUDs; E-IUD: copper-IUD for emergency contraception; BARR: barrier methods; FAB: fertility awareness-based methods; LAM: lactational amenorrhoea method; CI: coitus interruptus; STER: female and male sterilization.
1) background retinopathy, characterized by retinal microaneurysms and dot-blot hemorrhages; and
2) Proliferative retinopathy, marked by neovascularization.
The rapid institution of strict glycemic control in women with diabetes during pregnancy has been associated with acute progression of retinopathy, particularly in women with hypertensive disorders, including preeclampsia
women who demonstrate severe florid disc neovascularization that is unresponsive to laser therapy during early pregnancy may be at great risk for deterioration of their vision. Termination of pregnancy should be considered in this group of patients.
Women with proliferative retinopathy are generally advised to avoid the Valsalva maneuver to reduce the risk for retinal hemorrhage. Shortening of the second stage or cesarean delivery has been advocated; however, studies are lacking that address this issue.
