Complications Delivery information by diabtesasia.org
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Our aim is to alleviate human suffering related to diabetes and its complications among those least able to withstand the burden of the disease. From 2002 to March 2017, the World Diabetes Foundation provided USD 130 million in funding to 511 projects in 115 countries. For every dollar spent, the Foundation raises approximately 2 dollars in cash or as in-kind donations from other sources. The total value of the WDF project portfolio reached USD 377 million, excluding WDF’s own advocacy and strategic platforms.
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Complications Delivery information by diabtesasia.org
- 2. Objectives Discuss causes, prevention strategies and treatment of hypoglycemia for those women on insulin Discuss premature labour, recognizing contractions, and action to take Discuss diagnosis and treatment of preeclampsia 2
- 3. Definition of hypoglycemia 1. The development of autonomic or neuroglycopenic symptoms 2. Low plasma glucose (less than 4.0 mmol/L or 72 mg/dl) 3. Symptoms resolved by administration of carbohydrate Cryer, Davis, Shamoon, 2003 3
- 4. Risk of hypoglycemia (1 of 3) Only those taking glucose-lowering medicines or insulin are at risk Risk increases with: • Not enough carbohydrate consumption • Late or missed meal • Fasting or malnourishment • Too much insulin • Prolonged or unplanned activity 4
- 5. 5
- 6. 6 Canadian Diabetes Association, 2013
- 7. 7
- 8. Effect Of Hypoglycemia On Fetus Fetal heart rate, as well as fetal movements and placental perfusion appear to be unchanged during conditions of maternal hypoglycemia in the range of 2.5 – 3.0 mmol/L (45–55 mg/dL) Coustan, 2009 Diamond, Reece et al, 1992 Nisell, Persson, et al1994 Reece, Hagav, et al 1995 8
- 9. 9 Canadian Diabetes Association, 2013
- 10. Treatment Severe • 20 g glucose • Glucagon 1ml SC or IM; increases BG by 3 -12 mmol/L (54-216 mg/dl) over 60 min • IV dextrose- 20 to 50 ml of 50% dextrose over 2 to 3 minutes; immediate response is seen • Manage seizure- place person on their side if not too agitated 10
- 11. Follow-up management • Meal or snack (15 to 20 g carbohydrate + a protein source) • Next dose of insulin taken as usual if cause is known and hypo was mild • Consider reducing next dose of insulin if hypo was severe • Assess cause and prevent recurrence • Avoid BG levels < 4 mmol/L (72 mg/dL) 11
- 12. Premature Labour Preterm labour in GDM – can use steroids and tocolysis as for other pregnancies Preferably avoid betamimetic as tocolytics Nifidepine is a good choice Both steroids / tocolytics can push glucose up so need to monitor closely and cover with insulin / increasing dose of insulin Rule out UTI as a risk factor for preterm labour 12
- 13. Preeclampsia • Women with GDM are at increased risk of preeclampsia; this is partly due to the increased insulin resistance • It is possible that this increase could be accounted for by the fact that their age and BMI predispose them to GDM as well as hypertension. • Monitor BP & urine albumin every visit Hollander 2007 13
- 14. Delivery 14
- 15. Objectives Discuss when to deliver infant Discuss options for inducing labour Discuss implications of Caesarian section 15
- 16. Timing of delivery – the same for all? • Women with diabetes before pregnancy are at increased risk • In GDM perinatal mortality rates lower • If insulin requiring, best to use approach similar to pregestational DM • GDM managed on diet and exercise alone possibly not at any greater risk from baseline • Depends on severity and duration of diabetes as well as co morbidities 16
- 18. Consider…. Gestational specific risks for still birth continue to fall up to 38 weeks but increase slightly over 40 weeks In insulin dependent women most would plan delivery 38 - 39 weeks Between 38 and 39 weeks No difference in incidence of cesareans More larger babies in one study There is as yet not enough evidence that induction in diabetic pregnancies prevents fetal macrosomia 18
- 19. In diet controlled GDM women most would be comfortable to 40 weeks With good control and reassuring tests of well being some centres go on to 41 weeks Patel, Steer, Doyle et al. 2003 19
- 20. Mode of delivery Matter of choice High section rates – 30 – 80% averaging 50% in many centres Vaginal delivery is possible and safe Previous obstetric history EFW Other clinical factors Induction of labour is a safe option 20
- 21. Monitoring labour Labour is a time of unpredictable glucose and insulin demands – risk of hypoglycemia Sliding scale / infusion Maintain plasma glucose below 110 mg/dl to avoid maternal hyperglycemia and subsequent foetal hypoglycemia Careful intrapartum FHR monitoring Pay attention to second stage – slow progress is a red flag Caution with instrumental delivery Be prepared for shoulder dystocia Jovanovic L. 2005 21
- 22. References COMPLICATIONS Canadian Diabetes Association Expert Committee. Canadian Diabetes Association 2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Can J Diab 2013;37(suppl 1):S69-71 Coustan, D, Glob. libr. women's med., (ISSN: 1756-2228) 2009; DOI 10.3843/GLOWM.10162 Cryer P.E. Davis, S.N. Shamoon, H. Hypoglycemia in diabetes. Diabetes Care, 2003;26(6):1902-1912 Diamond MP, Reece EA, Caprio S et al: Impairment of counterregulatory hormone responses to hypoglycemia in pregnant women with insulin-dependent diabetes mellitus. Am J Obstet Gynecol 1992;166:70-77 Hollander M, Paarlberg KM, Huisjes AJM, 2007 Gestational Diabetes: A Review of the Current Literature and Guidelines Volume 62, Number 2 Obstetrical and Gynecological Survey Nisell H, Persson B, Hanson U, et al: Hormonal, metabolic and circulatory responses to insulin-induced hypoglycemia in pregnant and nonpregnant women with insulin-dependent diabetes. Am J Perinatol 1994;11:231-236 Reece EA, Hagay Z, Roberts AB et al: Fetal Doppler and behavioral responses during hypoglycemia induced with the insulin clamp technique in pregnant diabetic women. Am J Obstet Gynecol 1995;172:151-155. Saleh M., Grunberger, G. Hypoglycemia: A cause for poor glycemic control. Clinical Diabetes, 2001;19(4):161-167. DELIVERY Jovanovic L, Knopp RH, Kim H, et al. Elevated pregnancy losses at high and low extremes of maternal glucose in early normal and diabetic pregnancy: evidence for a protective adaptation in diabetes. Diabetes Care 2005; 28:1113. Patel RR, Steer P, Doyle P, Little MP, Elliot P. Does gestation vary by ethnic group? A London-based study of over 122000 pregnancies with spontaneous onset of labour. Int J of Epid. 2003;33:107-113.DOI: 10.1093/ijc/dyg238. 22
Editor's Notes
- Cryer P.E. Davis, S.N. Shamoon, H. (2003). Hypoglycemia in diabetes. Diabetes Care, 26(6),1902-1912
- Severe hypoglycaemia is more common following a previous episode of hypoglycaemia. This is because the normal subsequent counter-regulatory responses are blunted. It may also be that a person did not consume adequate carbohydrate in response to the initial hypoglycaemia. People who have frequent mild to moderate hypoglycaemic reactions may also have blunted glucagon response putting them at risk for severe hypoglycemia. Overcorrection of elevated blood glucose levels is a very common cause of hypoglycaemia. It is difficult to predict the effect of stress on blood glucose levels. Women with type 1 diabetes in their first trimester of pregnancy – particularly during weeks eight to 12 – often experience wide swings in blood glucose levels, including many low levels. Breastfeeding women are also at higher risk. Safety is a major concern; they should always eat before driving, for instance, and always test before feeding or bathing the baby. Comorbidities such as gastroparesis, liver disease or kidney failure may increase the risk of hypoglycaemia. Gastroparesis results in delayed gastric emptying and therefore delays the uptake of glucose. If medication has been taken, this may work before the glucose reaches the blood. Liver or kidney disease may alter the clearance of medicines and provoke prolonged action or build up of glucose-lowering medicines.
- Physiology forms the basis for definitions of low levels of blood glucose as “mild’’, “moderate’’ and “severe’’. It is important to assess hypoglycaemia in terms of incidence, realistic prevention goals and treatment. We should hope to prevent all severe hypoglycaemia. However, some mild-to-moderate hypoglycaemia must be expected given the current available diabetes treatments. Canadian Diabetes Association Expert Committee. Canadian Diabetes Association 2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Can J Diab 2013;37(suppl 1):S69-71
- People with diabetes, their families and healthcare providers fear hypoglycaemia. Their fears are justified: hypoglycaemia has social and health implications. People with diabetes who are hypoglycaemic may act “inappropriately’’ or appear drunk. The treatment of hypoglycaemia may also cause embarrassment. (Cryer, 2003) Presenting symptoms of hypoglycaemia are very troubling and frightening. Moreover, hypoglycaemia can lead to injury, such as falling and fracturing bones; an accident while driving – possibly resulting in loss of driving license as well as any physical consequences; cognitive impairment; and on rare occasions death. Hypoglycaemia, severe hypoglycaemia in particular, may be a major limitation to achieving desired goals of blood glucose control. Cryer P.E. Davis, S.N. Shamoon, H. (2003). Hypoglycemia in diabetes. Diabetes Care, 26(6),1902-1912 Saleh M., Grunberger, G. (2001). Hypoglycemia: A cause for poor glycemic control. Clinical Diabetes, 19(4), 161-167.
- Coustan, D, Glob. libr. women's med., (ISSN: 1756-2228) 2009; DOI 10.3843/GLOWM.10162 Diamond MP, Reece EA, Caprio S et al: Impairment of counterregulatory hormone responses to hypoglycemia in pregnant women with insulin-dependent diabetes mellitus. Am J Obstet Gynecol 1992;166:70-77. Nisell H, Persson B, Hanson U, et al: Hormonal, metabolic and circulatory responses to insulin-induced hypoglycemia in pregnant and nonpregnant women with insulin-dependent diabetes. Am J Perinatol 1994;11:231-236. Reece EA, Hagay Z, Roberts AB et al: Fetal Doppler and behavioral responses during hypoglycemia induced with the insulin clamp technique in pregnant diabetic women. Am J Obstet Gynecol 1995;172:151-155.
- Hypoglycaemia must be treated quickly. If possible, blood glucose levels should be measured with a meter to confirm hypoglycaemia. Do not delay treatment. If a meter is not available, treat the symptoms. If hypoglycemia occurs before a meal, it should be treated then the meal taken as usual. After treatment, wait 15 minutes before testing again. If blood glucose remains lower than 4 mmol/L (72 mg/dL), glucose should be consumed. Through fear or impatience, people have a tendency to over-treat hypoglycaemia. People with diabetes and healthcare professionals should learn not to over-treat; the blood glucose may get too high. This is known as rebound hyperglycemia. This slide shows examples of treatment of mild or moderate hypoglycaemia. The recommended measures are: Glucose tablets or glucose gel if available 1/2 (125 mls) cup fruit juice 150 mls soft drink 3 teaspoons sugar or honey 1 cup of milk Glucose should be given in a quickly absorbed form – that is as “straight’’ sugar. Canadian Diabetes Association Expert Committee. Canadian Diabetes Association 2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Can J Diab 2013;37(suppl 1):S69-71
- It is not advisable to repeat the glucagon; after a single dose, the person with diabetes will usually be able to take further glucose orally. If not, an ambulance should be called or the person transported to a hospital. In people with severe hypoglycaemia, when confusion or loss of consciousness prevents self-management, it is imperative to ensure their airway is clear before administering a form of glucose. If there is no glucagon available, and the person is not able to take fluids, honey or sugar substance could be smeared on the buccal mucosa. This has been shown not to work very well but when there is no other option it is worth trying.
- Treatment should be followed by the planned snack or meal. If the usual meal or snack is not planned for another hour or more, a snack consisting of carbohydrate (15-20 g) and protein may be needed. In mild to moderate hypoglycaemia, the next dose of diabetes medication or insulin is usually given. However, this should be individually assessed depending on the cause of the hypoglycaemia and the severity of the episode. After a severe episode, the next dose of insulin would likely be omitted or reduced by an amount predetermined by the health professional – by about 20% for 24 or 48 hours, for example. Although the causes of 50% of hypoglycaemic events are unknown, people with diabetes should be encouraged to try to determine the cause of hypoglycaemia and adjust treatment or lifestyle accordingly to prevent this occurring in the future.
- There may be iatrogenic prematurity in GDM or type 1 – if glucose levels are very high the decision may be taken to deliver before 37 weeks.
- Hollander M, Paarlberg KM, Huisjes AJM, 2007 Gestational Diabetes: A Review of the Current Literature and Guidelines Volume 62, Number 2 Obstetrical and Gynecological Survey
- In women with GDM, infant mortality rates at 39 weeks are lower than the overall mortality risk of expectant management for 1 week; absolute risks of stillbirth and infant death are low. http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=22464068
- In India, most will not allow beyond 40 weeks even if on diet alone and well controlled. ( ref of Indian babies maturing faster/ more meconium etc) Patel RR, Steer P, Doyle P, Little MP, Elliot P. Does gestation vary by ethnic group? A London-based study of over 122000 pregnancies with spontaneous onset of labour. Int J of Epid. 2003;33:107-113.DOI: 10.1093/ijc/dyg238.
- Jovanovic L, Knopp RH, Kim H, et al. Elevated pregnancy losses at high and low extremes of maternal glucose in early normal and diabetic pregnancy: evidence for a protective adaptation in diabetes. Diabetes Care 2005; 28:1113.