Endocrine Disorders in Pregnancy

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Endocrine Disorders in Pregnancy

  1. 1. MEDICAL DISORDERS COMPLICATING PREGNANCY ENDOCRINE DISORDERS IN PREGNANCY Prof.S.SUNDAR’s unit Dr.N. ARUN KUMAR,PG
  2. 2. Gestational Diabetes Mellitus
  3. 3. What is GDM? • Corbohydrate intolerance of variable severity with onset or first recognition during pregnancy
  4. 4. Pre-Gestational Diabetes • a known diabetic becomes pregnant • hyperglycemia presents throughout pregnancy and not just in the 2nd half as occurs in GDM • more prone for certain complications
  5. 5. Pathophysiology of GDM Fetoplacental hormones (GH, cortisol, prolactin, HPL) Increased insulin resistance Compensatory increase in insulin secretion if not so Normal pregnancy GDM
  6. 6. Insulin resistance & Compensatory stress due to increase in placental insulin hormones secretion
  7. 7. Epidemiology • Prevalence of GDM vary worldwide because of different criteria and screening regimen used for diagnosing GDM in various countries • India – 6% - 18%
  8. 8. Risk factors for GDM • Strong family h/o DM • Age >25 years • Women who delivered large infants (>4Kg) • h/o recurrent fetal loss • Part h/o glucose intolerance / diabetes in previous pregnancies • Obese/ over weight women (>15% of non-pregnant ideal body weight) • h/o still-birth, unexplained neonatal death, congenital malformations, prematurity • h/o pre-eclampsia • h/o polyhydramnios • h/o traumatic delivery • Chronic hypertension • Recurrent severe moniliasis/UTI
  9. 9. Whom to screen? Low risk Universal Universal screening is good in Indian setting because of the very high prevalence of both GDM & background T2DM
  10. 10. When to screen? 1st 2nd 3rd trimester trimester trimester
  11. 11. How to screen? If normal glucose tolerance in 1st trimester Repeat at 24-28 weeks Repeat at 32-34 weeks Repeat at later weeks (if increased Maternal weight gain & suspected Fetal macrosomia)
  12. 12. ADA Procedure 50 gm of GCT (Without regard to the time of last meal or time of the day) If 1 hr GCT value >140mg% <140mg% 100 gm of OGTT NORMAL at fasting
  13. 13. • 100 gm of OGTT is positive if there is any of the following 2 values: • Plasma glucose at 0 hr ≥95 mg% • Plasma glucose at 1 hr ≥180 mg% • Plasma glucose at 2 hr ≥155 mg% • Plasma glucose at 3 hr ≥140 mg%
  14. 14. WHO Procedure • 75 gm of OGTT • If 2 hr value ≥140 mg%  positive for GDM • This is parallel to impaired glucose tolerance in non-pregnant women • ADVANTAGES: • Need not be fasting • Least disturbances in pregnant women’s routine activities • Serves as both screening & diagnostic procedures
  15. 15. Glycemic criteria for diagnosis of different categories of glucose intolerance by 75 gm, 2 hr OGTT Criteria Fasting plasma 2 hr plasma glucose glucose Normal glucose tolerance <100 mg% <140 mg% Impaired fasting glucose 100-125 mg% - Impaired glucose tolerance - 140-199 mg% Diabetes mellitus ≥126 mg% ≥200 mg%
  16. 16. Plasma glucose In pregnancy Outside pregnancy 2 hr ≥200 mg% DM DM 2 hr 140-199 mg% GDM IGT 2 hr 120-139 mg% GGI Normal 2 hr <120 mg% Normal Normal
  17. 17. Maternal complications Effects of diabetes on mother Effects of pregnancy on diabetes 1st trimester – risk of recurrent abortions More insulin is necessary to achieve metabolic control Infection – chorioamnionitis & Progression to diabetic retinopathy postpartum endometritis Pre eclampsia – 10-25 % Worsening of diabetic nephropathy Postpartum bleeding Increased risk of death for patients with diabetic cardiomyopathy & MI Caesarian section – due to fetal macrosomia & CPD
  18. 18. Fetal complications • Congenital abnormalities – due to metabolic derangements present at the time of conception, during blastogenesis & organogenesis • Hyperglycmia macrosomia traumatic delivery • Hypocalcemia • Intermittent hypoglycemia IUGR • Hyperviscosity syndrome • Hyaline membrane disease • Apnoea & bradycardia • Unexplained fetal demise (last 4-8 weeks of gestation)
  19. 19. Effect on fetal growth Maternal hyperglycemia priming (16 weeks) fetal pancreas increased beta cell mass Increased insulin secretion
  20. 20. Persistent fetal hyperinsulinemia Over growth of insulin-sensitive tissue (mainly adipose tissue) Accelerated fetal growth (fetal macrosomia)
  21. 21. Macrosomic baby !
  22. 22. Neonatal complications • Respiratory distress • Hypoglycemia • Hypocalcemia • Hyperbilirubinemia • Cardiac hypertrophy • Long term effects on cognitive development
  23. 23. Inter-generational effect !!! GDM DM in offspring GDM DM in offspring GDM……………………….....
  24. 24. Management of GDM Diabetologist obstetrician /physician pediatrician dietician
  25. 25. Components of GDM management Medical Nutrition 1 Therapy (MNT) 2 Physical activity Pharmacological 3 therapy
  26. 26. Medical Nutrition Therapy (MNT) • Adequate calories & nutrients • Expected weight gain: 300-400gm/week • Total weight gain: 10-12 kg • Obese pregnant women: 5-6 kg • Meal plan: to provide sufficient calories to sustain adequate nutrition for mother & fetus to avoid excess weight gain & PP hyperglycemia
  27. 27. Medical Nutrition Therapy contd… • Calorie requirement depends on age, pre- pregnancy weight, activity & gestational week of pregnancy • Increase of 300kcal/day above basal requirement is needed in 2nd & 3rd trimester
  28. 28. Calorie counting • Distributing calorie consumption especially break fast • Splitting the usual break fast into 2 equal halves with a gap of 2 hr in between • Undue peak in plasma glucose levels after ingestion of the total quantity of break fast at one time is avoided • >90% of GDM can be managed by MNT
  29. 29. Physical Activity Planned physical activity – those who are capable of participating Exercises that use upper body muscles or those exercises which place little mechanical stress Brisk walking or arm exercise while seated in a chair for at least 10 mins after each meal
  30. 30. Glycemic targets ACOG – ADA – FIWC – venous plasma capillary Capillary • Fasting venous • Pre-meal 80- • Fasting <96mg% plasma ≤ 95mg% 110mg% • 1 hr PP <140mg% • 1 hr PP ≤ • 2 hr post-meal ≤ • 2 hr PP <130mg% 140mg% 155mg% • 2 hr PP ≤ 120mg% • Pre-meal 100mg% • HbA1C ≤ 6
  31. 31. Effects of 2 hr PG on offspring Acute Chronic If 2 hr PG >140mg% If 2 hr PG in 3rd trimester 120-139mg% Increase in birth weight, neonatal Risk of having T2DM at 24 years -19% adiposity, cord c peptide level >90th percentile If 2 hr PG in 3rd trimester 140-199mg% Risk of having T2DM at 24 years -30%
  32. 32. Diagnosis of GDM In 1st & 2nd trimester in 3rd trimester MNT for 2 weeks MNT for 1 week if fails if fails Insulin therapy insulin therapy
  33. 33. Insulin therapy Pre-mix insulin 30/70 4U–0–0 If target glycemic levels not achieved increase 2 units every 4th day (max 10 U) If FPG >90mg% 6U–0–4U If 2 hr PG is >200mg% 8U–0–0
  34. 34. General concepts in insulin therapy • Start with possible lowest effective dose • Of the total insulin dose  2/3 in morning, 1/3 in evening • Of the total insulin dose  1/3 is regular insulin, 2/3 is basal insulin • Increase gradually every 4th day according to FBS/PPBS values • If PPBS is high, increase the dose of regular insulin in the morning • If FBS is high, add basal insulin at night • Insulin requirements increased by 50% from 20-24 weeks to 30-32 weeks • GDM women don’t require >20 units/day • Pre-GDM women during pregnancy may require higher doses • Insulin dosages is always individualized & adjusted on follow up
  35. 35. OADs • Tolbutamide, chlorpropamide, glipizide diffuse across placenta freely – fetal hyperinsulinemia & prolonged neonatal hypoglycemia • Glyburide crosses the placenta the least • Fetal concentration of glibenclamide reaches not more than 1-2% of maternal levels – not associated with excess anomalies or hypoglycemia • Glybenclamide – safe & equally effective as insulin
  36. 36. Metformin • Safe for use in GDM • Alone or in combination with insulin – not associated with increased perinatal complications as compared to insulin • Combined treatment with both insulin & metformin – req lower dose of insulin, lesser weight gain than those on insulin alone
  37. 37. USG fetal measurements • Done in every trimester • Fetal echo –must at 24 weeks to R/O cardiac defects • Fetal biophysical profile in late trimester • Doppler umbilical blood flow measurement or CTG at 36 weeks in GDM with other pregnancy complications PE, HTN, APH, IUGR
  38. 38. Timing of delivery • Delivery before full term avoided, unless there is e/o macrosomia, polyhydramnios, poor metabolic control & other obstetric indications • Increased obstetric interventions (induction, caesarian section)
  39. 39. Delivery • Maintain good glycemic control during labour • Avoid hypoglycemia • Lower insulin requirements are common (often no insulin is necessary) • Blood sugar monitoring after delivery, 24 hrs postpartum if found to be high, follow up • Presence of neonatologist –must.
  40. 40. Plasma glucose & Insulin/ iv fluids during labour Blood sugar at the onset of Insulin /iv fluids labour < 70 mg% 5% GNS @ 100ml/hr 90-120mg% NS @ 100ml/hr 120-140mg% 4 units HA in 1 pint NS @ 100ml/hr 140-180mg% 6 units HA in 1 pint NS @ 100ml/hr >180mg% 8 units HA in 1 pint NS @ 100 ml/hr
  41. 41. Neonatal management • Normal birth weight: 2.5-3.5 kg • Monitoring for respiratory distress • Capillary blood glucose at 1, 2, 4 hrs after delivery & before feeding (cut off 44mg%) • Early breast feeding • In nursing PreGDM mothers good glycemic control during lactation, by insulin.
  42. 42. Follow up in GDM OGTT with 75 gm oral glucose (WHO criteria) at 6-8 weeks postpartum if normal twice yearly or yearly follow up • Considerable proportion of GDM women continue to have glucose intolerance
  43. 43. • Counselling • Increased risk of T2DM, metabolic syndrome • Healthy eating & exercise pattern • Planning future pregnancy contraceptive advice & counselling • Pre conception OGTT
  44. 44. Carry home messages…….. • Universal screening at 1st trimester, possibly at 1st ante natal visit • Use WHO criteria with single step procedure • Start insulin with possible lowest effective dose & stick into the insulin protocol • FBS maintained ≤90mg%; PPBS maintained ≤120mg% • USG & other fetal mesurements should be done at every trimester • Proper obstetric interventions (induction, C.S.) should be needed at proper time • Good glycemic control should be achieved during labour by using proper insulin & IV fluids as per the protocol • Post partum follow up is must
  45. 45. PREGNANCY & THYROID DISORDER
  46. 46. Changes in Thyroid gland Thyrotropic asialo hCG effect of hCG & asialo-hCG increase in Sr.TG conc. Thyroid gland enlarges by an average of 18%
  47. 47. Increased hepatic Increased synthesis & estrogen decreased metabolic clearance of TBG Increased total T4 & T3 Increased Free T4 & T3 TBG conc. Normal
  48. 48. 5 factors that alter Thyroid function in Pregnancy 1. Transient increase in hCG during 1st trimester  stimulates TSH-R (transient gestational hyperthyroidism) 2. Estrogen induced increase in TBG 3. Alterations in immune system  onset, exacerbation or amelioration of underlying autoimmune thyroid disease 4. Increase thyroid hormone metabolism by placenta 5. Increase in urinary iodide excretion  decreased thyroid hormone production in areas of marginal iodine deficiency
  49. 49. Hypothyroidism in pregnancy • Women with a h/o or high risk of hypothyroidism  ensure euthyroid prior to conception & during early pregnancy
  50. 50. Whom to screen? • if they have goiter/features of hypothyroidism • family h/o autoimmune thyroid disease
  51. 51. When to evaluate? • Prior to conception • Immediately after pregnancy is confirmed • At the beginning of 2nd & 3rd trimester
  52. 52. Maternal hypothyroidism Adversely affect Fetal neural development
  53. 53. Treatment of Hypothyroidism in pregnancy • Levothyroxine is the drug of choice • Usual dosage in non-pregnant state  1.6 mcg/kg/day (typically 100-150 mcg/day) • Dose is increased by ≥50% during pregnancy • Returned to previous levels after delivery
  54. 54. Diagnosis of thyrotoxicosis during pregnancy • Decrease in Sr.TSH levels <0.1mU/L • In 8-14 weeks  hCG causes stimulation of thyroid gland  only modest suppression of TSH (0.1-0.4 mU/L) • Confirmation of thyrotoxicosis  Sr.TSH <0.1mU/L; increase in free T4
  55. 55. TSH • 0.34-4.25 mU/L Normal At the end of 1st • 0.1-0.4 mU/L trimester Diagnosis of • <0.1 mU/L thyrotoxicosis in pregnancy
  56. 56. Treatment of thyrotoxicosis in pregnancy
  57. 57. Anti Thyroid Drugs • Propyl thio uracil (PTU)  usual initial dose is 100-200 mg every 6-8 hr • Carbimazole / Methimazole usual initial dose is 10-20 mg every 8-12 hr • MOA: all drugs inhibit the function of TPO, reducing oxidation & organification of iodide
  58. 58. PTU Anti thyroid drug of choice in pregnancy
  59. 59. Anti Thyroid Drugs • No greater risk to mother & fetus • Medical treatment is the treatment of choice • Dosage of ATD required to control the disease in later phases of pregnancy is decreased ( because of usual improvement in disease due to immunosuppression  decrease in TRAb in pregnancy)
  60. 60. • PTU & methimazole crosses placenta  concentrated in fetal thyroid  goiterous hypothyroidism in fetus • 150 mcg/day of PTU to mother  decrease fetal free T4 & increase TSH • PTU >200mcg/day especially in 3rd trimester  fetal goiter & neonatal respiratory distress • Sr. free T4 should be maintained in upper normal range; no attempt made to normalize Sr.TSH conc.
  61. 61. • Daily maintenance dose of PTU ≤200mcg/day in early pregnancy • PTU is the drug of choice • Pregnant women with Grave’s disease – monitoring fetus for intrauterine thyroid dysfunction (fetal heart rate, USG assessment of fetal growth rate, presence of goiter) • If dosage requirement >200mcg/day: indication for subtotal thyroidectomy (in 2nd trimester)
  62. 62. • Beta blocker: IUGR, delayed lung development, neonatal hypoglycemia, (can be given in lower dose for short period) • Post partum period is a time of major risk of relapse • Breast feeding is safe with lower doses of anti thyroid drugs
  63. 63. A common clinical problem Over-treatment of hyperthyroidism • Parallels influence of maternal hypothyroidism on fetal brain development & decreased IQ • Better to maintain in slightly hyperthyroid state rather than slightly hypothyroid state
  64. 64. Carry home message……. • Transient gestational hyperthyroidism is common in 1st trimester (TSH level should be <0.1mU/L to diagnose thyrotoxicosis) • Look at free T4 & T3; not total T4 & T3 • PTU is the drug choice – dose in early pregnancy is <200 mcg/day; later phases <150 mcg/day • Radio iodine treatment is contraindicated • Subtotal thyroidectomy – indicated in 2nd trimester, if the need of PTU >200 mcg/day • Over treatment of hyperthyroidism is a common clinical problem • Keep Sr. free T4 in upper level of normal range

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