DIABETES IN PREGNACY full presentation.pptx

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1. DIABETES IN PREGNACY PRESENTED BY GU-2

2. CASE-1 A 32 year old female presented to gynaec opd for routine ANC checkup at 20weeks of gestation. LMP-19/4/2022 EDD-26/1/2023 She was G3P2A0L1D1. First is FTND in hospital 4 years back, male child 3.0kg and no antepartum ,intrapartum and postpartum complications, died due to CHD. Second is Lscs 2 years back , male child 4.2 kg uneventful. P/H- KNOWN CASE OF DIABETES AND HYPERTENSION ON MEDICATION. ON INJ INSULIN 8IU BF AND 8IU BD. ON T.LABETELOL(100MG) BD FURTHER MANAGEMENT AND FOLLOW UP- ALL ROUTINE INVESTIGATIONS HBA1C, FBS, PP2BS URINE ROUTINE FUNDUS EXAMINATION USG WITH GCA SCAN

3. . PATIENT CAME WITH REPORTS HBA1C- 6% FBS-90 PP2BS-120 FUNDUS EXAMINATION –NAD URINE RM- NAD GCA SCAN-NAD ( FETAL 2DECHO NAD was advised as there was prev history of CHD in previous pregnancy) Pt was counselled about nutrition , high risk factors , signs of hypoglycemia, self glucose monitorin , self administration of insulin injection. Pt was called for follow up atleast once in a month. LSCS was done after 38 completed weeks of gestation.

4. TYPES

5. WHITES CLASSIFICATION .

6. SCREENING FOR GDM

7. A t 24 weeks, human placental lactogen is made from placenta. Insulin resistance

8. Screening for gdm PROTOCOLS FOR INVESTIGATIONS

9. Why in India separate guidelines for screening ? Indian females -11 fold increase risk of GDM than Caucasian Prevalence is 16.55% Universal screening detects more no. of GDM Single blood glucose measurements after GTC is economically feasible and has more patient compliance

10. Methodology: Test for diagnosis Single step testing using 75 gm oral glucose & measuring blood sugar 2 hours after ingestion. 75 gm glucose is to be given orally after dissolving in approximately 300 ml water whether the pregnant women comes in fasting or non-fasting state, irrespective of the last meal. The intake of the solution has to be completed within 5-10 minutes. A plasma standardized glucometer should be used to evaluate blood sugar 2 hours after the oral glucose load. If vomiting occurs within 30 minutes of oral glucose intake, the test has to be repeated the next day, or else refer to a facility. If vomiting occurs after 30 minutes, the test continues . The threshold blood sugar level of ≥140 mg/ dL (more than or equal to 140) is taken as cut off for diagnosis of GDM.

11. Specification for the glucometer is given at Annexure 11. Procurement of same type of glucometer Pregnant Woman Testing for GDM at 1st Antenatal visit (75 g oral glucose- 2 hr Blood sugar value ) Positive hr BS (2 ≥ 140 mg/dL) Positive (2 hr BS ≥ 140 mg/dL) Manage as GDM as per guidelines Negative (2 hr BS <140 mg/dL ) Negative (2 hr BS <140 mg/dL ) Manage as Normal ANC Manage as GDM as per guidelines Repeat Testing at 24-28 weeks Universal testing for GDM

12. MNT for 2 weeks Pregnant Woman with GDM 2 hr PPBS ≥ 120 mg/dL 2 hr PPBS < 120 mg/dL Start Human Insulin premix 30:70 Subcutaneous injection, 30 mins before breakfast, once a day Dose of insulin calculated by blood sugar level Continue MNT and physical exercise, repeat 2 hr PPBS as per high risk pregnancy protocol or as advised by the physician (at least once monthly) Blood sugar Dose of insulin Between 120-160 units 4 Between 160-200 units 6 More than 200 8 units ≥ mg/dL 120 mg/dL <120 FBS (Fasting Blood Sugar) & 2 hours PPBS every 3rd day Repeat FBS & 2 hr PPBS every 3 rd day till dose of insulin adjusted FBS <95mg/dL & 2 hrs PPBS <120 mg/dL FBS <95 mg/dL & 2 hrs PPBS ≥ 120 mg/dL FBS ≥ mg/dL & 2 hrs PPBS 95 ≥ 120 mg/dL Continue same dose of insulin + MNT and physical exercise Increase dose of insulin by 2 U pre-breakfast + MNT and physical exercise Give inj. insulin in 2 doses, same dose 2 U pre-breakfast and 4 U pre-dinner

13. Maternal complications of hyperglycemia ANTEPARTUM INTRAPARTUM POSTPARTUM Preeclampsia Preclampsia puerperal sepsis Polyhydroamnios PROM wound infection PROM APH,PPH sub involution of uterus APH Shoulder dystocia postpartum depression Need for IOL Need for Instrumental delivery Infection Lscs need for anormal labor Spontaneous abortion Progression of retinopathy

14. Neonatal complications Congenital malformations(MORE WITH PREGESTATIONAL ) Positive co relation with Hba1c >7 Birth injuries IUD,SB Neonatal hypogylcemia , hyperilirubinemia hypocalcemia and hypomagnesemia Infant respiratory distress syndrome( fetal hyperinsulinemia antagonises action of cortisol causing decreased production of surfactant )

15. FETAL MONITORING USG at 18-20 weeks ,anomaly scan Fetal echo ,20-24 weeks From 26 weeks –liquor ,volume every 2-3 weeks Abdominal circumference monitoring >70 :indication of insulin Chromosomal abnormalities ,neural tube defects

16. PATHOPHYSIOLOGY OF KETOACIDOSIS

17. MANAGEMENT

18. INSULIN IF BLOOD SUGAR NOT CONTROLLED BY DIET AND EXERCISE INSULIN SHOULD BE ADDED SHORT ACTING INSULINS ARE PREFFERD AS THEY HAVE BETTER CONTROL INSULIN DOSAGE IS BASED ON MATERNAL AGE AND GESTATIONAL AGE AND PRIOR SUAGR PROFILE ROUGH GUIDE 1 ST TRIMESTER -0.7U/KG 2 ND TRIMESTER-0.8U/KG 3 RD TRIMESTER -0.9-1U/KG INSULIN REGIMEN :MOST POPULAR IS 4 TIMES DAILY REGIMEN -3 INJECTIONS OF REGULAR SHORT ACTING INSULIN +BED TIME INTERMEDIATE ACTING ANOTHER REGIMEN IS 2 TIMES REGIMEN –COMBINATION OF REGULAR AND NPH INSULIN SUBCUTANEOUS INSULIN INFUSION OR INSULIN PUMP THERAPY MAY PROVIDE A BETTR CONTROL IN WOMEN NOT WELL CONTROLLED ON MULTIPLE INSULIN REGIMEN /TYPE 1

19. OHA ALTHOUGH USFDA HAS NOT APPROVED,METFORMIN AND GLYBURIDE ARE INCREASINGLY USED FOR GDM AND PREGESTATIONAL DM METFORMIN IS PREFERRED THAN GLYBURIDE AS IT HAS LOWER RISK OF PREGNANCY INDUCED HYPERTENSION,MACROSOMIA,AND MATERNAL HYPOGLYCEMIA.

20. MANEGEMENT INTRAPARTUM Attention to labour pattern, as cephalopelvic disproportion may indicate fetal macrosomia If steroids or beta agonist used ,increase insulin Skip morning insulin on day of induction Usually no need of insulin while labour Hourly blood glucose monitoring during active labour ,with insulin drip if necessary Notify paediatrics if pt has poorly controlled blood sugars antepartum or intrapartum

21. TIMING AND DELIVERY MODE PT WITH GDM WELL CONROLLED ON DIET CAN BE CONTINUED TILL 40 WKS. PT ON INSULIN,PREGNANCY IS USUALLY TERMINATED AT 38 WKS. ROUTINE LABOR INDUCTION AT 38 WKS REDUCES MACROSOMIA AND SHOULDER DYSTOCIA RISK. PREGNANCY TO BE TERMINATED EARLIER IF ASSO. HTN OF FETAL COMPROMISE DETECTED. ANTENATAL STEROIDS TO BE GIVEN IN PRETERM DELIVERY(SPONTANEOUS OR INDUCED).GLUCOSE MONITORING DONE INTENSELY FOR 5-7 DAYS AS IT AFFECTS GLYCEMIC CONTROL. FETAL WEIGHT B/W 4-4.5 KG IS AN INDICATION FOR ELECTIVE LSCS AS THERE IS INCREASED RISK OF SHOULDER DYSTOCIA.

22. DURING LABOR WHEN PT IS PLANNED FOR INDUCTION,IF BISHOP SCORE IS POOR-LOCAL PGs ARE GIVEN AND PTON REGULAR DIET AND INSULIN IF CERVIX IS FAVOURABLE,IV INDUCTION DONE AND MORNING INSULIN DOSE IS OMITTED.

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24. IMPORTANT TIPS FOR PLANNING MEALS FOR GDM POSITIVE MOTHER A mother should follow discipline regarding meal timings. Eating heavy at one meal or skipping any meal or fasting for long hours should be avoided. She should include all food groups in her daily diet i.e cereal, pulses, milk and milk products, fruits, vegetable, and fats. For non-vegetarian mothers, eggs, low fat meat like well-cooked fish or chicken can be included. Meal plan should be divided in to 3 major meals (breakfast, lunch and dinner) and 2-3 mid-day snacks. Breakfast A pregnant woman should start her day with a healthy breakfast. She should never skip her breakfast. Breakfast should consist of 1-2 carbohydrate servings (like chapati / dalia /sandwich/ poha / idli etc ) as mentioned in exchange list along with one serving from protein rich foods (like milk/curd/paneer/egg etc.) Lunch/dinner In lunch and dinner the thali/plate can be divided in two halves Fill the first ½ with vegetables like bottle gourd, ridge gourd, lettuce, broccoli, spinach, carrots, green beans, tomatoes, celery, cabbage, mushrooms etc. as vegetable provide fiber which helps in controlling post prandial sugar level. The remaining half should be divided into two equal ¼th parts. The ¼ portion of the plate can be filled with protein rich food like dal, soy nuggets, tofu, eggs, paneer, chicken, fish etc The remaining ¼ can be filled with chapati , brown rice, millets, cereals etc. Mother should have at least 1 serving of low fat, sugar-free yoghurt, curd or milk . Carbohydrate serving in lunch and dinner should be between 2 to 3. Taking heavy meals should be avoided.

25. IMMEDIATE POST-PARTUM AND NEWBORN CARE:

26. POSTPARTUM FAMILY PLANNING FOR WOMEN WITH GDM Low dose combind oral contraceptive are found to be very effective method of contraception. Barrier method and progesterone only pills can also been used as a method of contraception.

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