Diabetes in Pregnancy mch 2023.pptx

management of Diabestes in pregnancy for healthcare providers

1. Management of Diabetes in Pregnancy In a practical view

2. Definitions Management Post partum 01 Screening Diagnosis 02 03 04 05 CONTENTS

3. WHO?? WHAT?? HOW? WHY??

4. Lorenzo, Petra I. et al (2019). Molecular Modelling of Islet β-Cell Adaptation to Inflammation in Pregnancy and Gestational Diabetes Mellitus. International Journal of Molecular Sciences.

5. DEFINITION Gestational Diabetes Mellitus (GDM) Any degree of glucose intolerance which is first detected during pregnancy, whether or not the condition persists after pregnancy

6. Pre-existing Diabetes Mellitus In Pregnancy Definition: Diabetes Mellitus diagnosed before pregnancy Overt diabetes in pregnancy should be managed as pre-existing diabetes.

7. National Obstetric Report involving 14 tertiary hospitals showed incidence of diabetes in pregnancy was 8.66% in 2011 and 8.83% in 2012 - ~13% underwent Cesarean section - ~16% babies born to diabetic mothers weighed ≥4kg

8. Screening for GDM WHO? ** Presence of any risk factors: BMI >27 kg/m2 Previous history of GDM First-degree relative with DM History of macrosomia baby (BW >4kg) Bad obstetric history Glycosuria ≥2+ on two occasions at any POG Current obstetric problems (essential hypertension, Pregnancy-induced hypertension, polyhydramnios, and current use of corticosteroids)

9. Overt DM is suspected in the presence of at least one of the following: FPG ≥7.0mmol/L RPG ≥11.1mmol/L However, the diagnosis of overt DM should be confirmed with a second test (FPG/RPG/MOGTT)

10. Refer FMS/O&G specialist for initiation of pharmacological treatment Refer dietitian, trial of diet control & exercise with 2 weekly 7PBSP Diagnosed GDM If deranged 7PBSP, find out why; Non-compliant to diet control Improper 4-7PBSP checking time Improper insulin injection time/technique If Yes, recounsel . If No GENERAL MANAGEMENT OF GDM Reference: Management of DIabetes in Pregnancy. Clinical Practical Guidelines Malaysia 2017

11. Hyperglycemia

12. Hypoglycemia

13. Suku suku separuh DIET Reference: https://kliniksabah.com/tips-pemakanan-yang-sihat-dengan-prinsip-suku-suku-separuh/

14. Suku suku separuh DIET Reference: https://kliniksabah.com/tips-pemakanan-yang-sihat-dengan-prinsip-suku-suku-separuh/

15. Can pregnant women exercise?

16. Walking—Brisk walking gives a total body workout and is easy on the joints and muscles.   Swimming and water workouts Yoga and Pilates Strength training Exercise tips when you're pregnant: warm up and cool down afterward try to keep active on a daily basis – 30 minutes of walking each day can be enough avoid any strenuous exercise in hot weather drink plenty of water and other fluids if you go to exercise classes, make sure your teacher is properly qualified and knows that you're pregnant, as well as how many weeks pregnant you are you might like to try swimming because the water will support your increased weight. Some local swimming pools provide aqua-natal classes with qualified instructors.  exercises that have a risk of falling, such as horse riding, downhill skiing, ice hockey, gymnastics, and cycling, should only be done with caution. Falls carry a risk of damage to your baby Start with a low level of exertion and work up to 30 minutes a day, three to five times a week

17. WEIGHT MANAGEMENT Energy prescription should be individualized based on pre-pregnancy body weight Normal pre-pregnancy weight: 35 kcal/kg body weight. Overweight/obese woman: moderate caloric restriction 25 kcal/kg body weight. Recommended weight gain during pregnancy: Pre-pregnancy BMI (kg/m2) Total weight gain (kg) Mean rates of weight gain in 2nd and 3rd trimester (kg/week) Underweight (<18.5kg) 12.5-18.0 0.51 Normal weight (18.5-24.9) 11.5-16.0 0.42 Overweight (25.0 - 29.9) 7.0 - 11.5 0.28 Obese (>30) 5.0 - 9.0 0.22 Reference: Management of DIabetes in Pregnancy. Clinical Practical Guidelines Malaysia 2017

18. 03 02 SELF-MONITORING OF BLOOD GLUCOSE Target Reading: fasting or preprandial : ≤5.3 mmol/L 1-hour postprandial: ≤7.8 mmol/L 2-hour postprandial: ≤6.7 mmol/L Provide BSP monitoring chart. Educate patients on how to record 7PBSP readings. Advise taking meals regularly (breakfast, lunch, dinner). Check blood glucose using a glucometer before & 2hrs after each meal (Ensure correct timing). If the patient is on insulin, take insulin after checking pre-meal blood glucose (to omit the insulin if blood sugar <4.0mmol/L), take a meal after half an hour of insulin injection, and check blood sugar 2 hrs post-meal. Repeat the steps for lunch, dinner, and pre-bed. If a patient does not have her own glucometer: perform 7PBSP at the clinic as an outpatient/admit to the maternity ward. Reference: Management of DIabetes in Pregnancy. Clinical Practical Guidelines Malaysia 2017

19. COMPLICATIONS OF UNCONTROLLED GLUCOSE Reference: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4404707/ Outcome Frequency in GDM (%) Frequency in non-GDM (%) Frequency difference (%) Pre-eclampsia 9.1 4.5 4.6 Delivery at <37 weeks 9.4 6.4 3.0 Primary caesarean delivery 24.4 16.8 7.6 Shoulder dystocia or birth injury 1.8 1.3 0.5 Intensive neonatal care 9.1 7.8 1.3 Clinical neonatal hypoglycaemia 2.7 1.9 0.8 Neonatal hyperbilirubinemia 10.0 8.0 2.0 Birth Weight >90th percentile 16.2 8.3 7.9 Cord C-peptide >90th percentile 17.5 6.7 10.8 Percent body adipose tissue content >90th percentile 16.6 8.5 8.1

20. METFORMIN INSULIN In GDM, metformin(MTF) is offered when blood glucose targets are not met by modification in diet and exercise within 1–2 weeks. MTF is continued in women who are already on the treatment prior. MTF is not associated with any birth defects or adverse outcomes. MTF in GDM leads to better maternal outcomes (total weight gain, postprandial blood glucose, gestational hypertension) and fetal outcomes (severe neonatal hypoglycemia ) Insulin should be initiated when: blood glucose targets are not met after diet control and MTF therapy MTF is contraindicated or unacceptable or failed FPG ≥7.0 mmol/L at diagnosis (with or without metformin) - FPG of 6.0-6.9 mmol/L with complications such as macrosomia or polyhydramnios (start insulin immediately, with or without metformin). PHARMACOLOGICAL TREATMENT Reference: Management of DIabetes in Pregnancy. Clinical Practical Guidelines Malaysia 2017

21. TIMING OF DELIVERY In pregnant women with pre-existing diabetes with: - no complications, deliver between 37+0 and 38+6 weeks. - maternal and fetal complications, deliver before 37+0 weeks. In women with GDM: - on diet alone with no complications, deliver before 40+0 weeks. - on OHA or insulin, deliver between 37+0 and 38+6 weeks. - with maternal or fetal complications, deliver before 37+0 weeks. Mode of delivery should be individualised, taking into consideration EFW and obstetric factors. Reference: Management of DIabetes in Pregnancy. Clinical Practical Guidelines Malaysia 2017

22. Enter title POST PARTUM Most women with GDM should be able to discontinue their insulin therapy immediately after delivery. When breastfeeding, if glucose control is inadequate with diet control alone, insulin therapy should be continued at a lower dose. Low-dose metformin can be safely used in breastfeeding. For GDM women whose blood glucose normalized immediately after delivery; For OGTT at 6 weeks postpartum Early MOGTT during the next pregnancy For annual screening of diabetes and lifestyle modifications For PPC Reference: Management of DIabetes in Pregnancy. Clinical Practical Guidelines Malaysia 2017

23. DEFINITIONS PRE-EXISTING DIABETES MELLITUS IN PREGNANCY Definition: Diabetes Mellitus diagnosed before pregnancy Overt diabetes in pregnancy should be managed as pre-existing diabetes. Reference: Management of DIabetes in Pregnancy. Clinical Practical Guidelines Malaysia 2017

24. Start Refer FMS/O&G specialist for initiation of pharmacological treatment Refer dietitian, trial of diet control & exercise with 2 weekly 7PBSP Pre-existing DM in pregnancy If deranged 7PBSP, find out why; Non-compliant to diet control Improper 7PBSP checking time Improper insulin injection time/technique If Yes, recounsel. If No In pre-existing DM, additional work ups are needed: Baseline creatinine Baseline HbA1c Ophthalmology referral Detailed scan referral Screening of complications ( cardiac vasculopathy , nephropathy, retinopathy, dermopathy, neuropathy) GENERAL MANAGEMENT Start PE prophylaxis (T Aspirin 150mg ON at 12 weeks & T CaCO3 1g BD at 20 weeks) G/S with AFI: every 2-4 weeks from 28-36 weeks POG More frequent G/S (with Doppler) if there is evidence of FGR If antenatal corticosteroid is indicated, woman with diabetes should be monitored closely (≥4 times a day, 48 hrs from the 1st dose) for abnormal glucose levels and insulin should be initiated/titrated when indicated Reference: Management of DIabetes in Pregnancy. Clinical Practical Guidelines Malaysia 2017

25. PRE-PREGNANCY CARE FOR PRE-EXISTING DM Keep HbA1c <6.5% Weight reduction in obese/overweight Folic acid supplement for 3 months prior to contraception withdrawal Screen for diabetic retinopathy & nephropathy Satisfactory blood pressure control (<130/80) Patients with multiple cardiovascular risks should undergo cardiovascular assessment Reference: Management of DIabetes in Pregnancy. Clinical Practical Guidelines Malaysia 2017

26. Reference: https://www.cdc.gov/reproductivehealth/contraception/pdf/summary-chart-us-medical-eligibility-criteria_508tagged.pdf

27. THANK YOU