Diabetes in pregnancy powerpoint presentation.pptx

Diabetes in pregnancy

1. Diabetes in pregnancy dr. Anmol Deep

2. Pregnancy may be complicated by diabetes in two distinct forms: Gestational diabetes mellitus (GDM) is defined as glucose intolerance of varying severity with onset or first recognition during pregnancy. The most important perinatal concern in this group is macrosomia with resulting birth trauma. More than 50% women ultimately develop diabetes in the ensuing 20 years and this is linked with obesity. Pre-gestational diabetes is diabetes that antedates pregnancy. Pregnancies which are complicated by pre-gestational diabetes, type-1 or type-2, carry an additional risk to both mother and fetus beyond the effects on fetal growth and development in mid and late pregnancy.

3. Classification Pregestational diabetes: A lady with known diabetes who conceives while on treatment with diet, oral hypoglycemic agents or insulin. Type 1 DM, Type 2 DM, Secondary DM Gestational diabetes mellitus is defined as glucose intolerance of variable degree with onset or first recognition during pregnancy. Women found early in pregnancy to have gestational diabetes are a high-risk subgroup.

4. Risk Factors for gestational diabetes screening Strong family history of diabetes Past history of glucose intolerance or diabetes in a previous pregnancy Obesity; overweight women (>15% of non-pregnant ideal body weight) Ethnic group with a high prevalence of diabetes (e.g. Indians, Asians, Hispanic) Persistent glycosuria Age > 30 years Women who have given birth to large infants (>4 kg; 8 lbs 13 oz) History of recurrent fetal loss History of traumatic delivery with an associated neurological disorder in the infant

5. Risk Factors for gestational diabetes screening 10. History of stillbirth, unexplained neonatal death, congenital malformations, prematurity. 11. History of pre-eclampsia or polyhydraminos 12. Chronic hypertension 13. Recurrent severe candidiasis or urinary tract infection

6. Pathophysiology : Caused by placental production of human placental lactogen (HPL) and progesterone. Other hormones that may contribute include prolactin and cortisol. Early in pregnancy, relatively higher levels of estrogen enhance insulin sensitivity. As placenta develops, estrogen decreases as HPL and progesterone rise, resulting in increased insulin resistance at the end organs. Insulin resistance is most marked in the third trimester at which time GDM most often occurs. Insulin is the major fetal growth hormone . produces excessive fetal growth particularly in fat, the most insulin-sensitive tissue.

7. Growth Abnormalities(1) Two Extremes Of Growth Abn :

8. Whom to screen? Risk stratification Low risk: no screening Average risk: at 24-28 weeks High risk: as soon as possible Screening is done between the 24 th and 28 th weeks of pregnancy or earlier if any of the risk factors are present.

9. Age <25 years Weight normal before pregnancy Member of an ethnic group with a low prevalence of GDM No known diabetes in first-degree relatives No history of abnormal glucose tolerance No history of poor obstetric outcome Low risk for GDM

10. High risk for GDM Marked obesity Prior GDM Glycosuria Strong family history Ethnic group with high diabetes prevalence History of still birth History of congenital anomaly History of delivery of large infant (>4kg) Polyhydraminos Poor reproductive history ( >3 spontaneous abortions in first and second trimester) Recurrent UTI and candidiasis Age>30 years Intermediate risk for GDM Women of south east Asian origin ,including Indian Women of Native American,African

11. Screening test Oral Glucose Tolerance Test (OGTT): Measurement of plasma glucose after ingesting 75 g of glucose in 200ml of water in 10-15 mins.

12. Screening test Glucose Challenge Test (GCT): An excellent screening test for gestational diabetes is the measurement of plasma glucose 1 hour after ingesting 50 g of glucose. A value of <140 mg/dl is takes as normal a value of 140 -199 mg/dl identifies 80% women with GDM and is taken as cut off point for Glucose tolerance test Using a cut-off value > 200 mg/dl taken as overt diabetes Gluocse tolerance test – 100 gm glucose ingestion with 3 hour measurement of plasma gluscose . Two or more values should exceed the cut off for diagnosis of GDM

13. Congenital abnormalities Neonatal hypoglycemia Macrosmia (big baby syndrome > 4 Kg or >8 lb 13 oz) Jaundice Polycythemia / hyperviscosity syndrome Hypocalcemia, hypomagnesemia Birth trauma (due to macrosmia and shoulder dystocia) Prematurity Hyaline membrane disease Apnea and bradycardia Effects of GDM on the fetus

14. Effects of GDM on neonates Respiratory distress Hypoglycemia Hypocalcemia Hyperbilirubinemia Cardiac Hypertrophy Long term effects on cognitive development

15. Macrosomic infant Macrosomia (large for gestational age or big baby syndrome) (birth weight > 90% percentile for gestational age) Macrosomia is a result of persistent maternal hyperglycemia leading to fetal hyperglycemia and prolonged fetal hyperinsulinism. This stimulates excessive somatic growth mediated by insulin-like growth factors (IGFs). Macrosomia affects all organs except the brain.

16. Infant of a Diabetic Mother with Sacral Agenesis Cardiovascular anomalies: ASD, VSD,TGA Skeletal anomalies: sacral agenesis CNS anomalies Genitourinary anomalies: renal agenesis, polycystic kidneys

17. Congenital abnormalities due to GDM Cardiac (most common): transposition of great vessels, Ventricular septal defect, Atrial septal defect Central nervous system (7.2%): spina bifida, Anencephaly, hydrocephalus Skeletal: cleft lip/palate, caudal regression syndrome Genitourinary tract: ureteric duplication Gastrointestinal: anorectal atresia Renal agenesis, Duplex ureters , Cystic Kidney Situs inversus Poor glycemic control at time of conception: risk factor

18. Caudal regression syndrome (abnormal development of lower spine)

19. Pre-eclampsia: affects 10-25% of all pregnant women with GDM Infections: high incidence of chorioamnionitis Postpartum bleeding: high incidence caused by exaggerated uterine distension Cesarian section more common due to fetal macrosmia and cephalo-pelvic disproportion Weight gain Hypertension Miscarriages Third trimester fetal deaths Long term risk of type-2 diabetes mellitus Effects of GDM on the mother

20. Effect of pregnancy on diabetes More insulin is necessary to achieve metabolic control Progression of retinopathy: esp. severe proliferative retinopathy Progression of nephropathy: especially if renal failure + Increased risk of Coronary artery disease, and a high risk of maternal death in post MI patients Cardiomyopathy

21. Management: The goal is to prevent adverse pregnancy outcomes. A multidisciplinary approach is used. Patient is seen every 1-2 wks until 36 wks gestation and then weekly. Patient is asked to keep an accurate diary of their blood glucose concentration. Aim – to keep fasting plasma glucose - <95mg/ dl and 2 hr pp plasma glucose at < 120mg/dl.

22. Dietary Therapy : Dietary restriction – 1200-1800 kcal/day for obese ( BMI > 30kg/m2) ACOG rec ommends 55% carbs, 20% protiens , 25% fats of total calories Exercise Recommend a complex, high fiber diet Avoid concentrated sweets

23. When Dietary Therapy Fails: Insulin Oral Hypoglycemic Agents: -Glyburide -Metformin

24. Insulin Regimen: If the fasting value is > 105 mg/dL, or 2 hr value >140 mg/dL despite diet therapy. insulin therapy needs to be initiated. A total dose of 20 to 30 units divided into 2/3 rd morning ( 2/3 rd intermediate acting and 1/3 rd short acting insulin) and 1/3 rd night (1/2 intermediate ½ short acting) is started

25. Patient education Cornerstone in GDM management Instruct mother about maternal and fetal complications Medical Nutrition therapy Glycemic monitoring: teach mother about self monitored blood glucose measurement and glycemic targets Pre-conception counseling Fetal monitoring: ultrasound Planning on delivery Long term risks

26. Vaginal delivery: preferred Cesarean section only for routine obstetric indication GDM alone is not an indication ! > 4.5 Kg fetus: Cesarean delivery may reduce the likelihood of brachial plexus injury in the infant Unfavorable condition of the cervix is a problem Maintain euglycemia during labor Maternal hyperglycemia in labor: fetal hyperinsulinemia and worsen fetal acidosis Maintain sugars: 80-120 mg/dl (capillary: 70-110mg/dl ) Feed patient the routine GDM diet Monitor sugars 1-2 hrly intervals during labour Give insulin only if blood sugar >100 mg/dl Management of labor and delivery

27. Delivery: Early delivery may be indicated for: women with poor glycemic control pregnancies complicated by fetal abnormalities Otherwise, pregnancies are allowed to go to term.

28. Intrapartum: The goal is to maintain normoglycemia in order to prevent neonatal hypoglycemia. Check patient’s glucose q1-2 hours. Start insulin drip to maintain a glucose level of 100 mg/dL. Observe infant closely for hypoglycemia, hypocalcemia, and hyperbilirubinemia after birth.

29. Glycemic management during labour Later stages of labor: start dextrose to maintain basal nutritional requirements: 150-200 ml/ hr of 5% dextrose Elective Cesarean section: check fasting blood sugar; if within target range no insulin is needed; start dextrose drip Continue hourly self monitored blood glucose Post delivery keep patients on dextrose-normal saline till fed No insulin unless sugars more than normal ( not GDM targets ! )

30. Hypoglycemia: 50 % of macrosomic infants Starts when the cord is clamped Exaggerated insulin release secondary to pancreatic ß-cell hyperplasia Increased risk: blood glucose during labor and delivery exceeds 90 mg/dl Anticipate and treat hypoglycemia in the infant Immediate management of neonate

31. Management of neonate Hypoglycemia <45 mg/dl Encourage early breast feeding If symptomatic give a bolus of 2- 4 ml/kg, IV, 10% dextrose Check after 30 minutes, start feeding IV dextrose : 6-8 mg/kg/min infusion Check for calcium, if seizure/irritability/RDS Examine infant for other congenital abnormalities

32. Postpartum Care : After delivery: Measure blood glucose. -fasting blood glucose concentrations should be <105 mg/dL and one hour postprandial concentrations should be < 140 mg/dL. Administer one half of the pre-delivery dose before starting regular food intake. Follow up: If the pt’s postpartum GTT is normal, she should be re-evaluated at a minimum of 3 years interval with a fasting glucose. All pts should be encouraged to exercise and lose wt. All pts should be evaluated for glucose intolerance or DM before a subsequent pregnancy.

33. Check blood sugars before discharge Breast feeding: helps in weight loss Lifestyle modification: exercise, weight reduction Oral glucose tolerance test at 6-12 weeks postpartum: classify patients into normal/impaired glucose tolerance and diabetes Preconception counseling for next pregnancy Increased risk of cardiovascular disease, future diabetes and dyslipidemia Post partum follow up

34. Long term risk: offspring Increased risk of obesity and abnormal glucose tolerance due to changes in fetal islet cell function Encourage breast feeding: less chance of obesity in later life Lifestyle modification

35. Gestational diabetes is a common problem in worldwide Risk stratification and screening is essential in all pregnant women, particularly those from ethnicities with increased risk Tight glycemic targets are required for optimal maternal and fetal outcome Patient education is essential to meet targets Long term follow up of the mother and baby is essential Conclusion

36.                                                                                                                                  17 pound baby born to Brazilian diabetic mother Courtesy: MSNBC News Services Jan. 24, 2005