diabetes mellitus in pregnancy " gestational diabetes mellitus

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Diabetes in Pregnancy Presented by : Nassr Saif ALBarhi SULTANTE OF OMAN

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Page 1: Diabetes Mellitus in pregnancy " Gestational diabetes mellitus

Diabetes in Pregnancy

Presented by :Nassr Saif ALBarhi

SULTANTE OF OMAN

Page 2: Diabetes Mellitus in pregnancy " Gestational diabetes mellitus

OUTLINE:

Case scenario. Definition of GDM. Classification. Diagnosis. Management. Antepartum care

Page 3: Diabetes Mellitus in pregnancy " Gestational diabetes mellitus

A 24 years old Omani lady, G4P1A2 at 23+2 wks of gestation. LMP: 27/10/2013. EDD by date:3/8/2014 , by scan: 29/7/2014.

k/c/o Type I DM on insulin in 2012.

Hypothyroidism on thyroxin 50mcg OD.

Presented to the OPD with Reflow 15.8 mmol admitted for glycemic and VPG control.

Page 4: Diabetes Mellitus in pregnancy " Gestational diabetes mellitus

Also, she admitted for abnormal scan finding as fetus found to have ascites for further investigations.

She complain of polyphagia, morning nausea and burning sensation during voiding but she denied any polydepsia, vomiting, fever, vaginal discharge or labiality of mood.

Page 5: Diabetes Mellitus in pregnancy " Gestational diabetes mellitus

Past ObsH

1st pregnancy>> abortion at 12weeks GA, no D&C. 2nd pregnancy>> Abortion at 3 months GA, D&C done. 3rd pregnancy>> FT  LSCS for fetal distress  , Diagnosed

as DM and IOL. -----

This is Spontaneous pregnancy:During this pregnancy had admissions for Blood sugar control and insulin adjustment last was 2/4/2014.Was offered Insulin pump but patient not keen for that.

Page 6: Diabetes Mellitus in pregnancy " Gestational diabetes mellitus

Menstrual Hx: regular, 5/21days, small amount, mild pain, no intramenstrual

bleeding, LMP : 27/10/2013. EDD by date: 3\8\2014 PMH:

apart from OBS Hx, unremarkable Allergy:

nil Family Hx:

Her husband is 1st cousin of her father. Strong Family Hx of DM and HTN in first degree relatives

Social HX: Not smoker or alcohol consumer

Page 7: Diabetes Mellitus in pregnancy " Gestational diabetes mellitus

General examination:

Looks well, comfortable, obese, afebrile, alert and cooperative not in distress.

There no pallor , jaundice, dehydration BP: 110/69.

Physical examination:

Page 8: Diabetes Mellitus in pregnancy " Gestational diabetes mellitus

Abdominal examinations: Inspection:

The abdomen is distended. Umbilical is inverted scars Striae gravidarum. Linea nigra No visible veins No obvious masses. No change in skin colour. Normal hair distribution.

Palpation:

Abdomen is soft, not tender, uterus is relax and no contraction. FSH=29 cm. Fundal occuping by breach, supin: right side, cephalic presentation. FHR= 130.

Other systems are normal

Page 9: Diabetes Mellitus in pregnancy " Gestational diabetes mellitus

Investigations: Hb: 11.9, platelet normal LDH, LFT, coagulation, and electrolytes normal

VPG at the day of admission:

Pre breakfast

Post breakfast

Post lunchPost dinner

55.65.710.7

Page 10: Diabetes Mellitus in pregnancy " Gestational diabetes mellitus

Gestational diabetes

Page 11: Diabetes Mellitus in pregnancy " Gestational diabetes mellitus

Introduction Diabetes mellitus refers to a chronic disorder of metabolism that

due to an absolute or relative lack of insulin.

It is characterized by hyperglycaemia in postprandial or fasting state or both.

GDM is defined as glucose intolerance of variable degree with onset or first recognition during the present pregnancy.

Reports show a rate of 3% to 8% of gestational diabetes mellitus (GDM).

Page 12: Diabetes Mellitus in pregnancy " Gestational diabetes mellitus

Traditional classification :

Type 1 – IDDM – Juvenile diabetes

Type 2 – NIDDM – Maturity onset diabetes

Type 3 – Gestational diabetes.

Classification of diabetes

Page 13: Diabetes Mellitus in pregnancy " Gestational diabetes mellitus

Type 1. Immune mediated & idiopathic B cell dysfunction.

Type 2. DM of adult onset due to insulin resistance & relative insulin deficiency, or from a secretory defect.

Type 3.Specific types of diabetes 1.Genetic defect of B cell function 2.Genetic defect in insulin action 3. Diseases of exocrine pancreas.

Type 4. Gestational diabetes

New classification

Page 14: Diabetes Mellitus in pregnancy " Gestational diabetes mellitus

Classification of diabetes

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why glucose Intolerance in pregnancy??

Page 16: Diabetes Mellitus in pregnancy " Gestational diabetes mellitus
Page 17: Diabetes Mellitus in pregnancy " Gestational diabetes mellitus

Risk factors:

Maternal age > 25 years Obesity. Family history of diabetes in a first-

degree relative. Previous large baby. Previous still birth, or a child with a birth

defect Polyhydramnios. Previous pregnancy with GDM.

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Diagnosis

All women should be screened for GDM between 24-28 weeks of gestation.

Women with multiple risk factors!?

Page 19: Diabetes Mellitus in pregnancy " Gestational diabetes mellitus

OGCT Method: oral glucose screening test

(OGST) or OGCT

Need no preparation: not fasting A 50 gm glucose is giving in glass of water Venous plasma glucose taking before the

test and after 1 hr.

Results: <7.8 mmol/L = no GDM ≥7.8-10.3 mmol/L = further investigation

with OGTT ≥10.3 mmol/L= GDM

Page 20: Diabetes Mellitus in pregnancy " Gestational diabetes mellitus

How to do?

150 to 200gm CHO diet to be given for 3 days

before doing OGTT.

Overnight fasting

75 gm glucose giving in 300 ml of water

Venous plasma glucose taking before the test

and after 2hr.

OGTT

Page 21: Diabetes Mellitus in pregnancy " Gestational diabetes mellitus

OGTT on 75 mg oral glucose load

GDM FBS ≥ 5.5 mmol/L 2 PPBS ≥ 7.8mmol/L

ORAL GLUCOSE TOLERANCE TEST

WHO criteria for the 2-hour OGTT

Whole blood venous

(mmol/L)

Whole blood capillary (mmol/L)

Plasma venous

(mmol/L)

Plasma capillary (mmol/L)

Fasting=>6.1=>6.1=>7.0=>7.02 hours=>6.7=>7.8=>7.8>=8.9

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At booking (14 weeks) if at high risk: Family history of DM Previous GD Obesity Previous still birth Macrosomia Congenital malformation multiparty

When to do OGTT?

Page 23: Diabetes Mellitus in pregnancy " Gestational diabetes mellitus

Done in day care unit or in the ward Patient on diet or insulin

4 venous sampling are collected: Fasting… 2 hr post breakfast 2 hr post break lunch. 2 hr post break dinner.

Venous plasma glucose profile

Page 24: Diabetes Mellitus in pregnancy " Gestational diabetes mellitus
Page 25: Diabetes Mellitus in pregnancy " Gestational diabetes mellitus

Management

Page 26: Diabetes Mellitus in pregnancy " Gestational diabetes mellitus

Diet providing 30 kcal/kg –normal pregnant, 24 kcal/kg – over wt pregnancy women . Postprandial hyperglycemia - decreased by CHO

restricted, low glycemic index diets & small frequent meals

Increase Exercise improve blood sugar control 30 minutes a day recommended by NICE

guidelinies

Diet and Exercise

Page 27: Diabetes Mellitus in pregnancy " Gestational diabetes mellitus

If already on medication, generally switch to insulin therapy: continuing glyburide or metformin controversial teratogenicity unknown for other oral anti-

hyperglycemics

Tight glycemic control Diet management first line therapy Post-prandial blood glucose values seem to be the most

effective at determining thelikelihood of macrosomia or other adverse pregnancy outcomes

Aim for Fasting Plasma Glucose (PG) 3.5-5.9 mmol/L 1-hour post prandial PG ≤7.8 mmol/L 2-hour post prandial PG ≤7 mmol/L

Management of DM in pregnancy

Page 28: Diabetes Mellitus in pregnancy " Gestational diabetes mellitus
Page 29: Diabetes Mellitus in pregnancy " Gestational diabetes mellitus

If blood glucose not well controlled, initiate insulin therapy.

ƒInsulin dosage may need to be adjusted in T2 due to increased demand and increased insulin resistance

Insulin requirement- 0.6, 0.7 & 0.8 units / kg /day- 1st, 2nd & 3rd trimesters

Given as 2 injections/day (some require 3- 4 injections)

Insulin therapy

2/3rd am 1/3rd pm

2/3rd N 1/3rd R ½N ½R

Page 30: Diabetes Mellitus in pregnancy " Gestational diabetes mellitus

Available insulin preparations

TypeOnsetPeak (hours)Duration (hours)

Rapid

Lispro*

Aspart*

Glulisine

< 15 min

< 15 min

1 – 2

1 – 2

3 – 4

3 – 4

Short

regular insulin0.5 – 0.7 hour2 – 4 5 – 8

Intermediate

NPH(neutral protamine hagedorn)

Lente

1 – 2 hours

1 – 2 hours

6 – 12

6 – 12

18 – 24

18 – 24

Long acting

Ultralente

Glargine*

4 – 6 hours

2 – 4 hours

16 – 18

peakless

20 – 36

18 – 24

Page 31: Diabetes Mellitus in pregnancy " Gestational diabetes mellitus

TARGETS OF GLYCEMIC CONTROL

FASTING POST B.F. POSTLUNCH

PREDINNER

POSTDINNER

876543210

MM/L

V.P.G PROFILECut values

Pre: 5.5

Post: 8.0

Page 32: Diabetes Mellitus in pregnancy " Gestational diabetes mellitus

Monitor as for normal pregnancy plus initial 24-hr urine protein and creatinine clearance

Retinal exam, HbA1C

HbA1C: >8.5% of pre-pregnancy value associated with increased risk of spontaneous abortion and congenital malformations.

Increased fetal surveillance (BPP, NST)

Management of DM in pregnancy

Page 33: Diabetes Mellitus in pregnancy " Gestational diabetes mellitus

Why DM in pregnancy is a concern??

1. Maternal complications.

2. Fetal complications.

Page 34: Diabetes Mellitus in pregnancy " Gestational diabetes mellitus

Preterm labour.

Increase incidence of pre-eclampsia.

Polyhydramnios - AFI >240mm .

Macrosomia >4000gm .

Poorly controlled DM- subfertility, miscarriage, congenital anomalies, UTI.

Shoulder dystocia Perinatal mortalityPerinatal mortality

Complications of Diabetes

Page 35: Diabetes Mellitus in pregnancy " Gestational diabetes mellitus

Maternal Complications•Obstetric:

• Hypertension/preeclampsia (especially if pre-existing nephropathy/proteinuria)•PolyhydramniosDiabetic

Emergencies• Hypoglycemia

•Ketoacidosis •Diabetic coma

Diabetic Emergencies

• Hypoglycemia •Ketoacidosis •Diabetic comaEnd-organ involvement or deterioration

(occur in DM1 and DM2, not in GDM) •Retinopathy •Nephropathy

End-organ involvement or deterioration

(occur in DM1 and DM2, not in GDM) •Retinopathy •Nephropathy

•Other•Pyelonephritis/UTI

•Increased incidence of spontaneous abortion (in DM1 and DM2, not in GDM)

•Other•Pyelonephritis/UTI

•Increased incidence of spontaneous abortion (in DM1 and DM2, not in GDM)

Page 36: Diabetes Mellitus in pregnancy " Gestational diabetes mellitus

Fetal ComplicationsGrowth Abnormalities

• Macrosomia: maternal hyperglycemia leads to fetalhyperinsulinism resulting in accelerated anabolism

( •IUGR :)due to placental vascular insufficiency

Growth Abnormalities• Macrosomia: maternal hyperglycemia leads to fetal

hyperinsulinism resulting in accelerated anabolism

( •IUGR :)due to placental vascular insufficiency

Delayed Organ Maturity •Fetal lung immaturity

Delayed Organ Maturity •Fetal lung immaturity

Congenital Anomalies (occur in DM1 and DM2, not in GDM)

• 2-7x increased risk of cardiac (VSD), NTD, GU (cystic kidneys), GI (anal atresia), and MSK (sacral

agenesis) anomalies due to hyperglycemia

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Fetal Complications•Labour and Delivery

•Preterm labour/prematurity:•Preterm labour is associated with poor glycemic control •Increased incidence of stillbirth•Birth trauma: due to macrosomia, can lead to difficult vaginal delivery and shoulder dystocia

•Labour and Delivery•Preterm labour/prematurity:•Preterm labour is associated with poor glycemic control •Increased incidence of stillbirth•Birth trauma: due to macrosomia, can lead to difficult vaginal delivery and shoulder dystocia

•Neonatal•Hypoglycemia: due to pancreatic hyperplasia and excess insulin secretion in the neonate•Hyperbilirubinemia and jaundice: due to prematurity and polycythemia•Hypocalcemia: exact pathophysiology not understood, may be related to functional hypoparathyroidism•Polycythemia: hyperglycemia stimulates fetal erythropoietin production

•Neonatal•Hypoglycemia: due to pancreatic hyperplasia and excess insulin secretion in the neonate•Hyperbilirubinemia and jaundice: due to prematurity and polycythemia•Hypocalcemia: exact pathophysiology not understood, may be related to functional hypoparathyroidism•Polycythemia: hyperglycemia stimulates fetal erythropoietin production

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Antepartum Care

Page 39: Diabetes Mellitus in pregnancy " Gestational diabetes mellitus

Goals Minimize/eliminate the risk of fetal death Early detection of fetal compromise Prevent unnecessary premature delivery

Fetal Surveillance

Page 40: Diabetes Mellitus in pregnancy " Gestational diabetes mellitus

Frequent ANC Confirm viability & Gestational Age by early

scan Detailed anomaly scan ( 18-20 wks) Fetal echo cardiogram ( 24 weeks) Growth scans ( after 30 wks) BPP & Doppler ( after 34 wks)

FETAL SURVEILLANCE

Page 41: Diabetes Mellitus in pregnancy " Gestational diabetes mellitus

Monthly VPG profile HbA1c once every 3 monthes FBS & PPBS every visit

ASSESSMENT OF GLYCEMIC

CONTROL

Page 42: Diabetes Mellitus in pregnancy " Gestational diabetes mellitus

Timing and mode of delivery

Page 43: Diabetes Mellitus in pregnancy " Gestational diabetes mellitus

Patient well controlled on diet only to be delivered by 40 weeks.

GDM well controlled to be delivered at 38 weeks.

NICE guidelines recommends that pregnant women with diabetes be offered elective birth after 38 completed weeks gestation

Timing of Delivery

Page 44: Diabetes Mellitus in pregnancy " Gestational diabetes mellitus

o Spontaneouso Induced – PG/ARM/Syntocino Caesarean section

Mode of delivery

Page 45: Diabetes Mellitus in pregnancy " Gestational diabetes mellitus

Hourly reflos – keep Blood Sugar ( 5-8 mmols) < 5 mmols – start 5% dextrose > 8 mmol - I.V insulin pump –1unit/hr & titrate

Continous CTG.

Watch for progress of labour

Anticipate & prepare for shoulder dystocia

Spontaneous

labour

Page 46: Diabetes Mellitus in pregnancy " Gestational diabetes mellitus

Continue regular dose of insulin till the time of induction.

Reflo 4 hourly initially and 1-2 hourly in established labour.

Continue infusion of regular insulin in 5% dextrose at rate of .5 to 2 U of insulin/ hr and insulin dosage adjusted accordingly to maintain plasma glucose level (5-8 mmol)

Induction of labour

Page 47: Diabetes Mellitus in pregnancy " Gestational diabetes mellitus

For Elective Cesarean

Omit the morning dose of insulin. Check Fasting Reflo

If Reflo <=4 mmol start 5% Dextrose at 125ml\hours

If Reflo >=8 mmol start insulin infustion as per sliding scale.

Page 48: Diabetes Mellitus in pregnancy " Gestational diabetes mellitus

Postpartum period

Patient with GDM: stop the insulin and FBS and PPBS post-delivery.

Pre existing diabetics: start pre-pregnancy dose of insulin\oral hypoglycemic agents.

Patient with GDM are advised to do OGTT at 6 WEEKS POSTPARTUM.

Page 49: Diabetes Mellitus in pregnancy " Gestational diabetes mellitus

Evaluation of glycemic control HbA1c – gives control 2-3 months If high – control diabetes before conception Evaluation of B.P Evaluation of retinal status Evaluation of renal function Change to Insulin prior to / when pregnancy is

diagnosed.

Planning next pregnancy

Page 50: Diabetes Mellitus in pregnancy " Gestational diabetes mellitus

1. Pubmed

2. Uptodate.com

3. Hacker/Moore,2010 essentials of Obstetrics & Gynecology,saunders, fifth edition.

4. Obstetrics Guidelines,.SQUH, 20\1\2014.

5. Obstetrics Guidelines, University of Illinois at Chicago, Sept 2008

6. Pathophysiology of Gestational Diabetes Mellitus: The Past, the Present and the Future,Mohammed Chyad Al Noaemi1 and Mohammed Helmy Faris Shalayel2 1Al-Yarmouk College, Khartoum,2National College for Medical and Technical Studies, Khartoum,Sudan

References:

Page 51: Diabetes Mellitus in pregnancy " Gestational diabetes mellitus

THANK YOU