dm in pregnancy 5 points
DESCRIPTION
An alternative way at looking at pregnancy complicated by diabetes. A guide for the student in understanding this problem and the important points to be included in a clinical assessment.TRANSCRIPT
![Page 1: DM in pregnancy 5 points](https://reader036.vdocuments.site/reader036/viewer/2022081404/55851a1cd8b42aff298b5260/html5/thumbnails/1.jpg)
DIABETES MELLITUS IN PREGNANCY5 POINTS FOR THE UNDERGRAD TO CONSIDER
1
![Page 2: DM in pregnancy 5 points](https://reader036.vdocuments.site/reader036/viewer/2022081404/55851a1cd8b42aff298b5260/html5/thumbnails/2.jpg)
2
Associate Professor Dr Hanifullah Khan
![Page 3: DM in pregnancy 5 points](https://reader036.vdocuments.site/reader036/viewer/2022081404/55851a1cd8b42aff298b5260/html5/thumbnails/3.jpg)
FACTS ABOUT DM
![Page 4: DM in pregnancy 5 points](https://reader036.vdocuments.site/reader036/viewer/2022081404/55851a1cd8b42aff298b5260/html5/thumbnails/4.jpg)
Prevalence & ConsensusDiabetes mellitus (DM) and other forms of glucose intolerance are widely prevalent worldwide#
The incidence of GDM remains obscure mainly due to the lack of consensus on investigative and diagnostic criteria#
GDM develops as soon as pancreatic β-cell secretion becomes insufficient to compensate for the physiological insulin resistance#
usually manifests during the second half of pregnancy.
![Page 5: DM in pregnancy 5 points](https://reader036.vdocuments.site/reader036/viewer/2022081404/55851a1cd8b42aff298b5260/html5/thumbnails/5.jpg)
Important fact
To understand the effects of hyperglycaemia on the fetus, it should be remembered that glucose crosses the placenta freely but maternal insulin does not. #
Thus, maternal hyperglycaemia leads to fetal hyperglycaemia with a consequent rise in fetal insulin secretion
![Page 6: DM in pregnancy 5 points](https://reader036.vdocuments.site/reader036/viewer/2022081404/55851a1cd8b42aff298b5260/html5/thumbnails/6.jpg)
What does excess fetal insulin do?
Cause increased weight gain#
fetuses > 4000g are termed macrosomic#
Obstructed labour & caesarean section#
Due to disproportion between fetal size and birth canal #
Increased risk of injury and complications - those that do pass through#
may inflict maternal and fetal birth trauma#
shoulder dystocia #
Sudden fetal demise in utero at term - for reasons still unknown
![Page 7: DM in pregnancy 5 points](https://reader036.vdocuments.site/reader036/viewer/2022081404/55851a1cd8b42aff298b5260/html5/thumbnails/7.jpg)
Beyond delivery
Respiratory distress syndrome#
Hypoglycaemia#
Adulthood and associated obesity, diabetes and the metabolic syndrome
![Page 8: DM in pregnancy 5 points](https://reader036.vdocuments.site/reader036/viewer/2022081404/55851a1cd8b42aff298b5260/html5/thumbnails/8.jpg)
Maternal problems
Increased risk of developing DM#
Past history of GDM increases the risk of recurrence in subsequent pregnancies#
Increased risk of later occurrence of DM
![Page 9: DM in pregnancy 5 points](https://reader036.vdocuments.site/reader036/viewer/2022081404/55851a1cd8b42aff298b5260/html5/thumbnails/9.jpg)
1. It is important to differentiate between gestational & pregestational DM
2. Patients with DM are frequently asymptomatic 3. Certain factors will provide a clue of possible DM 4. Monitoring of DM involves history, examination
& investigation, in that order 5. DM may present late with complications of
pregnancy
9
5 Points
![Page 10: DM in pregnancy 5 points](https://reader036.vdocuments.site/reader036/viewer/2022081404/55851a1cd8b42aff298b5260/html5/thumbnails/10.jpg)
1. It is important to differentiate between gestational &
pregestational DM
![Page 11: DM in pregnancy 5 points](https://reader036.vdocuments.site/reader036/viewer/2022081404/55851a1cd8b42aff298b5260/html5/thumbnails/11.jpg)
What is DM?
A metabolic condition characterized by chronic hyperglycemia as a result
of defective insulin secretion, insulin action
or both
11
i. Type 1(IDDM) ii. Type 2(NIDDM) iii. Gestational diabetes iv. Others -genetic defects in insulin processing or
action -endocrinopathies -drugs -exocrine pancreatic defects -genetic syndromes associated with DM
![Page 12: DM in pregnancy 5 points](https://reader036.vdocuments.site/reader036/viewer/2022081404/55851a1cd8b42aff298b5260/html5/thumbnails/12.jpg)
Either type 1 or type 2#Type 1 #
younger age group #increased maternal and obs risks#
Type 2 #usually occurs in obese patients
![Page 13: DM in pregnancy 5 points](https://reader036.vdocuments.site/reader036/viewer/2022081404/55851a1cd8b42aff298b5260/html5/thumbnails/13.jpg)
• Glucose intolerance of variable severity with onset or first identification during the pregnancy
– Constitutes 90 percent of diabetes in pregnancy
– Generally occurs in the latter half of pregnancy
– Usually no effect on organogenesis (no congenital defects)
– Disappears after delivery
![Page 14: DM in pregnancy 5 points](https://reader036.vdocuments.site/reader036/viewer/2022081404/55851a1cd8b42aff298b5260/html5/thumbnails/14.jpg)
Pregnancy predisposes to persistent hyperglycaemia
• glucose is made available to the fetus – ↑ placental hormones – ↑ plasma cortisol – A state of insulin resistance – Further aggravated by ↑ body
weight and ↑ caloric intake during pregnancy
!
14
• Pregestational diabetes becomes worse during pregnancy
• GDM develops when the pancreas cannot overcome the effect of these hormones
![Page 15: DM in pregnancy 5 points](https://reader036.vdocuments.site/reader036/viewer/2022081404/55851a1cd8b42aff298b5260/html5/thumbnails/15.jpg)
1. It is important to differentiate between gestational & pregestational DM
2. Patients with DM are frequently asymptomatic 3. Certain factors will provide a clue of possible DM 4. Monitoring of DM involves history, examination
& investigation, in that order 5. DM may present late with complications of
pregnancy
5 Points
![Page 16: DM in pregnancy 5 points](https://reader036.vdocuments.site/reader036/viewer/2022081404/55851a1cd8b42aff298b5260/html5/thumbnails/16.jpg)
2. Patients with DM are frequently asymptomatic
16
![Page 17: DM in pregnancy 5 points](https://reader036.vdocuments.site/reader036/viewer/2022081404/55851a1cd8b42aff298b5260/html5/thumbnails/17.jpg)
In Asymptomatic Patients
Screening test needed – OGTT Either – Universal screening – Selective screening (based on risk factors)
![Page 18: DM in pregnancy 5 points](https://reader036.vdocuments.site/reader036/viewer/2022081404/55851a1cd8b42aff298b5260/html5/thumbnails/18.jpg)
OGTT
75 grams of oral glucose is given 3 readings -fasting glucose level, 1 hr and 2 hr post glucose The diagnosis of DM is made when fasting glucose level are ≥7.8 and or 2 hour level of >11.1 If the 2 hours levels are between 7.8 and 11.1,the patient is said to have impaired glucose tolerance test and should be treated as GDM
![Page 19: DM in pregnancy 5 points](https://reader036.vdocuments.site/reader036/viewer/2022081404/55851a1cd8b42aff298b5260/html5/thumbnails/19.jpg)
Screening Algorithm
![Page 20: DM in pregnancy 5 points](https://reader036.vdocuments.site/reader036/viewer/2022081404/55851a1cd8b42aff298b5260/html5/thumbnails/20.jpg)
1. It is important to differentiate between gestational & pregestational DM
2. Patients with DM are frequently asymptomatic 3. Certain factors will provide a clue of possible DM 4. Monitoring of DM involves history, examination
& investigation, in that order 5. DM may present late with complications of
pregnancy
5 Points
![Page 21: DM in pregnancy 5 points](https://reader036.vdocuments.site/reader036/viewer/2022081404/55851a1cd8b42aff298b5260/html5/thumbnails/21.jpg)
3. Certain factors will provide a clue of possible
DM
21
![Page 22: DM in pregnancy 5 points](https://reader036.vdocuments.site/reader036/viewer/2022081404/55851a1cd8b42aff298b5260/html5/thumbnails/22.jpg)
Factors for screening
★Risk Factors • Age>30 years • Previous GDM • Family history of DM • Bad Obs history • History of macrosomia • Prev. fetal anomalies • History of unexplained
stillbirth
Associated Clinical Factors • Congenital fetal
anomalies • Pre-eclampsia • Obesity > 90 kg • Recurrent UTI, vaginal
candidiasis • Presence of glycosuria
on more than 2 occasions
![Page 23: DM in pregnancy 5 points](https://reader036.vdocuments.site/reader036/viewer/2022081404/55851a1cd8b42aff298b5260/html5/thumbnails/23.jpg)
1. It is important to differentiate between gestational & pregestational DM
2. Patients with DM are frequently asymptomatic 3. Certain factors will provide a clue of possible DM 4. Monitoring of DM involves history, examination
& investigation, in that order 5. DM may present late with complications of
pregnancy
5 Points
![Page 24: DM in pregnancy 5 points](https://reader036.vdocuments.site/reader036/viewer/2022081404/55851a1cd8b42aff298b5260/html5/thumbnails/24.jpg)
4. Monitoring of DM involves history,
examination & investigation,
in that order
24
![Page 25: DM in pregnancy 5 points](https://reader036.vdocuments.site/reader036/viewer/2022081404/55851a1cd8b42aff298b5260/html5/thumbnails/25.jpg)
Assessment of the pregnancy
Take precise history - maternal well-being, FM#
Examine for complications - remember; maternal, fetal & placental#
Investigations - in order of priority#
ultrasound scan, urine, blood tests, CTG
![Page 26: DM in pregnancy 5 points](https://reader036.vdocuments.site/reader036/viewer/2022081404/55851a1cd8b42aff298b5260/html5/thumbnails/26.jpg)
1. It is important to differentiate between gestational & pregestational DM
2. Patients with DM are frequently asymptomatic 3. Certain factors will provide a clue of possible DM 4. Monitoring of DM involves history, examination
& investigation, in that order 5. DM may present late with complications of
pregnancy
5 Points
![Page 27: DM in pregnancy 5 points](https://reader036.vdocuments.site/reader036/viewer/2022081404/55851a1cd8b42aff298b5260/html5/thumbnails/27.jpg)
5. DM may present late
with complications of pregnancy
27
![Page 28: DM in pregnancy 5 points](https://reader036.vdocuments.site/reader036/viewer/2022081404/55851a1cd8b42aff298b5260/html5/thumbnails/28.jpg)
Maternal Complications - Obstetric
1. Pre-eclampsia 2. Recurrent infection-vaginal candidiasis,uti 3. Polyhydramnios—pprom, cord prolapse, 4. Increased instrumental and CS rates 5. Anomalies & abortions 6. Sudden IUD 7. Post-delivery, 40-60% of women develop type 2 DM
within 10 years
![Page 29: DM in pregnancy 5 points](https://reader036.vdocuments.site/reader036/viewer/2022081404/55851a1cd8b42aff298b5260/html5/thumbnails/29.jpg)
Maternal Complications - Medical
1. Retinopathy 2. Nephropathy 3. Neuropathy 4. Micro/macroangiopathy
![Page 30: DM in pregnancy 5 points](https://reader036.vdocuments.site/reader036/viewer/2022081404/55851a1cd8b42aff298b5260/html5/thumbnails/30.jpg)
Fetal complications
1. Congenital anomalies (4 fold) - sacral agenesis, NTD, cardiac and renal anomalies
2. Macrosomia 3. Respiratory distress
syndrom
4. Hypoglycemia-result of hyperplasia of beta cell
5. Prematurity 6. Malpresentation 7. Shoulder dystocia 8. Polycythemic -jaundice
Text
![Page 31: DM in pregnancy 5 points](https://reader036.vdocuments.site/reader036/viewer/2022081404/55851a1cd8b42aff298b5260/html5/thumbnails/31.jpg)
Mechanism of macrosomia
![Page 32: DM in pregnancy 5 points](https://reader036.vdocuments.site/reader036/viewer/2022081404/55851a1cd8b42aff298b5260/html5/thumbnails/32.jpg)
Shoulder Dystocia
![Page 33: DM in pregnancy 5 points](https://reader036.vdocuments.site/reader036/viewer/2022081404/55851a1cd8b42aff298b5260/html5/thumbnails/33.jpg)
1. It is important to differentiate between gestational & pregestational DM
2. Patients with DM are frequently asymptomatic 3. Certain factors will provide a clue of possible DM 4. Monitoring of DM involves history, examination
& investigation, in that order 5. DM may present late with complications of
pregnancy
5 Points
![Page 34: DM in pregnancy 5 points](https://reader036.vdocuments.site/reader036/viewer/2022081404/55851a1cd8b42aff298b5260/html5/thumbnails/34.jpg)
This is your group!