Medical Complication In Pregnancy

Diabetes

At the beginning of the 20th century , diabetic women suffered from infetility, and the rare women achieving pregnancy faced a poor prognosis. Maternal death was a real threat,and perinatal survival a more 40 percent.

The availability of insulin since 1922, restored fertility and virtually abolished maternal mortality. At the same time, perinatal survival did not change appreciatably. Since 1949 White Classification was developed, permitted individualized timing and mode of delivery, then perinatal mortality was reduced (nearly equivalent to that observed in normal pregnancies.)

I. Classification

Type I Diabetes Mellitus

----insulin-dependent

----immune-mediated and developed in genetically susceptible persons

----concordance rate for diabetes in monozygous twins is less than 50%

Type II diabetes

----noninsulin-dependent

----no HLA association

----familial occurrence

----concordance rate for diabetes in monozygous twins is 100%

Gestational Diabetes Mellitus Diabetes is the most common medical complication of pregnancy. Patient can be seperated into those diagnosed during pregnancy It is estimated that 90 percent of all pregnacies complicated by diabetes are due to gestational diabetesApproximately 15 percent of women with gestational diabetes will exibit fasting hyperglycemia

Classification during pregnancy

Table 1 gives a classification recommended by the American College of Obstetricians and Gynecologists in 1986.

class onset Fasting plasma glucose

2-hour postprandial glucose

therapy

A1 Gestational <105mg/dl <120mg/dl Diet

A2 Gestational >105mg/dl >120mg/dl Insulin

Class Age of onset(yr)

Duration(yr) Vascular disease

Therapy

B >20 <10 None Insulin

C 10-19 10-19 None Insulin

D <10 >20 Benign retinopathy

Insulin

F Any Any nephropathy InsulinR Any Any Proliferative r

etinopathyInsulin

H Any Any Heart Insulin

T Any Any Transplantation of kianey

Insulin

II. Diagnosis

(I)Diagnosis of Overt Diabetes during Pregnancy i.presence of classical signs and symptoms (such as polydipsia, polyuria, unexplained weight loss) ii.a random plasma glucose level greater than 200mg/dl or fasting glucose>= 126mg/dl iii.presence of ketoacidosis

(II)Diagnosis of gestational diabetes

i.High risk factors: a familial history of diabetes, given birth to large infants, unexplained fetal losses, obesity

ii.Screaning

50g oral glucose challenge test: A value of 140mg/dl(7.8mmol/l)or higher will identify 80% of all women with gestational diabetes

iii.Diagnosis criteria

If the results of 50g oral glucose challenge test exceed 7.8mmol/l, a diagnostic 100g oral glucose tolerance test is performed.

Table 2 American college of Obstetricians and Gynecologists 1994 Criteria for Diagnosis of Gestation

alDiabetes Using 100g of Glucose Taken Orally

Timing of Measurement

Plasma Glucose

National diabetes Data Group(1979)

Carpenter and Coustan(1982)

Fasting 105mg/dl(5.6mmol/l) 95

1hour 190mg/dl(10.5mmol/l) 180

2hour 165mg/dl(9.2mmol/l) 155

3hour 145mg/dl(8.0mmol/l) 140

III.Maternal and Fetal Effects

I)Maternal Effects

i.increasing abortion rate

ii.increasing incidence of Pregnancy-Induced Hypertension(PIH)

iii.tend to be infection

iv.polyhydramnios

v.Macrosomia

vi.Be susceptible to ketoacidosis

(II)perinatal Effects

i.Macrosomia incidence is as high as 25-40%

ii.Intrauterine Growth Retardation (restriction)

iii.Preterm Labor

iv.Fetal Anomalies

v.Stillbirth,Fetal death

vi.Congenital Malformations

(III)Infant Effects

i.Neonatal Respiratory Distress Syndrome

ii.Neonatal Hypoglycemia

iii.Hypocalcemia

iv.Hyperbilirubinamia

IV.Management(I)Diet Nutritional counseling is a cornerstone in management The goals of such therapy are: i.To provide the necessary nutrients for the mother and fetus ii.To control glucose level iii.To prevent starvation ketosis

Table 3 Recommend Daily Caloric Intake and Pregnancy Weight Grain in Women with Gestational Diabetes with and without Concomitant Insulin Therapy

Current Weight in Relation to Ideal Body Weight

Daily Caloric Intake(kcal/kg)

Recommend Pregnancy Weight Grain

<80-90% 36-40 28-40

80-120 30 25-35

120-150 24 15-25

>150 12-18 15-25

(II)Insulin therapy i.Indication---Insulin therapy is usually recommend when standard dietary management does not consistantly maintain the fasting plasma glucose at less than 105mg/dl or the 2-hour postprandial plasma glucose at less than 120mg/dl ii.At the beginning, a total dose of 20-30 units given once daily, before breakfast. The total dose is usually divided into two thirds intermediate-acting insulin and a third short-acting insulin

(III)Preconception

i.Control preconception glucose to optimal level(by using insulin)

ii.Hemoglobin AIc measurement

IV.Prenatal Care

(I)First trimester

i.Careful monitoring of glucose control is essential to management

ii.Diet:Total caloric intake of 30-35kcal/kg of ideal body weight

(II)Second trimester i.Maternal serum AFP ii.Ultrasonoscan(at 18-20w) to detect neural-tube defects and other anomalies

(III)Third trimester i.Weekly visits to monitor glucose control and to evaluate for preeclampsia ii.Serial ultrasonography to evaluate fetal growth and amnionic fluid volume iii.Other fetal surveillance tests iv.Accept hospitalization from 34w until delivery

V.Delivery

(I)Timing of delivery i.Women with gestational diabetes who do not require insulin ii.Women with gestational diabetes who require insulin iii.Overt diabetes women iv.Others v.If severe hypertantion,preeclampsia or other complications develop,delivery is carried out even though the ratio is less than 2.0 L/S

(II)Mode of delivery i.In gneral, women with GDM(who does not requre insulin), the way of delivery is spontaneous labor ii.Women with sonographic diagnosis of fetal macrosomia, elective induction of labor or cesarean section to prevent shouder dystocia iii.In the overtly diabetic women(besides class A), cesarean delivery has commonly been used to avoid traumatic birth of a large infant, or to avoid maternal or fetal complication due to more advanced diabetes.Especially for those with vascular diseases

(III)Control the blood glucose

Maintain a near normal glycemia level

Reduce the dose of insulin on the day of delivery, and ½ postpartum

(IV)Prevention of infection

(V)Neonatal care

i.detecting of blood glucose, plasma calcium, plasma bilirubin

ii.Be care for a preterm neonatal

iii.To find respiratory distress and treatment

iv.Prevention of postpartun hemorrhge