MEDICAL CONDITIONS

COMPLICATING PREGNANCY

Dr.Badi albaqawi , MD

KFMC-WSH, Riyadh

Objectives

• Common medical diseases affecting pregnant women.

• Course of the disease

• Course of the pregnancy

• Antenatal maternal and fetal surveillance

• Maternal outcome

• Fetal outcome

Introduction

• Diabetes and thyroid disorders are most common.

• How the physiologic changes of pregnancy may

affect the diagnosis and clinical course

• How the disease may affect the pregnancy.

PHYSIOLOGICAL CHANGES OF GLUCOSE

METABOLISM IN PREGNANCY

• Pregnancy is a state of insulin resistance & relative

glucose intolerance

• This is due to placental production of anti-insulin

hormones : hPL, cotisol, and glucagon

• FBS

• Postprandial glucose ↑ ↑

• Insulin production ↑ ↑ 2 folds in N women

• Insulin requirements ↑ ↑ in diabetic women

• renal threshold for glucose glycosuria

DIABETES MELLITUS

• The prevalence of diabetes mellitus has greatly increased

in the last 20 years.

• Range from 6-12% .

• 80-90% of diabetes in pregnant women is gestational, and

about 10% is pregestational.

GDM Pregestational

Gestational diabetes mellitus (GDM)

• Defined as glucose intolerance with onset or first

recognition during pregnancy.

• Human placental lactogen, progesterone,

prolactin, and cortisol

• GDM is considered stress test for future development of

DM .

Pregestational diabetes mellitus

• Diabetes present before pregnancy and may be

either type 1 or type 2 diabetes.

• White classification of diabetes during pregnancy

to assess disease severity and the likelihood of

complications .

EFFECT OF PREGNANCY ON DM

• Insulin requirement ↑ ↑ in pregnancy reaching a max at

term & being at least 2 X the pre-pregnancy requirement

• Pt with diabetic nephropathy deterioration in renal

function with in creatinine clearance & proteinuria

this deterioration in renal function is usually reversed

after delivery

EFFECT OF PREGNANCY ON DM

• 2 X ↑↑ in retinopathy

rapid improvement in glycemic control worsening

retinopathy due to ↑↑ retinal blood flow

• ↑↑ icidence of hypoglycemia

• Ketoacidosis is rare unless associated with hyperemesis,

infections, tocolytic & corticosteroid Rx

EFFECTS OF DM ON PREGNANCY

• ↑ incidence of congenital abnormalities

• The risk is related to the degree of glycemic control 5%

with Hb A1c > 8%

25% with Hb A1c > 10% with ↑↑ risk

of abortions

• Sacral agenesis, congenital heart defects, skeletal

abnormalities & neural tube defects

• Perinatal & neonatal mortality ↑↑ 2-4 X

• Unexplained IUFD at term / more in macrosomic babies

EFFECTS OF DM ON PREGNANCY

• Macrosomia the incidence is ↑↑ with poor diabetic

control

not eliminated by tight control

associated with ↑↑ risk of operative delivery, birth

trauma, & shoulder dystocia

• Hyperglycemia fetal polyuria polyhydramnios

PROM, preterm delivery

• Prematurity pose an added problem as pulmonary

surfactant production is slightly delayed in babies of

diabetic mothers

EFFECTS OF DM ON PREGNANCY

• Postnatally, babies are at risk of hypoglycemia & jaundice

• ↑↑ risk of PET especially in pt with pre-existing

hypertension & nephropathy where it reaches almost 30%

Diagnosis of Gestational Diabetes

Mellitus

• Low risk between 24 and 28 weeks’

• High risk1st antenatal visit.

• High risk previous pregnancy with GDM, a history of

polycystic ovarian disease, obesity, previous IUFD, history

of big baby

• If a first-trimester screen is done and is found to be

negative, it should be repeated at 24 to 28 weeks.

• 50 g OGTT >130mg/dl is +ve.

• If blood glucose >200mg/dl is +ve and no need for 2nd

step.

Diagnosis of Gestational Diabetes

Mellitus

Screening

One step using 75 g

glucose

Two steps using 50 g then

100g glucose

Complications

• Most fetal and neonatal effects are attributed to the

consequences of maternal hyperglycemia

• Fetal hyperglycemia during the period of embryogenesis

is teratogenic.

• direct correlation between birth defects in diabetic

pregnancies and increasing glycosylated hemoglobin A1C

(HbA1C)

• Fetal demise due to acidosis, hypotension from

osmotic diuresis, or hypoxia from increased metabolism,

coupled with inadequate placental oxygen transfer.

Hyperglycemia

Maternal hyperglycemia

Fetal hyperglycemia

Fetal pancreatic beta-cell hyperplasia

Fetal hyperinsulinaemia

Macrosomia,organomegaly, polycythaemia, hypoglycemia,

RDS

• Pregestational diabetes is generally associated with a

higher rate of maternal and fetal complications

Preexisting DM in Pregnancy

Effect of preexisting DM on pregnancy (Maternal)

1. increase risk of miscarriage

2. increase risk of preclampsia

3. increase risk of infection eg vaginal candidiasis, UTI,

endometrial or wound infection

4. increase LSCS rate

Preexisting DM in Pregnancy

Fetal

1. increase risk of congenital abnormalities

sacral agenesis, congenital heart disease,

neural tube defects

Hba1c level Risk

normal not increased

<8% 5%

>10% 25 %

Preexisting DM in Pregnancy

2. Perinatal mortality (excluding congenital abnormality ) 2

fold increased

3. Increase risk of sudden unexplained intrauterine fetal

death.

Complications of pregnancy in pre-

existing DMMaternal:

Increase insulin requirment’Hypoglycemia

Infection

Ketoacidosis

Deterioration in retinopathy’Increased proteinuria+

edema

Miscarriage

Polyhydramnios

Shoulder dystocia

Preeclampsia

Increased caesarean rate

Fetal:

Congenital abnormalities

Increased neonatal and perinatal mortality

Macrosomia

Late stillbirth

Neonatal hypoglycemia

Polycythemia

jaundice

Management

• a team approach

• education and counseling,

• ACHIEVING EUGLYCEMIA : FBS <95 mg/dl and 2hr pp is

< 120 mg/dl.

DIET EXERCISE

PHARMACOLOGIC THERAPY.

Diet

• 30-35 kcal/kg /day

• The diet is composed of about 45-50% carbohydrate, 20-

25% protein, and 20-25% fat.

• Contain a generous amount of fiber.

• Caloric intake is divided into 20% at breakfast, 30% at

lunch, 30% at dinner, and 20% at a bedtime snack.

PHARMACOLOGIC THERAPY

• Metformine.

• Oral hypoglycemic agent (glyburide) .

• Insulin .

• Insulin is the medication of choice to maintain eu-

glycemia in pregnancy and is the recommended therapy

in women with pregestational diabetes.

Antepartum Obstetric Management

• Multidisciplinary team including obstetricians, endocrinologists, dieticians, & midwives optimize outcome

• Preconception councelling

• To achieve normoglycemia

• Dietary advice on a low sugar, low fat, high fiber diet

• Regular capillary glucose series

Antepartum Obstetric Management

• Regular assessment of Hb A1c

• Ophthalmologic examination & Rx of retinopathy

• Regular monitoring of renal function in Pt with diabetic

nephropathy

• Detailed U/S screening for congenital malformations in

the 2nd trimester (20wk) to exclude NTD, sacral

agenesis, & cardiac defects

• Frequency of antenatal visits needs to be individualized

The timing of delivery

• depends on fetal and maternal status and the degree

of glucose control.

• Well-controlled GDM without other complications,

spontaneous onset of labor at term may be awaited.

• Earlier intervention is indicated if these conditions are not

met.

• For macrosomic babies, increased birth trauma to both

mother and fetus should be avoided. Cesarean delivery

may be elected for large fetuses (>4500 g).

Intrapartum Management

• Establishment of maternal euglycemia during labor.

• continuous infusion of regular insulin is given.

• Plasma glucose level between 80 and 120 mg/dL.

• Fetal heart rate monitoring is recommended for all

patients with diabetes.

Postpartum Period

• Insulin requirements drop sharply because the placenta .

• Plasma glucose levels should be monitored and lispro or

regular insulin given when plasma glucose levels are

elevated.

• Women with GDM should undergo a 75-g OGTT at 6 to

12 weeks postpartum.

• If the mother is breastfeeding, 500 calories/day should be

added to the prepregnancy diet.

• Contraception counseling