Diabetes in pregnancy

Naghshineh.E MD

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do not have overt vasculopathy do not have increased risk of congenital

malformations

GDM versus overt DM

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Macrosomia Preeclampsia(daily low dose ASA) Hydramnios Stillbirth Neonatal morbidity (RDS)

Strict glycemic control:-exacerbation of diabetic retinopathy-may impair fetal growth-not teratogenic in humans

Conditions more common in GDM:

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Glucose monitoring &control

Antenatal fetal testing(NST,BPP,CST):-GDM control with insulin or oral HGA:usually initiated at 32wks weekly, from 36 wks until delivery twice per week -GDM control with nutritional therapy :Not ante partum fetal surveillance

IUFD:3 per 1000 pregnancy (excluding congenital malformations)

Management of pregnancy

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Assessment of fetal growth:-induction of labor-scheduled c/s-not optimal glycemic control

---EFW≥4800 gr → 50% chance FW≥4500 gr ---sono 28-32 wks, repeat 3-4 wks ,last 38 wkor---single sono at 36 wks---not recommended in GDM with nutritional

therapy

Management of pregnancy

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PTL:16% Choice for tocolytic therapy : Nifedipin Or Indometacin Avoid Beta-adrenergic receptor : severe hyperglycemia Ante natal glucocorticoid : hyperglycemia 12 hrs after first dose, last 5 days

Management of pregnancy

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-Benefits of induction: Avoidance of late stillbirth Avoidance of delivery-related complications

-Disadvantage of induction: c/s in failed induction tachysystole neonatal morbidity in<39 wks

Timing of delivery

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GDM euglycemic with nutritional therapy: induction of labor at 40 wks GDM medically managed (ins or OHGA): induction of labor at 39 wks

ACOG recommended: c/s in DM :EFW≥4500 gr c/s in non DM: EFW≥5000 gr

Timing of delivery

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Cervical ripening agents are safe Fallow labor progress closely

Operative vaginal delivery: only if fetal vertex has descended normally

Higher risk of shoulder dystocia & brachial plexus injury

Management of labor

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avoid maternal hyperglycemia : risk of fetal acidosis & neonatal hypoglycemia

insulin requirement usually decrease during labor

Glucose is important for optimal myometrial function

GDM euglycemic with nutritional therapy: rarely require insulin during labor (2%) GDM medically managed (Ins or OHGA): may

need insulin infusion during labor (3.5%)

Labor & delivery

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Poorly controlled DM: Diabetic fetopathy ( prolonged hypoglycemia secondary to pancreatic hyperplasia & hyperinsulinemia)

Maternal normoglycemia can not prevent neonatal hypoglycemia

Labor & delivery

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Intrapartum glucose target:70-110 Check BS every 2-4 hrs during latent

phase ,1-2 hrs during active phase of labor Begin insulin infusion if BS>120 Check BS every 1 hour during insulin

infusion

GDM euglycemic with nutritional diet & exercise:

BS on admission, every 4-6 hours

Labor & delivery

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Mild hyperglycemia is less morbid than hypoglycemia

BS<50, BS>180:treated promptly

Protocols: 1-N/S infusion, when BS<70: DW5% 2-DW5%(100-125 ml/h)+Ins(0.5-1u/h) 3-Rotating fluids(N/S,DW5%,LR)

Labor & delivery

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Procedure scheduled early in morning NPO & Ins or OHGA withheld morning of

surgery Delay surgery until afternoon: 1/3 morning

NPH +DW5% (avoid ketosis) BS monitor & control with regular insulin

Hypoglycemia: wound infection, metabolic complications, neonatal hypoglycemia

Cesarian delivery

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Check FBS,BS (2hpp): 24 h after NVD & 48h after c/s Relaxed BS level:140-160 during first24-48 h

If FBS<126: follow up If FBS>126: monitoring and therapy

Postpartum depression is more common follow up 6-8 wks later: GTT,75 gr,2 hr

GDM Postpartum management

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DM-I: -1/2-2/3 (NPH+ Reg) prepartum

DM-II: -no medication first 24-48 hours -Ins 0.6 u/kg post partum weight -Metformin, glyburide (safe breastfeeding) -Metformin prefer in obese DM patients

Overt DM Postpartum management

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Hb A1C<7% FBS<120 BS 2hpp<170

After hospital discharge

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Insulin requirement:-early rise 3-7 wks-decline 7-15 wks-rise during reminder of pregnancy-if insulin fall after 35 wks>5-10%:R/O

placental insufficiency, fetal wellbeing tests ,not indication of delivery

Overt DM

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Screening for aneuploidy:-first trimester & ultrasound markers not

affected by maternal DM-Second trimester (QT):Decreased AFP & uE3

,must be adjusted MSAFP:NTD(2%) Anomaly scan:18 wks Fetal echocardiogram ? (50% ,conotruncal &VSD)

Overt DM

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Timing for delivery:- Well controled:38+4 wks- With vascular disease:37 wks

Overt DM

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Any type is acceptable Progestin-only pills, DMPA, levonogestrol

IUD : increased risk of developing DM-II ? Copper IUD

Contraception

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Towards a safe motherhood