preconception counseling and management of diabetic patients during pregnancy ghorbani h.md fellow...

Preconception Counseling and Preconception Counseling and Management of Diabetic Patients Management of Diabetic Patients During PregnancyDuring Pregnancy

Ghorbani H.MDGhorbani H.MD

Fellow of EndocrinologyResearch Institute for Endocrine Sciences

2007 Oct-18

Preconception CounselingPreconception Counseling

Prepregnancy evaluation and counseling of women DM Prepregnancy evaluation and counseling of women DM →→ minimize minimize the risk to the the risk to the F&MF&M

Poor glycemicPoor glycemic control during control during organogenesisorganogenesis→ → spontaneous spontaneous abortionabortion & congenital & congenital anomalies anomalies

Thus, the importance of evaluating glycemic control before Thus, the importance of evaluating glycemic control before

conception cannot be overstated.conception cannot be overstated.

Uptodate 2007

Amir

Preconception Care of Women With DiabetesCongenital malformations 6-9% vs. general population risk of 2- 3%.

Congenital defects account for 50% of perinatal mortality

Diabetes associated malformations are more often lethal or significantly disabling and generally involve 1 or more organ systems.

Spontaneous abortion in poorly controoled diabetes twice the rate in women without diabetes.

J Perinat Neonat Nurs Vol. 18, No. 1, pp. 14–25 c 2004

CONGENITAL MALFORMATIONS AND SPONTANEOUS ABORTIONS

The malformations most commonly associated with diabetes occur before the 7th week after conception

The finding of multiple associated anomalies suggests a"hit"during blastogenesis that occurs during the

first 4 weeks of fetal development

Anomalies during blastogenesis tend to be more severe than those that occur during organogenesis (weeks 4 to 5 after conception) And may increase the risk of spontaneous abortions

joslins textbook 2005

Thus, interventions to control glycemia and reduce the risk of malformations must begin before conception and continue through the first 7 weeks after conception.


The institution of strict glycemic control, as

soon as the woman with diabetes determines

that she is pregnant, very often is too late

to prevent structural damage to fetal organs

which have already formed.

Preconception Care of Women With Diabetes


Information and counselling should be provided to all women of reproductive age with diabetes

A meta-analysis has demonstrated a significantly lower prevalence of major congenital anomalies in offspring of women who attended for prepregnancy counselling (relative risk, 0.36; 95% CI, 0.22–0.59; absolute risk, 2.1% v 6.5%).

Management of women with diabetes before conception

MJA • Volume 183 Number 7 • 3 October 2005

PERICONCEPTIONAL CARE OF WOMEN WITH DIABETES

Because most pregnancies of diabetic women are either unplanned

or

without prenatal care until organogenesis has occurred, the efficacy of the intervention has been limited.

Education combined with accessibility to preconception care is the cornerstone of care

Obstet Gynecol Clin N Am 34 (2007) 225–239

A complete history and physical examination should be performed at the preconception visit.

This evaluation should include:

Information on the duration and type of diabetes

History of acute and chronic complications

Current and past glucose management

Physical activity, comorbid medical conditions

Gynecologic and obstetric history

Family issues .Uptodate 2007

Diabetes complications review

Retinopathy:

The eye examination should be conducted through dilated pupils by a person experienced in retinal examination .

Preexisting retinopathy may progress more rapidly in pregnancy .

Retinopathy that requires laser therapy should be treated before pregnancy.


Nephropathy:Overnight or 24 hour urine sample to quantify the albumin excretion rate.

Patients with pre-existing microalbuminuria are more likely to develop preeclampsia

If renal function is significantly impaired (cr> 0.2mmol/L), there is an increased risk of progression to dialysis during pregnancy


In patients with diabetic nephropathy and mild to moderate renal dysfunction ( cr 1.4 mg/dL and GFR over 90 mL/min), pregnancy per se does not worsen long-term outcom

Pregnancy seems to accelerate renal function

deterioration in women with moderate to severe renal dysfunction at the beginning of pregnancy.

Nephropathy:

Obstet Gynecol Clin N Am 34 (2007) 225–239

Macrovascular disease:

Pre-existing heart disease, requires cardiological review before conception

Significant CHD should be treated before pregnancy .


IdeallyIdeally, all antihypertensive , all antihypertensive drugsdrugs should be should be stopped stopped before conception if the BP remains before conception if the BP remains belowbelow 130/80 mmHg130/80 mmHg with dietary salt restrictionwith dietary salt restriction..

Methyl dopaMethyl dopa

HydralazineHydralazine

B-blockerB-blocker

Ca canal blockerCa canal blocker

ACEI and ARBs are contraindicatedACEI and ARBs are contraindicated

Thiazid is relatively contraindicatedThiazid is relatively contraindicated

BP should be managed aggressivelyBP should be managed aggressively

Management of hypertension

Uptodate 2007

Autonomic neuropathy:

The presence of autonomic neuropathy resulting in gastroparesis, orthostatic hypotension or hypoglycaemic

unawareness may severely complicate the management of

diabetes in pregnancy.

Other related issues:

Thyroid function should be measured for women with T1D


Management of hyperlipidemiaManagement of hyperlipidemia

StatinsStatins are are contraindicatedcontraindicated & should be & should be discontinued before conceptiondiscontinued before conception

HypertriglyceridemiaHypertriglyceridemia treat with treat with diet diet , , supplementation with supplementation with medium chain TGmedium chain TG and

use of intravenous heparin

Joslin text book 2005

BacteriuriaBacteriuria

Women should be Women should be screenedscreened for for asymptomatic asymptomatic bacteriuriabacteriuria and those with and those with positive testpositive test results should results should be be treatedtreated to prevent development of pyelonephritis to prevent development of pyelonephritis

Uptodate 2007

Clinically proven ischemic CAD →pregnancy is contraindicated.

women with diabetic Autonomic neuropathy involving the

CV system → fixed heart rate → pregnancy should be avoided.

Gastroenteropathy is a relative contraindication to pregnancy.

Women with active untreated PR should be counseled to delay pregnancy until after laser photocoagulation

Preconception CounselingPreconception Counseling


Preconception Treatment GoalsPreconception Treatment Goals Goal PlasmaGoal Plasma(mg/dl)(mg/dl) Wholeblood Wholeblood(mg/dl)(mg/dl)

Fasting and Premeal 80-110 70-100Fasting and Premeal 80-110 70-100

glucoseglucose

22--hpp 100-155 90-140hpp 100-155 90-140

HbA1c <7%;normal if possibleHbA1c <7%;normal if possible

Avoid hypoglycemiaAvoid hypoglycemia


WHITE CLASSIFICATION OF DMWHITE CLASSIFICATION OF DM DURING PREGNANCYDURING PREGNANCY

Gestational DMGestational DMClass A : diet alone ,any duration or ageClass A : diet alone ,any duration or ageClass B : age at onset > 20 y& duration < 10yClass B : age at onset > 20 y& duration < 10yClass C : age at onset 10- 19 or duration 10 Class C : age at onset 10- 19 or duration 10 –– 19 y 19 yClass D : age < 10 y or duration > 20 y or background Class D : age < 10 y or duration > 20 y or background retinopathy or HTN ( not preeclampsia)retinopathy or HTN ( not preeclampsia)Class R : proliferative retinopathy or vitreous HEClass R : proliferative retinopathy or vitreous HE

Class F : nephropathy with p. uria > 500 mgClass F : nephropathy with p. uria > 500 mgClass RF : R & FClass RF : R & FClass H : heart dxClass H : heart dxClass T : prior renal transplantationClass T : prior renal transplantation

Joslin textbook 2005

Postconception Ttreatment GoalsPostconception Ttreatment Goals

Goal Plasma whole bloodGoal Plasma whole blood

Fasting and premeal glocose 70 -106 60 -95Fasting and premeal glocose 70 -106 60 -95

BS -1hpp 100 -155 90 -140BS -1hpp 100 -155 90 -140

BS -2hpp 90 -130 80 -120BS -2hpp 90 -130 80 -120

Urinary ketones NegativeUrinary ketones Negative Normalization of HbA1cNormalization of HbA1c

Avoidance of severe hypoglycemiaAvoidance of severe hypoglycemia

Joslin textbook 2005

Management during pregnancy

Routinely review women every 1–4 weeks during the first 30 weeks and then every 1–2 weeks until delivery, depending on diabetes control and the presence of diabetic and obstetric complications.

It is recommended that tests be performed fasting and 1–2 hours after meals.

The HbAlc level should be monitored every 4–8

weeks and kept within the normal range.


Women should be monitored for signs or progression of diabetic complications, particularly:

Retinopathy

Proteinuria

Proteinuria should be assessed by dipstick at regular intervals, and quantitated where appropriate .



Complications of Diabetes during Pregnancy

pregnancy per se does not appear to hasten the natural progression to ESRD for most women

This This dependsdepends upon the upon the initial degreeinitial degree of renal of renal impairmentimpairment..

The risk is substantially increased in women with a The risk is substantially increased in women with a crcr aboveabove 2.0 2.0 mg/dL , many of whom have more than mg/dL , many of whom have more than 2 g2 g of of proteinuria per dayproteinuria per day..

NEPHROPATHY

Uptodate 2007

NEPHROPATHY

These findings can be considered These findings can be considered relativerelative contraindicationscontraindications to pregnancy to pregnancy . .

A A GFR below 50GFR below 50 mL/min before pregnancy is mL/min before pregnancy is associatedassociated with a high prevalence of with a high prevalence of HTNHTN and and fetalfetal wastagewastage

Uptodate 2007

MicroalbuminuriaMicroalbuminuria

Degree of glycemic controlDegree of glycemic control

Blood pressureBlood pressure

PregnancyPregnancy

The four major factors that have been associated The four major factors that have been associated with the development and progression of DNwith the development and progression of DN::

Uptodate 2007

These agents are a reasonable option for the treatmentThese agents are a reasonable option for the treatment

of HTN in pregnant women with of HTN in pregnant women with DNDN,,microalbuminuriamicroalbuminuria , ,

or or microvascular microvascular diseasedisease . .

Lowering BPLowering BP, , reducing microalbuminuriareducing microalbuminuria, and, and improving improving glycemicglycemic control have a protective effect on the glomeruli control have a protective effect on the glomeruli and decrease the GFRand decrease the GFR

CCBs mayCCBs may have have similarsimilar renal protective effects as renal protective effects as ACEI ACEI

Uptodate 2007

EFFECT OF NEPHROPATHY ON EFFECT OF NEPHROPATHY ON PREGNANCYPREGNANCYOvert nephropathy is associated with a variety of pregnancyOvert nephropathy is associated with a variety of pregnancy

complicationscomplications::

Fetal growth restrictionFetal growth restriction

Nonreassuring fetal statusNonreassuring fetal status

PreeclampsiaPreeclampsia

As a consequence, As a consequence, preterm deliverypreterm delivery and and cesareancesarean birth birth are often required for maternal or fetal indications are often required for maternal or fetal indications . .

Uptodate 2007

Patients with preexisting diabetes are at increased risk of hypertensive complications during pregnancy:

Chronic HTN

Preeclampsia—eclampsia

Preeclampsia--eclampsia superimposed on chronic HTN

Gestational HTN

Hypertensive disorderHypertensive disorder



– Chronic HTN: before or up to 20Chronic HTN: before or up to 20thth weeks of weeks of gestation & if HTN continue after 12 week after gestation & if HTN continue after 12 week after pregnancypregnancy

– Preeclampsia-eclampsia : ≥ 140/90 mmhg ,usually Preeclampsia-eclampsia : ≥ 140/90 mmhg ,usually after 20after 20thth weeks of gestation with proteinuria more weeks of gestation with proteinuria more than 300mg/24 hrsthan 300mg/24 hrs

– Preeclampsia-eclampsia superimposed on chronic Preeclampsia-eclampsia superimposed on chronic HTNHTN

– Gestational HTNGestational HTNjoslins textbook 2005

Start treatment from Start treatment from BP ≥ 130/ 80BP ≥ 130/ 80 mmHg mmHg especially ifespecially if microalbuminuria microalbuminuria or or proteinuriaproteinuria is presentis present



Ophthalmic assessmenOphthalmic assessmen Comprehensive Comprehensive eye examinatineye examinatin in pt with in pt with planing for pregnancyplaning for pregnancy

who become pregnant should have a comprehensive eye who become pregnant should have a comprehensive eye examinationexamination in the in the first trimesterfirst trimester and and close f/uclose f/u throughout throughout pregnancy and for pregnancy and for one year postpartumone year postpartum..

Frequent Frequent monitoringmonitoring is helpful to look for early is helpful to look for early worsening ofworsening of retinopathy as glycemic control improvesretinopathy as glycemic control improves

Laser Laser photocoagulation should be considered for women with photocoagulation should be considered for women with severe preproliferativesevere preproliferative diabetic retinopathy diabetic retinopathy . .

Uptodate 2007

RetinopathyRetinopathy

Risk of progression of retinopathy increase in pregnancyRisk of progression of retinopathy increase in pregnancyRisk is influenced with :Risk is influenced with :

severity of baseline retinopathyseverity of baseline retinopathy

HbAlc more than 6 SD above normal

intensively treated pt has 1.6 fold increase risk of retinopathy intensively treated pt has 1.6 fold increase risk of retinopathy

Conventionally treated pt has 2.4 fold increase in retinopathyConventionally treated pt has 2.4 fold increase in retinopathyIn DCCT study ,no difference in level of retinopathy in pt who In DCCT study ,no difference in level of retinopathy in pt who

became pregnant as compared with pt who never p.became pregnant as compared with pt who never p.


Formal eye review should be at least 3-monthly if:

baseline retinopathy is present

If there is a rapid improvement in glycaemic control

There has been a long duration of pre-existing diabetes.



Frequency of testing during pregnancy in women with Frequency of testing during pregnancy in women with pregestatonal diabetespregestatonal diabetes

Test FrequencyTest Frequency Hemoglobin A1c Every 4-6 weeksHemoglobin A1c Every 4-6 weeks Blood glucose Home measurements 4-8 times dailyBlood glucose Home measurements 4-8 times daily

Urine ketones During period of illness; when any blood Urine ketones During period of illness; when any blood glucose value is > 200 mg/dl glucose value is > 200 mg/dl

Urine protein Diptstick , quantitate 24 hour Urine protein Diptstick , quantitate 24 hour excretion each trimester in women with excretion each trimester in women with

nephropathy nephropathy

Serum creatinine Each trimester in women with nephropathySerum creatinine Each trimester in women with nephropathy

Thyroid function tests Baseline measurements of serum free T4 and TSHThyroid function tests Baseline measurements of serum free T4 and TSH

Eye examination Baseline and then as necessary per retinal specialistEye examination Baseline and then as necessary per retinal specialist

Uptodate 2007

Fetal SurveillanceFetal SurveillanceThe priciple is to The priciple is to verify fetal viability in the firstverify fetal viability in the first trimester trimester

Validate Validate fetal structuralfetal structural integrity in the integrity in the secondsecond trimester trimester

Monitor Monitor fetal growthfetal growth during most of the during most of the thirdthird trimester trimester

And ensure And ensure fetal well-beingfetal well-being in in late thirdlate third trimester trimester

Maternal- Fetal Medicine Textbook 2004

Fetal surveillanceFetal surveillance

In the past, unexplained fetal death occurred in In the past, unexplained fetal death occurred in 10-30% 10-30% of of type 1 diabetic pregnancies associated with type 1 diabetic pregnancies associated with macrosomiamacrosomia, , hydramnioshydramnios, , preeclampsiapreeclampsia,and ,and vascular diseasevascular disease..

Fetal surveillance Fetal surveillance is of utmost importance in optimizing a is of utmost importance in optimizing a good outcome good outcome for both for both mothermother and and fetusfetus

Endocrinol Metab Clin N Am 35 (2006) 79–97

USUS is the most useful tool for the assessment of the fetus is the most useful tool for the assessment of the fetus..It can be used to:

Estimate gestational age

Screen for structural anomalies

Evaluate growth

Assess amniotic fluid volume

Determine fetal status dynamically through Doppler

and biophysical studies Endocrinol Metab Clin N Am 35 (2006) 79–97


Macrosomia is usually defined as fetal weight greater than 4.0 kg to 4.5 kg or birth weight above the 90th percentile for gestational age

Macrosomia occurs in approximately 88% of fetuses in whom the abdominal circumference and estimated fetal weight both exceed the 90th percentile



US is essential for the evaluation of congenital anomalies .

A structural ultrasonogram can detect both neural tube defects and major cardiac defects

US is performed in the third trimester for the assessment ofgrowth and development and the presence of macrosomia.



In women who have diet-controlled gestational diabetes, fetal surveillance is not initiated usually until 40 weeks

Most centers defer testing until the 35th week if there is excellent glycemic control, but testing is started much earlier in women who have poor control, nephropathy,or hypertension

Antepartum surveillance surveillance


Fetal surveillance in type I and type II diabetic pregnanciesFetal surveillance in type I and type II diabetic pregnancies

Time TestTime TestPreconception Maternal glycemic controlPreconception Maternal glycemic control

8-108-10 w sonographic crown –rump measurementw sonographic crown –rump measurement1616 w Maternal serum alpha- fetoprotein levelw Maternal serum alpha- fetoprotein level

20-2220-22 w high–resolution sonography, fetal cardiac w high–resolution sonography, fetal cardiac echography in women in suboptimal diabetic control echography in women in suboptimal diabetic control

at first prenatal visit at first prenatal visit 24w Baseline sonographic growth assessment of the fetus24w Baseline sonographic growth assessment of the fetus

2828 w Daily fetal movement counting by the motherw Daily fetal movement counting by the mother3232 w Repeat sonography for fetal growthw Repeat sonography for fetal growth

3434 w Biophysical testingw Biophysical testing : : 2X weekly NST or2X weekly NST or weekly CST orweekly CST or

weekly biophysical profileweekly biophysical profile36w Estimation of fetal weight by sonography36w Estimation of fetal weight by sonography

37-38.537-38.5 w Amniocentesis and delivery for patients in poor controlw Amniocentesis and delivery for patients in poor control 38.538.5 – – 4040 ww Delivery without amniocentesisDelivery without amniocentesis for patients in good control who for patients in good control who

have excellent dating criteria have excellent dating criteria


TESTS OF FETAL WELL - BEINGTESTS OF FETAL WELL - BEING testtestfrequencyfrequencyReassuring resultReassuring resultcommentcomment

Fetal movement Fetal movement countingcounting

Every night Every night from 28 wfrom 28 w

Ten movement in <60 minTen movement in <60 minPerformed in all patientsPerformed in all patients

Non- stress testNon- stress testTwice Twice weeklyweekly

Two heart – rate acceleration Two heart – rate acceleration in 20 minutesin 20 minutes

Being at 28-34 w with Being at 28-34 w with insulin dependent diabetesinsulin dependent diabetes

Contraction stress Contraction stress testtest

weeklyweeklyNo heart rate decelerations in No heart rate decelerations in response to ≥ 3 contrations in response to ≥ 3 contrations in

10 minutes10 minutes

Same as for non stress testSame as for non stress test

Ultrasound Ultrasound biophysical profilebiophysical profile

weeklyweeklyScore of 8 in 30 minutesScore of 8 in 30 minutes33 movement =2movement =2

11 flexion = 2flexion = 2

3030 sec breathing = 2sec breathing = 2

22 cm amniotic fluid = 2cm amniotic fluid = 2


CONFIRMATION OF FETAL MATURITY BEFORE INDUCTION CONFIRMATION OF FETAL MATURITY BEFORE INDUCTION OR PLANNING CESAREANOR PLANNING CESAREAN

• Phosphatidyl glycerol > 3% in amniotic fluid collected from vaginal Phosphatidyl glycerol > 3% in amniotic fluid collected from vaginal pool or by amniocentesispool or by amniocentesis

• Completion of 38.5 weeks gestationCompletion of 38.5 weeks gestation

• Normal LMPNormal LMP

• First pelvic examination before 12 weeks confirm dates.First pelvic examination before 12 weeks confirm dates.

• Sonogram before 24 weeks confirm datesSonogram before 24 weeks confirm dates

• Documentation of more than 18 weeks by fetoscope of FHTDocumentation of more than 18 weeks by fetoscope of FHT


Medications used in management of premature labour

β-sympathomimetic agents given to suppress uterine contractions and corticosteroids given to enhance fetal lung maturity .

Following administration of salbutamol, there may be a rapid rise in blood glucose level

Alternative tocolytic agents such as nifedipine are recommended. Following administration of corticosteroid, the rise in blood glucose level usually starts about 6–12 hours later, and may persist for up to 5 days

BS level monitored every 1–2 hours until glycaemic control has stabilised


DeliveryDelivery should be at term unless obstetric or medical factors dictate otherwise (eg, fetal macrosomia, polyhydramnios, poor metabolic control, preeclampsia,IUGR).

Vaginal delivery is preferable unless there is an obstetric or medical contraindication.

Birthweight exceeds 4250–4500g warrants consideration of elective caesarean section.


Indication for deliveryIndication for delivery diabetic pregnancydiabetic pregnancy

Fetal Fetal Non reactive, Positive CSTNon reactive, Positive CST

mature fetusmature fetus Sonographic evidence of fetal growth arrestSonographic evidence of fetal growth arrest

Decline in fetal growth rate with decreased amnionic Decline in fetal growth rate with decreased amnionic fluidfluid

4040 – – 4141 w gestationw gestation

Maternal Maternal Severe preeclampsiaSevere preeclampsia

Mild preeclampsia, mature fetusMild preeclampsia, mature fetus Markedly falling renal functionMarkedly falling renal function

Obstetric Obstetric ppreterm labor with failure of tocolysisreterm labor with failure of tocolysis

Mature fetus , inducible cervixMature fetus , inducible cervix


Fetal Monitoring

Evaluations for neural tube defects and other congenital malformations begin with triple-screen testing at approximately 15 to 21 weeks of gestation.

A fetal anatomic survey is performed at 18 weeks of gestation .

Fetal echocardiography may be performed at 20 to 22 weeks of gestation

Indications for screening for CADIndications for screening for CAD::

Cardiac evaluationCardiac evaluation

women 35 years or older withe one or more:

Hypertension (blood pressure> 130/80mm Hg)

,Smoking

Positive family history

Hypercholesterolemia (LDL >100 mg/dL,HDL :<40 mg/dL)

Renal disease (microalbuminuria or nephropathy)

Fetal Monitoring

Ultrasound is used at 28 weeks of gestation to evaluatefetal growth and the quantity of amniotic fluid.

Fetal surveillance,including nonstress test and biophysical profile as well as maternal monitoring of fetal activity is

initiated in the third trimester to reduce the risk of stillbirth .

labor and Delivery

The method of delivery is based on the usual obstetric indications,as well as on fetal weight and the presence or absence of active retinal changes. Infants of diabetic mothers are more likely to be macrosomic.

Cesarean sections are recommended for fetuses of an estimated weight greater than 4,500 g.

It is important to maintain euglycemia during labor or prior

to a scheduled cesarean section .

Postpartum Management

Insulin dosing should be titrated daily toward the preconception dose as necessary.

Urine microalbumin, thyroid function, and HbAlcshould be reevaluated .

The American Academy of Pediatrics considers the ACEIs captopril and enalapril safe for use by the breastfeeding mother and are resumed in patients with nephropathy,

microalbuminuria and hypertension .

First trimesterFirst trimester

Same as preconception counseling careSame as preconception counseling care

Evaluate risk factorsEvaluate risk factors

Second trimesterSecond trimester

Visit the pt every 2 to 4 weeks or more if pt has complications or Visit the pt every 2 to 4 weeks or more if pt has complications or glycemic control is suboptimal .glycemic control is suboptimal .

Maternal analyte screening : screening for aneuploidy or neural Maternal analyte screening : screening for aneuploidy or neural tube defects ( tube defects ( αα fetoprotein ,unconjucated estriol ,HCG,inhibin fetoprotein ,unconjucated estriol ,HCG,inhibin A )A )

Diabetes does not increase the risk of fetal aneuploidy.Diabetes does not increase the risk of fetal aneuploidy.

Sonography : at 18 weeks of gestation Sonography : at 18 weeks of gestation

Third trimesterThird trimester

Visit for every 1 to 2 weeks untile 32 wks of gestation & then Visit for every 1 to 2 weeks untile 32 wks of gestation & then weekly weekly

Glycemic controlGlycemic control

Sonography Sonography

Estimation of fetal size Estimation of fetal size

Surveillance for pregnancy complicationSurveillance for pregnancy complication

Fetal surveillance : weekly NST at 32 weeks with suboptimal Fetal surveillance : weekly NST at 32 weeks with suboptimal HbA1C & from 34 - 35 weeks with nl HbA1C &HbA1C & from 34 - 35 weeks with nl HbA1C & two times two times per week from 36 weeks until deliveryper week from 36 weeks until delivery

Assess for macrosomia ,premature labor , hydramnious Assess for macrosomia ,premature labor , hydramnious

Fetal SurveillanceFetal Surveillance

The goals of management of diabetic pregnancy are to The goals of management of diabetic pregnancy are to prevent stillbirth and asphyxia while minimizing maternal prevent stillbirth and asphyxia while minimizing maternal morbidity associated with delivery. This involves morbidity associated with delivery. This involves monitoring fetal growth in order to select the proper monitoring fetal growth in order to select the proper timing and route of delivery. The first is testing fetal well- timing and route of delivery. The first is testing fetal wellbeing at frequent intervals and fetal sizebeing at frequent intervals and fetal size..

The priciple is to verify fetal viability in the first trimesterThe priciple is to verify fetal viability in the first trimester

Validate fetal structural integrity in the second trimesterValidate fetal structural integrity in the second trimester

Monitor fetal growth during most of the third timesterMonitor fetal growth during most of the third timester

Ensure fetal well-bing in the late third trimesterEnsure fetal well-bing in the late third trimester

Fetal SurveillanceFetal Surveillance

glycemic control plays an important role in reducing the frequency of fetal and neonatal complications.

) HbA1C values are useful in evaluating a woman's glycemic control early in pregnancy .

One goal of preconception care of women with diabetes is to evaluate glycemic control and recommend adjustments in diet, medications, and lifestyle, as needed, to achieve euglycemia.

Type 2 diabetics on oral anti-hyperglycemic agents should be switched to insulin therapy preconceptionally

Prepregnancy evaluation and counseling of women DM Prepregnancy evaluation and counseling of women DM

→→ minimize the risk to the minimize the risk to the F&MF&M

Women who are in poor glycemic control during the Women who are in poor glycemic control during the period of fetal organogenesis, which is nearly period of fetal organogenesis, which is nearly complete by seven weeks postconception, have a complete by seven weeks postconception, have a high incidence of spontaneous abortion and fetuses high incidence of spontaneous abortion and fetuses with congenital anomalies with congenital anomalies

Thus, the importance of evaluating glycemic control in Thus, the importance of evaluating glycemic control in

women with DM and achieving good glycemic women with DM and achieving good glycemic control before conception cannot be overstated.control before conception cannot be overstated.

Amir

Hyperglycemia is probably the most important determinant Hyperglycemia is probably the most important determinant of these risks.of these risks.

This conclusion is supported by repeated observations that This conclusion is supported by repeated observations that normalizing blood glucose concentrations before and normalizing blood glucose concentrations before and early in pregnancy can reduce the risk of spontaneous early in pregnancy can reduce the risk of spontaneous abortion and congenital malformations to nearly that of abortion and congenital malformations to nearly that of normal women normal women

The three major potential fetal/pregnancy complications The three major potential fetal/pregnancy complications among women with pregestational diabetes are: congenital among women with pregestational diabetes are: congenital malformations, spontaneous abortion, and macrosomia. malformations, spontaneous abortion, and macrosomia.

Information and counselling should be provided to all women of reproductive age with diabetes

A meta-analysis has demonstrated a significantly lower prevalence of major congenital anomalies in offspring of women who attended for prepregnancy counselling (relative risk, 0.36; 95% CI, 0.22–0.59; absolute risk, 2.1% v 6.5%).

Management of women with diabetes before conception

Assessment of renal functionAssessment of renal function

Spot urine for microalbumin /cr or time Spot urine for microalbumin /cr or time collection for 24 hrscollection for 24 hrs

Serum crSerum cr

Cr> 2mg/dl & GFR < 50 ml/min. & proteinuria Cr> 2mg/dl & GFR < 50 ml/min. & proteinuria more than 2 gr /day can be considered more than 2 gr /day can be considered relative contraindications to pregnancy relative contraindications to pregnancy

Initial prepregnancy assessment should document baseline Initial prepregnancy assessment should document baseline renal function, include protein excretion, serum creatinine, renal function, include protein excretion, serum creatinine, and creatinine clearanceand creatinine clearance

The risk of permanent decline in renal function is substantially The risk of permanent decline in renal function is substantially increased in women with a urine creatinine concentration increased in women with a urine creatinine concentration above 2.0 mg/dL many of whom have more than 2 g of above 2.0 mg/dL many of whom have more than 2 g of proteinuria per dayproteinuria per day..

These findings can be considered relative contraindications to These findings can be considered relative contraindications to pregnancypregnancy . .

A creatinine clearance below 50 mL/min before pregnancy is A creatinine clearance below 50 mL/min before pregnancy is associated with a high prevalence of hypertension and fetal associated with a high prevalence of hypertension and fetal wastagewastage

Preconception treatment goalPreconception treatment goal

PlasmaPlasma– FBS: 80-110FBS: 80-110

– 2hpp : 100-1552hpp : 100-155

– HbA1C : < 7% ; normal if possibleHbA1C : < 7% ; normal if possible

– Avoid hypoglycemiaAvoid hypoglycemia


Cardiac evaluationCardiac evaluation

Testing may include one or more of the following :

electrocardiogram, echocardiogram, and exercise

tolerance testing with the recognition that the resting

electrocardiogram is the least sensitive of these tests.

Thyroid disordersThyroid disorders

Prepregnancy evaluation should include measurement of Prepregnancy evaluation should include measurement of serum TSHserum TSH

Preconception counselingPreconception counselingEducation Education

Maternal risk assessmentMaternal risk assessment

Fetal risk assessment

Metabolic goals should be established prior to conception

Self-management skills should be reviewed.

Nutrition counseling to establish an individualized meal plan should be provided.

Daily folic acid : 1 mg prior conception & continue after Daily folic acid : 1 mg prior conception & continue after conceptionconception

Mental health professional should be availableMental health professional should be available

A formal dilated funduscopic examination and clearance for pregnancy by an ophthalmologist

Treatment of Diabetes during Pregnancy

Home blood glucose monitoring is performed a minimum of four times daily,including before breakfast, 2 hours after meals,

before driving,and with signs or symptoms of hypoglycemia .

Premeal and middle-of-the-night testing may be necessary in some patients.

First-void urine samples are tested for ketones.

Insulin requirements: what to expect

Hypoglycaemia, especially overnight, is more frequent from the 6th to 18th weeks of gestation

Insulin requirements can fall after 32 weeks

Any fall greater than 5%–10% should lead to an assessment of fetal wellbeing

First trimester ultrasound examinationFirst trimester ultrasound examination

First trimester USFirst trimester US examination is often obtained to examination is often obtained to document viabilitydocument viability

As the rate of spontaneous As the rate of spontaneous abortion is higherabortion is higher in diabetic in diabetic women women

andand

To assist in estimation of To assist in estimation of gestational agegestational age

Uptodate 2007

Fetal assessment

Screening for fetal anomalies should be done with first and second trimester

ultrasound and a fetal echocardiogram between 20 and 22 weeks’ gestation. As

Obstet Gynecol Clin N Am 31 (2004) 907– 933

Fetal Risk

Obstetric management

US examination for fetal morphology should be offered at 18–20 weeks .

Further examinations to assess fetal growth should be performed at 28–30 weeks and repeated at 34–36

weeks .

The latter will help to determine the timing and route of delivery .


preconception counseling and management of diabetic patients during pregnancy ghorbani h.md fellow...

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preconception care of

management of women

counseling of women

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