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IN THE NAME OF GOD

IN THE NAME OF GOD. PREGESTATIONAL DM. WHITE CLASSIFICATION OF DM DURING PREGNANCY. Gestational DM Class A : diet alone ,any duration or age Class B : age at onset > 20 y& duration < 10y Class C : age at onset 10- 19 or duration 10 – 19 y

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IN THE NAME OF GOD

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  1. IN THE NAME OF GOD

  2. PREGESTATIONAL DM

  3. WHITE CLASSIFICATION OF DMDURING PREGNANCY Gestational DM Class A : diet alone ,any duration or age Class B : age at onset > 20 y& duration < 10y Class C : age at onset 10- 19 or duration 10 – 19 y Class D : age < 10 y or duration > 20 y or background retinopathy or HTN ( not preeclampsia) Class R : proliferative retinopathy or vitreous HE Class F : nephropathy with p. uria > 500 mg Class RF : R & F Class H : heart dx Class T : prior renal transplantation Joslin textbook 2005 joslins textbook 2005

  4. Evaluation of diabetic women Risk assessment Preconception counseling

  5. Risk assessment

  6. Nephropathy • During pregnancy , complicated by nephropathy, GFR & albuminuria increase &also increase in mean BP, it may worsen preexisting nephropathy. • Women with class F diabetes demonstrate that a majority of these pts develop proteinuria in the nephrotic range by the third trimester but Creatinine is nl joslins textbook 2005

  7. Mild nephropathy don`t complicated • Moderate to severe nephropathy with GFR < 90 ml/min & proteinura more than 1 g /24 hrs have a more rapid decline in GFR joslins textbook 2005

  8. Retinopathy • Risk of progression of retinopathy increase in pregnancy • Risk is influenced with : • severity of baseline retinopathy • HbA1C > 8.5% at the first prenatal visit • intensively treated pt has 1.6 fold increase risk of retinopathy • Conventionally treated pt has 2.4 fold increase in retinopathy • In DCCT study ,no difference in level of retinopathy in pt who became pregnant as compared with pt who never p. joslins textbook 2005

  9. hypoglycemia • Most severe in first half of pregnancy : more insulin sensitivity , morning sickness , strict BS control • Severe hypoglycemia isnot teratogenic in human • Treat with 15 g carbohydrate & then rechecked BS after 15 min & additional 15 g carbohydrate use • It is Better use lispro( FDA safety rating of B ) and for aspart FDA safety rating of C joslins textbook 2005

  10. Hypertensive disorder • Chronic HTN: before or up to 20th weeks of gestation & if HTN continue after 12 week after pregnancy • Preeclampsia-eclampsia : ≥ 140/90 mmhg ,usually after 20th weeks of gestation with proteinuria more than 300mg/24 hrs • Preeclampsia-eclampsia superimposed on chronic HTN • Gestational HTN joslins textbook 2005

  11. Start treatment from BP ≥ 130/ 80 mmHg especially if microalbuminuria or proteinuria is present

  12. Management of diabetes in pregnancy

  13. Preconception counseling • Education • Maternal risk assessment • Fetal risk assessment • HbA1C levels should be normal Uptodate 2006

  14. Maternal risk assessment • HX & P/E • Review of complication • Current & past glucose management • Comorbid medical conditions • Gynecologic & obstetric hx • Discontinue oral anti-hyperglycemic agent • Daily folic acid : 1 mg prior conception & continue after conception • Self management skills should be reviewed • Nutrition counseling • Mental health professional should be available Uptodate 2006

  15. Control of HTN : BP < 130/80 • Thyroid dx : TSH , FT4 • Neuropathy ( peripheral & autonomic ) • vascular evaluation of lower extremities • Infection : UTI • SMBG • HbA1C • Discontinue alcohol & smoking Uptodate 2006

  16. Ophthalmic assessment • Comprehensive eye examinatin in pt with planing for pregnancy • f/u through pregnancy at least every 3 months & also one y after pregnancy • Tight glycemic control may accelerate retinopathy & need more attention by ophthalmologist • Laser photocoagulation for severe preproliferative diabetic retinopathy

  17. Assessment of renal function • Spot urine for microalbumin /cr or time collection for 24 hrs • Serum cr • Cr> 2mg/dl & GFR < 50 ml/min. & proteinuria more than 2 gr /day can be considered relative contraindications to pregnancy

  18. Cardiac evaluation • As the same as non pregnant women .(uptodate 2006) • Symptomatic CHF & Ischemic heart disease are contraindicated to pregnancy.( davidson 2004)

  19. Methyl dopa Hydralazine B-blocker Ca canal blocker ACE inhibitor is contraindicated Thiazid is relatively contraindicated BP should be managed aggressively Hold BP< 130 /80 mmHg MANAGMENT of HTN & /OR MICROALBUMINURIA Uptodate 2006

  20. Management of hyperlipidemia • Statins are contraindicated & should be discontinued before conception • Hypertriglyceridemia treat with diet , supplementation with medium chain TG Joslin text book 2005

  21. Plasma FBS: 80-110 2hpp : 100-155 HbA1C : < 7% Avoid hypoglycemia Preconception treatment goal Joslin text book 2005

  22. goals for glycemic control for women with GDM, (Fourth International recommendationsfrom the Workshop-Conference on GestationalDiabetes) suggest: • capillary blood glucose concentrations should be : • FBS: 95 mg/dl • BS-1hpp :140 mg/dl • and/or • BS-2hpp: 120 mg/dl ADA 2006

  23. First trimester • Same as preconception counseling care • Evaluate risk factors Uptodate 2006

  24. Second trimester • Visit the pt every 2 to 4 weeks or more if pt has complications or glycemic control is suboptimal . • Maternal analyte screening : screening for Dawn SX or neural tube defects ( α fetoprotein ,unconjucated estriol ,HCG,inhibin A ) • Sonography : at 18 weeks of gestation Uptodate 2006

  25. Third trimester • Visit for every 1 to 2 weeks untile 32 wks of gestation & then weekly • Glycemic control • Sonography • Estimation of fetal size • Surveillance for pregnancy complication • Fetal surveillance : weekly NST at 32 weeks with suboptimal HbA1C & from 35 weeks with nl HbA1C • Assess for macrosomia ,premature labor , hydramnious Uptodate 2006

  26. Davidsons DM 2004

  27. Fetal risk Congenital malformation & spontaneous abortion : incidence is 5% -9% when occurs in blastogenesis ( first 4 weeks of conception ) is more severe than organogenesis ( weeks 4-5 after conception ) HbA1C < 8.5 % 3.4% HbA1C > 8.5 % 22.4% Uptodate 2006

  28. Congenital m

  29. Thanks for your attention

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