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Diabetes in pregnancy

Diabetes in pregnancy. Naghshineh.E MD. GDM versus overt DM. do not have overt vasculopathy do not have increased risk of congenital malformations. Conditions more common in GDM:. Macrosomia Preeclampsia(daily low dose ASA) Hydramnios Stillbirth Neonatal morbidity (RDS)

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Diabetes in pregnancy

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  1. Diabetes in pregnancy Naghshineh.E MD

  2. GDM versus overt DM • do not have overt vasculopathy • do not have increased risk of congenital malformations diabetes in pregnancy

  3. Conditions more common in GDM: • 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 diabetes in pregnancy

  4. Management of pregnancy • 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) diabetes in pregnancy

  5. Management of pregnancy • Assessment of fetal growth: -induction of labor -scheduled c/s -not optimal glycemiccontrol ---EFW≥4800 gr → 50% chance FW≥4500 gr ---sono 28-32 wks, repeat 3-4 wks ,last 38 wk or---single sono at 36 wks ---not recommended in GDM with nutritional therapy diabetes in pregnancy

  6. Management of pregnancy • 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 diabetes in pregnancy

  7. Timing of delivery -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 diabetes in pregnancy

  8. Timing of delivery • GDM euglycemicwith 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 diabetes in pregnancy

  9. Management of labor • 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 diabetes in pregnancy

  10. Labor & delivery • avoid maternal hyperglycemia : risk of fetal acidosis & neonatal hypoglycemia • insulin requirement usually decrease during labor • Glucose is important for optimal myometrial function • GDM euglycemicwith nutritional therapy: rarely require insulin during labor (2%) • GDM medically managed (Ins or OHGA): may need insulin infusion during labor (3.5%) diabetes in pregnancy

  11. Labor & delivery • Poorly controlled DM: Diabetic fetopathy( prolonged hypoglycemia secondary to pancreatic hyperplasia & hyperinsulinemia) • Maternal normoglycemia can not prevent neonatal hypoglycemia diabetes in pregnancy

  12. Labor & delivery • 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 diabetes in pregnancy

  13. Labor & delivery • 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) diabetes in pregnancy

  14. Cesarian delivery • 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 diabetes in pregnancy

  15. GDM Postpartum management • 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 diabetes in pregnancy

  16. Overt DM Postpartum management • 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 diabetes in pregnancy

  17. After hospital discharge • Hb A1C<7% • FBS<120 • BS 2hpp<170 diabetes in pregnancy

  18. Overt DM • 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 diabetes in pregnancy

  19. Overt DM • 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) diabetes in pregnancy

  20. Overt DM • Timing for delivery: • Well controled:38+4 wks • With vascular disease:37 wks diabetes in pregnancy

  21. Contraception • Any type is acceptable • Progestin-only pills, DMPA, levonogestrol IUD : increased risk of developing DM-II ? • Copper IUD diabetes in pregnancy

  22. Towards a safe motherhood diabetes in pregnancy

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