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DIABETES AND PREGNANCY 0.5

CLASSIFICATION: . Diabetes mellitus type I --- insulin dependent (Ketosis-prone)Diabetes mellitus type II--- non-insulin dependent (Ketosis-resistant)Impaired Glucose Tolerance and Gestational Diabetes (IGT). Diabetogenic Effects of Pregnancy: . Insulin resistance Increased lipolysis Altere

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DIABETES AND PREGNANCY 0.5

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    1. DIABETES AND PREGNANCY (0.5%)

    2. CLASSIFICATION: Diabetes mellitus type I --- insulin dependent (Ketosis-prone) Diabetes mellitus type II--- non-insulin dependent (Ketosis-resistant) Impaired Glucose Tolerance and Gestational Diabetes (IGT)

    3. Diabetogenic Effects of Pregnancy: Insulin resistance Increased lipolysis Altered maternal gluconeogenesis

    4. ** WHITES Classification

    5. DEFINITIONS: DM= Fasting venous glucose concentration > 8.0 mmol/l and 2 hrs (75 gm load ) > 11.0 mmol/l (or) one of the above + Symptoms IGT = Fasting < 8.00 mmol/l, but 2 hr (75 gm load) = (9.0-10.9)

    6. WHO recommended modified GTT ( 75 gm load)

    7. How do diabetic patients present -Symptoms -Risk factors ( history & examination) -Blood tests--screening -Blood test

    8. Screening: WHY ? 30% have none of the Above risk factors Not all DM, IGT, have persistent glucosuria 50% of pregnant women have glucosuria at some time

    9. Risk factors DM, IGT, must be suspected in Pregnant women with Age > 30 Family history of DM Past history of: - Diabetes in a previous pregnancy - Unexplained I.U.F.D., Neonatal death - Congenital abnormalities - Recurrent abortions - Large babies > 90th centile Obesity Hypertension in multipara Polyhydramnios Recurrent infections:Urinary, Fungal Significant Glycosuria

    11. MATERNAL COMPLICATIONS Obstetric - Polyhydramnios - pre-eclampsia (10-15%) Diabetic Emergencies - Hypoglycaemia - Ketoacidosis - Diabetic coma Vascular & End-Organs - Renal - Ophthalmic - Peripheral vascular Neurologic - Peripheral neuropathy - Gastrointestinal disturbance Infections - Urinary

    13. Fetal complications (1) Macrosomia & Traumatic delivery (30% in seemingly controlled) (2) Delayed organ maturity (RDS) 6 times (3) Congenital malformations: Cardiovascular : Transposition of great vessels Ventricular septal defect Aortic coarctation Artial septal defect

    14. Fetal complications (cont) Central Nervous system - Anencephaly - Holoprosencephaly - Encephalocele Skeletal & spinal - Caudal regression Genitourinary - Renal agenesis - ureteral dupliction Gastrointestinal - anal atresia ** Note: when a two-vessel cord is found, suspect a high incidence of congenital anomalies (4) Intrauterine fetal Death (5) Growth restriction (in advanced DM)

    15. NEONATAL complications: Hypoglycaemia RDS Hypocalcaemia Polycythaemia

    16. Principles of management: Start in preconception time Specific during pregnancy

    17. Specific Diet: 16 x Wt. (pounds ) + 300 = CALORIES Carbohydrates 60% Fat 20% Protein 20% Insulin: Regiment A * 3 times sol.-with meals + lnt. Evening Or - Regiment B * 2 types (short & intermediate) Twice Daily Dose (daily) = wt. (kg) x 0.6 first x 0.7 second x 0.8 third 2/3 in A.M. 2/3 1nt + 1/3 short 1/3 in P.M. 1/2 1nt + short.

    18. CONTROL Control : Fasting < 5.0 mmol/1 2 hrs P.P. < 7.0 mmol/1 Adjustment when necessary Glycosylated Hb A1c (retrospective) < 6 Fetal well being: AFP 16-18 wks Detailed scan 19-20 wks Biophysical assay from 28 wks Fetal wt. & growth two weekly (3rd) Delivery: - Timing depends on: (Around 38 wks) Maternal factors Biochemical control Fetal status - Method --- LSCS in any medical or obstetric complication. **Insulin dose adjusted on hourly basis with caloric requirements intravenously.

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