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Diabetes in Pregnancy

Diabetes in Pregnancy. Dr Hennie Lombaard. Physiological changes. Fasting glucose levels decreased Serum levels increased after a meal. Doubling of insulin production Anti–insulin hormones: Human placental lactogen Glucagon Cortisol. Physiological changes.

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Diabetes in Pregnancy

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  1. Diabetes in Pregnancy Dr HennieLombaard

  2. Physiological changes • Fasting glucose levels decreased • Serum levels increased after a meal. • Doubling of insulin production • Anti–insulin hormones: • Human placental lactogen • Glucagon • Cortisol

  3. Physiological changes • Renal tubular threshold decrease • In normal pregnancy starvation leads to a breakdown of triglyceride, this leads to liberation of fatty acids and ketone bodies.

  4. Classification in pregnancy

  5. Diagnosis of Diabetes Mellitus • Random glucose: > 11,1mmol/l • Fasting plasma glucose >7,0mmol/l • HbA1C >6.5

  6. Diagnosis of GDM • Fasting plasma glucose >5.1 • OGTT 1 hour value: • >10 • OGTT 2 hour value: • >8.5

  7. Effect of pregnancy on pre-existing DM • Increase need of Insulin • Deterioration of nephropathy • 2fold increased risk of deterioration in retinopathy • Hypoglycaemia more common • Women with autonomic neuropathy experience deterioration of their symptoms.

  8. Effect of DM on pregnancy: • Increased risk of miscarriage • Increased risk of pre-eclampsia (1% increase in HbA1C cause a 60% increase in risk of PET) • DM nephropathy associated with normochromic normocytic anemia, severe oedema and proteinuria. • Increased c/section rate • Increased risk of infection.

  9. Fetal complications of DM • Congenital abnormalities: HBA1c < 8% risk is 5% and HBA1c > 10% risk is 25% • Increased neonatal mortality • Increased perinatal mortality • Macrosomia • Late stillbirth • Premature delivery • Neonatal hypoglycaemia • Polycytheamia • Jaundice

  10. Management: • Maternal near normal normoglycemia • Increased home glucose monitoring • Target values: • < 5,0 – 5,5mmol/l capillary fasting • < 7,0 – 7,5mmol/l post preandial. • Strict adherence to low-sugar, low-fat, high-fibre diet is important. Patients require 3 snacks.

  11. Management: • Basal bolus regimen with short acting before meals and intermediate acting insulin at bedtime. • Opthalmological examination • FBC, UCE, 24 hr urine protein creatinine clearance and ECG. • Strict hypertension control.

  12. Obstetric Management: • Early dating scan • 11 - 14 weeks nuchal translucency scan • 20 – 22 weeks detail anatomy scan • Regular growth scans in the 3rd trimester • Pregnancies not allowed to continue past 40 weeks

  13. Obstetric management: • The Academic Complex protocol: • If not macrosomic and good control: • Deliver at 38 weeks and if not confirm at 38 weeks with a positive PG • If a macrosomicfetus or poor control do PG from 35 weeks and deliver if mature

  14. Intrapartum management: • IV dextrose infusion 500ml/8hr with short acting insulin and aim for capillary glucose of 5-8mmol/l • Do hourly sliding scale. • Give potassium replacement or check potassium regularly. • After delivery of the placenta half the insulin infusion.

  15. Contra indications for pregnancy: • Ischaemic heart disease • Untreated proliferative retinopathy • Severe gastroparesis • Severe renal impairment

  16. Gestational diabetes mellitus: • Definition: National Diabetes Data Group (1985) • Carbohydrate intolerance of variable severity with onset or first recognition during the present pregnancy.

  17. Clinical features: • Asymptomatic and develop in the 2nd or 3rd trimester • More commonly diagnosed in women: • A family history of DM • Previous large-for-gestational-age infants • Obesity • Advanced maternal age • Certain ethnic groups

  18. Importance of GDM: • Women dx with GDM at increased risk for type 2 DM • Some women have pre-existing DM • GDM is associated with adverse pregnancy outcome

  19. Previous GDM Family history of DM Previous macrosomic baby Previous unexplained stillbirths Obesity Glycosuria Polyhydramnios Large-for-gestational-age infants Certain ethnic groups. Screening:Clinical risk factors:

  20. Management: • Diet advice the same as for DM • Obese women get a calorie reduced diet • Home glucose monitoring • Persistent hyperglycaemia an indication to start insulin. Fasting > 5,5mmol/l or post prandial > 7,5 -8,0mmol/l • Metformin can be used in pregnancy • Glibenclamide does not cross the placenta and may be an alternative

  21. Intrapartum management: • Women on oral or low insulin do not need continuous insulin therapy. • Women on large insulin needs continuous insulin therapy. • Women with GDM require a formal OGTT 6 weeks after delivery

  22. Hypertension in Pregnancy

  23. Physiological changes • Decrease in BP in 1st trimester until the 22nd to 24th week of pregnancy • BP drops immediately post partum

  24. Risk factors • General • Age • Obesity • Genetic • If their mother had PET risk is 25% • If a woman’s sister had PET her risk is 35-40%

  25. Obstertirc factors • Primiparity (2-3 fold risk) • Multiple pregnancy (2 fold) • Previous PET (7 fold) • Long birth interval (2-3 fold if 10 years) • Hydrops • Hydatiforme mole • Triploidy

  26. Medical factors • Pre-existing hypertension • Renal disease • Diabetes • Antiphosfolipid antibodies • Connective tissue disorders • Inherited thrombophilia

  27. Diagnosis: • Systolic BP > 140mmHg or a diastolic BP > 90 mmHg on more than 2 occasions at least 6 hours apart • A BP of more than 160/110 mmHg • For gestational or pre-eclampsia it is with onset after 20 weeks.

  28. Diagnosis PET • Hypertension with onset of 1 of the following: • Renal impairment • Liver impairment • Haematological impairment • Neurological impairment • Growth restriction

  29. Management: STABILIZATION: Admit High Care Obstetrics Unit Intra venous line: Ringer lactate 100ml bolus ivi over 20 min (The normal 300ml bolus is made up out of 100ml Ringers lactate and 200ml Saline) Maintenance: 5 gr four hourly Check before next dosage: Urine output > 30ml/hr Tendon reflexes present Respiratory rate more than 16/min 4gr Magnesium sulphate in 200ml saline over 20min ivi 5gr Magnesium sulphate with 1ml Lignocaine imi in each buttock. Magnesium Sulphate If signs of over dose FLUIDMANAGEMENT If any is absent Delay second doses with another 4 hours or only give half t If signs of over dose he dose. Give calcium gluconate

  30. FLUID MANAGEMENT Urinary Catheter Fluid management: Give Ringers lactate 125ml/hr ivi. Start a fluid balance chart. BLOOD PRESSURE CONTROLL Repeat blood pressure after 20min and if diastolic >110 or systolic > 160 Nifedipine Dosage: 10mg orally p.o. if BP > 160/110mmHg Contra indications: Pulse > 120 beats/min Cardiac lesion Unable to swallow. Urine output less than 30ml/hr Give Ringers lactate bolus 200ml. Urine output less than 30ml/hr Check her fluid balance Labetolol: Dosage: Start with 20mg, 40mg, 80mg, 80mg, and 80mg until a maximum of 300mg. Give bolus every 10min until BP less than 160/110 mmHg Contra indications: Patients with asthma Patients with ischaemic heart disease Check BP after 20 min If she is in a + fluid balance Low dose Dopamine infusion

  31. NEUROLOGICAL STATUS: If patient is still confused Check saturation and Blood pressure If abnormal Correct abnormality If normal: Give Haloperidol The patient should now have been stabilized. A full clinical evaluation needs to be done.

  32. CNS Resp. System CVS Liver Renal Hematological Immune system Musculosceletal Systemic clinical exam that include. High care observations. GCS, RR, BP, pulse, Sats, fluid balance chart. Biochemical eval. Hematocrit, platelets. Creatinine, AST. 24 hour protein clearance. EVALUATION: Mother

  33. Sonar. Estimated fetal weight. Structural abnormalities. Amniotic fluid index. Doppler umbilical art. Trans cerebellar diameter. Middle cerebral artery Doppler. Ductus Venousus waveform. CTG If regarded as viable 6 hourly EVALUATION: Fetus

  34. Once the mother is stable and the foetus is stable decide on further management. Better in Better out. Expectant management: Only if mother and foetus stable and no indication for delivery: Keep in High care/High risk until hand over round. Transfer to Silver white firm 6 hourly CTG Daily full clinical evaluation Twice weekly biochemical and haematological evaluation. • Indications for delivery: • Foetal distress • Intra uterine death • Expected weight more than 2kg or sure gestation more than 34 weeks. • Any signs of maternal organ invovement • Platelets < 100 • AST > 80 • Creatinine > 100 • Uncontrollable hypertension • Eclampsia • Proven lung maturity • Foetal abnormality Place on Disprin half tablet daily Place on Calcium daily

  35. Drugs: • Methyldopa • Depression • Liver function test abnormalities • Haemolytic anaemia • Calcium channel blockers • Headache • Facial flushing • Labetolol

  36. Prophylaxis: • Low-dose aspirin: • Hypertension and renal disease • Hypertension and diabetes • Women at risk of PET • Women who had PET • Antiphospholipid syndrome • Calcium • If calcium depleted diet 2gr/day

  37. Prophylaxis: • Folic acid • 5mg/day especially if hyperhomocysteinaemia

  38. Conclusion: • PET is a dangerous disease and aggressive management is needed. • Patients should be in a high care firm for the expectant management.

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