PERINATAL MANAGEMENT OF PREGNANCY DIABETES (GESTATIONAL DIABETES

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METABOLIC AND OBSTETRIC MANAGEMENT OF GESTATIONAL DIABETES:

METABOLIC AND OBSTETRIC MANAGEMENT OF GESTATIONAL DIABETES DR. JALAJA RAMESH (CONSULTANT DIABETOLOGIST)

INTRODUCTION TO PREGNANCY DIABETES:

INTRODUCTION TO PREGNANCY DIABETES Diabetes is one of the common medical complication of pregnancy Diabetes in pregnancy is clinically classified into two types Pre-gestational diabetes Gestational diabetes Pre-gestational diabetes – diabetes which antedates pregnancy. It may be type 2 DM or type 1 DM. it accounts for 10% of pregnancy diabetes. Gestational diabetes – it is a temporary glucose intolerance recognized first time during pregnancy . It accounts for 90% of pregnancy diabetes DR.JALAJA RAMESH

EPIDEMIOLOGY:

EPIDEMIOLOGY Prevalence of GDM varies between 4-14% . Prevalence of GDM is directly proportional to type 2 DM or impaired glucose intolerance IGT in a given population or ethnic group. Risk factors for developing GDM – Modifiable Non-modifiable Obesity Ethnicity Lack of physical exercise Family history of diabetes Stress Genetic mutation Smoking MODY Lack of adequate sleep High maternal age Increased dietary fat Multi parity Vitamin D3 deficiency Associated endocrine problem Past history of BOH DR.JALAJA RAMESH

WHY GDM TO BE DIAGNOSED AND MANAGED:

WHY GDM TO BE DIAGNOSED AND MANAGED GDM is a silent disease. It can have serious consequence. Recent landmark studies like Australian carbohydrate intolerance study Hyperglycemia and adverse pregnancy out come (HAPO) Shown that early diagnosis and management of gestational diabetes have beneficial effects on maternal and neonatal outcomes Fetal weight Decreased rate of shoulder dystoica Brachial Nerve Palsies Fractures Neonatal hypoglycemia DR.JALAJA RAMESH

TYPES OF GDM:

TYPES OF GDM GDM – A1 – GDM on diet only ( medical nutritional therapy) GDM – A2 – GDM on insulin along with medical nutritional therapy) Pathogenesis of GDM- GDM develops when the maternal pancreatic beta cells unable to compensate for the insulin resistance produced by the gestational hormones. DR.JALAJA RAMESH

SCREENING AND DIAGNOSIS:

SCREENING AND DIAGNOSIS As there is high prevalence of gestational diabetes in Indians, hence Universal screening Screening at first antenatal visit is recommended GDM is diagnosed if one or more value equals or exceeds the threshold indicated A.D.A W.H.O IADPSG DIPSI FBS 95mg/dl 92mg/dl 92mg/dl 1hr 180mg/dl 180mg/dl 180mg/dl 2hr 155mg/dl 153mg/dl 153mg/dl 140mg/dl DR.JALAJA RAMESH

MATERNAL , FOETAL AND NEONATAL COMPLICATIONS:

MATERNAL , FOETAL AND NEONATAL COMPLICATIONS MATERNAL FOETAL NEONATAL Recurrent vulvo vaginitis Still birth Neonatal hypoglycemia Pelvic floor injury Respiratory distress syndrome(RDS) Neonatal hypocalcaemia PIH Macrosomia Neonatal hyperbilirubinemia PROM IUGR Polycythemia Polyhydrominos Preterm Pre-term labour Shoulder dystoice Post partum hemorrhage Chorio amnionitis DR.JALAJA RAMESH

MANAGEMENT OF GESTATIONAL DIABETES:

MANAGEMENT OF GESTATIONAL DIABETES Metabolic management Obstetric management Metabolic management – Diet (medical nutritional therapy) Physical exercise Pharmaco therapy (insulin/ oral hypoglycemic agents) Stress management DR.JALAJA RAMESH

DIET – MEDICAL NUTRITIONAL THERAPY:

DIET – MEDICAL NUTRITIONAL THERAPY MNT is the corner stone in the management of gestational diabetes Goals of MNT - Diet should be individualized Diet should be culturally approximate Diet should flexible Diet should have adequate calories and nutrition to achieve optimum weight gain for foetus and mother Diet should be able to achieve euglycemia with out hypoglycemia DR.JALAJA RAMESH

SEGMENTS OF MNT :

SEGMENTS OF MNT MNT should have Calculation of calories Distribution of calories Distribution of nutrients Calculation of calories – Ideal body weight 30kcal/kg/wt Under weight 35kcal/kg/wt Obese 25kcal/kg/wt DR.JALAJA RAMESH

DISTRIBUTION OF CALORIES AND NUTRIENT:

DISTRIBUTION OF CALORIES AND NUTRIENT Distribution of calories – 10-20% at breakfast 20-25% at lunch 30-40% at dinner 30% - at snacks Morning (10%) Mid evening (10%) Bed time(10%) Distribution of nutrients – Carbohydrate – 40-50% Fat – 30-40% Protein – 20% DR.JALAJA RAMESH

EXERCISE:

EXERCISE Walking Cycling are recommended Swimming Small resistance exercise Post prandial walking – 10minutes after breakfast, lunch and dinner Contraindications to exercise – Low lying placenta Polyhydraminos Short cervix Impending pre-term labour High glycemic fluctuations Pregnancy induced hypertension DR.JALAJA RAMESH

BLOOD SUGAR VALUES:

BLOOD SUGAR VALUES Normal values during pregnancy – Plasma glucose levels target in pregnancy diabetes – Normal values Pregnant DM Non-pregnant adult DM Fasting blood sugar 60-92 70-100 Post breakfast 1hr Up to 140 2hr post breakfast 80-120 80-140 Pre-meal 70-90 HbA1c 5-5.2 / <6 Up to 6.5 Target Plasma glucose levels Fasting 60-95mg/dl Pre-meal 60-100mg/dl 1hr <140mg/dl 2hr <120mg/dl 2-6AM >60mg/dl DR.JALAJA RAMESH

PHARMACOTHERAPY:

PHARMACOTHERAPY INSULIN ORAL HYPOGLYCEMIC AGENTS According to ACOG/ADA indications for insulin are – If FBS > 95mg on 2 consecutive day after MNT If PPBS > 120mg on repeated tests If 2hr/1hr > 140mg on repeated test Elevated FBS > 120mg at diagnosis of DM Accelerated fetal growth in ultrasound Relative indication Symptomatic – Excessive hunger Loss of weigh Recurrent UTI DR.JALAJA RAMESH

INSULIN:

INSULIN Traditionally insulin has been considered the gold standard for management of diabetes. Goals in insulin therapy – To maintain normoglycemia throughout the day without hypoglycemia. Dose of insulin – initial dose of insulin is based on maternal weight and period of gestation. 0.8u/kg in 1 st trimester 1.ou/kg in 2 nd trimester 1.2u/kg in 3 rd trimester DR.JALAJA RAMESH

TYPES OF INSULINS:

TYPES OF INSULINS Type of insulin Onset Peak Duration Regular insulin 1/2hour 2-4hrs 6-8hrs Intermediate insulin acting(NPH) 3-4hrs 10-16hrs 18-20hrs Insulin analogue Rapid acting or Short acting Insulin lispro Insulin aspart 5-15minutes 1hr 2-4hrs DR.JALAJA RAMESH

Slide 17:

FBS is - bedtime NPH insulin Pre-breakfast 2hr post breakfast premix insulin 30:70 premix analogue 25:75 Post breakfast Post lunch regular insulin / rapid acting insulin analogue Post dinner Pre dinner 2hr post dinner premix insulin 30:70 premix analogue 25:75 DR.JALAJA RAMESH

ADVANTAGES AND DISADVANTAGES OF INSULIN:

ADVANTAGES AND DISADVANTAGES OF INSULIN Advantages Disadvantages Time tested molecule Expensive Safe Invasive No teratogenecity Multiple pricks Potent Needs training Lack significant trans-placental transport Risk for hypoglycemia DR.JALAJA RAMESH

ORAL HYPOGLYCEMIC AGENTS:

ORAL HYPOGLYCEMIC AGENTS Most current studies have shown that the oral hypoglycemic agents such as glyburide and metformin are safe to use in pregnancy diabetes with good maternal and perinatal outcomes. Similar to insulin treatment. But still ADA/ACOG has not approved OHA as first line pharmacotherapy in the management of pregnancy diabetes as large randomized. Studies with long term follow up needed DR.JALAJA RAMESH

GOALS OF OBSTETRIC MANAGEMENT:

GOALS OF OBSTETRIC MANAGEMENT Safe confinement – Healthy mother and baby Healthy postpartum With help of adequate fetal and maternal surveillance Prevention of still birth Prevention of iatrogenic prematurity Prevention of birth trauma like shoulder dystoice brachial plexus injury and fracture Prevention of respiratory distress syndrome Prevent maternal complication – pelvic floor injury DR.JALAJA RAMESH

PILLARS OF OBSTETRIC MANAGEMENT:

PILLARS OF OBSTETRIC MANAGEMENT Maternal surveillance (antenatal visit) – Regular antenatal visits both with obstetrician and diabetologist BP recording and weight recording Sugar monitoring and fetal heart monitoring Fetal surveillance – Fetal kick counts, non stress test Ultrasound, Doppler velocimetry Timing of delivery Planning the mode of delivery Postpartum follow up and advice DR.JALAJA RAMESH

ANTENATAL VISITS - MATERNAL SURVEILLANCE:

ANTENATAL VISITS - MATERNAL SURVEILLANCE Generally pregnancy diabetes patients are advised to come Once in 30 days from 1 st booking to 7 th month Once in 15 days from 7 th month to 36 weeks Once in 7 days from 37 weeks till delivery GDM patients on insulin or GDM patients with greater glycemic fluctuation or GDM patients with bad obstetric history or high risk GDM patients – patients with comorbid conditions like PIH/ chronic hypertension are recommended to come for more frequent visits DR.JALAJA RAMESH

ANTENATAL VISITS:

ANTENATAL VISITS Check uterine growth – fundal height measurement Diet recall and diet counseling Enquire about regular intake of medicines like folic acid, iron, calcium and low dose aspirin (if patient is on) Enquire about fetal movements 2 nd trimester Low backache white discharge burning micturition Weight to be recorded Blood pressure to be recorded Urine albumin and urine acetone to be checked DR.JALAJA RAMESH

TESTS TO ASSESS FETAL WELL BEING (FETAL SURVEILLANCE):

TESTS TO ASSESS FETAL WELL BEING (FETAL SURVEILLANCE) Fetal kick counts – by mother count of 10 Ultrasound evidence of fetal well being Amniotic fluid index – oligo / Polyhydrominos Fetal weight estimation – IUGR/ macrosomia Fetal movements Non-stress test (NST) common prenatal test to assess fetal health. It is a simple non invasive test Other parameters Modified fetal biophysical profile Doppler velocimetry Fundal height measurement DR.JALAJA RAMESH

ROLE OF ULTRASOUND IN THE OBSTETRIC MANAGEMENT OF GDM:

ROLE OF ULTRASOUND IN THE OBSTETRIC MANAGEMENT OF GDM Dating scan (7-8 weeks) – helps to calculate accurate date of delivery (EDD), there by preventing iatrogenic preterm delivery and also helps to plan anomaly scan, growth interval scan at approximate time Detailed anomaly scan – help to detect congenital anomalies. Assessment of amniotic fluid helps to assess fetal well being Scan at term – helps to assess presentation and plan the mode of delivery. DR.JALAJA RAMESH

MODE OF DELIVERY:

MODE OF DELIVERY Vaginal delivery is safe and most preferred method of delivery in GDM patients GDM is not a indication for c-section Patient may be delivered by c-section obstetric cause – Macrosomia – weight more than 4.5kg Cephalo -pelvic disproportion Non reassuring NST/non reactive NST Low lying placenta/ obstructed labour Pregnancy induced hypertension Previous L.S.C.S Polyhydrominos Elderly primi gravida Failed induction DR.JALAJA RAMESH

INTRAPARTUM MANAGEMENT:

INTRAPARTUM MANAGEMENT GOAL – The goal is to maintain normoglycemia in order to prevent neonatal hypoglycemia GDM on diet – Generally GDM patients on diet don’t require insulin during intra partum They need CBG – on admission and 4 th hourly depending upon the labour progress I.V fluids – CBG<100 – GNS/GRL CBG>100 – NS/RL TARGET – 80-110mg/dl DR.JALAJA RAMESH

GDM ON INSULIN:

GDM ON INSULIN GDM on insulin may require short acting insulin during labour depending upon the blood sugar values GDM Women should be instructed not to take their basal insulin during labour They need CBG monitoring hourly or 2 nd hourly depending on the blood sugar levels I.V fluids – CBG<100 – GNS/GRL CBG>100 – NS/RL If the blood sugar >120mg/dl – 2-4units of short acting insulin is given intra-venous If the patient on insulin infusion CBG to be measured hourly and potassium 2 nd hourly DR.JALAJA RAMESH

GLYCEMIC MANAGEMNET IN POST PARTUM PERIOD:

GLYCEMIC MANAGEMNET IN POST PARTUM PERIOD In GDM patient Immediately after the expulsion of placenta blood sugar returns to normal Insulin requirements usually come down completely or reduce significantly Generally GDM patients will not require insulin after delivery Patients requiring high dose of insulin during lactation due to distribution of calories they require only 25% or 50% of their insulin dose DR.JALAJA RAMESH

POST PARTUM ADVICE:

POST PARTUM ADVICE CBG – should be checked after delivery blood sugar – to be checked before discharge to asses glycemic status and for advising diet for breastfeeding 75gm oral GTT – 6-12 – weeks – after delivery 75gm oral GTT – 6months – after delivery 75gm oral GTT – 1 year – after delivery DR.JALAJA RAMESH

THANK YOU:

THANK YOU DR.JALAJA RAMESH

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