diabetes in pregnancy

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obs and gyane- management of diabetes in pregnancy

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DIABETES IN PREGNANCY:

DIABETES IN PREGNANCY Dr. Nidhi Singh

INTRODUCTION:

INTRODUCTION Abnormalities of carbohydrate metabolism occur frequently during pregnancy 3-5% of all pregnant patient show glucose intolerance 90% of these have gestational diabetes Approximately 50% of women with GDM will develop type II diabetes later in life.

Diabetogenic effects of pregnancy:

Diabetogenic effects of pregnancy 1. Insulin resistance Production of human placental lactogen Production of cortisol , estriol and progesterone Destruction by kidney and placenta 2. Increased lipolysis 3. Changes in gluconeogenesis

Effects of diabetes on mother:

Effects of diabetes on mother Preeclampsia Affects 10-25% of all pregnant diabetics I nfections Chorioamnionitis and postpartum endometritis Postpartum bleeding Cesarean section

Effects of diabetes on fetus:

Effects of diabetes on fetus Congenital abnormalities Hypoglycemia Hyperviscosity syndrome Hyaline membrane disease Macrosomia Hypocalcemia Apnea and bradycardia Traumatic delivery

Effects of pregnancy on diabetes:

Effects of pregnancy on diabetes More insulin required to achieve homoeostasis Progression of diabetic retinopathy Worsening of diabetic retinopathy Increased risk of death in diabetic cardiomyopathy

Etiological classification of diabetes:

Etiological classification of diabetes Type I: β cell destruction Immune mediated Idiopathic Type II DM Others Genetic defects of beta-cell function Genetic defects in insulin action Genetic syndrome Endocrinopathies Drugs Infections Gestational DM

White’s classification during pregnancy:

White’s classification during pregnancy Gestational diabetes Discovered during pregnancy, glycemia may or may not be maintained by diet alone; insulin may be required Class A Discovered before preg , controlled with diet alone, any duration or age of onset Class B Onset age 20 yr or older, duration less than 10yrs Class C Onset age 10-19yrs, duration 10-19yrs Class D Onset age under 10yrs, duration >20yrs, background retinopathy Class R Proliferative retinopathy, or vitreous hemorrhage Class F Nephropathy with proteinuria over 500mg/day Class RF Criteria for both classes R and F coexist Class H Arteriosclerotic heart disease clinically evident Class T Prior renal transplantation

Classification scheme used from 1986 through 1994 for Diabetes complicating pregnancy:

Classification scheme used from 1986 through 1994 for Diabetes complicating pregnancy Class Onset Fasting 2 hour PP Therapy A1 Gestational <105 mg/dl <120 mg/dl Diet A2 Gestational >105 mg/dl >120 mg/dl Insulin Class Age of onset (yr) Duration (yr) Vascular disease Therapy B >20 <10 yr None Insulin C 10-19 yr 10 to 19 None Insulin D <10 yr >20 Benign retinopathy Insulin E Any Any Nephropathy Insulin R Any Any Proliferative retinopathy Insulin H Any Any Heart Insulin

Gestational diabetes:

Gestational diabetes Onset in pregnancy Affects 1-2% of all pregnancies More than half of Gestational diabetes develop overt diabetes in 20yrs Obesity and diabetes in offspring

High risk for GDM:

High risk for GDM History of still birth History of neonatal death History of fetal macrosomia Concomitant obesity and hypertension Development of oligohydramnios , polyhydramnios , preeclampsia and fetal macrosomia Inadequate metabolic control with diet alone

Screening strategy for detecting GDM:

Screening strategy for detecting GDM Low risk: * Blood glucose testing not routinely required in: Member of an ethnic group with low prevalence No known diabetes in 1st degree relatives Age < 25yrs Weight normal before pregnancy Weight normal at birth No history of abnormal glucose metabolism No history of poor obstetrical outcome

Screening strategy for detecting GDM:

Screening strategy for detecting GDM Average risk * Blood glucose testing at 24-28 wks (1 step/2step) Member of an ethnic group with high prevalence Diabetes in a first degree relative Age ≥ 25yrs Overweight before pregnancy Weight high at birth

Screening strategy for detecting GDM:

Screening strategy for detecting GDM High risk * Blood glucose testing as soon as feasible Severe obesity Strong family history of type 2 diabetes Previous history of GDM Impaired glucose metabolism Glucosuria

Screening (OGTT):

Screening (OGTT) Plasma glucose level measured 1 hr after 50g glucose load Without regarding to time of day/ time of last meal Plasma glucose level > 130mg/dl; sensitivity 90% Plasma glucose level > 140mg/dl; sensitivity is 80%

Diagnosis of GDM by OGTT:

Diagnosis of GDM by OGTT Time 100 g Glucose (American diabetes association criteria) 75 g glucose (WHO criteria) Fasting 95 mg/dl 5.3 mmol /L 95 mg/dl 5.3mmol/L 1-h 180mg/dl 10mmol/L 180mg/dl 10mmol/L 2-h 155mg/dl 8.6mmol/L 155mg/dl 8.6mmol/L 3-h 140mg/dl 7.8mmol/L - -

Maternal risks:

Maternal risks Birth trauma Operative delivery Polyhydraminos 50% lifetime risk in developing Type II DM Recurrence risk of GDM is 30-50%

Fetal risks:

Fetal risks No increase in congenital anomalies Increased risk of stillbirth if fasting+ PP hyperglycemia Macrosomia, BW >4000gm occurs in 17-29% of pregnancies Birth trauma-shoulder dystocia and related complications Neonatal hypoglycemia

Fetal macrosomia:

Fetal macrosomia Defined as fetal weight > 4000gm Brain not effected, shoulder dystocia 3% Maternal hyperglycemia Fetal hyperinsulinemia Excessive somatic growth Diagnosis and management is important USG should begin at 20wks; to be done at every 4 wks Also due to IGF-1 and IGF-2 Maternal obesity is important confounding factor

Management of GDM:

Management of GDM Class Onset Fasting 2 hour PP Therapy A1 Gestational <105 mg/dl <120 mg/dl Diet A2 Gestational >105 mg/dl >120 mg/dl Insulin Nutritional therapy-total calorie intake: average 2000-2500 kcal/day. BMI >40 -- 12 kcal/kg/ideal body weight/d BMI>27 -- 25 kcal/kg/ideal body weight/d BMI 20-26 -- 30 “ BMI<20 -- 38 “

Management of GDM:

Management of GDM Diet : general principles 55% CHO 25% Protein 20% fat Normal weight gain 10-12 kg Avoid ketosis Liberal exercise program to optimize BG control Daily self BG monitoring Breakfast should provide 25%, Lunch 30% and dinner 30%. Obese women may be managed with lower caloric intake.

Management of GDM:

Management of GDM If persistent hyperglycemia after one week of diet control proceed to insulin 6-14 weeks 0.5u/kg/day 14-26 weeks 0.7u/kg/day 26-36 weeks 0.9u/kg/day 36-40weeks 1 u /kg/day

Oral hypoglycaemic agents:

Oral hypoglycaemic agents Traditionally not recommended in pregnancy because of teratogenic effects Glyburide and Metformin

Glyburide:

Glyburide Sulfonylureas MOA- release of insulin Hypoglycemia and weight gain are the main side effects Non- teratogenic , classified as category B drug

Glyburide treatment regimen who fail Diet therapy:

Glyburide treatment regimen who fail Diet therapy Glucometer BG measurment fasting and 1 or 2 hrs following breakfast, lunch and dinner Glucose level goals (mg/dl): fasting < 100, 1-h < 155 and 2hrs < 130 Glyburide starting dose 2.5mg orally with morning meals Increased daily glyburide dose by 2.5mg/wk, increment until 10mg/day, then switch to twice daily dosing until max of 20mg/day, then switch to insulin if 20mg/day does not achieve glucose goal.

Obstetrical management:

Obstetrical management Cesarean delivery should be considered in women with sonographical estimated weight > 4500gm Elective cesarean delivery has no significant effect on incidence of brachial plexus injury Fetal monitoring

Postpartum evaluation:

Postpartum evaluation Women diagnosed with GDM to be evaluated with 75gm OGTT at 6-12wks postpartum Metabolic assessment recommended after preg with GDM Contraception: low dose hormonal contraceptives Time Test purpose Postdelivery (1-3 d) Fasting or random plasma glucose Detect persistent, overt diabetes Early postpartum (6-12wk) 75g 2h OGTT PP classification of Glu met 1yr Postpartum 75g 2h OGTT Assess Glu metabolism Annually Fasting plasma glucose Assess Glu metabolism Tri- annually 75g 2h OGTT Assess Glu metabolism Prepregnancy 75g 2h OGTT Classify glu metabolism

Pregestational diabetes/ overt diabetes:

Pregestational diabetes/ overt diabetes Patients with symptoms of DM and plasma Glucose concentration 200mg/dl or more The condition may be preexisting or detected during present pregnancy

Criteria for diagnosis of impaired Glucose tolerance and diabetes with 75g oral glucose:

Criteria for diagnosis of impaired Glucose tolerance and diabetes with 75g oral glucose Time Normal tolerance Impaired glucose tolerance diabetes Fasting < 110 mg/dl ≥ 110 and <126 ≥ 126 mg/dl 2 hr Post glucose <140 mg/dl ≥ 140 and <200 ≥ 200 mg/dl

Maternal effects:

Maternal effects During pregnancy Abortions Preterm labor 20% Infections (UTI) Preeclampsia 25% Polyhydraminos 25-50% Maternal distress Diabetic retinopathy Diabetic nephropathy Ketoacidosis

Maternal effects:

Maternal effects During labor: Prolongation of labour due to big baby Shoulder dystocia Perineal injury Postpartum hemorrhage Operative interventions During Puerperium : Puerperal sepsis Lactation failure

Fetal hazards:

Fetal hazards Congenital anomalies 3 times increased risk Caudal regression- 1.3/1000 Situs invertus Spina bifida, hydrocephaly, other CNS defects Anencephaly Cardiac anomalies: VSD, TGA, ASD, COA Anorectal atresia Renal anomalies: agenesis, cystic kidney, duplex ureter

Fetal hazards:

Fetal hazards Unexplained stillbirth Hypoglycemia, hypocalcemia , hyperbilirubinemia , polycythemia Cardiomyopathies Inheritance of diabetes Shoulder dystocia Macrosomia IUGR RDS

Preconceptional counselling:

Preconceptional counselling Preconception Counselling Risk of NTD ~1-2% Folic Acid 400µg/day Preconceptional glucose control using insulin. Fasting < 70-100 mg/dl, and PP <140mg/dl at the end of 1 hr and <120mg/dl at the end of 2hr.

Preconceptional counselling:

Preconceptional counselling Normoglycemia prior to conception Ideally HBA1C 6% or less Team approach Glucose monitoring qid ACE inhibitors contraindicated Baseline HbA1C, 24h urine for protein Cr Cl , ophthalmology review Switch from OHA to insulin

Pregestational /Overt Diabetes:

Pregestational /Overt Diabetes Assess for end organ disease assess for nephropathy - inc risk of PIH Assess and treat retinopathy - may progress assess for neuropathy generally remains stable during pregnancy assess and treat vasculopathy CAD is a relative C/I for pregnancy

Maternal Surveillance:

Maternal Surveillance - Blood pressure monitoring renal function every trimester urine culture monthly thyroid function BG control HB A1C every trimester

Fetal Surveillance:

Fetal Surveillance USG for dating/viability ~ 8 weeks Transvaginal USG examination at 10-14 weeks Fetal anomaly detection nuchal translucency 11-14weeks maternal serum screen- free β HCG and PAPA-A MSAFP at 16w to screen for open Neural tube defect anatomy survey 18-20 weeks Fetal echo 22weeks Weekly biophysical profile, NST

Trimestric approach:

Trimestric approach 1 st Trimester: Careful monitoring of glucose control is essential OHA to Insulin therapy 2 nd trimester: Maternal serum alpha fetoprotein at 16-20wks Targeted sonographic examination at 18-20wks Euglycemia with self monitoring is the goal Increased insulin requirement after 24wks 3 rd Trimester: Cesarean delivery to avoid traumatic birth

Admissions :

Admissions At 34-36 weeks in uncomplicated cases It facilitates Stabilisation of diabetes Less incidence of Preeclampsia, Polyhydramnios and Preterm labour Selecting time and mode of termination

Insulin therapy:

Insulin therapy OHA not currently recommended for overt diabetes Maternal glycemic control with multiple daily insulin inj and adjustment of dietary intake S/C insulin infusion by calibrated pumps Self monitoring using glucometer recommended

Self monitored capillary BG goals:

Self monitored capillary BG goals Specimen Level (mg/dl) Fasting ≤ 95 Premeal ≤ 100 1 hr- postprandial ≤140 2 hr- postprandial ≤ 120 2-6hr ≥ 60 Mean (average) 100 Hb A1c ≤ 6

Management of diabetes in pregnancy insulin therapy:

Management of diabetes in pregnancy insulin therapy Insulin Pump Allows insulin release close to physiologic levels Use short acting insulin 50-60% of total dose is basal rate 40-50% given as boluses Potential complications Pump failure Infection Increased risk of DKA

Management of diabetes in pregnancy insulin therapy:

Management of diabetes in pregnancy insulin therapy Short acting Onset Peak Duration Regular Lispro Aspart 0.5 – 1 hr 20 mints 25 mints 2 – 4 hrs 0.5 – 1½ hr 30 – 1½ hr 4-6 hrs 3 – 4 hrs 3 – 4 hrs Intermediate acting NPH/ Isophane lente (Insulin zinc suspension 1 – 3 1 - 3 5 - 7 4 - 8 13 - 18 13 – 20 Long Acting Ultra lente / Protamine Glargine 4 – 6 1 – 4 14 – 18 Minimal peak activity 24 – 36 g 24hrs

Insulin therapy:

Insulin therapy Regular and NPH are the most commonly used preparations Regular insulin/NPH combination- Slow absorption, administered 30min before meals Midmorning & midafternoon snacks necessary Rapidly acting insulin like Lispro prevent hypoglycemia

Insulin therapy:

Insulin therapy Lispro and aspartate – should be taken immediately before meals Lispro and aspartate used for prandial insulin and insulin pump therapy

Insulin therapy:

Insulin therapy Glargine- Longest acting Less episodes of nocturnal hypoglycemia Given in morning hours Detemir

Timing of Delivery :

Timing of Delivery Diet controlled Same as non diabetic Offer induction at 41 weeks if undelivered On Insulin/Type II/Type I If suboptimal control deliver following confirmation of lung maturity if <39 weeks Otherwise deliver by 40 weeks Generally do not allow to go post term DOC for initial tocolysis : Nifedipine

Mode of Delivery:

Mode of Delivery Macrosomic infants of diabetic mothers have higher rates of shoulder dystocia Cord is to be clamped immediately Reasonable to recommend C/S delivery if EFW is >4500g

Insulin requirement in labor:

Insulin requirement in labor Insulin requirements During induction of labor During elective caesarean section Usual insulin dose and meal on evening before surgery Overnight fast from 12 midnight Day before IOL Normal diet Normal insulin dose evening before IOL No overnight fast Day of IOL give half the morning dose of insulin before light breakfast Insert prostaglandin gel as early as possible Continuous CTG Start IV insulin infusion once labor establishes

Insulin therapy intrapartum:

Insulin therapy intrapartum CG Level Management 60-90 mg/dl 5%-10% DNS at 100 ml/hr 90-120mg/dl 0.9% NS or RL at 100ml/hr 120-140 mg/dl 5Uin 500ml 5% dex at 100ml/hr If >140 mg% then plain insulin sc by sliding scale: 140-180 mg/dl 4U 180 -250 mg/dl 8U 250-400 mg/dl 12U >400 mg% 16U CG and urinary ketone level should be measured every 2 hourly.

Contraception in DM :

Contraception in DM Barrier methods are safe, inexpensive with fewer side effects OCPs cause insulin resistance due to progesterone component and there is high risk of thromboembolism, MI and CVA. IUCDs cause infection, glucose precipitates with Copper and thus reduction of efficacy. Permanent method are used in couples with complete family

Diabetic Ketoacidosis:

Diabetic Ketoacidosis 5-10% of pregnant Type 1 patients Serious medical emergency Risk factors New onset DM Infection Insulin pump failure Steroids Fetal mortality 10%

Diabetic Ketoacidosis:

Diabetic Ketoacidosis Diagnosis: BG conc > 250mg/dl Ketone bodies in urine and plasma Arterial pH <7.3 Serum bicarbonate < 15meq/L

Diabetic Ketoacidosis:

Diabetic Ketoacidosis Management ABC’s and ABG Assess BG, ketones electrolytes Insulin 0.2-0.4U/Kg loading and 2-10U/h maintenance Begin 5% dextrose when BG is 250 mg% When potassium is N range begin 20mEq/h Rehydration isotonic NaCl 1L in 1 st hour 0.5-1L/h over 2-4h 6-8 L over 1 st 24 hours. 250cc/h until 80% replaced Replace Bicarb and phosphate as needed

Metabolic syndrome:

Metabolic syndrome Definition (WHO) Diabetes, impaired glucose tolerance, impaired fasting glucose, insulin resistance+ atleast 2 of foll : Abdominal obesity Trigycerides > 150 mg/dl HDL < 40 mg/dl BP≥ 140/90 mm Hg Microalbuminuria > 20µg/min

Metabolic syndrome:

Metabolic syndrome Definition (NCEPATP III) At least 3 of the following : Fasting plasma glucose > 110mg/dl Abdominal obesity (waist circumference> 35 in.) Triglycerides >150 mg/dl; HDL < 50mg/dl BP ≥ 130/85 mmHg

Indian experience:

Indian experience Incidence of GDM is 3-5% Numbers are increasing 90% diagnosed cases are of GDM Fetal macrosomia 32% PIH 48% Hydramnios 4% IUD 12% Fetal malpresentation 16% Cesarean section 44% Maternal mortality 10 times

Medicolegal Pitfalls:

Medicolegal Pitfalls Congenital anomalies in infant- Explained to the mother Preventability by good glycemic control should be mentioned and recorded Birth injuries and Perinatal asphyxia USG should be done 2-3wks prior to delivery Offer cesarean section if EFW >4500gm

Take Home Message:

Take Home Message Preventing congenital anomalies is a challenge Maintaining euglycemia is the key Educating community is the cornerstone

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