Diabetes and pregnancy

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Diabetes and pregnancy : 

Diabetes and pregnancy DR.J.Vasantha DR. V. Ganesh DR.Anil kumar DR.Shankar DR.E.A.Ashokkumar

Prevalence : 

Prevalence Most common medical complication of Pregnancy affects 2-3% of pregnancies Gestational DM 90% Preexisting DM 10%

Physiological changes during pregnancy : 

Physiological changes during pregnancy Pregnancy is a state of insulin resistance & relative glucose intolerance This is due to placental production of anti-insulin hormones : hPL, cortisol, and glucagon FBS  Postprandial glucose ↑ ↑ Insulin production ↑ ↑ 2 folds in N women Insulin requirements ↑ ↑ in diabetic women  renal threshold for glucose  glycosuria

EFFECT OF PREGNANCY ON DM : 

EFFECT OF PREGNANCY ON DM Insulin requirement ↑ ↑ in pregnancy reaching a max at term & being at least 2 X the pre-pregnancy requirement Pt with diabetic nephropathy  deterioration in renal function with  in creatinine clearance & proteinuria  this deterioration in renal function is usually reversed after delivery

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2 X ↑↑ in retinopathy  rapid improvement in glycemic control  worsening retinopathy due to ↑↑ retinal blood flow ↑↑ icidence of hypoglycemia Ketoacidosis is rare unless associated with hyperemesis, infections, tocolytic & corticosteroid Rx

EFFECTS OF DM ON PREGNANCY : 

EFFECTS OF DM ON PREGNANCY ↑↑ incidence of congenital abnormalities The risk is related to the degree of glycemic control  5% with Hb A1c > 8%  25% with Hb A1c > 10% with ↑↑ risk of abortions Sacral agenesis, congenital heart defects, skeletal abnormalities & neural tube defects Perinatal & neonatal mortality ↑↑ 2-4 X Unexplained IUFD at term / more in macrosomic babies

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Macrosomia  the incidence is ↑↑ with poor diabetic control  not eliminated by tight control  associated with ↑↑ risk of operative delivery, birth trauma, & shoulder dystocia Hyperglycemia  fetal polyuria  polyhydramnios  PROM, preterm delivery Prematurity pose an added problem as pulmonary surfactant production is slightly delayed in babies of diabetic mothers

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Postnatally, babies are at risk of hypoglycemia & jaundice ↑↑ risk of PET especially in pt with pre-existing hypertension & nephropathy where it reaches almost 30%

Gestational Diabetes : 

Gestational Diabetes Definition CHO intolerance of variable severity first diagnosed in Pregnancy Prevalence 7% Risk Factors maternal age >25 Family history glucosuria prior macrosomia previous unexplained stillbirth ethnic group: Hispanic, Black, First Nat

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A fasting plasma glucose level >126 mg/dl (7.0 mmol/l) or a casual plasma glucose >200 mg/dl (11.1 mmol/l) meets the threshold for the diagnosis of diabetes, if confirmed on a subsequent day, and precludes the need for any glucose challenge. In the absence of this degree of hyperglycemia, evaluation for GDM in women with average or high-risk characteristics should follow one of two approaches:

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One-step approach: Perform a diagnostic oral glucose tolerance test (OGTT) without prior plasma or serum glucose screening. The one-step approach may be cost-effective in high-risk patients or populations (e.g., some Native-American groups).

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Two-step approach: Perform an initial screening by measuring the plasma or serum glucose concentration 1 h after a 50-g oral glucose load (glucose challenge test [GCT]) and perform a diagnostic OGTT on that subset of women exceeding the glucose threshold value on the GCT. When the two-step approach is employed, a glucose threshold value >140 mg/dl (7.8 mmol/l) identifies approximately 80% of women with GDM, and the yield is further increased to 90% by using a cutoff of >130 mg/dl (7.2 mmol/l).

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Screening PC 50/Trutol 1 hr after 50g load of glucose >7.8mmol/l (140mg/dl)abnormal* 15% of patients screen positive* value >10.3(190mg/dl) diagnostic of GDM (no OGTT needed)

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Screening 24-28 weeks routine no need to fast screen at 1st prenatal visit if hx of previous GDM screen earlier (12-24 weeks ) if risk factors

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Diagnosis OGTT 100gms 75gms 2 or more values greater than or equal to above cutoffs diagnostic of GDM single abnormal value indicates CHO intolerance Fasting 5.3 (95mg%) 1h 10.0 (180mg%) 2h 8.6 (155mg%) 3h 7.8 (140mg%) Fasting 5.3 1h 10.0 2h 8.6

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Maternal Risks birth trauma operative delivery 50% lifetime risk in developing Type II DM recurrence risk of GDM is 30-50%

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Fetal Risks no increase in congenital anomalies increased risk of stillbirth if fasting+ pc hyperglycemia macrosomia birth trauma-shoulder dystocia and related complications

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Management goal is to optimize BG levels to minimize risk of adverse perinatal outcomes diet exercise insulin therapy

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Management : Diet patients without fasting hyperglycemia Average 1950-2200 kcal/day. BMI>27 -- 25 kcal/kg/ideal body weight/d BMI 20-26 -- 30 “ BMI<20 -- 38 “

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Diet : general principles 55% CHO 25% Protein 20% fat Normal weight gain 10-12 kg avoid ketosis liberal exercise program to optimize BG control

GDM Carbohydrate ~35-40% of EnergyMeat, Cheese, Vegetables- not measured : 

GDM Carbohydrate ~35-40% of EnergyMeat, Cheese, Vegetables- not measured

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Programs of moderate physical exercise have been shown to lower maternal glucose concentrations in women with GDM. The beneficial glucose-lowering effects warrant a recommendation that women without medical or obstetrical contraindications be encouraged to start or continue a program of moderate exercise as a part of treatment for GDM.

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If persistent hyperglycemia after one week of diet control proceed to insulin Human insulin should be used when insulin is prescribed, and SMBG should guide the doses and timing of the insulin regimen. The use of insulin analogs has not been adequately tested in GDM. 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

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If fasting hyperglycemia start with NPH hs initial dose 6-8 U if only pc hyperglycemia use humalog 2-4u ac the specific meal adjust 2u/time 1 formula /time BG target ac <5.3(95mg%) 2 h pc <6.7(120mg%)

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Intrapartum management check bg hourly maintain BG 4mmol/L(72mg%)-6mmol/L(108mg%)

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Postpartum often will not require insulin if fasting hyperglycemia - more likely to develop persistent Diabetes 6 weeks post partum 75g OGTT yearly fasting BG emphasize importance of maintaining N weight, exercise

Preexisting Diabetes : 

Preexisting Diabetes Preconception Counselling risk of NTD ~1-2% Folic Acid 1-4 mg /day BG 3.5-5.3 prior to meals switch to MDI regimen (insulin ac meals and HS)

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Normoglycemia prior to conception ideally HBA1C 6% or less Team approach glucose monitoring qid ACE contraindicated : should be D/C at conception or use Diltiazem instead baseline HBA1C, 24h urine for protein Cr Cl , opthalmology review switch from OHA to insulin

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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

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Maternal Risks PIH /PET polyhydramnios preterm labour operative delivery ~50% birth trauma infection increase in insulin requirements DKA

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Fetal Risks congenital anomalies 3X inc risk unexplained stillbirth shoulder dystocia macrosomia IUGR

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

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Fetal Surveillance U/S for dating/viability ~ 8 weeks Fetal anomaly detection nuchal translucency 11-14w maternal serum screen anatomy survey 18-20 w Fetal echo 22 w

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Multidose Insulin breakfast 25% H lunch 15% H supper 25% H hs 35% NPH indicates insulin as a % of total daily dose

Insulin Sliding Scale Protocol : 

Insulin Sliding Scale Protocol Regimens: Low Dose Regimen: Suggested as starting point for the thin and elderly Medium Dose Regimen: Suggested as starting point for average weight High Dose Regimen: Suggested as starting point for overweight patients Very High Dose Regimen: Suggested as starting point for patients with infections or those receiving steroids

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Frequency of Monitoring: AC & HS Q 6 H (12 MN, 6 AM, 12 N, 6 PM) (If patient is NPO or on continuous tube feeding)

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Protocol: If Potassium is low (< 3.5 mEq/L), call M.D. Advance to next higher dose regimen if glucose level is > 250 two (2) times in 24 hours and all readings were > 100. Decrease to the next lower dose regimen if glucose level is between 60 and 100 twice in 24 hours. Physician should complete a new sliding scale protocol order sheet with dose regimen changes and send a copy to pharmacy.

Insulin Therapy : 

Insulin Therapy onset (h) peak duration insulin analogs .25 0.5-1.5 6-8 rapid acting 0.5 2-4 8-12 intermediate 1-1.5 4-8 12-18

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Insulin Pump Allows insulin release close to physiologic 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 if above happen

Timing of Delivery : 

Timing of Delivery GDM Diet controlled Same as non diabetic Offer induction at 41 weeks if undelivered GDM 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 postterm

Mode of Delivery : 

Mode of Delivery Macrosomic infants of diabetic mothers have higher rates of shoulder dystocia than non diabetic mothers Ultrasound estimates of fetal weight become significantly inaccurate after 4000g Reasonable to recommend C/S delivery if EFW is >4500g

Peripartum Management : 

Peripartum Management Withhold subcutaneous insulin from onset of labour or induction IV D10 @50cc/h IV short acting insulin in NS usually starting at 0.5-1u/h insulin rate usually based on BG and pre-delivery insulin requirement measure capillary BG hourly target: 4-6mmol/L

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Following delivery stop insulin infusion begin sub cutaneous insulin resume previous MDI schedule at 1/2 -2/3 the pre pregnancy dose maintain IV D5W @50cc/h until oral feeds tolerated

Oral Hypoglycemic agents : 

Oral Hypoglycemic agents Traditionally not recommended in pregnancy Recent RCT of oral glyburide vs insulin for GDM 440 patients BG measured 7x daily Treatment started after 11 weeks gestation Langer NEJM 2000

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Glyburide Insulin Achieved N BG 82% 88% LGA infants 12% 13% Macrosomia 7 4 C Section 23 24 Hypoglycemia 9 6 Preeclampsia 6 6 Anomalies 2 2 Glyburide is not FDA approved for the treatment of GDM and further studies are needed in a larger patient population to establish its safety.

Diabetic Ketoacidosis : 

Diabetic Ketoacidosis 5-10% of pregnant Type 1 pts Risk factors New onset DM Infection Insulin pump failue Steroids B mimetics Fetal mortality 10%

Bibliography : 

Bibliography Harrison*s internal medicine Diabetic journals.org NICE journals

THANK YOU : 

THANK YOU