Diabetes in pregnancy

Diabetes in pregnancy

General Consideration
Definition
abnormalities of carbohydrate metabolism
Incidence : 4% ( 10%overt, 90%gestational)

Pregnancy itself is diabetogenic

• insulin resistance
• Increased production of cortisol, estriol, progesterone
• Increased insulin destruction by kidney& placenta
• Production of placental somato- mmotropin
• Increased lipolysis: mother use fat for calories & saves glucose for fetus
• Changes in gluconeogensis: fetus use alanine & other a.a & depraves mother

Detection ( screening) of GD

High risk patients ( risk factors)
positive family history of DM
Poor obstetric hx (neonatal death)
Poly hydromnia in recent preg.
Previous delivery of a large baby.
Obese woman
Advanced maternal age ( more than 25 years)


screening
Random blood sugar test: 50 gm. Oral glucose, all preg woman between ( 24-28) wk. without diet prepartion
1 hour plasma glucose = 140 mg/dl ( cutoff value) = or less than 7 mmol/l.
2 hour plasma glucose = 120 mg/dl= (4-6 mmol/l)

General urine examination for sugar: if it more than 1+

OGTT (75 g) ( prepared patient): modified WHO used

DIABETIC

IGT
normal

• More than 7

Less than 7
Less than 7
fasting
More than 11
More than 7.8
Less than7.8
2 hours


Effect of diabetes on pregnancy
1. on the mother
Increase incidence of PE & eclampsia espicially in pre-existing DM.
Increase incidence of infection
Increase incidence of traumatic delivery & C/S.
Increase incidence of poly hydromna( fetal osmotic diuresis) induced by materno- fetal hyper glycemia
Increase PPH

2. ON the fetus

Intrauterine death ( sudden death of fetus in late pregnancy) due to hypoxia & metabolic acidosis
Neonatal death
Neonatal morbidity ( birth injury esp. brachial plexuses in shoulder dystocia)
Neonatal hypo-glycemia, hypo-calcemia
Congenital anomalies( sacral agenesis , CNS anomalies)

RDS ( respiratory distress syndrome): due to inhibition effect of cotisol on enz. System responsible for production of surfactant in fetal lung

• Antenatal measurement

• Early U/s ( for dating, viable)
• Folic acid supplement ( 3 months before& 1st trimester)
• Advice on hyperglycemic prevention
• HbA1C ( less than 6.5)
• Screening for diabetic complication
• 2 nd trimester
• Detailed U/S to exclude any congenital abnormalities
management


Assessment fetal growth & amniotic fluid from 28 wks of preg / 2 weeks
Surveillance for medical obstetric complications : increased risk for PIH
Optimization of glycaemic control :
By diet ( 3 meals& 3 snacks)
1800 cal /day
Diet ( CHO 40- 60%), (PROT 20-30% )& remaining fat
.

If 2 weeks no response . Start insulin

Regular 3 short acting & intermediate acting at bed time.
Aim FBS 4-6 mmol/l , 2 hour post prandial 7 mmol/l.
Or dose : insulin ( unit) = BWT 0.6 ( 1st trimester)
Total dose divided 2/3 before breakfast ( 2 intermediate : 1 soluble)
1/3 dinner 1 ( intermediate) :1( soluble)

Third trimester

• 1) Optimization of glycaemic control
• 2) Assessment of fetal growth ( at the end of the second trimester & every 4 weeks)
• 3) Timing & mode of delivery
• Delivery
• Protocol for insulin during labour & delivery


Intrapartum ( day of induction)
½ dose of insulin at the morning & light breakfast
labour establish 500cc of 10% dextrose ( 100cc/hr) & in other 6 unit of insulin in 60 cc of normal saline ( 1 unit / 10 cc/ hr)
Aim is blood sample = 4-6 mmol/l after ½ hr. if Bs less than 4 mmol/l then 5cc/hr ( ½ unit). If Bs more than 6 mmol/l then 20 cc/hr (2 unit/hr). Then should mointer Bs every hour.

After delivery ( post partum) :

adjustment of insulin dosage :Halve infusion rate until eating then stop.
Return to pre-pregnancy dose ( moniter blood sugar 2 hours & then post pranidal for 48 hours .
Discussing contraception
OGGT 6 weeks after delivery

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