diabetes and pregnancy-kabera rene

8/8/2019 Diabetes and Pregnancy-KABERA Rene

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KABERA Ren,MD

PGY III Resident

Family and Community Medicine

National University of Rwanda

Diabetes and Pregnancy


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PLAN

Introduction

Physiopathology

Diagnosis

Management

Complications

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INTRODUCTION

Diabetes mellitus is a clinical syndrome characterized by deficiency of or

insensitivity to insulin and exposure of organs to chronic hyperglycemia.

Deterioration of glucose tolerance occurs normally during pregnancy.

Gestational diabetes mellitus (GDM) is defined as any degree of glucose

intolerance with first recognition during pregnancy.

Preexisting diabetes is diagnosed prior to pregnancy.

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INTRODUCTION

Type 1 diabetes, results from a cellular-mediated autoimmune destruction of

the b cells of the pancreas.

Type 2 diabetes is characterized by insufficient insulin receptors to effect

proper glucose control after insulin is released (insulin resistance).

Gestational diabetes is similar to type 2 diabetes. 90% of the personsidentified have a deficiency of insulin receptors or a marked increase in

weight in the abdominal region.

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PHYSIOPATHOLOGY

Significant metabolic changes are necessary to provide proper energy

delivery to the growing conceptus. Hormones associated with pregnancy such as human placental lactogen

(HPL) and cortisol lower glucose levels, promote fat deposition, and

stimulate appetite.

Rising serum levels of estrogen and progesterone increase insulinproduction and secretion while increasing tissue sensitivity to insulin.

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PHYSIOPATHOLOGY

The overall result is a lowering of the fasting glucose levels .

The decrease is on average 15 mg/dL; thus fasting values of 70-80 mg/dL

are normal in a pregnant woman by the 10th week of gestation.

Hormones associated with pregnancy facilitate maternal storage of energy in

the first trimester and then assist in the diversion of energy to the fetus inlater pregnancy as demand increases.

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There are three ways to diagnose preexisting diabetes mellitus and each way

must be confirmed by a follow-up test. Criteria for diagnosing diabetes mellitus

include:

Symptoms of diabetes (polyuria, polydipsia, and/or unexplained weight loss)

plus a casual plasma glucose concentration of equal to or greater than 200

mg/dL,

Fasting plasma glucose (at least 8 hours without eating) equal to or greater

than 126 mg/dL,

OGTT

DIAGNOSIS

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The gestational DM diagnostic criteria are based on O'Sullivan and Mahan

and modified by Carpenter and Coustan works.

All pregnant women should be screened for diabetes at 24-28 weeks unless

clinical indications exist for earlier screening.

Indications for obtaining an early screen:

Unexplained prior stillbirth or fetal anomalies

Maternal glycosuria (2+ or greater).

Polyhydramnios in the current pregnancy.

DIAGNOSIS

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DIAGNOSIS

Previous history of gestational diabetes.

Family history of diabetes, in a first degree relative.

Characteristics of insulin resistance (obesity, hypertension, hyperlipidemia)

Maternal obesity (BMI greater than 29.0)

Maternal age greater than 35 years. Maternal polycystic ovary syndrome (PCOS)

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DIAGNOSIS

Screening test procedure

The screen is a load followed by a plasma blood sugar one hour after

administration.

The test may be performed at any time during the day and the patient

does NOT need to be fasting.

She should refrain from eating, smoking or drinking during the hourbetween administration of the 50-gram oral glucose and drawing of the

blood sugar.

Patients with an abnormal screen require an OGTT.

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DIAGNOSIS

Interpretation

Screen less than 135, no further screening required

Screen greater than 135, but less than 200, proceed to OGTT

Screen greater than 200, obtain fasting glucose.

If fasting equal to or greater than 105, treat as gestational diabetes.

If fasting less than 105, proceed to OGTT

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DIAGNOSIS

3-hour OGTT- American College of Obstetricians and Gynecologists

Fasting state before the test is started.

A fasting plasma blood sugar is obtained.

Then the patient is given 100 gram glucose load followed by blood sugars at

one hour, two hours and three hours.

If the fasting plasma sugar is over 125 mg per dl or a random glucose is

greater than 200, then the 100 gram glucose load should be withheld.

The test should be considered abnormal and the rest of the test canceled.

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DIAGNOSIS

Interpretations of the results: Carpenter and Coustan

Fasting less than 95 mg per dl

One Hour less than 180

Two Hours less than 155

Three hours less than 140

Two or more abnormal values are considered a positive test.

One abnormal value is considered borderline.

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MANAGEMENT

Objectives:

To relieve symptoms. To correct associated health problems and to reduce morbidity, mortality and

economic costs of diabetes.

To prevent as much as possible acute and long-term complications; to

monitor the development of such complications and to provide timelyintervention.

To improve the quality of life and productivity of the individual with diabetes.

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MANAGEMENT

Management Based On 3-hour OGTT Results

o Fasting value greater than 110, proceed immediately to treatment as A2

GDM.

o Fasting value 95 -110, initiate diet therapy and reevaluate within one week.

o Fasting values remain greater than 95 and /or 1 hour postprandial greaterthan 140 initiate therapy with insulin or glyburide: See management of A2

GDM.

o Fasting values less than 95 and 1 hour postprandial less than 140, follow

diet controlled gestational diabetes treatment. See management of A1 GDM.

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Management Of Gestational Diabetes A1

A. Nutritional counseling:

1.Calories

Body weight Category & Weight gain guidelines

Category BMI Kcal / kg Ideal weight gain

Underweight Less than 19.8 36-40 28-40

Normal 19.8-26 30 25-35

Overweight 26.1-29 24 15-25

Obese Greater than 29 12-18 Equal to or greater than 15

2.Suggested macronutrient distribution: 40-50% carbohydrate, 20-25% protein, and 30-40% fat.

3.Meal plan: Recommend three small meals and two-four snacks based on blood glucose control andpatients lifestyle.

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MANAGEMENT

B. Prenatal visits: Following diagnosis weekly to every other week

C. Glucose monitoring: Prescribe a glucometers for fingersticks before breakfast andone hour after each meal.

D. Indications for initiation of Insulin or Glyburide

1. fasting blood sugar greater than 95 mg per dl.

2. 1 hour postprandial greater than 140 mg per dl (2 hour > 120 mg per dl)

3. Polyhydramnios or LGA, especially if abdominal circumference greater than 75th

percentile at 29-33 weeks.

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MANAGEMENT

E. Laboratory tests

Patients with GDM are at increased risk of developing preeclampsia:

Electrolytes, BUN and Creatinine, platelets, uric acid, LFTs.

Fasting triglycerides (TG)(should be checked at some time Postpartum before

giving estrogen containing OCPs postpartum, since a fasting TG greater than

400 is a relative contraindication to OCPs).

Screen for asymptomatic bacteriuria: urine analysis or urine culture.

F. Fetal Surveillance

Fetal movement record starting at 28 weeks (should be performed daily).

In uncomplicated A1 DM with no evidence of complications, no testing isindicated.

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MANAGEMENT

If EFW greater than 4500 grams, then C-section should be considered due to

risk of shoulder dystocia.

Notify neonatology before delivery.

Postpartum Management

Up to 60% of gestational diabetes will become diabetic with a subsequent

pregnancy or later in life.

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MANAGEMENT

Initiation Of Insulin In GDM A2

Initiate of insulin therapy in non-insulin dependent diabetics and gestational

diabetics as follows:

a. Initial dose determined by actual body weight and gestational age:

0.5-0.7 units per kg in first trimester

0.5-0.8 units per kg in second trimester

0.5-0.9 units per kg in third trimester

b. Divide insulin dose into 2 injections:

2/3 of total dose in am (prior to breakfast)

1/3 total dose in pm (prior to dinner)

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MANAGEMENT

c. Composition of insulin dose is:

morning - 2/3 NPH & 1/3 regular

evening - 1/2 NPH & 1/2 regular

d. Patients should initially be placed on BID insulin.

If nocturnal hypoglycemia becomes a problem, then consider administeringthe evening NPH at bedtime instead of 5 p.m.

Hypoglycemia is extremely dangerous in a diabetic due to hypoglycemic

unawareness and should be avoided.

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MANAGEMENT

Obstetrical

Allow the pregnancy to continue to 40 0/7 weeks gestation in patients withan unfavorable cervix and documentation of good glycemic control,

reassuring antepartum fetal testing and no other maternal or fetal

complications.

Consider elective induction at 39 weeks without an amniocentesis in apatient with a favorable cervix, good dating criteria, optimal glycemic control,

EFW less than 4500 gms.

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MANAGEMENT

Obstetrical

Earlier induction should be considered for

Classes C or greater,(D-benign retinopathy, F-nephropathy ,H-heart

complications, R-Diffuse retinopathy)

Patients with obstetric reasons including IUGR, oligo-or polyhydramnios,

Non-reassuring Doppler flow, poor glycemic control,

Failure to obtain appropriate fetal surveillance

Deterioration of maternal status. Amniocentesis should be offered in patients

who are electively induced prior to 39 weeks.

Consider hospitalization 24-48 hours prior to delivery to stabilize blood

sugars if control has been difficult.

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COMPLICATIONSFetal

Delayed fetal lung maturity

Neonatal hypoglycemia,Hyperbilirubinemia,Polycythemia

Organomegaly.

Preterm birth.

Malformations (high glucose environment in first 8 weeks)

Cardiac, Neural tube defects, Caudal regression syndrome

Higher incidence of developing Type 2 DM as a child or as an adolescent,if

glucose control was poor during pregnancy.

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COMPLICATIONS

Maternal

Increased rate of preeclampsia (4.5 times the usual rate). Increased incidence of intrauterine deaths.

Increased incidence of polyhydramnios.

Increased incidence of wound and urinary tract infections cystitis and

pyelonephritis and PROM.

Increased incidence of vulvovaginitis (esp. candidiasis).

Increased incidence of operative delivery.

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THANK YOU

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diabetes and pregnancy-kabera rene

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