seminar 5 - dm in pregnancy
TRANSCRIPT
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Medical Complications in Pregnancy:
DIABETES MELLITUS
MUHAMMAD ZULHILMI BIN ABU BAKAR
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1. Type 1(IDDM)
2. Type 2(NIDDM)
3. Gestational diabetes
4. Others -genetic defects in insulin processing or action
-endocrinopathies
-drugs
-exocrine pancreatic defects
-genetic syndromes associated with dm
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E
ither type 1(iddm) or type 2(niddm)Type 1 occurs in younger age group and end
organ complications is likely to be
more.Hence they to have increased maternal
and obs risks
Type 2 usually occurs in obese patients and
have less maternal and obs compared to type
1
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Pregnancy alters carbohydrate in such away more glucose is made
available to the fetus
What cause the diabetogenic state?
Elevated placental hormones such asestrogens,progesterone,prolactin,human placental lactogen.
Plasma cortisol also rises during pregnancy.
Cause contrainsulin effect and state of insulin resistance
Further aggravated by increase body weight and increase caloric
intake during pregnancy Gestational diabetes develops when the pancreas ,despite the
production of insulin cannot overcome the effect of thesecounter regulatory hormones
In contrast pregestational diabetes becomes worse duringpregnancy
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1. Historical factors Age>30 years
Previous gdm
Family history of dm
Bad obs history
History of macrosomia
Prev. fetal anomalies
History of recurrent abortions or unexplained stillbirth
Drug history-steroids,tocolytic drug
2. Clinical factor in the present pregnancy Congenital fetal anomalies
Pre-eclampsia
Obesity>90 kg
Recurrent uti,vaginal candidiasis
Presence of glycosuria on more than 2 occasions
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Gdm is asymptomaticasymptomatic ,hence we need screening test to detect
gdm
1. Universal screening(all pregnant women)
2. Selective screening(presence of risk factors for gdm)
for universal screening do the glucose challenge testNo special preparation is needed for this test
50 grams of oral glucose is given between 24 to 28 weeks pog
Blood glucose is determined 1 hours later.
A plasma glucose level of > 7.8 is considered significant to perform
comfirmation diagnostic test.
Selective screening-oral glucose tolerance test 75 grams of oral glucose is given
Only 2 reading are taken-fasting glucose level and 2 hour post glucose
The diagnosis of dm is made when fasting glucose level are 7.8 and or 2
hour level of >11.1
If the 2 hours levels are between 7.8 and 11.1,the patient is said to have
impaired glucose tolerance test and should be treated as gdm.
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1. Pre-eclampsia
2. Recurrent infection-vaginal candidiasis,uti
3. Retinopathy
4. Nephropathy
5. Neuropathy
6. Micro/macroangiopathy
7. Polyhydramniospprom, cord prolapse,8. ketoacidosis
9. Increased instrumental and CS rates
10. Study shows that after gdm,40-60%of
women develop type 2 dm within 10years
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1. Miscarriage
2. Congenital anomalies(4 fold)-sacral
agenesis,ntd,cardiac and renal anomalies
3. Macrosomia
4. Respiratory distress syndrome
5. Hypoglycemia-result of hyperplasia of beta
cell
6. SIUD
7. Prematurity
8. Malpresentation
9. Shoulder dystocia.
10. polycythemic -jaundice
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1. Blood sugar level-weekly assessment is
required.useful in deciding wether to start
insulin or adjusting insulin dosage
2. Urine microscopy and culture-to excludeuti(bacteriuria)
3. HbA1c-done in first trimester.it gives
retrospective assessment 12 weeks
ago.high HbA1c at the end of firsttrimester indicates sugar control was poor
during organogenesis period.
4. Maternal serum AFP-done between 16 to
20 weeks pog
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5. Diagnostic imaging-gestational age, fetal
abnormalies, fetal growth, liquor volume .
6. Doppler of umbilical artery-done in cases of
diabetic vasculopathy
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Antenatal management
Plasma glucose level should be maitained between 4-6mmol/L
Early dating and scan to exclude fetal abnormalities
Diet control should be attempted first.if fail,insulinshould be started.
Admission-poor blood sugarcontrol,PIH,polyhydramnios.bsp should be monitored
Timing for delivery-if on insulin,38 weeks,if on diet
control,can prolonged to term Mode of delivery-lscs if macrosomia
baby,malpresentation,evidence of fetal compromise
Check BP
Fetal growth chart
Monitor closely with continuos ctg
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Oral hypoglycemic drug are generally not
recommended as it can cause teratogenic effect
towards fetus and can cross placenta causing
hypoglycemia
Diet therapy Total calories advised is 24-30 kcal/kg of the
present body weight.In obese diabetic pt.
24kcal/kg is adviced
The calories should be distributed between 3meals and 3 snacks
Dietery control decrease postprandial glucose
level and it also improve insulin action.
Blood glucose level and weight gain can be used
to formulate a meal plan
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Exercise
Light exercise help by lowering fatty acid
Contracting muscle help stimulate glucose
transport hence decrease blood sugar Better done after meals
Exercise involving the muscle of upper part of
the body is sufficient to lower down glucose
level.
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Insulin regimes
15% required insulin therapy
Insulin is indicated in all pregestational diabetes
and poorly controlled gdm The popular regimes use a mixture of short
acting and medium acting insulin
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Pre-pregnancy counsellingThis play an important roles for
pregestational diabetes in order to prevent
early pregnancy loss and congenital
anomalies.Complete assessment of diabetic status
should be done to find out wether she fit to
go through pregnancy.HbA1c can be done to
evaluate blood glucose control 12 weeks ago.Those with oral hypoglycemic should be
switched to insulin theraphy.
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15% of pt. with positive gct will have gdm
15% percent of GDM will required insulin
15% of GDM will have macrosomia
15% of GDM will have impaired gtt after
delivery