Diabetes Mellitus In Pregnancy PDF

DIABETES MELLITUS Dr.Khalida Hassan Muho Specialist OB\GYN Objectives Understand the epidemiology, aetiology, pathophysiology, clinical characteristics, prognostic features and management of gestational diabetes: Impaired glucose tolerance maternal, fetal and neonatal complications, diet,...

DIABETES MELLITUS Dr.Khalida Hassan Muho Specialist OB\GYN Objectives Understand the epidemiology, aetiology, pathophysiology, clinical characteristics, prognostic features and management of gestational diabetes: Impaired glucose tolerance maternal, fetal and neonatal complications, diet, drugs (insulins and hypoglycaemic agents Case scenario A primigravida, 29 weeks pregnant has been diagnosed with gestational diabetes on her 2 h OGTT. Her fasting plasma glucose on the OGTT Was 7.3 mmol/L. what are the risk to her pregnancy? Diabetes may complicate a pregnancy either because a woman has type 1 or type 2 diabetes mellitus before pregnancy or because impaired glucose tolerance develops during the course of her pregnancy (GDM). Prepregnancy counselling The aim of prepregnancy counseling is to achieve the best possible glycaemic control before pregnancy and to educate diabetic women about the implications of pregnancy. Advice includes: Optimization of glycaemic control to achieve an HbA1c of 85 mmol/mol is associated with a fetal loss during pregnancy of around 30%. Prepregnancy care is associated with reduced rates of congenital malformation. In the preconception period, diabetes therapy should be intensified and adequate contraception encouraged until glucose control is good. Targets for therapy prepregnancy are premeal glucose levels of 4–7 mmol/l. Improved glycaemic control may be achieved with newer insulin delivery systems such as continuous subcutaneous insulin infusion pumps and glucose sensors. Diabetic vascular complications are common in women of reproductive age and women with significant retinopathy, nephropathy and/or neuropathy benefit from multidisciplinary team review prior to pregnancy. It is important that a plan for medication adjustment is made and women are counseled regarding the additional potential complications associated with diabetic micro vascular disease. This is particularly important for women with nephropathy, which is associated with a significantly increased risk of complications arising in pregnancy that would necessitate preterm delivery as for women with other types of renal disease (80% chance if 125–180 μmol/l; 75% chance if 180–220 μmol/l; and 60% chance if >220 μmol/l). There is also a risk that retinopathy can progress in pregnancy and during the postpartum period. Maternal and fetal complications of types 1 and 2 diabetes mellitus Congenital abnormality is an important cause of mortality and morbidity in diabetic pregnancies and is seen 2–4 times more often than in pregnancies without diabetes, with a threefold excess of cardiac and neural tube defects. Accelerated growth patterns are typically seen in the late second and third trimesters and are attributable to poorly controlled diabetes in the majority of cases. In general, maternal morbidity in diabetic pregnancies is related to the severity of diabetic-related vascular disease preceding the pregnancy. The risk of preeclampsia is increased threefold in women with diabetes, and particularly in those with underlying microvascular disease. All women with diabetes should be offered low-dose aspirin from 12 weeks’ gestation to reduce the risk of preeclampsia. Women with diabetic retinopathy are at risk of progression of the disease and should be kept under careful surveillance (retinal screening at booking, 16–20 weeks’ and 28 weeks’ gestation). Effects of diabetes on pregnancy  Increased risk of miscarriage.  Risk of congenital malformation.  Risk of macrosomia(contributes to a traumatic birth and shoulder dystocia).  Increased risk of pre- eclampsia(particularly in those with underlying microvascular disease).  Increased risk of stillbirth.  Increased risk of infection.  Increased operative delivery rate. Effects of pregnancy on diabetes  Nausea and vomiting, particularly in early pregnancy.  Greater importance of tight glucose control.  Increase in insulin dose requirements in the second half of pregnancy.  Increased risk of severe hypoglycaemia.  Risk of deterioration of pre-existing retinopathy.  Risk of deterioration of established nephropathy. Management of types 1 and 2 diabetes in pregnancy Women with diabetes should be managed throughout their pregnancy by a multidisciplinary team involving diabetic specialist midwives and nurses, a dietician, an obstetrician and a physician. The primary goal of the team is to support the woman and her family during the pregnancy to safely optimize glycaemic control. Blood glucose monitoring is encouraged 7 times a day (before and 1 hour after meals) with targets of