presentation on diabetes mellitus

8/7/2019 Presentation on Diabetes Mellitus

http://slidepdf.com/reader/full/presentation-on-diabetes-mellitus 1/71

DIABETES MELLITUS IN PREGNANCY

DR. NAILA AMIN NITU

--------------------------------Junior Consultant

MCHTI, Azimpur

Dhaka, Bangladesh

[email protected]



Pre-gestational diabetes : Pregnancies which are

complicated by pre-gestational diabetes, type-1 ortype-2.

Gestational diabetes mellitus (GDM) : Any degree of

glucose intolerance with onset or first recognition during

pregnancy.



Metabolic changes during pregnancy

Pregnancy is a state of insulin resistance & relative

glucose intolerance due to placental production of

anti-insulin hormones :GH, hPL, cortisol, progesteroneand glucagon.

Due to peripheral insulin resistance which ensures an

adequate supply of glucose for the baby.




Relative baseline hypoglycemia.

Proliferation of pancreatic beta cells (insulin-secreting cells)

leads to increased insulin secretion

Insulin levels are higher than in pregnant than non-pregnantwomen in fasting and postprandial states.

Hypoglycemia between meals and at night

because of continuous fetal draw.




Lipid metabolism :

– Increased lipolysis (preferential use of fat for fuel, in

order to preserve glucose and protein)

– Spares glucose for fetus, since lipids do not cross

the placenta.



Magnitude of problem

Prevalence :

1% - 4 %



Congenital abnormalities

Macrosmia > 4 Kg

Birth trauma (due to macrosmia and shoulder dystocia )

Prematurity

Unexplained fetal death

IUGR

Delayed lung maturation.

Effects of DM on the fetus



Fetal Morbidity



Cardiac : transposition of great vessels, VSD, ASD, Coarctation of

Aorta.

CNS : Neural tube defects, Anencephaly, Microcephaly, Sacral

agenesis.

Skeletal: cleft lip/palate, caudal regression syndrome.

Gastrointestinal: duodenal or anorectal atresia.

Single umbilical artery.

Genitourinary : Renal agenesis, Duplex ureters, Cystic Kidney

Situs inversus.

Congenital abnormalities due to DM

Poor Glycemic control at time of conception: Risk factor



Effects of DM on neonates

Respiratory distress. Hypoglycemia.

Hypocalcaemia.

Hyperbilirubinemia.

Polycythaemia.

Cardiac Hypertrophy.

Chances of developing of Type 2 Diabetes.



Caudal regression syndrome

(abnormal development of lower spine)



Miscarriages , Repeated pregnancy loss.

Pre-eclampsia: 10-25%

Hypertension

UTI and Infections like- chorioamnionitis .

Polyhydramnios 25%-50%

Ketoacidosis.

Third trimester fetal deaths.

Preterm labour 20%.

Obstructed labour

Failed induction as unfavorable cervix Caesarean section.

Postpartum bleeding.

Long term risk of type-2 diabetes mellitus.

Effects of DM on the mother



Effect of pregnancy on diabetes

More insulin is necessary to achieve metabolic control

Progression of retinopathy: esp. severe proliferative

retinopathy

Progression of nephropathy

Increased risk of Coronary artery disease.



Risk stratification

Low risk: no screening

Average risk: at 24-28 weeks

High risk: as soon as possible

Whom to screen?

.



Age <25 years . Weight normal before pregnancy.

Member of an ethnic group with a low prevalence of GDM .

No known diabetes in first-degree relatives . Weight normal at Birth.

No history of abnormal glucose tolerance.

No history of poor obstetric outcome.

Low risk for GDM

USUALLY NOT ROUTINELY SCREENED.



Age >=25 years.

Diabetes in 1st degree relative

Over weight before pregnancy.

Weight high at Birth.

Member of an ethnic group with a average .prevalence of GDM

.

Average risk for GDM

Screening Test at 24-28 Weeks.



History of Still Birth, Neonatal death, Fetal macrosomia.

Marked obesity and / or hypertension.

Previous history of GDM, impaired glucose metabolism or

glycosuria.

Strong family history.

Ethnic group with high diabetes prevalence.

High risk for GDM

Screening test as soon as feasible, if negative then repeat at 26- 30 weeks.



Screening test

Two step approach

Glucose Challenge Test (GCT):

An excellent screening test for gestational diabetes is the

measurement of plasma glucose 1 hour after ingesting 50 g of glucose without regard to the time since the last meal.

Using a cut-off value > 7.8 mg/dl is considered cut-off point

for consideration of 3 hours glucose tolerance test (100 gm glucose).



Glucose Tolerance Test

– Draw a fasting glucose level .

– Give 100 gram glucose load with glucose levels drawn after 1, 2

and 3 hours.

F:<5.3 1 hr:<10 2 hr:<8.6 3 hr:<7.8

– 2 or more abnormal values = GDM.

Screening test



One-step approach:

Perform a diagnostic oral glucose tolerance test (OGTT)

screening with 75 gm glucose.

F: <6mmol/l2 hr after glucose: <7.8mmol/l.

Cost Effective.



What is our target ?



To keep fasting blood glucose <5.3 mmol/l and

2 hrs after breakfast < 6.8 mmol/l

To keep HbA1C <6.5%.

Target



Preconceptional counselling

Achieve optimum diabetes control before conception

Jointly seen by Obstetrician, Endocrinologist, Dietician

Ideally HbA1C should be < 6.5% before

conception.(HbA1C < 8% have 3% risk of congenitalanomalies while >10% the risk is 25%).

Screened for complications like retinopathy (Fundoscopy),

nephropathy and cardiac dysfunction.

Teach mother about need of good Glycemic control andself monitored blood glucose measurement and Glycemic

targets

Stop oral antidiabetic agent and start insulin and teach

how to administer insulin.



Emphasis on regular antenatal check up.

They should be counseled regarding possible pregnancy-

related risks.

Preconception folic acid 5mg/day should be started.

Cost of pregnancy.

Preconceptional counselling



How to manage ?



Diet

Exercise

Insulin

Drug

Treatment



Approximately 30 kcal/kg of ideal body weight.

Average 1950-2200 kcal/day.

BMI>27 -- 25 kcal/kg/ideal body weight/d

BMI 20-26 -- 30“

BMI<20 -- 38 “

45-50% should be carbohydrates, 20-25% protein, 25-30% fat.

6-7 meals daily (3 meals, 3-4 snacks). Bed time snack to preventketosis.

During lactation require an additional 200 calories.

Medical nutrition therapy



Breakfast 15-20 grams - 1 starch + ½ milk1 sl Bread or 1/c hot cereal + 4 oz milk

Morning snack 10-15 grams - 1 milk or 1 starch (or ½ of

each)

8 oz milk or 4 oz milk + 2 crackersLunch 45-60 grams - 2 starch, 1 milk, 1 fruit bread

Sandwich, milk, fruit and salad

Afternoon snack 10-15 grams - 1 milk or 1 fruitDiet yogurt or small apple

Dinner 45-60 grams - 2 starch, 1 fruit, 1milk1 cup potatoes, vegetables, small apple, 8 oz milk

Night Snack 10-15 grams – 1 milk

Diet yogurt



Walking.

Aerobic exercise.

Exercise



Insulin.

Other Oral Hypoglycemic agents.

Drugs in management of DM

in pregnancy



When to start ?



MANAGEMENT

Maintain blood sugar at FBS <5.3 , 2hrPBS< 6.7 mmol/l.

If this level is not achieved with diet control within 1

week then insulin should be started.

Start insulin immediately if fasting blood sugar > 5.8 and

2hrPBS >8.0 mmol/l.



Insulin in DM

Short and intermediate acting insulin can be

used to achieve postprandial control.

Long acting insulin is not licensed in pregnancy.

Insulin requirements increase by 50% from

24-28 weeks.



Twice or thrice daily ( before breakfast, lunch and

before dinner) injections of a combination of short

and intermediate acting insulin.

Patients usually receive two thirds their total dose

with breakfast and the remaining third in theevening.

Insulin therapy ….. cont.



6 times/day ( 4 times minimum), fasting and 2

hours after start of meals.

Maintain log book.

Self monitored blood glucose

(SBMG)



Each time the fasting or pre-meal glucose, the

patient refers to the supplemental regular insulin

scale to determine if additional regular insulin is

needed.

Insulin Dose adjustment



Supplemental regular insulin scale

Additional units

(regular insulin)

Pre-prandial

glucose mg/dl

0<100

2100-140

3140-160

4160-180

5180-2006200-250

8250-300

10>300



Management : Glycemic control

Significant benefit of insulin therapy

– Prior to insulin use, perinatal mortality was 65%

– After introduction of insulin therapy, perinatal mortality

declined to 5%.



Oral Hypoglycemic agents

Glyburide is a clinically effective in DM ( on-trial ).

(Langer et al. 2000)

Metformin is effective in DM ( Ratner et al., 2008 ;

Coustan, 2007)

Langer O, Conway DL, Berkus MD, Xenakis EM, Gonzales O. A comparison of glyburide and insulin in women withgestational diabetes mellitus. N Engl J Med . 2000;343:1134-8

Ratner RE, Christophl CA, Metzger BE, Dabalea D, Bennett PH, Pi-Sunyer X, Fowler S, Kahn SE, Diabetes

Prevention Program Research Group. Prevention of diabetes in women with a history of gestational diabetes: effects

of metformin and lifestyle interventions. J Clin Endocrinol Metab. 2008;93:4774-9

Coustan DR Pharmacological management of gestational diabetes: an overview. Diabetes Care. 2007;30 Suppl2:S206-8.



In patients who are not well controlled, a brief period

of hospitalization is often necessary for the initiation

and adjustment of therapy.

Hospitalization



Obstetric management



MANAGEMENT

Aims

To control diabetes.

Timing of delivery.

Management in labor.

Care of the newborn.

A t t l t



Antenatal management

1st trimester

Referral to combined diabetic obstetrics antenatal hospital

Dating scan.

Screening for diabetic complication in each trimester. Screening for non-diabetic co morbidities.

Assessment & optimization of Glycemic control.

Advice on hypoglycemia prevention.

Long term control can be checked using HbA1C levels Antenatal supervision should be a monthly intervals upto 20

weeks and thereafter 2 weeks intervals.




2nd trimester

Optimization of Glycemic control.

Screening for congenital abnormalities.

Surveillance for medical obstetrics complications.

Assessment of fetal growth.




3rd trimester

• Optimization of Glycemic control.

• Assessment of fetal growth.

• Timing and mode of delivery.





Fetal surveillance

A mid-trimester detailed anomaly scan at 16-20 weeks .

Maternal serum alpha fetoprotein at 16 week.

At 20-22 weeks Fetal echocardiography .

Umbilical and middle cerebral artery Doppler velocimetryat 24 weeks.

At 26 weeks onwards Regular fetal growth scans and AFI

at 4 weekly.

Close fetal surveillance in the third trimester including - Fetal kick chart.

NST, biophysical profile or modified BPP weekly from

32 weeks.





Maternal surveillance

Besides the routine baseline investigations, ECHO, RFTs

(to detect undiagnosed nephropathy) and fundoscopy (to

exclude proliferative retinopathy), thyroid function test

and urine analysis with urine culture should be done.

Hypertension should be treated with a target DBP of

80mmHg being advised.





Preterm labour is best managed with nifedipine and magnesium

sulphate as there is a high risk of hyperglycemia and ketoacidosis

with beta sympathomimetics.

Steroids to enhance lung maturity also increase the risk of

hyperglycemia.



Provided the pregnancy has gone well, aim should beto achieve a vaginal delivery at term

In low risk patient, termination can be done at 39-

40 weeks.

In high risk patient termination should be done at

38 weeks.

As there is small risk of IUD even with good glycemic

control after 38 weeks. Never over run beyond EDD.

Timing of delivery



Vaginal delivery usually preferred.

Caesarian section only for routine obstetric indication.

DM alone is not an indication. Failed induction due to unfavorable cervix is a

common problem.

Maintain euglycemia during labor (4.5-6.5 mmol/l).

Management of labor and delivery

Glycemic management during labour



Usual dose of intermediate-acting insulin is given atbedtime.

Morning dose of insulin is withheld.

Once active labor begins infusion of dextrose salineshould be started.

Glucose levels are checked hourly.

Regular insulin in administered by intravenous infusionpump

if glucose levels 6-8 mmol/l insulin 4 unit.

8-10 mmol/l insulin 6 unit.



Glycemic management during labour

Indication of Caesarean section



Elderly primigravida Multipara with a bad obstetrics history

Diabetes with complication or difficult to control

Obstetrics complication like pre-eclampsia,polyhydramnious, malpresentation

Fetal macrosomia >4 kg .

About 50% of diabetic mothers are delivered by C-section.

Indication of Caesarean section

I di t t f t



Neonatologist should be present at time of delivery.

Should be preferably delivered a center where

incubator is available.

Look for any congenital malformation.

Glucose should be checked within 2 hours of birth. Early breast feeding within ½ hours to minimise

hypoglycaemia (when sugar <40g/dl).

Anticipate and treat hypoglycemia in the infant

Immediate management of neonate

Postpartum management



Postpartum management

Following delivery, Adjustment of insulin as requirements fall to

pre-pregnancy levels.

GDM patients should perform OGTT at 6 weeks after delivery to

ensure that the diabetes has resolved. They should be counseledthat they have a risk of developing diabetes in later life of nearly

50% and before next pregnancy she should again undergone

screening test.

Contraceptive options like progesterone only contraception,

barrier methods should be discussed. Permanent sterilisation is

considered if family is completed.

l



Gestational diabetes is a common problem in worldwide.

Risk stratification and screening is essential in all pregnant

women, particularly those from ethnicities with increased risk.

Tight Glycemic targets are required for optimal maternal and fetal

outcome.

Patient education is essential to meet targets.

Long term follow up of the mother and baby is essential.

Conclusion



17 pound baby born of diabetic motherCourtesy: MSNBC News SeJan. 24, 2005



References

ACOG practice bulletin. Gestational Diabetes. ObstetricGynecology 2001;93:525-34

ADA position statement. Standards of Medical Care inDiabetes. Diabetes Care 2006;29:S4-42

Crowther CA et al. N Engl J Med 2005;352:2477-86

Casey BM et al. Obstetric Gynecology 1997;90:867-73

Practical guide to high risk pregnancy and delivery byFernando Arias, 3rd edition.

Dewhurst’s textbook of Obs and Gynae.

Current Obs and Gynae.

presentation on diabetes mellitus

Documents