Complicated Pregnancy - Diabetes Flashcards
What are 2 mechanisms by which pre-existing diabetes causes a problem?
- Raised insulin requirments of the mum
- Hyper-insulinaemia of the foetus
What causes insulin requirements of the mum to rise during pregnancy?
Production of certain anti-insulin hormones:
- Human Placental Lactogen
- Progesterone
- HCG
- Cortisol
This causes problems for mum if insulin doses aren’t adjusted well enough
By what mechanism do you get foetal hyper-insulinaemia in pre-existing diabetics?
High maternal glucose crosses placenta to bairn –> increase in foetal insulin production –> problems E.g. Macrosomia, neonatal hypoglycaemia and respiratory immaturity
What risks does pre-existing DM hold for the mother?
- Miscarriage
- Pre-eclampsia
- Worsening of diabetic complications i.e. nephropathy, retinopathy or hypos
- Infections
- Shoulder dystocia on delivery
What risks does pre-existing DM hold for the baby?
- Fetal congenital abnormalities; cardiac abdnormalities, sacral agenesis
- Macrosomia and Shoulder Dystocia
- Polyhydramnios
- Stillbirth
- Neonatal hypoglycaemia and resp distress
- Prematurity
Its useful to split obstetric management of pre-existing DM into 3 “phases”
Pre-conception, pregnancy and labour
What actions should we take prior to a diabetic actually getting pregnant?
- Better glycemic control, ideally blood sugars should be around 4 – 7 mmol/l pre-conception and HbA1c < 6.5% (< 48 mmol/mol)
- Golic acid 5mg
- Dietary advice
- Retinal and renal assessment
What medications can we provide diabetics during pregnancy?
- Insulin (increased dose or replacing oral drugs) to optimise glucose control
- < 5.3 mmol/l - Fasting
- < 7.8 mmol/l - 1 hour postprandial (lunch)
- < 6.4 mmol/l - 2 hours postprandia
- < 6 mmol/l – before bedtime
- Conc glucose solution or glucagon injections in case of hypos
What should we monitor in a pregnant diabetic during the actual pregnancy phase?
- Blood glucose
- BP and urine protein - Pre-eclampsia
- Look out for Ketonuria and Infections
- Foetal Growth
- Retinal Assessment at 28 and 34 wks
Do diabetic women deliver by normal delivery?
Most are induced around 38-40wks due to macrosomia
You should always consider C-section if the baby is large to avoid complications such as shoulder dystocia or tears
What else should we do during and after labour to ensure a diabetics mothers (and foetuses) health?
- Use insulin during labour to maintain the sugar level (dextrose infusion)
- Continuous CTG Feed the baby early to avoid hypos
- Early feeding of baby to reduce neonata hypoglycaemia
What is gestational DM?
Carbohydrate intolerance in pregnancy and abnormal glucose tolerance reverting to normal after delivery I
ts risky but not nearly as dangerous as Type 1 or 2 DM
What are the risk factors for developing gestational DM?
Previous GDM
A previous macrosomic baby
Polyhydramnios, large foetus or recurrent glycosuria in the current pregnancy
Increased BMI >30
Coming from a high risk group for DM e.g. Asian origin
Who do we screen for GDM?
Any women with risk factors
How do we screen for GDM?
- Risk factors?
- If HbA1C >43mmol/mol (6%) –> 75mg OGTT
- If OGTT is normal repeat it again at 24 wks
