Diabetes Mellitus Flashcards
Percentage of diabetic cases in pregnancy
2-5%
Percentage of diabetes by types in pregnancy
GDM 87.5%
Type1 7.5%
Type2 5%
Diabetes in pregnancy is associated with risks to the woman and to the fetus which are
Pregnancy:
- Miscarriage
- still birth
- preterm labor
Mother:
birth injury,
prenatal mortality,
preeclampsia
diabetic retinopathy
IOL
CS
Fetus:
congenital malformations (cardiac or sacral agenesis)
macrosomia
The preferable contraceptive method of a women with DM
Iucd
Dietary supplements of women with DM planning for pregnancy
- Women with BMI>27: lose weight
- Folic acid 5mg/day until 12 weeks
Target ranges for blood glucose in the preconception Period.
*HbA1c level below 48mmol/mol (6.5%)
Strongly against pregnancy if HBA1c level is above 86 mmol/mol
Safest diabetes mellitus drug during pregnancy
- Metformin is used instead of Insulin
- The short acting insulin analogues (aspart, lispro)
- Isophane Insulin is 1st choice long acting insulin analogues (insufficient evidence)
What diabetic complications medications are CI during pregnancy
ACEI, ARB AND STATINS
Retinal assessment in the preconceptional period in diabetic patient
At the first appointment, then annually
When to refer to nephrologist in diabetic patient
- S creatinine is abnormal (>120 µmol/L)
- ACR > 30 mg/mmol or
- GFR not yo be used during pregnancy
Give thromboprophylaxis in nephrotic range proteinuria >5g/d ~ ACR>220 mg/mmol
Risk factors for GDM
1- BMI>30kg/m2
2- previous macrosomic baby >4.5 kg
3- Previous GDM
4- Family History for DM
5- FAMILY origin with high prevelance
Screening if any of the 5 risk factors for gestational diabetes
2-hour post prandial 75g OGTT
At 24 to 28 weeks
Screening for GDM exclusion if there is glycosuria
2+ or more at 1 occasion
Or
1+ or more at 2 occasions
Screening for GDM in case of previous GDM
- early self monitoring of blood glucose
Or - 75g 2-hour OGTT at booking, if normal then repeat at 24-28 w
Diagnosis of GDM
Fasting: >5.6 mmol/L
Or
2hours: >7.8 mmol/L
Intervention if fasting plasma glucose level below 7mmol/L
- Trial to diet and exercise
(If it doesn’t reach target level in 1-2 w) - Metformin
(If contraindicated or unacceptable) - Insulin
Intervention if fasting plasma glucose level above 7mmol/L
Immediate ttt w/ insulin
Management of DM during pregnancy
- Diet and exercise or
- Oral therapy
- Rapid acting insulin analogues (aspart- lispro) better than human insulin during pregnancy
If woman w/ type 1 become unwell:
Exclude DKA
IF DKA confirmed:
1. Level 2 critical care
2. Daily fasting and 1 hour
Maintain GDM patient capillary plasma glucose
Fasting: <5.3 mmol/L
1 hour post prandial: <7.8 mmol/L Or
2 hour post prandial: <6.4 mmol/L
If on Insulin or glibenclamide: >4 mmol/L
Retinal assessment during pregnancy
If w/ prexisting DM-> Retinal assessment at booking:
1. If normal: repeat at 28 w
2. If retinopathy: 16-20 w
Mode of birth in case of Diabetic retinopathy
It isn’t a contraindication to vaginal birth
In DM pregnant woman, when to perform congenital malformations screening
18-20 weeks
Examination of the 4 chambers and outflow tracts
Monitring Fetal Growth and wellbeing in DM
- U/S scan for fetal structural abnormalities
- Fetal Heart~4 chambers , outflow tracts & 3 vessels (20 W)
- USG- FG & AF volume - every 4 weeks for 28 to 36 weeks
- If Risk of FGR - Umbilical a. doppler & fetal weelbeing b/f 38 W
Tocolysis in DM
Diabetes isn’t a CI of antenatal stroids or tocolysis
(Betamemitics is CI)
diabetic women who recieve antantal steroid for lung maturation
should have additional insulin and should be closely montiored
Increase 25%
Protocol of diabetic women who recieve antantal steroid for lung maturation
should have additional insulin and should be closely montiored
Mode and timing of delivery in type 1 or 2 DM
- IOL, elective CS bet. 37 to 38+6
- Elective birth bef. 37w (if complications)
Mode and timing of delivery in GDM
- IOL, elective CS no later than 40+6
- elective <40+6 if not delivered by 40+6 or complications
VBAC with Diabetic women?
Not contraindicted
What to do if you used general anasthesia on Diabetic woman
Blood glucose should be monitored every 30 mins. from induction till birth.. woman should be conscious
Glycemic control during labour
- Glucose should be 4-7 mmol/L
- if not: start IV dextrose & Insulin infusion
- Type 1: IV dextrose & Insulin infusion from onset of labour.
Fasting plasma glucose test after birth should be done at?
6-13 weeks after birth
Fasting plasma glucose test after birth below 6 mmol/L
or
HbA1c test below 39mmol/L (5.7%)
- low probability of having diabetes at present
- have moderate risk of developing type 2
Fasting plasma glucose test after birth bet. 6- 6.9 mmol/L
or
HbA1c test below 39-47mmol/L (5.7-6.4%)
High risk of developing type 2 diabetes
Fasting plasma glucose test after birth over 7 mmol/L
or
HbA1c test 48 mmol/L (6.5%)
- Likely to ahve type 2 diabetes
- Offer diagnostic test for confirmation
If ater birth fasting plasma glucose or HbA1c is negative
Annual HbA1c test
Why pregnancy is diabetogenic
Due to placental hormones:
1. human placental LACtogen: lipolysis, anti insulin, catabolic
2. Insulinase
Normal serum creatinine in pregnancy
Normal: 88 umol/L = 0.99 mg/dl
In pregnancy it decreases: 53 umol/l= 0.6 mg/dl
HbA1c monitoring preconception and during pregnancy
Type 1-2:
Pre: every month
Preg: every trimester
GDM:
At diagnosis in 3rd trimester
Annual after delivery
Rate of women with GD to develop type ii DM within 5 years
50%
In pregnant women with diabetic maculopathy how to treat
Better ttt with anti vascular endothelial factor-> CI
RANIBIZUMAB could be used to decrease plasma VEGF levels
