L13: DM in Pregnancy Flashcards by Ahmed Farag

Q

Def of DM

A

Chronic metabolic disorder in CHO metabolism è impact on fat & protein metabolism due to insulin dysfunction (deficiency or resistance).

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Q

Def of GDM

A

DM firstly discovered during current pregnancy

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Q

Def of DM in Pregnancy

A

Gestational DM + pregnancy in patients known to be diabetic

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Q

Incidence of DM in Pregnancy

A

2-5% of all pregnancies (80-90% are GDM)

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Q

Stages of DM

A

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Q

WHO Classification of DM

A

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Q

Modified White Classification of DM in Pregnancy

A

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Q

Modified White Classification of DM in Pregnancy

A1 & A2

A

A1: → FBS < 105 mg/d| & PPS < 120 mg/di.
A2: → FBS > 105 mg/dl & PPS > 120 mg/dl.

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Q

RF for GDM

A

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Q

Effects of Pregnancy on DM

A

Pregnancy is Diabetogenic
Change in Insulin Requirments
Increased Incidence of DM Complications
Aggravation of Retinopathy & Nephropathy

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Q

Clinical diabetes may appear for 1st time during pregnancy (GDM) due to …..

A

Anti-insulin effect of pregnancy hormones (as HPL, estrogen & progesterone).
Increased peripheral insulin resistance.
Secretion of insulinase enzyme by placenta.

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Q

Effects of Pregnancy on DM

Pregnancy is Diabetogenic

A

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Q

Effects of Pregnancy on DM

Change in Insulin Requirments

A

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Q

Effects of Pregnancy on DM

Increased incidence of DM Complications

A

Hypoglycemia: Blood glucose level < 60 mg/dI.
Diabetic ketoacidosis (DKA).
Starvation ketosis.
Diabetic comas: Hyperglycemic or hypoglycemic.

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Q

Effects of Pregnancy on DM

Aggravation of Retinopathy & Nephropathy

A

…

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Q

Effects of DM on Pregnancy

A

Maternal & Fetal & Neonatal

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Q

Maternal Effects of DM on Pregnancy

A

During Pregnancy
During labor
During Puerperium
Late Complications

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Q

Maternal Effects of DM on Pregnancy

Abortion

A

Due to Ag-Ab reaction associating DM or chromosomal abnormalities.

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Q

Maternal Effects of DM on Pregnancy

Preterm Labor

A

3-4 times higher in diabetics (MgSO4 is the tocolytic of choice).

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Q

Maternal Effects of DM on Pregnancy

Polyhydraminos

A

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Q

Maternal Effects of DM on Pregnancy

HTN

A

Due to vasculopathy or nephropathy.

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Q

Maternal Effects of DM on Pregnancy

Infection

A

UTI, vulvovaginitis (monilia) or chorioamnionitis (after ROM).

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Q

Maternal Effects of DM on Pregnancy

During Pregnancy

A

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Maternal Effects of DM on Pregnancy

During Labor

A

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Maternal Effects of **DM** on **Pregnancy** - During puerperium

1. PPH & puerperal sepsis. 2. Abnormal lactation: Due to changes in glucose level.

Maternal Effects of **DM** on **Pregnancy** - Late Complications

50% of cases è GDM will develop overt DM later on.

Neonatal Effects of **DM** on **Pregnancy**

- Respiratory distress syndrome (RDS) - Hypertrophic cardiomyopathy - Hypoglycemia - Hypocalcemia & hypomagnesemia - Hyperbilirubinemia - Polycythemia - Poor Feeding - Birth Trauma - Late Complications

Neonatal Effects of **DM** on **Pregnancy** - RDS

- Due to delayed lung maturity (because hyperinsulinemia inhibits secretion of pulmonary surfactant).

Neonatal Effects of **DM** on **Pregnancy** - Hypoglycemia

Blood glucose level < 40 mg/d| (due to hyperinsulinemia)

Neonatal Effects of **DM** on **Pregnancy** - Hyperbilirubenemia

Due to delay in liver maturation.

Neonatal Effects of **DM** on **Pregnancy** - Polycythemia

Hct value > 65% (due to chronic intrauterine hypoxia → T T erythropoietin production).

Neonatal Effects of **DM** on **Pregnancy** - Poor Feeding

Due to prematurity, RDS or congenital anomalies

Neonatal Effects of **DM** on **Pregnancy** - Late Complications

Increased risk of development of type I DM later in life (1-3% if mother only is diseased & 6% if father is diseased also

Fetal Effects of **DM** on **Pregnancy**

- Congenital Anomalies - Macrosomia - IUGR - IUFD

Fetal Effects of **DM** on **Pregnancy** - Congenital Anomalies

Most Common Congenital Anomalies in pregnancy with DM

Specially VSD

Most Specific Congenital Anomalies in Pregnancy in DM

Sacral agenesis (caudal regression or caudal dysplasia)

Fetal Effects of **DM** on **Pregnancy** - Macrosomia

Etiology of Macrosomia in DM in Pregnancy

Prevention of Macrosomia in DM in Pregnancy

Strict diabetic control before 2nd trimester.

Fetal Effects of **DM** on **Pregnancy** - IUGR

Due to chronic placental insufficiency (due to vasculopathy).

Fetal Effects of **DM** on **Pregnancy** - IUFD

Theories of Unexplained IUFD

Dx of **DM in Preegnancy** - Hx

Dx of **DM in Preegnancy** - Ex

Signs of complications (maternal or fetal).

Dx of **DM in Preegnancy** - Investigations

- Test for glucosuria - Oral glucose tolerance tests (OGTTs) - Glycosylated HbA1 (HbA1c) - Investigations to detect complications

Investigations for DM in pregnancy

...

Investigations for DM in pregnancy - Glucosuria

Done in each ANC visit & if +ve → blood investigations.

Investigations for DM in pregnancy - OGTT

- 50gm 1-hour OGTT - 100 gm 3-hours OGTT

Best Screening Test in DM with Pregnancy

50gm 1-hour OGTT

50gm 1-hour OGTT

The gold standard for diagnosis of GDM

100 gm 3-hours OGTT

100 gm 3-hours OGTT

Investigations for DM in pregnancy - HbA1c

Investigations for DM in pregnancy - To Detect Complications

Maternal & fetal

Managment Aspects of **DM in Pregnancy**

- Pre-Conceptional care - Managment During pregnancy - Managment of Delivery - Neonatal care - Postnatal care

Managment of **DM in Pregnancy** - Pre-Conceptional Care

Pre-Conceptional Care for **DM in Pregnancy**

ANC for **DM in Pregnancy**

ANC for **DM in Pregnancy** - Frequency of Visits

Glycemic Control for **DM in Pregnancy**

- Dietary recommendation - Insulin therapy

Glycemic Control for **DM in Pregnancy** - Dietary Recommendations

Dietary Recommendations for control of **DM in Pregnancy** - Total Caloric Intake

- 30 calories/kg/day → (for patients è ideal body weight) Total caloric intake: - 24 calories/kg/day → (for obese patients).

Dietary Recommendations for control of **DM in Pregnancy** - Components of Diet

35-55% CHO, 25% proteins & 20% fat.

Dietary Recommendations for control of **DM in Pregnancy** - No of meals per day

In type 1DM= 6 meals/day (3 meals + 3 snacks in () meals). Number of meals/day: * In type Il DM & GDM= 4 meals/day (3 meals + bed time snack).

Glycemic Control for **DM in Pregnancy** - Insulin Therapy

The standard treatment for DM è pregnancy.

Insulin Therapy for **DM in Pregnancy**

Insulin Therapy for **DM in Pregnancy** - Goals

Keeping FBS < 105 mg/dl & 2 hours PPS < 120 mg/di.

Insulin Therapy for **DM in Pregnancy** - Insulin Preparations

Ultrashort, short, intermediate & long acting.

Insulin Therapy for **DM in Pregnancy** - Routes of adminstration

SC

Insulin Therapy for **DM in Pregnancy** - Calculation of dose

In 1st half of pregnancy: → Body weight x 0.6 units/day. In 2nd half of pregnancy: → Body weight x 0.7 units/day.

Insulin Therapy for **DM in Pregnancy** - regimens

Glycemic Control for **DM in Pregnancy** - Oral Hypoglycemic Drugs

Oral Hypoglycemic Drugs aren't recommended & usually avoided during pregnancy because: ......

1. They cross placenta leading to: * Fetal teratogenic effects (most commonly in ear). * Severe neonatal hypoglycemia. 2. Tight glycemic control è them is difficult.

Managment Aspects of **DM in Pregnancy** - Maternal Observation

Managment Aspects of **DM in Pregnancy** - fetal Observation

Time of Delivery for A1 GDM

At 40 weeks (EDD)

Time of Delivery for GDM Other than A1

At 38 weeks

When to deliver at >37 weeks in **GDM**?

Prerequisites before induction of lobor in **DM in Pregnancy**

Precautions in Vaginal delivery **DM in Pregnancy**

CS in **DM in Pregnancy**

DM not indication for CS → ass. è increased incidence of CS (CS rate reaches 47%).

Indications of CS in **DM in Pregnancy**

Precautions of CS in **DM in Pregnancy**

- Glycemic control. - Prophylactic antibiotics. - Anesthesia: General anesthesia is the standard.

Neonatal Care in **DM in Pregnancy**

Postnatal Care in **DM in Pregnancy**

Postnatal Care in **DM in Pregnancy** - Prophylactic Antibiotic

Because these cases are more liable to infection.

Postnatal Care in **DM in Pregnancy** - Nutritive Fluids

Encourage patient to take highly nutritive light fluids.

Postnatal Care in **DM in Pregnancy** - Insulin Dose

Adjust insulin dose: Usually decrease by 1/3 (keep on hyperglycemic side).

Postnatal Care in **DM in Pregnancy** - Breast Feeding

Encourage breast feeding.

Postnatal Care in **DM in Pregnancy** - Contraceptive advice

Perinatal Mortality in **DM in Pregnancy**

2-5% (50% of them are due to congenital anomalies).