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Established diabetes in pregnancy (Management (Delivery (Conservative…
Established diabetes
in pregnancy
Definition
Pregnancy in a patient
with known diabetes
Epidemiology
1-2% pregnancies
Pathophysiology
Glucose metabolism
Preg hormones are diabetogenic (HPL, cortisol, glucagon, oestrogen, progesterone)
Increased insulin requirements in preg, max at term
DM on pregnancy
Maternal hyperglycaemia can lead to foetal glycaemia
Foetal hyperinsulinemia due to B-cell hyperplasia in pancreas
Insulin is a growth promoter (macrosomia, organomegaly, erythropoesis, foetal polyuria leading to polyhydraminos)
Removal of maternal glucose at birth but remaining high insulin levels in the foetus leads to neonatal hypoglycaemia
Respiratory distress syndrome in newborns due to surfactant deficiency
Pregnancy on DM
Strain on body resulting in ketoacidosis; may worsen with hyperemesis, infection, tocolytics (sympathomimetics), steroids
Increased risk of retinopathy from increased retinal flow
Nephropathy due to impaired function, proteinuria, pre-eclampsia
Ischemic heart disease due to increased workload
Management
Antenatal
Conservative
Education
Aim normoglycaemia, BMs 6x/d
Note hypoglycaemic awareness may be lost
Monitoring
Maternal:
HbA1C (monthly), dietician review
Foetal:
dating USS, anomaly screening (but AFP less accurate),
Mid-T (congenital abnormalities), foetal ECHO (20-24wk),
growth scans (USS 2-4wk for size an liquor), UA Doppler (if IUGR)
Delivery
Conservative
Timing
IOL at 38-39w
Monitoring
Maternal
BMs hourly, may need sliding scale insulin
(actrapid in normal saline by continueous infusion pump);
monitor carefully if steroids given (cause hyperglycaemia)
Foetal:
continous EFM
Normal vaginal delivery
Indication: normal size, well controlled DM
SEs: increased risk shoulder dystocia (irrespective of size)
Medical
IOL
Indication: 38-39w; macrosomia
MOA: stimulates onset of labour
Surgical
Elective CS
Indication: maternal choice, large baby (>4.5kg)
MOA: surgical extraction of foetus
Pre-pregnancy
Conservative
Severity assessment
Cardiac (BP, clinical), retinopathy (fundoscopy, ophthalmology), nephropathy (U+E, urinalysis, ACR), neuropathy (clinical)
Education
Stop smoking, lose weight, minimise alcohol
Effects of poor control (miscarriage, congenital abnormalities)
Inform Dr ASAP once confirmed pregnant
May need to stop some medications e.g. ACE
Discuss folic acid, rubella vaccine, contraception
Optimal control
Fasting glucose 3.5-5.9mmol/L, 1hr post-prandial <7.8mmol/L
Medical
Folic acid
Indication: 3m pre conception
E.g. folic acid 5mg/d
MOA: inc folate stores, reduces NTDs
Contraception
Indication: while good control is achieved
E.g. POP, Mirena, depot, implant
Rubella vaccination
Indication: unvaccinated women
MOA: protects against congenital rubella
Post-natal
Medical
Anti-diabetic medications
Insulin, metformin; avoid PO hypoglycaemics
Contraception
Indication: >6w post-partum
MOA: POP, depot, implant, Mirena, coil
NB. avoid COCP if breastfeeding/vascular disease
Conservative
Breast feeding
Early as possible to avoid neonatal hypoglycaemia
Monitoring
Glucose (maternal and foetal)
Complications
Child
Foetal
Death (miscarriage, intrauterine death)
Congenital abnormalities (NTDs, microcephaly, cardiac abnormalities, renal abnormalities, sacral agenesis)
Pregnancy complications (macrosomia, polyhydraminos,
IUGR, preterm labour)
Neonatal
Electrolyte disturbance (Hypo-Ca, Hypo-Mg)
Polycythaemia
Jaundice
Hypothermia
Medical complications (cardiomegaly, RDS)
Birth trauma (shoulder dystocia, fractures, Erb's palsy, aphyxia)
Maternal
Infections (candidiasis, UTIs)
Pregnancy complications (HTN, pre-eclampsia)
Delivery complications (obstruction, CS, assisted)
DM complications (retinopathy, nephropathy, cardiac disease)