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Diabetes in Pregnancy & GDM (Gestational Diabetes Mellitus) - Coggle…
Diabetes in Pregnancy & GDM (Gestational Diabetes Mellitus)
Diabetogenic hormones in pregnancy:
Human placental lactogen
Cortisol
Glucagon
Oestrogen
Progesterone
Effects of Diabetes on Pregnancy:
Maternal hyperglycaemia l/t
fetal hyperglycaemia
Fetal hyperglycaemia l/t hyperinsulinaemia
a) Macrosomia
b) Organomegaly
c) Increased erythropoiesis
d) Fetal polyuria (polyhydramnios)
Neonatal hypoglycaemia
Respiratory distress syndrome
(RDS)
Effect of Pregnancy on Diabetes:
Retinopathy
Nephropathy
Ischaemic Heart Disease (IHD)
Ketoacidosis (rare)
Complications of Diabetes in Pregnancy:
Maternal:
UTI
PIH / PE
Obstructed labour
Recurrent vulvovaginal candidiasis
Operative deliveries: CS / assisted vaginal deliveries
Increased retinopathy (15%)
Increased nephropathy
Cardiac disease
Fetal:
Miscarriage (in diabetics w/ poor control)
Congenital abnormalities (in diabetics w/ poor control):
a) NTD
b) Microcephaly
c) Sacral agenesis
d) Renal abnormalities
e) Cardiac abnormalities
Preterm labour
Macrosomia
Polyhydramnios
IUGR
Unexplained IUD
Neonatal:
Polycythemia
Hypoglycaemia
Hypocalcaemia
Hypomagnesaemia
Hypothermia
Birth trauma: Shoulder dystocia, Fractures, Erb's palsy, Asphixiation
Cardiomegaly
Respiratory distress syndrome
Antenatal Management:
Pre-pregnancy counselling:
a) Achieve
optimal glycaemic control
(fasting blood glucose 3.5-5.9mmol/L and 1hr postprandial <7.8mmol/L
b) Assessment of severity of diabetes (asses severity of HTN, retinopathy, nephropathy, neuropathy & cardiac disease)
c) Education
d)
General health
(stop smoking, optimize weight, minimize alcohol)
e)
Folic acid 5mg
f)
Rubella status
(give vaccination, if not immune)
g) Contraception
Antenatal care:
a)
Control
(aim for normoglycaemia)
b)
HbA1c
every month
c)
Dietitian review
(low sugar, low fat, high fibre diet, low GI)
d)
Dating ultrasound
(confirm viability and gestation)
e)
Down's Syndrome screening
(serum screening is affected by diabetes - decreased AFP; so use
nuchal translucency or invasive testing
)
f)
Anomaly scan
(increased risk of congenital anomalies)
g)
Fetal echocardiography
@ 20-24 weeks
h) Antenatal surveillance (Individualized care;
USS
every 2-4 weeks to detect
polyhydramnios, macrosomia, IUGR
; use of umbilical artery Doppler only used in cases of IUGR)
i)
Hypoglycaemia
(educate patient and family to supply with glucagon)
Labour & Postpartum Care:
Timing & mode of delivery should be individualized and based on EFW and obstetric factors (previous MOD, gestation, glycaemic control and antenatal complications)
Timing of delivery:
a) Some obstetricians advise elective delivery by
IOL @ 38-39 weeks
(if good glycaemic control and no maternal or fetal complications)
Mode of delivery:
a)
Vaginal delivery
preferred (continuous electronic fetal monitoring is advised in labour)
b) Elective CS of EFW is >4.5kg
c) If EFW is 4-4.5kg, use obstetric factors to influence decision.
d) Give
antibiotic and thromboprophylaxis
if CS is carried out.
Glycaemic control:
a) Diet controlled (if glucose is >6.0mmol/L, start sliding scale)
b) Insulin-dependent (continue SC insulin until established labour then convert to insulin sliding scale; if IOL or CS, continue normal insulin until day of procedure then start sliding scale early morning)
c)
Avoid maternal hyperglycaemia
(causes fetal hypoglycaemia)
d) If
steroids
are given, monitor closely for
hyperglycaemia
.
Postpartum care:
a) Encourage breastfeeding (
Avoid oral hypoglycaemic drugs if BF; Metformin & Insulin are safe
)
b) Baby needs
early breastfeeding and glucose monitoring
.
Contraception:
a) Avoid COCP if BF or vascular complications (
Progesterone-based
contraception is safe; should be fitted from
6 weeks postpartum onwards
; sterilization or vasectomy should be considered if the family is complete)
b) Review sliding scale regularly.
c) Renew insulin syringe every 24hrs.
d) IV fluids should be given with sliding scale:
i. Stable situations: 5% glucose
ii. High blood glucose: Normal saline
Postpartum insulin requirements:
a) Insulin requirements fall dramatically after delivery of placenta; halve the sliding scale initially.
b) Change back to SC insulin when eating and drinking (start with prepregnancy dose of SC insulin; if this is not known, it is roughly half the last dose).
c) Dose may need to be further reduced if BF.
d) Stop the sliding scale 1hr after giving SC dose.
e) Aim for blood sugar monitoring (BM)
4-9mmol/L
in the
postpartum period
.
Gestational Diabetes:
Definition:
Any degree of glucose intolerance
w/
onset or first recognition during pregnancy
.
Risk factors:
BMI >30kg/m^2
Previous macrosomic baby (>/=4.5kg)
Previous GDM
First-degree relative with diabetes
Family origin w/ high prevalence of diabetes (South Asian, Black Caribbean and Middle Eastern)
Diagnosis
is based on
OGTT @ 26-28 weeks
(OGTT to be repeated @ 34 weeks if there are concerns; low OGTT in early pregnancy does not signify GDM will not develop)
Management:
a) Measure glucose 4-6 times/day (1hr postprandial may be more effective in preventing macrosomia than pre-meal glucose)
b) Diet should be first-line treatment (normoglycaemia, avoid ketosis)
c)
Start insulin if:
i. Pre-meal glucose >6.0mmol?L
ii. 1hr post-prandial glucose >7.5mmol/L
iii. AC >95th centile despite apparent good control
d) No increased risk of miscarriage or congenital anomalies; other fetal and neonatal risks are similar to established diabetes (IUGR less likely)
e) Antenatal and intrapartum care as for established diabetes.
f) Postpartum:
i. Stop insulin and glucose infusions
ii. Check glucose prior to discharge to ensure normal (risk of previously undiagnosed T2DM)
iii. Arrange OGTT @ 6 weeks postpartum
iv. Education (50% risk of developing T2DM over next 25 years; risk can be reduced by maintaining physical activity and avoiding obesity)
OGTT (oral glucose tolerance test):
Overnight fasting (8hrs min)
a) Water only
b) No smoking
75g Glucose load in 250-300ml water
Plasma glucose measured fasting and @ 2hrs.
Results:
a) Diabetes:
i. Fasting glucose >/=7.0mmol/L
ii. 2hr glucose >/=11.1mmol/L
b) IGT (impaired glucose tolerance):
i. Fasting glucose <7.0mmol/L
ii. 2hr >/=7.8<11.0mmol/L
Only ONE value needs to be abnormal to make diagnosis.