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Diabetes Mellitus In Pregnancy - Coggle Diagram
Diabetes Mellitus In Pregnancy
Overview
Definition
Diabetes mellitus is a metabolic disease, involving inappropriately elevated blood glucose levels.
Several sub classification
Epidemiology
16.9% of pregnancies globally affected by hyperglycaemia in pregnancy
87.5% due to gestational diabetes
7.5% due to Type 1
5.0% due to Type 2
Classification
Prexisting Diabetes
Chronic metabolic disease prior to pregnancy
Type 1: Insulin dependent
Type 2: Orla medication and / or insulin
New Onset during Pregnancy
Diet / oral medications and / or insulin
Causes
Type 1
Autoimmune beta cell destruction, leading to abdsolute insulin deficiency
Onset usually within first 3 decades of life
Type 2
Peripheral insulin resistance and relative insulin deficiency
Associated with poor nutrition, being obese / overweight
Later age of onset
GDM
Pancreatic beta-cell dysfunction and marked insulin resistance secondary to placental hormone release
Usually diagnosed between 24-28 weeks gestation
GDM Pathophysiology
Insulin resistance
Maternal hormones
Placental hormones
HPL
Placental growth hormone
Weight gain during pregnancy
Increased caloric intake during pregnancy
Insulin resistance leads to ↑ ciculating blood sugar
Preferential shunting of glucose to growing fetus
Increased accumulation of fat in maternal adipose tissue
Managment
Preconception
T1DM & T2DM
Good BG control - offer monthly
HbA1c
/ monitors
HbA1cTarget
<48mmol/L
6.5%
Lifestyle Advice
Reduce BMI >27
Stop smoking
Folic Acid
5mg
/ day
Education
Risks involing vavy
Nephropathy AND Retinopathy assessment
Medication Review
May be teratogenic
ACEi
ARBs
Statins
Antenatal Care
Specialist diabetes-obstetric MDT
Target capillary BG levels
Pre-prandial & pre-bed
3.5-5.0 mmol/L
1hr postprandial
<7mmol/L
2hr postprandial
<6.4 mmol/L (NICE)
Blood Glucose + Ketone Testing
Self monitoring 7x day
Pre meals + 1hr post meal + before bed
HbA1c measured frequently
Ketone test strips prescribed for use in illness, hyperemesis, hyperglycaemia
Hypoglycaemia
Eduction on increased risk of hypoglycaemia
Patterns should be identified and managed on individual basis
Carry identification + Rapid acting glucose
Poor Glycaemic Control
Precipitating factors should be examined
Diet
Illness
Management adjustment
Hospitalisation may be only way to acheive optimal glycaemic control in some cases
Persistent hyperglyaemia - invetigate possibility of HONK in T2DM
Insulin Requirements
May alter rapidly during pregnancy
Requirements ↑ in 2nd trimester ↓ end of 3rd trimester
Balance glycaemic control and risk of hypo
Flexible bolus regime improves glycaemic control and pregnancy outcome
Continous subcut insulin infusion (CSII) if struggling
Aspirin Prophylaxis
T1DM & T2DM high risk of pre-eclampsia
75-150mg
daily from
12 weeks until birth
Health Promostion
Dietary advice
Support with positive lifestyle changes
Levels of recommended physical activity should be discussed with obs and endo
Retinal Assessment
T1DM
1st trimester by opthalmologist
Close follow up as required throughout pregnancy + 1year postpartum
Renal Assessment
T1DM & T2DM
Evaluate renal fx at first antenatal visit
All nephropathy ∝ Adverse pregnancy outcomes
UUGR
PET
PTL
Refer to specialist care
CVS
Bloop pressure at every visit
Autonomic Neuropathy
Bladder atony → persistent UTI's
Close monitoring
Uterine atony → PPH
Autonomic neuropathy → Inability to detect fetal movements
N/V due to neuropathy → Weight loss, dehydration, poor glycaemic control
Thyroid Assessment
T1DM Screen in 1st trimester
Alert paeds to newborn of mother with elevated TSH receptor levels
Intrapartum care
Preterm labour
Tocolysis and steroids for lung maturity not indicated
On insulin / steroids → admit and monitor gluose
T1DM / T2DM
Elective birth
37-38+6
weeks
Macrosomic baby
Discuss risks of NSVD, IOL, CS
Induction of Labour
HSE guidlines
No need to fast
IV fluids and insulin with sliding scale of subcut insulin
Coombe
On insulin
Stop and fast
Start IV fluids + Actrapid + Kcl
Monitor glucose 2hrly
Give insulin subcut as per sliding scale
Metformin
Stop and fast
Start non dextrose IV fluid
Monitor BG 2 hrly
Subcut insulin 2hrly according to sliding scale
Anaesthesia
Assessment in 3rd trimester - high BMI difficult airway
Glucose control
Monitor every hr during labour and birth
Maintain 4-7 mmol/L
Continous CTG
Recognise slow progress of labour as possible
cephalopelvic disproportion
Planned CS should be in morning - prevent prolonged fasting
Postnatal Care
Pre-Existing DM
Reduce insulin dose immediately
Commence postpartum insulin regime following 3rd stage of labour
Monito BG to determine appropriate dose
Encourage breastfeeding within 1 hr
Can continue metformin if breastfeeding
Continue routine diabetic care on discharge
Complications T1DM / T2 DM
Mother
↑ Risk of 1st trimester miscarriage
↑ Risk pre-eclampsia
Diabetic nephropathy
Diabetic retinopathy
DKA
Pregnancy induced HTN
Birth trauma, episiotomies, tears
Foetus
Congenital malformations
Stillbirth
Prematurity
Neonate
Hypoglycaemic
Polycythaemia
Hyperbilirubinaemia
Congenital heart disease
Respiratory distress
Hypocalcaemia
Hypomagnesemia
Macrosomia
Shoulder dystocia
DKA
Obstetric Emergency
Occurs in pre-existing and GDM
Triad
Acute hyperglycaemia
Metabolic acidosis
Ketosis
Epidemiology
Uncommon
Risk factors
N/V
Infections
Poor compliance
Steroid therapy
Presentation
N/V
Thirst
Polyuria
Polydipsia
Abdominal pain
Tachypnoea
Altered mental status
Complications
Decreased uteroplacental blood flow
Maternal acidosis
Hyperglycaemia
Electrolyte imblance
Foetal hypoxemia and acidosis
Management
Fluid therapy
Insulin therapy
Early aggressive treatment to avoid maternal / foetal morbidity / mortality
Hyperosmolar Non-Ketotic Syndrome (HONK)
Presentation
N/V
Adominal pain
Hyperglycaemia
Management
Correct
Dehydration
Insulin deficiency & electrolyte imbalance
Foetal monitoring if viable gestation
Determine underlying caus
Admit and manage in HDU
Congenital Abnormalities
Foetal monitoring
20 Wk: Structural Abnormalities
If cardiac views insufficient: 22-24WK: Cardiac scan
24-36WK every 2 weeks: Foetal growth + AFI
36 - Delivery every week: Foetal growth + AFI
Abnormalities
Facial
Cleft lip / palate
Renal
Hypospadias
Obstructive urinary
GI
Small left colon
Neuro
Neural tube defects
Hydrocephalus
CVS
ASD
VSD
PDA
Multisystem
Caudal regression syndrome
Nice Guidlines
Booking (10weeks)
Education and advice
Clinical hx
Retinal and renal ass if infication
Book joint contact with diabetes & ANC every 2 weeks
HbA1c if indicated
Confirm viability
OGTT if hx GDM
16WK
Retinal assessment if indicated
OGTT if hx GDM (who book in 2nd trimester)
20WK
Fetal anomaly scan
28WK
Foet US - Growth + AFI
Retinal reassessment
32WK
Foetal US - Growth + AFI
34WK
Rountine antenatal care
36WK
US - Growth and AFI
Discuss delivery, breastfeeding, pospartum care
37-38+6WK
Offer IOL / CS if indicated to T1dM / T2DM
38WK
Offer tests of foetal well being
39WK
Offer test of foetal well being
Advise women with uncomplicated GDM to give birt before 40+6
Gestational Diabetes
Pathophysiology
Pancreatic beta-cell dysfunction and marked insulin resistance secondary to placental hormone release
Risk Factors
GMI ≥ 30 (obese)
Advanced maternal age ≥ 40 years
Fhx diabetes 1st degree relative
Previous unexplained perinatal death
Long term steroids
Previous baby ≥ 4.5kg
PCOS
Polyhydamnios in current pregnancy
Macrosomia in current pregnancy
Ethnicity
Complications
Mother
Miscarriage
PET
DKA
OVD (operative vaginal delivery)
Tears
Wound complications
CS
↑ Risk of T2DM
Foetus
Prematuriy
Stillbirth
Neonate
LGA
Congenital abnormalities
Shoulder dystoia
Hypoglycaemia
Polycythaemia
Respiratory distress
Hyperbilirubinaemia
↑ Risk of Obesity / DM
Clinical Presentation
Often
asymptomatic
Polydipsia
Polyuria
Fatigue
Blurred vision
Assessment
History
Referred for screening based on risk factors
Previous stillbirth
Previous GDM
Examination
BMI
Vitals
Urinalysis
UTI
Glucosuria
Proteinuria
Weight at every visit
SFH
General examination
Screening
Timing
24-28 weeks
Indication
Women with risk factors
Method
OGTT
75g 2hr oral glucose tolerance test
Coombe : Lucozade 557ml consumed within 5 min after fasting BG sample taken
Diagnosis
One or more values are met or exceeded
Fasting blood glucose
Coombe: ≥ 5.1
NICE: ≥ 5.6
1hr post prandial
Coombe: ≥ 10
2hr post prandial
Coombe ≥ 8.5
NICE ≥ 7.8
Antenatal Care
Target Capillary BG levels
Education
Dietary advice
Physical activity
Blood glucose and ketone monitoring
Insulin therapy
Antenatl care plan
Timing and mode of delivery
Intrapartum Care
preterm labour
Induction of labour / active labour
Anaesthesia
Postpartum care GDM
Discontinue insulin / metformin
COntinue to monitor blood glucose levels
Investigate ovet diabetes if persistent hyperglycaemia
Skin to skin contact / encourage breastfeeding
Neonate increased risk of hypogylcaemia
OGTT 6 weeks postpartum
Shoulder Dystocia
Obstetric Emergency
complication of vaginal delivery
Epidemiology
0.58-0.7% of vaginal deliveries
Unpredictable and unavoidable
Cause
Persistent
anterior posterior
position of fetal shoulders as they enter pelvic inlet
Anterior fetal shoulder becomes impated behind maternal pubic symphysis
Risk factors
Previous shoulder dystocia
Maternal diabetes
Macrosomia
Clinical Diagnosis
Unable to deliver foetal shoulders solely using gentle downward traction
Turtle sign - retraction of foetal head towards the perineum
Documented head-to-body delivery interval of >1 min
Management
Call for help
Do not use fundal pressure
McRobert's manouvre
must be performd first
Suprapubic pressure
improves effectiveness of McRobert's manoeuvre
Complications
PPH
3d and 4th degree tears
Brachial plexus injury - neonate