Medical Complication In Pregnancy

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Medical Complication In Pregnancy

• Diabetes

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• At the beginning of the 20th century , diabetic
  women suffered from infetility, and the rare
  women achieving pregnancy faced a poor prognosis.
  Maternal death was a real threat,and perinatal
  survival a more 40 percent.

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• The availability of insulin since 1922, restored
  fertility and virtually abolished maternal
  mortality.
• At the same time, perinatal survival did not
  change appreciatably. Since 1949 White
  Classification was developed, permitted
  individualized timing and mode of delivery, then
  perinatal mortality was reduced (nearly
  equivalent to that observed in normal
  pregnancies.)

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I. Classification

• Type I Diabetes Mellitus
• ----insulin-dependent
• ----immune-mediated and developed in
  genetically susceptible persons
• ----concordance rate for diabetes in
  monozygous twins is less than 50

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• Type II diabetes
• ----noninsulin-dependent
• ----no HLA association
• ----familial occurrence
• ----concordance rate for diabetes in
  monozygous twins is 100

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• Gestational Diabetes Mellitus
• Diabetes is the most common medical
  complication of pregnancy. Patient can be
  seperated into those diagnosed during pregnancy
• It is estimated that 90 percent of all
  pregnacies complicated by diabetes are due to
  gestational diabetes
• Approximately 15 percent of women with
  gestational diabetes will exibit fasting
  hyperglycemia

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• Classification during pregnancy
• Table 1 gives a classification recommended by
  the American College of Obstetricians and
  Gynecologists in 1986.

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class onset Fasting plasma glucose 2-hour postprandial glucose therapy
A1 Gestational lt105mg/dl lt120mg/dl Diet
A2 Gestational gt105mg/dl gt120mg/dl Insulin
Class Age of onset(yr) Duration(yr) Vascular disease Therapy
B gt20 lt10 None Insulin
C 10-19 10-19 None Insulin
D lt10 gt20 Benign retinopathy Insulin
F Any Any nephropathy Insulin
R Any Any Proliferative retinopathy Insulin
H Any Any Heart Insulin
T Any Any Transplantation of kianey Insulin
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II. Diagnosis

• (I)Diagnosis of Overt Diabetes during Pregnancy
• i.presence of classical signs and symptoms
  (such as polydipsia, polyuria, unexplained weight
  loss)
• ii.a random plasma glucose level greater than
  200mg/dl or fasting glucosegt 126mg/dl
• iii.presence of ketoacidosis

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• (II)Diagnosis of gestational diabetes
• i.High risk factors a familial history of
  diabetes, given birth to large infants,
  unexplained fetal losses, obesity
• ii.Screaning
• 50g oral glucose challenge test A value of
  140mg/dl(7.8mmol/l)or higher will identify 80 of
  all women with gestational diabetes

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• iii.Diagnosis criteria
• If the results of 50g oral glucose challenge
  test exceed 7.8mmol/l, a diagnostic 100g oral
  glucose tolerance test is performed.

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Table 2 American college of Obstetricians and
Gynecologists 1994 Criteria for Diagnosis of
GestationalDiabetes Using 100g of Glucose Taken
Orally
Timing of Measurement Plasma Glucose
National diabetes Data Group(1979) Carpenter and Coustan(1982)
Fasting 105mg/dl(5.6mmol/l) 95
1hour 190mg/dl(10.5mmol/l) 180
2hour 165mg/dl(9.2mmol/l) 155
3hour 145mg/dl(8.0mmol/l) 140
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III.Maternal and Fetal Effects

• I)Maternal Effects
• i.increasing abortion rate
• ii.increasing incidence of Pregnancy-Induced
  Hypertension(PIH)
• iii.tend to be infection
• iv.polyhydramnios
• v.Macrosomia
• vi.Be susceptible to ketoacidosis

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• (II)perinatal Effects
• i.Macrosomia incidence is as high as 25-40
• ii.Intrauterine Growth Retardation
  (restriction)
• iii.Preterm Labor
• iv.Fetal Anomalies
• v.Stillbirth,Fetal death
• vi.Congenital Malformations

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• (III)Infant Effects
• i.Neonatal Respiratory Distress Syndrome
• ii.Neonatal Hypoglycemia
• iii.Hypocalcemia
• iv.Hyperbilirubinamia

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IV.Management

• (I)Diet
• Nutritional counseling is a cornerstone in
  management
• The goals of such therapy are
• i.To provide the necessary nutrients for the
  mother and fetus
• ii.To control glucose level
• iii.To prevent starvation ketosis

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Table 3 Recommend Daily Caloric Intake and
Pregnancy Weight Grain in Women with Gestational
Diabetes with and without Concomitant Insulin
Therapy
Current Weight in Relation to Ideal Body Weight Daily Caloric Intake(kcal/kg) Recommend Pregnancy Weight Grain
lt80-90 36-40 28-40
80-120 30 25-35
120-150 24 15-25
gt150 12-18 15-25
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• (II)Insulin therapy
• i.Indication---Insulin therapy is usually
  recommend when standard dietary management does
  not consistantly maintain the fasting plasma
  glucose at less than 105mg/dl or the 2-hour
  postprandial plasma glucose at less than 120mg/dl
• ii.At the beginning, a total dose of 20-30
  units given once daily, before breakfast. The
  total dose is usually divided into two thirds
  intermediate-acting insulin and a third
  short-acting insulin

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• (III)Preconception
• i.Control preconception glucose to optimal
  level(by using insulin)
• ii.Hemoglobin AIc measurement

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IV.Prenatal Care

• (I)First trimester
• i.Careful monitoring of glucose control is
  essential to management
• ii.DietTotal caloric intake of 30-35kcal/kg
  of ideal body weight

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• (II)Second trimester
• i.Maternal serum AFP
• ii.Ultrasonoscan(at 18-20w) to detect
  neural-tube defects and other anomalies
• (III)Third trimester
• i.Weekly visits to monitor glucose control and
  to evaluate for preeclampsia
• ii.Serial ultrasonography to evaluate fetal
  growth and amnionic fluid volume
• iii.Other fetal surveillance tests
• iv.Accept hospitalization from 34w until
  delivery

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V.Delivery

• (I)Timing of delivery
• i.Women with gestational diabetes who do not
  require insulin
• ii.Women with gestational diabetes who require
  insulin
• iii.Overt diabetes women
• iv.Others
• v.If severe hypertantion,preeclampsia or other
  complications develop,delivery is carried out
  even though the ratio is less than 2.0 L/S

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• (II)Mode of delivery
• i.In gneral, women with GDM(who does not
  requre insulin), the way of delivery is
  spontaneous labor
• ii.Women with sonographic diagnosis of fetal
  macrosomia, elective induction of labor or
  cesarean section to prevent shouder dystocia
• iii.In the overtly diabetic women(besides
  class A), cesarean delivery has commonly been
  used to avoid traumatic birth of a large infant,
  or to avoid maternal or fetal complication due to
  more advanced diabetes.Especially for those with
  vascular diseases

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• (III)Control the blood glucose
• Maintain a near normal glycemia level
• Reduce the dose of insulin on the day of
  delivery, and ½ postpartum
• (IV)Prevention of infection

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• (V)Neonatal care
• i.detecting of blood glucose, plasma calcium,
  plasma bilirubin
• ii.Be care for a preterm neonatal
• iii.To find respiratory distress and treatment
• iv.Prevention of postpartun hemorrhge