DIABETES IN PREGNANCY

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DIABETES IN PREGNANCY

• AHMED ABDULWAHAB

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• CLASSIFICATION
• INSULIN DEPENDANTDIABETES.I.D.D
• Diagnosis before pregnancy ,patient already in
  insulin usually young with little or no insulin.
• Non insulin dependant DM ,patient on oral
  hypoglycemic agents

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• STANDARD TEST FOR DIAGNOSIS
• 75 gm of glucose orally after over night fast.
• Fasting lt than 6 mmol one hour less than 11mmol .
  2hour lt9 . 3 hour should back to fasting level

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• GESTIONAL DIABETES
• Diabetes occurs during pregnancy , will come to
  normal after delivery
• INDICATION OF GTT
• High GCT more than 7.8 mmol
• Potential diabetes.
• Unexplained IUFD
• History of congenital anomalies

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• Glucose in urine more than twice
• Maternal weight more than 90 KG
• Previous big babies

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• WHY?
• Pregnancy has diabetogenic effect .
• There is a decreased sensitivity of insulin due
  to antagonizing effect by cortisone estrogen
  progesterone HPL , and degradation of insulin by
  placenta

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• GLUCOSE AND INSULIN RELATIONSHIP IN MOTHER AND
  FETUS.
• Glucose cross placenta by facilitated diffusion.
• Fetal pancreatic beta cell hypertrophy will
  increase the release of insulin.
• Insulin is a potent stimulus to growth .

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• EFFECT OF PREGNANCY ON DIABETES.
• Difficult to control
• Lowered renal threshold and diminished
  sensitivity to insulin
• Retinopathy. Need careful ophthalmic assessment ,
  there is increase prolifrative retinopathy
• Nephropathy may be confused with hypertension and
  edema ,assess renal function

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• EFFECT OF DIABETES ON PREGNANCY.
• Abortion.
• Infection UTI fungal infection.
• Pre eclampsia
• Polyhydramnios
• Prenatal death RDS anomalies
• Macrosomia.

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• Cont.
• Congenital anomalies poor control at early
  pregnancy, mainly CVS and CNS.
• Caudal regression syndrome is specific.
• Lung maturity, fetal insulin antagonize the
  effect of cortisone on surfactant .

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• MAAGEMENT
• Combined care ,obstetrician and physician.
• Without complication wait till 40 weeks
• Food plan. 50 carbohydrate 20 protein 20 fat ,
  fiber
• Majority need insulin short acting 2 or 3 doses
  may be required ..
• Doses rise progressively with advancing
  pregnancy.
• Oral hypoglycemic never to be used
• Keep FBS between 4-6. 2h postprandial below 8
  mmol
• HbA1C REFLECT average plasma glucose normal 6

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• OBSTETRIC CARE
• Early pregnancy control reduce anomalies.
• Late control reduce PET polyhydramnios and
  macrosomia .
• Early booking for accurate dating.
• Detailed USS ANOMALIES 18-20 WEEKS
• Alpha fetoprotein
• Regular follow up

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• DELIVERY.
• Normal pregnancy wait 40 weeks
• DM alone is not an indication for caesarian
  section
• Induction of labor IOL Insulin infusion , hourly
  checking of blood sugar (sliding scale)
• Close fetal heart monitoring .

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• POST PARTUM CARE .
• Insulin requirement fall rapidly after delivery
• Infant of diabetic mother has the following
  problems.
• Over weight, plethoric ,RDS, hypoglycemic.
• Hyperbilurbinaemia hypocalcaemia.