Preconception and early post conception counseling

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Preconception and early post conception
counseling in D.M
Fakhrolmolouk Yassaee. MD. Assistant professor
OBS GYN. Obstetric gynecologic department,
perinatology center Taleghani Hospital Shaheed
Beheshti medical science university Evin, Tehran,
IRAN
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• The question raised most frequently by diabetic
  women are
• What is know about the heritability of diabetes?
• What health measure can be implemented before
  conception?
• What type of obstetric care is recommended?
• Will retinal and renal complications worsen
  during pregnancy and shorten life expectancy?
• What sort of malformations do infants of diabetic
  mothers have and what causes them?

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• The obstetrician, internist, genetic counselor
  all have important roles in providing advice to
  diabetic women both before and throughout
  pregnancy. Genetic transmission of diabetes is
  complex and depends upon the type of carbohydrate
  intolerance.
• It is a chronic autoimmune disorder that occurs
  in genetically susceptible individuals. Major
  histocompatibility haplotype (HLA) strongly
• influence susceptibility. No genetic marker has
  been identified for IDDM but a major component of
  genetic susceptibility has been identified as a
  gene or genes located near within the HLA complex
  on the short arm of chromosome 6.

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• Genetic couseling and a careful medical
  assessment before conception are recommended for
  all diabetic women and those with a history of
  gestational diabetes during a previous pregnancy.
  In infants of diabetic mother (IDM), congenital
  malformation occur about 2-3 times as often as in
  those of nondiabetic women. (Mill 1982)

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• Ylinen and associates (1984) have also reported a
  higher risk of minor and major malformation is
  infants of diabetic mothers with elevated HbA1c
  concentrations.

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• The majority of lesions involve the central
  nervous system and the cardiovascular system,
  genitourinary and limb defects (cousins 1991).
• There is no increase in birth defects among
  offspring of diabetic fathers, prediabetic
  women, and women who develop gestational diabetes
  after the first trimester, suggesting that
  glycemic control during embryogenesis is the main
  factor in the genesis of diabetes- associated
  birth defects.

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• Miller and coauthors( 1981) compared the
  frequency of congenital anomalies in patients
  with normal or high first- trimester maternal
  glycohemoglobin and found only 3.4 rate of
  anomalies with HbA1c less than 8.5 whereas the
  rate of malformations in patient with poorer
  glycemic control in the periconceptional period
  (HbA1c gt 8.5) was 22.4

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• Because the critical time for teratogenesis is
  during the period 3-6 weeks after conception,
  nutritional and metabolic intervention must be
  institutes preconseptionally to be effective.

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• Fetal overgrowth is a major problem in
  pregnancies complicated by diabetes. Defined
  typically as birth weight above the 90th
  percentile for gestational age or greater than
  4000 g, macrosomia occurs in 15- 45 of diabetic
  pregnancies.
• Neonatal morbidity hypoglycemia, macrosomia,
  neonatal jaundice, one fifth of IDMS had
  disproportionate macrosomia (Hunter ,1993)
• (abdominal circumference greater than head
  circumference) compared with 1 control infants
  (Ballard, 1993)
• Birth injury, including shoulder dystocia and
  brachial plexus trauma is more common among IDM,
  and macrosomic fetuses are at the highest risk.(
  Keller 1991)

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• Acceleration of growth, stimulated by excessive
  glucose delivery during diabetic pregnancy, may
  extend into childhood and adult life. Silverman
  (1995) reported on the follow up of macrosomic
  IDMS through 8 years of age in which half of the
  IDMS weighed more than the heaviest 10 of the
  nondiabetic children. These investigator also
  found that the diabetic offspring have permanent
  derangement in glucose- insulin kinetics,
  resulting in increased incidence of impaired
  glucose tolerance in later childhood.

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• The macrosomic IDM dose not follow the growth
  pattern observed in euglycemic pregnancies.
  During the first and second trimesters,
  differentiation of diabetic from nondiabetic
  fetuses is extremely difficult using ultrasound
  measurements, suggesting that the period of fetal
  fat deposition (28 weeks and onward) is when
  abnormal fetal growth primarily occurs.

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• Morphologic studies of the IDM neonate indicate
  that the increased growth of the abdominal
  circumference (AC) is due to deposition of fat in
  the abdominal and interscapular area. This
  central deposition of fat is a key characteristic
  of diabetic macrosomic and underlies the dangers
  associated with vaginal delivery in these
  pregnancies. Acker (1980) reported that although
  the incidence of shoulder dystocia is 3 among
  infants weighing greater than 4000g, 16 of
  infant from diabetic pregnancies weighing greater
  than 4000g, sustained shoulder dysticia.

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• Key features of a preconceptional diabetes
  management program should include the following
• A through assessment of cardiovascular, renal,
  ophthalmologic, status. Blood pressures, 24- hour
  protein and creatinine, and retinal examination
  should be performed. Thyroid function ( TSH and
  FT4) should be evaluated. Antihypertensive agents
  should be initiated and regulated
• A regimen of frequent and regular monitoring of
  both pre-prandial and postprandial glucose
  capillary glucose levels.
• Target levels are fasting glucose 80- 95 mg/dl
  and 1- hour postprandial glucose less than
  130mg/dl or 2 hour postprandial glucose less than
  120 mg/dl

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• The insulin regimen should result in a smooth
  glucose profile throughout the day with no
  hypoglycemic reaction between meals or at night.
  The regimen should be initiated early enough
  before pregnancy so that the glycohemoglobin
  level is lowered into the normal range for at
  least 3 months prior to conception.
• Taking a daily prenatal vitamin ( including 400
  µg of folic acid ) at least 3 months prior to
  conception to minimize risk of neural tube
  defects in fetus.
• Particular attention should be paid to support
  systems that permit extended bed rest in the
  third trimester if necessary.

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• The goals of management of diabetic pregnancy are
  to prevent stillbirth and asphyxia while
  minimizing maternal morbidity associated with
  delivery. This involves monitoring fetal growth
  in order to select the proper timing and route of
  delivery. The first is testing fetal well- being
  at frequent intervals and fetal size.

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Fetal surveillance in type I and type II
diabetic pregnancies

• Time
  Test
• Preconception Maternal glycemic control
• 8-10 w sonographic crown rump
  measurement
• 16 w Maternal serum alpha-
  fetoprotein level
• 20-22 w high resolution
  sonography, fetal cardiac
  
  
  
  echography in women in in
  suboptimal diabetic control (HbA1c ) at
  first prenatal visit
• 24w Baseline sonographic
  growth assessment of the fetus
• 28 w Daily fetal movement
  counting by the mother
• 32 w Repeat sonography for
  fetal growth
• 34 w Biophysical seting
• 2X weekly NST or
• weekly CST or
• weekly biophysical
  profile
• 36w Estimation of fetal
  weight by sonography
• 37-38.5 w Amniocentesis and delivery
  for patients in poor control
  (persistent
  daily hyperglycemia)
• 38.5 40 w Delivery without
  amniocentesis for patients in good control who
  have excellent dating criteria
  
  

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TESTS OF FETAL WELL - BEING
comment Reassuring result frequency test
Performed in all patients Ten movement in lt60 min Every night from 28 w Fetal movement counting
Being at 28-34 w with insulin dependent diabetes Two heart rate acceleration in 20 minutes Twice weekly Non- stress test
Same as for non stress test No heart rate decelerations in response to 3 contrations in 10 minutes weekly Contraction stress test
3 movement 2 1 flexion 2 30 sec breathing 2 2 cm amniotic fluid 2 Score of 8 in 30 minutes weekly Ultrasound biophysical profile
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CHOOSING TIMING AND ROUTE OF DELIVERY

• Timing of delivery should be selected to minimize
  maternal and neonatal morbidity and mortality and
  mortality. Delivery delaying as near as possible
  to the EDC helps maximize cervical ripeness and
  improves the chances of spontaneous labor and
  vaginal delivery. Yet at the risks of fetal
  macrosomia, birth injury, and fetal death
  increase.
• ( Rasmussen, 1992). Although earlier delivery at
  37 wks. gestation might reduce the risk of
  shoulder dystocia, an increase in failed labor
  induction and poor neonatal pulmonary status must
  be considered. Thus, an optimal time for
  delivery of most diabetic pregnancies is between
  38.5 and 40 wks.

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Indication for delivery diabetic pregnancy

• Fetal Non reactive NST
• Positive CST
  
• Reactive NST,
  positive CST, mature fetus
• Sonographic
  evidence of fetal growth arrest
• Decline in
  fetal growth rate with decreased amnionic
• fluid 40
  41 w gestation
• Maternal Severe preeclampsia
• Mild
  preeclampsia, mature fetus
• Markedly
  falling renal function
• Obstetric preterm labor with failure of
  tocolysis
• Mature fetus
  , inducible cervix

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CONFIRMATION OF FETAL MATURTY BEFORE INDUCTION OF
LABOR OR PLANNING CESAREAN DELIVERY W DIABETIC
PREGNANCY

1. Phosphatidyl glycerol gt 3 in amniotic fluid
   collected from vaginal pool or by amniocentesis
2. Completion of 38.5 weeks gestation
3. Normal LMP
4. First pelvic examination before 12 weeks confirm
   dates.
5. Sonogram before 24 weeks confirm dates
6. Documentation of more than 18 weeks by fetoscope
   of FHT

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• After 38.5 weeks gestation, the obstetrician can
  await spontaneous labor if the fetus is not
  macrosomic and biophysical testing is reassuring.
  In patients with GDM and super glycemic control,
  continued fetal testing and expectant management
  can be considered until 41 weeks ( Lurie 1992)

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• In the fetus with on AC measurably greater than
  head circumference, induction should be
  considered. After 40 weeks, the benefits of
  continued conservative management are likely to
  be less than the danger of fetal compromise.
  Induction of labor 42 weeks in diabetic
  pregnancy- regardless of the readiness of the
  cervix- is prudent.

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• Given these data, the decision to attempt vaginal
  delivery or perform a cesarean is inevitably
  based on very limited data. The patients past
  obstetric history, the best EFW, a fetal adipose
  profile (abdomen larger than head), and clinical
  pelvimetry should all be considered. Most large
  series of diabetic pregnancies report a cesarean
  section rate of 30- 50. The best means by which
  this rate can be lowered is by early and strict
  glycemic control in pregnancy. Conducting long
  labor inductions in patients with a large fetus
  and marginal pelvis may increase morbidity and
  costs.

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