Ultrasound in hyperglycemia in pregnancy Dr. Chitra Ganesh Fetal Medicine Consultant Karthik Ultrasound Scan Centre Fortis Hospitals Bangalore Despite major progress in obstetrics over the last 100 years, the delivery of large fetuses remain a source of anxiety among health care personals because these pregnancies are at increased risk of secveral perinatal complications both to the mother and fetuses and also have long term implications on the offspring

Hyperglycemia in Pregnancy

Preexisting DM In Pregnancy increased risk of 1. miscarriage 2.preclampsia 3. congenital abnormalities 4. perinatal mortality ( excluding cong malformations ) 2 fold increase 5. Sudden unexplained IUFD HbA1c level Risk normal not increased <8% 5% >10% 25 %

Ultrasound & maternal diabetes Viability & Accurate dating Fetal abnormalities Macrosomia Fetal well being

Fetal surveillance in Diabetes Fetal anomalies Growth & environment Chromosomal Structural

Chromosomal Anomalies Fetal Anomalies Chromosomal Anomalies Risk is no higher MoM values will vary Structural Anomalies General Specific

Serum markers and FTS Lower by 15% in IDDM Correction required Influence of maternal IDDM on fetal NT and first-trimester maternal serum biochemical markers of aneuploidy K. Spencer,N. J. Cowans,  Prenatal Diagnosis , Volume 30, Issue 10, October 2010 PAPP-A Lower by 15% in IDDM Risk Correction required

Diabetes & II trimester screening AFP Lower Ue3 Risk Correction Beware AFP low despite high risk for NTDs

CARDIAC ANOMALIES TGA TOF FETAL ECHO MANDATORY

CNS- NEURAL TUBE DEFECTS

SACRAL AGENESIS

Caudal Regression

OROFACIAL CLEFTING

Anomalies specific to Diabetes

Diabetes - Pathophysiology Fetal Hyperglycaemia Increase the production & secretion of insulin from fetal pancreas Hyper insulinemia Accumulation of glucose in the liver Increased stimulation of triglycerides synthesis -increase in subcutaneous fat

Fetal Growth – MACROSOMIA MACROSOMIA – “ Big body ” Established limit No consensus Birth weight : > 4000 gm, > 4200 gm > 4500 gm ACOG Birth weight : > 4500 gm Irrespective of GA Macrosomia is diagnosed when excessive intra uterine growth occurs and the birth weight exceeds an established limit . There are no nationally or internationally agreed established weight limits for macrosomia . ACOG recommends 4500g because of marked increase in maternal and neonatal complications at this weight Large for GA EFW > 90th%tile, or > 2 SD for the period of gestation 8 – 14 % in normal pregnancies 25 – 45 % in Diabetic mothers

Macrosomia Diabetic Macrosomia - asymmetric macrosomia HC/FL less than 90th%tile AC more than 90th%ile Non Diabetic Macrosomia -symmetric macrosomia Constitutional - parents of large stature , recurs in subsequent pregnancies Genetic Syndromes

Diabetic Macrosomia Different body composition Significant increase in fat mass % & % of fat than fat free mass ( lean body mass ) Increased Fat mass & % body fat is also seen even when there is no macrosomia Disproportionate growth – more of truncal growth ( abdomen & shoulder ) than head & femur

Diabetic Macrosomia Excess growth happens in the III trimester Selective organomegaly Accelerated growth of fetal AC

Diabetic macrosomia Accelerated growth despite good glycemic control Diabetes Spectrum , April 2007 Coexisting risk : obesity, ethnicity, maternal age, wt gain Once fetal hyperinsulinemia is induced it is difficult to assess whether maternal glucose level reflects real situation fetus is using excess maternal glucose and artificially lowering maternal glucose level Accelerated AC growth before 24 weeks predicted macrosomia despite good maternal glycemic control

USG – Abdominal circumference AC – single most important & reliable parameter Two dimensional / elliptical method - equally accurate

Macrosomia & AC AC threshold for predicting macrosomia is of 35 – 38 cm www.uptodate.com AC > 35 cms - 93% PPPV of > 4000 gm – fetal diagnosis therapy 2013 Addition of EFW increased DR by 3%

Macrosomia – prediction Predicting macrosomia in Diabetes with poor glycemic control EFW – overestimates ( margin of error is +/ - 20 - 25% ) AC is the most sensitive parameter for fetal overgrowth AC > 75th %tile 28 -29 weeks increased risk of macrosomia / shoulder dystocia 5th International workshop conference on GDM Diabetes Spectrum April 2007 AC is the most sensitive parameter for fetal over growth AC > 75th %tile as a measure of glycemic control

Diabetes & Polyhydramnios Incidence Dashe et al 2002 All polyhydramnios 5% Gest DM 2% Pregestational DM Idris et al, 2010 All diabetics 18.8% Prevalence 8-20% 30 times more than normal Pregnancies

Polyhydramnios in DM 314 Pregnancies Pregestational diabetes singleton pregnancy > 24 weeks of gestation 1996 to 2006

Polyhydramnios in DM The incidence of polyhydramnios - 18.8%. Increased HbA1c in poly pregnancies Pre and in pregnancy Increased preterm delivery (54.2% vs. 33.3%, P = 0.004) Majority - iatrogenic preterm deliveries (44.1%). High El Cesarean section (83.0% vs. 62%; P = 0.006). No significant differences in perinatal mortality rates.

Fetal Growth Restriction & DM Diabetics with vasculopathy Preeclampsia Diabetes with strict glycaemic control If everything else is normal, and no reason for SGA – look for very tight control

Doppler in Diabetes – IUGR If FGR Dopplers change as in non IDDM Cannot prevent /predict DM related SB

Conclusions Gestational diabetes is a common problem in India’ Risk stratification and screening is essential in all Indian pregnant women Good glycemic targets are required for optimal maternal and fetal outcome

Conclusions Fetal surveillance starts with dating in first trimester Detailed Targetted imaging including ECHO mandatory Serial scans and plotting of graph helps identify growth abnormalities and aids further management

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