DIABETES IN PREGNANCY AHMED ABDULWAHAB

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

STANDARD TEST FOR DIAGNOSIS: 75 gm of glucose –orally after over night fast. Fasting < than 6 mmol one hour less than 11mmol . 2hour <9 . 3 hour should back to fasting level

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

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

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

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 .

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

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

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 .

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%

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

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 .

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