Antenatal care in Hyperglycemia in Pregnancy DR NAINA MIGLANI CONSULTANT Dayawati hospital

Antenatal care Maternal surveillance Fetal surveillance Blood sugar control Watch for complications due to hyperglycemia Fetal surveillance Fetal well being Appropriate growth Congenital anomalies

Counselling Reassure Reassure &

Antenatal check up First visit Hb Urine routine exam ABORH VDRL HIV HbsAg Anti HCV S.TSH Urine c/s HbA1c Antenatal investigations End organ evaluation Fundus examination Renal function tests Urine for proteins If prexisting diabetes or diagnosed in early pregnancy or DIPSI ≥ 200 mg/dl

Counselling If HbA1c > 8% in first trimester, increased possibility of congenital malformations If HbA1c > 9.5% in first trimester, 22% risk of congenital malformations If presence of end organ disease, more chances of fetal compromise and not so favourable outcome of pregnancy

Antenatal Check up Every visit Hemoglobin Urine routine exam Blood pressure Fundal height Clinically evaluate for hydramnios Blood sugar testing every 2 weeks on her own by glucometer and by venous blood sample Diet counselling Exercises Insulin if required and patient is educated to administer insulin herself

Antenatal care Routine Iron and calcium supplements Tetanus immunization Counsel for possibility of preterm labour If preterm labour Admit Tocolysis with nifedepine or magsulf Sympathomimmetics to be avoided Corticosteroids Important to be regular for antenatal checkup Explain how to monitor blood sugars

Fetal surveillance Accurate Dating by ultrasonography in first trimester USG at 18-20 weeks for congenital anomalies Fetal echocardiography in women with preexisting diabetes, diabetes diagnosed in early pregnancy USG in 3 rd trimester for fetal growth evaluation Daily fetal movement count

Danger signs Blood sugars Fasting > 95 mg/dl Postprandial 2 hrs > 120 mg/dl Any sugars <70 mg/dl Symptoms of hypoglycemia like sweating, syncopal attacks Pain abdomen, leaking or bleeding pv Reduced fetal movements Admit if any above or compromised maternal and fetal surveillance

Featl surveillance Women with previous stillbirth Associated preeclampsia Requiring insulin Preexisting diabetes Twice weekly NST and doppler assessment as and when required

Planning delivery

When to deliver? GDM well controlled on diet to be followed till 41 weeks GDM on insulin – pregnancy terminated at 38-39 weeks by induction of labour Earlier termination of pregnancy if associated hypertension or compromised fetal testing Antenatal corticosteroids to be administered if delivery< 34 weeks- careful blood sugar monitoring

How to deliver? Aim for vaginal delivery LSCS for obstetric indications Fetal weight >4kg consider elective cesarean section

Intrapartum care No definite protocol Gestational diabetics in labour do not require insulin and only blood sugar monitoring Omit morning dose of insulin if elective cesarean section Night doses as usual In induction of labour, omit the dose when in active labour Blood sugar monitoring at regular intervals and insulin accordingly

Intrapartum care Fetal heart to be closely monitored in labour More chances of prolonged labour More instrumental delivery Watch for Shoulder dystocia Birth injuries PPH