JEAN KALIBUSHI B.,MD Resident in GO at Butare teaching hospital

ANAMNESIS A known diabetic patient,34years old MC: transfert from outpatient for better menagement of Cervical incompetence on 16 weeks+ 5days of amenorrhea ATCDs:G3POEVOA2 LMP:15/09/2007 MEDICAL: Diabetic since 28/dec/2007,on 20UI/day of long acting insulin SURG: myomectomy on 2004

NEXT Tobacco:never taken Alcohol: stopped since 2years 1/2

CLINICAL EXAM Vital signs: NAD Thorax: NAD Abdomen: HF: 16cm Gyneco.Ex: not done on admission CCL: Cervical incompetence(BCI) on diabetic history whith pregnancy of 16weeks+5days of amenorrhea

MANAGEMENT Admission: programmation of cerclage Pre-op test: Normal range On 10/01/08: cerclage done

FOLLOW UP OF BLOOD SUGAR On 10/01/08,On 20UI/day of long acting insulin: -204mg/dl :M -280mg/dl:EVEN On 11/01/08: -245mg/dl:M -187mg/dl:EVEN

NEXT On 12/01/08: -112mg/dl:M On 13/01/08: -185mg/dl:M -164mg/dl:S On 14/01/08: -118mg/dl:M

NEXT On 15/01/08: -172mg/dl:M On 19/01/08: 206mg/dl:M On 21/01/08: 138mg/dl:M On 23/01/08: 141mg/dl:M On 24/01/08: 176mg/dl, change of dose at 26UI of long acting Insulin in the morning and discharged the same day

READMISSION On 23/feb/08 for pre-term labor of 23weeks of amenorrhea Management: READMISSION Blood sugar on empty stomach:157mg/dl on 26UI of rapid insulin and buscopan On 24/01/08: Discharged again

DEFINITION Diabetes is a metabolic disease of CH due to relative or absolute deficiency in insulin. Gestational diabetes: Carbohydrate intolerance with onset or recognition during pregnancy. WHO Classification: TypeI;TypeII and Gestational diabetes I &II: Chronic conditions Gest Diab.: typically resolves with delivery of the child

EPIDEMIOLOGY  Most common medical complications of pregnancy.  2% of all pregnancies affected by Diabetes  1% are GDM  USA: 3-5 % among them: *10% pregestational(Type 1 &2) *90% Gestational

PATHOPHYSIOLOGY  GD is similar to type 2 DM with a relative deficiency in insulin and insulin resistance.  Type1: early in life, destruction of Langerhans cells.  GD: Placenta produces hormones (hPL,P4,Cortisol,PGH,…) that antagonize insulin and reach max levels at 24 to 28 weeks. Early in pregnancy as a result of higher levels of estrogen, insulin sensibility will increase making diabetes patient more prone to hypoglycemia. In last 1/3 of gestation 40% of pregnant women become relatively insulin resistant and must secrete 3-4 X more insulin to maintain normal blood glucose level.

RISK FACTORS  Age>25 years  Strong familly ATCD of DM  Prior atcd of new born weigth>4000g.  Obesity (BMI≥ 30)  Repeated spontaneous abortion  Unexplained stillbirth or congenital abnormaly.  Persitant glucosuria  Polycystic ovarian sd.

Maternal affects 2x risk of UTI 2x risk of Pregnancy induced hypertension 2x risk Preeclampsia DKA (Peripartum mortality) Retinopathy Nephropathy Postpartum hemorrhage

Fetal effects 1-2% increased risk of anomalies Cardiac Limb Sacral agenesis Renal CNS abnormalities Macrosomia >4500g Polyhydramnios (>2000ml) Stillbirth

Neonatal effects Hypoglycemia Hyperbilirubinemia Hypocalcemia Polycythemia Pulmonary immaturity Organomegaly

SCREENING Fasting >125, 1hr PP >200 2 hr GTT: 1 hour 50g glucose challenge: > hour 100g glucose tolerance test: Fasting >95, 1hr >180, 2hr>155, 3 hr >140 2 or more abnormal values makes the diagnosis

WHITE Classification A1GDM: diet controlled A2GDM: requiring medical therapy B: Onset after age 20, duration <10yr, No vascular C: Onset between 10-19, duration 10-19yrs, no vascular disease D: Onset 20yrs, retinal or leg involvement F: Vascular nephropathy R: Retinopathy H: Coronary artery diseases.

TREATMENT

0bstetric Complications

REFERENCES 1.Lauren N. et al.Current diagnosis and treatment in GO.10th edition Gabbe SG, Graves CR. Management of diabetes mellitus complicating pregnancy.Obstet Gynecol 2003;102: ACOG.Pregestational diabetes mellitus.Obstet Gynecol 2005;105: Gary F.Williams obstetrics.22nd edition Kakudji.Cours de GO.Université de Lubumbashi.2003.