DR EBUNU E.N CONSULTANT OBSTETRICIAN AND GYANECOLOGIST ZONAL MD.GHE.

Management of women with diabetes mellitus in pregnancy: 1) Joint care with midwives, obstetricians and diabetic physicians is not necessary. 2) fetal wt of 4 kg and > should have c/s. 3) Dietary advice is not important. 4) Home blood glucose monitoring and clinic HbA Ic is important. 5) Fundoscopy at regular intervals is not necessary 6) Patient should continue her anti-diabetic drugs. 7) Scans for growth and liquor volume is not part of the management. 8) All patients should be allowed to come in spontaneous labour. 9) Increasing insulin dose is part of the management. 10) Corticosteroids are naturally diabetogenic

 In 1921 Banting and Best discovered insulin.  Fertility was restored  MM improved remarkably.  PM remained high  Fetal macrosoma, and IUFD were the causes.  Early delivery & C/S were the antidote.  Late IUFD was still a problem.  1930 White classification.

 M ost common endocrine disorder in preg.  Affects 2–3 % of all pregnancies  1.5% in Lagos ( Abudu et al )  0.7/1000 in Ibadan (Oladokun et al)  90% are cases of GDM.on the increase due to obesity  10% are pre-gestational DM

Diabetes in pregnancy Pre-existing diabetes IDDM (Type1) NIDDM (Type2) Gestational diabetes Pre-existing diabetes True GDM

 No consensus  FBS, 2HPP, (75g OGTT). RBS  50g glucose oral challenge, 1 hr glucose 140 mg/dl.  Poor screening tools: Urinalysis, HbA 1c, Fructosamine  Universal or selective  Timing of screening

 Selective Screening: Certain risk factors at early preg  If normal test are found in an early screening, follow up test should be performed at 24 – 28 weeks gestation  Universal Screening: Advocated by ACOG

 Symptoms & Signs: polydypsia, polyuria, polyphagia.  WHO Criteria: 75 g OGTT 2006 WHO Diabetes criteria ConditionFasting glucose2 hour glucose mmol/l(mg/dl) Normal<6.1 (<110)<7.8 (<140) Impaired fasting glycaemia ≥ 6.1(≥110) & <7.0(<126) <7.8 (<140) Impaired glucose tolerance <7.0 (<126)≥7.8 (≥140) Diabetes mellitus≥7.0 (≥126)≥11.1 (≥200) A single abnormal value in symptomatic patient.

 AIMS  Educating the individual  Euglycemia  Early detection and treatment of medical problems  Prevent obstetric complications  Optimal timing and appropriate mode of delivery  Family planning Appropriate.

 MUITIDISCIPLINARY;  Education, Diet, Exercise  MEDICAL ;  Insulin,oral hypoglycemic agents ?  OBSTETRICS;  Ante-partum  Intra-partum  Post-partum

 Pre-gestational DM/Counseling.  Aim to achieve euglycemia congenital anomalies in infants of diabetic is related to the presence of hyperglycemia early in gestation.  HgbAic level monitoring (< 6.5%)  a reflection of the patients degree of glycaemic control during the preceding 4-8weeks

 HgbAic levels > 10% indicates the most significant risk of developing malformation.  Fetal embryopathy may occur in patients with normal HgbAic levels.  Assess patients general medical status;  presence of retinopathy, nephropathy,hypertention,and ischaemic heart disease must be assessed

 Use of human insulin for pregnant diabetics and diabetics considering pregnancy [ADA recom]  Insulin need increase through out gestation from approx 0.7U/Kg/day from 6-18wks to 0.8U/Kg/day during wks 18-26wks to 0.9U/Kg during wks to 1.0U/Kg during wks

ADJUSTED TO SPECIFIC NEEDS  Two injection regimen:  2/3rds of total daily dose – am (2:1 ratio of lente to regular insulin)  1/3 rd -pm (1:1 ratio of lente to regular insulin)  Three injection regimen  Four injection regimen  Continuous sub cut insulin regimen

Therapeutic objectives:  Fasting levels (60-90mg/dl)  before lunch, dinner or bedtime snack levels ( mg/dL).  after meals 1hr levels ( mg/dL)  2hr levels (≤ 120mg/dL)

 1. rapid-acting insulin analogs (lispro) Cat B concerns about teratogenesis, antibodies formation, growth-promoting properties majority of evidence showed that it does not cross placenta, and has no adverse maternal or fetal effects

2. Long acting analogs glargine Cat C drug Not well studied systemically

 Hospitalization may be required in early gestation.  To provide intensive education and counseling, and to improve glycemic control.  Consencious out patient care  frequent visits and phone calls is essential to ensure optimal glucose control  Hospitalization is recom f or patients whose glycemic control is poor: Constantly exceed 200 mg/dl or those who experience significant hypoglycemic episodes

 teratogenic in animal studies esp first generation sulfonyureas  In humans, scattered case reports of congenital abnormality  Risk of congenital abnormality related to maternal glycemic control rather than mode of the anti-DM agents

Sulfonylureas  1 st generation drug increase risk of neonatal hypoglycemia  2 nd generation drug (Glyburide) no such effect and other morbidities.  Cat C drug  4%-20% patients failed to achieve glucose control with maximum dose of drug  Increase risk of preeclampsia and need for phototherapy Langer, N Eng Med J, 2000 Kremer, Am J Obst Gynaecol, 2004 Chmait, J Perinatol,2004 Langer, Am J Obst Gynaecol, 2005

 Biguanides ( metformin)  Cat B drug  used in PCOD to treat insulin resistance and normalize reprod fxn.  Not teratogeneic  Reduce first trimester miscarriage  10X reduce gestational diabetes Glueck, Fertil Steril 2002 Reece, Curr Opin Endocrinol Diabetes, 2006 Hague, BMJ, 2003 Glueck, Human Reprod, 2004

 Monitoring of BP, proteinuria and development of non-dependent oedema is imperative.  Since 25% of diabetic patients develop pre-eclampsia.  Early booking/dating  Ophthalmologic, cardiac, renal fxn should be assessed at the initial visit.  Reassessed during gestation as indicated  Urine M/C/S is recommended  Every trimester; so that asymptomatic bacteriuria can be treated in a timely fashion

 Maternal serum AFP should be carried out  At 16-20wks gestation; normal levels are lower in diabetic patients when compared to non diabetics  Sonogram at 18-20wks  To check for fetal anomalies.  Fetal echocardiogram at 20-22wks.  Serial sonograms  Because of the risk of both macrosomia and IUGR

 Non-stress test, Biophysical profile and CST.  Maternal monitoring of fetal activity (fetal kick chart).  A useful means of fetal surveillance.  Doppler USS  Useful in detecting changes in vascular resistance that may precede fetal compromise.

 based on both maternal and fetal risk factors.  Present recommendations.  Delivery should be delayed till term or onset of spontaneous labour:  As long as good metabolic control and adequate antenatal surveillance are maintained  Induction of labour is advised (38–40 weeks).  When diabetes is well controlled and pregnancy is uncomplicated, usually at 38 weeks.

 Options: Spontaneous labour,Induction of Labour, Caesarean Section.  Preterm labour:  Tocolytic therapy with  -sympathomimetic drugs should be avoided (may worsen control and cause ketoacidosis) if absolutely necessary can be covered by appropriate insulin infusions!  Corticosteroids to promote lung maturation:  Caution should however be exercised.

Breast feeding encouraged Additional 500 kcal/day Contraception Barrier Low dose OCP Mini-pills IUCD Sterilization-Vasculopathy OGTT 6-12 weeks later, OGTT yearly 60-70% recurrence of GDM

No consensus for 4 decades!

 Should all pregnant women be screened or only those with risk factors?  Is it safe to screen all?  Which screening test and which diagnostic test are the most reliable?  Which cut-off values should we use?  What are the risk for mothers and babies and can treatment improve outcome?  What is the connection between gestational diabetes and type 2 DM?  Is it physiological or pathological ?

(1) Preexisting DM in pregnancy Good glucose control is important for decreasing morbidities Insulin is still the gold standard of tx in pregnancy Increasing evidence for clincial effectiveness for treatment with oral hypoglycemic agents

(2) Gestational diabetes  no consensus  The morbidities increases as glucose level approaching the diagnosis as DM  Possible that treatment improves outcomes  Overlap with preexisting DM, esp type2  Long term implication for health of the mother and baby

Management of women with diabetes mellitus in pregnancy: 1) Joint care with midwives, obstetricians and diabetic physicians is not necessary. 2) fetal wt of 4 kg and > should have c/s. 3) Dietary advice is not important. 4) Home blood glucose monitoring and clinic HbA Ic is important. 5) Fundoscopy at regular intervals is not necessary 6) Patient should continue her anti-diabetic drugs. 7) Scans for growth and liquor volume is not part of the management. 8) All patients should be allowed to come in spontaneous labour. 9) Increasing insulin dose is part of the management. 10) Corticosteroids are naturally diabetogenic