1. DM in Pregnancy

2. DM in pregnancy There are two types of patients having DM in pregnency : There are two types of patients having DM in pregnency : 1- Patients who are already diabetic and got pregnant ( type 1 or type 2 diabetes ) 1- Patients who are already diabetic and got pregnant ( type 1 or type 2 diabetes ) 2- Patients who develop diabetes during pregnancy ( Gestational Diabetes : developes during pregnancy and disappears upto 6 weeks post partum ) 2- Patients who develop diabetes during pregnancy ( Gestational Diabetes : developes during pregnancy and disappears upto 6 weeks post partum )

3. First Case Already having DM ( type 1 or type 2 DM ) and got pregnant or wants to get pregnant. Already having DM ( type 1 or type 2 DM ) and got pregnant or wants to get pregnant. Ex.. 35 year old female, came to u as a case of DM type 2 on Oral hypoglycemic agent, asking you if she can get pregnant, what points you will do in this patient ? Ex.. 35 year old female, came to u as a case of DM type 2 on Oral hypoglycemic agent, asking you if she can get pregnant, what points you will do in this patient ? We should always start treating diabetic patients in the Pre-conception period We should always start treating diabetic patients in the Pre-conception period

4. Preconception management 1- Control Blood Sugar : life style modification (diet, reduce weight, control hypertension ), monitoring the blood sugar closely (aim for HbA1C <6 mmol/l) even switch to insulin if you cant control it. 1- Control Blood Sugar : life style modification (diet, reduce weight, control hypertension ), monitoring the blood sugar closely (aim for HbA1C <6 mmol/l) even switch to insulin if you cant control it. 2- take supplies of Folic acid (5mg/day) to decrease risk of NTD, fetal anomalies ( 3 months prior to conception ) 2- take supplies of Folic acid (5mg/day) to decrease risk of NTD, fetal anomalies ( 3 months prior to conception ) 3- make fundoscopy, KFT, Urine analysis, ECG for the presence of DM complications coz they are harder to deal with during pregnancy 3- make fundoscopy, KFT, Urine analysis, ECG for the presence of DM complications coz they are harder to deal with during pregnancy

5. If she got pregnant without consulting a doctor, what are the fetal risks associated in the first trimester ? If she got pregnant without consulting a doctor, what are the fetal risks associated in the first trimester ? Congenital malformations: incidence is lower in GDM Congenital malformations: incidence is lower in GDM –Cardiovascular: Transposition of great vessels Transposition of great vessels Ventricular septal defect (the commonest) Ventricular septal defect (the commonest) Aortic coarctation Aortic coarctation Artial septal defect Artial septal defect –Central Nervous system Neural tube defect (NTD) Neural tube defect (NTD) Anencephaly Anencephaly Holoprosencephaly (single ventricle) Holoprosencephaly (single ventricle) Encephalocele Encephalocele

6. –Skeletal & spinal: Caudal regression syndrome (sacral agenesis), this is characteristic for babies of DM mothers –Genitourinary Renal agenesis Renal agenesis Ureteral duplication Ureteral duplication –Gastrointestinal: anal atrisia

7. What tests should the patient have when she come to each antenatal visit (related to DM ) ? What tests should the patient have when she come to each antenatal visit (related to DM ) ? 1- Fasting glucose level (more than 5.6 mmol/l is abnormal ) 1- Fasting glucose level (more than 5.6 mmol/l is abnormal ) 2- if fasting glucose is normal we do 75 gm OGTT then 1,2,3 hours post prandial 2- if fasting glucose is normal we do 75 gm OGTT then 1,2,3 hours post prandial

8. What are possible complications at 2 nd, 3 rd trimester ? What are possible complications at 2 nd, 3 rd trimester ? 1- Macrosomia 1- Macrosomia 2- Polyhydramnios (preterm labour) 2- Polyhydramnios (preterm labour) 3- Sudden IUFD 3- Sudden IUFD 4- IUGR 4- IUGR 5- Abnormal F.H. Pattern 5- Abnormal F.H. Pattern

9. What complications do you expect on delivery ? What complications do you expect on delivery ? 1-Shoulder Dystocia (due to fat in the shoulder and truck (disproportionate fat distribution) 1-Shoulder Dystocia (due to fat in the shoulder and truck (disproportionate fat distribution) 2- increase risk of C/S 2- increase risk of C/S When is the best time to deliver this patient ? When is the best time to deliver this patient ? 38-39 weeks bcoz of higher incedence of RDS. 38-39 weeks bcoz of higher incedence of RDS.

10. What are possible fetal complications ? What are possible fetal complications ? Hypoglycaemia (due to sudden cut in glucose supply while being in a state of hyperinsulinemia) Hypoglycaemia (due to sudden cut in glucose supply while being in a state of hyperinsulinemia) RDS RDS Hypocalcaemia (due to effect of insulin and increased metabolism) Hypocalcaemia (due to effect of insulin and increased metabolism) Polycythaemia Polycythaemia

11. What are possible maternal complications ? What are possible maternal complications ? Obstetric - Polyhydramnios Obstetric - Polyhydramnios - pre-eclampsia (10-15%) this term describes hypertension in a prima gravid (first time pregnancy) while in a multiparaous women we describe her as having hypertension. - pre-eclampsia (10-15%) this term describes hypertension in a prima gravid (first time pregnancy) while in a multiparaous women we describe her as having hypertension. Diabetic Emergencies - Hypoglycaemia Diabetic Emergencies - Hypoglycaemia - Ketoacidosis - Ketoacidosis -Diabetic coma -Diabetic coma Obstetric and Diabetic emergencies can be found in both GDM and preexisting DM Obstetric and Diabetic emergencies can be found in both GDM and preexisting DM

12. Vascular & End-Organs: these are more likely to be found in a pre existing DM, and if the mother has these complications, the pregnancy is most likely to end in an abortion, the same applies for GI and neurologic complications. Vascular & End-Organs: these are more likely to be found in a pre existing DM, and if the mother has these complications, the pregnancy is most likely to end in an abortion, the same applies for GI and neurologic complications. - Cardiac - Cardiac -Renal -Renal -Ophthalmic -Ophthalmic -Peripheral vascular -Peripheral vascular Neurologic - Peripheral neuropathy Neurologic - Peripheral neuropathy Gastrointestinal disturbance Gastrointestinal disturbance Infections: both UTI’s and opportunistic infections are common in GDM and DM. Remember the effect of UTI on premature labor. Infections: both UTI’s and opportunistic infections are common in GDM and DM. Remember the effect of UTI on premature labor.

13. How would you manage this patient during pregnancy and delivery ? How would you manage this patient during pregnancy and delivery ? 1- Diet ( 16 X wt (pounds) + 300 ) 1- Diet ( 16 X wt (pounds) + 300 ) Total calories are divided into 20% Carbs, 20% protein and 60% fats; they are divided also on daily meals, breakfast, lunch, snacks and dinner. In obese Ptns we use lesser calories. 2- Insulin 2- Insulin

14. What regimen of insulin would you start with ? What regimen of insulin would you start with ? mix short with intermediate acting insulin and given twice daily, with a higher dose in the morning. mix short with intermediate acting insulin and given twice daily, with a higher dose in the morning. How to estimate the daily dose? How to estimate the daily dose? –In the first trimester: Wt. (in Kgs) x 0.6 –Second trimester: Wt. x 0.7 –Third trimester: Wt. x 0.8 2/3 of the total dose given in the A.M period (morning) and 1/3 in P.M. 2/3 of the total dose given in the A.M period (morning) and 1/3 in P.M. The A.M dose contains 2/3 of Intermediate acting and 1/3 short acting, while the P.M dose contains ½ intermediate and ½ short. The A.M dose contains 2/3 of Intermediate acting and 1/3 short acting, while the P.M dose contains ½ intermediate and ½ short.

15. Adjustment of dose is done after initiating insulin; we do pre and post prandial glucose levels, our goal is to keep FBG up to 5 mmol/l and the 2-hour post prandial up tp 7 mmol/l, and the ultimate objective is keeping HbA1c less than 6 mmol/l. (note that postprandial levels are related to macrosomia). This is the control regiment for the mother. Adjustment of dose is done after initiating insulin; we do pre and post prandial glucose levels, our goal is to keep FBG up to 5 mmol/l and the 2-hour post prandial up tp 7 mmol/l, and the ultimate objective is keeping HbA1c less than 6 mmol/l. (note that postprandial levels are related to macrosomia). This is the control regiment for the mother.

16. 3- Confirm health of fetus : 3- Confirm health of fetus : At 11 wks we check Nuchal (neck) thickening (the nucha is thickened in down syndrome) At 11 wks we check Nuchal (neck) thickening (the nucha is thickened in down syndrome) Alpha Feto Protein (AFP) and HCG at 16-18 wks, values are lower for non-diabetics. Alpha Feto Protein (AFP) and HCG at 16-18 wks, values are lower for non-diabetics. Detailed anomaly scan 19-20 wks Detailed anomaly scan 19-20 wks Biophysical assay from 28 wks, the Abdominal Circumference (AC) is the most indicative value for growth, if it is normal by 28 wks then most likely the baby is normal. Biophysical assay from 28 wks, the Abdominal Circumference (AC) is the most indicative value for growth, if it is normal by 28 wks then most likely the baby is normal. Fetal wt. & growth bi-weekly (in the 3rd trimester), checking for Wt. and fluids; if we have polyhydramnios this is indicative of poor control. So control is assessed also clinically. Fetal wt. & growth bi-weekly (in the 3rd trimester), checking for Wt. and fluids; if we have polyhydramnios this is indicative of poor control. So control is assessed also clinically.

17. 4-Delivery Time: the delivery time and mode for Diabetic mothers depend on many factors in order to wait for term delivery, or to go with C/S, some of these factors are: 4-Delivery Time: the delivery time and mode for Diabetic mothers depend on many factors in order to wait for term delivery, or to go with C/S, some of these factors are: Clinical status Clinical status Biochemical control Biochemical control Fetal status and biophysical control Fetal status and biophysical control Obstetric history Obstetric history 5-During delivery, the daily caloric intake is given as IV glucose, and the Insulin dose is divided and given on hourly basis. 5-During delivery, the daily caloric intake is given as IV glucose, and the Insulin dose is divided and given on hourly basis.

18. Gestational DM, case 2 For GDM, Risk factors are : For GDM, Risk factors are : The age is above 30 yrs old The age is above 30 yrs old Family history for GDM: either for one first degree relative, or two second degree relative Family history for GDM: either for one first degree relative, or two second degree relative Past history of: Past history of: –DM in previous pregnancies –Unexplained intrauterine fetal death, or early neonatal death –Recurrent abortions –Congenital abnormalities in previous babies –Large babies (above 90th centile), meaning large for gestational age

19. Obesity: BMI > 25. Obesity: BMI > 25. Hypertension in multiparous: Hypertension in multiparous: Polyhydramnios: Polyhydramnios: Recurrent infections: in particular opportunistic infections like Candidiasis, bacterial vaginosis, and UTIs Recurrent infections: in particular opportunistic infections like Candidiasis, bacterial vaginosis, and UTIs Significant glucosuria: normally, pregnant women might have glucosuria; so significant glucosuria is a persistent glucosuria, or taken as a second fasting urine specimen. Significant glucosuria: normally, pregnant women might have glucosuria; so significant glucosuria is a persistent glucosuria, or taken as a second fasting urine specimen.

20. How do u screen ? For patients with risk factors, we use the previous tests for diagnosing DM For patients with risk factors, we use the previous tests for diagnosing DM For patients who doesn’t have risk factors we use screening test 50 mg OGTT and 1 hour post prandial if > 7.8 mmol/l we do the previously mentioned tests. Or we can measure 2 hours postprandial Glucose with urine glucose test to increase sensitivity. For patients who doesn’t have risk factors we use screening test 50 mg OGTT and 1 hour post prandial if > 7.8 mmol/l we do the previously mentioned tests. Or we can measure 2 hours postprandial Glucose with urine glucose test to increase sensitivity.

21. When, and why ? When does it occur mostly ? When does it occur mostly ? Peak on 24-28 weeks gestation Peak on 24-28 weeks gestation Why ? Go to the lecture about glucose intolerence mechanism Why ? Go to the lecture about glucose intolerence mechanism Q:why use insulin instead of OHA ? Q:why use insulin instead of OHA ? Because insulin doesn’t cross placenta and the safety of OHA are not proved. Because insulin doesn’t cross placenta and the safety of OHA are not proved.

22. How does it differ from type 1 or 2 ? How does it differ from type 1 or 2 ? The onset and duration: GDM starts during pregnancy, usually in the second trimester (after the differentiation of the fetus) and ends after delivery, while usual DM is pre-, during, and post pregnancy. The onset and duration: GDM starts during pregnancy, usually in the second trimester (after the differentiation of the fetus) and ends after delivery, while usual DM is pre-, during, and post pregnancy. Possible complications: fetal anomalies for example are less common in GDM than in DM, because the fetus is already developed when GDM starts. Also complications per say, like neuropathy, micro and macro vascular problems, retinopathy, nephropathy etc, are more common in usual DM especially in advanced cases. So don’t expect to find such complications in GDM, but you may find acute complications like hypoglycemia or ketoacidosis. Possible complications: fetal anomalies for example are less common in GDM than in DM, because the fetus is already developed when GDM starts. Also complications per say, like neuropathy, micro and macro vascular problems, retinopathy, nephropathy etc, are more common in usual DM especially in advanced cases. So don’t expect to find such complications in GDM, but you may find acute complications like hypoglycemia or ketoacidosis.