1. Diabetes Mellitus Fifth Stage-Medicine Dr. Sarbast Fakhradin MBChB, MSc Diabetes Care & Management

2. Diabetic foot 40–60% of all amputations of the lower extremity are performed in patients with diabetes more than 85% of these amputations are precipitated by a foot ulcer deteriorating to deep infection or gangrene

3. Prevention Advice to all diabetic patients includes: –Inspect feet every day –Wash feet every day –Moisturise skin if dry –Cut toenails regularly –Change socks or stockings every day –Avoid walking barefoot –Check footwear for foreign bodies –Wear suitable good-fitting shoes –Cover minor cuts with sterile dressings –Do not burst blisters –Avoid high and low temperatures A podiatrist is an integral part of the diabetes team Specially manufactured and fitted orthotic footwear is required to prevent recurrence of ulceration and protect the feet of patients with Charcot neuroarthropathy

4. Treatment 1. Remove callus 2. Treat infection 3. Avoid weight-bearing 4. Ensure good glycaemic control 5. Control oedema 6. Undertake angiogram to assess feasibility of vascular reconstruction where indicated

5. Diabetes in pregnancy Increase insulin resistance, particularly in the second half of pregnancy. The renal threshold for glycosuria is reduced. 2 -5% of pregnancies involve women with diabetes. Gestational diabetes: diabetes with first onset or recognition during pregnancy.

6. Risk factors 1. obesity 2. Ethnicity (South Asian, black, Hispanic, Native American) 3. Family history of type 2 diabetes 4. Previous glucose abnormalities during pregnancy 5. Previous macrosomia. 6. Maternal age more than 37 Y. 7. Polycystic ovarian syndrome

7. Historically 87.5% are Gestational Diabetes Mellitus (GDM). 7.5% are Type 1. 5% are Type 2. GDM is associated with an increased risk of later development of type 2 diabetes in the mother, 50% after 5 years. Screening: as soon as pregnancy confirmed in risky individuals, if negative or not risky screen at 24-28 weeks of gestation

8. Diagnosis

9. Pre-conception preparation: 1. Strict glycaemic control 2. Pregnancy should be planned: folic acid supplementation 5mg 3.Basal-bolus insulin regimens may be required if not controlled by metformin.

10. Management: 1. Frequent self-monitoring of blood glucose 2. Strict glycaemic control. Lifestyle modification. Metformin can be useful. other oral agents should be avoided. Insulin is often required. 3. Check for ketonuria. 4. Microalbuminuria (every semester) 5.Retinal screening (every semester) 6. Regular monitoring of fetal size, and screening for fetal abnormalities. 7. Time & mode of delivery 8. Re-assessed by OGTT 6 weeks after pregnancy.

11. Maternal Complications 1. Hypoglycaemia/DKA 2. Microvascular problems 3. Pre-eclampsia – twice as common 4. Premature labour 5. Spontaneous abortion 6. Obstructed labour 7. Polyhydramnios 8. Infection

12. Fetal Complications Diabetes is Teratogenic particularly before 8 weeks gestation. Birth Trauma, Hypoglycaemia, Hypocalcaemia, RDS, Cardiomyopathy, Jaundice Macrosomia Major defects:

21. Q1/ How you diagnose a case of DM in a non-pregnant adult? Q2/ Write short note on hypoglycemia in diabetic patient? Q3/ Enumerate oral antidiabetic medications and write short note on metformin.

22. Q4/The mechanism of action of metformin includes all of the following except: A. Decrease gastrointestinal glucose absorption B. Decrease the production of glucose by the liver (gluconeogenesis) C. Increase the uptake of glucose by the tissues D. Increase insulin secretion from the pancreas

23. Q5/ Which one of the following is a feature of diabetic autonomic neuropathy? 1. Sixth cranial nerve pulsy 2. Carpal tunnel syndrome 3. Diabetic amyotrophy 4. Gastroparesis 5. stocking distribution of sensory loss in the legs.

24. Q6/ Regarding oral hypoglycemics: A. Are the treatment of choice in hyperosmolar nonketotic states B. Are safe in pregnancy C. Hypoglycemia is rarely caused by metformin D. Treatment with metformin may be complicated by constipation E. Metformin causes weight gain.

25. Q7/ What is the biggest cause of mortality in diabetic patient? 1. Ischemic heart disease 2. Hypoglycemia 3. Renal failure 4. Diabetic ketoacidosis 5. Infection

26. Q8/ Milano Ahmad Kareem, 20 year student from Bakrajo with type 1 DM presented to ER with loss of consciousness. RBS= 32 mg/dl What is your diagnosis & treatment?

27. Thank You & Good Luck Questions?