1. Naghshineh.E MD

2.  do not have overt vasculopathy  do not have increased risk of congenital malformations 2diabetes in pregnancy

3.  Macrosomia  Preeclampsia(daily low dose ASA)  Hydramnios  Stillbirth  Neonatal morbidity (RDS)  Strict glycemic control: -exacerbation of diabetic retinopathy -may impair fetal growth -not teratogenic in humans 3diabetes in pregnancy

4.  Glucose monitoring &control  Antenatal fetal testing(NST,BPP,CST): -GDM control with insulin or oral HGA: usually initiated at 32wks weekly, from 36 wks until delivery twice per week -GDM control with nutritional therapy : Not ante partum fetal surveillance  IUFD:3 per 1000 pregnancy (excluding congenital malformations) 4diabetes in pregnancy

5.  Assessment of fetal growth: -induction of labor -scheduled c/s -not optimal glycemic control ---EFW≥4800 gr → 50% chance FW≥4500 gr ---sono 28-32 wks, repeat 3-4 wks,last 38 wk or---single sono at 36 wks ---not recommended in GDM with nutritional therapy 5diabetes in pregnancy

6.  PTL:16%  Choice for tocolytic therapy : Nifedipin Or Indometacin  Avoid Beta-adrenergic receptor : severe hyperglycemia  Ante natal glucocorticoid : hyperglycemia 12 hrs after first dose, last 5 days 6diabetes in pregnancy

7. -Benefits of induction:  Avoidance of late stillbirth  Avoidance of delivery-related complications -Disadvantage of induction:  c/s in failed induction  tachysystole  neonatal morbidity in<39 wks 7diabetes in pregnancy

8.  GDM euglycemic with nutritional therapy: induction of labor at 40 wks  GDM medically managed (ins or OHGA): induction of labor at 39 wks  ACOG recommended: c/s in DM :EFW≥4500 gr c/s in non DM: EFW≥5000 gr 8diabetes in pregnancy

9.  Cervical ripening agents are safe  Fallow labor progress closely  Operative vaginal delivery: only if fetal vertex has descended normally  Higher risk of shoulder dystocia & brachial plexus injury 9diabetes in pregnancy

10.  avoid maternal hyperglycemia : risk of fetal acidosis & neonatal hypoglycemia  insulin requirement usually decrease during labor  Glucose is important for optimal myometrial function  GDM euglycemic with nutritional therapy: rarely require insulin during labor (2%)  GDM medically managed (Ins or OHGA): may need insulin infusion during labor (3.5%) 10diabetes in pregnancy

11.  Poorly controlled DM: Diabetic fetopathy ( prolonged hypoglycemia secondary to pancreatic hyperplasia & hyperinsulinemia)  Maternal normoglycemia can not prevent neonatal hypoglycemia 11diabetes in pregnancy

12.  Intrapartum glucose target:70-110  Check BS every 2-4 hrs during latent phase,1-2 hrs during active phase of labor  Begin insulin infusion if BS>120  Check BS every 1 hour during insulin infusion  GDM euglycemic with nutritional diet & exercise: BS on admission, every 4-6 hours 12diabetes in pregnancy

13.  Mild hyperglycemia is less morbid than hypoglycemia  BS 180:treated promptly  Protocols: 1-N/S infusion, when BS<70: DW5% 2-DW5%(100-125 ml/h)+Ins(0.5-1u/h) 3-Rotating fluids(N/S,DW5%,LR) 13diabetes in pregnancy

14.  Procedure scheduled early in morning  NPO & Ins or OHGA withheld morning of surgery  Delay surgery until afternoon: 1/3 morning NPH +DW5% (avoid ketosis)  BS monitor & control with regular insulin  Hypoglycemia: wound infection, metabolic complications, neonatal hypoglycemia 14diabetes in pregnancy

15.  Check FBS,BS (2hpp): 24 h after NVD & 48h after c/s  Relaxed BS level:140-160 during first24-48 h  If FBS<126: follow up  If FBS>126: monitoring and therapy  Postpartum depression is more common  follow up 6-8 wks later: GTT,75 gr,2 hr 15diabetes in pregnancy

16.  DM-I: -1/2-2/3 (NPH+ Reg) prepartum  DM-II: -no medication first 24-48 hours -Ins 0.6 u/kg post partum weight -Metformin, glyburide (safe breastfeeding) -Metformin prefer in obese DM patients 16diabetes in pregnancy

17.  Hb A 1 C<7%  FBS<120  BS 2hpp<170 17diabetes in pregnancy

18.  Insulin requirement: -early rise 3-7 wks -decline 7-15 wks -rise during reminder of pregnancy -if insulin fall after 35 wks>5-10%:R/O placental insufficiency, fetal wellbeing tests,not indication of delivery 18diabetes in pregnancy

19.  Screening for aneuploidy: -first trimester & ultrasound markers not affected by maternal DM -Second trimester (QT):Decreased AFP & uE 3, must be adjusted  MSAFP:NTD(2%)  Anomaly scan:18 wks  Fetal echocardiogram ? (50%,conotruncal &VSD) 19diabetes in pregnancy

20.  Timing for delivery: - Well controled:38+4 wks - With vascular disease:37 wks 20diabetes in pregnancy

21.  Any type is acceptable  Progestin-only pills, DMPA, levonogestrol IUD : increased risk of developing DM-II ?  Copper IUD 21diabetes in pregnancy

22. Towards a safe motherhood 22diabetes in pregnancy