DIABETIC MELLILUS IN PREGNANCY:

CONTEMPORARY MANAGEMENT.

DR EBUNU E.NCONSULTANT OBSTETRICIAN AND

GYANECOLOGISTZONAL MD.GHE.

PRE-TESTManagement 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 HbAIc is important.5) Fundoscopy at regular intervals is not necessary6) 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

INTRODUCTION 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.

INCIDENCE Most 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

SCREENINGNo consensusFBS, 2HPP, (75g OGTT). RBS 50g glucose oral challenge, 1 hr glucose 140 mg/dl.

Poor screening tools:Urinalysis, HbA1c, Fructosamine

Universal or selectiveTiming 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

SCREENING CONTD.

DIAGNOSIS Symptoms & Signs: polydypsia, polyuria,

polyphagia. WHO Criteria: 75 g OGTT

2006 WHO Diabetes criteriaCondition Fasting glucose 2 hour glucose

mmol/l(mg/dl) 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.

MANAGEMENT AIMS

Educating the individualEuglycemiaEarly detection and treatment of medical

problemsPrevent obstetric complicationsOptimal timing and appropriate mode of

deliveryFamily planning

Appropriate.

MANAGEMENT GDM MUITIDISCIPLINARY;

Education, Diet, Exercise MEDICAL ;

Insulin,oral hypoglycemic agents ? OBSTETRICS;

Ante-partumIntra-partumPost-partum

PRECONCEPTION CARE

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

INSULIN THERAPY

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 26-36 to 1.0U/Kg during wks 36-41.

REGIMENADJUSTED TO SPECIFIC NEEDS Two injection regimen:

2/3rds of total daily dose – am (2:1 ratio of lente to regular insulin)

1/3rd-pm (1:1 ratio of lente to regular insulin)

Three injection regimen

Four injection regimen

Continuous sub cut insulin regimen

RECOMMENDED LEVELSTherapeutic objectives: Fasting levels (60-90mg/dl)

before lunch, dinner or bedtime snack levels (60-105 mg/dL).

after meals 1hr levels (130-140mg/dL)

2hr levels (≤ 120mg/dL)

INSULIN ANALOGUES 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

INSULIN ANALOGUES2. Long acting analogs glargine

Cat C drugNot well studied systemically

SUPERVISION 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 for patients whose glycemic control is poor:

Constantly exceed 200 mg/dl or those who experience significant hypoglycemic episodes

ORAL HYPOGLYCEMIC AGENTS 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

ORAL HYPOGLYCEMIC AGENTSSulfonylureas 1st generation drug increase risk of

neonatal hypoglycemia 2nd 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 , 2000Kremer, Am J Obst Gynaecol, 2004Chmait, J Perinatol ,2004Langer, Am J Obst Gynaecol, 2005

ORAL HYPOGLYCEMIC AGENTS 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 diabetesGlueck, Fertil Steril 2002Reece, Curr Opin Endocrinol Diabetes, 2006Hague, BMJ, 2003Glueck, Human Reprod, 2004

ANTEPARTUM CARE

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

FETAL ASSESMENT 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

FETAL ASSESSMENT CONTD……

Non-stress test, Biophysical profile and CST.

Maternal monitoring of fetal activity (fetal kick chart).A useful means of fetal surveillance.

Doppler USSUseful in detecting changes in vascular resistance

that may precede fetal compromise.

TIMING OF DELIVERY 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.

DELIVERY

Options: Spontaneous labour,Induction of Labour, Caesarean Section.

Preterm labour:Tocolytic therapy with b-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.

ARE WE STILL AWAKE??

POST PARTUMBreast feeding encouragedAdditional 500 kcal/dayContraception

BarrierLow dose OCPMini-pillsIUCDSterilization-Vasculopathy

OGTT 6-12 weeks later, OGTT yearly60-70% recurrence of GDM

GESTATIONAL DIABETES

No consensus for 4 decades!

GESTATIONAL DIABETES 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 ?

DIABETES AND PREGNANCYCONCLUSION(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

DIABETES AND PREGNANCYCONCLUSION(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

THANK YOU FOR KEEPING AWAKE!

POST-TESTManagement 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 HbAIc is important.5) Fundoscopy at regular intervals is not necessary6) 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