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IN THE NAME OF GOD. PREGESTATIONAL DM. WHITE CLASSIFICATION OF DM DURING PREGNANCY. Gestational DM Class A : diet alone ,any duration or age Class B : age at onset > 20 y& duration < 10y Class C : age at onset 10- 19 or duration 10 – 19 y - PowerPoint PPT Presentation
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WHITE CLASSIFICATION OF DM DURING PREGNANCYGestational DMClass A : diet alone ,any duration or ageClass B : age at onset > 20 y& duration < 10yClass C : age at onset 10- 19 or duration 10 – 19 yClass D : age < 10 y or duration > 20 y or background retinopathy or HTN ( not preeclampsia)Class R : proliferative retinopathy or vitreous HE
Class F : nephropathy with p. uria > 500 mgClass RF : R & FClass H : heart dxClass T : prior renal transplantation
Joslin textbook 2005
Nephropathy
During pregnancy , complicated by nephropathy, GFR & albuminuria increase &also increase in mean BP, it may worsen preexisting nephropathy.
Women with class F diabetes demonstrate that a majority of these pts develop proteinuria in the nephrotic range by the third trimester but Creatinine is nl
joslins textbook 2005
Mild nephropathy don`t complicated Moderate to severe nephropathy with GFR < 90
ml/min & proteinura more than 1 g /24 hrs have a more rapid decline in GFR
joslins textbook 2005
Retinopathy
Risk of progression of retinopathy increase in pregnancy Risk is influenced with :
severity of baseline retinopathy HbA1C > 8.5% at the first prenatal visit intensively treated pt has 1.6 fold increase risk of retinopathy Conventionally treated pt has 2.4 fold increase in retinopathy In DCCT study ,no difference in level of retinopathy in pt who
became pregnant as compared with pt who never p.
joslins textbook 2005
hypoglycemia
Most severe in first half of pregnancy : more insulin sensitivity , morning sickness , strict BS control
Severe hypoglycemia isnot teratogenic in human Treat with 15 g carbohydrate & then rechecked BS
after 15 min & additional 15 g carbohydrate use It is Better use lispro( FDA safety rating of B ) and
for aspart FDA safety rating of C
joslins textbook 2005
Hypertensive disorder
Chronic HTN: before or up to 20th weeks of gestation & if HTN continue after 12 week after pregnancy
Preeclampsia-eclampsia : ≥ 140/90 mmhg ,usually after 20th weeks of gestation with proteinuria more than 300mg/24 hrs
Preeclampsia-eclampsia superimposed on chronic HTN
Gestational HTN
joslins textbook 2005
Preconception counseling
Education Maternal risk assessment Fetal risk assessment HbA1C levels should be normal
Uptodate 2006
Maternal risk assessment
HX & P/E Review of complication Current & past glucose management Comorbid medical conditions Gynecologic & obstetric hx Discontinue oral anti-hyperglycemic agent Daily folic acid : 1 mg prior conception & continue after
conception Self management skills should be reviewed Nutrition counseling Mental health professional should be available
Uptodate 2006
Control of HTN : BP < 130/80 Thyroid dx : TSH , FT4 Neuropathy ( peripheral & autonomic ) vascular evaluation of lower extremities Infection : UTI SMBG HbA1C Discontinue alcohol & smoking
Uptodate 2006
Ophthalmic assessment
Comprehensive eye examinatin in pt with planing for pregnancy
f/u through pregnancy at least every 3 months & also one y after pregnancy
Tight glycemic control may accelerate retinopathy & need more attention by ophthalmologist
Laser photocoagulation for severe preproliferative diabetic retinopathy
Assessment of renal function
Spot urine for microalbumin /cr or time collection for 24 hrs
Serum cr Cr> 2mg/dl & GFR < 50 ml/min. & proteinuria
more than 2 gr /day can be considered relative contraindications to pregnancy
Cardiac evaluation
As the same as non pregnant women .(uptodate 2006)
Symptomatic CHF & Ischemic heart disease are contraindicated to pregnancy.( davidson 2004)
MANAGMENT of HTN & /OR MICROALBUMINURIA Methyl dopa Hydralazine B-blocker Ca canal blocker ACE inhibitor is
contraindicated Thiazid is relatively
contraindicated
BP should be managed aggressively
Hold BP< 130 /80 mmHg
Uptodate 2006
Management of hyperlipidemia
Statins are contraindicated & should be discontinued before conception
Hypertriglyceridemia treat with diet , supplementation with medium chain TG
Joslin text book 2005
Preconception treatment goal
Plasma FBS: 80-110 2hpp : 100-155 HbA1C : < 7% Avoid hypoglycemia
Joslin text book 2005
•goals for glycemic control for women with GDM, (Fourth International recommendations from the Workshop-Conference
on Gestational Diabetes) suggest:capillary blood glucose concentrations should be:
FBS: 95 mg/dlBS-1hpp :140 mg/dl
and/orBS-2hpp: 120 mg/dl
ADA 2006
Second trimester
Visit the pt every 2 to 4 weeks or more if pt has complications or glycemic control is suboptimal .
Maternal analyte screening : screening for Dawn SX or neural tube defects ( α fetoprotein ,unconjucated estriol ,HCG,inhibin A )
Sonography : at 18 weeks of gestation
Uptodate 2006
Third trimester
Visit for every 1 to 2 weeks untile 32 wks of gestation & then weekly
Glycemic control Sonography Estimation of fetal size Surveillance for pregnancy complication Fetal surveillance : weekly NST at 32 weeks with
suboptimal HbA1C & from 35 weeks with nl HbA1C Assess for macrosomia ,premature labor , hydramnious
Uptodate 2006
Fetal risk
Congenital malformation & spontaneous abortion : incidence is 5% -9%
when occurs in blastogenesis ( first 4 weeks of conception ) is more severe than organogenesis ( weeks 4-5 after conception )
HbA1C < 8.5 % 3.4%
HbA1C > 8.5 % 22.4%
Uptodate 2006