Post on 17-Nov-2015
description
Diabetes Melitus Gestasional
Classification Pregestational diabetes
Type 1 DM Type 2 DM Secondary DMGestational diabetes
Definition Gestational diabetes (GDM) is defined as glucose intolerance of variable degree with onset or first recognition during the present pregnancy. Pregestational diabetes precedes the diagnosis of pregnancy.
Whom to screen ? Risk stratification based on certain variables Low risk : no screening
Average risk: at 24-28 weeks
High risk : as soon as possible
To satisfy all these criteria
Age
High risk Marked obesity Prior GDM Strong family history
Intermediate risk At least one of the criteria in the list
How to screen? Oral glucose tolerance test ( OGTT) with 100 gm glucose Overnight fast of at least 8 hours
At least 3 days of unrestricted diet
and unlimited physical activity
> 2 values must be abnormal
Fasting95 mg/dl1-h180 mg/dl2-h155 mg/dl3-h140 mg/dl
Urine glucose monitoring is not useful in gestational diabetes mellitus
Urine ketone monitoring may be useful in detecting insufficient caloric or carbohydrate intake in women treated with calorie restriction
Urine monitoring
Problems of GDM: fetal
Increases the risk of fetal macrosomia Neonatal hypoglycemia Jaundice Polycythemia Hypocalcemia, hypomagnesemia Birth trauma Prematurity
Problems: fetal Cardiac( including great vessel anomalies) : most common
Central nervous system: 7.2%
Skeletal: cleft lip/palate, caudal regression syndrome
Genitourinary tract: ureteric duplication
Gastrointestinal : anorectal atresia
Poor glycemic control at time of conception: risk factor
Caudal regression syndrome
Problems of GDM: maternal Weight gain Maternal hypertensive disorders Miscarriages Third trimester fetal deaths Cesarean delivery (due fetal growth disorders) Long term risk of type 2 diabetes mellitus
Pregnancy in diabetic mother: risksProgression of retinopathy: esp. severe proliferative retinopathy
Progression of nephropathy: especially if renal failure +
Coronary artery disease: Post MI patients: high risk of maternal death
Management
Preconception counselling Diabetic mother : glycemic control with insulin/SMBG
Target: HbA1c < 7%
Folic acid supplementation: 5 mg/day
Ensure no transmissible diseases: HBsAg, HIV, rubella
Try and achieve normal body weight: diet/exercise
Stop drugs : oral hypoglycemic drugs, ACE inhibitors, beta blockers
Clinical parameters: checked at each visit
medications pre-pregnancy weight weight gain edema pallor blood pressure Fundal height
Patient education
Cornerstone in GDM management
Maternal complicationFetal complicationMedical Nutrition therapyGlycemic monitoring: SMBG and targetsFetal monitoring: ultrasoundPlanning on deliveryLong term risks
GDMFailure to maintain glycemic targets
INSULIN THERAPY Medical nutrition therapy
Medical nutrition therapyPromote nutrition necessary for maternal and fetal health
Adequate energy levels for appropriate gestational weight gain,
Achievement and maintenance of normoglycemia
Absence of ketones
Regular aerobic exercises
Medical nutrition therapyApproximately 30 kcal/kg of ideal body weight
> 40-45% should be carbohydrates
6-7 meals daily( 3 meals , 3-4 snacks). Bed time snack to prevent ketosis
Calories guided by fetal well being/maternal weight gain/blood sugars/ ketones
Energy requirements during the first 6 months of lactation require an additional 200 calories above the pregnancy meal plan.
Fetal monitoring Baseline ultrasound : fetal sizeAt 18-22 weeks: major malformations
fetal echocardiogram 26 weeks onwards: growth and liquor volumeIII trimester: frequent USG for accelerated growth
( abdominal: head circumference)
Management of labor and deliveryMaternal hyperglycemia in labor: fetal hyperinsulinemia,
worsen fetal acidosisMaintain sugars: 80-120 mg/dl (capillary: 70-110mg/dl )Feed patient the routine GDM diet Maintain basal glucose requirementsMonitor sugars 1-4 hrly intervals during labourGive insulin only if sugars more than 120 mg/dl
Post partum follow up Check blood sugars before discharge
Breast feeding: helps in weight loss
Lifestyle modification: exercise, weight reduction
OGTT at 6-12 weeks postpartum: classify patients into normal/impaired glucose tolerance and diabetes
Preconception counseling for next pregnancy
Increased risk of cardiovascular disease,future diabetes and dyslipidemia
Long term risk: offspring
Increased risk of obesity and abnormal glucose tolerance
thank you