DIABETES IN PREGNANCYDIABETES IN PREGNANCY

AHMED ABDULWAHABAHMED ABDULWAHAB

CLASSIFICATION:CLASSIFICATION: INSULIN DEPENDANTDIABETES.I.D.DINSULIN DEPENDANTDIABETES.I.D.D Diagnosis before pregnancy ,patient already Diagnosis before pregnancy ,patient already

in insulin usually young with little or no in insulin usually young with little or no insulin.insulin.

Non insulin dependant DM ,patient on oral Non insulin dependant DM ,patient on oral hypoglycemic agents hypoglycemic agents

STANDARD TEST FOR DIAGNOSIS:STANDARD TEST FOR DIAGNOSIS: 75 gm of glucose –orally after over night 75 gm of glucose –orally after over night

fast.fast. Fasting < than 6 mmol one hour less than Fasting < than 6 mmol one hour less than

11mmol . 2hour <9 . 3 hour should back to 11mmol . 2hour <9 . 3 hour should back to fasting levelfasting level

GESTIONAL DIABETES:GESTIONAL DIABETES: Diabetes occurs during pregnancy , will Diabetes occurs during pregnancy , will

come to normal after delivery:come to normal after delivery: INDICATION OF GTT;INDICATION OF GTT;High GCT more than 7.8 mmolHigh GCT more than 7.8 mmol Potential diabetes.Potential diabetes. Unexplained IUFDUnexplained IUFD History of congenital anomaliesHistory of congenital anomalies

Glucose in urine more than twiceGlucose in urine more than twice Maternal weight more than 90 KGMaternal weight more than 90 KG Previous big babies Previous big babies

WHY?WHY? Pregnancy has diabetogenic effect .Pregnancy has diabetogenic effect . There is a decreased sensitivity of insulin There is a decreased sensitivity of insulin

due to antagonizing effect by cortisone –due to antagonizing effect by cortisone –estrogen –progesterone HPL , and estrogen –progesterone HPL , and degradation of insulin by placenta degradation of insulin by placenta

GLUCOSE AND INSULIN RELATIONSHIP GLUCOSE AND INSULIN RELATIONSHIP IN MOTHER AND FETUS.IN MOTHER AND FETUS.

Glucose cross placenta by facilitated Glucose cross placenta by facilitated diffusion.diffusion.

Fetal pancreatic beta cell hypertrophy will Fetal pancreatic beta cell hypertrophy will increase the release of insulin.increase the release of insulin.

Insulin is a potent stimulus to growth .Insulin is a potent stimulus to growth .

EFFECT OF PREGNANCY ON DIABETES.EFFECT OF PREGNANCY ON DIABETES. Difficult to control Difficult to control Lowered renal threshold and diminished sensitivity Lowered renal threshold and diminished sensitivity

to insulinto insulin Retinopathy. Need careful ophthalmic assessment Retinopathy. Need careful ophthalmic assessment

, there is increase prolifrative retinopathy, there is increase prolifrative retinopathy Nephropathy may be confused with hypertension Nephropathy may be confused with hypertension

and edema ,assess renal function and edema ,assess renal function

EFFECT OF DIABETES ON PREGNANCY.EFFECT OF DIABETES ON PREGNANCY. Abortion.Abortion. Infection UTI fungal infection.Infection UTI fungal infection. Pre eclampsia Pre eclampsia Polyhydramnios Polyhydramnios Prenatal death RDS – anomalies Prenatal death RDS – anomalies Macrosomia.Macrosomia.

Cont.Cont. Congenital anomalies –poor control at early Congenital anomalies –poor control at early

pregnancy, mainly CVS and CNS.pregnancy, mainly CVS and CNS. Caudal regression syndrome is specific.Caudal regression syndrome is specific. Lung maturity, fetal insulin antagonize the Lung maturity, fetal insulin antagonize the

effect of cortisone on surfactant . effect of cortisone on surfactant .

MAAGEMENTMAAGEMENT Combined care ,obstetrician and physician.Combined care ,obstetrician and physician. Without complication wait till 40 weeksWithout complication wait till 40 weeks Food plan. 50% carbohydrate 20% protein 20% fat , fiberFood plan. 50% carbohydrate 20% protein 20% fat , fiber Majority need insulin –short acting 2 or 3 doses may be Majority need insulin –short acting 2 or 3 doses may be

required ..required .. Doses rise progressively with advancing pregnancy.Doses rise progressively with advancing pregnancy. Oral hypoglycemic never to be used Oral hypoglycemic never to be used Keep FBS between 4-6. 2h postprandial below 8 mmolKeep FBS between 4-6. 2h postprandial below 8 mmol HbA1C REFLECT average plasma glucose normal 6% HbA1C REFLECT average plasma glucose normal 6%

OBSTETRIC CAREOBSTETRIC CARE Early pregnancy control reduce anomalies.Early pregnancy control reduce anomalies. Late control reduce PET polyhydramnios and Late control reduce PET polyhydramnios and

macrosomia .macrosomia . Early booking for accurate dating.Early booking for accurate dating. Detailed USS ANOMALIES 18-20 WEEKSDetailed USS ANOMALIES 18-20 WEEKS Alpha fetoprotein Alpha fetoprotein Regular follow up Regular follow up

DELIVERY.DELIVERY. Normal pregnancy wait 40 weeksNormal pregnancy wait 40 weeks DM alone is not an indication for caesarian DM alone is not an indication for caesarian

sectionsection Induction of labor IOL Insulin infusion , Induction of labor IOL Insulin infusion ,

hourly checking of blood sugar (sliding hourly checking of blood sugar (sliding scale)scale)

Close fetal heart monitoring .Close fetal heart monitoring .

POST PARTUM CARE .POST PARTUM CARE . Insulin requirement fall rapidly after delivery Insulin requirement fall rapidly after delivery Infant of diabetic mother has the following Infant of diabetic mother has the following

problems.problems. Over weight, plethoric ,RDS, hypoglycemic.Over weight, plethoric ,RDS, hypoglycemic. Hyperbilurbinaemia hypocalcaemia.Hyperbilurbinaemia hypocalcaemia.