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monitoring During Pregnancy by diabetesasia.org

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monitoring During Pregnancy by diabetesasia.org

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  1. Monitoring During Pregnancy

  2. Objectives • After completing this Module the participant will be able to • Discuss the benefit of self monitoring of blood glucose (SMBG) when available • Determine appropriate timing of SMBG depending on availability of strips • Decide on expected target values for fasting and post prandial BG • Discuss methods of fetal monitoring

  3. How often should SMBG occur? Metzger, Buchanan et al 2007 SeshiahBalaji, 2006 • Daily monitoring provides immediate feedback to the mother and is the ideal. • Woman must know targets • Must know how to respond to results out of target range • When resources are limited • Once weekly monitoring until targets reached • When targets reached check once per month until late in the 2nd trimester • Then increase to every 1 - 2 weeks

  4. Targets Metzger, Buchanan et al 2007 SeshiahBalaji, 2006 ADA 2015 • Fasting: <95 mg/dl ( < 5.3 mmol/l) • 1 hour PP : < 140 mg/dl ( < 7.8 mmol/L) • 2 hour PP : < 120mg/dl ( < 6.7 mmol/L)

  5. HbA1C during pregnancy? • May be valuable in determining those who had undiagnosed diabetes prior to pregnancy • May give indication of overall control during pregnancy BUT • Not valuable for day-to-day management during pregnancy • May give falsely low results • Other factors such as anemia make it unreliable

  6. Fetal movement counting Lalor et al 2008 The rationale - decreased fetal movements may signal decreased oxygenationwhich often precedes fetal demise Reduction of activity associated with chronic fetal distress Among inactive fetuses, approximately 50% are either stillborn, tolerate labor poorly or require resuscitation at birth

  7. Fetal movement • Inexpensive, involving the mother, easy to use • Foetal movements related to maternal glucose levels • Patients taught generally from late third trimester - after 35 weeks at routine ANC • Reduced activity needs to be evaluated by NST(non stress test)

  8. Other parameters Blood pressure – every visit Values above 140/90 mm Hg are of concern If > 140/90 re measure same day; If > 150/100 initiate therapy If BP > 140/90 check urine for albuminuria Estimate Urine albumin / sugar dip stick Though urine sugar not of value in a known GDM, albumin is important as sometimes predates BP in preeclampsia

  9. Ultrasound fetal measurement • Early pregnancy scan - 7-8 weeks • Dating and viability • Dating important to offer appropriate timing for antenatal visits/ scans and delivery • Accurate dating prevents iatrogenic prematurity

  10. 11-13 week scan • As for non- diabetic pregnancies • Can pick up 60% of structural abnormalities – value for women with suspected diabetes or early gestational diabetes

  11. 18-20 week target scan Reece CA 2004 • Detailed level 2/3 scan to ensure structural normalcy • Foetal echo for all DM and GDM detected early in pregnancy

  12. Serial growth scan Julie DL 2007, NICE 2008 • 28 weeks onwards, growth estimation is done by ultrasound to monitor fetal growth and identify both SGA and LGA babies. • Scan to monitor growth is recommended every 4 weeks till 36 weeks. • Growth plotted on growth charts to see centiles

  13. 2. 1. 3. 4. 5.

  14. Growth - macrosomia • Macrosomia is common in GDM especially if there is poor control • If macrosomia is suspected, then additional measurements that can be taken: • include frontal truncal skin fat layer, • skin thickness above the scapula, • amniotic fluid index • Post prandial blood sugars rather than fasting sugars correlate better with birth weight and foetal size

  15. Growth - IUGR • IUGR seen in • Women with vasculopathy • Preeclampsia • Diabetes with too strict glycaemiccontrol SGA babies(< 10th centile for GA) have an increased risk of perinatal morbidity and mortality

  16. Doppler Doppler studies are not useful for LGA fetuses Doppler studies are useful in IUGR

  17. Antenatal surveillance Coustan 2009, NICE 2008 From 36 weeks, CTG / modified BPP are tests of fetal well being No consensus or recommendation on when to start such tests or the frequency of monitoring In women who want to await spontaneous labour, these tests are indicated weekly after 38 weeks

  18. References • American Diabetes Association. Standards of Medical Care 2015. Diabetes Care 2015;38(suppl 1): S77 • Austin M.M., Haas L., Johnson T., Parkin C.G., Parkin C.L., Spollett G., Volpone, M.T.  (2006). AADE Position Statement:  Self-monitoring of blood glucose: benefits and utilization. The Diabetes Educator, 32:835-847. • Bode, B.W. (2007). Incorporating postprandial and fasting plasma glucose into clinical management strategies.  Insulin, 2:17-29. • Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2013 Clinical practice guidelines for the prevention and management of diabetes in Canada; Diabetes and pregnancy. Can J of Diabetes. 2013;37(suppl 1):S168-183. • Coustan D, Glob. libr. women's med. (ISSN: 1756-2228) 2009; DOI 10.3843/GLOWM.10162 • Julie DL 2007 • Lalor JG, Fawole B, Alfirevic Z, Devane D. Biophysical profile for fetal assessment in high risk pregnancies. Cochrane Database of Systematic Reviews 2008, Issue 1. Art. No.: CD000038. DOI: 10.1002/14651858.CD000038.pub2 • Landon and GabbeAntepartumsurveillence in gestational diabetes Diabetes Supplement 2 50-54, 1985 • McAndrew L., Schneider, S.H., Burns, E., Levethal, H. (2007). Does patient blood glucose monitoring improve diabetes control? The Diabetes Educator, 33:991-1011. • Metzger, BE, Buchanan TA, Coustan DR, et al. Summary and recommendations of the Fifth International workshop-Conference on Gestational Diabetes Mellitus. Diabetes Care. 2007;30(Supple 2):S251-260. • National Collaborating Centre for Women’s and Children’s Health. Diabetes in pregnancy. Revised reprint July 200. London:RCOG Press. (www.nice.org.uk) • NICE 2008 • Parkin C.G., Hinnen, D., Campbell, K., et al. (2009). Effective Use of Paired Testing in Type 2 Diabetes: Practical Applications in Clinical Practice, The Diabetes Educator, 35, 915.

  19. Reece CA 2004 • Roberts AB, Stubbs SM, Mooney R, et al. Fetal activity in pregnancies complicated by maternal diabetes mellitus. Br J ObstetGynaecol. 1980;87:845–849. • Seshiah V, Balaji V, et al. Gestational Diabetes Mellitus – Guidelines. J Assoc Physic of India. 2006;54:622-28. • The International Diabetes Federation Clinical Guidelines Task Force, in conjunction with the SMBG International Working Group. Guideline on Self-Monitoring of Blood Glucose in Non-Insulin-Treated Type 2 Diabetes, 2009. • Vintzileos AM. Antenatal assessment for the detection of fetal asphyxia: an evidence-based approach using indication-specific testing. Ann N York Acad Sci. 2000;900:137–150. • ,

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