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DIABETIC MELLILUS IN PREGNANCY: CONTEMPORARY MANAGEMENT.

DIABETIC MELLILUS IN PREGNANCY: CONTEMPORARY MANAGEMENT. DR EBUNU E.N CONSULTANT OBSTETRICIAN AND GYANECOLOGIST ZONAL MD.GHE. Pre-Test.

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DIABETIC MELLILUS IN PREGNANCY: CONTEMPORARY MANAGEMENT.

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  1. DIABETIC MELLILUS IN PREGNANCY: CONTEMPORARY MANAGEMENT. DR EBUNU E.N CONSULTANT OBSTETRICIAN AND GYANECOLOGIST ZONAL MD.GHE.

  2. Pre-Test Management 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

  3. Introduction • In 1921 Bantingand 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.

  4. 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

  5. Screening • No consensus • FBS, 2HPP, (75g OGTT). RBS • 50g glucose oral challenge, 1 hr glucose 140 mg/dl. • Poor screening tools: • Urinalysis, HbA1c, Fructosamine • Universal or selective • Timing of screening

  6. SCREENING contd. • 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

  7. DIAGNOSIS • Symptoms & Signs: polydypsia, polyuria, polyphagia. • WHO Criteria: 75 g OGTT • A single abnormal value in symptomatic patient.

  8. Management • AIMS • Educating the individual • Euglycemia • Early detection and treatment of medical problems • Prevent obstetric complications • Optimal timing and appropriate mode of delivery • Family planning • Appropriate.

  9. Management GDM • MUITIDISCIPLINARY; • Education, Diet, Exercise • MEDICAL ; • Insulin,oral hypoglycemic agents ? • OBSTETRICS; • Ante-partum • Intra-partum • Post-partum

  10. 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

  11. 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,andischaemic heart disease must be assessed

  12. INSULIN THERAPY • Use of human insulin for pregnant diabetics and diabetics considering pregnancy [ADA recom] • Insulin needincrease 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.

  13. REGIMEN ADJUSTED 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

  14. Recommended levels Therapeutic 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)

  15. 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

  16. Insulin Analogues 2. Long acting analogs glargine Cat C drug Not well studied systemically

  17. 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 recomfor patients whose glycemic control is poor: • Constantly exceed 200 mg/dl or those who experience significant hypoglycemic episodes

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