1 / 16

2004 NJ ACP Obstetric Medicine Workshop

2004 NJ ACP Obstetric Medicine Workshop. Michael P. Carson, MD Asst. Clin. Prof of Medicine and Obstetrics UMDNJ - RWJMS Chief, Division of General Internal Medicine Saint Peter’s University Hospital. Common Disorders. Asthma – No changes to management Hypothyroidism

oliana
Download Presentation

2004 NJ ACP Obstetric Medicine Workshop

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. 2004 NJ ACPObstetric Medicine Workshop Michael P. Carson, MD Asst. Clin. Prof of Medicine and Obstetrics UMDNJ - RWJMS Chief, Division of General Internal Medicine Saint Peter’s University Hospital

  2. Common Disorders • Asthma – No changes to management • Hypothyroidism • Check TSH each trimester. • Check it 4 weeks after any dosing change • SLE – Be very careful. • Increased risk of flare • RA • flares postpartum • Multiple Sclerosis – • increased flare risk, follow-up period may not be adequate.

  3. Diabetic Ketoacidosis Background: Pregnancy & DKA • Respiratory alkalosis leads to Bicarb loss by kidneys. • HCO3- is ~ 20 • Less buffering capacity • Ketogenesis is accelerated 2-4 times during pregnancy • Less hyperglycemia is required to cause DKA during pregnancy • Mortality: • Maternal 5-15% • Fetal 50-90%

  4. Diabetic Ketoacidosis Metabolic Effects of DKA • Abnormal Insulin:Glucagon ratio favors triglyceride release from adipose tissue. Then, they’re metabolized to ketones rather than being stored or metabolized to carbon dioxide. • Notice a theme here? • Ketones: • Primary is beta-hydroxybutyric acid • Aceto acetic acid • Reacts with the nitroprusside test. • Responsible for fruity odor on the breath.

  5. Glyburide • Increases Pancreatic Insulin Output Langer et al. N Engl J Med 2000;343:1134-8 A comparison of glyburide and insulin in women with gestational diabetes mellitus • 404 women with GDM requiring treatment • Insulin or glyburide between 11-33 weeks • Insulin 0.7 U/kg (admission) tid &  weekly prn • Glyburide 2.5 mg/d;  weekly up to 20 mg/d max.

  6. Glyburide

  7. Glyburide

  8. Glyburide • Metabolic control similar in both groups • Maternal hypoglycemia  in insulin group • Glyburide not detected in cord blood • Despite being present in maternal serum • Corroborates their in vitro data • Only given after 11 weeks gestation • No first trimester data

  9. Glyburide: When • Started for the same indications as insulin • Compliance • Trend • 2.5mg once a day • Timing depends on the pattern • May give doses BID • Max is 20mg • Test as an A2 GDM.

  10. Metformin • Used since the 1950’s • Several mechanisms of action have been proposed: • Enhanced peripheral glucose uptake and utilization. • Increased insulin receptor affinity (reduced insulin resistance). • Inhibition of hepatic gluconeogenesis (glucose production). • Most Significant • Will improve fertility in PCOS

  11. Metformin: PCOS and GDM • Gluek 2002 • Retrospective 39 Women with PCOS and NO h/o DM • GDM in 14/60 pregnancies (23%) • Prospective 33 Women with PCOS • 8/12 (67%) developed GDM during historical pregnancies • GDM 1/33 (3%) when treated • Metformin may decrease GDM, but Fetal effects?

  12. Metformin: PCOS and IVF • Clomiphene Resistant PCOS • IVF cycles: 46 Women 60 Cycles • ½ cycles given Metformin 1000-1500 mg Met Control • Oocytes Retrieved 22 +/- 1.9 20.3 +/- 1.5 • Mature Oocytes 18.4 +/- 1.5 13 +/- 1.5 • Embryos Cleaved 12.5 +/- 1.5 5.9 +/- 0.9 • Fertilization rates 64% 43% • Clinical Pregnancy Rates 70% 30% Stadtmauer. Fertil Steril. 2001 Mar;75(3):505-9.

  13. Metformin: PCOS and SAB • Gluek 2001 and 2002 • 72 Women with PCOS treated with Metformin • 84 Pregnancies • First Trimester Miscarriages • Historically: 40 women had 100 pregnancies • 62% First Trimester Loss • With Metformin 14 of 84 Pregnancies • 17% First Trimester Loss • Congenital Defects • None in the 63 completed pregnancies • 9 ongoing pregnancies >13 weeks have normal U/S

  14. Metformin and...oops • Hellmuth 2000 • Known diabetics in Pregnancy (160 Pregnancies) Metformin Glyburide Insulin n 50 68 42 PIH (%) 32 7 10 Mortality (%) 11.6 1.3 (combined)

  15. Summary: Oral Agents • Glyburide appears effective • Accepted by patients • Has data • Metformin • Improves fertility in PCOS • May decrease first trimester loss in PCOS • Appears to improve IVF results • May increase risk of PIH and Mortality • Duration?

  16. SLE, APLAb, Anti-beta-2 Glycoprotein-1 n Clincial Serology b2GP1 Total 94 Group 1 21 + + Group 2 18 + - Group 3 33 - - Group 4 22 - + [Cabiedes J Rheumatol 1995;22:1899] 35/39 2/55

More Related