DIABETES MELLITUS (DM) IN PREGNANT WOMEN

1. DIABETES MELLITUS (DM) IN PREGNANT WOMEN Dr. Shamanthakamani Narendran MD (Pead), PhD (Yoga Science) How yoga helps?

2. Pregnancy induced DM • Gestational Diabetes Mellitus is glucose intolerance during pregnancy. • Prevalence of DM among women of childbearing age is increasing. • Sedentary lifestyles - changes in diet. • Childhood and adolescent - obesity.

3. Pregnancy induces progressive changes in maternal carbohydrate metabolism. • As pregnancy advances insulin resistance and diabetogenic stress due to placental hormones necessitate compensatory increase in insulin secretion. • When this compensation is inadequate gestational diabetes develops.

4. Women diagnosed to have GDM are at increased risk of future diabetes predominantly type 2 DM as are their children. • Thus GDM offers an important opportunity for the development, testing and implementation of clinical strategies for diabetes prevention. • Timely action taken now in screening all pregnant women for glucose intolerance, achieving euglycemia in them and ensuring adequate nutrition may prevent in all probability, the vicious cycle of transmitting glucose intolerance from one generation to another.

5. Women and diabetes • Diabetes no longer means • Abstinence • Amenorrhea • Inability to conceive • Inability to deliver healthy children • Death during pregnancy

6. Diabetes and fertility • Delayed menarche in T1 • Menstrual abnormalities • Premature Ovarian Failure • PCOD

7. Diabetes in pregnancy • Placental structure and function is affected • Early IUGR as high BG inhibits trophoblast proliferation • Hypertension, renal disease more frequent • High glycogen content in placenta

8. Fetal morbidity in GDM • Miscarriages • Growth restriction • Fetal macrosomia

9. Newborn complications • Birth defects • Birth injury • Polycythemia • Hypoglycemia • Hypocalcemia • Hyperbilirubinemia • Respiratory problems

10. Maternal morbidity • Diabetic retinopathy • Renal complications • Chronic hypertension • Preeclampsia

11. Screening for GDM • WHO: FBG and 2h PPBG or 2h post-75 g glucose BG • 1 h post- 50 g glucose load BG [GCT] • ADA: FBG, 1 h, 2 h, 3 h post- 75 or 100 g glucose BG • One-step or two-step protocol • At first visit; reassess at 24 – 28 weeks

12. 1 hr GCT 140 mg % 130 mg % 75 g GTT 2 h: 155 mg % 100 g GTT 1 h: 180 mg % 2 h: 155 mg % 3 h: 140 mg % Screening for GDM Any time of day No regards to meals

13. Criteria for diagnosis of GDM with 100 gm oral GTT

14. Criteria for diagnosis of impaired glucose tolerance and diabetes with 75 gm (WHO) oral glucose

15. Management • Dietary therapy • Glucose monitoring • Insulin therapy • Oral hypoglycemic agents –Metformin • Timing of delivery

16. Management of delivery • Referred to well equipped hospital to prevent maternal and fetal complications.

17. DIET

18. Medical Nutrition Therapy • 6 meal pattern • Substantial night snack; light breakfast • Encourage complex carbohydrates, fruits • 30 cal/kg/day = 1500 cal for a 50 kg lady • Avoid starvation/ketosis • Increase intake in 3rd trimester • Weight reduction if BMI > 27

19. Avoid • High fiber foods – fresh fruits and vegetables, whole grain breads, cooked dried beans and bran cereals. • Beverages with added sugar, corn syrup, honey, maple syrup, jams and jellies. • Read the labels of packaged foods to find the grams of carbohydrate a serving has in it.

20. Calorie Intake • Needs about 300 extra calories per day in the second and third trimesters to gain enough weight. This equals about 16 to 17 calories per pound of ideal body weight. • An extra 10 to 12 grams of protein per day helps baby grow normally. It helps to get 45-60% of calories from carbohydrates, 15-25% from protein and 20-30% from fat.

22. Food Selection Pyramid • Prefer • Bajra, • Jowar, • Wheat flour mixed with black channa flour whole, • Split & sprouted pulses, • Green leafy vegetables & fresh fruits, • Skimmed milk & curd, • Light tea, • Vegetable juices.

23. Food Selection Pyramid • Limit • Rice, • Biscuts, • Naan & food prepared with maida, • Roots & tubers – potato, arbi jimikand & sweet potato, • Whole milk, • Tea & coffee

24. Food Selection Pyramid • Avoid • Fat, • Sweets, • Pastries, • Fruits like – mango, grape, banana, chiku dates, custard apple, • Cold drinks & alcoholic drinks, • Non-veg food stuffs, • All nuts & oil.

26. Yoga practices • Hands in & out Breathing • Hands stretch breathing • Ankle stretch breathing with wall support • Side twist breathing • Instant relaxation technique [IRT]

27. Yoga practices • Leg raise breathing • Hip raise breathing • Spine & abdominal stretch breathing • Cycling in the supine pose • Tiger breathing

28. Yoga practices • Ankle rotation • Kneecap contraction

29. Yoga practices • Eye exercises • Alternate nostril breathing • Shavasana in left lateral position. Avoid • Jogging • Suryanamaskar • Kapalabhathi & Bhastrika

30. Group practice Hands In & Out Ankle Stretch

31. Tiger Stretch Side Stretch

32. Loosening Exercises Forward Bending Backward Bending

33. Sitting Postures Vajrasana Ardha Matsyendrasana

34. Badha Konasana Squatting

35. UphavistaKonasana

36. Sasankasana

37. Supine Postures Viparita Karani Viparita Karani with Wall Support

38. Pranayama Mastery over Prana – Slowing of breath – Awareness of breathing – Balance between the two nostrils. 2. There is intimate connection between mind and Prana.

39. Cooling Pranayamas Sitkari (Folded – up – Tongue Pranayama) Sitali (Beak – Tongue Pranayama) Sadanta (Suck – through – Teeth Pranayama

40. Relaxation Techniques Instant Relaxation Technique (IRT) Quick Relaxation Technique (QRT) Deep Relaxation Technique (DRT)

41. Meditation Omkar Meditation

42. Mudra Aswini Mudra