4Preexisting diabetes in pregnancy Type 1 DM ( IDDM)Type 2 DM (NIDDM)
5Preexisting DM in pregnancy Effect of pregnancy on pre-existing DMIncrease requirement for insulin dosesNephropathy , autonomic neuropathy may deteriorateProgress in diabetic retinopathy (2X)HypoglycemiaDiabetic ketoacidosis
6Preexisting DM In Pregnancy Effect of preexisting DM on pregnancyMaternal1. increase risk of miscarriage2. increase risk of preclampsia3. increase risk of infection eg vaginal candidiasis, UTI, endometrial or wound infection4. increase LSCS rate
7Preexisting DM in Pregnancy (2) Fetal1. increase risk of congenital abnormalitiessacral agenesis, congenital heart disease,neural tube defectsHba1c level Risknormal not increased<8% %>10% %
11ManagementAimAchieve maternal near normoglycemic level to prevent adverse perinatal outcomes
12Diet Low-carbohydrate diet , high fibre with caloric restriction Frequent small snacks may be needed between mealsAvoid starvation
13Insulin3 pre-meal short acting insulin (actrapid) +/- intermediate-acting insulin (protophane) as it allows maximum flexibilityTarget blood glucose:fasting < 5mmol/L2 hr <7 mmol/L
14Oral Hypoglycemic agents Implicated as teratogeneic in animal studies esp first generation sulfonyureasIn humans, scattered case reports of congenital abnormalityRisk of congenital abnormality related to maternal glycemic control rather than mode of the anti-DM agents
15Oral hypoglycemic agents For Type 2 DM patients,to stop oral hypoglycemic agents and change to insulinReassure that the risk of congenital abnormality due to drug is small
16Oral hypoglycemic agents Biguanides ( metformin)Cat B drugCommonly used in Polycystic Ovarian Disease (PCOD) to treat insulin resistance and normalize reproductive functionNot teratogeneicReduce first trimester miscarriage10X reduce gestational diabetesGlueck, Fertil Steril 2002Reece, Curr Opin Endocrinol Diabetes, 2006Hague, BMJ, 2003Glueck, Human Reprod, 2004
17Oral hypoglycemic agents Sulfonylureas1st generation drug increase risk of neonatal hypoglycemia2nd generation drug (Glyburide) no such effect and other morbidities .Cat C drug4%-20% patients failed to achieve glucose control with maximum dose of drugIncrease risk of preeclampsia and need for phototherapyLanger, N Eng Med J , 2000Kremer, Am J Obst Gynaecol, 2004Chmait, J Perinatol ,2004Langer, Am J Obst Gynaecol, 2005
18Insulin Analogues 1. rapid-acting insulin analogs (lispro) Cat B concerns about teratogenesis, antibodies formation, growth-promoting propertiesmajority of evidence showed that it does not cross placenta, and has no adverse maternal or fetal effects
19Insulin Analogues 2. Long acting analogs glargine Cat C drug Not well studied systemically
20Monitoring Regular home glucose monitoring with h’stix Insulin may be need to be adjusted as gestation advancesHba1c monitoringFetal monitoring with USGRefer ophthamologist
21Delivery Timing and mode of delivery individualised Intrapartum insulin infusion with glucose monitoringno contraindication for Breast feeding either with insulin or oral hypoglycemic agents
22Pre-conception Counselling Allows for optimisation of diabetic control prior to conception, and assessment of the presence of complications like hypertension, nephropathy, and retinopathyShould counsel that good control and lower hba1c lower the risk of congenital abnormalities and improve outcomeIf necessary, proliferative retinopathy may be treated with photocoagulation prior to conceptionContraindications to pregnancy only :ischemic heart dx, untreated proliferative retinopathy, severe renal impairment(creatinine>250 mmol/L)
23Gestational diabetes Definition Carbohydate intolerance of variable severity first recognised during the present pregnancy.This includes women with preexisting but previously unrecognised diabetes
24No consensus for 4 decades! Gestational diabetesNo consensus for 4 decades!
25Gestational diabetesShould all pregnant women be screened or only those with risk factors?Is it safe to screen all?Which screening test and which diagnostic test are the most reliable?Which cut-off values should we use?What are the risk for mothers and babies and can treatment improve outcome?What are the connection between gestational diabetes and type 2 DM?Is it physiological or pathological ?
26Gestational diabetes Screening and diagnosis In general, the test is performed btn wk because at this point in gestation the diabetogenic effect of pregnancy is manifest and there is sufficient time remaining in pregnancy for therapy to exert its effect
27Gestational diabetes Screening and diagnosis In general, risk factor includes:1. age>25y2. BMI > 253. previous GDM4. Family hx of DM in 1st degree relative5. previous macrosomic baby (<4 kg)6. polyhydramnio7. large for date baby in current pregnancy8. previous unexplained stillbirth
30Gestational diabetes Incidence 2-9% more common in Asian and Indian womenIn developed countries, increasing trend because of epidemic of obesity
31Gestational diabetes Clinical significance of GDM High incidence of macrosomia, and adverse pregnancy outcomes,A significant proportion(30%) identified as GDM in fact have DM before pregnancy
32Gestational diabetesWomen with glucose intolerance just above normal range are at low risk for pregnancy complications, those with more severe glucose intolerance approaching the criteria of diabetes are at risk of neonatal complications
33Fetal complications Macrosomia (>4 kg) risk is 16-29% as compared to 10% in controlIncrease in caesarean delivery, intrumental deliveries ( forceps/vacuum), birth trauma, such as brachial plexus injuries , clavicular fracturesIncrease in neonatal hypoglycemia (24% ), hyperbilirubinemia, hypocalcemia, polycythemiaChildren are at risk of type 2 DM and obesity in life
34Maternal complications Increase risk of hypertensive disordersIncrease risk of caesarean and intrumental deliveriesIncreased Risk (40-60%) of developing type 2 DM within10-15 yr.
35Gestational diabetes Does treatment improves outcomes? Conflicting results1. Cochrane datebase systemic review 2005 (3 studies only)no difference in outcomes except neonatal hypoglycemia2. Australian Carbohydrate Intolerance Study in Pregnant Women (ACHOIS study) 2005 ( 490/510 subjects)treatment of diabetes reduces serious perinatal morbility and mayimprove the woman’s health-related quality of life
36Gestational diabetes Large randomized study on going HAPO trial in USA (Hyperglycemia and Adverse Pregnancy Outcome study)
37Gestational diabetes Management Management similar as preexisting DM Need for glucose monitoringStart with Diet controlCommence insulin for poor controlDelivery plan individualised
38Gestational diabetes In view of risk of developing type 2 DM the woman should be screened annually for DM on yearly basis.
39Diabetes and Pregnancy Conclusion Preexisting DM in pregnancyGood glucose control is important for decreasing morbiditiesInsulin is still the gold standard of tx in pregnancyIncreasing evidence for clincial effectiveness for treatment with oral hypoglycemic agents
40Diabetes and pregnancy conclusion (2) Gestational diabetesno consensusThe morbidities increases as glucose level approaching the diagnosis as DMPossible that treatment improves outcomesOverlap with preexisting DM, esp type2Long term implication for health of the mother and baby