1. DIABETES IN PREGNANCY AHMED ABDULWAHAB

2.  CLASSIFICATION:  INSULIN DEPENDANTDIABETES.I.D.D  Diagnosis before pregnancy,patient already in insulin usually young with little or no insulin.  Non insulin dependant DM,patient on oral hypoglycemic agents

3.  STANDARD TEST FOR DIAGNOSIS:  75 gm of glucose –orally after over night fast.  Fasting < than 6 mmol one hour less than 11mmol. 2hour <9. 3 hour should back to fasting level

4.  GESTIONAL DIABETES:  Diabetes occurs during pregnancy, will come to normal after delivery:  INDICATION OF GTT; High GCT more than 7.8 mmol  Potential diabetes.  Unexplained IUFD  History of congenital anomalies

5.  Glucose in urine more than twice  Maternal weight more than 90 KG  Previous big babies

6.  WHY?  Pregnancy has diabetogenic effect.  There is a decreased sensitivity of insulin due to antagonizing effect by cortisone – estrogen –progesterone HPL, and degradation of insulin by placenta

7.  GLUCOSE AND INSULIN RELATIONSHIP IN MOTHER AND FETUS.  Glucose cross placenta by facilitated diffusion.  Fetal pancreatic beta cell hypertrophy will increase the release of insulin.  Insulin is a potent stimulus to growth.

8.  EFFECT OF PREGNANCY ON DIABETES.  Difficult to control  Lowered renal threshold and diminished sensitivity to insulin  Retinopathy. Need careful ophthalmic assessment, there is increase prolifrative retinopathy  Nephropathy may be confused with hypertension and edema,assess renal function

9.  EFFECT OF DIABETES ON PREGNANCY.  Abortion.  Infection UTI fungal infection.  Pre eclampsia  Polyhydramnios  Prenatal death RDS – anomalies  Macrosomia.

10.  Cont.  Congenital anomalies –poor control at early pregnancy, mainly CVS and CNS.  Caudal regression syndrome is specific.  Lung maturity, fetal insulin antagonize the effect of cortisone on surfactant.

11.  MAAGEMENT  Combined care,obstetrician and physician.  Without complication wait till 40 weeks  Food plan. 50% carbohydrate 20% protein 20% fat, fiber  Majority need insulin –short acting 2 or 3 doses may be required..  Doses rise progressively with advancing pregnancy.  Oral hypoglycemic never to be used  Keep FBS between 4-6. 2h postprandial below 8 mmol  HbA1C REFLECT average plasma glucose normal 6%

12.  OBSTETRIC CARE  Early pregnancy control reduce anomalies.  Late control reduce PET polyhydramnios and macrosomia.  Early booking for accurate dating.  Detailed USS ANOMALIES 18-20 WEEKS  Alpha fetoprotein  Regular follow up

13.  DELIVERY.  Normal pregnancy wait 40 weeks  DM alone is not an indication for caesarian section  Induction of labor IOL Insulin infusion, hourly checking of blood sugar (sliding scale)  Close fetal heart monitoring.

14.  POST PARTUM CARE.  Insulin requirement fall rapidly after delivery  Infant of diabetic mother has the following problems.  Over weight, plethoric,RDS, hypoglycemic.  Hyperbilurbinaemia hypocalcaemia.