diabetes, dr alka
TRANSCRIPT
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Diabetes Mellitus in
Pregnancy
Dr. Alka Kriplani
Professor, Head - Unit-II
Department of Obst. & Gynae.
All India Institute of edi!al "!ien!es
#e$ Del%i
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Gestational diabetes mellitus
+arbo%ydrate intoleran!e of *ariable se*erity
$it% onset or first re!onition durin
prenan!y
eardless of $%et%er insulin is used for
treatment or t%e !ondition persists after
prenan!y
Does not e)!lude unre!onied lu!oseintoleran!e before prenan!y
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Screening
%om to s!reen/
et%od of s!reenin/
0ime 1POG2 of s!reenin/
Ad*antaes and disad*antaes of
s!reenin and sele!ted met%od
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Whom to screen
A+OG and HO 3
uni*ersal s!reenin at 45-46 $eeks
%i% risk $omen- s!reenin at fist antenatal
*isit
ADA 147762- risk fa!tor analysis
-OG00 if indi!ated
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Risk factors for GDM Obesity 18477 lbs or 89:; of non prenant ideal body $ei%t2
Positi*e family %istory of diabetes 1siblin or parent2
Persistent ly!osuria
H
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Universal vs selectivescreening- Indian scenario
Pre*alen!e of GD- 9?.::; 1"es%ia% @ et al. Asso! P%ysians India 47752
of GD in Indians 99.> times !ompared to $%ite
$omen (Diabet Med 1992)Uni*ersal s!reenin
ore sensiti*e
BOH !omponent not a*ailable in nulliparousissin GD -ad*erse lon term effe!ts
Universal screening is preferred over selective
screening in India
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Glucose challenge test
world wide accepted50g glucose load regardless of meals
140mg/dl 130mg/dl
Sensitivity C; 7;
specificity 6C;
Need for GTT 95-96; 47-4:;
With 140mg/dl as cut-off-ood reprodu!ibility
If 9%r -957m
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Diagnosis of GDM
Glu!oseload0%res%olds 1m%r
AA
977
1+arp& +2
=: = 967 = 9:: = 957
C: = : = 967 = 9::
A!"G
#NG2
977 = 97: = 97 = 9?: = 95:
$%" C: = 94? = 957
COG, 2007
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ne ste! diagnosis of GDM
HO 3 C: OG00
useful in populations $it% %i% pre*alen!e of GD 1 India2
1J Obstet Gynecol India. 2005;55(6) 525!529)
Does not reuires :7 G+0
Glu!ose load Fastin
1m
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ne ste! diagnosis of GDMcontd"""
Ad*antaes o*er 977OG00
"inle step met%od
ore sensiti*e
+%eap n !on*enient for t%e patients
Does not need :7 G+0
Disad*antaes
O*er dianosis
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)MP'I)%$I&S
"(stetric
+onenital anomalies
"pontaneous abortion
Poly%ydroamnios
Preterm deli*ery
a!rosomia
Une)plained fetaldeat%
Pre-e!lampsia
IUG
0raumati! deli*ery
)edical
etinopat%y
#ep%ropat%y
Diabeti! keto-a!idosis
Hypertension
Hypoly!emia
#europat%y
Infe!tions
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Congenital anomalies+ardio*as!ular
0GA, @"D, A"D, +oar!. of aorta, situs in*ersus+#"A!rania, anen!ep%aly, #0Ds, mi!ro!ep%aly
"keletal system
Hemi*ertibra, +AUDA (G(""IO# "#DO(14:4times more !ommon2
enalenal aenesis, ureter dupli!ation, %ydronep%rosis
Gastrointestinal-duodenal atresia, imperforate anus
%(A1c levels vs ris* of anomalies?;- >;
9:;- 857;
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)acrosomiaE Birt% $t E +4'0 *g in dia(etic+4'5 *g in non,dia(etic
!omplications of macrosomia )aternal
in'uries to t%e birt% !anal
in!reased risk of "+" ->7;
(Jensen et al.Diabetes Med 20002 -etal
Intrapartum asp%y)ia birt% trauma 1e.. !la*i!ular fra!tures2
s%oulder dysto!ia
bra!%ial ple)us in'ury
fetal deat% 17.5;2
Macrosomia*'G%
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Pathogenesis -Pederson hy!othesis
J
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M%&%G#M#&$
DI#$#+#R)IS#I&SU'I& $,#R%P
. R%' ,PG')#MI)S
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Medical nutrition thera!y
Primary t%erapy for >737; of $omen dianosed$it% GD
92"tart $it% diet
onitorin E9-4 $eekly till >? $eeks
eekly after >? $eeks
42 .ercise- >-5 times $eekly for 47->7 min per session
>2 Blood sugar profile- FB" - post meals
ostprandial monitoring results in more improvedglycemic control in G)
(eciana ) * +ng , )ed 1"" !%%%#12&1-&%'
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)om!osition of diabetic diet
(uly!emi! diet- old !on!ept
*uch diet causes
excessi!e weight gainse!ere postprandial hyperglycemia
+urrent !on!ept- lo$ !arbo%ydrate diet
8maternal postprandialglucose,impro*ed maternal & fetal out!ome
(,ovanovic .lin stet necol 2000!4%(1'#4-'
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$arget glucose levels during!regnancy
Time enous plasmaglucose levels #mg/dl2
Fastin 1BBF2 ?7-7
Before lun!%, dinner ,bedtime sna!k
?7-97:
After meals14%2 947
4E77 to ?E77am 8?7
CG 2007
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$y!es of insulin0P( O#"(0 P(AK DUA0IO#
U0A-"HO0 A+0I#G
ispro, Aspart, Glulisine7-9:min >7-
7min5-:%rs
"HO0-A+0I#G
(GUA>7-5:min 4-5%rs ?-6%rs
I#0((DIA0( A+0I#G
#PH
ente
1semilenteLultralente2
9-4%rs
9-4.:%rs
5-97%rs
?-94%rs
96-45%r
47-45%r
O#G-A+0I#G Ultra-lente
Glarine
5- 6%rs
9%r
6-94%rs
none
>?%rs
45%rs
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Insulin thera!y
+al!ulate total dose1 4- intermediate a!tin 1isop%ane2 L 9
s%ort a!tin insulin1 a!trapid2
4 of t%e dose in mornin and 9 in e*eninornin-4 isop%aneL 9 a!trapid
(*enin -9
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Insulin thera!y- facts
)orning doseA(domen
#15,30min2
9unc : dinner
Arm
#30,45min2
7edtime doseTig
#45,;0min2
)aimum
rapid
:a(sorption
Slowa(sorption4 $eeks if IUG, PIH,
#ep%ropat%y,insulin re 8977U2Biop%ysi!alprofile
$eekly
52 Doppler in early dete!tion of
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$iming of deliveryPlan for indu!tion at >6.: $eek
If (F 85.:k- ele!ti*e "+" (*OG 200+)
((+0I@( "+"
Plan early mornin
Usual H" dose
#PO
ornin dose $it%%eld
Blood suar monitorin
"tart #"
:; de)trose if blood suar C7m
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'o5 dose insulin infusion for thediabetic 5oman during the
intra!artum !eriodBlood lu!ose
1m
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Post-!artum managementInsulin reuirement de!reases rapidly 1first 45-C4 %rs2aginal delivery
GD
on diet - no monitorin reuired
on insulin - fastin & PP *alues before dis!%are
Preestational D
"tartin reular diet
One %alf of t%e pre-prenan!y dose 1 PPD92
A!"G &005
9
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Post-!artum management
After cesarean deliveryBld suar monitorin 5-? %rly
eular insulin - if blood suar 8957 -9:7 m
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Post !artum glucose testing;,1& wee*s postpartum
=5g glucose testing
ia(etes
mellitus
mpaired
Glucosetolerance
-7G#>110mg/dl2
=C.7 mmol
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l , l i i
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ral ,y!oglycemic agents in!regnancy
)etformin
7iguanide @!ategory 7 drug
In prenan!y
"%ould it be !ontinued in P+O" patients after
prenan!y/
+an it be used for GD patients/
+an patients $it% type II D !an a!%ie*e ly!emi!!ontrol $it% metformin as insulin and lyburide/
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Metformin in P)S
Gilbert et al. systemi! re*ie$ and meta analysis0reatment $it% metfromin in first trimester $as
asso!iated $it% :C; prote!tion effe!t $it% an anomaly
rate of 9.C; in metformin roup and C.4; in !ontrol
roup.)etformin use not associated 6ith ma7or malformations
(*an J ,&a'acol 2005;12(1)125)
de!reases t%e in!iden!e of GD
(Gl-e *J /- e'od 200;19(3)510!2)
edu!es t%e in!iden!e of spontaneous abortions
( J *lin 4ndoc'inol Metabol 2002;8+52)
MiG t d 3M tf i i t ti l
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MiG study 3Metformin in gestationaldiabetes4
etformin p Insulin p
#o. of patients >?>
-4.?; re!*d metformin
-5?.>; re insulinPrimary out!ome-neonatal%ypoly!emia, prematurity,D", p%otot%erapy need, lo$apar s!ore
>4; >4.4;
"e!ondary out!ome-maternally!emi! !ontrol,%ypertensi*e !ompli!ations,postpartum lu!ose
toleran!e, ) a!!eptability
#o sinifi!ant differen!e bet$een 4roups
RCT7!" women with #DM$2%&& w'sP(#) ( 4n J Med 2008;3582003!2015)
C?.?; $omen preferred to take metformin
in ne)t prenan!y
Gl b id
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Glyburide
*econd generation sulphonylurea +,ategory .
/oes not cross placenta +fetal le!els 0)' of maternal le!els.
/ose 1 start with 2mg 3*4 #ax upto 2%mg5day
6,7- perinatal outcome similar to insulin
(Langer L N Eng J Med ;2000:343)(fficacy similar to insulin till F*0)8%mg5dl
,urrently not recommended by F/9
Rea*hing established levels of gly*emi* *ontrol and not themode of therapy is the 'ey to improve perinatal o+t*ome in
#DM
(Am J Obstet Gyne!"200#;$%2:$34&$3%)
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!ontraception Barrier met%ods- %i% failure rates
Intrauterine de*i!es- no in!reased risk of PID in all diabeti!s. +anbe used safely
(7os et al.Obstet Gynecol *lin o't& A 1996;2323!58)
+ombined O+PMs3
Use lo$est dose +O+
A*oid if %ypertension and ot%er !ardio*as!ular risk fa!torspresent
inipill3 impaired ly!emi! !ontrol
1 proesterone indu!ed %yperly!emia2
In'e!tables3 a*oided as t%ey !ause altered lipid profile, Glu!oseintoleran!e
Indi!ation - estroen !ontraindi!ated
- non !omplian!e 1 HO 92
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