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Published by: Senopati Khanjie on May 28, 2012
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01/27/2013

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Medical Complications in Pregnancy

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DIABETES MELLITUS
MUHAMMAD ZULHILMI BIN ABU BAKAR

A metabolic disorder of multiple aetiology that affects the normal metabolism of carbohydrates. insulin action or both diagnosis  Fasting plasma concentration: >7.1.(pre diabetes) .8 and 11. fats and protein characterized by chronic hyperglycemia as a result of defective in insulin secretion.most likely pt. have impaired glucose tolerance test.1 mmol/L  If two hours level are between 7.8 mmol/L  2 hour plasma concentration(OGTT): >11.

2.1. 4. 3. Type 1(IDDM) Type 2(NIDDM) Gestational diabetes Others -genetic defects in insulin processing or action -endocrinopathies -drugs -exocrine pancreatic defects -genetic syndromes associated with dm .

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 Constitutes 90 percent of diabetes in pregnancy  Generally occurs in the latter half of pregnancy.  Therefore it has no effect on organogenesis and does not cause congenital defects  Disappear after delivery . Defined as glucose intolerance of variable severity with onset or first identified during the present pregnancy.

 Either type 1(iddm) or type 2(niddm)  Type 1 occurs in younger age group and end organ complications is likely to be more. Hence they to have increased maternal and obs risks  Type 2 usually occurs in obese patients and have less maternal and obs compared to type 1 .

Plasma cortisol also rises during pregnancy. Pregnancy alters carbohydrate in such away more glucose is made available to the fetus What cause the diabetogenic state?  Elevated placental hormones such as estrogens.despite the production of insulin cannot overcome the effect of these counter regulatory hormones. Cause ‘contrainsulin’ effect and state of insulin resistance Further aggravated by increase body weight and increase caloric intake during pregnancy Gestational diabetes develops when the pancreas . progesterone. human placental lactogen. prolactin. In contrast pregestational diabetes becomes worse during pregnancy      .

1. fetal anomalies History of recurrent abortions or unexplained stillbirth Drug history-steroids. tocolytic drug 2. vaginal candidiasis Presence of glycosuria on more than 2 occasions .         Historical factors Age>30 years Previous gdm Family history of dm Bad obs history History of macrosomia Prev.      Clinical factor in the present pregnancy Congenital fetal anomalies Pre-eclampsia Obesity>90 kg Recurrent uti.

 Gdm is asymptomatic . A plasma glucose level of > 7.8 and or 2 hour level of >11.1. Universal screening(all pregnant women) Selective screening(presence of risk factors for gdm)  for universal screening –do the glucose challenge test No special preparation is needed for this test 50 grams of oral glucose is given between 24 to 28 weeks pog Blood glucose is determined 1 hours later.8 and 11.   Selective screening-oral glucose tolerance test     75 grams of oral glucose is given Only 2 reading are taken-fasting glucose level and 2 hour post glucose The diagnosis of dm is made when fasting glucose level are ≥7.hence we need screening test to detect gdm 1.8 is considered significant to perform confirmation diagnostic test. . 2.the patient is said to have impaired glucose tolerance test and should be treated as gdm.1 If the 2 hours levels are between 7.

1. 9. ketoacidosis Increased instrumental and CS rates Study shows that after gdm. 5. 2. 6.uti Retinopathy Nephropathy Neuropathy Micro/macroangiopathy Polyhydramnios—pprom. 4. 3. cord prolapse.40-60% of women develop type 2 dm within 10 years . 10. 7. Pre-eclampsia Recurrent infection-vaginal candidiasis. 8.

Polycythemic -jaundice . 5. 7. 4.cardiac and renal anomalies Macrosomia Respiratory distress syndrome Hypoglycemia-result of hyperplasia of beta cell SIUD Prematurity Malpresentation Shoulder dystocia. 2.1.ntd. 9. 8. 3. 10. 6. Miscarriage Congenital anomalies(4 fold)-sacral agenesis.

It gives retrospective assessment 12 weeks ago. High HbA1c at the end of first trimester indicates sugar control was poor during organogenesis period. Blood sugar level-weekly assessment is required. Maternal serum AFP-done between 16 to 20 weeks pog . 2. 4.1. 3. Useful in deciding whether to start insulin or adjusting insulin dosage Urine microscopy and culture-to exclude uti(bacteriuria) HbA1c-done in first trimester.

fetal growth. Diagnostic imaging-gestational age. fetal abnormities. liquor volume. 6.5. Doppler of umbilical artery-done in cases of diabetic vasculopathy .

malpresentation. If failure insulin should be started.38 weeks. polyhydramnios. can prolonged to term  Mode of delivery-lscs if macrosomia baby.evidence of fetal compromise  Check BP  Fetal growth chart  Monitor closely with continuous ctg .  Admission-poor blood sugar control. BSP should be monitored  Timing for delivery-if on insulin. if on diet control. PIH.Antenatal management  Plasma glucose level should be maintained between 4-6 mmol/L  Early dating and scan to exclude fetal abnormalities  Diet control should be attempted first.

 Oral hypoglycemic drug are generally not recommended as it can cause teratogenic effect towards fetus and can cross placenta causing hypoglycemia  Diet  therapy    Total calories advised is 24-30 kcal/kg of the present body weight. 24kcal/kg is advised The calories should be distributed between 3 meals and 3 snacks Dietary control decrease postprandial glucose level and it also improve insulin action. Blood glucose level and weight gain can be used to formulate a meal plan .In obese diabetic pt.

 Exercise     Light exercise help by lowering fatty acid Contracting muscle help stimulate glucose transport hence decrease blood sugar Better done after meals Exercise involving the muscle of upper part of the body is sufficient to lower down glucose level. .

 Insulin    regimes 15% required insulin therapy Insulin is indicated in all pregestational diabetes and poorly controlled gdm The popular regimes use a mixture of short acting and medium acting insulin .

Pre-pregnancy counselling  This play an important roles for pregestational diabetes in order to prevent early pregnancy loss and congenital anomalies.  Those with oral hypoglycemic should be switched to insulin therapy. .  Complete assessment of diabetic status should be done to find out whether she is fit to go through pregnancy. HbA1c can be done to evaluate blood glucose control 12 weeks ago.

 15% of pt. with positive gct will have gdm  15% percent of GDM will required insulin  15% of GDM will have macrosomia  15% of GDM will have impaired gtt after delivery .

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