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Treatment of diabetes in

preg
Aim of management
Principles of management
Preconception care
Aim of management – to reduce perinatal
and maternal morbidity and mortality.
• Manage complications that can
• Principle of management deteriorate – blood pressure control,
• To achieve glycaemic control before retinopathy, nephropathy, ischaemic heart
conception disease.
• Prevent obst complication by good • Counsel on contraception.
antenatal care.
• Antenatal management
• Early detection and prompt Rx of
• Team management – obstetrican,
medical problems
physician, dietician etc
• Careful timing and appropriate mode • Main objective – mean 24hr glucose
of delivery
profile of 5mmol/l
• Intensive neonatal care
• Antenatal complications
• Preconception care • Infections
• Good control before pregnancy/treat- • Miscarriages
ment • IUGR
• Prevent congenital anomalies – folate • Macrosomia
• Counsel couples – about DM in preg, • Hydramnios
insulin therapy, hypoglycaemia, weight/ • Premature labour
dietry advise. • Preeclampsia
• Fetal growth assessment –
Medical complications macrosomia (25-40%) AC > 36cm;
keto-acidosis, hypoglycaemia, visual IUGR (PE); fundal height
deterioration, gaustattory vomiting, measurement; USS – 2-4weekly (DM =
ischaemic heart disease. from 24weeks GA, while in IGT and
GDM from 28weeks)
• Obstetric management. • Antenatal fetal monitoring
• Encourage early booking • High risk of fetal hypoxia and IUFD
• History – UTI, candidiasis • Fetal kick chart
• Clinical examination – BP , • Auscultation
polyhydramnios • Continuous fetal monitoring – ideally
• Investigations – urinalysi, urine- daily
m/c/s, HVS for candidiasis, FBC, • Biophysical profile – weekly or twice
E,U&C, blood sugar profile twice weekly
weekly • Doppler uss.
• Early viability scan/dating IGT – does not require intensive
monitoring unless there are other
• Antenatal monitoring problems
• See more frequently – 2 weekly until Admit patient for stabilization of blood
28 weeks of gestation, thereafter sugar if necessary.
weekly until delivery
Dietary management
• Morphology scan at 20weeks –
Neural tube defects, cardiac defects Aim – to control blood glucose level
(transposition of great vessels most Caloric intake
common major cardiac anomaly), renal
30-35 cal/kg/day
• Distribution • Dose – 2/3 of total daily for
• Carbohydrate – 50% morning and 1/3 for evening
• Fat – 30% • Morning dose – 2/3 intermediate
• Protein – 20% insulin and 1/3 soluble insulin
Avoid concentrated or refined sugars • Evening dose – ½ intermediate
Medical management insulin and ½ soluble insulin
• Stop all oral hypoglycaemic drugs – • Dose adjustment + 4units
less reliable in action and cross placenta barrier.
• Aim – blood glucose of 4-6mmol/l
• Patient should have a glucometer
for home glucose monitoring • Monitoring response to
• Good control – assess 2-3 times therapy
weekly • Clinical – hydramnios,
• Poor control – 6 times daily ( before macrosomia, hypoglycaemia
meals and snacks) • Glycosylated haemoglobin monthly
• Insulin therapy – well controlled = < 8.0% (Normal
• Soluble insulin – 6.0%), poorly controlled = >
• Long acting PZI (lente) 11.0%
Mixture of insulin – soluble and • Side effects of insulin
intermediate acting insulin therapy
Daily insulin requirement – 0.7- • Lipoatrophy
1.0units/kg body weight.
• Hypoglycaemia
Intrapartum management
• Timing of delivery • Set up 10% dextrose water – 100ml/hr
• Optimal diabetic control – 39-40weeks (10g/hr).
• Poorly controlled – early delivery, if • Set up insulin pump at 1.0units/hour =
before 34weeks use steroids 4-6 mmol/l
(dexamethasone 12mg 12hourly x 2 • Blood glucose > 6mmol/l – double
doses) insulin (2.0unit/hr)
• Mode of delivery • Blood glucose < 4mmol/l – ½ insulin
• Spontaneous vag delivery – primary dose (0.5unit/hr)
goal • ½ insulin infusion rate after delivery
• Indications for c/s – fetal weight > • Where insulin pump is not
4.5kg, previous history of shoulder available
dystocia, previous c/s, other
contraindication to vag delivery. • Set up 5% dextrose water
• • Administer insulin as follows on table
Management in labour below
• Set up two IVF line • Second regimen
• Capillary blood glucose hourly
• 5% D/W
• Aim to maintain blood glucose level
between 4-6mmol/l • S.C insulin 1unit hourly
• Only soluble insulin should be used • Other management in labour
• Insulin administration • Monitor labour on partogram
• Ideally use insulin pump • Adequate analgesia – hyperglycaemia
• Continuous fetal monitoring – fetal
By preventing hyperglycemia during labour,
distress and perinatal mortality
ketoacidosis is prevented and the incidence of
Table for insulin therapy

Capillary blood Soluble insulin in Time (hrs) for Supplementary


glucose (mmol/l) 500ml of infusion infusion (rate in s.c dose insulin
drops per minute) given 6 hourly

< 2.0 Nil 2 hrs (84dpm) 0


2.0-3.9 Nil 6 hrs (28dpm) 0
4.0-7.9 6 units 6 hrs (28) 0
8.0-11.9 6 units 6 hrs (28) 6 units
12.0-15.9 6 units 6 hrs (28) 10 units
> 16.0 Call physician Call physician
• Labour should be managed by • Give insulin as stated above
experienced obstetrician. (duration should
be less than 12hrs) • Puerperal management
• Availability of neonatal services and • Readjust insulin dose
neonatologist to attend delivery. • Pre-gestational DM – ½ dose
• Poor progress in labour – do c/s • GDM – give only if blood glucose
• Induction of labour demands control
• Morning/breakfast insulin should not be • Discontinue hourly glucose estimation
given in the antenatal ward • Four point test – fasting, pre-breakfast,
• Admit to labour ward at 6.00am pre-lunch and 21.00hrs
• Capillary glucose hourly from 6.00am – • Encourage breast feeding
starting with fasting blood glucose. • Food supplementation after
• Do ARM and set up oxytocin drip on breastfeeding
one arm • Do OGTT at 6weeks post partum and
• Set up 5% D/W on the second line at 3 months after delivery
• Give S.C insulin 8units stat dose • Refer to the diabetic clinic if either of
• Commence insulin titration as in the above result is positive
table. • Contraception – at 6 weeks
• Patient for caesarean delivery
• First on the operation list
• If blood glucose is > 6mmol/l –
postspone surgery
• Do capillary blood glucose hourly from
Somogyi effect

• Somogyi effect is a state of rebound reactive


hyperglycemia, that occurs in diabetes on long acting
insulin, following a period of relative unrecognised
nocturnal hypoglycemia, which stimulates the release of
hyperglycemic agents – adrenaline, noradrenaline, cortisol,
glucagon and growth hormone (which produces the
hyperglycemia the next morning). The patient suffers
nightmares and night sweats.
• Documenting hypoglycemia between 1.00-5.00am is
diagnostic of this phenomenon
• Treatment is to decrease the amount of long acting insulin
the patient takes before super or at bedtime.
Dawn phenomenon