Endocrine disorders in pregnancy

By By

Dr. Khattab KAEODr. Khattab KAEO

Prof. of Obstetrics and Gynaecology Prof. of Obstetrics and Gynaecology Faculty of Medicine, Al-Azhar Faculty of Medicine, Al-Azhar

University, University, DamiettaDamietta

Diabetes mellitus (DM)

Physiology:Physiology:

In the nonpregnant state the ingested glucose is:In the nonpregnant state the ingested glucose is:1- through the enterohepatic circulation, and with the aid 1- through the enterohepatic circulation, and with the aid

of insulin, is deposited in the liver as glycogen. of insulin, is deposited in the liver as glycogen.

2- through the general circulation: A- a proportion is 2- through the general circulation: A- a proportion is metabolised directly by the tissues; B- some is metabolised directly by the tissues; B- some is converted to depot fat; C- A proportion is stored as converted to depot fat; C- A proportion is stored as muscle glycogen (with the aid of insulin). muscle glycogen (with the aid of insulin).

Blood glucose is maintained between 4.5 and 5.5 mmol/LBlood glucose is maintained between 4.5 and 5.5 mmol/L

Placental and cerebral glucose uptake is Placental and cerebral glucose uptake is independent of insulin. independent of insulin.

This is the commonest cause of This is the commonest cause of glycosuria during pregnancy.glycosuria during pregnancy.

It occurs in 15% of healthy pregnant It occurs in 15% of healthy pregnant women due to increased women due to increased glomerular filtration rate and due glomerular filtration rate and due to higher postprandial glucose to higher postprandial glucose levels. levels.

False glycosuria: Women with more False glycosuria: Women with more than usual glycosuria in pregnancy than usual glycosuria in pregnancy may have sustained renal damage may have sustained renal damage from earlier untreated UTI.from earlier untreated UTI.

Physiological glycosuria of pregnancyPhysiological glycosuria of pregnancy

Using 75 g oral glucose WHO defined normal glucose tolerance as fasting venous plasma glucose level of <6 mmol/L and 2-h level of <8 mmol/L. "Impaired glucose tolerance" (IGT) in non-pregnant women as: fasting glucose 7.8 mmol/L or 2-h glucose 8-11 mmol/L. DM is defined if: fasting glucose is >7.8 mmol /L and/or 2-h glucose >11 mmol/L.

Definition and classification

Overt or clinical DM: Abnormal 2 values of a Overt or clinical DM: Abnormal 2 values of a 3-h GTT with polyphagia, poly-uria, 3-h GTT with polyphagia, poly-uria, polydipsia & other related sympt If polydipsia & other related sympt If

symptoms are absent, the condition is then symptoms are absent, the condition is then called "chemical DM". Now, “type I” DM called "chemical DM". Now, “type I” DM has has

replaced the term “IDDM”.replaced the term “IDDM”. It usually results It usually results from a cell-mediated autoimmune from a cell-mediated autoimmune

destruction of the destruction of the cells. This destruction cells. This destruction is marked by auto-antibodies to insulin, to is marked by auto-antibodies to insulin, to

islet cells & to glutamic acid islet cells & to glutamic acid decarboxylase. One, and usually more, of decarboxylase. One, and usually more, of these antibodies are present in 85-90% of these antibodies are present in 85-90% of cases. In type II DM, insulin receptors are cases. In type II DM, insulin receptors are

deficient. deficient.

Gestational Impaired Glucose Tolerance & Gestational Impaired Glucose Tolerance & Gestational DMGestational DM: :

GDM is defined as “carbohydrate intolerance with GDM is defined as “carbohydrate intolerance with onset or first recognition during pregnancy”. onset or first recognition during pregnancy”. GDM & GIGT occur as a consequence of the GDM & GIGT occur as a consequence of the increased insulin resistance that develops du-increased insulin resistance that develops du-ring pregnancy due to the secretion of placental ring pregnancy due to the secretion of placental hormones, particularly progesterone & hPL. hormones, particularly progesterone & hPL. GDM in the 1st GDM in the 1st ½½ of pregnancy may suggest of pregnancy may suggest glucose intolerance before pregnancy. There glucose intolerance before pregnancy. There may be marked weight gain, particularly in the may be marked weight gain, particularly in the abdominal region. There may be oedema early abdominal region. There may be oedema early in pregnancy. in pregnancy.

There is no evidence that GIGT is associated with excess There is no evidence that GIGT is associated with excess fetal mortality, or maternal or fetal morbidity. fetal mortality, or maternal or fetal morbidity.

The main risks of GDM are fetal macrosomia.The main risks of GDM are fetal macrosomia.

Screening:Screening:

At booking whether or not there is any risk factor. At booking whether or not there is any risk factor.

Again at 24-28 w or earlier if there is risk factor(s). Indeed, screening is repeated Again at 24-28 w or earlier if there is risk factor(s). Indeed, screening is repeated becausebecause glucose intolerance glucose intolerance becomes worse during pregnancy. becomes worse during pregnancy.

Screening may be not recommended in women under 25 years, with normal Screening may be not recommended in women under 25 years, with normal weight, no personal or family history of DM, no history of poor obstetric weight, no personal or family history of DM, no history of poor obstetric outcome & does not belong to an ethnic group predis-posed to DM.outcome & does not belong to an ethnic group predis-posed to DM.

Currently recommended screening procedure in North America is a two step Currently recommended screening procedure in North America is a two step procedure i.e. screening by a 50g glucose challenge; if 1-h serum glucose procedure i.e. screening by a 50g glucose challenge; if 1-h serum glucose 140 140 mg/dl (7.8mmol/L), a 3-h 100g GTT (sensitivity = 80% & specificity = 80%) is mg/dl (7.8mmol/L), a 3-h 100g GTT (sensitivity = 80% & specificity = 80%) is indicated. But it is costly and may not be justified in population with a low indicated. But it is costly and may not be justified in population with a low prevalence of DM or in a developing country population.prevalence of DM or in a developing country population. Whole blood glucose Whole blood glucose values are lower than plasma levels due to glucose uptake by haemoglobin. values are lower than plasma levels due to glucose uptake by haemoglobin.

A screening system based on assaying random blood sugar (RBS) in the early A screening system based on assaying random blood sugar (RBS) in the early third trimester is less sensitive and specific but may be more convenient for the third trimester is less sensitive and specific but may be more convenient for the above-mentioned population. Alternatively, if glycosuria is detected, RBS is above-mentioned population. Alternatively, if glycosuria is detected, RBS is done. If >6 mmol/L while the patient was fasting or >2 h postprandial, or 7 done. If >6 mmol/L while the patient was fasting or >2 h postprandial, or 7 mmol/L up to 2 h after meal, a 75 g GTT is performed. RBS >11 mmol/L = mmol/L up to 2 h after meal, a 75 g GTT is performed. RBS >11 mmol/L = abnormal glucose tolerance; a GTT is not needed. abnormal glucose tolerance; a GTT is not needed.

A one step screening procedure proposed by the WHO and is mostly used in A one step screening procedure proposed by the WHO and is mostly used in Europe is a two hours 75 g GTT. Europe is a two hours 75 g GTT.

Hb A1c >10% is diagnostic of DM. However, it has a low sensitivity as a Hb A1c >10% is diagnostic of DM. However, it has a low sensitivity as a screening test. screening test.

Indications for GTT include: abnormal result of a primary screening test (50g Indications for GTT include: abnormal result of a primary screening test (50g glucose challenge), previous birth weight >4500 g at term or >the 95th centile glucose challenge), previous birth weight >4500 g at term or >the 95th centile for gestational age, current macrosomia, maternal weight >100 kg and/or a BMI for gestational age, current macrosomia, maternal weight >100 kg and/or a BMI >30, previous unexplained perinatal death, previous glucose in-tolerance, DM in >30, previous unexplained perinatal death, previous glucose in-tolerance, DM in a first degree relative, polyhydramnios, previous congenital abnormality and 2+ a first degree relative, polyhydramnios, previous congenital abnormality and 2+ glycos-uria (glycos-uria (2 episodes in early pregn. or once in late pregnancy).2 episodes in early pregn. or once in late pregnancy).

USA: 50g glucose challenge; if 1-h serum USA: 50g glucose challenge; if 1-h serum glucose glucose 140mg/dl (7.8mmol/L) a 3-h 140mg/dl (7.8mmol/L) a 3-h 100g GTT is indicated. But it is costly & 100g GTT is indicated. But it is costly & may not be justified in population with a may not be justified in population with a low prevalence of DM or in developing low prevalence of DM or in developing countries.countries. A screening system based on A screening system based on assaying RBS in the early 3rd trimester is assaying RBS in the early 3rd trimester is less sensitive & specific but may be more less sensitive & specific but may be more convenient for the convenient for the above-mentionedabove-mentioned population. Alternatively, if glycosuria is population. Alternatively, if glycosuria is detected, RBS is done. If >7 mmol/L, a detected, RBS is done. If >7 mmol/L, a 75 g GTT is performed. RBS >11mmol/L 75 g GTT is performed. RBS >11mmol/L = abnormal glucose tolerance; a GTT is = abnormal glucose tolerance; a GTT is not needed. not needed.

WHO&Europe 1-step screening procedure WHO&Europe 1-step screening procedure is a 2 h 75 g GTT. is a 2 h 75 g GTT.

Hb A1c >10% is diagnostic of DM. Hb A1c >10% is diagnostic of DM. However, it has a low sensitivity as a However, it has a low sensitivity as a screening test. screening test.

Indications for GTT include: abnormal Indications for GTT include: abnormal result of a 1ry screening test (50g result of a 1ry screening test (50g glucose challenge), previous B Wt > glucose challenge), previous B Wt > 4500 g at term or >the 95th centile for 4500 g at term or >the 95th centile for gestational age, current macrosomia, gestational age, current macrosomia, maternal weight >100 kg &/or a BMI maternal weight >100 kg &/or a BMI >30, previous unexplained perinatal >30, previous unexplained perinatal death, previous glucose intolerance, death, previous glucose intolerance, DM in a 1st DM in a 1st °° relative, polyhydramnios, relative, polyhydramnios, previous congenital abnormality & 2+ previous congenital abnormality & 2+ glycosuriaglycosuria ( (2 episodes in early preg. or once in late pregnancy). 2 episodes in early preg. or once in late pregnancy).

Interpretation of GTT:Interpretation of GTT:

Fasting Fasting 105 mg/dl 105 mg/dl 6 mmol/L 6 mmol/L

1-h 1-h 190 mg/dl 190 mg/dl 11.5mmol/L 11.5mmol/L

2-h 2-h 165 mg/dl 165 mg/dl 9.5mmol/L 9.5mmol/L

3-h 3-h 145 mg/dl 145 mg/dl 7.5 mmol/L 7.5 mmol/L

2 of these values = GDM. 2 of these values = GDM.

Effect of pregnancy:Effect of pregnancy: Pregnancy is diabetogenic. Diabetes may Pregnancy is diabetogenic. Diabetes may appear for the 1st time during pregnancy. Insulin appear for the 1st time during pregnancy. Insulin antagonists (hPL & steroids) reduce the amount of antagonists (hPL & steroids) reduce the amount of glycogen deposited in liver & Ms. glycogen deposited in liver & Ms.

This poor glycogen reserve together with increased fat This poor glycogen reserve together with increased fat absorption & metabolism result in tendency to ketosis. absorption & metabolism result in tendency to ketosis.

Insulin is secreted in greater amounts during pregnancy. This Insulin is secreted in greater amounts during pregnancy. This is required postprandially to counter insulin resistance & is required postprandially to counter insulin resistance & anti-insulin factors. However, tissue sensitivity to insulin anti-insulin factors. However, tissue sensitivity to insulin decreases as gestation advances by up to 80% as an decreases as gestation advances by up to 80% as an effect mainly of hPL. This results in higher PPS &decrease effect mainly of hPL. This results in higher PPS &decrease in FBS. Therefore FBS is no more used in the definitions in FBS. Therefore FBS is no more used in the definitions of IGT during pregnancy, and higher cut-offs are used. of IGT during pregnancy, and higher cut-offs are used.

Insulin dose gradually increase after the 3rd month. However, Insulin dose gradually increase after the 3rd month. However, early in pregnancy insulin dose may be reduced because early in pregnancy insulin dose may be reduced because N&V lead to maternal hypoglycaemia So, diabetes may N&V lead to maternal hypoglycaemia So, diabetes may be difficult to control. During labour there is liability to be difficult to control. During labour there is liability to hypo-glycaemia because of uterine activity, & insulin hypo-glycaemia because of uterine activity, & insulin requirem. decrease after delivery. requirem. decrease after delivery.

Pregnancy Pregnancy accelerated diabetic complications. Retinopathy accelerated diabetic complications. Retinopathy progresses in 85% of patients and the deterioration in progresses in 85% of patients and the deterioration in nephropathy persist postpartum. Either of these complic. nephropathy persist postpartum. Either of these complic. is indication for termination Laser photocoagulation is is indication for termination Laser photocoagulation is safesafe Retinal hages may increase in initial stages of Retinal hages may increase in initial stages of improved glucose control as bl flow increases to these improved glucose control as bl flow increases to these terminal bl.v. clearing atherosclerotic plaques. terminal bl.v. clearing atherosclerotic plaques.

Diabetic nephropathy:Diabetic nephropathy: Bacteriuria, PE, edema & nephrotic syn Bacteriuria, PE, edema & nephrotic syn

Effect on pregnancy:Effect on pregnancy:Maternal complications:Maternal complications:Increased abortion rate. Increased abortion rate. Pregnancy-specific complications are Pregnancy-specific complications are

more frequent. There is a 14.4% more frequent. There is a 14.4% prevalence of pre-eclampsia (directly prevalence of pre-eclampsia (directly related to the degree of control & the related to the degree of control & the presence of renal & vascular complic.). presence of renal & vascular complic.). There is increased incidence of There is increased incidence of polyhyd.polyhyd.

There is increased liability to infections There is increased liability to infections including candidiasis, UTI (triple the including candidiasis, UTI (triple the normal rate of asymptomatic bacteri-normal rate of asymptomatic bacteri-uria) & puerperal sepsis.uria) & puerperal sepsis.

GDMGDM→→a 50% chance of developing NIDDM a 50% chance of developing NIDDM within 10-15 years if dietary control within 10-15 years if dietary control was sufficient. 20% will develop IDDM was sufficient. 20% will develop IDDM within 5 years if insulin was required.within 5 years if insulin was required.

Fetal complications:Fetal complications:1- Major malformations = 8% (7-8-x 1- Major malformations = 8% (7-8-x ). The RR is 3-5:1. The risk is ). The RR is 3-5:1. The risk is

related to the degree of glucose control in early pregnancy. related to the degree of glucose control in early pregnancy. NTDsNTDs, , gutgut atresia (duodenal, anorectal & small Lt colon syndr) atresia (duodenal, anorectal & small Lt colon syndr) & cardiomegaly, transposition of the great vessels, VSD, coarct & cardiomegaly, transposition of the great vessels, VSD, coarct The RR of The RR of caudal atresiacaudal atresia(sacral agenesis,the caudal regression (sacral agenesis,the caudal regression syndrome) & situs inversus is much more high. syndrome) & situs inversus is much more high. RenalRenal vein vein thrombosis, hydronephrosis, renal agenesis & ureteral duplic. thrombosis, hydronephrosis, renal agenesis & ureteral duplic. It is vital that control is achieved before pregnancy. If the It is vital that control is achieved before pregnancy. If the initialinitial Hb A1c value is <8, the % of major malformations would be Hb A1c value is <8, the % of major malformations would be about 3.3; values between 8 & 10 are associated with 8%; about 3.3; values between 8 & 10 are associated with 8%; while >10 values are associated with 23%. while >10 values are associated with 23%.

2- DM 2- DM low AFP levels low AFP levels invalid screen for Down syndrome. invalid screen for Down syndrome. 3- Although the fetus of diabetic mother is too much prone to 3- Although the fetus of diabetic mother is too much prone to

macrosomia, the embryo may show early growth delay! There macrosomia, the embryo may show early growth delay! There is increase in body fat, mass of muscle &organomegally except is increase in body fat, mass of muscle &organomegally except kidneys & brain. This predisposes to dystocia. However, excess kidneys & brain. This predisposes to dystocia. However, excess of heavy weight infants can be prevented by ttt with insulin. of heavy weight infants can be prevented by ttt with insulin.

4- Fetal hyperglycaemia delays lung maturity because it blocks 4- Fetal hyperglycaemia delays lung maturity because it blocks surfactant production by type 2 pulmonary cells. surfactant production by type 2 pulmonary cells.

5- NN hypoglycaemia (<40mg/dl in up to 40% of the neonates), 5- NN hypoglycaemia (<40mg/dl in up to 40% of the neonates), polycythaemia (Ht V >65%), hypomagnesaemia & hypocalcempolycythaemia (Ht V >65%), hypomagnesaemia & hypocalcem

6- Increased perinatal mortality rate: IUD occurs in 5% of cases 6- Increased perinatal mortality rate: IUD occurs in 5% of cases especially after 36w due to maternal ketosis, hypoglycaemia, especially after 36w due to maternal ketosis, hypoglycaemia, congenital malformation, preeclampsia or placental insuffici. congenital malformation, preeclampsia or placental insuffici. NND (5%) occurs mainly due to prematurity, RDS, congenital NND (5%) occurs mainly due to prematurity, RDS, congenital anomalies & hypoglycaemia. anomalies & hypoglycaemia.

7- IDM has a 10-x increased risk of developing DM in later life. 7- IDM has a 10-x increased risk of developing DM in later life. The lighter babies are most at risk.The lighter babies are most at risk.

Management:Management: Multidisciplinary provided by Multidisciplinary provided by an obstetrician, a diabetologist and a diet-an obstetrician, a diabetologist and a diet-atian. However, the most important member atian. However, the most important member of the team is the woman herself. Members of the team is the woman herself. Members of the extended primary health care team of the extended primary health care team who have an important role in managing the who have an important role in managing the patient’s pregnancy are dietician, community patient’s pregnancy are dietician, community midwife, health visitor, diabetic liaison nurse midwife, health visitor, diabetic liaison nurse and GP. Extended primary health care team and GP. Extended primary health care team are those working in the practice and those are those working in the practice and those who visit the practice and/or patients in the who visit the practice and/or patients in the community. community.

Preconception:Preconception:Good control can be monitored by assaying Good control can be monitored by assaying

glycosylated haemoglobin (Hb A1c) level. glycosylated haemoglobin (Hb A1c) level. Dietetic control: No regimen is best. Dietetic control: No regimen is best. Shift from oral hypoglycaemics to insulin once Shift from oral hypoglycaemics to insulin once

planned for pregnancy.planned for pregnancy.

During pregnancy:During pregnancy:

The aim should be to limit weight gain to 7 kg for The aim should be to limit weight gain to 7 kg for obese patients by supplying 25-obese patients by supplying 25-35 Cal/kg35 Cal/kg (1500-1800Cal/day to obese & 1800-2400 (1500-1800Cal/day to obese & 1800-2400 Cal/day to non-obese women) in 3 meals & 3 Cal/day to non-obese women) in 3 meals & 3 snacks; 50% from carbohydrate sources. snacks; 50% from carbohydrate sources. Soluble fibre satiates hunger & reduces Soluble fibre satiates hunger & reduces glycaemic swings. In addition it improves glycaemic swings. In addition it improves insulin receptor sensitivity.insulin receptor sensitivity.

Increased exercise with a particular attention to Increased exercise with a particular attention to abdominal muscles. Water intake is increased abdominal muscles. Water intake is increased prior to & during exercise. Swimming is the prior to & during exercise. Swimming is the safest exercise for massively obese patients safest exercise for massively obese patients to reduce joint trauma; walking or stationary to reduce joint trauma; walking or stationary biking are excellent alternatives. biking are excellent alternatives.

Insulin is very rarely required for GDM. The goal of control is to achieve a bl sugar level as close to Insulin is very rarely required for GDM. The goal of control is to achieve a bl sugar level as close to normal as possible (ie fasting & prepran. level <105mg/dl if this is possible without normal as possible (ie fasting & prepran. level <105mg/dl if this is possible without hypoglycemia hypoglycemia (>70mg/dl) (>70mg/dl) & a postprandial level <120 mg/dl. If fasting & pre-prandial levels & a postprandial level <120 mg/dl. If fasting & pre-prandial levels are are 7mmol/L insulin would not be beneficial. 7mmol/L insulin would not be beneficial.

If preprandial level is>8mmol/l or remains>6mmol/l after dietetic control pre-prandial short-acting If preprandial level is>8mmol/l or remains>6mmol/l after dietetic control pre-prandial short-acting insulin is added. The desired dose is 0.5, 0.6 &0.7U/kg/d in the 1insulin is added. The desired dose is 0.5, 0.6 &0.7U/kg/d in the 1stst, 2, 2ndnd & 3 & 3rdrd trimesters, 2:1 trimesters, 2:1 morning:eveningmorning:evening

2:1 1 : 1 2:1 1 : 1 NPH R NPH R NPH R NPH R R is injected a min of 30 min prior to meal. The evening NPH injection is transferred to bedtime. R is injected a min of 30 min prior to meal. The evening NPH injection is transferred to bedtime.

Noctural hypoglycaemia could be suggested with nightmares, sleep walking, tossing & turning Noctural hypoglycaemia could be suggested with nightmares, sleep walking, tossing & turning in bed, & waking with headache The snack for hypoglycemia shouldbe milk or peanutin bed, & waking with headache The snack for hypoglycemia shouldbe milk or peanut

Alternatively, the dose can be provided as 3 pre-prandial R insulin inj + a single NPH inj at bed Alternatively, the dose can be provided as 3 pre-prandial R insulin inj + a single NPH inj at bed time. time.

Monitoring: Ideally, the dose of insulin is established by 'trial & error'. Glucose is assayed in 4 bl Monitoring: Ideally, the dose of insulin is established by 'trial & error'. Glucose is assayed in 4 bl samples (Fasting, 2-h after breakfast, before dinner & 2-h after dinner) & the type & dose of samples (Fasting, 2-h after breakfast, before dinner & 2-h after dinner) & the type & dose of insulin is adjusted accordingly.insulin is adjusted accordingly.

Alternatively, a glucose meter is needed to estimate bl glucose levels 6-x /day before each meal & Alternatively, a glucose meter is needed to estimate bl glucose levels 6-x /day before each meal & snack. This can be reduced to 2-3 times weekly with good control. It is advised to avoid snack. This can be reduced to 2-3 times weekly with good control. It is advised to avoid squeezing the area of lancet puncture; the sample becomes diluted with tissue fluid. squeezing the area of lancet puncture; the sample becomes diluted with tissue fluid.

The risk of tight control is nocturnal hypoglycemia which causes rebound hyperglycemia by the The risk of tight control is nocturnal hypoglycemia which causes rebound hyperglycemia by the morning. Generally, pregnant diabetic women are more resistant to hypoglycemia than non-morning. Generally, pregnant diabetic women are more resistant to hypoglycemia than non-pregnant women especially in the 3rd trimester. In the event of severe hypoglycemia pregnant women especially in the 3rd trimester. In the event of severe hypoglycemia glucagon IM should be given.glucagon IM should be given.

Dexamethazone inj to enhance fetal lung maturity = concurrent insulin. Dexamethazone inj to enhance fetal lung maturity = concurrent insulin.

4- Treatment of 4- Treatment of diabetic ketoacidosis: diabetic ketoacidosis: R insulin R insulin 0.15 U/kg bolus then 0.15 U/kg/h (=5-10 U/ 0.15 U/kg bolus then 0.15 U/kg/h (=5-10 U/ 100 ml saline). If after 2 h glucose did not 100 ml saline). If after 2 h glucose did not come down to 200mg/dl, the dose is doubledcome down to 200mg/dl, the dose is doubled

5- ANC visits/2 weeks until 28 w, then weekly. 5- ANC visits/2 weeks until 28 w, then weekly. 6- Monthly glycosylated Hb. 6- Monthly glycosylated Hb. 7- Folate 5 mg daily due to the interaction of 7- Folate 5 mg daily due to the interaction of

hyperglycaemia with folate receptors. hyperglycaemia with folate receptors. 8-Funduscopy shouldbe performed at least 3-x 8-Funduscopy shouldbe performed at least 3-x 9- Thyroid function tests because of the 9- Thyroid function tests because of the

potential multi-endocrine impact of DM. potential multi-endocrine impact of DM. 10- ECG in patients ≥35y or with disease 10- ECG in patients ≥35y or with disease

duration >5 years. duration >5 years. 11- 24h creatinine clearance & total protein if 11- 24h creatinine clearance & total protein if

protein is <200 mg, test urine for protein is <200 mg, test urine for microalbminuria which is associated with microalbminuria which is associated with increased vascular disease in the future. increased vascular disease in the future.

12- Antenatal fetal assessment: As 12- Antenatal fetal assessment: As usual. NST is performed twice/w usual. NST is performed twice/w after the 30th week + BPP weekly after the 30th week + BPP weekly or twice weekly from 36 w. or twice weekly from 36 w.

13- Postdatism is not allowed. Pregn 13- Postdatism is not allowed. Pregn may even be terminated at 37-38 may even be terminated at 37-38 ww if the fetus is considered to be if the fetus is considered to be excessively grown or if glucose excessively grown or if glucose values remain labile. In such cases values remain labile. In such cases lung maturity may be determined lung maturity may be determined by PG or an L/S ratio of ≥3.5. Fetal by PG or an L/S ratio of ≥3.5. Fetal hyperglycemia delays lung maturityhyperglycemia delays lung maturity

During labourDuring labour The IV infusion may be given separately as D5 The IV infusion may be given separately as D5 Lactated Ringer’s solution. Women Lactated Ringer’s solution. Women >160kg>160kg will will require more glucose. If insulin is needed require more glucose. If insulin is needed 25U/250mL saline (25U/250mL saline ( 0.1U/mL) is given at a 0.1U/mL) is given at a rate of 0.5-2U/h. Alternatively, rate of 0.5-2U/h. Alternatively, ½½ the insulin the insulin dose + 500ml 5%glucose is given /4 h. Ideally, dose + 500ml 5%glucose is given /4 h. Ideally, bl. glucose should remain between 70-bl. glucose should remain between 70-100mg/dl. Bl. glucose & potassium levels are 100mg/dl. Bl. glucose & potassium levels are checked/2 h. Urine should be checked for checked/2 h. Urine should be checked for ketones/2h too If the pregnancy insulin dose is ketones/2h too If the pregnancy insulin dose is unknown, add 10U insulin to 500ml 10% unknown, add 10U insulin to 500ml 10% glucose at a rate of 2 U/h. glucose at a rate of 2 U/h. Epidural anaesthesia is ideal. Epidural anaesthesia is ideal. CEFM. Give careful attention to decelerations CEFM. Give careful attention to decelerations as fetal tolerance to stress is limited. Scalp pH as fetal tolerance to stress is limited. Scalp pH is indicated if worrisome patterns persist. is indicated if worrisome patterns persist. Induction: Morning insulin dose is omitted. 5 Induction: Morning insulin dose is omitted. 5 U/500 ml D5%w is infused. U/500 ml D5%w is infused.

After delivery:After delivery: Postpartum insulin dose Postpartum insulin dose decreases to ½ or 1/3 the dose needed in late decreases to ½ or 1/3 the dose needed in late pregnancy; the pre-pregnancy dose is required pregnancy; the pre-pregnancy dose is required again within 4-7 days of delivery. GTT is again within 4-7 days of delivery. GTT is recommended 6 w to 3 months postpartum. A recommended 6 w to 3 months postpartum. A high 1-h value represents decreased insulin high 1-h value represents decreased insulin capacity and advocates limitation of simple capacity and advocates limitation of simple sugars in the diet, whereas an elevated 3-h sugars in the diet, whereas an elevated 3-h value reflects decreased insulin receptors.value reflects decreased insulin receptors.

Care of the newborn:Care of the newborn: The newborn should be The newborn should be managed as a preterm baby regardless of its managed as a preterm baby regardless of its weight. Exchange transfusion is indicated if weight. Exchange transfusion is indicated if Ht.V. is >65%. Ht.V. is >65%.

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