IN THE NAME OF GOD

PREGESTATIONAL DM

WHITE CLASSIFICATION OF DM DURING PREGNANCYGestational DMClass A : diet alone ,any duration or ageClass B : age at onset > 20 y& duration < 10yClass C : age at onset 10- 19 or duration 10 – 19 yClass D : age < 10 y or duration > 20 y or background retinopathy or HTN ( not preeclampsia)Class R : proliferative retinopathy or vitreous HE

Class F : nephropathy with p. uria > 500 mgClass RF : R & FClass H : heart dxClass T : prior renal transplantation

Joslin textbook 2005

Evaluation of diabetic women

Risk assessment

Preconception counseling

Risk assessment

Nephropathy

During pregnancy , complicated by nephropathy, GFR & albuminuria increase &also increase in mean BP, it may worsen preexisting nephropathy.

Women with class F diabetes demonstrate that a majority of these pts develop proteinuria in the nephrotic range by the third trimester but Creatinine is nl

joslins textbook 2005

Mild nephropathy don`t complicated Moderate to severe nephropathy with GFR < 90

ml/min & proteinura more than 1 g /24 hrs have a more rapid decline in GFR

joslins textbook 2005

Retinopathy

Risk of progression of retinopathy increase in pregnancy Risk is influenced with :

severity of baseline retinopathy HbA1C > 8.5% at the first prenatal visit intensively treated pt has 1.6 fold increase risk of retinopathy Conventionally treated pt has 2.4 fold increase in retinopathy In DCCT study ,no difference in level of retinopathy in pt who

became pregnant as compared with pt who never p.

joslins textbook 2005

hypoglycemia

Most severe in first half of pregnancy : more insulin sensitivity , morning sickness , strict BS control

Severe hypoglycemia isnot teratogenic in human Treat with 15 g carbohydrate & then rechecked BS

after 15 min & additional 15 g carbohydrate use It is Better use lispro( FDA safety rating of B ) and

for aspart FDA safety rating of C

joslins textbook 2005

Hypertensive disorder

Chronic HTN: before or up to 20th weeks of gestation & if HTN continue after 12 week after pregnancy

Preeclampsia-eclampsia : ≥ 140/90 mmhg ,usually after 20th weeks of gestation with proteinuria more than 300mg/24 hrs

Preeclampsia-eclampsia superimposed on chronic HTN

Gestational HTN

joslins textbook 2005

Start treatment from BP ≥ 130/ 80 mmHg especially if microalbuminuria or proteinuria is present

Management of diabetes in pregnancy

Preconception counseling

Education Maternal risk assessment Fetal risk assessment HbA1C levels should be normal

Uptodate 2006

Maternal risk assessment

HX & P/E Review of complication Current & past glucose management Comorbid medical conditions Gynecologic & obstetric hx Discontinue oral anti-hyperglycemic agent Daily folic acid : 1 mg prior conception & continue after

conception Self management skills should be reviewed Nutrition counseling Mental health professional should be available

Uptodate 2006

Control of HTN : BP < 130/80 Thyroid dx : TSH , FT4 Neuropathy ( peripheral & autonomic ) vascular evaluation of lower extremities Infection : UTI SMBG HbA1C Discontinue alcohol & smoking

Uptodate 2006

Ophthalmic assessment

Comprehensive eye examinatin in pt with planing for pregnancy

f/u through pregnancy at least every 3 months & also one y after pregnancy

Tight glycemic control may accelerate retinopathy & need more attention by ophthalmologist

Laser photocoagulation for severe preproliferative diabetic retinopathy

Assessment of renal function

Spot urine for microalbumin /cr or time collection for 24 hrs

Serum cr Cr> 2mg/dl & GFR < 50 ml/min. & proteinuria

more than 2 gr /day can be considered relative contraindications to pregnancy

Cardiac evaluation

As the same as non pregnant women .(uptodate 2006)

Symptomatic CHF & Ischemic heart disease are contraindicated to pregnancy.( davidson 2004)

MANAGMENT of HTN & /OR MICROALBUMINURIA Methyl dopa Hydralazine B-blocker Ca canal blocker ACE inhibitor is

contraindicated Thiazid is relatively

contraindicated

BP should be managed aggressively

Hold BP< 130 /80 mmHg

Uptodate 2006

Management of hyperlipidemia

Statins are contraindicated & should be discontinued before conception

Hypertriglyceridemia treat with diet , supplementation with medium chain TG

Joslin text book 2005

Preconception treatment goal

Plasma FBS: 80-110 2hpp : 100-155 HbA1C : < 7% Avoid hypoglycemia

Joslin text book 2005

•goals for glycemic control for women with GDM, (Fourth International recommendations from the Workshop-Conference

on Gestational Diabetes) suggest:capillary blood glucose concentrations should be:

FBS: 95 mg/dlBS-1hpp :140 mg/dl

and/orBS-2hpp: 120 mg/dl

ADA 2006

First trimester

Same as preconception counseling care Evaluate risk factors

Uptodate 2006

Second trimester

Visit the pt every 2 to 4 weeks or more if pt has complications or glycemic control is suboptimal .

Maternal analyte screening : screening for Dawn SX or neural tube defects ( α fetoprotein ,unconjucated estriol ,HCG,inhibin A )

Sonography : at 18 weeks of gestation

Uptodate 2006

Third trimester

Visit for every 1 to 2 weeks untile 32 wks of gestation & then weekly

Glycemic control Sonography Estimation of fetal size Surveillance for pregnancy complication Fetal surveillance : weekly NST at 32 weeks with

suboptimal HbA1C & from 35 weeks with nl HbA1C Assess for macrosomia ,premature labor , hydramnious

Uptodate 2006

Davidsons DM2004

Fetal risk

Congenital malformation & spontaneous abortion : incidence is 5% -9%

when occurs in blastogenesis ( first 4 weeks of conception ) is more severe than organogenesis ( weeks 4-5 after conception )

HbA1C < 8.5 % 3.4%

HbA1C > 8.5 % 22.4%

Uptodate 2006

Congenital m

Thanks for your attention