Obstetric Management of Obstetric Management of pregnancy Complicated by pregnancy Complicated by

Diabetes MellitusDiabetes Mellitus

BYBY

DR. BENNET ARIWERYOKUMADR. BENNET ARIWERYOKUMA

DEPT. OF OBSTETRICS & GYNAECOLOGYDEPT. OF OBSTETRICS & GYNAECOLOGY

UPTH PORT HARCOURT.UPTH PORT HARCOURT.

INTRODUCTIONINTRODUCTION

The discovery of insulin in The discovery of insulin in

1921 is the most significant advancement in 1921 is the most significant advancement in the treatment of pregnancy complicated by the treatment of pregnancy complicated by diabetes mellitus.diabetes mellitus.

Prior to that time, pregnancy in the Prior to that time, pregnancy in the diabetic woman was uncommon and was diabetic woman was uncommon and was accompanied by high maternal and fetal accompanied by high maternal and fetal morbidity and mortality.morbidity and mortality.With improved understanding of the patho With improved understanding of the patho physiology of the disease, coupled with physiology of the disease, coupled with improved fetal surveillance and timing of improved fetal surveillance and timing of the delivery, perinatal mortality has the delivery, perinatal mortality has dropped from 65% to less than 5%.dropped from 65% to less than 5%.

There is the rule of 15:There is the rule of 15:-15% of the obstetric population has abnormal -15% of the obstetric population has abnormal

glucose metabolism glucose metabolism -15% of that population has abnormal OGTT-15% of that population has abnormal OGTT-15% of those who have abnormal OGTT will -15% of those who have abnormal OGTT will

require insulinrequire insulin-15% of all patients with GDM have fetal birth -15% of all patients with GDM have fetal birth

weight >4kg weight >4kg

Types of Diabetes mellitus in PregnancyTypes of Diabetes mellitus in Pregnancy90% are GDM90% are GDM10% are type I and II diabetes mellitus.10% are type I and II diabetes mellitus.

IMPORTANCE OF OBSTETRIC MANAGEMENTIMPORTANCE OF OBSTETRIC MANAGEMENT -- Hyperglycaemia is teratogenic-- Hyperglycaemia is teratogenic FETAL:FETAL: CNS –microcephaly, meningocoele, cuadal regresion CNS –microcephaly, meningocoele, cuadal regresion

syndrome, sacral agenesis, retinopathy. syndrome, sacral agenesis, retinopathy.

CHEST-respiratory distress syndrome.CHEST-respiratory distress syndrome.

CVS –ventricular & atrial septal defects, cardiomegaly , transposition CVS –ventricular & atrial septal defects, cardiomegaly , transposition of the great vessels. of the great vessels.

-Renal- congenital abnormality of the kidney; -Renal- congenital abnormality of the kidney;

hydronephrosis, renal agenesis, double ureters.hydronephrosis, renal agenesis, double ureters.-GIT- duodenal and anal atresia, gastrochisis, -GIT- duodenal and anal atresia, gastrochisis,

small left colon syndrome, single umbilical small left colon syndrome, single umbilical artery.artery.

-SKELETAL – polydactyly, sacral agenesis, -SKELETAL – polydactyly, sacral agenesis, excessive fat and muscles.excessive fat and muscles.

Mother:Mother: -abortion, premature Iabour, UTI, -abortion, premature Iabour, UTI,

-pyelonephritis, candidiasis.-pyelonephritis, candidiasis. -nephropathy-nephropathy -worsening retinopathy-worsening retinopathy -vasculopathy of the uterine and -vasculopathy of the uterine and placental vessels. placental vessels.

AIMS OF MANAGEMENT OF AIMS OF MANAGEMENT OF PREGNANCY COMPLICATED BY PREGNANCY COMPLICATED BY DIABETIS MELLITUSDIABETIS MELLITUS

- good glycaemic control of 4-6mmol/L- good glycaemic control of 4-6mmol/L - glycosylated haemoglolin of <8% before - glycosylated haemoglolin of <8% before

and during pregnancy.and during pregnancy. - early detection of pregnancy and fetal- early detection of pregnancy and fetal abnormalities.abnormalities.

- fetal surveillance- fetal surveillance

- detection and treatment of obstetric and - detection and treatment of obstetric and medical complications.medical complications.

- timing and mode of delivering.- timing and mode of delivering.

- good management of the puerperium; - good management of the puerperium; lactation and contraception.lactation and contraception.

MANAGEMENT IS BY A MANAGEMENT IS BY A MULTIDICIPLINARY TEAM MADE UP MULTIDICIPLINARY TEAM MADE UP OF:-OF:-

- Obstetrician- Obstetrician

- Diabetic physician: control of blood sugar - Diabetic physician: control of blood sugar and its complications .and its complications .

- Diabetic neonatologist: to resuscititate the - Diabetic neonatologist: to resuscititate the baby at birth and further management.baby at birth and further management.

hypomagnesaemia, hypocalcaemia hypomagnesaemia, hypocalcaemia polycythemia, hyperbilirubinaemia.polycythemia, hyperbilirubinaemia.

- Dietician: plans the diet for the obese, normal - Dietician: plans the diet for the obese, normal weight and the underweight.weight and the underweight.

- Diabetic nurse : counsel, teach hygiene, insulin Diabetic nurse : counsel, teach hygiene, insulin injection and storage. injection and storage.

- An anaesthetist: for labour analgesia & An anaesthetist: for labour analgesia & operative deliveries operative deliveries

- The patient herself: motivation & co-operation - The patient herself: motivation & co-operation

PRECONCEPTION CAREPRECONCEPTION CARE

- particularly for pregestational diabetics.- particularly for pregestational diabetics.

- counsel patient on the need to control - counsel patient on the need to control diabetis before pregnancy.diabetis before pregnancy.

- treat complications like retinopathy and - treat complications like retinopathy and nephropathy that may deteriorate in nephropathy that may deteriorate in pregnancy.pregnancy.

- diet - diet

- ANC and the use of insulin.- ANC and the use of insulin.

- Lactation and Contraception .- Lactation and Contraception .

ANTENATAL CAREANTENATAL CARE

-Ideally patient should graduate from the -Ideally patient should graduate from the preconception clinic to the antenatal clinic preconception clinic to the antenatal clinic with a controlled blood sugar. This with a controlled blood sugar. This ensures early booking.ensures early booking.

History – age, educational level, occupationHistory – age, educational level, occupation parity, LMP, EDD, gestation at booking, parity, LMP, EDD, gestation at booking,

symptoms, URTI, UTI, Candidiasis.symptoms, URTI, UTI, Candidiasis. - Past obstetric history;- Past obstetric history;

previous hx. of GDMprevious hx. of GDM stillbirth, macrosomia, IND stillbirth, macrosomia, IND duration of diabetic disease duration of diabetic disease - Medications; - Medications;

oral hypoglycaemic agentsoral hypoglycaemic agents insulininsulin

- Family history of diabetes. - Family history of diabetes.

Clinical examination should look for weight, Clinical examination should look for weight, fever, pallor, hypertension, fundal height, fever, pallor, hypertension, fundal height, polyhydramnous, retinoscopy and vaginal polyhydramnous, retinoscopy and vaginal candidiasis .candidiasis .

INVESTGATIONSINVESTGATIONS: General tests: pcv, : General tests: pcv, urinalysis for sugar, protein and ketones.urinalysis for sugar, protein and ketones.

E/U/Cr, blood group and genotype.E/U/Cr, blood group and genotype.

Specific Tests:-Specific Tests:- - Fasting blood sugar.- Fasting blood sugar. - glucose challenge test of 50gm- glucose challenge test of 50gm followed by 2 hours post prandial followed by 2 hours post prandial blood sugar blood sugar - OGTT - FBS >7.8mmol/l - OGTT - FBS >7.8mmol/l 2hrs > 11mmol/l2hrs > 11mmol/l Indications Indications for OGTT – maternal weight>90kg, birth for OGTT – maternal weight>90kg, birth

wt>4kg, Diabetic 1 wt>4kg, Diabetic 1st degree relative, st degree relative,

Glycosuria x1<20wks, or x 2>20wks, previous IUFD, Glycosuria x1<20wks, or x 2>20wks, previous IUFD, polyhydramnous, IND.polyhydramnous, IND.

gn

FREQUENCY OF ANCFREQUENCY OF ANC:-:-

2wkly until - 28wks2wkly until - 28wks

wkly from 28wks until delivery .wkly from 28wks until delivery .

Ultrasound Ultrasound

11stst scan – at 7 weeks to confirm fetal life scan – at 7 weeks to confirm fetal life and number of fetuses . and number of fetuses .

22ndnd scan - 16-20 weeks for structural scan - 16-20 weeks for structural abnormalities. abnormalities.

33rdrd scan – 22-24 weeks specifically for fetal scan – 22-24 weeks specifically for fetal echocardiogram. echocardiogram.

--Estimation of fetal growth patternEstimation of fetal growth pattern using HC, BPD, AC, FL to using HC, BPD, AC, FL to calculate the fetal weight . However, birth calculate the fetal weight . However, birth weight USS assessment is not very weight USS assessment is not very accurate. With fetal weight above 3kg, accurate. With fetal weight above 3kg, scan assessment of the weight is a little scan assessment of the weight is a little better than clinical assessment. better than clinical assessment.

44thth scan scan :- monthly fetal growth and :- monthly fetal growth and amniotic fluid volume monitor.amniotic fluid volume monitor.

FETAL SURVELLANCEFETAL SURVELLANCE :- :-

- weekly from 32 weeks.- weekly from 32 weeks.

- twice weekly from 36 weeks.- twice weekly from 36 weeks.

1. Biochemical tests (oestriol and HPL) & 1. Biochemical tests (oestriol and HPL) & contraction stress tests have been contraction stress tests have been abandoned. abandoned.

..Cardiff kick countCardiff kick count for 12 hours for 12 hours

>10 kicks in 12 hours is normal>10 kicks in 12 hours is normal

- this is cheap and useful but does not prevent - this is cheap and useful but does not prevent unexplained stillbirth.unexplained stillbirth.

-reliable for 24 hrs.-reliable for 24 hrs.

4.Non stress test (CTG4.Non stress test (CTG) :-) :-

A cardiotocograph is used to monitor the fetal A cardiotocograph is used to monitor the fetal heat rate for 20-30 minutes. heat rate for 20-30 minutes.

The result can be reactive or non reactive.The result can be reactive or non reactive. Reactive – baseline heart rate- 120 -160 bpm Reactive – baseline heart rate- 120 -160 bpm -2 accelerations within 20mins of -2 accelerations within 20mins of

15bpm above the baseline each lasting 15sec. 15bpm above the baseline each lasting 15sec. - Baseline variation of 5-15 bpm- Baseline variation of 5-15 bpm -No declerations-No declerations -However, the predictive value of CTG -However, the predictive value of CTG

is in doubt. is in doubt.

BBiophysical profilesiophysical profiles:-To evaluate the fetus with a :-To evaluate the fetus with a Non reactive NST.Test is done for 40mins.Non reactive NST.Test is done for 40mins.

Score 2 0Score 2 0 NST Reactive Non reactiveNST Reactive Non reactive HR >2 accelerations <2 accelerationsHR >2 accelerations <2 accelerations FBM 1 nil FBM 1 nil TFBM >3 <2TFBM >3 <2 F-tone >1 absent/slowF-tone >1 absent/slow MVP 2-7cm <2cmMVP 2-7cm <2cm or AFI 10-25cm <5 >25cmor AFI 10-25cm <5 >25cm

Maximum score- 10Maximum score- 10

Minimum score- 0Minimum score- 0

8 -10 Normal 8 -10 Normal

4 – 6 equivocal,4 – 6 equivocal,

therefore repeat test.therefore repeat test.

0 – 2 poor,0 – 2 poor,

terminate pregnancy terminate pregnancy

-Doppler umbilical artery velocimetry to -Doppler umbilical artery velocimetry to study the systolic and diastolic wave study the systolic and diastolic wave forms.The presence of reverse diastolic forms.The presence of reverse diastolic wave calls for immediate delivery.wave calls for immediate delivery.

-Lecitin / sphyngomylin ratio of 2:1 indicates -Lecitin / sphyngomylin ratio of 2:1 indicates fetal lung maturity.fetal lung maturity.

Admission Admission

All patients with poor diabetic control should All patients with poor diabetic control should be admitted for stabilization anytime in be admitted for stabilization anytime in pregnancy. pregnancy.

Dietary ManagementDietary Management

-30-35 cal/kg/day -30-35 cal/kg/day

1800-2400cal/day1800-2400cal/day

Obese patient =1600cal-1800cal/day Obese patient =1600cal-1800cal/day

Normal patient = 2000 cal/dayNormal patient = 2000 cal/dayUnder weight patient >2000 cal/dayUnder weight patient >2000 cal/dayCarbohydrate 40-50%Carbohydrate 40-50%Fat 30% Fat 30% Protein 20-30%Protein 20-30%Patient should avoid simple sugars.Patient should avoid simple sugars.

Snacks are taken to prevent Snacks are taken to prevent Hypoglycaemia. Hypoglycaemia.

Medical managementMedical management

-stop all hypoglycaemic agents because -stop all hypoglycaemic agents because they are teratogenic and cause fetal they are teratogenic and cause fetal hyperinsulinaemia.hyperinsulinaemia.

-patients should have glucometer to -patients should have glucometer to measure the blood glucose for good measure the blood glucose for good control.control.

Humulin, -regular, intermediate, long Humulin, -regular, intermediate, long acting, or mixture of soluble and acting, or mixture of soluble and intermediate insulin are used.intermediate insulin are used.

Daily insulin requirement is 0.7- 1 unit /kg Daily insulin requirement is 0.7- 1 unit /kg body weightbody weight

Insulin therapy is bd or tds Insulin therapy is bd or tds

A dose of 2/3 of the total daily dose in the A dose of 2/3 of the total daily dose in the morning and 1/3 in the evening.morning and 1/3 in the evening.

And the morning dose should be 2/3 And the morning dose should be 2/3 intermediate and 1/3 soluble .intermediate and 1/3 soluble .

Evening dose should be ½ intermediate Evening dose should be ½ intermediate and ½ soluble.and ½ soluble.

Timing of DeliveryTiming of Delivery:-:-

-Knowledge of delayed lung maturity, stillbirth, macrosomia -Knowledge of delayed lung maturity, stillbirth, macrosomia is importantis important

-For well controlled patient delivery at 39-40wks is -For well controlled patient delivery at 39-40wks is recommended.recommended.

- Delivery at 40 weeks may be complicated by placenta Delivery at 40 weeks may be complicated by placenta failure & sudden fetal deathfailure & sudden fetal death

-For poorly controlled diabetic delivery should be at 37--For poorly controlled diabetic delivery should be at 37-38weeks.38weeks.

Route of deliveryRoute of delivery

- vaginal delivery is the main objective.- vaginal delivery is the main objective.

- C/S for fetal macrosomia & other obstetric - C/S for fetal macrosomia & other obstetric indications.indications.

- The rate of C/S in diabetic patients is 50%- The rate of C/S in diabetic patients is 50%

LabourLabour

- Inform anaesthetist, neonatologist and the - Inform anaesthetist, neonatologist and the physician.physician.

FBS on admission, then hourly until delivery.FBS on admission, then hourly until delivery.

- IVF of 5% dextrose at 125ml/hr to provide energy - IVF of 5% dextrose at 125ml/hr to provide energy and prevent ketosis.and prevent ketosis.

- 1 unit of insulin subcut hourly to maintain blood - 1 unit of insulin subcut hourly to maintain blood sugar between 4-6 mmol/lsugar between 4-6 mmol/l

- monitor labour with parthogram.- monitor labour with parthogram.

- Epidural analgesia for pain relief as it reduces - Epidural analgesia for pain relief as it reduces stress.stress.

- continuous CTG monitoring. - continuous CTG monitoring.

Blood sugar Blood sugar mmol/lmmol/l

Insulin inInsulin in

500ml of500ml of

5% dextrose5% dextrose

Drops/minDrops/min More insulinMore insulin

<2<2 nilnil 8484 nilnil

2-3.92-3.9 nilnil 2828 nilnil

4-7.94-7.9 6 units6 units 2828 nilnil

8-11.98-11.9 6 units6 units 2828 6 units6 units

12-15.912-15.9 6 units6 units 2828 10 units10 units

>16>16 Call Call physicianphysician

Induction of labourInduction of labour

-Start at 6 am-Start at 6 am

-skip morning insulin dose-skip morning insulin dose

- Do FBS- Do FBS

-ARM & oxytocin in normal saline-ARM & oxytocin in normal saline

-iv 5% dextrose at 125ml /hr-iv 5% dextrose at 125ml /hr

-add to infusion10 units of insulin to run at 1U/hr.-add to infusion10 units of insulin to run at 1U/hr.

Caesarean Section;Caesarean Section;-1-1stst patient on the list patient on the list-If blood glucose >6mmol/l postpone surgery.-If blood glucose >6mmol/l postpone surgery.-check blood sugar hourly-check blood sugar hourlyPUERPERIUMPUERPERIUM-reduce insulin to1/2 in the pregestational diabetic-reduce insulin to1/2 in the pregestational diabetic-For GDM, give insulin if blood sugar is high.-For GDM, give insulin if blood sugar is high.Lactation:Lactation:-patient should lactate and take snacks.-patient should lactate and take snacks.

-Do 4 point blood sugar tests--Do 4 point blood sugar tests-Lactation is encouraged and the patient should Lactation is encouraged and the patient should

take snacks.take snacks.OGTT at 6wks postpartum and at 3months.OGTT at 6wks postpartum and at 3months.ContraceptionContraceptionBTLBTLBarrier methodsBarrier methodsCOC - with caution for fear of cardiovascular COC - with caution for fear of cardiovascular

complicationscomplicationsPOP causes irregular bleeding POP causes irregular bleeding

PRETERM LABOURPRETERM LABOUR;-;-

-Magnesium sulphate-Magnesium sulphate

-beta adrenergic agents and steroids are -beta adrenergic agents and steroids are diabetogenicdiabetogenic

RecurenceRecurence of GDM is 60-70% of GDM is 60-70%

10% of GDM patients develop frank diabetes 10% of GDM patients develop frank diabetes after 10-20 years after 10-20 years