Transcript Diabetes in Pregnancy

Diabetes in Pregnancy
Prof N Palaniappan
Chennai
Panelists
•Dr Dilshath
•Dr Ambigai Meena
•Dr Meena
•Dr Chitra
Case 1
• Mrs G 32 yrs primi referred to the AN OPD with
leaking pv for 3 hrs
• AN care with a local doctor
• Past h/o
»
»
»
»
»
»
Md 1 yr
Mother diabetic
2 doses TT given
Fe & ca tablets taken regularly
Anomaly scan at 21 wks – no anomalies
HIV, HbsAg, VDRL negative
•
•
•
•
•
•
O/E Pt GC Fair
Vitals stable
At Ut 34 wks, relaxed
Cephalic, FH good
Clear Liquor leaking P/V, HVS taken
P/V cx 1.5cm long, soft, posterior
– Os 1 cm dilated
– Memb absent
– Cephalic above the brim
What will you do?
•
•
•
•
Induce labour – If so with What?
Give Tocolysis and steroids – If so with what?
Give antibiotics – If so with what?
Investigate – What?
•
•
•
•
•
•
•
Random blood Sugar - 261
USG – Baby wt 2.8kg Ut 32 wks
AC falls above 95th percentile
Cleft lip and cleft palate seen
Heart normal
Liquor 8 cms
Placenta - Anterior
What will you do?????
• Steroid cover
• FBS/PPBS next day
• LSCS
Prognosis Explained
•
•
•
•
Cleft lip, cleft palate explained
Other anomalies – not ruled out, explained
Salvagability explained
Steroids given and T. Erythromycin
250mg 1 qid
LSCS done after 48 Hrs
• Baby – 2.9kg, Macrosomic Plethoric,
Grunting +, Cleft lip, Palate +
• Admitted to NICU
Baby
Mother
Had RDS
Wound Infection
Needed C pap Ventilation
Sugar followed up
Needed 1 dose of Surfactant
Very High
Discharged on 14th day of life
Rx with Actrapid Insulin * 3 days
Wound Resuturing done
• Mother followed up – With what???
• Baby to undergo surgery for Cleft
lip/Palate at later date
Moral of the Story
• Diabetes needs to be
screened at needed time
• Treated vigorously
Case 2
• Mrs X 24 year old, family h/o diabetes, 10
weeks primi referred
• So far AN history – nil significant
• Routine investigations – normal
• How would you screen her for diabetes?
Spot Test
•
•
•
•
•
Irrespective of fasting
At about 20-22 wks of Pregnancy
50 gms of glucose
1 hr spot value 140, 130
increases sensitivity from 80% to 90%
Diagnosing DM
• WHO currently recommends OGTT with
75gms
• Fasting >= 126
• 2hrs >= 140
How do you screen for
Chromosomal anomalies?
Screening for Chromosomal
Anomalies
• Downs syndrome does not increase with
DM
• Triple screening less accurate as both
MSAFP and UE3 are lower in diabetic
pregnancies
• I Trimester screening mandatory – NT +
PAPPA+B Hcg for Congenital anomalies
• DM confirmed with OGTT
• No chromosomal anomalies
• How would you treat her?
Drug Therapy in DM
• Insulin
• OHA ….????
•
•
•
•
Patient was put on human insulin
Six value sugars done
Insulin dose titrated as per need
20 weeks anomaly scan and 24 weeks
fetal echo done
• What is the role of HbA1C?
HbA1C – Rule of 8
• HbA1c of 8% equals average glucose of
180 mg/dl
• Each 1% up or down increases or
decreases the average glucose by
30mg/dl
• 1 unit of rapid acting insulin will reduce
glucose by 30mg/dl
• When will you want to deliver her?
• What antepartum fetal surveillance would
you do?
AP Fetal Surveillance
• Unexplained still birth > 30% after 36 wks
in type 2 DM
• NST – Bi weekly
• BPP – Bi weekly
• Doppler – Umbilical artery Doppler can be
used selectively
Timing of Delivery
• Well controlled GDM – Not later than
40wks
• IDDM without Vasculopathy – Not later
than 40wks
• Pts with Vasculopathy – 38.5 wks
Any special precautions during labour and
delivery?
Labour & Delivery
• NPO after midnight
• Usual bedtime dose is given
• 5u of short acting Insulin with
500ml of 5% Dex on the day of
surgery / Delivery
• Hourly glucose levels
• RA is preferred in LSCS
• Anticipate shoulder dystocia
and PPH
What Postpartum Follow up?
Usually sugars return to normal range
immediately after delivery but may not be
the case always as in
– Pre existing type2DM that was identified as
GDM
– Those with islet cell antigen that will progress
to type 1DM
– Unexpected rise of sugars postpartum
Postpartum Glucose Testing
• Till now no standard, Universally accepted
recommendation
• Followed up in 3 discrete phases
– After Delivery
– Early Postpartum
– Long term
Recommendations at the V
International workshop
conference on GDM 2007
– Metzger BR, Buchanan TA, Coustan
DR etal
Time
Test
Purpose
Post delivery (1-3d)
Fasting or Random Plasma
glucose
Detect Persistent, overt
diabetics
Early Postpartum
75g-2h OGTT
Postpartum classifications of
glucose metabolism
Annually
FPG
Assess glucose metabolism
Tri annually
75g 2h OGTT
Assess glucose metabolism
Pre Pregnancy
75g 2h OGTT
Classify glucose metabolism
Future risk of Cardiovascular
Disease
• GDM pts have high prevalence of CVD
• Carpenter MW, Gestational diabetes, pregnancy
hypertension and late vascular disease. Diabetes care
2007:30:5246-5250
• They experience
–
–
–
–
More Obesity
More insulin resistance
More chronic HT
Metabolic Syndrome
• But conclusive evidence is on further research
What contraception would you
advice?
Contraception
• Barrier methods
• LNG IUD>cu IUD – risk weighed
• OCP
CASE 3
• Mrs. S 34yr old md for 6 years,
IT professional treated for
primary infertility-3 yrs
• Known Diabetic for the last 3
yrs on T.Pioglitazone 1 OD ,
• she had regular periods and was
diagnosed as PCOS .
• Had 3 cycles of OI, IUI, sugars raised,
HbA1C 7-8 but conceived spontaneously
on the 4 th cycle
• Had spontaneous miscarriage at 8 weeks
and D & C done
What advice would you give?
•
•
•
•
Abstinence
Contraception
Treat overt diabetes
Start folic acid
• Was started on T. Glimulin and
H. Insulin 6 units
• 3 cycles of OCP’s for PCOS
• Folic acid
• Weight reduction
• Diet control
•
•
•
•
•
6 months later patient was started on
T. Glycomet 500mg 1 BD
Ovulation induction with Letrozole , IUI
Sugars 95, 125
HbA1C – 5.5
Patient conceived on the 3 rd cycle
of IUI
• On regular Ante natal visits
• Patient was on T. Glycomet 500mg 1 BD
– FBS- 90-100
– PPBS- 120 -130
– Hba1c 5-5.5
– TVS- at 6 weeks + 3 days corresponded to 5
wks + 5 days
• Would you change to insulin?
• Would metformin cause teratogenicity?
Why not OHA in pregnancy
• From educated guess to accepted practice
• ISSUES
– Congenital anomalies
BUT NO STUDIES
– Fetal compromise
– Fetal hypoglycaemic episodes
Evidence
• IN 2000, Langer ‘O etal
NEJM- compared
• Glyburide & insulin
• And swung the use of
glyburide in Pregnancies &
subsequently approved
What is the Evidence for
metformin ?
MIG Trail – Metformin in Gestational
Diabetes trail
METFORMIN – BIGUANIDES
• Acts only in the presence of
insulin
• Improves insulin sensitivity at
the cellular level
• Does not stimulate insulin
secretion
• Does not cause hypoglycaemia
• Does not stimulate the fetal
pancreas to oversecrete insulin
• Although crosses the placenta it is a class
B drug
• Dose – 500mg start & can go upto
2000mg/day
• Caution
• Renal disease
• Vit B 12 deficiency
• Lactic acidosis
• Metformin use in pregnancy is not
contraindicated
• Glycemic control over the 2 trimester is not
adequate and hence is the only reason to add
insulin after 1 trimester
• No teratogenicity
• Glueck GJ etal , fertility sterility 2002 ,77, 520-525
Should PCO patients remain on
metformin throughout Pregnancy?
Yes. They can continue Metformin
Class B drug
» Glueck GJ etal. Metformin therapy throughout
pregnancy reduces the development of GDM in
women with PCOS. Fertil steril-2002;77;520-525
• Patient was continued on
metformin 500mg 1BD.
• Regular ante natal check up with
FBS,PPBS& Hba1c
How many USG s ????
When &
For what
• 1 trimester screening for down’s syndrome
with NT, PAPP – A & beta HCG screen negative –risk calculated was
1:5000
• Anomaly scan at 19 wks –normal
• Fetal echo at 24 wks –normal
• At 22wks + 5 days
• FBS- 98
• PPBS- 162
• Hba1c – 5.3
• Along with metformin, human insulin
30/70 4 units in the morning
• At 24 wks + 5 days
with insulin and
glycomet
• Sugars were 89, 128
ALL IS WELL
• Pt underwent elective LSCS at 37 weeks 5
days
• Baby 3. 4 kg
• Post partum follow up done
Awaiting Success
To improve is to change; to be
perfect is to change often.
– Winston Churchill
Sugar – The Killer
But
Medicine heals doubts as well as
diseases
Karl Marx
May 5th 1818