Transcript Diabetes and Pregnancy - Hong Kong Medical Association

Diabetes and Pregnancy
Dr Wong Pui Yee, Bonnie
MBChB, MRCOG
FHKAM(OG), FHKCOG
Subspecialist in Fetal Maternal Medicine
2 parts:
Preexisting DM and
pregnancy
Gestational diabetes
Diabetes in pregnancy
Pre-existing diabetes
IDDM
(Type1)
NIDDM
(Type2)
Gestational diabetes
Pre-existing diabetes
True GDM
Preexisting diabetes in pregnancy
Type 1 DM ( IDDM)
Type 2 DM (NIDDM)
Preexisting DM in pregnancy
Effect of pregnancy on pre-existing DM
• Increase requirement for insulin
doses
• Nephropathy , autonomic
neuropathy may deteriorate
• Progress in diabetic retinopathy (2X)
• Hypoglycemia
• Diabetic ketoacidosis
Preexisting DM In Pregnancy
Effect of preexisting DM on pregnancy
(1) Maternal
1. increase risk of miscarriage
2. increase risk of preclampsia
3. increase risk of infection eg vaginal
candidiasis, UTI, endometrial or
wound infection
4. increase LSCS rate
Preexisting DM in Pregnancy
(2) Fetal
1. increase risk of congenital abnormalities
sacral agenesis, congenital heart disease,
neural tube defects
Hba1c level
Risk
normal
<8%
>10%
not increased
5%
25 %
Preexisting DM in Pregnancy
2. Perinatal mortality (excluding
congenital abnormality ) 2 fold
increased
3. Increase risk of sudden unexplained
intrauterine fetal death.
Complications of pregnancy in preexisting DM
Maternal:
Fetal:
Increase insulin requirment’
Hypoglycemia
Infection
Ketoacidosis
Deterioration in retinopathy’
Increased proteinuria+edema
Miscarriage
Polyhydramnio
Shoulder dystocia
Preeclampsia
Increased caesarean rate
Congenital abnormalities
Increased neonatal and perinatal
mortality
Macrosomia
Late stillbirth
Neonatal hypoglycemia
Polycythemia
jaundice
Maternal hyperglycemia
|
Fetal hyperglycemia
|
Fetal pancreatic beta-cell hyperplasia
|
Fetal hyperinsulinaemia
|
Macrosomia,organomegaly,
polycythaemia, hypoglycemia, RDS
Management
Aim
Achieve maternal near normoglycemic
level to prevent adverse perinatal
outcomes
Diet
Low-carbohydrate diet , high fibre with
caloric restriction
Frequent small snacks may be
needed between meals
Avoid starvation
Insulin
3 pre-meal short acting insulin
(actrapid) +/- intermediate-acting
insulin (protophane) as it allows
maximum flexibility
Target blood glucose:
fasting < 5mmol/L
2 hr
<7 mmol/L
Oral Hypoglycemic agents
Implicated as teratogeneic in animal
studies esp first generation
sulfonyureas
In humans, scattered case reports of
congenital abnormality
Risk of congenital abnormality related
to maternal glycemic control rather
than mode of the anti-DM agents
Oral hypoglycemic agents
For Type 2 DM patients,
to stop oral hypoglycemic agents and
change to insulin
Reassure that the risk of congenital
abnormality due to drug is small
Oral hypoglycemic agents
Biguanides ( metformin)
Cat B drug
Commonly used in Polycystic Ovarian Disease
(PCOD) to treat insulin resistance and
normalize reproductive function
Not teratogeneic
Reduce first trimester miscarriage
10X reduce gestational diabetes
Glueck, Fertil Steril 2002
Reece, Curr Opin Endocrinol Diabetes, 2006
Hague, BMJ, 2003
Glueck, Human Reprod, 2004
Oral hypoglycemic agents
Sulfonylureas
1st generation drug increase risk of neonatal
hypoglycemia
2nd generation drug (Glyburide) no such effect and
other morbidities .
Cat C drug
4%-20% patients failed to achieve glucose control
with maximum dose of drug
Increase risk of preeclampsia and need for
phototherapy
Langer, N Eng Med J , 2000
Kremer, Am J Obst Gynaecol, 2004
Chmait, J Perinatol ,2004
Langer, Am J Obst Gynaecol, 2005
Insulin Analogues
1. rapid-acting insulin analogs
(lispro) Cat B
concerns about teratogenesis, antibodies
formation, growth-promoting properties
majority of evidence showed that it
does not cross placenta, and has no
adverse maternal or fetal effects
Insulin Analogues
2. Long acting analogs
glargine
Cat C drug
Not well studied systemically
Monitoring
Regular home glucose monitoring
with h’stix
Insulin may be need to be adjusted as
gestation advances
Hba1c monitoring
Fetal monitoring with USG
Refer ophthamologist
Delivery
Timing and mode of delivery
individualised
Intrapartum insulin infusion with
glucose monitoring
no contraindication for Breast feeding
either with insulin or oral
hypoglycemic agents
Pre-conception Counselling
Allows for optimisation of diabetic control prior to
conception, and assessment of the presence of
complications like hypertension, nephropathy, and
retinopathy
Should counsel that good control and lower hba1c
lower the risk of congenital abnormalities and
improve outcome
If necessary, proliferative retinopathy may be
treated with photocoagulation prior to conception
Contraindications to pregnancy only :ischemic
heart dx, untreated proliferative retinopathy,
severe renal impairment(creatinine>250 mmol/L)
Gestational diabetes
Definition
Carbohydate intolerance of variable
severity first recognised during the
present pregnancy.
This includes women with preexisting
but previously unrecognised diabetes
Gestational diabetes
No consensus for 4
decades!
Gestational diabetes
Should all pregnant women be screened or
only those with risk factors?
Is it safe to screen all?
Which screening test and which diagnostic
test are the most reliable?
Which cut-off values should we use?
What are the risk for mothers and babies
and can treatment improve outcome?
What are the connection between
gestational diabetes and type 2 DM?
Is it physiological or pathological ?
Gestational diabetes
Screening and diagnosis
In general, the test is performed btn
24-28 wk because at this point in
gestation the diabetogenic effect of
pregnancy is manifest and there is
sufficient time remaining in pregnancy
for therapy to exert its effect
Gestational diabetes
Screening and diagnosis
In general, risk factor includes:
1. age>25y
2. BMI > 25
3. previous GDM
4. Family hx of DM in 1st degree relative
5. previous macrosomic baby (<4 kg)
6. polyhydramnio
7. large for date baby in current pregnancy
8. previous unexplained stillbirth
Gestational diabetes
Screening
Fasting / random glucose/ glucose
challenge test(50gm)
Diagnosis
Glucose challenge test
(75gm/100gm ?)
Gestational diabetes
Diagnosis
WHO criteria 1998,
75 gm glucose
fasting
Impaired fasting glucose
6.1-6.9
IGT
DM
<or =7
>or = 7
2 hr (mmol/L)
and
or
7.8-11
> or=11.1
Gestational diabetes
Incidence
2-9%
more common in Asian and Indian
women
In developed countries, increasing
trend because of epidemic of obesity
Gestational diabetes
Clinical significance of GDM
1. High incidence of macrosomia, and
adverse pregnancy outcomes,
2. A significant proportion(30%)
identified as GDM in fact have DM
before pregnancy
Gestational diabetes
Women with glucose intolerance just
above normal range are at low risk for
pregnancy complications, those with
more severe glucose intolerance
approaching the criteria of diabetes
are at risk of neonatal complications
Fetal complications
Macrosomia (>4 kg)
risk is 16-29% as compared to 10% in control
Increase in caesarean delivery, intrumental
deliveries ( forceps/vacuum), birth trauma, such as
brachial plexus injuries , clavicular fractures
Increase in neonatal hypoglycemia (24% ),
hyperbilirubinemia, hypocalcemia, polycythemia
Children are at risk of type 2 DM and obesity in life
Maternal complications
Increase risk of hypertensive
disorders
Increase risk of caesarean and
intrumental deliveries
Increased Risk (40-60%) of
developing type 2 DM within10-15 yr.
Gestational diabetes
Does treatment improves outcomes?
Conflicting results
1. Cochrane datebase systemic review 2005 (3 studies only)
no difference in outcomes except neonatal hypoglycemia
2. Australian Carbohydrate Intolerance Study in Pregnant Women (ACHOIS
study) 2005 ( 490/510 subjects)
treatment of diabetes reduces serious perinatal morbility and may
improve the woman’s health-related quality of life
Gestational diabetes
Large randomized study on going
HAPO trial in USA
(Hyperglycemia and Adverse
Pregnancy Outcome study)
Gestational diabetes
Management
Management similar as preexisting
DM
Need for glucose monitoring
Start with Diet control
Commence insulin for poor control
Delivery plan individualised
Gestational diabetes
In view of risk of developing type 2
DM
the woman should be screened
annually for DM on yearly basis.
Diabetes and Pregnancy
Conclusion
(1) Preexisting DM in pregnancy
• Good glucose control is important
for decreasing morbidities
• Insulin is still the gold standard of tx
in pregnancy
• Increasing evidence for clincial
effectiveness for treatment with oral
hypoglycemic agents
Diabetes and pregnancy
conclusion
(2) Gestational diabetes
no consensus
The morbidities increases as glucose level
approaching the diagnosis as DM
Possible that treatment improves outcomes
Overlap with preexisting DM, esp type2
Long term implication for health of the
mother and baby
Thank you very much!