Transcript 6._DM_in_Pregnancy

Diabetes Mellitus
Fifth Stage-Medicine
Dr. Sarbast Fakhradin
MBChB, MSc Diabetes Care & Management
Diabetic foot
•40–60% of all amputations of the lower extremity are performed in patients with diabetes
• more than 85% of these amputations are precipitated by a foot ulcer deteriorating to deep
infection or gangrene
Prevention
• Advice to all diabetic patients includes:
– Inspect feet every day
– Wash feet every day
– Moisturise skin if dry
– Cut toenails regularly
– Change socks or stockings every day
– Avoid walking barefoot
– Check footwear for foreign bodies
– Wear suitable good-fitting shoes
– Cover minor cuts with sterile dressings
– Do not burst blisters
– Avoid high and low temperatures
• A podiatrist is an integral part of the diabetes team
• Specially manufactured and fitted orthotic footwear is required to
prevent recurrence of ulceration and protect the feet of patients with
Charcot neuroarthropathy
Treatment
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1. Remove callus
2. Treat infection
3. Avoid weight-bearing
4. Ensure good glycaemic control
5. Control oedema
6. Undertake angiogram to assess feasibility of vascular
reconstruction where indicated
Diabetes in pregnancy
• Increase insulin resistance, particularly in the second half
of pregnancy.
• The renal threshold for glycosuria is reduced.
• 2 -5% of pregnancies involve women with diabetes.
• Gestational diabetes: diabetes with first onset or
recognition during pregnancy.
Risk factors
• 1. obesity
• 2. Ethnicity (South Asian, black, Hispanic, Native
American)
• 3. Family history of type 2 diabetes
• 4. Previous glucose abnormalities during pregnancy
• 5. Previous macrosomia.
• 6. Maternal age more than 37 Y.
• 7. Polycystic ovarian syndrome
Historically
• 87.5% are Gestational Diabetes Mellitus (GDM).
• 7.5% are Type 1.
• 5% are Type 2.
• GDM is associated with an increased risk of later development
of type 2 diabetes in the mother, 50% after 5 years.
• Screening: as soon as pregnancy confirmed in risky individuals,
if negative or not risky screen at 24-28 weeks of gestation
Diagnosis
• Pre-conception preparation:
• 1. Strict glycaemic control
• 2. Pregnancy should be planned: folic acid supplementation 5mg
• 3.Basal-bolus insulin regimens may be required if not controlled by
metformin.
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• Management:
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1. Frequent self-monitoring of blood glucose
2. Strict glycaemic control. Lifestyle modification. Metformin can be
useful. other oral agents should be avoided. Insulin is often
required.
3. Check for ketonuria.
4. Microalbuminuria (every semester)
5.Retinal screening (every semester)
6. Regular monitoring of fetal size, and screening for fetal
abnormalities.
7. Time & mode of delivery
8. Re-assessed by OGTT 6 weeks after pregnancy.
Maternal Complications
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1. Hypoglycaemia/DKA
2. Microvascular problems
3. Pre-eclampsia – twice as common
4. Premature labour
5. Spontaneous abortion
6. Obstructed labour
7. Polyhydramnios
8. Infection
Fetal Complications
• Diabetes is Teratogenic
particularly before 8 weeks
gestation.
• Birth Trauma, Hypoglycaemia,
Hypocalcaemia, RDS,
Cardiomyopathy, Jaundice
• Macrosomia
• Major defects:
• Q1/ How you diagnose a case of DM in a
non-pregnant adult?
• Q2/ Write short note on hypoglycemia in
diabetic patient?
• Q3/ Enumerate oral antidiabetic medications
and write short note on metformin.
• Q4/The mechanism of action of metformin
includes all of the following except:
• A. Decrease gastrointestinal glucose
absorption
• B. Decrease the production of glucose by the
liver (gluconeogenesis)
• C. Increase the uptake of glucose by the
tissues
• D. Increase insulin secretion from the
pancreas
• Q5/ Which one of the following is a feature
of diabetic autonomic neuropathy?
• 1. Sixth cranial nerve pulsy
• 2. Carpal tunnel syndrome
• 3. Diabetic amyotrophy
• 4. Gastroparesis
• 5. stocking distribution of sensory loss in
the legs.
• Q6/ Regarding oral hypoglycemics:
• A. Are the treatment of choice in
hyperosmolar nonketotic states
• B. Are safe in pregnancy
• C. Hypoglycemia is rarely caused by
metformin
• D. Treatment with metformin may be
complicated by constipation
• E. Metformin causes weight gain.
• Q7/ What is the biggest cause of mortality in
diabetic patient?
• 1. Ischemic heart disease
• 2. Hypoglycemia
• 3. Renal failure
• 4. Diabetic ketoacidosis
• 5. Infection
• Q8/ Milano Ahmad Kareem, 20 year student
from Bakrajo with type 1 DM presented to
ER with loss of consciousness.
• RBS= 32 mg/dl
• What is your diagnosis & treatment?
Thank You & Good Luck
Questions?