Diabetes in Pregnancy

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Diabetes in Pregnancy

• JEAN KALIBUSHI B. ,MD
• Resident in GO at Butare teaching
• hospital

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CASE REPORT
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ANAMNESIS

• A known diabetic patient ,34years old
• MC transfert from outpatient for better
  menagement of Cervical incompetence on 16 weeks
  5days of amenorrhea
• ATCDsG3POEVOA2
• LMP15/09/2007
• MEDICAL Diabetic since 28/dec/2007,on 20UI/day
  of long acting insulin
• SURG myomectomy on 2004

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• Tobacconever taken
• Alcohol stopped since 2years 1/2

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CLINICAL EXAM

• Vital signs NAD
• Thorax NAD
• Abdomen HF 16cm
• Gyneco.Ex not done on admission
• CCL Cervical incompetence(BCI) on diabetic
  history whith pregnancy of 16weeks5days of
  amenorrhea

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MANAGEMENT

• Admission programmation of cerclage
• Pre-op test Normal range
• On 10/01/08 cerclage done

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FOLLOW UP OF BLOOD SUGAR

• On 10/01/08,On 20UI/day of long acting insulin
• -204mg/dl M
• -280mg/dlEVEN
• On 11/01/08
• -245mg/dlM
• -187mg/dlEVEN

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• On 12/01/08
• -112mg/dlM
• On 13/01/08
• -185mg/dlM
• -164mg/dlS
• On 14/01/08
• -118mg/dlM

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• On 15/01/08
• -172mg/dlM
• On 19/01/08 206mg/dlM
• On 21/01/08 138mg/dlM
• On 23/01/08 141mg/dlM
• On 24/01/08 176mg/dl, change of dose at 26UI of
  long acting Insulin in the morning and discharged
  the same day

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READMISSION

• On 23/feb/08 for pre-term labor of 23weeks of
  amenorrhea
• Management READMISSION
• Blood sugar on empty stomach157mg/dl on 26UI of
  rapid insulin and buscopan
• On 24/01/08 Discharged again

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LITTERAL VIEW
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• DEFINITION
• Diabetes is a metabolic disease of CH due to
  relative or absolute deficiency in insulin.
• Gestational diabetes Carbohydrate intolerance
  with onset or recognition during pregnancy.
• WHO Classification
• TypeITypeII and Gestational diabetes
• I II Chronic conditions
• Gest Diab. typically resolves with delivery of
  the child

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EPIDEMIOLOGY

• Most common medical complications of pregnancy.
• 2 of all pregnancies affected by Diabetes
• 1 are GDM
• USA 3-5 among them
• 10 pregestational(Type 1 2)
• 90 Gestational

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PATHOPHYSIOLOGY

• GD is similar to type 2 DM with a relative
  deficiency in insulin and insulin resistance.
• Type1 early in life, destruction of Langerhans
  cells.
• GD Placenta produces hormones
  (hPL,P4,Cortisol,PGH,) that antagonize insulin
  and reach max levels at 24 to 28 weeks. Early in
  pregnancy as a result of higher levels of
  estrogen, insulin sensibility will increase
  making diabetes patient more prone to
  hypoglycemia. In last 1/3 of gestation 40 of
  pregnant women become relatively insulin
  resistant and must secrete 3-4 X more insulin to
  maintain normal blood glucose level.

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RISK FACTORS

• Agegt25 years
• Strong familly ATCD of DM
• Prior atcd of new born weigthgt4000g.
• Obesity (BMI 30)
• Repeated spontaneous abortion
• Unexplained stillbirth or congenital abnormaly.
• Persitant glucosuria
• Polycystic ovarian sd.

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Maternal affects

• 2x risk of UTI
• 2x risk of Pregnancy induced hypertension
• 2x risk Preeclampsia
• DKA (Peripartum mortality)
• Retinopathy
• Nephropathy
• Postpartum hemorrhage

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Fetal effects

• 1-2 increased risk of anomalies
• Cardiac
• Limb
• Sacral agenesis
• Renal
• CNS abnormalities
• Macrosomia gt4500g
• Polyhydramnios (gt2000ml)
• Stillbirth

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Neonatal effects

• Hypoglycemia
• Hyperbilirubinemia
• Hypocalcemia
• Polycythemia
• Pulmonary immaturity
• Organomegaly

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SCREENING

• Fasting gt125, 1hr PP gt200
• 2 hr GTT
• 1 hour 50g glucose challenge gt130-140
• 3 hour 100g glucose tolerance test Fasting gt95,
  1hr gt180, 2hrgt155, 3 hr gt140
• 2 or more abnormal values makes the diagnosis

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WHITE Classification

• A1GDM diet controlled
• A2GDM requiring medical therapy
• B Onset after age 20, duration lt10yr, No
  vascular
• C Onset between 10-19, duration 10-19yrs, no
  vascular disease
• D Onset ltage 10, duration gt20yrs, retinal or leg
  involvement
• F Vascular nephropathy
• R Retinopathy
• H Coronary artery diseases.

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TREATMENT
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0bstetric Complications
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REFERENCES

• 1.Lauren N. et al.Current diagnosis and treatment
  in GO.10th edition.2007.
• 2.Gabbe SG, Graves CR. Management of diabetes
  mellitus complicating pregnancy.Obstet Gynecol
  2003102857-868.
• 3.ACOG.Pregestational diabetes mellitus.Obstet
  Gynecol 2005105675-685.
• 4.Gary F.Williams obstetrics.22nd edition.2005.
• 5.Kakudji.Cours de GO.Université de
  Lubumbashi.2003.

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MURAKOZE