Diabetes Care solution in india

1
Complications

• Hypoglycemia
• Premature Labour
• Preeclampsia

2
Objectives

• Discuss causes, prevention strategies and
  treatment of hypoglycemia for those women on
  insulin
• Discuss premature labour, recognizing
  contractions, and action to take
• Discuss diagnosis and treatment of preeclampsia

3
Definition of hypoglycemia

• The development of autonomic or neuroglycopenic
  symptoms
• Low plasma glucose (less than 4.0 mmol/L or 72
  mg/dl)
• Symptoms resolved by administration of
  carbohydrate
• Cryer, Davis, Shamoon, 2003

4
Risk of hypoglycemia (1 of 3)

• Only those taking glucose-lowering medicines or
  insulin are at risk
• Risk increases with
• Not enough carbohydrate consumption
• Late or missed meal
• Fasting or malnourishment
• Too much insulin
• Prolonged or unplanned activity

5
Risk of hypoglycaemia (2 of 3)
6
Symptoms of hypoglycaemia
Canadian Diabetes Association, 2013
7
Possible consequences of hypoglycaemia
8
Effect Of Hypoglycemia On Fetus
Fetal heart rate, as well as fetal movements and
placental perfusion appear to be unchanged during
conditions of maternal hypoglycemia in the range
of 2.5 3.0 mmol/L (4555 mg/dL)
Coustan, 2009 Diamond, Reece et al, 1992 Nisell,
Persson, et al1994 Reece, Hagav, et al 1995
9
Treatment (1 of 2)
Canadian Diabetes Association, 2013
10
Treatment (2 of 2)
Treatment

• Severe
• 20 g glucose
• Glucagon 1ml SC or IM increases BG by 3 -12
  mmol/L (54-216 mg/dl) over 60 min
• IV dextrose- 20 to 50 ml of 50 dextrose over 2
  to 3 minutes immediate response is seen
• Manage seizure- place person on their side if not
  too agitated

11
Follow-up management
Follow-up management

• Meal or snack (15 to 20 g carbohydrate a
  protein source)
• Next dose of insulin taken as usual if cause is
  known and hypo was mild
• Consider reducing next dose of insulin if hypo
  was severe
• Assess cause and prevent recurrence
• Avoid BG levels lt 4 mmol/L (72 mg/dL)

12
Premature Labour

• Preterm labour in GDM can use steroids and
  tocolysis as for other pregnancies
• Preferably avoid betamimetic as tocolytics
• Nifidepine is a good choice
• Both steroids / tocolytics can push glucose up so
  need to monitor closely and cover with insulin /
  increasing dose of insulin
• Rule out UTI as a risk factor for preterm labour

13
Preeclampsia

• Women with GDM are at increased risk of
  preeclampsia this is partly due to the increased
  insulin resistance
• It is possible that this increase could be
  accounted for by the fact that their age and BMI
  predispose them to GDM as well as hypertension.
  
• Monitor BP urine albumin every visit

Hollander 2007
14
Delivery
15
Objectives

• Discuss when to deliver infant
• Discuss options for inducing labour
• Discuss implications of Caesarian section

16
Timing of delivery the same for all?

• Women with diabetes before pregnancy are at
  increased risk
• In GDM perinatal mortality rates lower
• If insulin requiring, best to use approach
  similar to pregestational DM
• GDM managed on diet and exercise alone possibly
  not at any greater risk from baseline
• Depends on severity and duration of diabetes as
  well as co morbidities

17
Timing of delivery
18
Consider.

• Gestational specific risks for still birth
  continue to fall up to 38 weeks but increase
  slightly over 40 weeks
• In insulin dependent women most would plan
  delivery 38 - 39 weeks
• Between 38 and 39 weeks
• No difference in incidence of cesareans
• More larger babies in one study
• There is as yet not enough evidence that
  induction in diabetic pregnancies prevents fetal
  macrosomia

19

• In diet controlled GDM women most would be
  comfortable to 40 weeks
• With good control and reassuring tests of well
  being some centres go on to 41 weeks

Patel, Steer, Doyle et al. 2003
20
Mode of delivery

• Matter of choice
• High section rates 30 80 averaging 50 in
  many centres
• Vaginal delivery is possible and safe
• Previous obstetric history
• EFW
• Other clinical factors
• Induction of labour is a safe option

21
Monitoring labour

• Labour is a time of unpredictable glucose and
  insulin demands risk of hypoglycemia
• Sliding scale / infusion
• Maintain plasma glucose below 110 mg/dl to avoid
  maternal hyperglycemia and subsequent foetal
  hypoglycemia
• Careful intrapartum FHR monitoring
• Pay attention to second stage slow progress is
  a red flag
• Caution with instrumental delivery
• Be prepared for shoulder dystocia

Jovanovic L. 2005
22
References

• COMPLICATIONS
• Canadian Diabetes Association Expert Committee.
  Canadian Diabetes Association 2013 Clinical
  Practice Guidelines for the Prevention and
  Management of Diabetes in Canada. Can J Diab
  201337(suppl 1)S69-71
• Coustan, D, Glob. libr. women's med., (ISSN
  1756-2228) 2009 DOI 10.3843/GLOWM.10162
• Cryer P.E. Davis, S.N. Shamoon, H. Hypoglycemia
  in diabetes. Diabetes Care, 200326(6)1902-1912
• Diamond MP, Reece EA, Caprio S et al Impairment
  of counterregulatory hormone responses to
  hypoglycemia in pregnant women with
  insulin-dependent diabetes mellitus. Am J Obstet
  Gynecol 199216670-77
• Hollander M, Paarlberg KM, Huisjes AJM, 2007
  Gestational Diabetes A Review of the Current
  Literature and Guidelines Volume 62, Number 2
  Obstetrical and Gynecological Survey
• Nisell H, Persson B, Hanson U, et al Hormonal,
  metabolic and circulatory responses to
  insulin-induced hypoglycemia in pregnant and
  nonpregnant women with insulin-dependent
  diabetes. Am J Perinatol 199411231-236
• Reece EA, Hagay Z, Roberts AB et al Fetal
  Doppler and behavioral responses during
  hypoglycemia induced with the insulin clamp
  technique in pregnant diabetic women. Am J Obstet
  Gynecol 1995172151-155.
• Saleh M., Grunberger, G. Hypoglycemia A cause
  for poor glycemic control. Clinical Diabetes,
  200119(4)161-167.
• DELIVERY
• Jovanovic L, Knopp RH, Kim H, et al. Elevated
  pregnancy losses at high and low extremes of
  maternal glucose in early normal and diabetic
  pregnancy evidence for a protective adaptation
  in diabetes. Diabetes Care 2005 281113.
• Patel RR, Steer P, Doyle P, Little MP, Elliot P.
  Does gestation vary by ethnic group? A
  London-based study of over 122000 pregnancies
  with spontaneous onset of labour. Int J of Epid.
  200333107-113.DOI 10.1093/ijc/dyg238.