DIBETES MELITUS WITH PREGNANCY

🔅DEFINITION:
the woman becomes diabetic due to hormonal changes. glucose intolerance or variable degree with onset or first recognised during pregnancy most of cases became normal after delivery but some remain diabetic.

🔅INCIDENCE:
2-12% of all pregnancies.90% are gestational diabetes.10%pregestational or
preconceptional diabetes.

🔅CLASSIFICATION:
--Classification of maternal diabetes in pregnancy:
• Pregestational diabetes: pre-existing type 1 or type 2 or secondary
• Gestational diabetes: diagnosis is made post- gestationally; normal glucose tolerance
• Any type of diabetes mellitus occurring first in pregnancy.

--White’s classification of diabetes during pregnancy Class A Diet alone sufficient, any duration or age at onset Class B Age at onset ≥20 years and duration <10 years Class C Age at onset 10-19 years or duration 10-19 years Class D Age at onset <10 years or duration ≥20 years or background retinopathy or hypertension (not preeclampsia) Class R Proliferative retinopathy or vitreous hemorrhage Class F Nephropathy with proteinuria >500 mg/day Class RF Criteria for both R and F classes coexist Class H Arteriosclerotic heart disease clinically evident Class T Prior renal transplantation
🔅 HIGH RISK FACTORS:
•Previous diagnosis of GDM
•Prediabetes
•History of macrosomic infant
•1st degree relative with diabetes
•Glycosuria
•Member of a high-risk population (Aboriginal, Hispanic, South Asia, Asian, African Canadian)
•Multiple gestation
•Age ≥ 35 years • BMI ≥ 30 kg/m2
•Ancanthosis nigricans
•Corticosteroid use
•History of unexplained stillbirth
•Polycystic Ovary Syndrome (PCOS)
•Pancreatic insufficient cystic fibrosis
•Current fetal macrosomia or polyhydramnios.
.Diabetogenic Effect Of Pregnancy diabetes may appear only during pregnancy or become aggravated by pregnancy because the human placental lactogen .prolactin.oestrogens.progesterone.
cortisol antagonist insulin.
placental enzyme insulinase destroys insulin

🔅EFFECT OF PREGNANCY ON DIABETE :
1-the disease may appear for the first time.
2-insulin requirement gradually increase atfer third month until term
3-diabetic Nephropathy.retinopathy.neuropathy may be aggravated
4-during labour there is liability to hypoglycaemia due to uterine activity
5-drop in level of placental hormones which antagonist to insulin after deleivary lead to decreases insulin requirements :

🔅EFFECT OF DIBETES ON PREGNANCY (COMLICATIONS):
A-Fetal Complications:
1-intrauterine fetal death occure in about 5% of cases especially after 36 weeks.
2-neonatal death 5% due to prematurity. respiratory distress syndrome.congenital anomalies.hypoglycaemia from fetal hyperinsulinamia.
3-congenital malformations 5-10% due to maternal hyperglycaemia during organogenesis.all organs can be affected.commonest lesion is cardiac anomalies.sacral agenesis or caudal regression syndrome.
4-macrosomia 25-50.infant long.large.
fatty and plethoric weight 4 or more KG due to maternal hyperglycaemia lead to fetal hyperglycaemia and hyperinsulinamia which insulin act as growth hormone and lead to more formation of glycogen.fat.protein.
5-intrauterine growth restriction.rare .when there is vascular complications lead to placental insufficiency.
6-fetal birth injury due to macrosomia.
7-infant may inherite type 2 diabetes 1-3%.
8-infant liable to develop obesity and cardiovascular disease.
B-Maternal Complication:
1-abortion if diabetes not controlled
2-preterm labour
3-pre-eclampsia10-30%
4-polyhydramnios 5-15% in well controlled.
30% in poorly controlled cases.
5-increased liability to infection.
6-obstructed labour and birth trauma due to macrosomia
7-postpartum haemorrhage.
8-increased incidence of caesarean section up to 50%.
9-defective lactation.
10-hyperglycaemic or hypoglycaemic coma due to difficulty of control of diabetes.

🔅HOW TO MANAGEMENT:
A-before pregnancy:
1-conrol of blood sugar level by conrol of diet.daily exercise and medical treatment.
2- folic acid 5mg daily before conception and during first trimaster to reduce incidence of neural tube defects.
3-regular pretenatal care during pregnancy.
B-During Pregnancy:
1-conrol of blood sugar level by conrol of diet 50%carbohydrate. 20%proteins. 30%fat.daily exercise and insulin if necessary.hypoglycaemic druges not used because do not control properly glucose level and cause sever hypoglycaemia in infant and may teratogenic.
2-case seen by obstetrician diabetitian . dietitian .
3-measure of maternal serum alpha-fetoprotein at 16-18weeks to exclude neural tube defect.
4-a screening test for all cases at 22-24-28weeks.
5-sonography (in firt trimaster.18-20 weeks.38 weeks.) to confirm GA.exclude congenital fetal anomalies and IUFD and macrosomia.to estimated fetal wieght.
6-estimation of HbA1c .
7-examination of fundus oculi for retinopathy.
8-regular antenatal care every 2weeks till 32weeks then weekly.
9-admission if diabetes not control or there complication as
pre-eclampsia.
10-nonstress test and daily kick count to assess fetal well-being.
11-if diabetes is well control terminat of pregnancy at 38-40 weeks.
if terminat before 38 weeks for any reasons determine lung maturity by presence of phosphatidylglycerol more
2 mg%.L/S ratio. if lung not mature betamethasone or dexamethasone is given for 24 h (12mg im every 12 h for 2 doses) then terminate.either by artificial rupture of membrane and oxytocin drip or vaginal prostaglandin or ceasarean section depending on clinical finding of cervix.
C-During labour:
1-continues infusion of insulin in glucose is given.ten unit in 500ml of 5% glucose at a rate of 125ml/hour(2,5 unit/h for 4h)
2-determine capillary sugare every 2 h.
3-urin is test for ketons /2h.
4-continues CTG. :

D-During Puerperium:
1-insulin give in reduced dose
2-random blood glucose level. :

E-Managed Of Infant:
as preterm baby liable to develop RDS cammonest cause of death .
hypoglycaemia.hypocalcaemia.hypomagnesaemia. hyperbilirubinaemia.hypertrophic cardiomyopathy. polycythaemia because intrauterine hypoxia or hyperglycaemia stimulate erythropoietin production.

د.سامي عارف عبدالجليل الشميري.