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OBSTETRIC MANAGEMENT IN GDM. Dr.parichehr pooransari Perinatalogist in shohada hospital. Gestational Diabetes Mellitus. When a selective approach to screening is to be applied, then the recommended screening historic risk factors are as follows : • BMI of 30 or above.
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OBSTETRIC MANAGEMENT IN GDM Dr.parichehrpooransari Perinatalogist in shohada hospital
When a selective approach to screening is to be applied, then the recommended screening historic risk factors are as follows : • • BMI of 30 or above. • • Previous macrosomic infant. • • Previous pregnancy complicated by GDM. • • Family history of diabetes in first-degree relatives. • • Ethnic origin with known high prevalence of diabetes including subcontinental Asia, black Caribbean, and Arabic, particularly of Middle Eastern origin.
Assessment for and treatment of asymptomatic bacteriuriais particularly important because there is a three- to five-fold greater propensity for asymptomatic bacteriuria in diabetic women. Rescreening among those who did not have bacteriuria on the initial test is generally not performed in low-risk women, but is reasonable in women at high risk for infection, such as women with diabetes mellitus
Assessment of comorbidities • Baseline renal function. Initial quantification of urinary proteinuria is performed on a random urine sample using the urinary protein-to-creatinine ratio • Thyroid stimulating hormone (TSH) and thyroid peroxidase status if unknown, as the incidence of thyroid dysfunction in women with type 1 diabetes is as high as 40 percent.
Electrocardiogram, as a screen for ischemic heart disease, especially in women with cardiovascular symptoms, hypertension, or evidence of diabetic vasculopathy. • ●Dilated, comprehensive eye examination by an ophthalmologist to detect retinopathy . Close follow-up is indicated during pregnancy, with the frequency determined by baseline findings. The American Diabetes Association suggests eye examinations every trimester and for one year postpartum, as indicated by degree of retinopathy
Retinal Assessment • g severe visual loss: • • Presence of vitreous or preretinal hemorrhage. • • Presence of new vessels. • • Location of new vessels on or near the optic disk. • • Severity of new vessels.
TABLE 44–6 Dietary Advice for Pregnant Women with Diabetes
Prevention of preeclampsia — Pregestational diabetes is a risk factor for preeclampsia. The United States Preventive Services Task Force and American Diabetes Association recommend that women at high risk for preeclampsia, including all those with type 1 and 2 diabetes, begin low-dose aspirin after 12 weeks of gestation .
The author prescribes folic acid 1 mg daily during the first three months of pregnancy to reduce the risk of neural tube defects; doses of 0.4 to 5 mg/daily have been recommended by others • We begin antepartum surveillance at about 32 weeks of gestation, increasing the frequency of testing to two times per week from 36 weeks until delivery . In complicated patients with intrauterine growth restriction, oligohydramnios, preeclampsia, or poorly controlled blood glucose concentrations, testing may start as early as 26 weeks of gestation and is performed more frequently. Any significant deterioration in maternal status necessitates reevaluation of the fetus
Screening for Congenital Malformations • Diabetes in pregnancy is associated with an increased risk of NTDs. • In practice, many consider that there is no benefit from maternal AFP screening in women with diabetes if routine 20-week anomaly screening is in place. ,
We monitor capillary blood glucose concentrations hourly, beginning 12 hours after the first dose of betamethasone and continuing for 24 hours after the second dose, and then reduce the frequency to several times per day thereafter if glucose levels are reasonably well controlled. For values >120 mg/dL (6.7 mmol/L), we treat with subcutaneous insulin but, in recognition of the risk of diabetic ketoacidosis in these patients, we begin continuous intravenous insulin infusion on the labor unit if values continue to rise in spite of such treatment, or if values are above 180 to 200 mg/dL (10 to 11.1 mmol/L
Preterm Labor Management and Outcomes • To avoid this in women with type 1 diabetes, one group recommended that daily insulin doses should be increased by enhancement of their existing regimes as follows : • Day 1 Insulin dose increased by 25%. • Day 2 Insulin dose increased by 40%. • Day 3 Insulin dose increased by 40%. • Day 4 Insulin dose increased by 20%. • Day 5 Insulin dose increased by 10%. • Day 6 Return to previous insulin doses.
Timing of delivery — We and others see little benefit in continuing pregnancy beyond 39 weeks in women with diabetes, particularly those with a favorable cervix. • when glycemic control is suboptimal or there are other maternal or fetal reasons for concern (eg, maternal vascular disease). In these cases, an acceptable approach is to induce labor at 37 weeks (or earlier) . When such a plan is chosen, the risks of a failed induction due to an unfavorable cervix must be weighed against the risks associated with continuing the pregnancy.
POSTPARTUM — Breastfeeding should be encouraged • Postpartum depression is more common among women with diabetes (pregestational or gestational) than in nondiabeticwomen • Depot medroxyprogesterone acetate(DMPA) and combined estrogen-progestin contraceptives are generally avoided in women with vascular disease . The progestin-releasing IUD, copper IUD, and etonogestrel implant have lower risk of thromboembolic events than estrogen-progestin contraceptives . • Ophthalmologic follow-up during the first year postpartum is advised since retinopathy can be aggravated anytime during pregnancy or postpartum .
GDM • The American College of Obstetricians and Gynecologists (ACOG) has suggested antenatal fetal assessment beginning at 32 weeks of gestation for all women treated with insulin or oral agents • the American College of Obstetricians and Gynecologists (ACOG) has suggested antenatal fetal assessment beginning at 32 weeks of gestation for women with GDM and poor glycemic control on nutritional therapy . No specific recommendations were made for fetal assessment in patients with well-controlled GDM on nutritional therapy, except for assessment of amniotic fluid volume. This decision was left to local practice patterns. If the practitioner chooses to order NSTs or BPSs, the tests can be begun nearer to term since no increased risk of stillbirth has been demonstrated before 40 weeks in this population.
Timing of delivery • A1 GDM • ACOG has opined that delivery should not be planned before 39 weeks of gestation unless otherwise indicated, and that expectant management up to 40+6 weeks is generally appropriate with antepartum testing • A2 GDM • ACOG suggests delivery at 39+0 to 39+6 weeks of gestation for women with A2 GDM well controlled with medication . However, guidance for women with poor glycemic control is less precise. They suggest delivery at 37+0 to 38+6 weeks of gestation may be reasonable, but that delivery prior to 37+0 weeks should only be done when more aggressive efforts to control blood sugars, such as hospitalization, have failed.
The ACOG practice bulletin on GDM recommends discussing the risks and benefits of scheduled cesarean delivery with women with GDM and estimated fetal weight ≥4500 grams • transient hypoglycemia can be caused by intrapartum maternal hyperglycemia, which induces an acute rise in fetal insulin . • Insulin requirements usually decrease during labor, as oral caloric intake is typically reduced and the work of labor, particularly uterine contractions, requires extra energy. Women with GDM who were euglycemic without use of insulin or oral antihyperglycemic drugs during pregnancy do not normally require insulin during labor and delivery, and thus do not need their blood glucose levels checked hourly.
We generally check blood glucose measurements every two hours during labor and begin intravenous insulin at glucose levels above 120 mg/dL (6.7 mmol/L). We prefer this approach because mild hyperglycemia is generally less morbid and easier to treat than intrapartum hypoglycemia, which may occur when a long-acting insulin is administered subcutaneously. • For women undergoing scheduled cesarean delivery, insulin or antihyperglycemic drugs are withheld the morning of surgery and the woman is not allowed any oral intake after midnight
ABLE 44–5 Recognition and Management of Diabetic Ketoacidosis in Pregnancy DKA(0.5%-3%)maternal mortality:<1%prenatal mortality(9-30%)
DKA regime: • ○ Admit HDU: Commence IV normal saline and administer 1000 mL in first hr. Give second 1000 mL over 2 hr. • ○ K + replacement in normal saline, based on serum potassium measurement: • ▪ >5.5 mmol/L no KCl supplement, repeat U & E in 2 hr. • ▪ 4–5.5 mmol/L 20 mmol KCl/1000 mL saline. • ▪ <4.0 mmol/L 40 mmol KCl/1000 mL saline. • • Insulin
C & S, culture and sensitivity; CTG, cardiotocogram; DKA, diabetic ketoacidosis; FBC, full blood count; HDU, high-dependency unit; MSU, midstream urine; U & E, urea and electrolytes.
Iatrogenic DKA and on some occasions fetal death have been provoked in the past by treatment of suspected preterm labor with β-sympathomimetic drugs and/or maternal steroids, both of which have insulin counterregulatoryactions). In addition to the urgent treatment of DKA, underlying causes such as maternal urinary infection or respiratory infection should be sought and treated as appropriate. The recognition of fetal distress in association with DKA in late pregnancy will generally provoke urgent delivery, but here close cooperation with an experienced obstetric anesthetist is essential because there are maternal risks of induction of anesthesia in someone who may have a deteriorating pattern of metabolic acidosis.
