DIABETES MELLITUS IN PREGNANCY Diabetes mellitus is the most common endocrine disorder of pregnancy.

Gestational diabetes mellitus (GDM) accounts for approximately 90% to 95% of all cases. Gestational Diabetes Mellitus Carbohydrate intolerance of variable severity with onset or first recognition during pregnancy GDM and Type 2 Diabetes share impaired insulin secretion and insulin resistance. Insulin resistance results in decreased glucose uptake in skeletal muscles, adipose tissue, and liver and suppression of hepatic glucose production. Overt Diabetes Fasting plasma glucose of >125mg/dL Glucosuria Ketoacidosis Random plasma glucose level greater than 200mg/dL Presence of classic signs and symptomspolydipsia, polyphagia, polyuria and unexplained weight loss High index of suspicion if with the followingstrong family history of diabetes, previous having delivery of large infants, unexplained fetal losses, persistent glucosuria Screening for Gestational Diabetes Perform between 24 and 28 weeks Do on pregnant women not known to have glucose earlier in pregnancy Do a one or two step procedure One Step Procedure o Take a fasting blood sample o Ask the patient to ingest 75g glucose o Extract another blood sample 2 hours after glucose ingestion o An FBS value >105mg% and a 2 hour post-glucose values of >140mg% are diagnostic of GDM Two Step Procedure o 50g glucose challenge test o 100g oral glucose tolerance test is done if result of the 50g glucose load is abnormal Adverse Perinatal Outcome Gestational Diabetes Fetal Effects of Gestational Diabetes Stillbirth Aberrant Fetal Growth

Metabolic (hypoglycemia, hypocalcemia) Hematologic (bilirubinemia, polycythemia) Respiratory complications Congenital anomalies and spontaneous abortion Long-term complications

Maternal Effects of Gestational Diabetes Increased frequency of hypertension and the need for cesarean section Overt Diabetes Fetal Effects of Overt Diabetes Perinatal losses Abortion Malformations Hydramnios Preterm delivery Inheritance of diabetes Altered fetal growth Maternal Effects of Overt Diabetes Diabetic Nephropathy Diabetic Retinopathy Diabetic Neuropathy Preeclampsia Ketoacidosis Infection Management Treatment Modalities in Gestational Diabetes: 1. Insulin Therapy 2. Diet 3. Exercise 4. Oral anti-diabetic drugs Insulin Therapy Recommended when standard dietary management does not consistently maintain fasting plasma glucose at less than 105mg/dL or the 2-hour postprandial plasma glucose at less than 120mg/dL. American Diabetes Association has suggested insulin therapy when diet alone fails to maintain fasting blood glucose at or below 95mg/dL or 2-hour postprandial blood glucose levels at or below 120mg/dL. For non-obese patients= 0.8 U/kg For overweight and obese= 0.9 to 1.0 U/kg The total insulin dose is divided so that two thirds is administered in the morning, which is further split in a ratio of 2:1 (intermediate and rapid-acting), and one third is administered

with supper and bedtime in a ratio of 1:1 (rapidacting and intermediate). If after 3 to 7 days, the GDM patient has not achieved the desired level of glycemic control, the total insulin dose should increase by 10% to 20% and thereafter adjusted when needed. Diet

Hypertension without proteinuria occurring after 20 weeks gestation or postpartum Pre-eclampsia Presence of hypertension and proteinuria occurring after the 20th week of gestation except in cases of extensive trophoblastic proliferation Severe Pre-eclampsia BP of at least 160mmHg systolic or 110mmHg diastolic Proteinuria of at least 4g/day or a persistent qualitative 2+ or more on dipstick Oliguria of less than 400cc/day Severe headache or visual disturbances Pulmonary edema or cyanosis Intrauterine growth restriction Abdominal pain, epigastric pain or RUQ in location Hemolysis Elevated liver enzymes Low platelet count Eclampsia Presence of convulsions in a woman with underlying pre-eclampsia Chronic Hypertension Presence of blood pressure of 140/90mmHg or greater prior to pregnancy or is detected before the 20th week of pregnancy and persists long after delivery. Superimposed Pre-eclampsia Increased diastolic or systolic blood pressure over baseline hypertensive readings and is accompanied by proteinuria and signs and symptoms of end-organ dysfunction Superimposed Eclampsia Convulsion occurring in a woman with chronic hypertension and superimposed pre-eclampsia Diagnosis: Clinical History Risk Factors associated with the pregnant woman: First pregnancy (6-7x risk) Age under 20 or over 35 High blood pressure before pregnancy Previous pre-eclamptic pregnancy Short inter-pregnancy interval Family history (mother or sister had preeclampsia)

Diet is the mainstay of treatment in GDM Two current approaches are recommended: Decreasing the proportion of carbohydrates to 35% to 40% in a daily regimen of three meals and three to four snacks Lowering the glycemic index so that carbohydrates account for approximately 60% of daily intake Normal weight women= 30kcal/kg Overweight and Obese= 25kcal/kg Morbidly Obese= 20kcal/kg

Exercise A moderate exercise program for pregnant diabetic women who are willing and able may improve postprandial blood glucose levels and insulin sensitivity. Oral anti-diabetic drugs The most data regarding safety in pregnancy for oral antidiabetic drugs are with the use of metformin and glyburide. The American Diabetes Association recommends the following for follow-up of GDM: Women diagnosed with GDM should undergo evaluation with a 75g oral glucose tolerance test at 6-12 weeks after delivery. Women whose 75g test is normal should be reassessed at a minimum of 3 year interval. -------------------------HYPERTENSIVE DISEASES IN PREGNANCY Hypertensive diseases in pregnancy continue to be a leading cause of maternal and perinatal mortality and morbidity worldwide. Local data show that they cause roughly 1 out of 4 maternal obstetric deaths. Proteinuria Urinary protein of at least 300mg/24 hours urine sample or 1000mg/ random sample of urine taken 6 hours apart Dipstick: Mild Proteinuria= traces to 1+ Heavy Proteinuria= 2+ to 4+ Gestational Hypertension

Obesity Diabetes, Kidney disease, Rheumatoid arthritis, Lupus or Scleroderma Low socio-economic status Poor protein or low calcium in the diet

Offers theoretical advantage over Nifedipine in that it acts more selectively on the peripheral vasculature with less inotropic effect of tachycardia and related symptoms of flushing and hot flushes.

Risk Factors associated with the pregnant womans husband or partner: First time father Previously fathered a pre-eclamptic pregnancy Risk Factors associated with the fetus Mutifetal pregnancy Hydrops/triploidy Hydatidiform mole Laboratory Tests: Hematocrit Proteinuria (>300mg/24hours) Serum uric acid Hemoglobinuria, Hyperbilirubinemia, Elevated LDH, SGPT, Thrombocytopenia= HELLP Syndrome Treatment Control of Convulsion Control of Hypertension Optimum Time and Mode of Delivery Control of Convulsion Give a loading does of 4Gm IV bolus slowly over 5 minutes followed by a maintenance dose of 12 Gms per hour IV drip. Give a loading dose of 4Gm IV bolus slowly over 5minutes and 10Gm IM (5Gm into each buttock) followed by a maintenance dose of 5 Gms every 6 hours. Safety of MgSO4 is monitored using the following points: Presence of deep tendon reflexes Respiratory rate of >12 per minute Urine output of at least 100cc every 4 hours Serum magnesium for greater accuracy Control of Hypertension Hydralazine o Initial dose is given as a 5mg IV bolus followed by 5mg incremental increases half-hourly if diastolic BP does not improve up to a total dose of 20mg Nifedipine Nicardipine

Optimum Time and Mode of Delivery Current opinion states that immediate delivery may be done for the following: All cases of eclampsia regardless of age of gestation Severe pre-eclamptics who are at least 34 weeks pregnant in the presence of a mature fetal lung and adequate nursery facilities Evidence of severe maternal disease as evidenced by uncontrollable hypertension of 160/100mmHg, oliguria <400 hours, thrombocytopenia <100,000/cu, pulmonary edema and impending eclampsia Evidence of fetal compromise based on abnormal fetal movement counting, CTGs, Biophysical Profile Score monitoring and ARED patterns on Doppler velocimetry