Outline:
What is Pre-Gestational Diabetes?
Pre-Gestational Diabetes Diagnosis.
HbA1c Levels
Medical Managements of Pre-Gestational Diabetes.
Obstetric managements
Maternal complications with Pre-Gestational Diabetes and Gestational Diabetes mellitus.
Fetal complications of Pre-Gestational Diabetes and Gestational Diabetes mellitus.
Congenital malformations seen in Pre-Gestational Diabetes.
What is Macrosomia?
What is Shoulder Dystocia?
Neonatal complications- Pre-Gestational and Gestational.
What is Pre-Gestational Diabetes?
Answer: It is the Diabetes present in a female before getting conceive.
Hyper-glycemia present from Day 1 of pregnancy. Hyper-glycemia form fetotoxicity by producing Free radicals. These free radical can easily cross placenta and fetotoxicity caused leads to congenital malformations in fetus.
But Gestational Diabetes does not leads the congenital malformations in fetus.
Pre-Gestational Diabetes Diagnosis
Explaination: Making diagnosis confirmed if…
1] If fasting blood sugar levels are more than or equals to 126 mg/dl.
2] If 2 hour PP or Random blood sugar (RBS) levels are more than or equals to 200 mg/dl.
3] If HbA1c more than or equals to 6.5
HbA1c Levels
Explaination: According to researches, congenital malformations in fetus is strictly related to HbA1c Levels. Higher the levels of HbA1c higher the risk of congenital malformations in the fetus. There is structural anomalies only not the chromosomal.
So we called the HbA1c Levels as a Risk Assessment tool.
Level Less than 6.5 = No risk
Level 6.5 = 3% risk
Level 9 = 15-20% risk
Medical Managements of Pre-Gestational Diabetes.
Answer: Drug of choice by doctors should be Insulin therapy.
Start the therapy as soon as pregnancy diagnosed.
Folic Acid supplements- 400 mcg/Day. Like in normal female pregnancy but dose is 4 mg/day in female with history of fetus with Neural tube defects.
Level 2 scan-Anomaly scan should be done to detect The Structural abnormalities. At 18-20 weeks.
Fetal ECHO cardiography between 22-24 weeks.
If diabetes found much before in 1st trimester then dont have to wait till 18-20 weeks to perform the Anomaly scans.
We should do a HbA1c test then follow with USG at 11-13 weeks. It help in finding neural tube defects if there is any aneuploidy or malformations.
A pregnant diabetic female has a high chances of IUD and stillbirths.
To reduce the risk do Fetal monitoring. Best time to start is 32 weeks of pregnancy.
Method: Daily fetal movements counts, NST weekly, Biophysical profile weekly.
No doppler unless until PIH and vasculopathy.
Prescribe Insulin right away. Stops any oral hypoglycemic drugs she was on.
And along with insulin start Medical nutritional therapy as well.
There is no importance of prescribing MNT alone or Oral hypoglycemic drugs alone like (metformin and Glyburide).
Metabolic goals for Rx is:
Fasting blood glucose levels = less than 95 mg/dl
1 hour PP = Less than 140 mg/dl
2 hour PP value = less than 120 mg/dl
Average Capillary pressure = less than 100 mg/dl
HbA1c values = less than 6
Obstetric managements
Answer: Termination of pregnancy in case of
– Overt diabetic mother with well controlled Blood sugar levels and no complications: continue till 39 weeks of pregnancy.
– Overt diabetic mother not well controlled Blood sugar levels and with complications: continue till 37-38+6 Days weeks of pregnancy.
Maternal complications with Pre-Gestational Diabetes and Gestational Diabetes mellitus.
Explaination:
1] Polyhydramnios: Due to high glucose levels fetus got polyuria and eventually develops Polyhydramnios.
Polyhydramnios can leads to complications like Pre-term labor, Placenta abruptio, Premature rupture of membranes.
2] Placentomegaly: It Increases risk for pre-eclampsia and PIH. Give low dose aspirine to avoid PIH development.
3] Infections: Diabetic patients are more prone to infections.
Should be done- Urine routine microscopy in each trimester.
Asymptomatic bacteuria
Urinary tract infections
Vaginal Candidiasis.
4] Birth trauma and operative delivery due to Macrosomia.
5] Post partum hemorrhage PPH. Result in less uterus tone due to overdistended uterus due to Polyhydramnios and Macrosomia.
6] 50% mother with Gestational diabetic mother develops Type 2 diabetes.
After the delivery – 6 weeks later do Glucose tolerance Test GTT with 75g of glucose.
Fetal complications of Pre-Gestational Diabetes and Gestational Diabetes mellitus.
Explaination: Congenital malformations: present in cases of Pregestational diabetes because blood sugar levels are high with fetotoxic characteristics of free radicals. These fetotoxic free radicals are present even before organogenesis. But in Gestational Diabetes mellitus will be no Congenital malformations.
High glucose in mother (hyperglycemia) –> High glucose in fetus –> fetus pancrease produces high insulin in response –> Hyperinsulinemia in a fetus.
At the same time similar, Insulin-like-growth factors are increased leads to Macrosomia. (Most common fetal complication).
Hyperinsulinemia prevents surfactant production so delayed lung maturity in fetus, prone to respiratory distress syndrome.
Necrotising Entero-colitis
Increased chances of Abortion, IUD and stillbirths.