After diagnosis of the diabetes, the Clinician and the patient should discuss to set a follow up plan. The aim of the follow up plan is to ensure that the patient is compliance with treatments and at the same time the patient should have a normal life as well.
Steps are as follows
1. Life style modifications
2. stick to treatment regime
3. regular assessment
4. patient education
Life style modification
Stop smoking
Moderate alcohol consumption or stop
Regular exercise
Dietary control
Stick to treatment regime
This is utmost important. Compliance should be assessed regularly. Regime can be changed to have a good glycemic control.
Regular assessment
This is very important to ensure the good blood sugar control. Clinical examination should be carried out to detect complications. Several investigations should be done regularly; eg
1. Fasting blood sugar
2. Lipid profile
Patient education
No longer is it satisfactory to provide patients who have diabetes with brief instructions and a few pamphlets and expect them to manage their disease adequately. An apt sports analogy would be the patient as the player on the field and the physician, nutritionist, diabetes educator, and other health professionals as spectators on the sidelines instructing and cheering on the patient.
Nonphysician health professionals usually are much more proficient at diabetes education and have much more time for this very important activity. Believing that diabetes education is limited to 1 or 2 encounters is misguided; it is a lifetime exercise.
Sunday, February 1, 2009
Diabetes and pregnancy
INTRODUCTION
Diabetes is a metabolic disease characterized by hyperglycemia resulting from defects in insulin secretion or insulin action or both.
About 3-10% of pregnant mothers are suffering from diabetes. Depending Recent studies suggest that the prevalence of diabetes among women of childbearing age is increasing in the world. This increase is believed to be attributable to
1. more sedentary lifestyles,
2. changes in diet,
3. the virtual epidemic of childhood and adolescent obesity
Although 80% or more of this glucose intolerance during pregnancy occurs in women with gestational diabetes mellitus (GDM), the associated fetal and newborn morbidity rates are disproportionate.
Infants of mothers with preexisting diabetes experience double the risk of serious injury at birth, triple the likelihood of cesarean delivery, and quadruple the incidence of newborn intensive care unit admission. Recent studies indicate that the risk of these morbidities in individual cases is proportional to the degree of maternal hyperglycemia. For this reason, the excessive fetal and neonatal morbidity attributable to diabetes in pregnancy should be considered preventable.
The prevalence of gestational diabetes is strongly related to the patient's race and culture.
• Typically, only 1.5-2% of white persons from the mid western United States develop GDM, while American Indians from the southwestern United States may have rates as high as 15%.
• In Hispanic, African American, and Asian populations, the rate is 5-8%.
PATHOPHYSIOLOGY (HOW DOES IT HAPPENS)
Normal metabolism during pregnancy
The goal of metabolism during pregnancy is to ensure that an ample, but not excessive, supply of glucose is available to the mother and fetus. To achieve this goal with each feeding, the pregnant woman undergoes a complex series of maternal hormonal actions:
1. a rise in blood glucose,and
2. the secondary secretion of pancreatic insulin, glucagon, somatomedins, and adrenal catecholamines.
The key features of this complex interaction include the following:
• A pregnant woman has a tendency to develop low sugar level (hypoglycemia) between meals and during sleep than that of nonpregnant woman because the fetus continues to draw glucose across the placenta from the maternal bloodstream, even during periods of fasting.
• The mean insulin level is 50% higher during last trimester than that of nonpregnant. This due to the high levels of placental steroid and peptide hormones (eg, estrogens, progesterone, chorionic somatomammotropin). These hormones increase the tissue resistance to insulin therefore insulin secretion is increased
• If insulin secretion is inadequate, both the mother and fetus develop high sugar levels (hyperglycemia). This can lead to accelerated fetal growth, which can bring many fetal and maternal complications
During a healthy pregnancy, mean fasting blood sugar levels decline progressively to a remarkably low value of 74 ± 2.7 (standard deviation) mg/dL. On the other hand, peak postprandial blood sugar values rarely exceed 120 mg/dL. Meticulous replication of the normal glycemic profile during pregnancy has been demonstrated to reduce the rate of macrosomia (large fetus). Specifically, when 2-hour postprandial glucose levels are maintained at less than 120 mg/dL, approximately 20% of fetuses demonstrate macrosomia. Conversely, if postprandial levels range up to 160 mg/dL, macrosomia rates rise to 35%.
Diabetes is a metabolic disease characterized by hyperglycemia resulting from defects in insulin secretion or insulin action or both.
About 3-10% of pregnant mothers are suffering from diabetes. Depending Recent studies suggest that the prevalence of diabetes among women of childbearing age is increasing in the world. This increase is believed to be attributable to
1. more sedentary lifestyles,
2. changes in diet,
3. the virtual epidemic of childhood and adolescent obesity
Although 80% or more of this glucose intolerance during pregnancy occurs in women with gestational diabetes mellitus (GDM), the associated fetal and newborn morbidity rates are disproportionate.
Infants of mothers with preexisting diabetes experience double the risk of serious injury at birth, triple the likelihood of cesarean delivery, and quadruple the incidence of newborn intensive care unit admission. Recent studies indicate that the risk of these morbidities in individual cases is proportional to the degree of maternal hyperglycemia. For this reason, the excessive fetal and neonatal morbidity attributable to diabetes in pregnancy should be considered preventable.
The prevalence of gestational diabetes is strongly related to the patient's race and culture.
• Typically, only 1.5-2% of white persons from the mid western United States develop GDM, while American Indians from the southwestern United States may have rates as high as 15%.
• In Hispanic, African American, and Asian populations, the rate is 5-8%.
PATHOPHYSIOLOGY (HOW DOES IT HAPPENS)
Normal metabolism during pregnancy
The goal of metabolism during pregnancy is to ensure that an ample, but not excessive, supply of glucose is available to the mother and fetus. To achieve this goal with each feeding, the pregnant woman undergoes a complex series of maternal hormonal actions:
1. a rise in blood glucose,and
2. the secondary secretion of pancreatic insulin, glucagon, somatomedins, and adrenal catecholamines.
The key features of this complex interaction include the following:
• A pregnant woman has a tendency to develop low sugar level (hypoglycemia) between meals and during sleep than that of nonpregnant woman because the fetus continues to draw glucose across the placenta from the maternal bloodstream, even during periods of fasting.
• The mean insulin level is 50% higher during last trimester than that of nonpregnant. This due to the high levels of placental steroid and peptide hormones (eg, estrogens, progesterone, chorionic somatomammotropin). These hormones increase the tissue resistance to insulin therefore insulin secretion is increased
• If insulin secretion is inadequate, both the mother and fetus develop high sugar levels (hyperglycemia). This can lead to accelerated fetal growth, which can bring many fetal and maternal complications
During a healthy pregnancy, mean fasting blood sugar levels decline progressively to a remarkably low value of 74 ± 2.7 (standard deviation) mg/dL. On the other hand, peak postprandial blood sugar values rarely exceed 120 mg/dL. Meticulous replication of the normal glycemic profile during pregnancy has been demonstrated to reduce the rate of macrosomia (large fetus). Specifically, when 2-hour postprandial glucose levels are maintained at less than 120 mg/dL, approximately 20% of fetuses demonstrate macrosomia. Conversely, if postprandial levels range up to 160 mg/dL, macrosomia rates rise to 35%.
Maternal problems (morbidity) associated with diabetes during pregnancy
Diabetes is a condition which can affect any system. Therefore monitoring of functions of all the systems is important to detect the problems. But common maternal problems are as follows;
1. Diabetic retinopathy
2. Deterioration of renal functions
3. Chronic hypertension
4. Preeclampsia
Diabetic retinopathy
This is one of the major causes of blindness in women in reproductive age group. Degree of retinal damage depends on the type of diabetes, duration of diabetes and glycemic control. Patients with preexisting diabetes have a higher risk than that of patients with gestational diabetes. A prospective study showed that while half the patients with preexisting retinopathy experienced deterioration during pregnancy, all the patients had partial regression following delivery and returned to their prepregnant state by 6 months postpartum. However, when the total effect of pregnancy on ophthalmologic status was considered, pregnant women had a slower progression of retinopathy than nonpregnant women.
Deterioration of renal function
Degree of renal damage depends on the type of diabetes, duration of diabetes and glycemic control. Patients with preexisting diabetes have a higher risk than that of patients with gestational diabetes. If there is preexisting renal damage, patient will have varying degree of deterioration of renal function during pregnancy as renal blood flow and the glomerular filtration rate increase 30-50% during pregnancy, the degree of proteinuria also increases. The most recent studies indicate that pregnancy does not measurably alter the time course of diabetic renal disease and it does not increase the likelihood of progression to end-stage renal disease.
Perinatal complications are greatly increased in patients with diabetic nephropathy. Preterm birth, intrauterine growth restriction, and preeclampsia are all significantly more common in women with diabetic nephropathy during pregnancy.
Chronic hypertension
About 10% of diabetic pregnancies are complicated with chronic hypertension. . Patients with underlying renal or retinal vascular disease are at a substantially higher risk. The risk of Intra Uterine growth Restriction (IUGR), preeclampsia, placental abruption and maternal stroke are high when the diabetes and chronic hypertension co-exist.
Preeclampsia
Preeclampsia is a clinical syndrome (collection of signs and symptoms). Abrupt elevation in blood pressure, significant proteinuria, and elevated uric acids level, evidence of hemolysis, elevated liver enzymes and low platelet count are the features of preeclampsia. The frequency of preeclampsia is higher when the pregnancy is complicated with diabetes.
1. Diabetic retinopathy
2. Deterioration of renal functions
3. Chronic hypertension
4. Preeclampsia
Diabetic retinopathy
This is one of the major causes of blindness in women in reproductive age group. Degree of retinal damage depends on the type of diabetes, duration of diabetes and glycemic control. Patients with preexisting diabetes have a higher risk than that of patients with gestational diabetes. A prospective study showed that while half the patients with preexisting retinopathy experienced deterioration during pregnancy, all the patients had partial regression following delivery and returned to their prepregnant state by 6 months postpartum. However, when the total effect of pregnancy on ophthalmologic status was considered, pregnant women had a slower progression of retinopathy than nonpregnant women.
Deterioration of renal function
Degree of renal damage depends on the type of diabetes, duration of diabetes and glycemic control. Patients with preexisting diabetes have a higher risk than that of patients with gestational diabetes. If there is preexisting renal damage, patient will have varying degree of deterioration of renal function during pregnancy as renal blood flow and the glomerular filtration rate increase 30-50% during pregnancy, the degree of proteinuria also increases. The most recent studies indicate that pregnancy does not measurably alter the time course of diabetic renal disease and it does not increase the likelihood of progression to end-stage renal disease.
Perinatal complications are greatly increased in patients with diabetic nephropathy. Preterm birth, intrauterine growth restriction, and preeclampsia are all significantly more common in women with diabetic nephropathy during pregnancy.
Chronic hypertension
About 10% of diabetic pregnancies are complicated with chronic hypertension. . Patients with underlying renal or retinal vascular disease are at a substantially higher risk. The risk of Intra Uterine growth Restriction (IUGR), preeclampsia, placental abruption and maternal stroke are high when the diabetes and chronic hypertension co-exist.
Preeclampsia
Preeclampsia is a clinical syndrome (collection of signs and symptoms). Abrupt elevation in blood pressure, significant proteinuria, and elevated uric acids level, evidence of hemolysis, elevated liver enzymes and low platelet count are the features of preeclampsia. The frequency of preeclampsia is higher when the pregnancy is complicated with diabetes.
Fetal abnormalities with diabetes during pregnancy
Diabetes during pregnancy is a leading cause which can results many fetal abnormalities/problems
1. Miscarriages
2. Birth defects
3. Growth restriction
4. Growth acceleration
5. Fetal obesity
6. Central obesity
Miscarriages
There is a strong association between the degree of blood sugar control prior to pregnancy and the miscarriage rate. Poor blood sugar control may double the miscarriage rates. Patients with long-standing diabetes (glycohemoglobin,HbAc , exceeding 11%) have been shown to have miscarriage rates of up to 44%. Conversely, recent reports demonstrate a normalization of the miscarriage rate with excellent glycemic control.
Birth defects
The occurrence of birth defects in normal population is 1-2%. But the likelihood of structural abnormalities in fetus of diabetic mothers is increased 4-8 folds. Most lesions involve the central nervous and cardiovascular systems. The periconceptional glycemic control is the main factor in the genesis of diabetes-associated birth defects.
1. cardiac malformations(ASD, PDA, VSD)
2. Neural tube defects
3. sacral agenesis
4. hypoplastic left colon
Growth restriction
Usually fetuses with diabetic mothers are macrosomic but there is a risk of Intra Uterine Growth restriction (IUGR) as well. The risk is three fold as compared to fetuses of non diabetic mothers. The risk is higher when the diabetes is preexisting.
The most import predictor of fetal growth restriction is underlying maternal vascular disease. Specifically, pregnant patients with diabetes-associated retinal or renal vasculopathies and/or chronic hypertension are most at risk for growth restriction.
Growth acceleration
Excessive body fat stores, stimulated by excessive glucose delivery during diabetic pregnancy, often extend into childhood and adult life. The adverse downstream effects of deranged maternal metabolism have been documented well into puberty. Glucose intolerance and higher serum insulin levels are more frequent in offspring of diabetic mothers compared with normal controls. By age 10-16 years, offspring of diabetic mothers have a 19.3% rate of impaired glucose intolerance.
Fetal obesity
Macrosomia is typically defined as a birth weight above the 90th percentile for gestational age or greater than 4000 g. In pregnant diabetic women, macrosomia occurs in 15-45% of cases, a 3-fold increase from normoglycemic controls. The infants of diabetic mothers (IDMs) had 5-fold higher rates of severe hypoglycemia, a 4-fold increase in macrosomia, and a doubled increase in neonatal jaundice. Birth injury, including shoulder dystocia and brachial plexus trauma, is more common among IDMs, and macrosomic fetuses are at the highest risk.
Central obesity
The macrosomic fetus develops a unique pattern of overgrowth, involving central deposition of subcutaneous fat in the abdominal and interscapular areas. Skeletal growth is largely unaffected. Neonates of diabetic mothers have a larger shoulder and extremity circumference, a decreased head-to-shoulder ratio, significantly higher body fat, and thicker upper extremity skin folds compared with nondiabetic control infants of similar weights.
1. Miscarriages
2. Birth defects
3. Growth restriction
4. Growth acceleration
5. Fetal obesity
6. Central obesity
Miscarriages
There is a strong association between the degree of blood sugar control prior to pregnancy and the miscarriage rate. Poor blood sugar control may double the miscarriage rates. Patients with long-standing diabetes (glycohemoglobin,HbAc , exceeding 11%) have been shown to have miscarriage rates of up to 44%. Conversely, recent reports demonstrate a normalization of the miscarriage rate with excellent glycemic control.
Birth defects
The occurrence of birth defects in normal population is 1-2%. But the likelihood of structural abnormalities in fetus of diabetic mothers is increased 4-8 folds. Most lesions involve the central nervous and cardiovascular systems. The periconceptional glycemic control is the main factor in the genesis of diabetes-associated birth defects.
1. cardiac malformations(ASD, PDA, VSD)
2. Neural tube defects
3. sacral agenesis
4. hypoplastic left colon
Growth restriction
Usually fetuses with diabetic mothers are macrosomic but there is a risk of Intra Uterine Growth restriction (IUGR) as well. The risk is three fold as compared to fetuses of non diabetic mothers. The risk is higher when the diabetes is preexisting.
The most import predictor of fetal growth restriction is underlying maternal vascular disease. Specifically, pregnant patients with diabetes-associated retinal or renal vasculopathies and/or chronic hypertension are most at risk for growth restriction.
Growth acceleration
Excessive body fat stores, stimulated by excessive glucose delivery during diabetic pregnancy, often extend into childhood and adult life. The adverse downstream effects of deranged maternal metabolism have been documented well into puberty. Glucose intolerance and higher serum insulin levels are more frequent in offspring of diabetic mothers compared with normal controls. By age 10-16 years, offspring of diabetic mothers have a 19.3% rate of impaired glucose intolerance.
Fetal obesity
Macrosomia is typically defined as a birth weight above the 90th percentile for gestational age or greater than 4000 g. In pregnant diabetic women, macrosomia occurs in 15-45% of cases, a 3-fold increase from normoglycemic controls. The infants of diabetic mothers (IDMs) had 5-fold higher rates of severe hypoglycemia, a 4-fold increase in macrosomia, and a doubled increase in neonatal jaundice. Birth injury, including shoulder dystocia and brachial plexus trauma, is more common among IDMs, and macrosomic fetuses are at the highest risk.
Central obesity
The macrosomic fetus develops a unique pattern of overgrowth, involving central deposition of subcutaneous fat in the abdominal and interscapular areas. Skeletal growth is largely unaffected. Neonates of diabetic mothers have a larger shoulder and extremity circumference, a decreased head-to-shoulder ratio, significantly higher body fat, and thicker upper extremity skin folds compared with nondiabetic control infants of similar weights.
Investigations of diabetes during pregnancy
Investigations play a major role during pregnancy. Types of investigations are laboratory investigations, imaging studies and other investigations. Type of the investigation required is determined by the trimester of the pregnancy.
Goals of investigations are;
1. To ensure the maternal wellbeing.
2. To ensure the fetal wellbeing.
Lab Studies
First trimester (in addition to normal prenatal laboratory tests)
1. Hemoglobin A1C
2. Blood urea nitrogen and creatinine
3. Thyrotropin
4. Free thyroxine
5. Twenty-four–hour urine collection for protein and creatinine
6. Blood sugar levels from a capillary device 4-7 times daily
Second trimester
1. Repeat 24-hour urine studies in women with elevated creatinine value in first trimester or 24-hour protein or creatinine clearance less than 100 mL/min
2. Repeat HbA1C
3. Blood sugar levels from capillary device 4-7 times daily in all women with diabetes
If preeclampsia is suggested
1. Repeat 24-hour urine studies
2. Blood urea nitrogen and creatinine
3. Liver function tests
4. Uric acid
5. CBC count with platelets
6. Assessment of fetal well-being with nonstress test, amniotic fluid index, fetal growth, and Doppler examination of the umbilical cord and middle cerebral artery
Imaging Studies
First trimester
1. Ultrasonogram (crown-rump length) for dating and viability
Second trimester
2. Detailed anatomy ultrasonogram at 18-20 weeks' gestation
3. Fetal echocardiogram if HbA1C value was elevated in first trimester
Third trimester
1. Growth ultrasonogram to assess fetal size every 4-6 weeks from 26-36 weeks' gestation in women with overt preexisting diabetes
2. Growth ultrasonogram for fetal size at least once at 36-37 weeks' gestation for women with GDM (Consider performing this study more frequently if macrosomia is suggested.)
Other Tests
• First trimester - Ophthalmologic evaluation
Procedures
• Third trimester - Amniocentesis for fetal lung profile if delivery is contemplated prior to 39 weeks' gestation
Goals of investigations are;
1. To ensure the maternal wellbeing.
2. To ensure the fetal wellbeing.
Lab Studies
First trimester (in addition to normal prenatal laboratory tests)
1. Hemoglobin A1C
2. Blood urea nitrogen and creatinine
3. Thyrotropin
4. Free thyroxine
5. Twenty-four–hour urine collection for protein and creatinine
6. Blood sugar levels from a capillary device 4-7 times daily
Second trimester
1. Repeat 24-hour urine studies in women with elevated creatinine value in first trimester or 24-hour protein or creatinine clearance less than 100 mL/min
2. Repeat HbA1C
3. Blood sugar levels from capillary device 4-7 times daily in all women with diabetes
If preeclampsia is suggested
1. Repeat 24-hour urine studies
2. Blood urea nitrogen and creatinine
3. Liver function tests
4. Uric acid
5. CBC count with platelets
6. Assessment of fetal well-being with nonstress test, amniotic fluid index, fetal growth, and Doppler examination of the umbilical cord and middle cerebral artery
Imaging Studies
First trimester
1. Ultrasonogram (crown-rump length) for dating and viability
Second trimester
2. Detailed anatomy ultrasonogram at 18-20 weeks' gestation
3. Fetal echocardiogram if HbA1C value was elevated in first trimester
Third trimester
1. Growth ultrasonogram to assess fetal size every 4-6 weeks from 26-36 weeks' gestation in women with overt preexisting diabetes
2. Growth ultrasonogram for fetal size at least once at 36-37 weeks' gestation for women with GDM (Consider performing this study more frequently if macrosomia is suggested.)
Other Tests
• First trimester - Ophthalmologic evaluation
Procedures
• Third trimester - Amniocentesis for fetal lung profile if delivery is contemplated prior to 39 weeks' gestation
problems associated with pregnancies complicated with diabetes
Perinatal morbidity and birth injuries will be high if the mother is diabetic during the pregnancy. Apart from these two conditions, other perinatal conditions associated with gestational diabetes are;
1. Perinatal mortality
2. Polycythemia
3. Hypoglycemia
4. Neonatal hypocalcemia
5. Postnatal hyperbilirubinemia
6. Respiratory problems
7. Hypertrophic cardiomyopathy
Perinatal mortality
Perinatal mortality is higher among the fetuses of diabetic mothers than that of nondiabetic mothers. The current perinatal mortality rates among diabetic women remain approximately twice those observed in the nondiabetic population.
Congenital malformations, respiratory distress syndrome (RDS) and extreme prematurity are the leading causes of most perinatal deaths in the context of diabetes during pregnancy. Because of intensive obstetrics and infant care, the perinatal mortality rate is going down. But this provides a major contribution to infant mortality in developing countries.
Birth injury
The factors which increase the birth injuries are macrosomia, prematurity, etc. These conditions are more prevalent among fetuses/infants of diabetic mothers. Common birth injuries associated with diabetes are brachial plexus trauma, facial nerve injury, cephalohematoma and shoulder dystocia.
Polycythemia
A central venous hemoglobin concentration greater than 20 g/dl or a hematocrit value greater than 65% (polycythemia) is not uncommon in infants of diabetic mothers (IDMs) and is related to glycemic control. Treatment with partial exchange transfusion to reduce the hematocrit may be required.
Hypoglycemia
Transient hypoglycemia is common during the first day of life from fetal hyperinsulism, but often be prevented by early feeding .The infant’s blood glucose should be closely monitored during first 24 hours and hypoglycemia treated. Unrecognized postnatal hypoglycemia may lead to neonatal seizures, coma, and brain damage.
Neonatal hypocalcemia
Up to 50% of IDMs have low levels of serum calcium (<7 mg/100 mL). With improved management of diabetes in pregnancy, this rate has been reduced. These changes in calcium appear to be attributable to a functional hypoparathyroidism, although the exact pathophysiology is not well understood.
Postnatal hyperbilirubinemia
Hyperbilirubinemia occurs in approximately 25% of IDMs, a rate approximately double that in a normal population. The causes of hyperbilirubinemia in IDMs are multiple, but prematurity and polycythemia are the primary contributing factors. Increased destruction of red blood cells contributes to the risk of jaundice and kernicterus.
The treatment of this complication is usually phototherapy, but exchange transfusions may be necessary if bilirubin levels are markedly elevated.
Respiratory problems
Neonatal respiratory distress syndrome (RDS) is one of the dreaded complications of gestational diabetes. This is due to the delayed lung maturation.
1. Perinatal mortality
2. Polycythemia
3. Hypoglycemia
4. Neonatal hypocalcemia
5. Postnatal hyperbilirubinemia
6. Respiratory problems
7. Hypertrophic cardiomyopathy
Perinatal mortality
Perinatal mortality is higher among the fetuses of diabetic mothers than that of nondiabetic mothers. The current perinatal mortality rates among diabetic women remain approximately twice those observed in the nondiabetic population.
Congenital malformations, respiratory distress syndrome (RDS) and extreme prematurity are the leading causes of most perinatal deaths in the context of diabetes during pregnancy. Because of intensive obstetrics and infant care, the perinatal mortality rate is going down. But this provides a major contribution to infant mortality in developing countries.
Birth injury
The factors which increase the birth injuries are macrosomia, prematurity, etc. These conditions are more prevalent among fetuses/infants of diabetic mothers. Common birth injuries associated with diabetes are brachial plexus trauma, facial nerve injury, cephalohematoma and shoulder dystocia.
Polycythemia
A central venous hemoglobin concentration greater than 20 g/dl or a hematocrit value greater than 65% (polycythemia) is not uncommon in infants of diabetic mothers (IDMs) and is related to glycemic control. Treatment with partial exchange transfusion to reduce the hematocrit may be required.
Hypoglycemia
Transient hypoglycemia is common during the first day of life from fetal hyperinsulism, but often be prevented by early feeding .The infant’s blood glucose should be closely monitored during first 24 hours and hypoglycemia treated. Unrecognized postnatal hypoglycemia may lead to neonatal seizures, coma, and brain damage.
Neonatal hypocalcemia
Up to 50% of IDMs have low levels of serum calcium (<7 mg/100 mL). With improved management of diabetes in pregnancy, this rate has been reduced. These changes in calcium appear to be attributable to a functional hypoparathyroidism, although the exact pathophysiology is not well understood.
Postnatal hyperbilirubinemia
Hyperbilirubinemia occurs in approximately 25% of IDMs, a rate approximately double that in a normal population. The causes of hyperbilirubinemia in IDMs are multiple, but prematurity and polycythemia are the primary contributing factors. Increased destruction of red blood cells contributes to the risk of jaundice and kernicterus.
The treatment of this complication is usually phototherapy, but exchange transfusions may be necessary if bilirubin levels are markedly elevated.
Respiratory problems
Neonatal respiratory distress syndrome (RDS) is one of the dreaded complications of gestational diabetes. This is due to the delayed lung maturation.
Diagnosis of diabetes during pregnancy
Diagnosis of diabetes during pregnancy is a difficult task as pregnant mothers can be suffered from all four types of diabetes. Recognition of the exact type is essential for the definitive management.
WHO diagnostic criteria;
1. One abnormal sugar level (fasting blood sugar/random blood sugar) in symptomatic patients or two abnormal values (taken two weeks apart) are needed to diagnose diabetes.
A) Fasting Blood Sugar(FBS) > 7mmol/l (126mg/dl)
B) Random Blood Sugar(RBS)> 11.1mmol/l(200mg/dl)
2. Glucose Tolerance Test (GTT)needed for borderline cases and for GDM
A) Method for adults; 75g glucose in 300 ml water should be given. Then blood sugar level should be measured 2 hours after the ingestion of glucose.
B) Method for children; 1.75g/kg body weight given and blood sugar measured after 2 hours.
• If the 2 hour sugar level is greater than 11.1mmol/l, patient can be labeled as diabetes.
• This test can be used to diagnose the gestational diabetes as well. This is the diagnostic test during 24-28 weeks of pregnancy.
Diagnosis of type 1 diabetes
Usually these patients know that they are diabetic before they become pregnant. They are typically diagnosed during an episode of hyperglycemia, ketosis and dehydration. Type 1 diabetes is diagnosed only rarely during pregnancy and is most often accompanied by unexpected coma because early pregnancy may provoke diet and glycemic control instability in patients with occult diabetes. Therefore as a precaution, a pregnancy test should be performed in all reproductive-aged women admitted to the hospital for blood sugar management.
Diagnosis of type 2 diabetes
This is very difficult to diagnose as severe form of gestational diabetes mimic type 2 diabetes. If the first trimester HbA1C value of 8% is highly suggestive of preexisting type 2 diabetes, definitive diagnosis of type 2 diabetes must be made after pregnancy using the 75-g, 2-hour glucose tolerance test.
Diagnosis of gestational diabetes
Gestational diabetes (GDM) is a state of carbohydrate intolerance of varying degrees and it is first recognized during pregnancy with a probable resolution after the end of pregnancy. Diabetes, glucose intolerance or insulin resistance may have existed before the pregnancy. GDM is not the same as Type 1 or Type 2 Diabetes. Glucose Tolerance test is used to diagnose this condition
WHO diagnostic criteria;
1. One abnormal sugar level (fasting blood sugar/random blood sugar) in symptomatic patients or two abnormal values (taken two weeks apart) are needed to diagnose diabetes.
A) Fasting Blood Sugar(FBS) > 7mmol/l (126mg/dl)
B) Random Blood Sugar(RBS)> 11.1mmol/l(200mg/dl)
2. Glucose Tolerance Test (GTT)needed for borderline cases and for GDM
A) Method for adults; 75g glucose in 300 ml water should be given. Then blood sugar level should be measured 2 hours after the ingestion of glucose.
B) Method for children; 1.75g/kg body weight given and blood sugar measured after 2 hours.
• If the 2 hour sugar level is greater than 11.1mmol/l, patient can be labeled as diabetes.
• This test can be used to diagnose the gestational diabetes as well. This is the diagnostic test during 24-28 weeks of pregnancy.
Diagnosis of type 1 diabetes
Usually these patients know that they are diabetic before they become pregnant. They are typically diagnosed during an episode of hyperglycemia, ketosis and dehydration. Type 1 diabetes is diagnosed only rarely during pregnancy and is most often accompanied by unexpected coma because early pregnancy may provoke diet and glycemic control instability in patients with occult diabetes. Therefore as a precaution, a pregnancy test should be performed in all reproductive-aged women admitted to the hospital for blood sugar management.
Diagnosis of type 2 diabetes
This is very difficult to diagnose as severe form of gestational diabetes mimic type 2 diabetes. If the first trimester HbA1C value of 8% is highly suggestive of preexisting type 2 diabetes, definitive diagnosis of type 2 diabetes must be made after pregnancy using the 75-g, 2-hour glucose tolerance test.
Diagnosis of gestational diabetes
Gestational diabetes (GDM) is a state of carbohydrate intolerance of varying degrees and it is first recognized during pregnancy with a probable resolution after the end of pregnancy. Diabetes, glucose intolerance or insulin resistance may have existed before the pregnancy. GDM is not the same as Type 1 or Type 2 Diabetes. Glucose Tolerance test is used to diagnose this condition
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