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MRCOG PART 2 SBAs and EMQs

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Essay 328: Diabetes in pregnancy

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		Posted by Ir A. Fri Jul 16, 2010 03:12 am
a) The main issue that will influence preconceptional counselling will be her current glycaemic control. The other issue would be long-term complications of diabetes. A history suggestive of diabetic neuropathy should be elicited. She should be evaluated for diabetic retinopathy by fundus examination after mydriasis. Her blood urea, serum creatinine and urine protein should be checked to assess diabetic nephropathy. and neuropathy. She should be asked if she is on any oral hypoglycemic agents or any antihypertensives. The patient should be advised to conceive only after achieving optimal glucose control as evidenced by HbA1c of less than 6.1%. She should be counselled that uncontrolled diabetes is associated with increased risk of miscarriage, congenital anomalies, macrosomia and unexplained intrauterine fetal demise or stillbirth. If she has high BMI, she should be referred to a dietician and advised to lose weight before conceiving. Her understanding of her medical condition and the support she has from her partner or family can influence management outcomes. b)This is a high risk pregnancy and should be managed in a consultant led unit. She will require multidisciplinary management in conjunction with an endocrinologist, nephrologist and ophthalmologist. She should be prescribed folic acid 5 mg once a day till 12 weeks gestation to minimise risk of neural tube defects. Her BMI should be documented at the first visit. Apart from routine antenatal bloods and urine microscopy, her renal function tests and HbA1c should be done. A fundus examination should be done monthly for evaluating retinopathy. She should be asked to maintain a home glucose monitor chart and should be counselled that the target glucose levels are 3.5-5.9 mmol/litre fasting and less than 7.9mmol/litre one hour after meals. HbA1c should be repeated every month. She should be educated about signs and symptoms of hypoglycemia like sweating, giddiness and palpitaions. The excessive vomiting in first trimester can mask these symptoms. A four chamber view ultrasound for fetal heart should be offered at 18 to 20 weeks as the risk of congenital heart disease is higher in pregnancy complicated by IDDM. A detailed fetal anomaly scan should be done at 22 to 23 weeks. This patient is at increased risk of pregnancy induced hypertension and preeclampsia. Hence, her BP should be measured at each visit and urine tested for protein and sugar. Fundal height should be documented at each visit. A growth scan should be done at 32 weeks. The insulin requirement increases from second trimester and insulin doses should be adjusted according to home monitoring charts in consultation with the endocrinologist. If she does not go into spontaneous labour, induction of labour at 38 weeks should be discussed with her due to the risk of unexplained IUD. She should be provided with written information and contact information of support groups. The involvement of her partner or fmaily in her antenatal care is helpful in achieving optimal outcome.
		Posted by A- N. Fri Jul 16, 2010 04:31 am
I will council regarding establishing good glycaemic control preconceptionally and contuining it through out pregnancy, reduces risks like miscarrage, stillbirths, congenital abnormalities. I will educate her to maintain blod sugars with in normal limits. folic acid 5 milligrammes once daily starting preconceptionally and till 12 weeks reduces risks neural tube defects. Alteration in her medication like avoiding anti hypertensives like ACE inhibitors and beta blockers if she is taking. Basic retinal and renal assessment is important to assess the base line function and to identify if any deterioration occours during pregnancy. life style modifications like excerse, diet if BMI more than 30 will help in better control of blood sugars. advise regarding reduction of smoking, alcohol will improve her general well being. b) She is a high risk case, care should be consultant led. She is to be managed by multidisciplinary team involving obstetrician diabetic specialist/physician, diabitic nurse, midwife, pediatriatian, anaesthetist so as to optimise her care during pregnancy delivery and in post partum period. At booking apart from regular infection screen, full blood count, basic retinal and renal assessment is done to assess any evidence of endothelial damage as the presence of these has got a poorer prognosis for her pregnancy and long term well being. Assessment of HB1AC will provide the estimate of glycemic control over the period of early pregnancy as raised HB1AC will imply poorer prognosis with increase in incidence of miscarrage, congenital abnormalities. She is educated regarding the importance of good glycemic control between 3.5-6.9 mmols/l and is encouraged to learn to check her blood sugars 4 times daily to optimise the insulin requirements. good glycemic control will help in reducing the complications such as congenital anomolies, polyhydramnios, macrosomia, still births. I would review her in combained medical and obstetric clinic every 2-3 weeks to ensure her glycemic control is good and no further complications. I would suppliment her with 5 milligrams of folic acid till about 12 weeks gestation so as to reduce the risk of neural tube defects. changes to short acting and intermediate acting insulin at night is done after liasing with the diabetic team. this will help in stabilisin the blood sugars throughout the day and will prevent fluctuting blood sugars which will increase the complications. the nucal translucency screening may be adopted for downs syndrome screening as the serum screening may be inaccurate as MSAFP is reduced in IDDM. Fetal survey scan between 18-20 weeks should include detailed cardiac screening including 4 chamber to rule out cardiac abnormalities. retinal assessment if abnormal at booking is done at 16 weeks and 4 weekly there after, if normal at booking then done at 28 weeks. serial growth scans from 28 weeks onwards, every 4 weeks, 2 weeksly if necessary to identify polyhydramnios, macrosomia, fetal growth restriction. anaesthetic review at 36 weeks especially if obese will helkp inplanning labour analgesia, and anaesthetic if operative intervention is required.this is to be planned and agreed planis to be documented in antepartum notes. At 36 weeks mode of delivery, timing of delivery, should be discussed. Induction of labour is to be done after 38 weeks so as to reduce the risks of unexplained still births that is more in IDDM.Caeserean section is offered for obstetric indications and for fetal macrosomia especially if the estimated fetal weight is more than 4.5 kilogrammes, as at this weight there is a significant risk of shoulder dystocia. Patients wishes should be discussed regarding the mode of delivery. If steriods are indicated for inducing foetal lung maturity, this is to be done as an inpatient, with preferablly insulin sliding scale so as to maintain strict glucose level maintainance, this is because the steroids will cause rapid changes in glucose levels and this may cause stillbirth. Documented plan for labour in unit having high dependency unit,using sliding scale in so that the glucose levels as well maintained, avoiding dehydration this will reduce the devlopment of ketoacidosis, and reducing the insulin doses to prepregnancy levels post delivery, as with the delivery of placenta the insulin requirement falls. The neonate is to be checked regularly by neonatal unit as there is a high risk of hypoglycaemia, electrolyte imbalances in baby.
		Posted by MR R. Fri Jul 16, 2010 04:43 am
MR A 35 year old woman with insulin dependent diabetes mellitus attends for pre-conception counselling. (a) Discuss the specific issues relating to her diabetes that will influence your counselling [5 marks]. A good control of her diabetic status is vital for good maternal and fetal outcome.Her blood sugar levels should be ideally maintained (Fasting - 3.5 - 5.5, PP <6.8) on her current therapy.A HbA1c levels of < 6.8 is aimed as this reduces the rate of miscarriages & congenital anamolies like sacral agenesis,heart defects and skeletal abnormalities.If current therapy is not sufficient to control her blood sugar levels then increase in insulin doses might be required.An effective contraception should be provided until tight control reached is acheived to optimise the outcome.Periconceptual folic acid 5mgs reduces the incidence of nueral tube defetcs.Diabetic retinopathy status should be determined with appropraiate opthalmic assessment. Photocoagulation if required should be ideally done before pregnancy.The extent of diabetic nephropathy determined by urine proteinuria and protein/creatinine ratio reveals kidney reserve as this worsens with pregnancy.Dietrary advice for both glucose control and to reduce BMI should be given(aim for BMI<30).Patient should be given written information leaflets and also Diabetic support group contact addresses.Coexisting medical conditions like hypertensio and their control is assessed and therapy optimised. (b) Discuss and justify the changes that you will make to her antenatal care [15 marks]. The aptient should be advised to attend for early pregnancy booking scan to confirm viability as there is increased risk of miscarriage.Pregnancy care should be hospital based with obsterician,endocrinologist,diabetic nurse pecialist,midwife and dietician.I will advice her to continue 5mgs of folic acid till 12 weeks as this reduces the incidence of neural tube defects.Patient eduacted regarding hyperemesis and its influence on sugar control and when to seek advice.Appropriate calorie intake advice is given to maintain weight and also her blood sugars.I will review her every 4 weeks regularly or more frequently if clinical situation demands.Diabetic nurse will stay in touch in between clinic visits.BP check with appropraite cuff(if obese) will be done at each visit as they are at increased risk of PET.Urinalysis at each visit for proteinuria,ketones and also Protein/Creatinine ratio is determined.24 hours urine is carried out if there is proteinuria.A blood sugar diary is maintained by the patient to help sugar control(FBS - 3.3 - 5.5 & PP < 6.8) and optimise dose if required at each visit.HbA1c is checked if sugar control not satisfactory.I will educate her regarding hypoglycemic episodes(tremors,sweating & fainting episodes) and give her glucagon for emergency purposes.I will also tell her regarding ketoacidosis( during infection, vomiting) and provide her with ketone strips for testing.Long acting insulin/Insulin pump can be substituted if required.namoly scan should be done by an experienced person to identify specific defects like skeletal abnormalatied and sacral agenesis.A cardiac fetal anomaly scan is arranged at 22 - 24 weeks as they are at high risk of cardiac anamolies.An increase in the insulin dose might be required in the 2nd and 3rd trimester because of increasing plasma volume and demands.Growth are arranged at 24,28,32, & 36 weeks to monitor macrosomia and polyhydramnios.IOL is arranged at 39 -40 weeks because of the increased risk of still birth/PNMR towards the end of the pregnancy.Caesarean section is only for obstetric indication.The plan of care during the pregnancy should be documented in her hand held notes.
		Posted by Bee N. Fri Jul 16, 2010 04:48 am
A 35 year old woman with insulin dependent diabetes mellitus attends for pre-conception counselling. (a) Discuss the specific issues relating to her diabetes that will influence your counselling [5 marks]. (b) Discuss and justify the changes that you will make to her antenatal care [15 marks]. (Bee) A) Issue relating to her diabetes that will influence my preconceptual conselling will include her HbA1C level. Values below 6.1% are encouraged prior to conception as it shows good glucose control and less likelyhood of pregnancy complications. I will ask for presence of recent acute complications such as hypoglycaemia and ketoacidosis or chronic complications like retinopathy or rephropathy which may signify poor control. I will ask for the treatment she is on as drugs like belonging to the sulphonyurea and ACE inhibitors are contraindicated in pregnancy. I will ask for previous Obstetric complications and ask about her social history such as smoking, support from spouse which may further contribute to complicating her pregnancy. B)Changes I will make in her antenatal care will include involvemnet of multidisciplinary team in her care which would include diabetologist, obstetrician, specialist midwife, anaesthetist. I will base her care in a consultant led unit. I will check her HbA1C in each trimester and do 24 hour urine protein at booking for a baseline value of proteinuria. I will also do her kidney and liver function test at booking and repeated each trimester. I will ensure she is seen more frequently (twice weekly until 28 weeks and weekly thereafter ). I will organise a cardiac scan at 24 weeks apart from the routine anomaly scan at 20 weeks. I will organise growth scans as from 28 weeks to detect macrosomia (or even IUGR which is also possible). I will encourage home glucose monitoring and offer a blood glucose diary. I will inform of the risk of hypoglyceamia unawareness in pregnancy. I will give ketone strip to detect ketonuria if she becomes hypoglyceamic and also give concentrated glucose solutions and glucagon for initial treatment in case of hypoglyceamia. Blood glucose target will be between 3.5 - 5.9 mg/dl for fasting blood sugar but <7.8 for 1 hour post prandial sugar. She should remember to check blood glucose before going to bed at night. I will do fundoscopic examination at booking and every trimester. I will plan for induction of labour at 38-39 weeks and reserve ceasarean section at about the same time for obstetric reasons. Earlier delivery may be necessary if complication such as nephropathy worsens.
		Posted by nazia M. Fri Jul 16, 2010 05:05 am
A)Ask about duration of diabetes,glycemic control,dosage of insulin.Explain risks to mother and baby;congenital anomalies,iugr,hydramnios,preterm delivery,macrosomia,still birth,increase perinatal mortality and morbidity,maternal risks are increase requirement of insulin,hypoglycemia,ketoacidosis,nephropathy,retinopathy,hypertension,IHD,nuropathy so good glycemic control before conception will reduce the risks.HbA1c <6.1% will reduce the risk of congenital anomalies.Advice about life style modification;if body weight is increased refer to dietician,exercise,smoking cessation and avoid alcohol,folic acid 5mg as increase risk of neural tube defect.If any complications of diabetes like nephropathy,retinopathy,cardiovascular,hypertension present then patient should be reffered for appropriate consultation and treatment and allow to become pregnant if complications are controlled..If she is taking ACE inhibitors discontinue as risk to fetus alternative antihypertensive should be given.A early booking should be stressed. B)Patient should be managed in joint diabetes and antenatal clinic.Regular glycaemic control assessment.Aim of fasting blood glucose is 3.5-5.9mmolL and 1hr postprandial<7.8mmolL.Hbaic is not routinely done in 2nd and 3rd trimaster.Fasting blood glucose and blood glucose 1hr after each meal should be considered.Urine ketone testing if they become hypoglycaemic as increase risk of diabetic ketoacidosis admission is required in this situation.Patient should also be advised the risk of hypoglycemia and hypoglycemic awareness in pregnancy especially in 1st trimester if hypoglycemia ocur glucose solution or glucagon is needed patient and family members should be instructed.Dating scan in 1st trimester and nuchal translucency offered.Regular bp monitoring to detect hypertension and treat accordingly.Regular retinal assessment with fundoscopy to exclude retinopathy as rapid optimization of glycaemic control detetoriate the condition.Regular renal assessment for detecting nephropathy by blood urea,serum creatinine,proteinuria refer to nephrologist if indicated.Detailed anomalies scan required at 18-20 week gestation especially 4 chambers and outlet cardiac scan as increase risk of cardiac anomalies.Ultrasound growth scan from 28 week because increase risk of iugr and macrosomia.Doppler ultrasound and liqour volume monitoring weekly if iugr and hydramnios suspected. At 36 week gestation patient should be given information about;timing, mode of delivery and birth plan and about insulin infusion requirement.Also give information about breast feeding,contraception and falling insulin requirement after delivery,management of baby after delvery.At 38-39 week offer induction of labour or caesarean if indicated.
		Posted by nazia M. Fri Jul 16, 2010 05:12 am
At 38-39 week offer induction of labour because of increase riskof unexplained iud and caesarean if indicated.
		Posted by S V. Fri Jul 16, 2010 07:03 am
SV A 35 year old woman with insulin dependent diabetes mellitus attends for pre-conception counselling. (a) Discuss the specific issues relating to her diabetes that will influence your counselling [5 marks]. Good glycaemic control is paramount in diaberic women before embarking on pregnancy.If the Hba1c is > 10%, the patient should be advised against conception and to use contraception till the HBA1C is < 6.0%.This is associated with a decreased risk of congenital abnormalities in fetus and risk of miscarriage. ACE inhibitors and angiotensin II receptor inhibitors should be changed preconceptually due to teratogenic risks. retinal assessment should be done if not done in the last annum. Nephropathy should be excluded because if creatinine is >120mmol, there is an increased risk of pregnancy induced hypertension, fetal growth restriction and preterm delivery. If the patient has a BMI>27, advise on weight loss, diet and exercise should be given. Folic acid 5mg reduces the risk of neural tube defects if commenced preconceptually and continued until 12 weeks. (b) Discuss and justify the changes that you will make to her antenatal care [15 marks]. The patient should be managed in a Joint obstetric diabetic clinic.The diabetic team should check every 2 weeks for good glycaemic control.A home glucose monitoring kit and book should be provided so patient can check and record premeal and post meal blood glucose and before bed levels. The patient should be made aware of risks of diabetic ketoacidosis and need for increased insulin doses if vomiting or unwell with hyperglycaemia. The risks of hypoglycaemia and unawareness should be educated to the patient and family.Glucagon administration or glucose drinks should be provided and the family taught to recognise signs of hypoglycaemia.Ketone testing strips should be provided to the patient to check for ketonuria and get admitted early. Retinal assessment should be offered at 16 and 28 weeks.Strict glycaemic control detriorates retinopathy. AN early scan at 7-9 weeks to check viability The anomaly scan at 18- 20 weeks should check for a four chamber heart view with outflow tracts as diabetes is associated with increased risks of fetal cardiac abnormalities. Offer serial scans for growth and liquor volume assessment every 4 weeks between 28 to 36 weeks will help exclude macrosomia and polyhydramnios. The care plan should include and explained to the patient regarding mode of delivery, analgesia,postanatal insulin requirements, management of baby after birth , commencing early breastfeeding and avoiding hypoglycaemia during breastfeeding .A dextrose insulin infusion in labour and postnatal requirements and monitoring recorded. Elective delivery should be arranged at 38 weeks to reduce consequences of macrosomia like birth trauma.
		Posted by L S. Fri Jul 16, 2010 07:03 am
LS: (a) Discuss the specific issues relating to her diabetes that will influence your counselling [5 marks]. The main issue is her glycaemic control as a good glycaemic control before and during pregnancy can help reduce but not eliminate the risk of miscarriage, stillbirth and congenital malformation. Her latest HbA1c assessed as a value more than 10% can help advice her against pregnancy till her value is below 6.1%. Her complications of having diabetes like diabetic retinopathy enquired so that she can be offered an assessment before pregnancy and also prior to a sudden strict glycaemic control as this can worsen retinopathy if present. Her other complication which she might have is diabetic nephropathy and should be offered for assessment as if present can lead to risk of pre-eclampsia, pre-term delivery and poor perinatal outcome. Her other co morbid like hypertension should be detected and treated pre-pregnancy. Her current drugs assessed so that those which are not safe in pregnancy can be stop prior to pregnancy like statins. (b) Discuss and justify the changes that you will make to her antenatal care [15 marks]. Upon conception she will need immediate contact with a combined diabetic and antenatal clinic so that her glycaemic control can be assessed by the diabetic care team and optimized while she is pregnant. This is usually carried out every 1-2 weeks throughout pregnancy. Individualized targets of self monitoring of blood glucose agreed with the woman taking into account risk of hypoglycaemia. The main aim is to keep fasting glucose between 3.5-5.9mmol/l and 1 hour post prandial level below 7.8mmol/l during pregnancy. She should be offered ketone testing strips so that she can test for ketouria if she becomes unwell. If this occurs diabetic ketoacidosis need to be excluded as a matter of urgency and if suspected should be admitted immediately for level 2 critical care. Risk of hypoglycaemia and hypoglycaemia unawareness which is common in pregnancy especially in the first trimester should be informed to the patient and her family members. She should be given glucagon and her family instructed in their use. Her retinal assessment need to be repeated at 16 weeks and again at 28 weeks if she had shown signs of diabetic retinopathy during her pre pregnancy assessment. If her pre pregnancy assessment for retinopathy was normal then she should be assessed again at 28 weeks. This is to pick up deteoration in her retinopathy due to tight glycaemic control so that an early intervention by ophthalmological team in about 6 months following birth can be organized. Her renal assessment for nephropathy should be carried out every month if she has no pre pregnancy signs of nephropathy. If she has pre existing signs of nephropathy, she should be managed in collaboration with the nephrologist. If her proteinuria is more than 5g/l she should be considered for thromboprophylaxis due to high risk of pre-eclampsia. Due to risk of fetal malformation and anomalies in diabetes she should be offered screening for Downs syndrome and antenatal examination of four-chamber view of the fetal heart and outflow tracts in addition to the routine detailed scan which are done between 18-20 weeks. She should be offered ultrasound monitoring of fetal growth and amniotic fluid volume every 4 weeks from 28-36 weeks to monitor fetal growth and fetal well-being as diabetic babies have risk of macrosomia, intra uterine growth restriction(IUGR) and unexplained intra-uterine death. However routine monitoring for fetal wellbeing before 38 weeks is not recommended unless there is a risk of IUGR. At 36 weeks her timing and mode of delivery should be discussed so that she can be prepared for an early induction if required. She should be offered induction or caesarian section if indicated (suspected fetal macrosomia) at 38 weeks as risk of unexplained stillbirth increases about 4 weeks before the expected date of delivery and the risk of respiratory distress in fetus increases if earlier induction due to delay in surfactant and fetal lung maturation need to considered. Regular test (weekly) for fetal well being need to instituted if she declines induction and wishes to await spontaneous labour.
		Posted by Syamala H. Fri Jul 16, 2010 07:13 am
ans a: specific issue that will influence councelling relating to her diabetes are degree of glycemic control, presence of vasculopathy(retinal, renal) presence of hypertension and medications that she is already on including amount,type and dose of insulin she is on and other medications like ACE inhibitor, angiotensin receptor blocker and statins. she should be counselled by a joint multidiciplinary team. counsel regarding risk of uncontrolled diabetes and importance of glycemic control. risk include increased risk of misscarriage, congenital anamoly, macrosomia ,iugr , still birth, poly hydraminos increased incidence of induction of labour and cesarean section, trauma to mother and fetus., increased neonatal morbidity and risk of neonatal death . increased risk of obesity and diabetes in later life of baby. counselling in supportive enviroment preferably with partner. to aviod unplanned pregnancy and to continue contraception till her medical condition is optimised. counsell regarding general measure like diet, exercise and wt reduction(specially ifBMI>27). start on folic acid 5 mg and to continue till 12 wks. retinal and renal asses ment if not performed in prevoius 6 mnths. explain that there is increased risk of hypoglycemia specially in first trimester and its symptoms like sweating palpitation and dizziness may be masked by symptoms of early pregnancy.provide glucagon kit and educate partner.indivisualise blood sugar monitoring. target HbA1c 6.1% or less if safe. it reduces the risk but doesnot eliminates. aviod pregnancy if its >10%.test for ketosis if unwell and hyperglycemic.consider referral to nephlogist if serum creatinine >120mmol/l and eGFR ,45ml/min/1.73 square.rapid optimistion of blood sugar to be avoided before retinal assesment. ansb:: antenatal care by joint diabetic and obstetic team, consultant led. at first visit take history of duration of diabetes, previous pregnancy and their outcome,history of congenital anomaly assess for comorbidity like hypertension and obesity ,review medication. take blood pressure and test urine for glucose and protien. record BMI. renal and retinal assesment if not done in previous 12 mnths. blood sugar monitoring chart. aim to have fasting between 3.5-5.9mmol/l and 1 hr postprandial <7.8mmol.l stop ACE inhibitors statins and angiotensin receptor blocker and to be shifted to safer antihypertensive. risk of hypoglycemia unawreness so cousell and provide glucagon kit and educate partener.test urine for ketone if unwell or hyperglycemic ,provide emergency telephone number. confirm viability and location of pregnancy between7-9 wks. scan for NT nasal bone and gross congenital anamoly between 11-14 wks. sreum screening for aneuploidy may be not reliable. test for retinopathy at16-18 wks if present at first visit. anamoly scan with extended view of fetal heart and outflow tract between 18-22 wks. retinopathy testing at 28 wks if first exam normal,test for signs of pre-ecclmpsia every visit,other than clinical exam of fundal height for iugr and macrosomia ,scan every 4 wks for 28-36 to look for IUGR macrosomia and polyhydraminos.test for fetal wellbeing usingCTG and liqour volume every wk from 38 wk onwards.. plan mode ,place and time of delivery at 36 wks . alternative care plan if patient goes in labour earlier. anesthetic assesment for analgesia requirment and if comorbidity like obesityor autonomic neuropathy.insulin requirement decreases during labour and postpartum . cesarean section for obstetric indication. plan delivery between38-39 wks according to unit protocol.deliver in place equipped for emergency cesarean section and 24hr advanced neonatal resucsitation facility.councell regardindg increased risk of hypoglycemias during brestfeeding. discuss contraception.
		Posted by sonu P. Fri Jul 16, 2010 08:01 am
a) An optimum glycemic control is key to a successful pregnancy outcome in type I diabetes. The issues will be the overall duration of the disease, whether it is optimally controlled, any evidence of end organ disease in the form of nehropathy, retinopathy and neuropathy and recent HbA1c levels. I will take previous obstetric history in the form of difficulties in glycemic control and the obstetric outcome for the mother and the baby. Any episodes of ketoacidosis recently and number of hospital admissions. I will need to explore her compliance with insulin and blood glucose monitoring. b) The pregnancy should only be embarked when the glucose control is good and in absence of untreated complications. At booking, I will emphasize on the importance of maintaining tight glucose control as it is associated with better pregnancy outcome and absence of macrosomia;and provide her with urine ketone testing strips to diagnose keto acidodsis early.I will advise her not to try to loose weight while pregnant but calorie intake should be modest(25kcal/kg). She should take 5 mg folic acid throughout pregnancy.Her pregnancy should ideally be managed in a joint clinic with the endocrinologist, specialist diabetic midwife and dietician. She will be a consultant led care with 2 weekly visits to check for compliance with insulin. I will advise her about the situation when her insulin requirement might increase like stress, infection and feeling unwell. An early viability and dating scan along with combined testing will be offered. The final estimation of risk takes the diabetic condition into account. A fetal echo should be arranged between 16-20 weeks along with the routine anomaly scan, followed by serial growth scans in the 2nd and 3rd trimesters. She should be provided with the contact details of the specialist diabetic midwife for advise if she is finding it hard to control the blood sugars. She will be arranged to have baseline renal function test and fundoscopy if not done in previous 12 months. I will tell her and partner/family memebers about the risk of unawareness of hypoglycaemia and provide with glucagons injections.I will also advise her about the possible increase in her usual dose of insulin as pregnancy progresses. A regular fetal monitoring schedule should be started in the late 3rd trimestor in the form of CTG to reassure the patient and the obstetrician; but its value in predicting or preventing adverse perinatal outcome is not certain. Majority of IDDM patients are induced about 38-39 weeks of gestation.
		Posted by leelavathi C. Fri Jul 16, 2010 08:31 am
maternal glycaemic control is the main isssue. good glycaemic control before pregnancy will reduce the risk of misscarriage, congenital malformation, stillbirth,and neonatal death. if women HbA1c more than 10% advise againest pregnancy.aim to keep HbA1c <6.1%. check her recent blood reports(FBS,RFTs,GFR). if serum creatinin is > 1.2micromol/lit or more and GFR is > 45ml/min refer to nephrologist before discontineu contraception. check previous date of retinal assessment , if ther is no assessment within 6 months need retinal assessment. and advice patient do not optimise glycimic control rapidly until retinal assessment and treatment completed.enquire about any recent admission for hypoglycaemia or diabetic ketoacidosis indicates poor glycimic control . councel about hypoglycemia and pregnancy related nausea and vomiting and glycimic control.maternal BMI >27kg/m2 need councelling of weight loss, diet , exercise. B) diabetis in pregnancy associated with maternal and fetal risks including misscariage, congenital malformations, pre eclampcia, preterm delivery, fetal macrosomia, IOL,birth trama, still birth. her antenatal care should jointly managed by antenatal and diabetic clinic. iwill advice early booking in antenatal clinic., and to perform dating scan to confirm fetal viability, and gestational age. contact with diabetic care team every 1-2 weeks to assess glycaemic control.good glycaemic control in early pregnancy and through out pregnancy reduceses the maternal and fetal risk.advise to test fasting and 1-hour post prondial sugar after every meal during pregnancy. agree individual targets for self monitoring. advise women check blood suger level before go to bed. offer retinal assessment at 16 weeks who had signs of diabetic retinopathy at the first antenatal appointment. or at 28 weeks if the first assessment normal. offer four chamber view of fetal heart and outflow tracts at 18- 20 weeks, to rule out congenital cardiac anomalies. ultrasound monitoring of fetal growth and amniotic fluid volume every 4 weeks from 28 weeks to 36 weeks. offer ketone testing strips and advise to test ketone level if they are hyper glycaemic or feeling unwell. if diabetic ketoacidosis suspected admit patient into level 2 care, where both obstetric and medical care avaailable. regular BP monitering, test for protineuria should be done. beacause pre eclampcia, IUGR risk associated with diabetic nephropathy. thromboprophylaxis need if protinuria is above 5grm/d. careful plan about delivery should be recorded in antenatal notes.
		Posted by VINITA N. Fri Jul 16, 2010 10:41 am
A 35 year old woman with insulin dependent diabetes mellitus attends for pre-conception counselling. (a) Discuss the specific issues relating to her diabetes that will influence your counselling [5 marks]. (b) Discuss and justify the changes that you will make to her antenatal care [15 marks]. VN I will first want to know if she is maintaining good euglycaemic control. I would also check her HBa1C to know about her previous 3 month glycaemic control. Next I would ask about her eye test and whether she has retinopathy, if yes, she should have it treated before embarking on pregnancy. I will also check her renal function tests to ascertain that she doesnt have nephropathy. I will also advice her regarding maintaing ideal BMI and taking folic acid to prevent neural tube defect in baby. I will explain that she can get hypoglycaemic, especially in first trimester and give her written information regarding maintaining glycaemia and antenatal care. She will also be given contact numbers to call f any concerns with glycaemia. B) She should be warned about hypoglycaemia in first trimester and symptoms not being pronounced. She should be advised to take sweet tablet if hypoglycaemic. She should be advised to avoid contacting any infections ass it can disrupt euglycaemia balance. she should be on folic acid 5 mg daily.nuchal scan and trisomy screening done in first trimester. Continue to maintain her blood sugar diary and to call if more than 2 high result in a week. she should have eye test around 14-16 weeks. Anomaly scan to be organised around 20 weeks and also check for umblical artey notching as it could be a predictor of Pre ecllampsia. if any concerns with anomaly scan detailed cardiac scan to be organised with FMU specialist. She should have regular 4 weekly scans for growth and liquor volume as more prone to develop big babies and also IUGR. Poly and oligohydramnios is more common in diabetic mums. She should be cared in a multi disciplinary team comprising of consultant obstetrician with interest in diabetes, endocrinologist, neonatologist,dietician and midwife with special interest in diabetes. Her blood pressure should be checked in every visit and urine for proteins as they are at higher risk to develop PET. If any concerns with growth or blood pressure needing preterm delivery, mother should receive steroids for fetal lung maturity. This should be done as an inpatient with sliding scale insulin. If pregnancy is progressing as planned she should await spontaneous labour, or induction of labour if she doesnt labour by 40 weeks.
		Posted by zara A. Fri Jul 16, 2010 12:26 pm
a]There are factors in history ,examination and investigations that should be taken into account while giving herpreconception advice .HISTORY taken about duration of diabetes,dose of insulin required ,current diabetes control, acute diabetic complications.She should be asked that she hadany chronic diabetic complications like nephropathy ,neuropathy ,and retinopathy .HER obstetric history parity ,previous out come of babies and any antenatal and intrapartum complications ,mode of delivery.drug history [ACE inhibitors,statins] should be taken .Examination SHOULD be done for BMI and BLOOD PRESSURE should be taken , FUNDOSCOPY should be done .If she had poor diabetic control she should be counselled that her glycemic control optimised before conception to reduce risk of fetal problems like miscarriage ,congenital anamolies] and neonatal problems.She should defer her pregnancy if she had poor glycemic control until her glycemic control is good. IFSHE had retinopathy should defer her pregnancy , and no need of strict glycemic control until treatment completed,specialist referal arranged.Her urine checked for microalbuminuriaand 24 hour quantitativeproteinuria,SERUM creatinine ,HAIC should be done.IF she had MICROALBUMIN URIA,serum creatinine >120mmol/litre she should be advised contraception and refer to nephrologist .IF her HAICis more than10% she should defer pregnancy as risk of congenital anamolies high.She shoud defer pregnancy until HAIC is 6.1%. SHE should take folic acid 3 m0nths before conception.If taking ACE inhibitors or statins then stop and alternative antihypertensive prescribed. B]b]The patient should be managed by multi disciplinary team[consultant obstetrician ,dietecian,diabetic nurse,endocrinlogist,anesthetist] in joint diabetic and obstetric clinic.Establishment of glycemic control is done with diet ,exercise,and insulin titrated according to glycemic levels.PATIENT and family educated about risk associated with poor glycemic control fetal[miscarriage,congenital anamolies,still birth,macrosomia],maternal[retinopathy ,nepheropathy], increased intervention[c section ,induction] and shoulder dystoscia. She should be given glucometre ,and moniter her blood sugar 1hour after every meal ,andfasting ,aim is to mantain fasting 3.5 to 5.9 mmolL ,and post perindial <7.8.SHE should had antenatal visit 1to2 weekly to review blood sugar. HAIC REPEATED monthly. She should be warned about hypoglycemia and provided glucagon as nausea and vomiting of pregnancycauses hypoglycemia. ketone strips povided and advice to check when feeling unwell.Diabetes is associated with risk of pre eclampsia so her blood presssure and proteinuria should be monitered frequently.she should take 5mg folic acid upti l 12 weeks as risk of neural tube defects.SHE should be assessed for nephropathyat booking if serum creatinine >120mmolLLITRE then refer to nepherologist.Her fundoscopy should be done at booking ,as there is risk of retinopathy ,if normal repeat at 28 weeks if abnormal repeat at 16 weeks as there is risk of detrioration of retinopathy. She should be offered scan for viability [risk of miscarriage],dating scan [iugr,macrosomia].DETAILED anamoly scan at 20 weeks and 4 chamber and outflow cardiac scan,as fetus is at risk of congenital anamolies. AmniOtic fluid andGrowth scan should be done 4 weekly from28 week to 36 weeks ,as diabetic pregnancy complicated by macrosomia and iugr and poly hydromnias.I F PRETERM Labour occurs then admit steroids should be given with careful blood sugar monitering and avoid tocolytics as risk of blood sugar detrioration.ANTENATAL plan should be made at 36 weeks and anaesthetic review arrranged to avoid delivery complications.DElivery should be DONE at 38 completed weeks.offer c section if macrosomia [>4.5kg]to avoid shoulder dystoscia.IF NO CONTRA INDI CATION THEN VAGINAL DELIVERY. I f deivery not done at 38 weeks then weekly moniter for fetal wellbeing uptil 41weeks as risk of intrauterine death.Patient should be given information leaf lets and emergency contact numbers .
		Posted by Im F. Fri Jul 16, 2010 01:55 pm
a).All the women with IDDM should be informed of the importance of good glycemic control before becoming pregnant and maintaining it throughout pregnancy; will reduce the risks of congenital anomalies ,miscarriages ,still birth and premature delivery. she should be seen with diabetic team. The other specific issue will be assessment and management of diabetic complications. Her HbA1c should be checked monthly and ideal is 6.1%.she should be advised NOT to become pregnant if HBA1C is more than 10.Assessment of retinopathy and nephropathy should be done if not done in previous 6 months.Renal assessment before considering pregnancy should be done(check microalbuminuria)refer nephrologist if eGFR is less 45 ml/min or s.creatinine is morethan 120 micromol/litre.All the women should be discouraged from unplanned pregnancy. they should be advised to take folic acid 5mg daily to reduce risks of NTD.The next issue will be optimization and review of her medication.she should be advised to see health personnel as soon as become pregnant. b).Patient should be seen in MDT having diabetic team,obstetrician,dietician,and paeditrician.The single most important factor in her antenatal management is the optimum blood glucose control. women should be advised to that fasting blood sugar between 3.5- 5.9 mmol and postparendial less than 7 is associated with less maternal and fetal complications . She should be advised to self monitor and check fasting and post paredial 1 hr levels. Women should have individualised controls .Dating scan should be done on first contact and a NT scan between 11- 14 weeks. Detailed anomaly scan should be done around 20 weeks which should include fetal cardiac echo to rule out cardiac defects in fetus. she should be seen regularly 1-2 weekly basis initially by diabetic team. She should be given Ketone strips(to check for ketoacidosis) glucose solutions and glucagon injections(in case of hypoglycaemia) Hypoglycaemia is quite trouble some in women taking insulin and having HEG. Her partner and family should also be informed about sign and symptoms of hypoglycemia and whom to contact. Detection and treatment of preexisting complications should be done as soon as possible. She should have retinal and renal assessment if not have been done previously and should be treated accordingly. Retinal assessment is repeated at 16 and 28 weeks. Thromboprophlaxis should be offered if sever proteinuria morethan 5g/day.Her medications should be reviewed. Short acting and intermediate acting insulin(aspart and listero) are safe options. Insulin pump therapy if poor control with multiple injections. Metformin can also be continued if the benfits outweigh the risks. Assess renal function U&E and 24h urine for protein and creatinine clearance. Nephropathy carries poor prognosis. Change anti-hypertensive medication ; ACE inhibitors are terratogenic and impair fetal renal function, b-Blockers can cause IUGR. Assessment of fetal growth and wellbeing should be done every 2-4 weeks TRO macrosomia and IUGR by serial scanning+- doppler and CTG where required. She should be monitored for maternal complications like PE, preterm delivery , fetal macrosomia and hydroamnios. Risk of PE is more if she has preexisting hypertension which is associated with IUGR. Hydroamnios is associated with poorly controlled diabetes and ends up in preterm labour and neonatal morbidity. If steroids to be given for fetal lung maturity, there should be inpatient monitiong. Amnioreduction can be offered to reduce maternal discomfort and prolong delivery.she should be informed that inspite of good care and followup the risk of stillbirth cannot be excluded.A birth plan should be made around 36 weeks if there has been no complication to deliver baby around 39-40 weeks with good glycaemic control and early induction for borderline macrosomia at 38 wks.Elective c-sec for those with gross macrosomia. She should be informed of need of neonatal monitoring for hypoglycemia, hypocalcemia and hyperbilirubinaemia. she should be encouraged for breast feeding antenatally.
		Posted by Kiran J. Fri Jul 16, 2010 02:12 pm
A 35 year old woman with insulin dependent diabetes mellitus attends for pre-conception counselling. (a) Discuss the specific issues relating to her diabetes that will influence your counselling [5 marks]. (b) Discuss and justify the changes that you will make to her antenatal care [15 marks]. a: Firstly is her Glycemic controle, she should have Glycosylated HbA1c levels done monthly and aim at levels of 6.1 or lower.If HbA1C is 10 or above she is strongly adviced to delay pregnancy until better controle is achived.She should be adviced that optimal glycemic controle is associated with reduced risk of miscarriage,stillbirth,macrosomia and neural tube defects.She can be adviced to check her BMs at fasting and post parandial to evaluate her glycemic controle.She should be reassured that short acting insulin and Isophane as long acting insulin is safe in pregnancy.She should have her retinal screening done if not done in last 6 months and advice to defer intesifying glycemic controle until the results of retinal screen as it can deteriorate retinopathy.Similarly in Nephroathy screening not done in past 6 months, that should be done via urine protien excretion,serum urea and creatnine and eGFR.I microalbuminurea,creatnine >120mmol/l or eGFR<45ml/min/1.73 m2, then refer to nephrologist.. She should be advised to take 5 mg of folic acid for effective prevention of the neural tubal defects.If she is hypertensive and on medication ,assess which medications such as captopril (ACE inhibitor) and change to another anti-hypertensive because of the risk of major congenital abnormalities, neonatal renal impairment and fetal death. Methyldopa, calcium channel blockers such as nifedipine, and peripheral vasodilators are suitable alternatives.If there is hypertensio Optimum pre-pregnancy control of hypertension is essential to avoid superimposed pre-eclampsia and IUGR.Screening for rubella,HIV and HepB.Contraception adviced if suboptimal glycemic controle.If BMI 27 or above advice to loose weight.she is to be educated regarding hypoglycemia and its increased risk especially in first trimester. b> She is to be seen in a joint obstetric and diabetic clinic.She should be seen by the diabetologist every 2 weeks.Careful history at booking and offer early viability scan at 7 weeks.Should take 5mg oral folic acid until 12 weeks due to risk of neral tube disease of fetus.retinal scan as soon as possible if not done in past 12 months.If noral repeat at 28 weeks.If abnormal repeat at 16-20 weeks.If proliferative diabetic retinopathy, post natal f/u will be needed by ohthalmologist but can have vagial delivery.Nephropathy screen by urine testing for protienurea and serum creatnine,if more than 120 refer to nephrophysicians.Consider thromboprphylaxis if protienurea >5gm/day and vigilant to check for s/o for Pre-eclampsia.Mother should be educated about hypoglycemia and should have glucagon in her handbag and provide ketostrips to test urine for ketones if hyperglycemia or unwell.Glucomter can be provided and aim to keep BMs at 3.5-5.9fasting and 7.8 1 hour post meal. fetal can be assessed at 20 week routine scan and a fetal heart scan to see outflow tracts.growth scans to commence from 28 weeks to see growth,liqour volume and dopplers.AT 36 weeks review to discuss birth plan,mode of delivery,anaesthtic review.Educate on transient neonatal morbidity and need to go to SCBU.She should be adviced about neonatal hypoglycemia and breast feeding initiation to prevent that. At 38 weeks she is offered Induction of labour or c-section depending on indication like malpresentation.If she wishes to await spontaneous labour offer test of fetal well bieng. Incase of other antenatal events like preterm labour tocolysis and steroids can be given.Corticosteroid should be given after strict adherence to uniy protocol(Concomitant sliding scales of insulin),avoid beta mimmetics for tocolysis.
		Posted by H H. Fri Jul 16, 2010 04:48 pm
hhh My counseling will be influenced by the adequacy of her control of diabetes, if it is tightly controlled or not, her doses of insulin , and if she is regularly checking her fasting blood sugar keeping it between 3.5 – 5.9 mmol/l and her postbrandial <7.8 mmol/l one hour after meal. Also influenced (AI) by presence of complications as problems of vision, renal problems ,peripheral neuropathy and hypertension and what was offered to these as treatment. AI if she had previous attacks of hypoglycemia (need proper education of patient and relatives) or diabetic ketoacidosis (inadequate control). AI by her previous obstetric history ,miscarriages, congenital malformation, growth retardation, fetal macrosomia,preterm labour ,polyhydramnios,shoulder dystocia and her neonatal outcome and need for NICU admission.AI by her rubella status and if need rubella vaccination as she will need to delay pregnancy for one month after vaccination. AI by medications she is taking as some will need to be stoped and replaced eg ACE inhibitors . AI if she is a smoker or taking drugs as will need advice. If not taking folic acid ,this should be given at dose 5mg daily.Contraception should be used till adequate control of diabetes. There should be local guidelines and protocols for diabetes with pregnancy,these should be regularly audited to comply with national guidelines as NICE . Her antenatal care should be multidisciplinary including consultant obstetrician, diabetologist, ophthalmologist( review in each trimester for diabetic retinopathy which is worsened by control of diabetes and might need photo coagulation), nephrologist ,midwife and GP.Her antenatal visits should be more frequent. She should have been put on folic acid 5mg daily prepregnancy and this should be continued same dose during first trimester. Serum screening tests for trisomy and neural tube defects are not sensitive. Nuchal thickness(NT) at 13wk should be used and risk determined in conjunction with age. As she 35y(risk of down 1 in 350 at term risk increase if added to NT ), she is counseled regarding chorion villus sampling after 10 wk or amniocentesis after 15wk and their risks( miscarriage, failure,bloody tap,infection) and this is documented in notes. Fetal anomaly scan done at 20 wk( sacral agenesis ,) and fetal echography at 22wk for cardiac anomalies. Growth scan from 24wk every 2wk to detect fetal macrosomia which mean inadequate diabetic control and need to increase insulin dose. If control of her diabetes is not possible on out patient basis, she is admitted for control.Admission is also needed if she develops diabetic ketoacidosis , pre eclampsia, infection or pre term labour. Proper monitoring of BP in third trimester and urine tests for development of pre eclampsia. Proper monitoring of renal function ( urea and electrolytes and serum creatinine)in conjunction with the nephrologist . Proper monitoring of fetal wellbeing by CTG starting after 28 wk. Aim for delivery at 38-39wk.Vaginal delivery by induction of labour if cephalic and no macrosomia. Cesarean section for obstetric indications and if there is macrosomia. Patient given written information all through her antenatal care regarding diabetes in pregnancy ,its control and how to use insulin ,how to inject, complications specially hypoglycemia and how to manage it.
		Posted by A A. Fri Jul 16, 2010 07:05 pm
AA a) An optimum glycemic control is the main issue. I will offer councilling in a supportive way & encourage her partner or a family member to attend. I will ask overall duration of the disease, recent HbA1c levels. Any evidence of end organ disease like nehropathy, retinopathy or neuropathy. Any recent episodes of hypoglycemia/ ketoacidosis and number of hospital admissions. I will need to explore her compliance with insulin and blood glucose monitoring. Ask her Obstetric history for outcomes or complications to the mother and the baby. If the Hba1c is > 10%,she should be advised against conception and to use contraception till the HBA1C is < 6.1%.This is associated with a decreased risk of congenital abnormalities in fetus and risk of miscarriage & still birth. Offer retinal assessment if not done in the last annum. Baseline renal function test, if creatinine is >120mmol, refer to nephrologist. Drug modification & insulin dose adjustment according to diabetic physician advice. ACE inhibitors and angiotensin II receptor inhibitors should be changed preconceptually , substitute with suitable antihypertensive. If the patient has a BMI>27, advise on weight loss, diet and exercise should be given. Folic acid 5mg reduces the risk of neural tube defects. Rubella & hepatitis B immunization if non immune .I will provide written information & emergency telephone number for support. b) She should be managed by multidisciplinary team ( obstetrician, diabetic physician, dietician. Diabetic nurse & midwife) in joint diabetic & antenatal clinic. Individualized care plan with education & information to patient at each visit is crucial. Offer 1-2 weekly visits to monitor glycemic control. Aim is to keep fasting blood glucose between 3.5 and 5.9 mmol/litre and 1-hour postprandial blood glucose < 7.8mmol/litre during pregnancy. Insulin doses may need to be increased. Rapid acting insulin analogues are safe in pregnancy. She should daily check her fasting blood glucose levels and 1 hour after every meal & before going to bed at night. HbA1c should not be used routinely for monitring in the second and third trimesters. I will provide her ketone testing strips and advised to test ketone levels if become hyperglycaemic or unwell. If suspected of having diabetic ketoacidosis should be admitted immediately for level 2 critical care. I will explain the risk of hypoglycemia .Educate her regarding glucagon use when needed. A retinal assessment is performed at booking & at 28 weeks. If diabetic retinopathy is present, an additional retinal assessment should be performed at 16-20 weeks. Renal assessment (urea &creatinine) at booking , If serum creatinine is abnormal (120 micromol/litre or more) or if total protein excretion exceeds 2 g/day, referral to a nephrologists & thromboprophylaxis if above 5 g/day should be considered. Frequent antenatal visits according to departmental protocol. At booking an accurate dating scan & at 18-20 weeks the four-chamber view of the fetal heart and outflow tracts should be offered .Her Diabetes mellitus should be taken into account when offered screening for Down syndrome. Ultrasound monitoring of fetal growth and amniotic fluid volume every 4 weeks from 28 to 36 weeks. Routine monitoring of fetal well-being before 38 weeks is not recommended unless there is a risk of IUGR. If antenatal steroids are needed for fetal lung maturity, she may need additional insulin and close monitoring. Avoid Beta mimetic drugs for tocolysis .
		Posted by Chitra.s M. Fri Jul 16, 2010 09:07 pm
A.The duration of diabetes influences the counselling as the complications of pregnancy with diabetes increases with the duration of diabetes.Glycaemic control,assessed by measuring HbA1c, is important in preconceptual counselling as poor glycemic control adversely affects pregnancy outcome.Contraceptive advice needs to be given until good glycaemic control is achieved.Presence of diabetic complications like retinopathy and neuropathy influence the counselling as it allows for appropriate referral, investigations and treatment for optimising the condition prior to conception.The drugs the woman is on for dibetes and /or its complications has an impact on counselling.Drugs like ACE inhibitors,angitensin receptor blockers and statins have to be changed over/stopped preconceptually/on pregnancy confirmation.The woman is advised 5mg folic acid beginning preconceptually and continued till 12 weeks gestation. B.The woman is cared for in a joint clinic(antenatal-diabetic). She is advised to continue /start 5mg folic acid/day till 12 weeks gestation as there is an increased risk of fetal neural tube defects.She is seen in the joint clinic every 1-2 weeks throughout her pregnancy for optimising glycaemic control and early detection of complications.She is advised to self monitor fasting,1hr postprandial after every meal and night blood glucose levels with a glucometer.The woman and her partner are educated about hypoglycemic episodes,hypoglycemia unawareness and use of glucagon injection.She is offered ketones testing strips and advised to check for ketonuria is she becomes hyperglycemic/unwell as diabetic ketoacidosis requires prompt and urgent treatment to minimise mortality/morbidity.The woman is offered retinal assessment at the first visit,if not done in previous 12 months, to detect diabetic retinopathy and minimise short and long term reduction in visual acuity.She is offered screening for micro /macroalbuminuria and serum creatinine as diabetic nephropathy is associated with increased likelihood of preecclampsia,fetal growth restriction and preterm delivery.Early ultrasound scan (USS) is offered for viability and dating.Ongoing risk assessment for venous thromboembolism is done for potentially increased risk due to age and possible diabetic complications(preclampsia).Measurement of bloodpressure and urine dipstix for proteinuria is done in each visit, for early detection of complications like preclampsia. Retinal assessment is offered at 16 weeks if previous assessment showed evidence of retinopathy or at 28 weeks if previously normal.Anomaly scan with 4 chamber view of caria and outflow tracts is done at 20 weeks gestation as they is an increased risk of cardiac and other anomalies.Growth scans are offered every 2-4 weeks from between 24-36 weeks for fetal growth and liqour volume to detect macrosomia/growth restriction.Anaesthesia referral is arranged in 3rd trimester for discussion of labour analgesia/anaesthesia.Plan for delivery is discussed and documented.Delivery is planned at 38 completed weeks of gestation to minimise the risk of intrauterine fetal death and because neonatal respiratory morbidity is low after this gestational age.Caeserean section is planned for complications like macrosomia or for obstetric indications. Corticosteriod administration for fetal lung maturity in preterm labour needs close surveillance as it can impair glycaemic control.Betamimetic tocolytics are avoided as they can cause hyperglycaemia.
		Posted by Dr Dyslexia V. Fri Jul 16, 2010 11:28 pm
X a) The importance of tight glycemic control are of paramount importance to embark in this pregnancy. Any complications from the diabetes should be checked such as renal nephropathy which could detiorate in pregnancy. Diabetic retinopathy could still detiorate in pregnancy in spite tight control. The use of statins or ACE-inhibitors if present should be stopped and changed to drugs such as methyldopa, nifedipine or labetolol. The HbAIc should be maintained to less than 6.1% and pregnancy should be post-poned if the HbAIc is more than 10%. She should be adviced to stop smoking if she is and adviced to take folic acid of 4 mg minimum of 3 months prior to pregnancy to prevent neural tube defect. She should be adviced on maintaining contraception till her disease is optimized. Her wishes in regards to fetal screening and termination should be discussed in view of high risk of fetal abnormality. b) She should be managed by a multidisciplinary team which consist of an obstertrician, diabetologist, nurses, mid-wife, dietician and neonatologist to attend the multiple aspects of her diabetic care. She should be monitored regularly about 2 weeks with blood pressure monitoring urine for proteinuria as she is high risk to develop preeclampsia. She should also be managed with regular renal profile and HbAIc to monitor her diabetes and renal function. Referral to nephrologist should be done if creatinine of more than 120 mmol/l. She should ideally be thought home glucose monitoring for daily monitoring of glucose and insulin requirement. She should maintain a fasting glucose of 3.5 to 5.9 mmol/l and 1 hour post prandial of less than 7.8mmol/l. She should also monitor with Ketone strips to watch out for diabetic Ketoacidosis. She should also be aware in regards to symptoms of hypoglycemia and thought to use of glucagon pen to reverse it. The control of HbAIc should be maintained to less than 5.6% in the first trimester. She should also have three monthly eye assessment to assess degree of retinopathy if present and as it could deteriote despite of good glysamic control. Details scan should be done at 18 to 20 weeks to look for fetal anomaly such as neural tube defect, caudal regression and heart abnormality. Regular growth scan should be done to look out for fetal macrosomia and polyhydrominos. She should ideally should be delivered at 38 to 39 weeks as there is increased risk of intra uterine death in these pregnancies. She should not be induced earlier as there is higher risk of respiratory distress syndrome as well. She should also be adviced to enroll in diabetic health groups for support in pregnancy. A clear and well documented plan should be planned out for this pregnancy.
		Posted by cricket chandu C. Sat Jul 17, 2010 12:42 am
a)Duration of diabetes and complications of diabetes such as retinopathy, nephropathy, cardiac disease and peripheral vasucal diseas will alter the pregnancy care and their association is more likely to have a poor outcome. Another factor which should be considered is suboptimal glycaemic control indicated by history of episodes of hyperglycaemia, history of admission for diabetic ketoacidosis The level of risk of congenital anomalies is directly related to the degree of glycemic contol around the time of conception. Note should be made about previous pregnancies and occurrence of complications due to diabetes for eg: history of miscarriages, congenital anomalies, macrosomia , IUD and PET. She should asked regarding social support as maternal social deprivation is associated with poor pregnancy outcome in the presence of diabetes Certain social and lifestyle factors have also been shown to be associated with poor pregnancy outcome unplanned pregnancy ,no contraceptive use in the 12 months prior to pregnancy no preconception folic acid and, smoking. b)Antenatal care is provided in a joint diabetic and antenatal clinic under diabetic care team which includes Obstetrician, diabetologist, specialist midwife and dietician as evidence shows that outcome can be improved by care at tertiary level . More frequent antenatal visits are required fpr assessment of glycemic control,every 1 or 2 wks. Assessment is undertaken to establish the extent of diabetes its control ( Hb A1C assessment), and complications such as nephropathy and retinopathy.Asessment is undertaken by taking history (visual problems in case of retinopathy) and appropriate investigations i.e, quantification of protienuria, creatinin clearance and fundoscopy Retinal assessment by fundoscopy should be done during the first antenatal visit as well as at 28 weeks to detect retinopathy. Medication for diabetes and its complications is reviewed and appropriate changes are made for eg: ACE inhibitors are associated with fetal growth retardation so changed to safer antihypertensives . At the first antenatal checkup opportunity is taken to reinforce information, education and advice in relation to achieve optimal glycemic control for better pregnancy outcome. Encouragement is provided for self monitored home blood glucose testing. Education includes target capillary glucose levels 3.5 - 5.9 mg/dl for fasting blood sugar but <7.8 for 1 hour post prandial sugar.and dietary advise. Woman’s family is involved regarding management of complications by teaching the partner or relative about hypoglycaemia , its unawareness and glucagon injection . Prompt inpatient admission is indicated if she is unable to achieve glycaemic control, or in the presence of complications like diabetes ketoacidosis Apart from anomaly scan at 18-20 wks cardiac scan is indicated at 22 wks to exclude structural cardiac anomalies From 28 wks onwards serial ultrasound scanning is required at every 3-4 wkly intervals to assess fetal growth and liquor as diabetes is associated with polyhydramnios and macrosomia. Induction of labour or CS are indicated at 38 wks to prevent still birth and to avoid birth trauma due to macrosomia.
		Posted by millionaire2004 A. Sat Jul 17, 2010 02:25 am
Ag A 35 year old woman with insulin dependent diabetes mellitus attends for pre-conception counselling. (a) Discuss the specific issues relating to her diabetes that will influence your counselling [5 marks]. Maternal and perinatal morbidity related to pre-existing diabetes mellitus in pregnancy can be reduced if the disease is well controlled before conception. Optimisation of glycaemic control need to be addressed. Aim HbA1c level lesser than 6.1% if safely achievable. Defer pregnancy if HbA1c is more than 10%. Presence of diabetic retinopathy and nephropathy need to be ascertained. offer digital retinal assessment and serum creatitine and 24 hour urine protein measurement if not done in the last 6 months. Counsel her to defer pregnancy in the presence of diabetic retinopathy until it is treated. Presence of associated diseases such as hypertension and hypercholesterolaemia need to be controlled. Antihypertensive drugs such as angiotensin converting enzyme inhibitors and angiotensin 2 receptor blocker need to be subsituted with other agents such as methyldopa. Statins need to be withheld. Educate her and her partner on effects of diabetes on pregnancy (miscarriage,stillbirth,macrosomia) and effect of pregnancy on diabetes (increase in insulin requirement and hypoglycaemia unawareness). Educate her partner or family members on complication of diabetes such as hypoglycaemia and diabetic ketoacidosis. Provide glucagon and urine ketone strip and advice when to use. Counsel regarding usage of pre-pregnancy folate (5mg/day) until 12 week gestation. (b) Discuss and justify the changes that you will make to her antenatal care [15 marks]. Her 1st visit should be managed by a multidisciplinary team in a combined obstetrics and diabetic clinic. Team should include obstetrician, diabetic physician,dietitian,diabetic nurse and midwife. Reinforce education and advice given in pre-pregnancy clinic or offer advice and education relating to glycaemic control if she has not attended pre-pregnancy clinic. Measure glycosylated hemoglobin level to assess long term glycaemic control. Rapid glycaemic control may be needed if HbA1c is greater than 10% at initial visit. Offer screening for diabetic retinopathy and nephropathy if not done in the preceeding 12 months. Arrange contact with diabetic care team 1-2 weekly to assess glycaemic control. Adjust insulin dosage according to glycaemic control. Do ultrasound scan to confirm fetal viability earlier (7-9 weeks) because she has higher risk of miscarriage. At 16 weeks, do retinal assessment if the booking assessment showed diabetic retinopathy. at 20 week, do ultrasound scan for fetal anomaly, four chamber view of heart and outflow tracts. Woman with diabetis has 5 times higher risk for congenital anomaly ( neural tube defect, congenital heart defects, cleft lip/palate). At 28 weeks, do ultrasound scan for fetal growth and amniotic fluid volume. Repeat this at 32 and 36 weeks gestation. Poor glycaemic control lead to polyhydramnios and large for gestation fetus. Also do retinal assessment at 28 weeks if the booking assessment was normal. At 32 weeks, do all investigation (urine protein,blood pressure) that would have been done at 31week gestation (if primigravida). At 36 weeks, discuss the birth plan with the woman covering timing,mode and management of labour and birth including labour analgesia/anaesthesia. Also discuss regarding intrapartum and postpartum changes to glycaemic control, early neonatal feeding,effect of breast feeding on glycaemic control and follow up plan. Birth plan detailed out earlier because the woman has risk of delivering earlier either spontaneously or medically indicated early delivery. At 38 week, offer induction of labour or caesarean section. offer monitoring of fetus wellbeing (umbilical artery doppler velocimetry, cardiotocography,biophysical profile) if the woman chooses to await spontaneous labour. At 40 and 41 weeks, offer monitoring for fetal wellbeing if not delivered yet. Her glycaemic control need to be assessed 1-2 weekly. Offer home glucose monitoring device and encourage her to do fasting and a mixture of premeal and post meal glucose level. maintain glucose level between 4-6 mmol/l. Educate her partner and her family member on usage of im glucagon in the event of hypoglycaemia. give urine ketone strip and advice to use it if she is unwell or hyperglycaemic. this is to detect diabetic ketoacidosis.
		Posted by Bgk H. Sat Jul 17, 2010 02:27 am
bgk a. Control of her disease is important to be assessed as poorly controlled diabetes mellitus associated with increase risk of congenital anomalies and should be advised against pregnancy. It can be assessed by HbA1c measurement and level of more than 7.1% is associated with higher risk. Her diabetic complications need to be identified. This includes her renal function which can be guided by urea and electrolytes level. Cardiovascular complication such as hypertension and peripheral vascular disease need to be determined. I will also review her medication and to optimally adjust the dose accordingly. If she is associated hypertensive, her antihypertensive medication should be reviewed and she should be warned to stop if she is taking ACE inhibitor. I will explore her past obstetrics history regarding her complications and mode of deliveries and any previous history shoulder dystocia. Her dietary history should be asked and referral to dietician is appropriate. She should be advised to take folic acid of 5mg daily preconception at least for 3 months. b. She should be managed as multidisciplinary approach including obstetricians with special interest, endocrinologist, diabetic nurse and dietician. Any medication such as antihypertensive (ACE inhibitor) should be stopped. She should be aware regarding signs and symptoms of hypo or hyperglycaemia. Family member should also be educated regarding action to be taken during hypoglycaemic attack. Close monitoring of her sugar controlled need to be done and home glucose monitoring should be encouraged. Self alteration of the insulin dose should be thought. Proper disposal of needle should be thought. Close monitoring of her blood pressure and proteinuria should be done. Baseline renal function and 24hr urine protein measurement need to be determined as future reference. If normal, repeated test should be done for every trimester. Referral to ophthalmologist needed for retinal assessment and need to be treated if present and rapid glucose control may be harmful. Early ultrasound scan need to be done and NT measurement perform between 11 to 13w6d. Further scan at 20 weeks for anomaly scan. Fetal echocardiogram also should be done. Growth scan should be done to detect growth abnormalities and detection of macrosomic fetus and polyhydramnious. Provided that her blood glucose is well controlled and no maternal and fetal complication, her pregnancy should be continued to 39 weeks and induction of labour should be recommended by then. Her plan of labour should be clearly documented. LSCS only for obstetrics indication. Early anaesthetic referral should be done if there is any concern. Patient information sheet should be given and contact number in case of emergency.
		Posted by Bobey B. Sat Jul 17, 2010 03:25 am
The risks of miscarriage, congenital malformation , stillbirth , fetal macrosomia and birth injury are increased during pregnancy complicated with diabetes. So, the importance of optimum diabetic control preconceptually must be emphasized . Pre-pregnancy counseling allows for optimization of diabetic control prior to conception , as well as assessment of the presence and severity of complication such as hypertension , nephropathy and retinopathy . The risk of preeclampsia is increased in the presence of microalbuminuria . Proteinuria should be quantified prior to pregnancy. The woman usually requires upward alteration of insulin during pregnancy. Advice should be given for review of medications , glyacemic targets and self monitoring. Plans should be made to optimize diabetic control and to continue to use contraception until the glycosolyated haemoglobin is within accepted range ( below 6.1 % ). The effect of the pregnancy on diabetic related complications should be considered. The woman should be informed that poor control will lead to deterioration of diabetic retinopathy and nephropathy. Retinal and renal assessment should be advised .Base line renal function tests should be performed. The specific congenital abnormalities are heart defect , skeletal abnormalities and neural tube defects . Taking folic acid supplements ( 5 mg / day ) from preconception until 12 weeks of gestations should be advised . b)Multidisciplinary care involving joint clinic with diabetologist , obstetrician , specialist midwife and dietician. Glycaemic control should be optimized . She should be advised to aim for fasting blood glucose between 3.5 and 5.9 mmol / L and 1-hour postprandial blood glucose below 7.8 mmol / L. Ketone testing strips should be offered and the woman should be advised to test ketone levels if she hyperglycaemic or unwell . If diabetic ketoacidosis is suspected , she should be admitted for level 2 critical care . Concentrated oral glucose solution should be offered. The woman , partner and family members should be advised on use of oral glucose solution and glucagon for hypoglycaemia. Rapid acting insulin ( aspart and lispro ) should be considered ,which have advantage over soluble human insulin during pregnancy. She should be advised for risk of hypoglycaemia and hypoglycaemia unawareness especially in the first trimester. Retinal and renal assessment should be offered if these have not performed in the previous 12 months. Retinal assessment should be offered at 28 weeks if the first assessment is normal and at 16-20 weeks if any diabetic retinopathy is present. Referral to a nephrologist if serum creatinine is 120 micromol / L or more , or total protein excretion exceeds 2 gm/day. Glycaemic should be assessed by the diabetes care team every 1-2 weeks throughout the pregnancy. Screening after counseling for congenital anomalies should be done. Antenatal examination of the four-chamber view of the fetal heart and outflow tract at 18-20 weeks should be performed. Serial ultrasound monitoring of fetal growth should be offered . Growth scan and fetal wellbeing if there is risk of IUGR should be offered after 38 weeks gestation. At 36 weeks gestation , ultrasound monitoring of fetal growth and amniotic fluid volume should be offered. Also, information and advice should be offered about : Timing , mode and management of birth , analgesia , anaesthesia , changes to hypoglycaemic therapy during and after birth. Information should be offered about initial care of the baby , initiation of breast feeding and the effect of breast feeding on glycaemic control, contraception and follow-up. At 38 weeks : Induction of labour or caesarean section if indicated for fetal macrosomia should be offered. At 39-41 weeks , weekly tests for fetal wellbeing should be offered.
		Posted by Aruna R. Sat Jul 17, 2010 10:04 am
aruna A 35 year old woman with insulin dependent diabetes mellitus attends for pre-conception counselling. (a) Discuss the specific issues relating to her diabetes that will influence your counselling [5 marks]. (b) Discuss and justify the changes that you will make to her antenatal care [15 marks Prepregnancy counselling : Glycaemia control: High glucose environment is associated with increased risk of congenital anomalies .so tight glycaemia control is important before planning pregnancy. HbA1c of less than 6.1 should be achieved.. If >10 pregnancy should be avoided. Nephropathy and retinopathy can worsen in pregnancy .So Prepregnancy retinal assessment and treatment of retinal disease if necessary is advised.Renal function assessed before pregnancy and if creatinin level >120 mmol/l ,pregnancy avoided by giving her suitable contraceptives. Optimising the severity of the disease is essential. Explaining the maternal risks (like miscarriage, ketoacidosis, hypoglycaemia , preterm labour, increased risk of operative deliveries and perineal trauma) and fetal risks (like Increased risk of congenital anomalies, iugr, macrosomia, ards,stillbirth). The effect of diabetes on pregnancy and pregnancy on diabetes. Due to increased vomiting, poor intake and pregnancy hormones producing insulin resistance achieving optimal glycaemic control is difficult. So glucagon injection and ketoacidosis testing kit are provided with the patient. Review of medications and changing them may be necessary. ACE inhibitors and statins should be stopped. Insulin dose adjusted according to the level of blood sugar. Folic acid tablet 5mg daily should be started preprgnancy and continued upto12 weeks pregnancy. Need for increased antenatal visits and interventions should be explained.Checking for rubella immunity ,stopping smoking and weight reduction advise are important. Antenatal Care: Multidisciplinary care involving endocrinologist, anaesthetist,nephrologist,ophthalmologist, obstetrician,neonatologist,dietician and aspecialist nurse because iddm is a multisystem disease. Regular blood sugar monitoring and maintaining the level fasting 3.5 to5.9 and postprandial <7.1. HbA1c should not be used for diabetic control in pregnancy. High glucose environment is associated with increased risk of congenital anomalies .so tight glycaemia control is important. Due to increased vomiting, poor intake and pregnancy hormones producing insulin resistance achieving optimal glycaemic control is difficult. So glucagon injection and ketoacidosis testing kit are provided with the patient. Family members should be taught about the management of hypoglycaemia. Early booking is arranged and appropriate scan assessment of gestational age will be useful to for downs screening, and induction decision later in pregnancy. Anomaly scan around 20 weeks is important because diabetes is associated with increased risk of congenital anomalies. Regular growth scan may be necessary according to clinical ssessment because iugr and macrosomia can occur in IDDM. Continuing folic acid 5mgs upto12 weeks of pregnancy to reduce the risk of neural tube defects. Retinal assessment at booking visit and if normal one more at 28weeks is needed. If abnormal one visit at 20 weeks and one more at 28 weeks. Renal assessment at booking and at 28 weeks is essential. If abnormal nephrologists’ advise obtained. Proteinuria >5gms is significant needs thromboprophylaxis. This is justified because nepropathy and retinopathy can woren in pregnancy and high proteinuria is associated with thrombosis. Surveillance after 36 weeks focus on fetal wellbeing because iud is common with diabetes.mode delivery plan made at 36 weeks depending upon the size of the baby. Aim for vaginal delivery ,caesarean section for obstetric indication. Steroids can be given if preterm delivery is anticipated to improve the lung maturity. Tocolysis needed sympathomimitics avoided due to risk of pulmonary odema.
		Posted by NIRMALA M. Sat Jul 17, 2010 10:53 pm
Nirmala a. The importance of strict glycemic control should be explained to the patient and the family as poor glycemic control in pregnancy might lead to miscarriages, congenital anomalies, traumatic deliveries due to shoulder dystocia, still births and neonatal deaths. With the help of diabetic team, I will review and optimise current medication. I will optimise strict diabetic control by setting individualised targets for home blood glucose monitoring in order to achieve HbA1C < 6.1 before conception. Pre conceptional folic acid 5 mgs/day should be started. Life style modifications like reducing weight, stopping smoking should be advised and prompt referral to dietetian and smoking cessation clinics as needed. Complications of diabetes such as diabetic retinopathy and nephropathy should be evaluated by fundal examination, urine PCR and kidney function tests and referral to renal physician and ophthalmologist if abnormal. Optimise her blood pressure before conception. Patient information leaflets should be given to her to give better understanding of the condition which in turn lead on to better compliance. Complex preconception cases should be discussed at multidisciplinary post antenatal diabetes clinic meetings. b. She should be managed in a Consultant led care. Her antenatal care should be provided by multi-disciplinary team consisting of a Consultant Obstetrician with special interest in diabetes, diabetes physician, diabetes specialist nurse, midwife and dietetician. Her glycemic control should be assessed by FBS, 2 hours PPBS, and HbA1C. Setting of individualised monitoring targets, generally fasting glucose concentration of 3.5-5.5 mmol/l and post prandial values < 7.8 mmol/l (1 hour) and < 7 mmol /l (2 hour) should be maintained through out pregnancy. Her antenatal visits is increased to every 2-4 weeks depending on the chronicity of the condition. Assess for any diabetic associated complications like nephropathy and retinopathy and prompt referral to nephrologist and ophthalmologist as needed and if fundus is normal at booking, repeat at 28 weeks. Change from ACE inhibitors to pregnancy compatible anti hypertensives during the booking visit if she is a known hypertensive. Consider low dose aspirin, 75 mgs/ day if previous history of preeclampsia, stillbirths and BMI >35. Education about hypoglycaemic episodes and provision of glucagon is important. Education about ketoacidosis and conditions like dehydration, infections precipitating ketoacidosis is necessary and she should be provided with ketostix. I trimester dating scan should be done strictly especially TVS if raised BMI as decision for delivery will be based on EDD. Nuchal translucency should be done before 14 weeks to rule out associated chromosomal abnormalities. Anomaly scan and dopplers should be done at 20 weeks as more for congenital abnormalities and if notching persists, dopplers should be repeated at 24 weeks. Cardiac anomaly scan should be done at 22 weeks as more prone for cardiac defects. Growth scans should be done at 28,32,36 weeks as increased risk of IUGR due to placental vasculopathy. Measurement of her glycaemic control at every antenatal visit by checking her home monitoring records of blood glucose levels and by doing FBS, PPBS and HbA1C. If glycaemic control is poor, admission to hospital till optimal glycaemic control achieved is needed. During her every antenatal visits, blood pressure, urinanalysis looking for proteinuria, UTI, measurement of weight, SFH should be done as macrosomia and polyhydramnios are complcations of uncontrolled diabetes. If proteinuria is of nephrotic range, consider clexane prophylaxis. Patient should be advised that she would be induced at 38 weeks provided there is good glycaemic control as increased chances of still birth after 38 weeks. Clear delivery plan regarding mode of delivery and insulin regimen during induction and labour should be documented. Cautioning her to report immediately if reduced fetal movements or absent fetal movements in third trimester is helpful. Explaining the need for baby to be admitted in neonatal care unit and educating her the signs and symptoms of hypoglycaemia in baby, how to react and importance of early breast feeding is necessary.
		Posted by KWASI RICHARD A. Sun Jul 18, 2010 01:38 am
KRA A. Inform her establishing good glycaemic control before conception and maintaining this throughout pregnancy will resuce the risk of miscarriage, congenital malformations, still birth and neonatal death. Explain to her that the risks can be resduced but not eliminated. Advise her that HbA1c levels of 6.1% are safe and strongly recommend not to get pregnant wth levels above 10%. Offer information about how diabetes affects pregnancy and the effects of pregnancy on diabetes. Information will include the role of diet, body weight and exercise. If her body mass index is gretaer than 27kg/m2 weight loss will be advised. Information will also include the risk of hypoglycaemia and hypoglycaemia awareness in pregnancy, the need for assessment for diabetic retinopathy before and during pregnacy and the need for assessment of diabetic nephropathy before pregnancy. Advise to take folic acid supplements 5mg daily from pre-conception untill 12 weeks gestation to reduce the risk of neural tube defects. B. Her care would be managed by a multidisiplinary team consisting of obstetrician, diabetic endocrinologist, dietician and midwife and general practioner. She will be seen every 1-2 weeks to assess her glyceamic control. Her current medications will be reviewed and their complications. She will be advised to continue her folic acid 5mg daily untill 12 weeks of conception. The aim of glycaemic control is to keep fasting blood glucose between 3.5-5.9 mmol/litre and one hout post prandial glucose below 7.8mmol/litre. Blood glucose metre for self monitoring will be given and patient advised to test blood sugar one hour after every meal and before going to bed, and record a diary of her results. She will also be offered some ketone testing strips and advised to test for ketonuria of she becomes hyperglycaemicor unwell. She will be advised about the risk of hypoglycaemia and hypoglycamic awareness in pregnancy and offer concentrated gluoce to her for use in the event of hypoglycaemia. First trimester pelvic ultra sound scanning between 7-9 weeks to confirm viability and dating . Nuchal scan between 11-14 weeks to screen for chromosomal abnormalitiesbecause serum screening is unreliable. At 20 weeks four chamber viewof the fetal heart and outflow tracts will be offered looking for structural heartmalformations plus anomaly scan between 18-20 weeks She will be offered retinal assessment at first visit and again at 28 weeks if first assessment is normal , however if diabetic retinopathy is present retinal assessment will be performed between 16-20 weeks. Renal assessment will be offered by performing urea electrolytes and creatinine, if creatinine is above 120micromol/litre referral to a nephrologist will be done. Ultrasound scan for growth, liqour volume at 28, 32, 36 weeks gestations. At each visit blood pressure will be measured and urine tested for proteinuria and sugar because of the risks of pre eclampsia. At 36 weeks timing mode and management of delivery will be discussed and she will be reffered to an anaeathetist to discuss analgesia. Induction of labour will be offered at 36 weeks or caeseran section if indicated. If she is awaiting spontaneous labour offer weekly tests for fetal well being between 39-41 weeks. Involve here and her partner in decisions about her care.
		Posted by KWASI RICHARD A. Sun Jul 18, 2010 03:07 am
KRA A. Inform her establishing good glycaemic control before conception and maintaining this throughout pregnancy will resuce the risk of miscarriage, congenital malformations, still birth and neonatal death. Explain to her that the risks can be resduced but not eliminated. Advise her that HbA1c levels of 6.1% are safe and strongly recommend not to get pregnant wth levels above 10%. Offer information about how diabetes affects pregnancy and the effects of pregnancy on diabetes. Information will include the role of diet, body weight and exercise. If her body mass index is gretaer than 27kg/m2 weight loss will be advised. Information will also include the risk of hypoglycaemia and hypoglycaemia awareness in pregnancy, the need for assessment for diabetic retinopathy before and during pregnacy and the need for assessment of diabetic nephropathy before pregnancy. Advise to take folic acid supplements 5mg daily from pre-conception untill 12 weeks gestation to reduce the risk of neural tube defects. B. Her care would be managed by a multidisiplinary team consisting of obstetrician, diabetic endocrinologist, dietician and midwife and general practioner. She will be seen every 1-2 weeks to assess her glyceamic control. Her current medications will be reviewed and their complications. She will be advised to continue her folic acid 5mg daily untill 12 weeks of conception. The aim of glycaemic control is to keep fasting blood glucose between 3.5-5.9 mmol/litre and one hout post prandial glucose below 7.8mmol/litre. Blood glucose metre for self monitoring will be given and patient advised to test blood sugar one hour after every meal and before going to bed, and record a diary of her results. She will also be offered some ketone testing strips and advised to test for ketonuria of she becomes hyperglycaemicor unwell. She will be advised about the risk of hypoglycaemia and hypoglycamic awareness in pregnancy and offer concentrated gluoce to her for use in the event of hypoglycaemia. First trimester pelvic ultra sound scanning between 7-9 weeks to confirm viability and dating . Nuchal scan between 11-14 weeks to screen for chromosomal abnormalitiesbecause serum screening is unreliable. At 20 weeks four chamber viewof the fetal heart and outflow tracts will be offered looking for structural heartmalformations plus anomaly scan between 18-20 weeks She will be offered retinal assessment at first visit and again at 28 weeks if first assessment is normal , however if diabetic retinopathy is present retinal assessment will be performed between 16-20 weeks. Renal assessment will be offered by performing urea electrolytes and creatinine, if creatinine is above 120micromol/litre referral to a nephrologist will be done. Ultrasound scan for growth, liqour volume at 28, 32, 36 weeks gestations. At each visit blood pressure will be measured and urine tested for proteinuria and sugar because of the risks of pre eclampsia. At 36 weeks timing mode and management of delivery will be discussed and she will be reffered to an anaeathetist to discuss analgesia. Induction of labour will be offered at 36 weeks or caeseran section if indicated. If she is awaiting spontaneous labour offer weekly tests for fetal well being between 39-41 weeks. Involve here and her partner in decisions about her care.
		Posted by hassan M. Sun Jul 18, 2010 07:04 am
Management of this patient should be multidisciplinary in liason with dietician,endocrinologist obstetrician and special mid wife.Patient should be informed that unless she has tight control of her diabetes she should practice contraception.She should be informed that poor controle at conception is associated with increased maternal risk such as pre eclampsia ,diabetic retinopathy and nepheropathy,opeartive delivery and fetal risk of miscarriage ,congenital anomalies ,aneuploidy, shoulder dystocia &IUFD. She should be given general pre pregnancy advice regarding folic acid to be taken 5 mg to prevent risk of neural tubal defects.Smoking cessation or reduction in liason with smoking cessation help group.If rubella negative should be given rubella vaccine to prevent risk of exposure in pregnancy.A detail previous obsteric history and medical history is taken to know about course of disease in pregnancy weather she developed pre-ecampesia ,retinopath and out come and mode of previous delivery. History of preterm labour,preecalmpsia,shoulder dystocia IUGR,and IUFD is explored.Aim should be to attain pre-pregnancy HBA1c levels below 6.1. befor embarking on pregnancy. It is considered as high risk pregnancy and care should be multi disciplinary ,counsultant lead ,hospital based with frequent antenatal visits with aim to achive near normal blood sugar levels ie fasting 5.3mmol/l and RBS of 7.8mmol/l. All booking screening and investigation are carried out according to national screening guide lines. Biochemical screening for Down syndrome are not be interpretable in case of IDDM and nuchal translucency is recommended.Base line renal function tests ie uric acid ,serum creatinine ,craetininen clearence is done to compare in case of deteriation ocuurs later. if serum creatininie is > 140mmol/l patient should be refered to nepherologist.Blood pressure should be checked manually with sypghnomanometer with appropriate size cuff.Patient should be given glucose checking dipstick for monitering at home and glucose drinks in case of episode of hypoglycemia occurs at home. Fundoscopy is carried out at booking if not done in last one year with the help of mydriasis otherwise it should be done at 16 weeks and if normal should be repaeated at 28 weeks. Anomlay USS is done at 18-20 weeks and fetal echo should be carried out around 24 weeks with 5 chamber view to exclude cardiac anomaly. If suspicion of poly hydramnios and macrosomia regular USS should be done to asses severity and to plan time and mode of delivery. Serial USS is done from 28-34 weeks with doppler to exclude IUGR. Induction of labour is adviced at 38 weeks to prevent risk of IUFD due to placental insufficiency .Pregress in first and second stage is plotted on partogram as delay may anticepate risk of shulder dystocia.Blood sugra monitering should be done hourly and if >7.8mmol/l insulin infusion should be staretd with KCL 20 mmol/liter to keep blood sugar below 7.8 mmol/l If estimation of fetal weight is>4.5 kg Elective ceasarean section should be adviced to prevent risk of shoulder dystocia . Neonatologist should be informed at birth as there is risk to neonate of hypoglycemia ,hypomagnesemia ,hyperkalemia hyperbilirubinemia .
		Posted by Mohamed D. Tue Jul 20, 2010 09:48 am
Mohamed A) Good glycaemic control reduces the risk of congenital malformations and complications of preganacy.HBA1c level of 6.1% or less is indicative of good glycaemic control, while those with levels above 10% should be advised against preganacy. Any assocciated system afection should be optimized prepregnancy. Proliferative retinopathy is an indication to postpone pregancy till treatment as it is contraindication for rapid glycamic control. Nepropathy had been associated with increased risks of preeclampsia and poor obstetric outcomes. Weight reduction if obese, as BMI above 30 had been associated with more preganancy complications. B) Folic acid 5 mg dose to reduce the risk of congenital malformations especially the neural tube defects should be prescribed. She shold be advised for tight blood sugar control as it reduces the risk of complications and to be aware of hypoglycaemia symptoms anad how to use glucagon if needed. She should be informed that serum screening for aneuploidy is not reliable and needs a NT scan for accurate estimation of her risk. Her medications should be optomized; change of ACE inhibitors for her blood pressure control into a safer medication in pregnancy like alpha methyle Dopa or Labetalol, and her insulin requirement may be reduced in the first trimester with nausea and vomiting. Hospital based ANC with multidisiplenary team with diabetes specialzed midwife.She should be offered a glucometer and adised about times to check her blood sugar and normal values in pregancy for accurate control. Digital fundus examination at 16-18 weeks preganacy if not yet ahd been done in the last 12 months for assessment of retinopathy, and to be repeated at 28 weeks. Nephropathy should be checked with baseline renal function tests at 16-18 weeks and to be repeated at 28 weeks with 24 hour urine collection for proteinurea. Growth can should be arranged at 28, 32 and 36 weeks, to role out macrosomia and FGR. Fetal well being test, CTG and AFI with Dopplers from 38 weeks onwards. Delivery should be planned around 38-40 weeks if well controlled. Vaginal delivery should be advised unless macrosomia is suspected as there is increases risk of shoulder dystocia.