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MRCOG PART 2 SBAs and EMQs

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ESSAY 183 - IDDM

Posted by Sarwa aldoori A.
Councelling this patient starts with history . Enquiries age at onst her insulin regimen, compliance with medications reflected by frequent hospitalisation dut to poor control , previous pregnancies and their outcome,her outlook at the disease and whether she understand the gravity of the problem, any additional inormatios that she would like to give that we did not ask about. the main objectives is to let her know that there is increased perinatal morbidity and mortality associated and thatcareful good control of her blood sugar is the key to successful outcome.Also to determine vasculopathy reflected by retinopathy by ophthalmologic exam and referral to specialist if any treatement required, nephropathy, as well as hypertension. Poor signs in the hisotry is recurrent ketoacidosis, pyelonephritis.hypertension and poor attendence to the clinic. Investigations to be done are HBA1C, reflect glucose control on three previous months, renal function in terms of urinary microalbuminuria, s.creatinine,,EKG,BP measurement. Also need to assess her awareness of hypoglycemia.If glucose control is suboptimal , we need to check her reubella immune status, provide proper contraception, check thyroid function, and follow up . Also discuss increase incidence of malformation with particular refrences to heart and CNS, and provide folic acid 5 mg daily for the three months period before embarking on pregnancy. We need to edcuate the patient and her partner about our management plan of diabetes. Obviously this is a multidisciplinary approach, referral t dibetologist, diabetes nurse, dietition
The patient need to be under regular surveillance throughout this period.,untill optimisation acheived.
During pregnancy to optimise oucome ,regular check on her HBA1C, her insul regiment , provide her with diary to write down her bg control, we aim at probably 5 to six time check depending on intial level ,mean level 100mg/dl fasting<95mg/dbefore lunch,supper,bedd time snack<100mg,one hr -two hr after meal 120-140.
regular visit to the diabetes nurce, dietitien, and the diabetologist either in combined clinics or sepratelt.Dating scan to confirm the pregnancy,10-13 scan t rule out anaencephalt, measure nuchal translucency, MSAFP at 16 wek,comprehensive detailed scan at 20 week, fetal echocardiogram at 22wk.
having gone through this period, then pateitn seen 2 weekly, growth scan 4 weekly. When reach 32- 34weeks then weekly, provide her with kick chart ,discuss the increase risk of IUD late a
Assuming that all is well and the pregnancy is running smoothly , informing the anaesthetist about the patient to discuss mode of pain releif in labour. theoughour her visit in the antepartum period ,close observation to vital pulse BP weight, glucose control, estimated fetal weight to rule out macrosomia, Awreness oof increased incidence of PIH,
Induction done pending her glycemic status, in labour two iv lines, soliding scale, U_E checked 4hrly, bg 1hrly,epidural encouraged, (neonatologist) informed beforehand.
encourage beast feeding and assess dietary adjustenment, also go tp prepreg,level of insuln, provide proper contraception
Posted by Sarwat F.
She will be counselled regarding the risks of diabetic pregnancies and need for treatment and follow up. Diabetic pregnancy is a high-risk pregnancy and it is associated with considerable maternal and perinatal morbidity and mortality. There is a risk of preeclampsia, worsening of diabetes, risk of retinopathy and nephropathy. When planning a pregnancy she will be advised to start taking folic acid 0.4 mg as prophylactic dose or 4 mg daily if there is any previous history of congenital abnormality. She will be advised to contact her GP as soon as she becomes pregnant. Regular follow up will be arranged then to ensure optimal diabetic control. Her insulin regime will be adjusted during pregnancy, as dose will need to be increased. Multidisciplinary care in the form of care by endocrinologist will be required in specialized diabetic clinic. Diabetic nephropathy and diabetic retinopathy will be checked in the preconception period, as retinopathy gets worse in pregnancy.
It is associated with 3 to 5 fold increased risks of congenital anomalies. There is also slightly increased risk of miscarriages. Serum screening can be advised in mid trimester to check for neural tube defects. A detailed anomaly scan and fetal echocardiography will be arranged at 22 to 26 weeks. Diabetes is associated with polyhydramnios, preterm labour and fetal macrosomia, whereas fetal growth restriction is also noted especially with IDDM. There is a risk of placental insufficiency, antenatal asphyxia and preeclampsia in pregnancy. Tight glycaemic control will be maintained to prevent these complications. She will be seen fortnightly till 32 weeks and weekly thereafter although frequency of antenatal visits may vary according to hospital protocol and woman?s condition. Fetal growth will be monitored at antenatal visits for macrosomia, however there is no evidence to support early induction to prevent macrosomia. With optimal diabetes control induction of labour is advised at 38 to 39 completed weeks of gestation. Delivery should take place at tertiary level hospital with appropriate SCBU facilities. Insulin is given with syringe pump and intravenous glucose is also given with insulin dose adjusted according to it. There is a risk of poor progress of labour, fetal distress, instrumental delivery, and caesarean section and shoulder dystocia. Risks to neonates include hypoglycaemia, electrolyte imbalance, jaundice and polycythemia. After delivery insulin dose is reduced to prepregnancy levels and blood glucose monitored. She will be advised that oral contraceptive pills may interfere with glycemic control and progesterone methods are preferred.
Various measures that can be taken to improve outcome include optimal diabetic control throughout pregnancy, delivery in a tertiary care unit with multidisciplinary input and appropriate neonatal care. Senior anaesthetist should be present for regional or general anaesthesia. Adequate haemostasis will be secured during the procedure. Appropriate aseptic techniques to prevent infection as diabetic pregnancies are associated with risk of infection. Insulin dose should be titrated to optimise blood glucose levels. A paediatrician must be present at the time of delivery as baby is at the risk of hypoglycemia, hypokalemia, hypomagnesuimia, hyponatremia, polycythemia and jaundice.
Posted by adnan S.
IDDM is the most common medical disorder of pregnancy.Accounts for 1-2% of all pregnanies.Un controlled IDDM is associated with adverse fetal outcome like miscarriage ,congenital anomalies ,fetal macrosomia ,IUGR pretem delivery ,still births overall perinatal mortality &morbidity is increased.Maternal risks are diabetes ketoacidosis,hypoglycemia,pre-eclampsia ,poly-hydromnios.Pre pregnancy counseling allows for optimization of diabetic control prior to conception as wellas assessment of the presence and severity of complications like hypertention,retinopathy &nephropathy.

Detailed history is taken regarding duration of NIDDM ,associated hypertention ,retinopathy,nephropathy .Obstetric history regarding congenital anomalies ,stillbirths ,macrosomia.On examination weight &height noted to calculate BMI, blood pressure is recorded .Investigations fasting &posprondial blood sugar HbA1c .FBC,U&E,serum creatinine clearance if proteinuria.fundoscopy for retinopathy.If the blood sugar is poorly controlled advice against pregnancy maintain adequate contraception until well controlled blood sugar .Aim at achieving normoglycemia as congenital anomalies develop during the first 5-6 wks of pregnancy. Glucose values should ideally remain at 4-6 mmol/l by using a regimen of thrice daily short acting insulin before meals together with intermediate acting preprations at nightGlycosylated Hb should be <6.5% before conception..If retinopathy detected should be trearted as rapid improvement of glycemic control results in deterioration of retinopathy .Nephropathy carries poor prognosis&high risk of pre-eclampsia,preterm delivery and poor perinatal out come.Anti hypertensive medications like ACE inhibitors are teratogenic and impair fetal renal functions,beta blockers cause IUGR should be changed to methyl dopa.

General advice like lifestyle modifications ,reducing smoking. Diatery advice diet high in complex carbohydrates are recommended,fat worsens insulin resistence.Folic acid 5 mg /day should be commenced.rubella status should be checked immunised if not immunized.Inform her about the demand of antenatal diabetes controland the potential effects on the womans work &family life.

Antenatal care by multidisciplinary team by a single obstetric consultant team in conjunction with diabetologist,dietician and diabetes specialist midwife,not the least woman her self plays the important role.Written information is provided along with telephone contact numbers with direct access to their carers.Dating scan is important for assessment of fetal growth&timing of delivery.Increase insulin requirement in pregnancy may be precipitated by vomiting need in-patient admission to stabilize glycemia ,tight control leade to risk of hypoglycemia ,woman and her family are taught to recognize signs of hypoglycemia & use glucose drinks/glucogon injection .Reassure that hypoglycemia is not harmful to fetus.Detailed fetal anomaly scan is done to look for neural tube defects renal anomalies and sacral agenesis.Cardiac scan for septal defects & transposition of great vessels is done.Downs screening serum markers are at lower levels.hence adjustments for diabetes in screening for aneuploidy is required.Nuchal translucencymeasurement and fetal nasal bone +/- is helpful..
Fetal growth and well-being is assessed by growth scan every 2-4wkly+/- umbilical artery Doppler as there is risk of fetal macrosomia,increased risk hypoxia and acidosis,&un-explained fetal death in utero.The value of fetal kick chart amniotic fluid volume and umbilical artery Doppler is uncertain.Early recognition and treatment of pre-eclampsia,poly hydromnios.retinopathy and neophropathy by blood pressure monitoring,regular ophthalmic examination,and renal function testing.If preterm delivery is anticipated administration of corticosteroids is associated with marked hyperglycemia insulin sliding scale is required.

To optimize the outcome the usual dose of insulin and food should be given on the evening before c-section and woman fasted from 12 mid-night.On the morning of the delivery commence on insulin infusion and 10%dextrose to maintain blood glucose levels between 4-7mmols.Monitor glucose levels every 15mts till the baby is deliverd.Half the rate of insulin infusion after delivery of placenta adjust dose to maintain blood glucose level of 4-9mmol/l,continue insulin infusion till she starts eating.Neonatologist should be present at the time of delivery as ther is risk of RDS hypoglycemia ,hypocalcaemia ,hypomagnesaemia ,&hypothermia.Antibiotic prophylaxis,postoperative adequate pain relief, is considerd .Assessment of VTE is done heparin sc is given if high risk of VTE,other wise adequate hydration and early mobilasation is considerd.
Posted by Sreekala S.
IDDM significantly affects the maternal morbidity and the neonatal outcome. She should be seen in a pre-conceptional diabetic clinic. Pregnancy should be planned when there is a tight glycemic control as guided by the HbA1c levels. Folic acid 5mg/day should be commenced as soon as she plans pregnancy. A tight glycemic control is essential to reduce the risk of fetal anomalies.
She should be counselled that once she becomes pregnant, there is a need for frequent monitoring of her blood glucose, her general health and fetal surveillance. There is an increased risk of congenital abnormalities and perinatal morbidity and mortality for the baby and increased risk of infection for her.
She should be informed that she would need a multidisciplinary team care involving the diabetologist, consultant obstetrician, diabetic specialist nurse, dietician and midwives. Her insulin dosage may need to be increased during pregnancy and may need admission to adjust the dosage. She and her partner should be taught the signs/symptoms of hypoglycemia and how to use the glucagon kit.
Modification of any medication like antihypertensives(ACE inhibitors if taken) should be considered. Neuropathy, nephropathy and opthalmopathy should be looked into and referred to specialists if indicated. Fundoscopy should be performed and referral to an ophthalmologist if required.Fasting blood sugar, post lunch, pre-dinner and post dinner blood sugars need to be monitored at home 2-3 times weekly to maintain euglycemia and the aim should be to maintain 4-6 mmol/l .
She needs to be reviewed at the clinic every 2 weeks until 34weeks and weekly thereafter or sooner if required. At every visit BP and urinary protein should be checked and MSSU sent off if UTI is suspected. Second trimester serum screening should be offered and a detailed 20weeks scan to look for any congenital anomalies. A detailed cardiac/anomaly is indicated at 32 weeks. Growth scans should be performed at 28, 32 and 36 weeks with Doppler if required. There is an increased risk of congenital anomalies, polyhydramnios, IUGR, shoulder dystocia, increased need for operative delivery, unexplained IUD and Pre-eclampsia during this pregnancy. Electronic fetal monitoring will be required during labour. The baby will be at an increased risk of hypoglycemia, hygpocalcemia, jaundice, respiratory distress syndrome and polycythemia and therefore needs to be reviewed by the paediatrician immediately after delivery. Leaflets and addresses of support groups given and further appointments arranged if she desires.
Tight glycemic control is required to optimise the outcome and it is achieved by frequent monitoring of blood glucose and altering the dosage in liaison with the diabetologist/physician. The morning dose of insulin should be skipped on the day of the elective caesarean delivery and Glucose-insulin infusion started with frequent blood glucose monitoring. She should be reviewed by the anaesthetist preferably one day before the planned delivery. Regional anaesthesia is preferable to general anaestesia. Prophylactic antibiotics should be considered after delivery as there is an increased risk of infection. VTE prophylaxis should be given. Paediatrician should be available at delivery. Glucose-insulin infusion given until she starts eating. Insulin dose may need to decreased to pre-pregnancy dose following the delivery. Contraception should be discussed at the 6 week postnatal visit.
Posted by Vaani M.
Insulin dependent diabetes mellitus could be associated with maternal, fetal and neonatal problems if not well controlled and managed well. A multidisciplinary approach involving obstetrician, diabetologist, diabetic nurse specialist, dietician, neonatologist would be needed for this woman.

Prepregnancy counselling would begin with assessing her diabetic control, knowing number of years she has been on treatment, hospitalisation for complications like diabetic ketoacidosis, ophthalmic check up to look for any retinopathy, renal functions to assess for nephropathy. A well controlled diabetic without complications would do well if pregnant with appropriate antenatal care. Poorly controlled diabetic would be advised to continue contraception until treatment and control of diabetes has been achieved. Nephropathy and retinopathy should be managed by the appropriate specialists during this period. She would be advised to stop smoking, minimise alcohol intake, reduce weight, and begin folic acid prior to planning pregnancy. If she is on any drug as ACE inhibitors she needs to have her blood pressure controlled with an alternative drug if planning pregnancy. Poorly controlled diabetic if pregnant would have maternal complications as diabetic ketoacidosis, worsening of the retinopathy. The fetus would be at risk of miscarriage, congenital anomalies especially cardiac, neurological anomalies.

During pregnancy her baseline assessment of diabetic control, glycosylated haemoglobin to assess past control and compliance with treatment should be reconfirmed. Glycosylated haemoglobin needs to be repeated every month to adjust dose of treatment due to increasing insulin requirements through pregnancy,which may reduce near term. Regular antenatal examination and assessment in the specialised diabetic pregnancy clinic should be done in every visit. Her diet and insulin requirements need to be adjusted during pregnancy, if required in -patient care and adjustment of dose may be done. Prompt treatment of hyperemesis, avoiding dehydration, treatment of infections, would help in avoiding complications during pregnancy.

Dating scan to confirm expected date of delivery should be considered, this would also help in the serum screening for anomalies. Detailed cardiac anomaly scan should be done at 22 to 24 weeks of gestation preferably in a specialised ultrasound unit. The fetus should also be watched for macrosomia or intrauterine growth restriction by serial ultrasound examination if suspected. Polyhydramnios could also develop in a diabetic pregnancy more so if the fetus was anomalous and needs to be watched for.

Delivery needs to be planned electively after 38 weeks preferably, if she has any complications as pregnancy induced hypertension, growth restricted fetus, gross macrosomia. In a well controlled diabetic vaginal delivery could be allowed except for obstetric indications. When she is in labour or prior to planned delivery she needs to stop insulin injections herself, and on admission she would be changed to a sliding scale insulin infusion pump in labour for control of diabetic status.

Postnatally breast feeding is to be encouraged. Insulin requirements for the mother will decrease and need to be adjusted to half to one third of pregnancy dose, or the prepregnancy doses. The neonate should be watched for respiratory distress, hypoglycaemia, hypocalcaemia, hypomagnaesemia, jaundice and polycythaemia. Contraception should be advised and follow up with diabetologist postnatally should be continued.

To optimise the outcome during elective caeserean at 38 weeks a planned pregnancy, with well controlled diabetes without any complications would be the first step. Consultant led care with senior involvement and decision about delivery, pre-anaesthetic check up, well prepared neonatologist unit should be available. Insulin infusion along with potassium infusion should begin on the day of surgery. Postoperatively infusion could be stopped and insulin continued once she starts oral diet. Prophylactic antibiotics and thromboprophylaxis is to be given. Catheterisation should be minimal to avoid urinary tract infection. Wound care should be appropriate to avoid any infection and wound complications
Posted by Farzana N.
Prepregnancy counseling in this patient would aim at achieving optimum glycemic control; detecting and treating any associated diabetic complications for an optimum pregnancy outcome.
Patient should be advised that a poor glycemic control increases the risk of fetal malformations five fold and also increases the risk of miscarriage. However with good glycemic control, as suggested by HbA1c <6.5%, these risks are approximate to the women without diabetes. This should be stressed without alarming the patient, since even with poor control many women will not have congenitally abnormal baby. Contraception should be advised until glycemic control is achieved.Lifestyle modifications such as stopping smoking should be stressed.
As soon as the pregnancy is confirmed, she should report and a dating scan arranged. this would ensure accurate dating and confirmation of on going pregnancy. Serum screening tests are affected by diabetes; ultrasound screening is preferable to assess the risk of Downs?s syndrome. Anomaly scan would be done at 18-20 wks for structural abnormalities and also for cardiac, kidney and CNS anomalies, which have higher association in babies of diabetic mothers.
Patient should be advised to continue on a suitable diet and referred to a diabetic nurse and diatecian. Rubella status should be checked and folic acid prescribed to reduce the risk of NTD.Blood glucose levels should be closely monitored and kept at<5.5 fasting and <7 postmeals. She should be taught to monitor her glucose levels and have her blood checked for HbA1c to monitor long-term control. She is at increased risk of diabetic ketoacidosis and hypoglycemia .PT and her family should be educated about the signs and symptoms of these complications and use of glucagons.
If she has HTN and is on medications, these need to be reviewed and changed e.g. ACE inhibitors (impair fetal renal function), beta-blockers (associated with growth restriction) to methyl dopa, which is more safer in pregnancy. Retinopathy should be assessed and treated, since rapid improvement in glycemic control results in deterioration of retinopathy.
Performing renal function tests, with 24hrs and creatinine clearance, would assess nephropathy, which is associated with pre-eclampsia, preterm delivery and poor perinatal outcome.
Before elective cs her blood sugar should be optimally controlled, high blood sugar is associated with impaired wound healing. She should receive her evening dose of insulin on the previous day and morning dose should be avoided on the day of operation. She should preferably be first on the list. Prophylactic antibiotics should be given to reduce the risk of infection. Intrapartum hyperglycemia is associated with fetal distress and increases risk of fetal hypogylycemia. Intravenous insulin infusion should be given with 10%dextrose and potassium chloride at the rate of 100ml/hr. Blood glucose should be checked hourly adjusting the rate of insulin infusion. Good hemostasis should be secured during operation and drains kept to avoid hematoma formation. Postoperatively early mobilization and adequate hydration is advised. Insulin requirements fall to prepregnancy level, once the patient is on oral feeding, thus the dose should be readjusted according to blood sugar levels.Neonatologist should be available.

Posted by Aroosha B.
Pregnancy in IDDM is associated with considerable neonatal morbidity and mortality. The counseling will be done by knowing her pervious diabetic control, previous pregnancies and its outcome, any associated retinopathy, neuropathy, nephropathy and any hypoglycemic attack.. Her pervious glycemic control can be known by asking or contacting her diabetic physician. In case information are not available, the level of HbA1C can give information regarding her diabetic control in previous 3 months. In case of poor glycemic control she should be advised against pregnancy. Contraception should be given be given unless a good glycemic control is achieved. Patient should be advised of increased association of hyperglycemina and teratogenecity. Patient should be advised folic acid 5 mg, avoidance of smoking and rubella status checked. Folic acid should be given in a dose of 5 mg, because of increased association of IDDM with neural tube defects. The pregnancy should be managed by multidisciplinary team consisting of obstetrician, diabetic physician, diabetic nurse and dietician. At initial visit her renal function should be checked for and an assessment for retinopathy, nephropathy and neuropathy should be done. Patient with nephropathy should be informed of increased risk of PE, preterm labor and IUGR. In case of hypertension drug therapy should be reviewed as ACE inhibitors are associated with congenital malformation and should be stopped. At initial visit dietary advise and special attention to the sign and symptoms of nausea and vomiting should be given and early recourse to antemetics should be ensured. The patient should be informed of increased insulin requirement during pregnancy and an easy approach to the diabetic nurse. The blood sugar level should be maintained between 5.5 and 6.5 m mol/liter. All information should be given in written which the patient can take home and her partner involved. Patient should be informed of good outcome in 70 % of patients and a good relationship established.
Accurate gestational age should be determined by ultrasound. Serum screening for triploidy should be carefully assessed as they vary with poor glycemic control and result in low level of HCG and AFP. The use of nuchal translucency measurement is preferred in diabetic patients and have benefit of providing marker for congenital heart disease.
A detailed anomaly scan should be carried at 20 weeks because of increased risk of cardiovascular, neural tube, renal and skeletal anomalies. An echocardiography should be carried out at 22 weeks or as a minimum 5 chamber view at the routine screening scan.
In pregnancy complicated by vasculopathy a uterine Doppler carried at 20 weeks helps in detection of those pregnancy which are at risk of complications.
There is a increased risk of polyhydroamnios, pre term labor 17 % and PE 12 % in diabetic patients. Forth weekly scan should be carried out , but the prediction of macrosomia by ultrasound is poor. Fetal monitoring from 28 weeks gestation if there is evidence of macrosomia or growth restriction but not necessary if there is normal growth. In case of pre term labour steroids should be given as benefits gained by the fetus out weigh the risk of poor glycemic con ol which can be achieved on in patient basis. Fetal monitoring should be done with by daily CTG, but interpretation must take into account, the alteration in fetal heart rate parameters in diabetic pregnancy. Doppler studies are helpful in those pregnancies where there is vasculopathy resulting in IUGR. BPP should be done on weekly basis.
In case of elective LSCS at 38 weeks patient should be assessed by anesthetist a day before the operation. Her morning dose of insulin should be omitted, Epidural anesthesia should be preferred and ideally should be given by senior anesthetist. Operation should be carried out by senior obstetrician as there is risk of macrosomic baby and PPH. Blood should be cross matched, prophylactic antibiotic should be given. Blood sugar level to be maintained at 8 m mol/liter and glycemic control team should be available. A pediatrician should be available at time of delivery because the fetus is at increased risk of hypoglycemia, hypocalcemia, hypomegnesmia and hypotherimia. Thromboprophylacis should be considered.
Posted by adnan S.
Respected sir
In Pre-pregnancy counseling generic plan you have given along with assessment of severity by history/examination /investigation ,contrpl of disease ,adequate contraception ,revieng drug therapy effect of disease on preg&preg on disease to discuss management of preg like antenatal care itrapartum care &post-partum care ,is the disease indication for c-section please help me in clearing these doubts .Thank you ,if you don?t mind please help for that question suspected SROM at 17 wks.With regards&love Adnan
Posted by Aroosha B.
Dear Dr Paul
six questions have been checked out of seven
my no is seven waiting for your kind reconsideration
thanks dr aroosha
Posted by Aroosha B.
Dear Dr Paul
six questions have been checked out of seven
my no is seven waiting for your kind reconsideration
thanks dr aroosha
Posted by Aroosha B.
Dear Dr Paul
six questions have been checked out of seven
my no is seven waiting for your kind reconsideration
thanks dr aroosha
Posted by SWATI M.
Before counselling the woman, review her diabetic control and note if associated hypertension and its treatment, renal or eye affection.Take into account her previous obstetric history and their outcome.Examination includes measurement of BP and fundoscopy.Investigations include urine examination for proteinuria.24 hour urinary protein and creatine clearance are measured if kidneys are affected.HbA1c estimation is done to know the diabetic control.
Advice her against pregnancy until diabetes is well controlled and provide adequate contraception till then.Refer her to the diabetologist for diabetic control.Review her drug treatment with physician.Antihypertensives such as ACE inhibitors should be changed when planning for pregnancy to methyldopa.B- blockers can cause IUGR with long term use and needs to be changed during pregnancy.Pregnancy is contemplated when diabetes is well controlled.
Diabetes control may be difficult during pregnancy .Insulin resistance increases as the pregnancy advances and need for frequent monitoring of blood glucose by the woman and modification of insulin dosage should be explained.
Diabetes can have effect on pregnancy outcome .There is increased risk of miscarriage,congenital anomalies,fetal macrosomia or IUGR,operative deliveries and shoulder dystocia.Neonate is at increased risk of hypoglycaemia, RDS,hypothermia,hypocalcaemia ,polycythemia , jaundice and IDDM later in life.Mother is at risk of developing ketoacidosis , hypoglycaemia and deterioration of ophthalmic function with rapid glucose control during pregnancy.
Early booking during pregnancy is desirable.She should be managed at joint clinic with diabetologist and diabetic nurse with increased visits.She should monitor blood glucose regularly at home and insulin doasages are adjusted.She and her family should be taught to recognize symptoms of hypoglycaemia and about glucagoninjection.Early dating scan should be offered with anomaly scan at 18-20 weeks and cardiac scan at 24 weeks.Fetal growth should be monitored clinically and serial ulrasound scans every 4 weeks.
Spontaneous labour is preferable but induction will be offered at 38 weeks if not delivered.During labour insulin drip with dextrose will be used .Hourly blood glucose monitoring is done and levels are maintained at 4-6mmols/L.Continuouse electronic fetal monitoring is recommended.Monitoring of the labour with partogram and early caesarean section is recommended if labour is not progressing satisfactorily.
Reduce insulin dose to prepregnancy levels after delivery with further dose reduction if breast feeding.Discuss contraceptive methods.
Usual prepregnancy advice about folic acid intake in prepregnancy period,checking for rubella antibody status,vaccinate if sensitive with contraceptive advice.
Woman undergoing elective CS,she should have usual diet and insulin dose previous night.Omit morning dose of insulin on the day of CS.Insulin should be given through glucose,insulin potassium drip with dosage adjustment by hourly glucose monitoring.Regional anaesthesia is preferred.CS should be done early with priority in operating list.All aseptic precautions are observed and prophylactic antibiotics are given.In obese woman interrupted skin sutures are preferred.Neonatologist should be present and cord blood glucose is measured.Encourage early postop mobilisation with appropriate thromboprophylaxis.Reduce dosage of insulin postoperatively and prepregnancy dosage started when she start on regular diet.
Posted by M H.
Sorry for late reply...

Diabetes Mellitus, when uncontrolled, poses significant morbidity rates on both baby and mum. Preconception counselling in these women, preferable in conjunction with her partner and her endocrinologist will provide them with evidence based information in a non directed manner to enable them to make an informed choice.

The length of her illness, her diabetic control and the presence of complications arising from diabetes will all impact on her management. Optimisation of her diabetic control, switching over to insulin injections will reduce the complications associated with diabetes to her foetus. Poorly controlled diabetes have been associated with foetal cardiac defects. However, the rapid control of her diabetes, she would be at increased risk of hypoglycaemia, diabetic ketoacidosis and worsening retinopathy. It is important to detect retinopathy and treat it prior to embarking on this. Hypertension and ischaemic heart disease which oftern affects diabetic women should be checked for and treated if present. Her partner and the lady should also be educated on how to detect and treat hypoglycaemia. In pregnancy, there is also an increased risk of foetal macrosomia and intrauterine growth restriction. If hypertensive, there may also be superimposed pre eclampsia.

She should also be adviced to avoid tobacco, alcohol and polypharmacy as well as commence on folic acid supplementation. Her rubella status should be ascertained and immunisation should be carried out if necessary. Her blood group and rhesus status should also be made known. Once pregnant, she should be adviced to have a first trimester dating ultrasound with a second trimester anomaly scan with special attention to the foetal heart. Her care in pregnancy will be handled jointly by the endocrinologist and the obstetrician. Contraception should be provided till her condition is optimised.

The couple should be allowed time to absorbed this information and be allowed to ask questions. A second opinion, referral to support group and a second appointment be made if necessary. All verbal information should be supplemented with written information.

In the event of a insulin dependant diabetic woman requiring caesarean section, she should be adequately fasted and a infusion of insulin commenced with fasting with hourly blood sugar monitoring; 4 hourly biochemical profile with potassium replacement if necessary. Ideally, she should be placed first on the list to reduce the time she fasts. Prophylactic antibiotics, aseptic technique and good haemostasis will reduce her infection risks. Prophylactic thromboprophylaxis, early ambulation and TED stockings should be in place post operatively. Her insulin requirements should be tailed down to her pre pregnancy doses and monitored with glucose. Breastfeeding should be encouraged. Prior to discharge, contraceptive advice should be given.