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MRCOG PART 2 SBAs and EMQs

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Essay 237 - IDDM

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		Posted by Valerie T. Fri Jul 13, 2007 05:55 am
A 32 year old insulin dependent diabetic is planning a pregnancy and attends the pre-conception clinic. (a) Justify your clinical assessment and investigations [9 marks]. (b) What will you tell her about the risks to her health? [5 marks] (c) What will you tell her about the risks to her fetus? [6 marks] a) I would take a history to determine the onset of the diabetes and whether the patient had good blood glucose control. If there is currently poor control, the blood sugar should be controlled before conceiving. I would find out whether there were symptoms of diabetes. I would find out what type of insulin and the frequency of her medication. I would find out whether she has had any medical problems such as retinopathy or nephropathy. These conditions if already existing may deteriorate in pregnancy. I would take her blood pressure and measure her BMI. The bloood sugar would need to be controlled before conception. If the BMI is raised this could lead to increased fetal and maternal morbidity. I would advise her to lose weight before conception. Investigations I would perform an oral glucose tolerance test which would give us information on the current blood glucose contol. I would perform a glycosylated haemoglobin test which will give information about the patient\'s long term glycemic control. I would do blood urea, creatinine and electrolytes to assess the kidney function which could be altered in diabetics. I would test the urine for protein. Proteinuria may be suggestive of diabetic nephropathy or urine infection. Both of which would need to be treated. b) I would tell her that the pregnancy will increase her insulin requirements. However, this may lead to hypoglycemic episodes. There is an increased risk of retinopathy, nephropathy and hypertension. The hypertension may be superimposed with preeclampsia. If her blood sugar is uncontrolled this may lead to the development of diabetic ketoacidosis. This may be caused by an infection, vomiting or diarrhoea. c) I would tell her that there are increased risks of illness and death to the fetus. However, these risks are less if there is good control of her blood glucose. Maternal hyperglycemia leads to high levels of blood glucose. This results in the fetal insulin producing large quantities of insulin (hyperinsulinemia) and fetal hypoglycemia. There is also an increased risk of hypocalcemia and hypomagnesemia. If the blood glucose is uncontrolled, there is an increased risk of miscarriage. But if there is good control of the blood glucose, there is no risk of miscarriage. The fetus is also at risk of congenital anomalies such as sacral agenesis, neural tube defects and cardiac anomalies. Maternal hyperglycemia increases the risk of the fetus developing macrosomia. This may lead to shoulder dystocia at vaginal delivery or an elective caesarean section. There is an increased risk of intrauterine growth retardation (IUGR). There is an increased risk of the fetus developing hypoxia and acidosis. There is an increased risk of stillbirth.
		Posted by Malar R. Fri Jul 13, 2007 07:25 am
Assessment starts with establishing the duration of her diabetes, her insulin regime, her blood glucose levels in her diary and enquiring about any pre existing complications secondary to diabetes such as recent diabetic keto acidosis episodes,retinopathy, previous laser treatment, nephropathy,and need for dialysis. The above will give an indication of the severity of her diabetes and provide an insight into current glucose control. It is also important to ensure that she is under the care of a Diabetes physician , dietician and specialist nurse already and if not she should be referred to them as soon as possible along with a midwive specialising in diabetes. Her previous obstetric history, if existent ,should be enquired as previous complications such as stillbirths, preeclampsia, shoulder dystocia and caesarean section require specific input in this pregnancy. A baseline HbA1c , renal function test (Us and Es) and liver function test should be done to check current diabetes control and kidney and liver function. In the presence of poor diabetes control, she should be advised to defer pregnancy annd use appropriate contraception until better control. Her rubella status should be checked and if negative, she should be immunised and advised against pregnancy and use contraception for 1 month.This is to prevent risk of congenital rubella syndrome if she contracts rubella in pregnancy. Her BP should be checked and urine checked for proteinuria to look for preexisting hypertension and nephropathy. A 24 hour urine can be sent to look for microalbuminuria.Fundoscopy should also be performed to assess for retinopathy.Her weight should be checked and if overweight, the dietician shouldbe involved. Folic acid should be started if she is ready to start conceiving to reduce the risk of neural tube defects. Her risks if pregnant include recurrent miscarriages if poor diabetes control, preterm delivery(could be iatrogenic due to maternal/fetal concerns),worsening retinopathy and nephropathy(potentially reversible), difficulty in controlling blood sugar resulting in hypoglaemia or diabetic ketoacidosis especially in the first trimester in the prsence of hyperemesis.pre eclampsia. need for assisted delivery caesarean section or instrumental delivery and recurrent urinary tract infections or thrush. The fetal risks include congenital malformations including heart defects, sacral agenesis and neural tube defects, intrauterine growth restriction, prematurity, respiratory distress syndrome, birth injury due to shoulder dystocia especially if macrosomic and risk of stillbirth.Postnatally, baby can have hypoglycaemia and need to be in special care.
		Posted by Idris O. Fri Jul 13, 2007 12:43 pm
a) History of polyuria, polydipsia, polyphagia and weight loss to assess the degree of control of diabetes mellitus. Any previous episodes of hypo/hyperglycaemic crisis or admissions for DKA will also be helpful. Ask for any complications of diabetes mellitus like current treatment for coronary heart disease , hypertension, nephropathy, neuropathy and retinopathy which may worsen with pregnancy. Enquire about her obstetric history, previous pregnancies and number of children, miscarriages, previous big baby, congenital malformation and stillbirth at term which may suggest the degree of control in previous pregnancies. Ask for symptoms of hypothyroidism with weakness, lethargy and cold clammy extremities or current treatment for thyroid disease because of the close relationship between both disease and its effect on fertility and pregnancy. Examine for BMI as morbidly obese diabetic >35 are more likely to have difficult diabetic control in pregnancy due to increase in insulin requirement in pregnancy. Perform an opthalmic examination checking the optic fundi for retinopathy, neurologic examination for peripheral neuropathy and renal examination checking the renal angles for tenderness suggestive of pyelonephritis. Investigations will include urinalysis for proteins/leuccytes suggestive of UTI or nephropathy, glycosuria which may suggest the degree of control of diabetes mellitus. HbAic >6.5% will determine the degree of control in the previous 4-6wks and her home blood glucose monitoring and insulin dose will also determine her diabetic control looking for FBS < 5.5Mm/l and 2hPP <7.5Mm/l. Renal assessment is undertaken with U+Es+creatinine and a creatinine clearance. 24h protein estimation may be done to quantity proteinuria and determine the degree of renal impairment. A thyroid function test is performed to check for hypothyroidism. An ECG, cardic enzymes and cardiac ECHO will confirm coronary heart disease. This assessment would identify those diabetics with significant contraindications to pregnancy if BUN >30mg/dl, low creatinine clearance or coronary heart disease and the need to offer contraception. b) Poor control with consequence of hypo/hyperglycaemic crisis and risk of DKA. Increased risk of polyphagia with worsening obesity and risk of coronary artery disease and thrombo embolism. Recurrent UTI with risk of pyelonephritis and renal failure. Increased risk of monilial infection and difficult treatment. Nephropathy and retinopathy more likely to get worse in pregnancy despite photocoagulation treatment for retinopathy. Increased need for caesarean section with maternal morbidity and mortality from anaesthetic and operative risks due to poor control in pregnancy. Increased risk of 3rd/4th degree tears and PPH. c) Fetal risks include congenital malformation like neural tube defects, cardiac, musculoskeletal and caudal regression syndrome with poor control in the first trimester. This increases the risk of spontaneous miscarriage. Poor control in the 2nd half of pregnancy increases risk polyhydramnios.premature delivery, RDS and big baby. In labour there is difficulty during delivery with risk of shoulder dystocia, Erbs palsy, perinatal morbidity and mortality compared with non diabetics. Post partum has increased risk of hypoglycaemia, hypocalcaemia,hypomagnaessaemia,polycythaemia, NNJ, need for respiratory support and neonatal admissions. Overall have an increased perinatal mortality and morbidity.
		Posted by Mohammad H. Sat Jul 14, 2007 12:07 am
A 32 year old insulin dependent diabetic is planning a pregnancy and attends the pre-conception clinic. (a) Justify your clinical assessment and investigations [9 marks]. (b) What will you tell her about the risks to her health? [5 marks] (c) What will you tell her about the risks to her fetus? [6 marks] History about duration of the disease and how much her blood sugar is controlled and the dose of insulin she is receiving as controlled blood sugar is associated with less complications in pregnancy . Any complications as diabetic retinopathy or nephropathy as these should be treated before pregnancy. Previous obstetric history ,fetal complications , mode of delivery and any complications during pregnancy. Symptoms of UTI,retinopathy to be treated before pregnancy. Assessment of BMI as if she is overweight , reduction of weight is to be tried before pregnancy.Fundal examination for retinopathy and chest examination to rule out chest infection . Urine analysis for sugar , ketone bodies and microbiological examination. Assessment of fasting and postprandial blood glucose.Assessment of glycosylated haemoglobin gives idea about the control of blood sugar in the previous 12 weeks and it is ideally to be 7%.Urea and electoytes and creatinine clearance to assess the kidney function before pregnancy. About the risks to the patient health, I will reassure her that with well contolled diabetes the effect of pregnancy on her health is minimal . Risks include difficulty in control of blood sugar and need for increase the dose of insulin specially in the second half of pregnancy and increased risk of diabetic ketoacidosis as well as increased risk of hypoglycaemia and increased risk of hospial admission for dose adjustement of insulin and for treatment of complications.There is increased risk of miscaariage in cases of uncontrolled IDDM . There is increased risk of diabetic nephropathy and retinopathy that is usually reversible after pregnancy. The patient is more prone to pre-eclampsia and regular antenatal assessment of blood pressure and proteinuria is mandatory.There is increased risk of operative vaginal delivery and caesarean section . About the risks to the fetus,there is increased risk of structural abnormalities as neural tube defects that can be reduced by 5 mg folic acid given prophylactically 12 weeks before pregnancy untill 12th week of pregnancy ,there is increased risk of congenital cardiac problems and sacral agenesis.There is difficulty in interpretting serum screening tests for congenital anomalies in diabeticsso, anomaly scanning should be done at 20-22 weeks gestation and seriual growth scans should be offered..There is increased risk of polyhydramnios,PROM, cord prolapseand preterm deleveries with its consequences.There is increased risk ofmacrosomia and intrauterine fetal death in the last month of gestational age .the fetus is more prone to trauma during labour,incresed risk of shoulder dystocia and neonatal hypoglycaemia, hypocalcaemia and hypermagnesemia.
		Posted by Sabahat S. Sat Jul 14, 2007 03:23 am
A) The patient should explained, that due to the inherent nature of her condition ( IDDM )it willbe a high risk pregnancy. The severity of the disease is assessed by taking a good history, examination of the patient & relevant investigation MSU for ME, C/s is done, CBC, blood sugar profile is done LFT & KFT serum electrolytes is done to rule out any renal involvement. Any preexisting anaemia, hypertension, UTI is treated. Opthalmic examination is done to rule out retinopathy. The pre pregnancy weight should be optimised by appropriate dietary modifications.She should be referred to a Dietician & physician if required. The dose of insulin should be adjusted to optimize the glycaemic control, as the pre pregnancy & early pregnancy glycaemia is responsible for most of the developmental malformations.She should be given advise about adhering strictly to her insulin dose & dietary advise & not to experiment with her diet,which will have ramifications with the future pregnancy. Life style modifications in form of daily moderate exercise, maintaining an optional weight, avoiding smoking, alchohol., Optimisation of her diabetic condition should be sought by referral to a physician if required, with possible adjustment of her insulin dose ( & other medications ) in case her diabetes is not stabilized or not well in control, she should strongly be advised, not to attempt a pregnancy till good glycaemic control & optimization of disease status is acheived. Appropriate contraception should be advised & supplied to her till such time.Folic acid 2mg is advised daily. Varicella immunity should be tested, and if not immune, should be vaccinated. She should also be screened for HIV,‎Hepatitis-B,C, syphilis. B) She will be at risk of detorioration of her glycaemic control & worsening of her diabetes during her pregnancy. There is a risk of development of preeclampsia,onset or worsening of nephropathy,retinopathy. she may have difficulty in maintaining blood glucose at optimal level, which may fluctuate widely due to the pregnancy physiology. She may require an increase in her insulin dose. All this will require frequent & regular antenatal visits & a close followup of her pregnancy with intense fetal surveillance. She is at risk of prolonged labour due to fetal macrosomia, induction of labour; with all the inherent complications & a high risk of CS.Even in case of delievering vaginally, she may sustain 3rd or 4th degree perineal trauma due to the large fetal size, or instrumental delivery.There is also a risk of postpartum sepsis. c)The fetus will be at risk of miscarriage, missed miscarriage, congenital malformations are more common in diabetic pregnancy ( 6 - 7 % in diabetic preg. as compared to 1 % in background population ). The baby may be growth restricted, or macrosomic, & therefore regular followup & surveillance with growth scans, BPP & fetal dopplers will be required. Unexplained IUFD at or near term is more common in diabetic pregnancies even with good glycaemiccontrol. There is a risk of PPROM, preterm labour with all its inherent risks of RDS, IVH & necrotizing enterocolitis, cerebral palsy & neurodevelopmental delay. The labour could be dysfunctional due to the large fetal size, with high risk of emergency CS. There is a risk of prolonged labour ending up in a difficult ( may be instrumental vaginal delivery ) with the high risk of shoulder dystocia,erbs palsy, fetal abdominal trauma.
		Posted by Fahima A. Sat Jul 14, 2007 04:27 am
a) The approach would be multidisciplinary, including her diabetic physician, GP, diabetic nurse and the obstetrician. The severity of her diabetes needs to be assessed taking a detailed history , examination and relevant investigations regarding her Glycaemic control (symptoms, home blood glucose monitoring and recent HbA1C results), complications (cardiac, renal function and opthalmoscopic examination can be checked from her clinical notes) as is the drugs review (insulin, its type, dose and frequency, antihypertensive drugs that may need to be changed). Past obs history should be taken which includes any complication, whether the pregnancyies were complicated by miscarriage, anomalies, IUD, mode of deliveries and whether she is currently on contraceptive should be noted. Effective contraception should be advised till control of the DM and it?s complications, Rubella immunity would be checked and immunized as needed and folic acid 5 mg daily will be prescribed to reduce NTD risk in the fetus. Examination would include her blood pressure and opthalmoscopic evaluation by an opthalmologist. Investigations will include, Hb A1C ( if 6%, recent glycaemic control is favourable), preprandial and post prandial blood glucose (if < 5.5 and < 7.5 mmol/l, is reassuring ) to check her status of glycaemic control. The risks of congenital anomaly is 5% if HbA1C is <8% and rises to 25% if HbA1c is >10%. Mid stream Urine for infection, and protein would be checked to assess renal function. Renal function tests will also include urea, creatinine and electrolytes. If the creatinine level is >125micromol/L, pregnancy should be advised against. Her cardiaovascular status would be assessed by a cardiologist, poor cardiac function should be corrected before conception to improve outcome. b) She would be told regarding the risks of pregnancy to her health that it depends upon the prepregnancy status, degree of glycaemic control, presence of rtinopathy and nephropathy and cardiaovascular status. Her degree of glycaemic control, renal, ophthalmologic and cardiaovascular status may deteriorate during pregnancy, delivery and puerperium. She is at increased risk of having hypo and hyperglycemia and diabetic ketoacidosis. She may need hospital admission for glucose control. If poorly controlled,she may suffer from infertility and the pregnancy may be complicated by miscarriage, polyhydramnios, preterm delivery, and there is a >50% increased risk of delivering by caesarean section. Vaginal delivery may be complicated by shoulder dystocia. Her Down?s screening tests will be affected by her diabetes. She would be reassured that maternal diabetes does not increase the risk of having chromosomal abnormality over the background population. There is increased risk of her developing pre eclampsia. There is an increased risk of vaginal canandiasis, urinary tract infection and puerperal sepsis. wound infections are also more common in diabetics. The discussion should be supported by information leaflets and further appointments if necessary. C) Regarding the risks to the fetus, she would be told that, these also depend on her glycemic control status at conception and throughout the pregnancy, and if well controlled the risks are similar to the background population. However, if poorly controlled, the fetus may suffer miscarriage. Congenital anomalies are 2 to 4 times more and include skeletal, neural tube defects, cardiac defects and caudal regression syndrome, and intra uterine death. Besides, the baby may be macrosomic and may suffer from preterm delivery, birth injuries, Erb?s or Klumpke?s pulsy due to difficult delivery complicated by shoulder dystocia. If her renal function is affected by diabetes there may be IUGR. The baby of the diabetic mother is at increased risk of complications like transient tachypnoea of the newborn, hypoglycaemia, hypomagnesimia and jaundice. The baby?s condition may necessitate SCBU admission. Despite the increased risks, she has the chances of having a normal delivery of a healthy baby. The woman should be supplied with information leaflets regarding IDDM and pregnancy.
		Posted by Saad A. Sat Jul 14, 2007 09:53 pm
The clinical assessment is needed to assess the pre pregnancy and organ complications of Diabetes Mellitus like retinopathy,nephropathy and neuropathy and advice for contraception is given if they are present. There is need of multidisciplinary approach i.e obstetrician, diabetiologist, dietician, neuro physican, diabetic nurse and GP. Detailed history is obtained from the patient regarding any history of still birh, congenital anomalies, macrosomia, polyhydroamnios and shoulder dystocia in previous pregnancy. Family history is acquired and present status of signs and symptoms are questioned like polyuria, polydispia and increased frequency of urine. Opthalmic examination done to assess her severity. Her BP and BMI is checked. Visual examination is carried out to exclude retinopathy, leg examination for ulcer. There is a need for full blood glucose profile assessment and adjustment of insulin in consultation with the diabetiologist, obstetrician and physician in close collaboration. Patient is advised for frequent medical and fetal monitoring antenatally. Dating scan is needed for exact gestational age at 10-12 weeks. Anomaly scan is needed at 18-20 weeks for exclusion of structural and congenital anomalies. Cardiac scan at 22-24 weeks to exclude cardiac abnormalities .Serial growth scan is require if there is risk of pre eclampsia and also of monitoring of macrosomia factor as associated with IDDM.. It is advised forthnightly from 24-48 weeks depending on severity . Doppler USG and CTG will be needed. Serum screening for NTD is advised (HCG, alpha feto protein,u) full blood count, s.urea and electrolytes, liver function tests are needed to evaluate as there is risk of pre eclampsia and for knowing the prior status for early detection of complication of IDDM. Adequate control of blood sugar is required throughout the pregnancy with dose adjustment. Patient is given education about the signs and symptoms of hypoglycaemia and usage of glucose. b. There is risk of development of complications of diabetes mellitus like nephropathy, neuropathy and retionopathy. The chance of pre-eclampsia is also increased. There is increased risk of UTI and candidiasis. She will be told about the risk of hypoglycaemia and shall be advised to report immediately to GP .Relative shall also be given education regarding this. Education of glucose intake is given and education of s/c injection of insulin will be given. There is a risk of shoulder dystocia that should be told.and increased risk of perineal tears. C. there is risk of development of congenital abnormalities like caudal regression syndrome, neural tube defects, cardiac defect in the fetus for which she will be advised folic acid 5mg once daily. There is a risk of IUGR in the fetus if pre- eclampsia develops so serial scanning is advised. The most common fetal risk is macrosomia. Foetus with this abnormality is increased risk of preterm delivery, prematurity so early reporting and frequent visits are needed. Then the patient is told about the post birth risks like RDS, hypoglycaemia, hypocalcaemia ,jaundice so neonatologist is needed at the time of delivery for the assessment of these and other congenital abnormalities.
		Posted by Reena M. Sun Jul 15, 2007 12:08 am
Optimal diabetic control preconceptionally is very important for the optimal pregnancy outcome . Diabetis mellitus is is a chronic disease which has its effect on both microvascular and macrovascular systems.Her blood sugar control , need to be optimal , with aim of fbs <6mmol/l and ppbs at <7.1mmol/l. HBA1C <6%. Raised HBA1C 10% increases the congenital malformations to 35%.Renal function need to be checked .RFT should be checked. If she is hypertensive and on antihypertensives , like ACE inhibitors - change of antihypertensive , is advised at diagnosis of pregnancy. Baseline ecg, and lipid profile to assess cardiac function is required[macrovascular involvment] Fundoscopic examination[microvascular] to assess retinopathy is important .Proliferative retinopathy will progress during pregnancy Her rubella status enquired and immunised if not done previously .Folic acid periconceptually is offered to minimise the risk of neural tube defects .I will enquire about her diet history and advise given regarding proper diet and need for tighter control of blood sugar during preganancy . Healthy habits advised, like stopping smoking and alcohol . Home blood sugar monitoring advsied There is increased chance of hypoglycemia during pregnancy especially during early pregnancy.With advancing gestation , need for insulin increases and 6 point glycemic profile with insulin adjustment is advised. soluble ,and intermediate acting insulins are used during pregnancy. With 1% fall of HBA1C , there is 33 % chance of hypoglycemia . Diabetic keto acidosis occurs around 1% of pregnant woman with uncontrolled DM.There is increased chnace of infections , especially UTIS and vulvovaginal candiasis with DM.Severe diabetic nephropathy , prior to pregancy may worsen to End stage renal disease. mild and moderate nephropathy changes revert after pregnancy.There is 10 % risk of progression of retinopathy . But proliferative retinopathy , worsen in 50%.DM mother shoud be monitored for increased occurance of Pregnancy induced hypertension DM mother have incresed risk of operative deliveries with 60% lscs rate and its morbidity. Fetus of DM mother is at risk of 10 % chance of congenital malformations. Cardiac , Neural tube defects are common. Sacral agenesis is specific to DM , but rare, with good control. Dm mother needs more frequent monitoring , Macrosomia is prevalent - in 30% . and polyhydramnios in around 15%. Pre term delivery , Operative delivery are increased Shoulder dystosia is incresed in fetus of diabetic mothers.. Neonate is also prone to complications, respiratory distress syndrome , hypoglycemia , hypocalcemia , hyperbilirubinemia , polycythemia .
		Posted by Kiran R. Tue Jul 17, 2007 12:18 pm
a) I will begin my clinical assessment of this lady with detailed history. Which include the duration of IDDM , her treatment and management in diabetic clinic under consultant physician and diabetic nurse and her punctuality of keeping her appointments. It is very important to liaise with her physician, nurse, dietician and gp to give her appropriate care. I will ask about the past obstetrics history regarding complications of diabetic pregnancy such as miscarriages ,congenital abnormalities in new born, macrosomia , IUGR ,pre term delivery ,still birth and c sections. In case of her first chance of getting pregnant, I will take her menstrual history to know the likely hood of ovulation and chances of conception. I will ask about any renal, cardiovascular and eye problems in addition to her medical and surgical history, as the involvement of these systems is common in diabetics. The history of immunization, contraception and medication is equally important .if she is not checked and immunised against rubella then she should be immunised and advised to take contraception at least for three months. Her existing medications should be checked for suitability during pregnancy or referred to concerned physician or GP.her insulin requirement, dosage, and compliance with treatment should be taken into account. She should be weighed and her body mass index will be calculated and recorded as it is important to control the weight gain during pregnancy .High BMI is associated with foetal macrosomia and shoulder dystosia .Her blood pressure must be measured to know the baseline reading before pregnancy. Urine analysis by dipstick for signs of infection. 24 hours urine collection for proteins should be done to have a baseline record of kidney function. I will check HbA1c to know the control of her blood glucose in recent past. FBC, CRP and ESR should be done to rule out any infection and to get baseline Hb .renal and hepatic function tests must be done to know the state of the systems before pregnancy. She should be referred to ophthalmologist for fundoscopy to know the presence or extant of retinopathy as it can detoriate rapidly in pregnancy. b) I will inform her about the detritions of diabetes during pregnancy she might need increment in her insulin doses. her blood glucose levels might be difficult to control and result in episode of hypoglycaemia and keto acidosis need early recognition and emergency treatment .she herself and her partner will be given education and information to deal prevent and deal with the situation in future .I will tell her about the detoriarion of retinopathy ,neuropathy and nephropathy if they are already present or detected first time in pregnancy .she will be explained the increased risk of pre aclamsia ,urinary infections and polyhydromnios.the incread possibility of c section .I give her written information and tell her that good glycemic control and increased surveillance in antenatal period give good outcome in term of her health. c)The risks inlove to the fetus are increased incident of 1st trimester miscarriage ,preterm labour and still birth .the risk of congenital abnormalities increased to one to ten fold .These include neural tube defect ,cardiac and renal abnormalities, and caudal regression syndrome. There is high risk of intra utine growth restriction of fetus, and macrosomia .she must be reassured that majority of foetus born normal and health without any defect .with good control of diabetes and proper antenatal care chances of fetal problems can decrease to many fold .she should be optimist about outcom
		Posted by Jancy V. Tue Jul 17, 2007 06:48 pm
A 32 year old insulin dependent diabetic is planning a pregnancy and attends the pre-conception clinic. (a) Justify your clinical assessment and investigations [9 marks]. (b) What will you tell her about the risks to her health? [5 marks] (c) What will you tell her about the risks to her fetus? [6 marks] (a) Preconception period is the ideal time for assessment and counseling of patients with IDDM. I will ask her about the age of onset of the disease because long standing diabetics are more prone for end organ damage. I will enquire the treatment history, and how were her recent blood glucose levels, because pregnancy can be advised only if the glycemic control was good. I will also enquire about symptoms suggesting renal damage, features suggestive of cardiac , liver disease, retinopathy, neuropathy, to rule out end organ damage or failure. Besides, I will go through her medical records and get details of her treatment so far. Physical examination should include general examintaion to look for pallor, edema, skin lesions. Systemic examination of respiratory and cardiovascular systems should be done. These patients should also have an ophthalmology consultation for fundoscopy, to rule out retinopathy. Investigations needed are blood sugar profile , with 6 readings a day - fasting, pre and post meal blood glucose levels. Glycosylated Hb levels should be done as it gives indication of glycemic control in recent months. An elevated HbA1C more than 7.0 is associated with a higher chance of congenital anomalies for the fetus. I will also ask for a full blood count, renal and liver function tests as these may suggest organ failure. Echocardiography will be done if there is any evidence of cardiovascular disease. (b) I will tell the woman that pregnancy in IDDM is high risk and needs special care. Pregnancy as such is a diabetogetnic state and adjustment in insulin doses may have to be made frequently to ensure glycemic control. She is more prone for miscarriage . If glycemic control is not optimum, she has the risk of ketoacidosis and hypoglycemia , symptoms of which are masked by physiological changes of pregnancy. She is also prone for development of hypertension and pre eclampsia, preterm labour, premature rupture of membranes. Diabetic mothers tend to have macrosomic babies, which increases her intrapartum risk, and can predispose to prolonged labour, difficult delivery, shoulder dystocia and postpartum hemorrhage. The chance of cesarean section is around 50% in diabetic mothers. Pregnancy can lead to worsening of retinopathy and nephropathy. (c) Fetus of diabetic mother is likely to have a higher risk of anomalies if the glycemic control during preconception and conception period is sub optimal. In addition, there is increased risk of miscarriage. The fetus maybe born premature, and is more prone to infections. The fetus tends to be macrosomic, hence there is increased risk of birth injuries especially Erb?s palsy due to shoulder dystocia. There is delayed lung maturity in fetuses of diabetic mothers.and higher rates of iatrogenic prematurity.
		Posted by Natalie P C. Wed Jul 18, 2007 03:19 am
A I would start by getting a good history to assess how well her diabetic control is and whether she has developed any complications due to her diabetes. I would ask what her blood sugars are usually, whether she has any blurred vision to suggest retinipathy, any edema to suggest renal compromise, any leg pain to suggest vessel disease or neuropathy, chest pain to suggest ischaemic heart disease and whether she has hypertension. I would do this because if she is a brittle diabetic then control in pregnancy may be difficult. Also she needs to optimise her diabetic control pre-pregnancy, at the time of conception and in the 1st trimester to reduce the risk of congenital anomalies. I would check her blood pressure and dipstick for protein as if present they increase her risk of developing pregnancy induced hypertension and pre-eclampsia. I would check a HbA1c, renal function tests, creatinine clearance and 24 hr protein collection and nephropathy can worsen in pregnancy and increase the risk or pre-eclampsia. I would also refer her for ophthalmology assessment as retinopathy can worsen in pregnancy and is best treated pre-pregnancy. Is she does suffer with specific symptoms that they will warrant further investigations like check pain and a cardiology referral. If her diabetes is very severe and she has severe complications like renal insufficiency (Cr>250mmol/L) or severe ischaemic heart disease we ay advise against pregnancy. B I would inform her that her insulin requirement with increase in pregnancy where on average it is double by term. She would therefore need to do more regular home blood glucose monitoring. She would also be at greater risk of infections, like urinary tract. She is at risk of developing hypoglycaemic episodes especially in the first trimester due to tighter control and possible vomiting in early pregnancy so family members should learn how to give her glucagons. She is at risk of pre-eclampsia and this is even higher if she already has hypertension, renal insufficiency or microalbuminaemia. Retinopathy can develop for the first time or worsen in pregnancy. She is also at increased risk of caesarean section (about 67%). C I would inform her that her baby is at risk of congenital abnormalities like cardiac, neural tube, bowel and skeletal and that this is worse if her diabetes is not well controlled. She would be offered Folate 5mg daily. Her baby is also at risk of macrosomia and polyhydramnios increasing the risk of shoulder dystocia, traumatic delivery and preterm labour. The newborm can have hypoglycaemia and jaundice. Her baby is also at risk of fetal distress or being stillborn. All the risks are reduced but not eliminated when blood sugars are well controlled.