DIABETES AND PREGNANCY

Dr Nancy Ngugi

INTRODUCTION

Until 1920s diabetic women seldomly become pregnant, fertility was low Those poorly controlled who became pregnant had
High mortality- 50 % diabetic coma High perinatal mortality - 40/60% Few live births - ass with congenital malformation

Insulin era
So, introduction of insulin led to Life expectancy beyond the child bearing age Fertility In number of pregnant diabetics
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PLANNED PREGNANCY

Intensive stabilisation pre-pregnancy care Reinforce education on diet and insulin adjustment Aim at random blood glucose less than 8 mmol/l As soon as pregnancy is confirmed intensify efforts to achieve normoglycaemia There should be a close cooperation with obstetrician
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PRE PREGNANCY CARE

Is a complete medical check up to make sure that the woman is healthy enough to have a baby
It is important that the pregnant women have successful outcome of pregnancy which is dependent on good diabetic control of the mother

It is important that during the first few weeks of pregnancy the blood glucose level is normal when the babys organs are developing. Very high blood glucose levels in the first 8/40 of pregnancy can cause abnormalities in the baby. Usually by 8/40 pregnancy is not confirmed, it might be too late as the baby is already formed
It is therefore important to have normal blood glucose even 6 before pregnancy

WHY IS PREPREGANCY CARE NEEDED

PRE PREGNANCY CARE -III

WHAT IS DONE

Regular weighing Urine testing for proteinuria- to check kidney function and that there is no infection Checking the lungs and heart, Blood pressure measurements If BP is raised treatment is started before pregnancy A general check of the feet, eyes etc.
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PRE PREGNANCY CARE - IV Advice given

Regular dental check ups- as even minor dental infection can cause unstable blood glucose control To know what drugs are used to control blood glucose. Most centres will stop use of OHA as this will make the baby produce too much insulin of his own. Insulin is used instead during pregnancy

Stop smoking as the baby will be starved of oxygen. Excessive alcohol should be stopped before and during pregnancy.
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DURING PREGNACY First Trimester

When pregnancy is confirmed, aim at normoglycaemia. The amount of insulin / OHA will be noted and regulated accordingly Please note- during the first week of pregnancy the symptoms of morning sickness or being under the weather may reduce the appetite. This makes the woman at risk of hypoglycaemia. She should be advised to eat small amounts and often and may need to adjust the dose of insulin / OHA
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First Trimester

See the patient weekly to achieve normoglycaemia

Cooperate with Obstetrician Admit only for obstetric reasons or when glycaemic control is not achieved
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Second Trimester

Continue treatment as above Maintain adequate dietary input Continue 2 weekly visits Admission criteria as above

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Third Trimester

Insulin requirements rise progressively Intensive control especially from 30/40 Admit at 37-38/40, early if
have obstetric indications Poor glycaemic control

Aim at planned delivery at 38 to 39 weeks , to avoid sudden unexplained IUD.

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During Pregnancy

At about 28 weeks of pregnancy, placenta secretes Human Placental Lactogen (HPL) HPL make insulin less active a result insulin requirements may increase. When the baby is born the insulin requirements go back to pre-pregnancy levels. It is advisable to do gentle exercise during pregnancy for example swimming.
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During Labour

Delivery can be planned at 38- 40 weeks of pregnancy . During labour an I.V. drip of insulin and glucose can be used to maintain normal blood glucose levels. This is because glucose is poorly absorbed from the stomach. Fetal heart rate is recorded through out labour. As with non diabetic women when labour is uncomplicated birth is normal.

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DELIVERY

Planned delivery minimizes mx problems Induction:

Start 1 Lt. 10 % dextrose + 20iu soluble insulin or 5% dextrose +10iu soluble insulin- run at 100 ml/hr Add 20 mls / 10mmol/l KCL Monitor BG 2 hourly aim at BG of 4-6 mmol/l Immediately after delivery reduce soluble insulin by 50- 70% Recommence pre-pregnancy regime with 1st meal
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Delivery - 2
Caesarian

Section:

As above, but continue glucose potassium infusion post delivery. Operation may increase insulin requirement, but demand decreases with removal of the placenta
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Post delivery

It is advisable to eat more carbohydrates and drink plenty of liquid like milk or porridge. Keep the blood glucose levels higher (6-10mmol/L) to avoid hypoglycaemic attacks while breast feeding. Babies of diabetic women are prone to hypoglycaemia in the first 48 hours of life. So give early and regular feeds
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MMC Experience

Between June 1986 and 31 August 1989, all 49 pregnant women were studied. Aim - was to determine if close supervision and cooperation with obstetrician resulted in better pregnancy outcome ANC and diabetes care was done fortnightly

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Pregnancy outcome

Incidence of diabetic pregnancy (0.3%) was comparable to most reported African series. PNM - 10% mainly in those seen late in pregnancy It was less than reports from other African centres. 13% Durban, 24% Ibadan, 25% NRB and 32% Addis. Early MX of preg. and strict BG control reduced PNM
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Treatment (MMC)

All patients on OHA were changed to insulin except one

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