Pregestational and Gestational Diabetes

Transcription

1 Pregestational and Gestational Diabetes Francis S. Nuthalapaty, MD Greenville Health System University of South Carolina School of Medicine - Greenville

2 Case History 30 year old black female presents to an internist for a general medical examination 2 years ago her family doctor started her on insulin for Type II Diabetes Mellitus. She admits that her glucose control recently has not been good because she has not been measuring her glucose levels or following a diabetic diet.

3 Question How is diabetes classiaied in pregnancy?

4 White Classification of Diabetes in Pregnancy Class A1 Gestational diabetes Onset in pregnancy Diet controlled Class A2 Gestational diabetes Onset in pregnancy Insulin controlled

5 White Classification of Diabetes in Pregnancy Class Age of Onset (years) Duration (years) Vascular Disease B Over 20 < 10 None C None D < 10 > 20 Benign retinopathy F Any Any Nephropathy R Any Any Proliferative retinopathy H Any Any Heart T Any Any Transplantation

6 Question Based on the White ClassiAication, how should this patient be classiaied?

7 Problem List Diabetes Age of onset = 28 Duration = 2 years Vasculopathy = unlikely with < 2 years duration

8 Question What additional tests could be ordered to further deaine this patient s diabetic disease status?

9 Tests for Vasculopathy Renal: 24 hour urine protein Protein / creatinine ratio Ophthalmic Fundoscopic examination Cardiac: EKG

10 Question What should you counsel the patient are the maternal, fetal, and neonatal risks of diabetes in pregnancy?

11 Maternal Risks Organ System Renal Ophthalmic Nervous Cardiovascular Endocrine Nephropathy can worsen during pregnancy, but no long term sequelae Retinopathy can be accelerated Neuropathy may worsen Increased risk for preeclampsia; not related to glycemic control Increased risk for ketoacidosis

12 Frequency of Preeclampsia in Pregnancies Complicated by Type 1 DM Class Preeclampsia % B C D F Total

13 Diabetic Ketoacidosis in Pregnancy Maternal fasting hypoglycemia Increasing fetal glucose needs Hypoglycemia + Hypoinsulinemia => Hyperketonemia Increased insulin resistance Increasing levels of human placental lactogen, cortisol, prolactin

14 Fetal Risks Spontaneous abortion Preterm delivery Congenital malformation Stillbirth Altered fetal growth Hydramnios

15 Neonatal Risks Hypoglycemia Hypocalcemia Hyperbilirubinemia Respiratory distress Polycythemia

16 Question The patient admits to being in poor diabetic control during the Airst trimester. What is her risk of having an infant with a congenital malformation? What are the most common malformations in the diabetic pregnancy?

17 Common Malformations Cardiovascular (5 fold increased risk above baseline 8/1000 live births) CNS (10 fold increased risk above baseline 1-2/1000 live births) Transposition VSD ASD Hypoplastic left ventricle Situs inversus Anencephaly Encephalocele Meningomyelocele Holoprosencephaly Microcephaly

18 Common Malformations Skeletal GU GI Caudal regression Spina biaida Absent kidneys Polycystic kidneys Double ureter TE Aistula Bowel atresia Imperforate anus

19 Question What tests can be ordered to screen this fetus for congenital anomalies?

20 Malformation Screening Tests HgA1C MSAFP Targeted ultrasound Fetal Echo

21 Question Considering these maternal/fetal risks, what type of management strategy would you like to implement for this diabetic patient?

22 Management Strategy Baseline assessments Optimize glycemic control Screen for fetal anomalies Fetal surveillance Assess growth Antepartum testing in 3 rd trimester Delivery planning Postpartum contraception

23 Questions?