Complications Hypoglycemia Premature Labour Preeclampsia
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Objectives Discuss causes, prevention strategies and treatment of hypoglycemia for those women on insulin Discuss premature labour, recognizing contractions, and action to take Discuss diagnosis and treatment of preeclampsia
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Definition of hypoglycemia 1. The development of autonomic or neuroglycopenic symptoms 2. Low plasma glucose (less than 4.0 mmol/L or 72 mg/dl) 3. Symptoms resolved by administration of carbohydrate
Cryer, Davis, Shamoon, 2003
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Risk of hypoglycemia (1 of 3) Only those taking glucose-lowering medicines or insulin are at risk Risk increases with: • • • • •
Not enough carbohydrate consumption Late or missed meal Fasting or malnourishment Too much insulin Prolonged or unplanned activity
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Risk of hypoglycaemia (2 of 3)
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Symptoms of hypoglycaemia
Canadian Diabetes Association, 2013 6
Possible consequences of hypoglycaemia
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Effect Of Hypoglycemia On Fetus
Fetal heart rate, as well as fetal movements and placental perfusion appear to be unchanged during conditions of maternal hypoglycemia in the range of 2.5 – 3.0 mmol/L (45–55 mg/dL) Coustan, 2009 Diamond, Reece et al, 1992 Nisell, Persson, et al1994 Reece, Hagav, et al 1995 8
Treatment (1 of 2)
Canadian Diabetes Association, 2013
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Treatment (2 of 2) Treatment Severe • 20 g glucose • Glucagon 1ml SC or IM; increases BG by 3 -12 mmol/L (54-216 mg/dl) over 60 min • IV dextrose- 20 to 50 ml of 50% dextrose over 2 to 3 minutes; immediate response is seen • Manage seizure- place person on their side if not too agitated 10
Follow-up management Follow-up management • Meal or snack (15 to 20 g carbohydrate + a protein source) • Next dose of insulin taken as usual if cause is known and hypo was mild • Consider reducing next dose of insulin if hypo was severe • Assess cause and prevent recurrence • Avoid BG levels < 4 mmol/L (72 mg/dL)
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Premature Labour Preterm labour in GDM â&#x20AC;&#x201C; can use steroids and tocolysis as for other pregnancies Preferably avoid betamimetic as tocolytics Nifidepine is a good choice Both steroids / tocolytics can push glucose up so need to monitor closely and cover with insulin / increasing dose of insulin Rule out UTI as a risk factor for preterm labour 12
Preeclampsia • Women with GDM are at increased risk of preeclampsia; this is partly due to the increased insulin resistance • It is possible that this increase could be accounted for by the fact that their age and BMI predispose them to GDM as well as hypertension. • Monitor BP & urine albumin every visit Hollander 2007 13
Delivery
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Objectives Discuss when to deliver infant Discuss options for inducing labour Discuss implications of Caesarian section
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Timing of delivery – the same for all? •
Women with diabetes before pregnancy are at increased risk
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In GDM perinatal mortality rates lower
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If insulin requiring, best to use approach similar to pregestational DM
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GDM managed on diet and exercise alone possibly not at any greater risk from baseline
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Depends on severity and duration of diabetes as well as co morbidities
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Timing of delivery TOO EARLY
LATE?
RDS
LATE IUFD
PREMATURIT Y
MACROSOMIA
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Consider…. Gestational specific risks for still birth continue to fall up to 38 weeks but increase slightly over 40 weeks In insulin dependent women most would plan delivery 38 - 39 weeks Between 38 and 39 weeks No difference in incidence of cesareans More larger babies in one study There is as yet not enough evidence that induction in diabetic pregnancies prevents fetal macrosomia
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In diet controlled GDM women most would be comfortable to 40 weeks With good control and reassuring tests of well being some centres go on to 41 weeks
Patel, Steer, Doyle et al. 2003 19
Mode of delivery Matter of choice High section rates – 30 – 80% averaging 50% in many centres Vaginal delivery is possible and safe Previous obstetric history EFW Other clinical factors
Induction of labour is a safe option
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Monitoring labour Labour is a time of unpredictable glucose and insulin demands – risk of hypoglycemia Sliding scale / infusion Maintain plasma glucose below 110 mg/dl to avoid maternal hyperglycemia and subsequent foetal hypoglycemia
Careful intrapartum FHR monitoring Pay attention to second stage – slow progress is a red flag Caution with instrumental delivery Be prepared for shoulder dystocia Jovanovic L. 2005 21
References COMPLICATIONS Canadian Diabetes Association Expert Committee. Canadian Diabetes Association 2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Can J Diab 2013;37(suppl 1):S69-71 Coustan, D, Glob. libr. women's med., (ISSN: 1756-2228) 2009; DOI 10.3843/GLOWM.10162 Cryer P.E. Davis, S.N. Shamoon, H. Hypoglycemia in diabetes. Diabetes Care, 2003;26(6):1902-1912 Diamond MP, Reece EA, Caprio S et al: Impairment of counterregulatory hormone responses to hypoglycemia in pregnant women with insulin-dependent diabetes mellitus. Am J Obstet Gynecol 1992;166:70-77 Hollander M, Paarlberg KM, Huisjes AJM, 2007 Gestational Diabetes: A Review of the Current Literature and Guidelines Volume 62, Number 2 Obstetrical and Gynecological Survey Nisell H, Persson B, Hanson U, et al: Hormonal, metabolic and circulatory responses to insulin-induced hypoglycemia in pregnant and nonpregnant women with insulin-dependent diabetes. Am J Perinatol 1994;11:231-236 Reece EA, Hagay Z, Roberts AB et al: Fetal Doppler and behavioral responses during hypoglycemia induced with the insulin clamp technique in pregnant diabetic women. Am J Obstet Gynecol 1995;172:151-155. Saleh M., Grunberger, G. Hypoglycemia: A cause for poor glycemic control. Clinical Diabetes, 2001;19(4):161-167. DELIVERY Jovanovic L, Knopp RH, Kim H, et al. Elevated pregnancy losses at high and low extremes of maternal glucose in early normal and diabetic pregnancy: evidence for a protective adaptation in diabetes. Diabetes Care 2005; 28:1113. Patel RR, Steer P, Doyle P, Little MP, Elliot P. Does gestation vary by ethnic group? A London-based study of over 122000 pregnancies with spontaneous onset of labour. Int J of Epid. 2003;33:107-113.DOI: 10.1093/ijc/dyg238.
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