Diabetes in Pregnancy

Clinical Description

It is a group of metabolic disease characterized by hypersensitivity from defects in insulin secretion, action or both. Can be gestational or preexisting.

Signs and Symptoms

• History: Polyuria, polyphagia, polydipsia. Suspect/screen in macrosomia, unexplained IUD, Family Hx of DM, Maternal obesity, excessive weight gain

At Health Centre

Refer to the next level

At District hospital

Treatment

Goal is to maintain FBS at 6 - 8MMOl/lfor gestational

Investigations

• RBS, Hb A1C, Ophthalmic examination, baseline urine dipsticks for proteinuria, baseline renal function tests.

Note: (It is advisable to manage only uncomplicated diabetes mellitus)

Pregnancy Care

• Pregnancy counselling: diet, ideal weight, and sugar levels
• Switch to insulin if unstable on oral drugs

Antenatally

• Continue pre- pregnancy regimen if blood sugar is controlled.
• Consider in patient admission for DMS education and glucose control.
• Antenatal care every 2 weeks until 30 wks. gestation, then weekly until delivery
• Check FBS. If <6mmol/l (108 mg/dl), patient is managed by diet alone.
• If > 6 mmol/l Insulin must be started.
• If first trimester, total daily dose = weight x 0.7 units
• If second trimester, total daily dose = weight x 0.8 units
• If third trimester, total daily dose = weight x 0.9 - 1.0 units
• Given as 2/3 of total daily dose in the morning at breakfast: 1/3 Soluble Insulin and 1/3 as Long-Acting Insulin
• Given as 1/3 of total daily dose in the evening at dinner (17 hrs): 1⁄2 as Long-Acting

Insulin

• For example, for weight of 72 kgs in third trimester, give 16 units Soluble Insulin and 32 units Long-Acting Insulin at breakfast and 12 units Soluble Insulin and 12 units Long-Acting Insulin at supper.
• Ultrasound every 4 weeks

Intrapartum Management

• Elective delivery at 38 -39 weeks
• No specific treatment if labor progresses normally and quickly
• For induction, or prolonged labor: add 1/3 of her daily insulin as soluble to 1 L of Dextrose Normal Saline (DNS) and treat 40dpm
• For caesarean: skip A.M Insulin, start DNS
• Place Oxytocin in separate bag of Normal
• Saline (NS) fluid using separate IV access
• At 39 weeks’ gestation for women with well controlled blood sugar and no vascular disease.
• At earlier gestation for class D and higher, polyhydramnios, macrosomia, poor blood glucose control, Chronic Hypertension on medication or IUGR and IUD
• Caesarian delivery for EFW > 4S00 on UD.

Postnatal period

• Breastfeeding infant early and notify pediatric clinician of maternal diabetes
• Use insulin sliding scale for 5 days post vaginal delivery and then resume pre pregnancy regimen
• Treat with DNS at 3L daily post C/S until tolerating PO and then use insulin sliding scale
• Advise mothers to start diabetic diet as soon as possible.

Note: COMPLICATED DIABETES (Refer to central hospital)