TEALE FENNING

shachi · Joined: 10 Jun 2008 Posts: 16

OK guys...try this one...

What are the risk factors associated with diabetes in pregnancy? (10 marks)
How can these risks be minimised?( 10 marks)

manoj · Joined: 22 Jun 2008 Posts: 7

1. Diabetes in pregnancy could be a) pre-existing diabetes mellitus or b) Gestational diabetes mellitus(GDM). Implications with preexisting diabetes are maternal effects like exacerbation of pre-existing underlying diseases like retinopathy, nephropathy and cardiac functions mainly with underlying ischaemic heart disease.
Late pregnancy and intrapartum risks are similar with both groups a) and b) which include pregnancy-induced hypertension and pre-eclampsia. There is also risks for recurrent vulvo vaginal infections, increased possibility of obstructed labour with big babies in diabetic patients with increased incidence of operative deliveries (foreps/ventouse/caesarean section), vaginal deliveries may increase risk for perineal tears and morbidity. GDM usually resolve with pregnancy with a risk of recurrance of diabetes mellitus in later part of life and there is increased risk of recurrance of GDM with subsequent pregnancies.
Fetal risks for pre-existing diabetes include high risk of congenital abnormalities involving central nervous system(neural tube defect, holoprosencephaly, microcephaly), Cardiac (transposition of great vessesl, septal defects, situs inversus), skeletal abnormalities(caudal regression/sacral agenesis), gastrointestinal and genitiurinary abnormailites.
Late pregnancy risks are similar for preexisting and GDM with risks of polyhydramnious, macrosomia and preterm labour. Risk of traumatic deliveries and injuries associated with complications like shoulder dystocia. Risk of unexplained still birth, risk of neonatal complications like respiratory distress syndrome, jaundice, polycythemia and metabolic complications like hypoglycaemia, hypocalcaemia and hypomagnesemia.
Also associated with long term risks of childhood obesity especially if mother is associated with obesity (recent hot topic on BBC).

2. Risk reduction is the priority of Obstetritian and currently increased burden on NHS with an increase in incidence of Diabetes especially with change in life style and obesity on rise and with immigrant population (high predisposition for diabetes).
Preconceptionally it is very important to have good gycaemic control because the risk of congenital abnormalities is significantly reduced with HBA1c <8% and can be reduced to close to non diabetic population, in obese individual advice strongly to reduce weight before conception, in smokers to stop smoking and folic acid supplementation at least 12 weeks prior from conception into second trimester.
Women with preexisting condition like nephropathy/ retinopathy/ cardiac problems should have full discussion regarding the aspect of worsening of conditions and liasions with specialists(Nephrologist/ Opthalmologist/ Cardiologist)
Antenatal appointment ideally booked under Obstetitian with special interest in diabetes with a multidisciplinary team involving diabetologist/physician, diabetic nurse, dietitian, midwives.
Booking visit should record BP and urine for proteins and fortnightly BP and urine protein checks from second trimester, because of risk of preeclampsia, early detection during preganncy and treatment of hypertenion is important to reduce risk associated with the same. prepregnancy protein levels in urine would also be ideal to be documented.
It is important to document pre-preganncy insulin levels and ensure good glycaemic control to minimise both maternal and fetal risks.
Prenatal sreening should be offered for other chromosomal abnormalities even though there is no increased risk of chromosomal abnormality with diabetes but reference values for hcg etc. are different.
Treating vulvo-vaginal infection may reduce the risk of preterm labour.
Prenatal diagnosis involves offering detailed anomaly scan at 20 weeks and 32 weeks to detect anomalies and make informed choice of continuing pregnancy if anomalies detected with paediatric team involvement or choice of termination of pregnancy.
Antenatal follow up with multidisciplinary team ideally every 2 week untill 32 weeks and then weekly ANC for good glycaemic control.
Monitor for intra uterine growth restriction with growth scans and with increased risk of preterm deliveries, if before 32 weeks consider steroids with adequate gylcaemic controls (may need sliding scale insulin for steroid cover)
A mode of delivery planned ideally at 36 weeks depending on patient choice, clinical situation and size of baby should be documented, if estimated fetal weight is >4.5kg offer Caesarean secton as mode of delivery to reduce intra-partum risks.
Intrapartum good glycaemic control with sliding scale insulin, good pain relief ideally with epidural (patient choice) as increased catecholamines can cause hyperglycaemia and this in turn can cause increased fetal heart rate abnormalities.
Regular hospital drills & teaching sessions on intrapartum complictions like shoulder dystocia and postpartum haemorrhages will also reduce risk for diabetic patients.
Proper documentation of events in labour and delivery including incident form reporting and risk management can all reduce the risk.
Post natally lesser dose of insulin for preexisting diabetics and in GDM may not need insulin but will need blood sugar monitoring for breast feeding mothers inparticular because of risk of hypoglycaemia.

( This is too big an essay to finish writing in 25 minutes )
Sad

Hope I learn to write properly tommorrow at the course