TEALE FENNING

farha · Century Club Joined: 18 May 2007 Posts: 157

Q) A 38 yrs old woman with IDDM presents to the ANC for advice.she
wants to attempt first pregnancy.She is poorly controlled diabetic .a).What advice you would give her(b) Justify the interventions you will undertake to ensure the best possible outcome if she presents in spontaneous labour at 38 weeks.(c)What are the expected neonatal complications.

a) Pregnency in a woman with diabetes especially when it is poorly controlled is a high risk pregnancy so requires multidisciplinary approach involving a senior obstetrician , diabetologist ;dietitian diabetic nurse and senior midwife along with the active participation of patient herself. Patient should know that all the complications of diabetes increases manyfold if glycemic control is poor. .
Prepregnency counseling in this case will provide chance to optimize diabetic control
and assessment of presence and severity of complications. This is best achieved by taking a detailed history ( duration of diabetes ,associated hypertension peripheral neuropathy , leg ulcers, visual loss and drug therapy )examination( including blood pressure measurement and specially fundoscopy for retinopathy) and investigations(urine dipstix for proteinuria, and 24 hours protein if proteinuria , serum creatinine; urea and electrolytes for nephropathy.
In the presence of complications and poorly controlled diabetes pregnancy should not be recomended and effective contraception is advised and patient should be referred to appropriate specialists .Drug therapy may need modification especially if she is taking ACE inhibitors as ACE inhibitors effects fetal kidney and are not recommended in pregnancy..
Patient should be told about effects of diabetes on pregnancy like (congenital anomalies, fetal macrosomia,/IUGR,hypertensive disorders , preterm delivery . increased risk of c/s.)
She must know that pregnancy increases the requirement of insulin, deteriorates certain complications like retinopathy and increases the risk of hypoglycemia
She needs to know the implications of pregnancy care (more frequent visits, detailed anomaly scan and regular growth scan.).Her age related risk of chromosomal anomalies should be discussed and appropriate screening test should be offered.
Folic acid 5 mg should be advised to prevent neural tube defects along with the avoidance of smoking and alcohol .Rubella status needs to be tested. If she is negative then should be immunized.
Written information and support group contacts should be provided
b)Woman ,s antenatal record for growth and planned mod of delivery need to be reviewed and if c/s is planned in the notes for fetal macrosomia then emergency c/s is recommended otherwise vaginal delivery is anticipated.
.Intrapartum managementof diabetes should be according to the unit protocol and insulin sliding scale should be set up with 10% dextrose running at 100ml/hour .Maternal blood glucose concentration is kept between 4 -6mmol/l by checking glucose concentration hourly and adjusting insulin dose accordingly.
Continous electronic fetal monitoring is recommended as there is an icreased risk of
Fetal distress
Regional anesthesia is ideal for pain relief but maternal wishes should be explored and respected .Patrtogram is plotted and low threshold is kept forc/s if progress is slow . Oxytocin should be considered for primary dysfunctional labour but this should be discussed with a senior colleague.
As there is risk of shoulder dystocia so senior obstetrician ,s presence be ensured. Neonate is at increased risk of respiratory morbidity and undetected congenital abnormalities so neonates need to be reviewed by neonatologist . and if complications like hyperbilurubinemia then appropriate treatment is offered.
As there is a rapid fall in insulin requirements after the delivery of placenta therefore insulin dose is reduced and once patient has started eating then prepregnency insulin regime is reinstated.
Breast feeding is encouraged and hypoglycemic episodes are avoided and
and future contraception is discussed befor discharge.

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farha · Century Club Joined: 18 May 2007 Posts: 157

C) Neonatal complication expected to occur includes neonatal hypoglycemia because of betacell hyperplasia and neonatal hyperinsulinemia and elimination of maternal glucose supply as the cord is clamped.
Respiratory distress syndrom is another complication as hyperinsulenemia inhibbits the growth of type two pneumocytes in alveoli..Electrolyte(hypomagnesemia and hypocalcemia) imbalance can also be one of the complications.Remaining complications are poly cythaemia due to fetal hypoxia which stimulates medullary and extramedullary haematopoiesis and lastly is neonatal jaundice.

farha · Century Club Joined: 18 May 2007 Posts: 157

Nick i need your comments on the essay and if anybody else then he or she will be more then welcomed.

stewartdisu · Joined: 24 Jun 2007 Posts: 20

Think your answer is quite long

a. Advice should stem from prenatal counselling

Diabetic pregnancy is a high risk pregnancy that Needs hospital based care and consultant led care. This requires close monitoring by a dedicated team of Senior obstetrician with a special interest in diabetes, an endocrinologist, diabetic nurse specialist and neonatologist after birth.

Glycaemic control reduces the risk of congenital anomalies.
Poor control predisposes to risks of still birth x 4.7, major cardial anomaly x 2, neonatal death x 2.6 hence administration of folic acid 5mgat least 12 weeks prior to planning a pregnancy shouls be taken.

Contraception is therefore required and consideration for Mirena if BMI is high or a progeterone only pill (nulliparous) and Coc has relative contraindications

Dibetic nurse specialist visit to assess Hb A1c prior to pregnancy and see a dietician for food advice

Antenatal care would involve the diabetic team with early booking to ensure dating the pregnancy and ensure glycaemic control in first trimester and subcequent trimesters.
Fundal assessment to rule out diabetic retinopathy
Cardiac anomaly scan at 22- 24 weeks for major cardiac lesions in fetus
Serial 4 weekly growth scans from 24 weeks using abdominal circumference and 2 weekly if Large for gestational age or from 32 weeks,
Regular visits to the dedicated diabetic team and plan delivery in a hospital setting for not exceeding 40 weeks gestation with adequate neonatal support to provide optimal glucose monitoring after delivery

B. I agree with most of your answers in part b
Labour ward with constant 1:1 midwifery care
intraveous access and glucose/insulin sliding scale monitoring
Electronic fetal monitoring
Caesarean section for obstetric indications only
Senior obstetrician to watch out for shoulder dystocia
Neonatal support to offer standardised monitoring of blood glucose within the first 6 hours and prevent hyposglycaemia in the baby as a result of hyperinsulinaemia

What do you think Farha, Nick?