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Management of Diabetes in Obstetrics and Gynecology
Shilpa GB
1:
The Rising Prevalence of Diabetes Mellitus
PROBLEM IN INDIA
PREVALENCE OF GDM
ESTABLISHED GDM RISK FACTORS
MODIFIABLE GDM RISK FACTORS
PREVENTION OF GDM
2:
Carbohydrate Metabolism
METABOLISM IN NORMAL NON-PREGNANT STATE
POST-ABSORPTIVE STATE
INSULIN
Mechanism of Action
Action of Insulin
Amino Acids
Metabolic Adaptations during Short Term Starvation
Glucose Ingestion
METABOLIC ADAPTATIONS TO PREGNANCY
DURING FASTED STATE
PATHOPHYSIOLOGY OF GDM
OBESITY AND INSULIN RESISTANCE
PATHOPHYSIOLOGY OF DIABETES MELLITUS
PREGESTATIONAL TYPE I DIABETES IN PREGNANCY
PREGESTATIONAL TYPE II DIABETES
3:
The Role of Placenta in Pregnancy Complicated by Diabetes Mellitus
4:
Definition and Classification of Diabetes in Pregnancy
DEFINITION
WHO,1985
WHO,1999
AMERICAN DIABETIC ASSOCIATION(ADA), 1997
GESTATIONAL DIABETES MELLITUS
CLASSIFICATION OF DIABETIC PREGNANCY
THE WHITE CLASSIFICATION5,6
MODIFIED WHITE CLASSIFICATION
WHO, ADA CLASSIFICATION8,9
5:
Periconceptional Care of Women with Diabetes
6:
Testing for Gestational Diabetes
INTRODUCTION
REQUIREMENTS
GLUCOSE TOLERANCE TEST (GTT)
INDICATIONS
TYPES
ORAL GLUCOSE TOLERANCE TEST (OGTT)
O’SULLIVAN AND MAHAN DIAGNOSTIC CRITERIA
NATIONAL DIABETES DATA GROUP CRITERIA (NDDG)
CARPENTER AND COUSTAN METHOD
TESTING WITH THE 75 G OGTT
PERFORMANCE OF THE TEST
INTRAVENOUS GLUCOSE TOLERANCE TEST
SCREENING FOR GESTATIONAL DIABETES MELLITUS
GLUCOSE POLYMER CHALLENGE TEST
GLYCOSYLATED HEMOGLOBIN (HbA1c)
FRUCTOSAMINE ASSAY
FASTING GLUCOSE AND POTENTIAL DIABETIC FEATURES
AMNIOTIC FLUID STUDIES
POSTPARTUM TESTING
7:
Diet and Exercise Management
DIETARY MANAGEMENT
METABOLIC ALTERATIONS OF PREGNANCY
CALORIC REQUIREMENT
DISTRIBUTION OF DAILY CALORIC ALLOWANCE
CARBOHYDRATES
ROLE OF ARTIFICIAL SWEETENERS
Fibre
Protein
Fat
Meal Plans for Diabetes Management
CARBOHYDRATE COUNTING AND TOTAL AVAILABLE GLUCOSE
LIFESTYLE CONSIDERATIONS
ROLE OF EXERCISE IN PREGNANT WOMEN WITH DIABETES
ACUTE METABOLIC EFFECTS OF EXERTION
GLUCOSE UPTAKE DURING AND AFTER ACUTE EXERCISE
PREGNANT NON-DIABETIC WOMEN
ENDOCRINE AND METABOLIC CHANGES
ROLE OF EXERCISE IN TYPE I DIABETES PREGNANCY
PREGNANT PATIENTS WITH TYPE II DIABETES AND GDM
FETAL SAFETY DURING MATERNAL EXERCISE
EXERCISE GUIDELINES IN PREGNANT WOMAN WITH DIABETES
8:
Insulin and Oral Hypoglycemic Agents
INSULIN THERAPY
INSULIN PREPARATIONS
HUMAN INSULIN
Advantages
INSULIN LISPRO
Advantages
ASPART INSULIN
INSULIN GLULYSINE
GLARGINE INSULIN
Advantages
INSULIN PREPARATIONS
CONVENTIONAL INSULIN PREPARATIONS
HIGHLY PURIFIED
HUMAN INSULIN
HUMAN INSULIN ANALOGUES
Insulin Syringe
FACTORS AFFECTING INSULIN ABSORPTION
INSULIN THERAPY IN GDM
INSULIN REQUIREMENT PER DAY9
INSULIN REGIMENS
CONVENTIONAL REGIMEN12
PATTERN I
PATTERN II
PATTERN III
PATTERN IV (SPLIT – MIX TYPE)
INTENSIVE THERAPY
Indication
Contraindication
REGIMEN I13
FRACTION OF TOTAL DAILY INSULIN
REGIMEN II8
CONTINUOUS SUBCUTANEOUS INSULIN INFUSION - INSULIN PUMP
Advantages
Disadvantages
ARTIFICIAL PANCREAS (CLOSED LOOP SYSTEM)
INSULIN DURING LABOR AND DELIVERY
Protocol for infusion of insulin and Intravenous fluid during labor for women with DM:
ELECTIVE LSCS
POSTPARTUM
POST DELIVERY
POST LSCS
ORAL HYPOGLYCEMIC AGENTS
INTRODUCTION
INDICATION FOR DRUG THERAPY
CLASSIFICATION OF ORAL HYPOGLYCEMIC AGENTS1
Sulfonylureas
Sulphonylureas
GLYBURIDE (GLIBENCLAMIDE OR GLIBENCYCLAMIDE)
Side Effects
Advantages
Success Rate
GLIMEPIRIDE
BIGUANIDES
Mechanism of Action
Side Effects
ROLE IN GDM
Thiazolidinediones
α-GLUCOSIDASE INHIBITORS
9:
Glucose Evaluation and Control
OTHER FORMS OF GLUCOSE DETERMINATION3
CONTINUOUS BLOOD GLUCOSE MONITORING
FRUCTOSAMINE ASSAY
GLYCOSYLATED HEMOGLOBIN
Based on the Results
Glycemic threshold for prevention of diabetic fetopathy complications
10:
Fetal Surveillance in Pregnancy Complicated by Diabetes Mellitus
FETAL MONITORING TECHNIQUES
DAILY FETAL MOVEMENT COUNT (DFMC)
NON-STRESS TEST
FETAL BIOPHYSICAL PROFILE (BPP)
DOPPLER VELOCIMETRY
ULTRASONOGRAPHY
Protocol for Antenatal Fetal Testing
ANTEPARTUM FETAL TESTING IN GDM
ANTEPARTUM FETAL TESTING IN IDDM
TESTING FOR FETAL LUNG MATURITY (FLM)
ROLE OF ULTRASOUND IN ANTEPARTUM FETAL SURVEILLANCE
GESTATIONAL AGE ESTIMATION
First Trimester
Second Trimester
CONGENITAL ANOMALIES
ASSESSMENT OF GROWTH ABNORMALITIES
IUGR
DYNAMIC ASSESSMENT (FETAL WELL BEING) USING USG
11:
Obstetric Management
CLINIC VISITS
PRE-CONCEPTIONAL CARE
Laboratory Tests
CARE DURING PREGNANCY
FIRST TRIMESTER
SECOND AND THIRD TRIMESTER
Criteria for Hospitalization
Factors influencing the time of delivery in diabetic pregnancies
TIMING AND ROUTE OF DELIVERY
INSULIN DEPENDENT DIABETES
MILD GDM (CONTROLLED WITH DIET)
ROLE OF CESAREAN SECTION
DURING LABOR
12:
Postpartum Management
PUERPERIUM
METABOLIC ASSESSMENT RECOMMENDED AFTER GDM6
RECLASSIFICATION OF DISEASE BY 75G OGTT POSTPARTUM IN WOMEN WITH GDM
DIET
LACTATION
FOLLOW-UP CARE
PATIENT EDUCATION
In women with type I and type II diabetes
WOMEN WITH PRIOR GDM
CONTRACEPTION
HORMONAL CONTRACEPTION
IUCD
13:
Fetus and Infant of the Diabetic Mother
NORMAL MATERNAL GLUCOSE REGULATION
14:
Obstetric Complications
PREECLAMPSIA
SPONTANEOUS PRETERM DELIVERY
CESAREAN DELIVERY
SPONTANEOUS ABORTIONS
INFECTION
MONILIAL VAGINITIS AND VULVITIS
STILLBIRTH
PATHOPHYSIOLOGY OF STILLBIRTH
PREVENTION OF STILLBIRTH IN DIABETIC PREGNANCY
ACHIEVING AND MAINTAINING EUGLYCEMIA
ANTEPARTUM FETAL SURVEILLANCE
MACROSOMIA
DEFINITION
PATHOPHYSIOLOGY
MODIFIED PEDERSON’S HYPOTHESIS (by FREINKEL et al)
EARLY DETECTION AND IMPLICATION FOR TREATMENT/ PREVENTION
DETECTION OF MACROSOMIA
CONGENITAL MALFORMATIONS
PATHOGENESIS AND ETIOLOGICAL FACTORS
ABNORMAL DEVELOPMENT OF THE NEURAL TUBE AND YOLK SAC
TYPES OF BIRTH DEFECTS
STRUCTURAL ABNORMALITIES
MALFORMATIONS OF THE CNS
CARDIAC ANOMALIES
RENAL ANOMALIES
SKELETAL ANOMALIES
OTHER ANOMALIES
FUNCTIONAL ABNORMALITIES
PREVENTION
15:
Medical Complications
HYPOGLYCEMIA
DEFINITION
MANAGEMENT OF THE HYPOGLYCEMIC PREGNANT PATIENT
SEQUELAE OF RECURRENT HYPOGLYCEMIA
DIABETIC KETOACIDOSIS (DKA)
PATHOPHYSIOLOGY OF DKA
HOW PREGNANCY AFFECTS DKA ?
HOW DKA AFFECTS PREGNANCY ?
RISK FACTORS FOR DIABETIC KETOACIDOSIS
CLINICAL FEATURES OF DKA
INVESTIGATIONS
MANAGEMENT
POTASSIUM
FLUID REPLACEMENT
INSULIN
POTASSIUM ADMINISTRATION
BICARBONATE ADMINISTRATION
CHRONIC COMPLICATIONS OF DIABETES IN PREGNANCY
DIABETIC RETINOPATHY IN PREGNANCY
Classification of Retinopathy
Etiopathogenesis of Retinopathy
Effects of Pregnancy on Retinopathy
Pregnancy Outcomes in the Presence of Diabetic Retinopathy
Other Ocular Complications
Management of Diabetic Retinopathy during Pregnancy
Diabetic Nephropathy and Pregnancy
Stages of Diabetic Nephropathy
PATHOGENESIS OF DIABETIC NEPHROPATHY
Prevention of diabetic nephropathy
MANAGEMENT
Antihypertensive Treatment
NEPHROPATHY DURING PREGNANCY
MANAGEMENT OF DIABETIC NEPHROPATHY DURING PREGNANCY
Preconceptional
I Trimester:
II Trimester:
III Trimester:
At all times:
MANAGEMENT OF DIABETIC PREGNANCY COMPLICATED BY CORONARY ARTERY DISEASE AND NEUROPATH
Coronary Artery Disease (CAD)
Diabetes Neuropathy
Symmetrical Distal Polyneruopathy
Autonomic Neuropathy
Asymmetric Neuropathies
Influence of Pregnancy on Diabetic Neuropathy
Influence of Diabetic Neuropathy on Pregnancy Outcome
16:
Diabetes in Gynecology
ADOLESCENCE
TYPE I DM
TYPE II DIABETES
DIABETES IN REPRODUCTIVE AGE GROUP
MENOPAUSE AND DIABETES
EFFECTS OF DIABETES ON MENOPAUSE:
TYPE I DIABETES
TYPE II DIABETES
EFFECT OF MENOPAUSE ON DIABETES
HRT IN MENOPAUSAL WOMEN WITH DIABETES
ADDITIONAL RISKS IN WOMEN WITH DIABETES
INDEX
TOC
Index
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