Friday, October 15, 2010

Diabetes Mellitus In Pregnancy (Gestational Diabetes)

What is gestational diabetes?
Gestational diabetes is the diabetes mellitus that develop for the first time during pregnancy. It disappeared 6 weeks after delivery.

How does it occur?
During pregnancy, the placental secretes 3 anti-insulin hormones ® estrogen, hPL(human placental lactogen) & cortisol. These hormones against the function of insulin (The function of insulin is to reduce the blood sugar level). To counter this effect, the pancreas produces and secretes more insulin. Thus, the level of insulin is raised by the action of the placental hormones, placing a burden on the insulin-secreting cells (pancreatic islets). The pancreas may be unable to meet these demands in women genetically predisposed to develop both types of diabetes.

There are 2 scenarios of diabetes in pregnancy:
·       Established diabetes
Women who are already diabetic at the start of pregnancy (most cases)

·       Gestational diabetes
Development of diabetes for the first time during pregnancy.
Gestational diabetes may or may not disappear following delivery. Repeated pregnancy may increase the likelihood of developing permanent diabetes, particularly in obese women. Studies have shown that some 80% of women with gestational diabetes ultimately develop permanent clinical diabetes requiring treatment.

How to confirm gestational diabetes?
It is diagnosed by a test, called Modified Oral Glucose Tolerance Test (MOGTT), which show raised blood sugar level.
Procedure for MOGTT:
        MOGTT should be done in the morning after at least 3 days of normal diet and usual physical activity
        The test should be proceed by an overnight fast of 10-16 hours during which plain water may be allowed
        Subjects should be at rest for the duration of test. Smoking is not permitted. The presence of factors that influence interpretation of the result of the test must be recorded. (e.g. medication, inactivity, infection)
        After collection of fasting blood sample, the subject is required to drink 75g of anhydrous glucose in 250-300ml water within 10 minutes
        Another blood sample must be collected 2 hrs after finishing glucose drink
It is confirmed if:
        Fasting blood sugar  >7.0mmol/L or
        2 hours Post-sugar - >11.1 mmol/L
1-2% of women will develop gestational diabetes and they are having risk to develop diabetes mellitus type 2 in future.

What are the risk factors?
        Women >35 years old
        Maternal obesity (BMI >30)
        Family background of diabetes mellitus among 1st degree relatives
        Previous history of big baby (>4 kg)
        History of gestational diabetes in previous pregnancy
        History of unexplained fetal death
        History of congenital anomaly in previous pregnancy

What are the symptoms?
        Usually no symptom
        Sometime may develop:
       Excessive passage of urine
       Extreme thirsty
       Excessive passage of urine at night or during sleep
       Extreme hunger
       Sweet smelling breath
       Unusual weight loss

What are the effects to the mother and the baby?

Effects to the pregnant mother

1.     Pregnancy induced hypertension (2 times greater risk to develop hypertension compared to non diabetic pregnant mother and it is because of the effect of estrogen hormone and the abnormality of blood vessel)
2.     Excessive amniotic fluid + premature rupture of amniotic membrane
3.     Premature labour give rise to premature baby
4.     Infection
Urinary tract infection (d/t high sugar level in the urine, therefore bacteria are more likely to grow)
Candidiasis of the vulva and vagina

Effects to the fetus/baby

1.     Early pregnancy
Spontaneous abortion
Congenital anomalies (heart, limbs, spinal cord)
2.     Later pregnancy
Big baby (more than 4kg at birth, it is because when the mother’s blood sugar levels are elevated, the sugar crosses the placenta and cause blood sugar level in fetus increased as well. The fetus in such a setting is “overfed” and grows large, with increased deposits of fat and glycogen. Large baby has a significantly increased risk for birth trauma. Besides that, high blood sugar level in fetus also causing overproduction of insulin in the fetus. Insulin promotes growth, therefore the fetus grow rapidly)
Fetal death (Due to poor oxygen delivery to the fetus)
Polycythemia (A condition marked by an abnormally large number of red blood cells in the circulatory system as a compensation of lack of oxygen.)+ hyperbilirubinemia (excessive bilirubin in blood due to excessive breakdown of the red blood cell and it cause jaundice)
3.     After delivery
Low blood sugar level (Fetus exposed to high blood sugar level results in over production of insulin hormone. When it is delivered and the sugar supply is cut off but the insulin secretion persists, the infant can develop extremely low sugar level, especially during the early hours of life. This can be serious since the brain utilizes sugar as a major substrate. Prolonged low blood sugar level can produce brain dysfunction.)
Jaundice (yellowish discoloration of the whites of the eyes, skin, and mucous membranes)
Breathing difficulty (because of delayed fetal lung maturation and the harming effect of insulin hormone on lung maturation)

What should I do to prevent/ overcome this problem?

·       Control maternal blood sugar levels
·       Early delivery (at least not post date) in an appropriate site based on fetal heart testing and lung maturity

4 stages of precaution/ management:
  1. Preconceptual/ before pregnant
  2. During pregnancy
  3. During delivery
  4. After delivery

1. Preconceptual
         Normal healthy diet (A balanced diet consisting of 50-60% energy from carbohydrate, 15-20% energy from protein and 25-30% energy from fats are encouraged. 35 calories /kg (body weight). A high fiber diet (20-30g fiber/day or 5-7 servings/day) consisting of vegetables, fruits, legumes and whole grain cereals is encouraged. Take low glycemic index food such as fruits, green leafy vegetables, beans, legumes, nuts, breads which are wholegrain or wholemeal in nature, etc.) Avoid high glycemic index food such as white potatoes and white rice as they bring up the blood sugar level rapidly)
        Regular exercise (at least 3 days per week and 30 minutes per day)
        Maintain normal BMI (less than 30kg/m2)
        Medical counseling
        Assessment of risk factors
        Assessment of complications e.g. kidney function and eyes
        Control blood sugar to optimal level before conception

2. During pregnancy

What should I do if been diagnosed to have gestational diabetes?
        Early booking (first antenatal check up) & frequent follow up
        Start with diet control (take healthy diet as mentioned above)
        Check blood sugar profile (BSP) at clinic 2 weeks later, start on insulin therapy only if BSP more than 6.7, otherwise continue diet control
        Consult your doctor about the type and the dose of insulin
        Self monitoring of blood sugar level
        Maternal assessment (blood sugar profile, urine sugar level, body weight, blood pressure, urine protein)- look for diabetic status & screen for hypertension
        Fetal  assessment
- Early ultrasound for dating in the 1st trimester
- Detailed ultrasound for fetal abnormality at 18-20 weeks
- Serial scan (Fortnightly) for fetal growth. Include measurement of head circumference and abdominal circumference
- Regular monitoring of fetal well being on weekly or two weekly in 3rd trimester, by biophysical profile together with fetal heart monitoring
- Monitor fetal kick count (normal count is at least 10 kicks per day)

How frequent should I go for antenatal follow up?
        Antenatal visit 2 weekly till 32 weeks, weekly after that until delivery

Should I been admitted to hospital?
It is indicated when:
        The diabetic status is poorly controlled
        When need to adjust the insulin dose
        For blood sugar profile
        Complications occur eg. Mother develop hypertension, fetal compromise (showed in ultrasound scanning or reduced fetal kick count)
        When delivery is indicated

3. During delivery

When to deliver?
        If diabetic is optimally controlled with diet only, can deliver at the estimated date of delivery (40 weeks, but not post date as the fetus will grow bigger with duration and causing difficulty in delivery later)
        If diabetic is optimally controlled with diet & insulin, deliver at 38-40 weeks is recommended (as fetal lung maturation is completed after 38 weeks)
        If not well controlled & associated with fetal compromise, delivered before 38 weeks ( make sure the mother is given dexamethasone before delivery, which is helping in fetal lung maturation)

What are the methods of delivery in gestational diabetes?

        Normally vaginal delivery is recommended if absence of any complication
        Consider operation if:
       Big baby (more than 4kg)
       A previous operation delivery
       Abnormal head position
       Size of the fetal head larger than the pelvic outlet
       Excessive amniotic fluid
       Evidence of fetal compromise
       Bad obstetric history
       History of infertility
       Poor diabetic control
       Vascular complications

4. After delivery

        Monitor blood sugar (glucostix) 6 hourly for 1 day
        Repeat MOGTT 6 weeks after delivery ( normally blood sugar level return to normal 6 weeks after delivery, if it still persisted that means the mother is having permanent diabetes and she need treatment)
        Contraception (at least 2 years recommended to ensure good spacing)
        Early antenatal booking for the future pregnancy

        The baby should be observed closely after delivery for respiratory difficulty
        Blood sugar should be monitored at 1 hour of age and before the first four feeds (and for up to 24 hours in high risk baby)
        Levels <2.6 mmol/L should be considered abnormal and treated
        Breastfeeding is actively encouraged as human breast milk is the best source of immunity & it promote mother-baby relationship

Can I take oral contraceptive pil (OCP) if I am having permanent diabetes?
        OCP is not recommended for diabetics because combined contraceptive pill increase the risk of vascular complications while progesterone-only pills is associated with irregular menstrual flow and higher failure rate
        Barrier method is the best option eg. Condom
        IUCD (intrauterine contraceptive device) is also not recommended in diabetics since there is an increase chance of infections

Cardiopulmonary Resuscitation (CPR) – for lay rescuer

“…The most important determinant of survival from sudden cardiac arrest is the presence of a bystander who is ready, willing, able, and equipped to act”

  • Resuscitation is most successful if defibrillation is performed within 5 minutes after victim collapse.
  • Without CPR, the survival rate reduced 7-10% every minute.
  • CPR plus defibrillation(shock) within 3 – 5 minutes produce survival rates as high as 49-75%
  • In many communities, the time interval from EMS call to EMS arrival is 7 – 8 minutes or longer.
  • This means that in the first minutes after collapse, the chance of survival of the victim is in the hands of bystanders.
  • Many of them can survive if bystanders act immediately while ventricular fibrillation (VF) is still present, but successful resuscitation is unlikely once the rhythm deteriorates to asystole.
  • About 75-80% of all out-of-hospital cardiac arrests happen at home, so being trained to perform CPR can save the life of your loved one.
  • Effective bystander CPR provided immediately after cardiac arrest can double a victim’s chance of survival.
  • The interventions that unquestionably contribute to improved survival after cardiac arrest are
    1. Early defibrillation for VF/ pulseless VT( ventricular tachycardia)
    2. Prompt effective bystander BLS

Steps of CPR
Mnemonic: DR ABCD

D – Danger
R – Response
A – Airway
B – Breathing
C – Chest compression
D – Defibrillation

Remove the danger from the victim, ie. move the victim from center of road to road side.

Gentle shaking the victim and call him to see any response. If there is no response, Call 999 and return to the victim.

Head tilt, chin lift to see any foreign body inside the mouth & try to remove it with careful.

Look for chest rise, feel and listen for breathing, If there’s no breathing, give 2 rescue breaths by pinch nose and cover the mouth fully with your mouth and blow until you see the chest rise.  Each breath should take 1 second.

Chest compression
For lay rescuer, do not check for sign of circulation but start the chest compression immediately after giving 2 rescue breaths. Compress the chest 1½ to 2 inches 30 times right between the nipples.  Compress at the rate of 100/minute.
Continue with 2 breaths and 30 compressions until help arrives.

Use automated external defibrillator (AED). For adult and children 8 years old & older, use adult pads, do not use child pads or child system. For children 1-8 years old, use child pads/ system if available, if not, use adult AED and pads. Defibrillation is not recommended for infant less than 1 year old.

What is effective rescue breath?
·       Take a normal (not a deep) breath before giving a rescue breath to the victim. Each rescue breath should be given over 1 second and should produce visible chest rise. If the victim’s chest is not rise after giving the 1st rescue breath, perform the head tilt, chin lift again before giving the 2nd rescue breath. All rescuers should give the recommended number (2) of rescue breaths. Avoid delivering too many breaths or too forceful as it may be harmful by reduce the blood flow generated by chest compressions.  Besides that, it may cause gastric inflation and its complications.

What is effective chest compression?
Effective chest compressions produce blood flow during CPR
·       To give effective chest compressions, all rescuers should “push hard and push fast.” Compress the chest at a rate of about 100 compressions per minute for all victims (except newborns- less than one week old baby).
·       Allow the chest to recoil (return to normal position) completely after each compression.
·       Try to limit interruptions in chest compressions. Every time you stop chest compressions, blood flow stops.
·       When cardiac arrest is present, there is no blood flow. Chest compressions create a small amount of blood flow to the vital organs, such as the brain and heart.
·       The better the chest compressions is performed (ie, with adequate rate and depth and allowing complete chest recoil), the more blood flow can be produced.
·       Blood flow stops when chest compressions are interrupted. Every time chest compressions begin again, the first few compressions are not as effective as the later compressions. The more interruptions in chest compressions, the worse the victim’s chance of survival.

How to perform chest compression in children/infant?
·       For children, use 1 or 2 hands to perform chest compression at right between the nipples as in adult.
      (2 hand: heel of 1 hand, 2nd hand on top, 1 hand: heel of 1 hand only)
·       For infant, compress with 2 fingers at the breastbone just below the nipple level.
·       For adult, use 2 hands.

How deep should I compress?
·       1.5-2 inches for adult and children 8 years old & older.
·       Half the depth of the chest for children 1-8 years old & infant.

Is the compression-ventilation ratio different for different ages of victim and number of rescuer?
·       For lay rescuer, it is one universal compression-ventilation ratio of 30:2 for all victims
·       But for health care provider (well trained), the ratio is different as shown below:

Age of victim
Adolescent & older
Infant - adolescent
Compression-ventilation ratio
(1 or 2 rescuers)
30:2 (1 rescuer)
15:2 (2 rescuers)

What should I do if the victim is choking?
·       Ask the victim to cough/ vomit out the foreign body. If failed, perform abdominal thrust for children & adult victim. Whereas, perform back slaps & chest thrust for infant.