| Management |
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| Pregnancy & Diabetes |
Dr. Anirban Majumder MD., DM(PGT)Department of Endocrinology, I.P.G.M.E. & R., Kolkata
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| Diabetes may antedate pregnancy (pregestational) or it may develop in the later part of pregnancy (gestational). Prevalence of diabetes in our country varies between 1.2% to 12% and approximates the prevalence of western world. Diabetes complicates around 6% pregnancies. |
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| Though diabetes is now classified very elaborately, we encounter 4 basic types of diabetes in our clinical practice. |
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| Insulin Dependent diabetes Mellitus (IDDM) or Type I Diabetes |
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- Younger age of onset (usually less than 15 years)
- Prone to develop ketoacidosis
- Usually lean patient
- Depends on insulin for survival
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| Non-Insulin Dependent Diabetes Mellitus (NIDDM) or Type 2 Diabetes |
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- Older age of onset (usually more than 30 years)
- Usually does not develop ketoacidosis
- Usually obese
- Can be controlled by oral hypoglycaemic agent (OHA)
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| Malnutrition Related Diabetes Mellitus (MRDM) or Ketosis Resistance-Young Diabetes (KYED) |
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- Younger age of onset (usually less than 30 years)
- Does not develop ketoacidosis
- Usually very lean & malnourished
- Pancreatic calcification may be present
- Always associated with clinical or subclinical pancreatic insufficiency
- Usually requires insulin to control hyperglycaemia
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| Gestational Diabetes Mellitus (GDM) |
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- Develops during pregnancy between 24-28 weeks
- Basically an unmasking of potential Type 2 diabetes
- Not associated with long term complications of diabetes
- Diabetes state resolves spontaneously following delivery of foetus
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| Effect Of Pregnancy On Diabetes (Pregestational Diabetes) |
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- Pregnancy is the only physiological event of a diabetogenic nature. In the first trimester of pregnancy insulin action is enhanced by oestrogen and progesterone. In early few weeks of pregnancy, requirement of insulin in Type 1 diabetes patients decreases from their prepregnancy requirement.
- Then gradually requirement increases with the progression of pregnancy and in late pregnancy the requirement increases 2.5 to 3 times the prepregnancy requirement. After delivery, the women’s insulin requirement is markedly diminished due to marked increase in insulin sensitivity and post partum insulin dose is less then one half the prepregnancy dose, which returns to prepregnancy value after a few days.
- In late pregnancy, insulin requirement increases due to peripheral insulin resistance conferred by Human Placental Lactogen.
- Pregnancy is a state of accelerated starvation. Glucose utilization rate is as high as 6 mg/kg/min in human foetus at term in contrast to glucose turnover 3 mg/kg/min in normal adults. Foetus also drains a considerable amount of maternal nitrogen reserve. But the triglycerides cross the placental barrier poorly and the net transfer of free fatty acids to the foetus is limited. Ketone is formed in maternal liver and can readily cross the placental barrier. Pregnant women fasted for few hours show an increased tendency to develop hyperketonaemia, compared to nonpregnant counterpart. Pregnancy in a uncontrolled diabetic subject can precipitate ketoacidosis. Maternal ketonaemia has an adverse effect on developing brain cells, on organogenesis and can result in a reduction in the IQ of the offspring in childhood.
- Pregnancy aggravates retinopathy. Retinopathy of all types tends to progress during pregnancy and revert post partum to the level noted before pregnancy. All diabetic women should undergo ophthalmological examination before entering into pregnancy and then in each trimester. Patients having pre-proliferative retinopathy or non-proliferative retinopathy should receive treatment for retinopathy before planning for pregnancy. Gestational diabetic patients do not require ophthalmological check up.
- Proteinuria due to diabetic nephropathy & proteinuria due to preeclampsia often get confused. Women who do not have proteinuria in early pregnancy but develop it later, probably have preeclampsia. Women who have proteinuria before pregnancy usually develop severe proteinuria with progression of pregnancy. Whether pregnancy actually worsens the course of renal disease and hastens renal failure is not known definitively. Moderate degree renal failure with serum creatinine concentration 3 mg/dl or more is incompatible with foetal life.
- Neuropathy is a common complication of diabetes and can complicate pregnancy. Usually it is sensory neuropathy and involves mainly lower limbs. Carpal tunnel syndrome may complicate pregnancy. Gastropathy (due to autonomic neuropathy) may mimic hyperemesis gravidarum and at times it is difficult to distinguish between two.
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