Indian Write-Ups
| Management | ||||||||||||||||
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| Prevention Of Diabetes Starts Before Birth | ||||||||||||||||
| - Dr.V.Seshiah, Dr.V.Balaji |
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| The intriguing fact is that the morbidity associated with diabetic pregnancy also manifests in the life of women during her reproductive period even before she becomes a frank diabetic; “coming events casts their shadow before”. Dames destined to develop diabetes divulge direful destiny with fruitful fecundity frequently forming fat, flabby and feeble fetuses. Abnormal glucose tolerance has been observed to be an important factor for bad obstetric history. In diabetic women there are increased rates of hydraminos, severe toxaemia, premature birth, heavy for date babies, perinatal mortality and congenital malformations and it is interesting that the same features also occur with unusual frequency in the period of women’s life before diagnosis of diabetes, “pre diabetic phenomenon” | ||||||||||||||||
| The offsprings of women with glucose intolerance on follow up between fourteen and seventeen years were found to have Impaired Glucose Tolerance (IGT) and were also obese compared to control subjects. These findings support the hypothesis that the intra uterine environment of glucose intolerance predisposes the offspring to glucose intolerance and obesity in their later life, thereby creating a vicious circle by which “ diabetes begets diabetes”. Nurture characterized by maternal fuel modifies the nature, the genetic environment of the fetus. Hence in the prevention of diabetes attention should be focused on the intra uterine environment as the maternal metabolism has a crucial implication in fetal development. | ||||||||||||||||
| If a known diabetic women desires to conceive she should have a pre pregnancy counselling and to be on insulin during pre conceptual period and throughout pregnancy. Glucose intolerance that develops during pregnancy can be managed by meal plan in many instances. If the meal plan fails to achieve the target level of blood sugar during pregnancy exogenous insulin becomes essential for the well-being and normal development of the fetus. High blood sugar “glucotoxicity” is harmful to the fetus and not the insulin. The high glucose level of the mother crosses the placenta and stimulates the beta cells of the fetus. This can cause morbidity, like congenital malformations, heavy for date babies, intra uterine death and perinatal mortality depending on the glucose intolerance that occurs at the time of conception, in early weeks of pregnancy, mid and late pregnancy periods. The aim is to maintain the recommended target level of blood sugar throughout the pregnancy (fasting < 90 and 2hr post meal < 120) The main concern should be the blood glucose levels than the dose of insulin. | ||||||||||||||||
| The long-term outlook of the offspring of the pregnant women with abnormal glucose tolerance depends upon the glucose control during pregnancy. The stress is more on the intrauterine environment, which has been proved experimentally that embryos with low genetic risk when transferred into a diabetic uterus have high risk for Diabetes. Increasing maternal hyperglycemia is associated with increasing pregnancy morbidity and increased likelihood of subsequent diabetes in the mother in addition maternal hyperglycemia has a direct effect on the development of fetal pancreas and is associated with increased susceptibility to future diabetes in the infant an effect which is independent of genetic factors. If control can be maximized to the extent that the fetus no longer recognizes that the mother has glucose intolerance then the treatment of the mother during pregnancy may become the first step in the prevention of obesity and glucose intolerance in the offspring. Non-diabetic pregnant women are advised to have adequate nutrition to avoid low birth weight infants, as they are also likely to develop diabetes and hypertension if they adopt affluent life style later in their life. Appropriate management of pregnant women with abnormal glucose tolerance constitute a meaningful strategy for modifying some of the self perpetuating and apparently congenitally acquired contribution to such public health problems like diabetes, obesity and hypertension. | ||||||||||||||||
| In conclusion, no single period in the human development, provides a greater potential (than pregnancy) for a long range “pay off ” via a relatively short-range period of intensive metabolic manipulation. Hence the strategy at present is to focus on the intra uterine milieu to prevent fetal origin of adult diseases. | ||||||||||||||||
| Table 1 | ||||||||||||||||
| Diagnostic criteria of Diabetes Mellitus recommended by American Diabetes Association | ||||||||||||||||
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