Tiêu đề DIABETES MELLITUS IN PREGNANCY ✅

ESSENTIAL DIABETES MELLITUS / GESTATIONAL DIABETES MELLITUS HISTORY TAKING 1. History ● Usually patient mention ‘tersekat minum air gula’ which means diagnosed during MOGTT which usually done at booking (with risk factor) or 24-28 weeks POG (no risk factor) ● Ask regarding how was she being diagnosed (OGTT results, treatment, control) ○ Risk factors of GDM : ● Age ≥25 ● BMI >27 kg/m2 ● Previous hx of GDM - ask in detail (Any eventful pregnancy, meds) ● First degree relative with diabetes mellitus ● History of macrosomia (birth weight >4kg) ● Bad obstetric history (unexplained IUD, congenital anomalies, shoulder dystocia) ● Glycosuria ≥2+ on two occasions ● Current obstetric problems (essential hypertension, pregnancy-induced hypertension, polyhydramnions and current use of corticosteroids) ● Glycosuria ≥2+ on two occasions ● Current obstetric problems (essential hypertension, pregnancy-induced hypertension, polyhydramnios and current use of corticosteroids) ● Others : Twin pregnancy, PCOS, abnormal weight gain during pregnancy ○ Complications Maternal Fetal ● UTI ● Abortion ● Pre-eclampsia ● Traumatic delivery (shoulder dystocia) ● Increase chance of C-sec/ instrumental ● Metabolic syndrome ● Recurrent fungal infection - vaginal candidiasis ● Exacerbation of pre-existing ds - retinopathy, nephropathy ● Congenital anomalies ● Macrosomia >4.5kg ● Delayed surfactant production - RDS ● Hypocalcemia ● Polycythemia ● Hyperinsulinemia ● Polyhydramnios ● IUFD ● Post partum : Hypoglycemia, kernicterus 2. Systemic Review ○ Look for complications - as mentioned above 3. Past Medical History
○ Any underlying diseases : HPT, DM (essential DM), PCOS, Thyroid ds, Asthma i. Complaint and when diagnosed ii. Current control or status iii. Complications of disease and treatment 4. Past Drug History - ● Any teratogenic, traditional or other medication ● Any change of medication during pregnancy ● Dosage ● Side effect ● Compliance 5. Social History ● Smoking/ alcohol abuse ● Distance from home ● Knowledge of the dise ● Smoking/ alcohol abuse ● Distance from home ● Knowledge of the disease 6. Diet History ● Practice diabetic diet PHYSICAL EXAMINATION ○ General : Obese ○ Inspection of abdomen : Previous scar (important for plan of delivery) ○ SFH : Uterus larger than date (Macrosomia, Polyhydramnios, Twin) ○ Retinopathy (if possible)
COMMON QUESTIONS 1. How do you do preconception care for patient with Diabetes Mellitus? ● Preconception care, provided by a multidisciplinary team, consists of: o discussion on timeline for pregnancy planning o lifestyle advice (diet, physical activities, smoking cessation and optimal body weight) o folic acid supplementation o appropriate contraception o full medication review (discontinue potentially teratogenic medications) o retinal and renal screening o relevant blood investigations ● Women with pre-existing diabetes should be informed of the glycaemic control targets and empowered to achieve control before conception. They are also counselled on the risk and expected management approaches during pregnancy 2. How do you manage pre-existing DM : ○ Low dose aspirin supplementation (75-150 mg daily) should be given to women with pre-existing diabetes from 12 weeks of gestation until term. ○ In women with pre-existing diabetes, o retinal assessment should be performed at booking and repeated at least once throughout the pregnancy o renal assessment should be performed at booking; those with pre-existing renal disease should be managed in a combined clinic 3. General management of Diabetes Mellitus in Pregnancy : 1. Optimize Lifestyle changes - diabetic diet, exercise 2. Self-monitoring of blood glucose (SMBG) o fasting or preprandial: ≤5.3 mmol/L o 1-hour postprandial: ≤7.8 mmol/L o 2-hour postprandial: ≤6.7 mmol/L 3. Metformin Therapy : a. Offered when blood glucose targets are not met by modification in diet and exercise within 1–2 weeks b. Continued in women who are already on the treatment before pregnancy 4. Insulin Therapy : ● Initiated when: o blood glucose targets are not met after MNT and metformin therapy
o metformin is contraindicated or unacceptable o FPG ≥7.0 mmol/L at diagnosis (with or without metformin) o FPG of 6.0-6.9 mmol/L with complications such as macrosomia or polyhydramnios (start insulin immediately, with or without metformin). ● Human insulins are the preferred choice in pregnant patients who need insulin therapy. ● Both rapid and long acting (basal) insulin analogues are as efficacious as human insulin in pregnant women with pre-existing diabetes and GDM. ● Insulin analogues are associated with fewer incidences of hypoglycaemia. 5. Frequent fetal surveillance by ultrasound scan : 4. When to deliver this patient ? CASE 1 EXAMINER NO GILIRAN PELAJAR BATCH FINAL DIAGNOSIS PROBLEM LIST - - BATCH 5 GDM and Asthma in pregnancy 1. Gestational Diabetes Mellitus