Sunday, February 1, 2009

Follow up of diabetes mothers following delivery

This is very important as many complications may occur following the delivery. If the type of diabetes is not diagnosed, further investigations should be carried out in order to diagnose the type of diabetes. Following points should be addressed in follow up;

1. Further inpatient care

A) Avoiding shoulder dystocia
B) Intrapartum glycemic management
C) Treatment of neonates

2. Prevention
3. Patient education


Further Inpatient Care
Avoiding shoulder dystocia
Mainstay for assessing risk in pregnancy complicated with diabetes is ultrasound scan. But its sensitivity is 65% in the detection of macrosomia whereas the specificity is 50-60% therefore rate of false positive is 30-50%. In this context normal vaginal delivery could be done for macrosomic fetuses on the basis of ultrasound scan results. These infants should be closely monitored in order to detect birth injuries as early as possible. When taking the decision for mode of delivery, risk of birth injuries associated with vaginal deliveries and risk of caesarian section should be considered.

Intrapartum glycemic management
Maintenance of intrapartum metabolic homeostasis optimizes postnatal infant transition by reducing neonatal hyperinsulinemia and subsequent hypoglycemia.
The use of a combined insulin and glucose infusion during labor to maintain maternal blood sugars in a narrow range (80-110 mg/dl) during labor is a common and clinically efficient practice. Typical infusion rates are 5% dextrose in Ringer lactate solution at 100 mL/h and regular insulin at 0.5-1.0 U/h. Capillary blood sugar levels are monitored hourly in these patients.



Treatment of the neonate
The most critical metabolic problem affecting IDMs is hypoglycemia. Unmonitored and uncorrected hypoglycemia can lead to neonatal seizures, brain damage, and death. The strongest predictor of neonatal hypoglycemia is the maternal mean blood glucose level during labor. IDMs also appear to have disorders of both catecholamine and glucagon metabolism and have a diminished capability to mount normal compensatory responses to hypoglycemia. Therefore continuous monitoring of the neonate is essential to detect hypoglycemia and to prompt treatment.
Prevention

Prevention of gestational diabetes is an attractive concept, but no progress has been made, despite attempts in smaller studies. Because body fat and diet contribute to the risk of GDM, patients who lose weight prior to pregnancy and follow an appropriate diet may lower their risk of GDM. However, the pregnancy hormones impose such a high degree of insulin resistance that in very susceptible individuals, even marked weight loss and attention to diet are not likely to be successful.
Patient Education

Education is the cornerstone of effective metabolic management of the patient with diabetes during pregnancy. Patients should be educated on importance of dietary control, compliance and attendance of clinics regularly. However, specially trained and certified nurses and dietitians (ie, certified diabetes educators) are the most effective in this regard. Most large programs treating women with diabetes during pregnancy assist the patient with a staff that includes a registered nurse, a certified diabetes educator, a dietitian knowledgeable about pregnancy, and a social worker. Successful management of diabetic pregnancy is optimized when this type of team care is available.

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