Diabetes mellitus in pregnancy: Gestational diabetes mellitus diagnostic criteria

Diagnosis of gestational diabetes mellitus is based on oral glucose tolerance test, which is usually done after 24 weeks of gestation. In most parts of the world the diagnostic criteria are based on either the 100 gram 3-hour test or the 75 gram 2-hour test. Many national bodies have created their own criteria based on local experience and their healthcare systems. The test is usually done when there is indication, which is the presence of risk for gestational diabetes mellitus. Risk assessment for gestational diabetes mellitus should be undertaken at the first antenatal visit. Pregnant women with no risk may not need to undergo the test. Some women with very high risk for gestational diabetes mellitus may need to take the test earlier than 24 weeks.

These are some different guidelines for diagnosis of gestational diabetes mellitus.

One abnormal value is sufficient for diagnosis

One abnormal value is sufficient for diagnosis
IADPSG=International Association of Diabetes and Pregnancy Study Groups

At least 2 abnormal values are needed to make diagnosis
ADA=American Diabetes Association

Positive screening indicates need for diagnostic test of 100g glucose load
For the diagnostic test, least 2 abnormal values are needed to make diagnosis
ACOG=American College of Obstetricians and Gynecologists

Positive screening indicates need for diagnostic test of 75g glucose load
For the diagnostic test, least 2 abnormal values are needed to make diagnosis

Diabetes mellitus in pregnancy: ultrasound work up during antenatal phase

-Example of ultrasound schedule-
TVS=transvaginalsonography; CRL=crown - rump length; increased in nuchal translucency indicates that the baby is at higher risk for Down's syndrome; manning score is used to assess for fetal well-being

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See also Diabetes mellitus in pregnancy: antenatal management

Diabetes mellitus in pregnancy: insulin therapy during antenatal phase

Total daily insulin requirement

The starting insulin dose can be calculated based on the patient's body weight with insulin dose of 0.5 - 0.8 unit/kg/day.

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Insulin regimen

Either one of these 2 regimens are usually used for insulin therapy:

Intensive regimen

2 to 5 pre-meals injections of bolus insulin (rapid/short-acting insulin : regular, aspart, lispro) plus 1 (pre-bed) to 2 (pre-bed + pre-breakfast) injections of basal insulin (intermediate or long-acting insulin : NPH, zinc, extended zinc, lispro-protamine, glargine) are given . Example of the regimen is, 3 pre-meals injections (pre-breakfast, pre-lunch, pre-dinner) of actrapid, plus 1 pre-bed injection of NPH. Generally, requirement for basal insulin is 50% to 70% of total daily insulin requirement, and requirement for pre-meals bolus insulin is 30% to 50% of total daily insulin requirement.

Example of calculation:

Body weight : 50 kg

Total daily insulin requirement : 0.5 x 50 = 25 units

Regimen : 3 pre-meals actrapid injections + 1 pre-bed NPH injections

=Intensive regimen of 3 pre-meals injections (pre-breakfast, pre-lunch, pre-dinner) of actrapid, plus 1 pre-bed injection of NPH

Dose of 3 pre-meals actrapid : 

50% of total daily insulin requirement (50 to 70%)

=50% x 25 unit

=12.5 unit

Therefore,

Dose for each pre-meal actrapid

= 12.5 unit / number of meals

= 12.5 unit / 3

=4.16unit ~ 4 unit

Dose of 1 pre-bed NPH :

50% of total daily insulin requirement (30 to 50%)

=50% x 25 unit

=12.5 unit ~ 13 unit

or,

Dose of 3 pre-meals actrapid : 

70% of total daily insulin requirement (50 to 70%)

=70% x 25 unit

=17.5 unit

Therefore,

Dose for each pre-meal actrapid

= 17.5 unit / number of meals

= 17.5 unit / 3

=5.83unit ~ 6 unit

Dose of 1 pre-bed NPH :

30% of total daily insulin requirement (30 to 50%)

=30% x 25 unit

=7.5 unit ~ 8 unit

Conventional regimen

1-2 injections of a mixture of rapid/short-acting and intermediate-acting insulins is given. Twice daily injections are preferred for better glycemic control. With the 2-injection regimen, generally two-thirds of the total daily insulin requirement is given before breakfast and one-third is given before the evening meal.

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If after around 3 days started insulin with the calculated dose the patient does not achieve the desired level of glycemic control, the insulin dose is titrated accordingly.

-Example of insulin titration algorithm-
Generally, glucose level of 4 - 6 or 7 mmol/l is acceptable, therefore, usually the algorithm is not followed too strictly
Refer conversion table below for unit conversion

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(See also Diabetes mellitus: antenatal management)

Diabetes mellitus in pregnancy: antenatal management

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Management of diabetes mellitus in pregnancy can be divided into phases:

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These are the crucial components in the management of diabetes mellitus in pregnancy during antenatal period:

1. Dating
2. Glucose level assessment
3. Glucose control
4. Management of complications
5. Determination of mode and timing of delivery

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Dating

Accuracy of gestational age is really important for the management of diabetes mellitus in pregnancy, especially for determination of timing of delivery. The earlier dating is done, which is done by using ultrasound, the more accurate the estimated gestational age of the fetus.

There is some special cases in which early dating is not done, and the dates are not certain. In such cases, amniocentesis might need to be done, to check for lecithine syringomyeline (L:S) ratio, to assess for fetal lung maturity.

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Glucose level assessment

Blood sugar profile (venous blood sugar) is usually done monthly or every 2 weeks, aim to achieve blood sugar level of 4 - 6 mmol/L. It reflects the recent blood sugar control.

Meanwhile, HbA1c is done once in each trimester, with target of HbA1c <6 - 7%. It reflects the glucose control for the previous 2 - 3 months, hence, also reflects the adequacy of BSP testing schedule.

Blood sugar home monitoring (capillary blood sugar) is recommended for all patients.

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Glucose control

Blood sugar level is controlled either by diet control or by using subcutaneous insulin. Oral anti-diabetic agents are not recommended because of the teratogenic risk.

If sugar control is not achieve by diet control only, then the use of subcutaneous insulin is initiated.

Different consultant might prefer different regimen of insulin. Common regimen used is a regimen of three premeal injections of short acting insulin. There are also other regimen that can be used such as a twice daily regimen of short and intermediate acting insulin. See also Diabetes mellitus in pregnancy: insulin therapy during antenatal phase

The aim of premeal blood sugar level range from 4 to 6 mmol/L.

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Management of complications

Early detection of complications is important, either maternal complications or fetal complications.

See also Diabetes mellitus in pregnancy: ultrasound work up during antenatal phase

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Determination of mode and timing of delivery

Optimally controlled of the diabetes, the pregnancy should be allowed to at least 38 - 39 weeks, but not to go beyond the expected date of delivery.

Poorly controlled diabetes might need earlier delivery, usually because of the complication, such as macrosomic baby.

Vaginal delivery is the mode of delivery if there is no other obstetric complications such as dysfunctional labour, which may call for emergency caesarean section.

Elective caesarean section should be considered in women with:

• Bad obstetric history
• History of subfertility
• Poor diabetic control
• Vascular complications
• Macrosomia

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*Antenatal visit frequency

Antenatal visits should be done every 2 weeks until 32 - 34weeks and then weekly thereafter.

Chronic liver disease: Child - Pugh Score

Child - Pugh score has been used as a prognostic tool for patient with chronic liver disease / cirrhosis. It is seldom useful in the management of the disease except in case of hepatocellular carcinoma, which Child - Pugh score is included in the assessment to determine wether the liver is resectable or not.

Child - Pugh score divides patients into 3 categories: A, B, and C. These categories are determined by the total sum of points from each of those 5 criteria.

Cervical carcinoma: Staging

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After a diagnosis of cervical carcinoma is established, staging is the next crucial step in determining the choice of treatment for the patient. International Federation of Gynecology and Obstetrics (FIGO) staging of cervical carcinoma is commonly used for this purpose.

Refer diagram just below

refer table above for description

Recommended treatment based on FIGO staging

Diabetes mellitus: General guideline of management

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A general guideline on how to initiate treatment after a diagnosis of DM is established, and how to step up treatment during follow up.

-refer diagram just below for description-

General guideline on management of type2 DM

Oral anti - diabetic agent groups

Hypertensive emergency : Hypertensive emergency syndromes and appropriate treatments

picture

Physicians should understand the appropriate classification of patient with hypertensive emergency. It is important to determine the classification as it will determine the appropriate treatment strategy. Hypertensive emergency can be classified based on the presenting hypertensive syndrome. Based on the presenting hypertensive syndrome, one should determine what medication is the most appropriate to be used and how much blood pressure reduction should be aim.

Manage hypertensive emergency syndromes with appropriate drugs

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Generally, the blood pressure (mean blood pressure) should be reduced by 25% (not more than that) over 3 - 12 hours, but not lower than 160/90mmHg. Too rapid reduction should be avoided as it may precipitate or worsen ischemic event. However, some special circumstances may need more rapid blood pressure reduction, especially in case of aortic dissection which requires reduction in systolic blood pressure to at least 120mmHg in 20 minutes, with protection against reflex tachycardia. 

Acute rheumatic fever (ARF): Diagnosis (criteria)

Previously, diagnosis of rheumatic fever is usually made using the Jones criteria. Later, further updated versions of Jones criteria is established with some improvements made, including those modified by WHO. Currently, there are newer criteria made with further modification of Jones criteria which is the Australian guideline for the diagnosis of rheumatic fever. These modifications are made to improve the sensitivity of previous criteria in diagnosing rheumatic fever as it has been noticed that quiet a number of ARF cases do not fulfill the diagnostic criteria of rheumatic fever.

Initial Jones criteria

Exception criteria is added later

WHO criteria add specific criteria for recurrent ARF with established RHD-rheumatic heart disease

Recent Australian guideline - as to improve sensitivity of previous WHO criteria

Hypertension : Antihypertensive agents

Anti hypertensive agents:

1. ACE-inhibitor

2. Angiotensin receptor blocker

3. Calcium channel blocker

4. Diuretics

5. Beta blocker

6. Others

?Alpha blocker

?Combined alpha, beta blocker

?Centrally acting antihypertensive agents

?Direct vasodilators

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General guideline of initiating antihypertensive agents

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Drugs and dosage

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Contraindications and adverse effects

ACE-inhibitor

Contraindication 

?Pregnancy

?Bilateral renal artery stenosis

?Serum creatinine increased >30% within 2 months of starting ACE inhibitor

Adverse effect

?Dry cough

?Angioedema (rare)

?May cause deterioration in renal function in patient with renovascular disease or renal impairment

Angiotensin receptor blocker

Contraindication and adverse effect are similar to those of ACE-inhibitor except persistent dry cough is less problematic in ARB, therefore it is recommended in ACE-inhibitor intolerance patient

Calcium channel blocker

Adverse effect

?Initial tachycardia  *Verapamil may cause bradycardia

?Headache

?Flushing

?Constipation

?Ankle edema

Diuretics

Contraindication

?Serum potassium of 5 and above (potassium sparing diuretics)

?Used with caution in patient with renal insufficiency due to risk of hyperkalemia (potassium sparing diuretics)

Adverse effect

?Hypokalemia

?Hyperkalemia (potassium sparing diuretics)

?Hyponatremia

?Hypomagnesemia

?Hyperglycemia

?Hyperuricemia - may precipitate acute attack in gout patient

?Hypercholesterolemia

Beta - blockers

Contraindication

?Obstructive airway disease

?Severe peripheral vascular disease

?Heart block

Adverse effect

?Dyslipidemia

?Masking of hypoglycemia

?Increase incidence of new onset diabetes mellitus

?Erectile dysfunction

?Bradycardia

Acute exacerbation of asthma : Medication dosage

See also Acute exacerbation of asthma : Management

Medication dosing in acute asthma. SABA  :  short acting B2 agonist

Acute exacerbation of asthma: Management

There are many guidelines created for management of acute exacerbation of asthma. The management will be based on the classification of the severity. One guideline may be used to supplement, rather than substitute for, professional judgement and may be changed depending upon individual's need.
See also Acute exacerbation of asthma(AEBA): classification. (mild, moderate, severe, life-threatening)

General guideline management of acute asthma.
IV:intravenous, MgSO4: magnesium sulfate

See also Acute exacerbation of asthma : medication dosage

Acute exacerbation of asthma (AEBA) : Classification

Classification of acute exacerbation of asthma is based on the severity. This classification is important to determine the management, for example, wether the patient should be treated in the red zone or yellow zone/asthma bay, wether the patient can be discharge home or have to be admitted in ward or ICU, or wether the patient need ventilation support or not.

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