My Clinical Notes

Diabetes

 

• Fetal exposure to maternal hyperglycaemia causes premature stimulation of beta cells of the islets of Langerhans resulting in fetal hyperinsulinaemia. This also leads to ecessive fetal growth leading to macrosomia
• Women identified as having gestational diabetes have an increased risk of developing it later in life
• Poor diabetic control can lead to congenital malformations

 

Management

• If preprandial blood glucose concentration is between 6 to 8 mmol/L, management it via diet
• Insulin therapy begins if levels are above 8mmo/L
• Oral hypoglycaemics are not used because they cross the placenta and stimulate fetal pancreatic beta cells causing fetal hyperinsulinaemia
• Important normoglycaemia is maintained during labour to prevent neonatal hypoglycaemia
• This can be achieved by insulin-dextrose infusions
• Insulin requirements decrease during labour, due to increased glucose required by the uterine muscles
• After delivery there is a rapid decline in insulin sensitivity following delivery of the placenta therefore requiring insulin infusion rate to be reduced
• Pregnancy may accelerate retinopathy in diabetic women
• Diabetic nephropathy increases the risk of pre-eclampsia and growth retardation but will probably not get worse during pregnancy
• Serum AFP and unconjugated oestriol are normally lower in a diabetic pregnancy than normal pregnancy

 

Obstetric complications

• Pre-eclampsia – test serum urate and creatine concentrations
• Polyhydramnios
• Premature labour

 

• Poorly controlled diabetes predisposes the fetus to pulmonary and hepatic immaturity which predisposes to neonatal respiratory distress syndrome and jaundice

 

• During labour there should be continuous CTG monitoring
• Pain relief is important as high levels of pain can cause catecholamine release causing glycogenolysis and hyprglycaemia

 

• Increased risk of infection following surgical procedures
• Breast feeding decreases insulin requirements

Vitamin D deficiency

 

·        Vitamin D is involved in regulation of calcium metabolism. It does this by;

·        Increasing calcium absorption from the intestine

·        Decreasing calcium excretion by the kidney

·        In conjunction with PTH, mobilising calcium from bone

·        In utero and childhood, vitamin D deficiency may cause growth retardation, skeletal abnormalities such as neonatal rickets and increased risk of hip fractures later in life

·        In adults, vitamin D deficiency may exacerbate oestopenia, oestoporosis, muscle weakness and fractures

 

Toxaemia

 

·        Refers to pre-eclampsia, characterised by hypertension, proteinuria and oedema

·        Becomes evident from the second half of pregnancy

·        Primigravidae women are more at risk

·        A history of migraine predisposes to pre-eclampsia

·        The presence of the trophoblast is necessary for disease but the fetus is not as it can occur in hydatiform mole

·        Maternal syndrome due to endothelial dysfunction

·        The proteinuria is associated with impaired glomerular perfusion and filtration, this results in reduced creatine clearance and increased plasma levels of creatine and urea

 

Lab tests aiding diagnosis

 

·        Hyperuricaemia is characteristic and often precedes proteinuria (>6mmol/L)

·        Creatine is also measured and increased with pre-eclampsia (>100umol/L)

 

·        Clotting system can become disturbed, increased plasma fibrin and raised liver enzymes. Alk phos is always elevated in late pregnancy and gamma-GT only rises late in disease. Therefore the best measurements of liver function are plasma aspartate amino-transferase and lactate dehydrogenase

 

·        Platelet levels can fall

 

·        Microangiopathic haemolysis leading to a drop in haemoglobin levels, haemoglobulinuria, fragmented RBC on blood film

 

 

Liver Disorders

 

Intrahepatic cholestasis

• Associated with puritis around week 30 and jaundice developing 2 to 4 weeks later
• Mildly raised conjugated hyperbilirubinaemia
• Twice the upper normal limits of aspartate transferase, alanine aminotransferase and alkaline phosphatase
• Fetal distress, premature labour and intrauterine death may occur.
• Elevated levels of bile acid correlate with severity of puritis and fetal distress
• Neonatal vitamin K should be given immediately postpartum

 

 

 

Acute Fatty Liver of Pregnancy

• Typically occurs in obese women in the 3^rd trimester
• May be associations with hypertension, twin pregnancy and a male fetus
• Presenting complaints include, abdominal pain, headache, nausea and vomiting
• Progressive jaundice, encephalopathy, hypoglycaemia, coagulopathy and renal failure can develop
• Histologically a perilobular faty infiltration of the liver is seen
• There is a risk of maternal and fetal death

This entry was posted on Tuesday, October 9th, 2007 at 5:18 pm and is filed under Gynaecology/Obstetrics. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.