Friday, December 21, 2007

PRINCIPLES OF MANAGMENT(2) .... DM

This is a rough guide. It is no doubt incomplete. Therapy is definitely individualized but for the benefit of my junior 'comrades'......

The aim of Obstetric Management in GDM is to achieve the delivery of a healthy baby at term with minimum adverse effect to the health of the mother.

'Term' here is limited to EDD (40 weeks)

Timing of delivery is an art. But in general,
GDM on diet, well controlled - delivery at 40 weeks POA
GDM on insulin - deliver at 38weeks or EARLIER

Early delivery (earlier than 38 weeks) is indicated when:
1. Maternal reasons:
Difficulty in achieving adequate glycaemic control
Signs and symptoms or complications of Diabetes predominate
2. Fetal reasons:
Severe macrosomia +/- polyhydramnios
Suspicion of a 'sick baby' based on reduced fetal movements, poor BPP

Mode of delivery is dependant entirely on the usual Obstetrics indications

When you encounter a woman (with GDM or DM complicating pregnancy) during antenatal care, the following universal steps are taken (over and above the usual care):
1. In the case of pre-existing DM,
Admit the patient at her first visit, the minute she's known to be pregnant
Do a 4-point BSP
Commence on Insulin
Refer to Diabetic team - usually comprise of Dietitian, Nurse & Dr
Dietitian emphasises need for diet control and guides the patient accordingly
Nurse teaches the patient on the technique of self-injection & home sugar
monitoring
Dr co-ordinates the overall progress & decides on the following:

  • Eye assessment (if the patient haven't had any)
  • Referral to Endocrinologist, if the glycaemic control is inadequate
  • Detailed fetal anomaly scan at 18-22weeks
  • HbA1c / Serum Fructosamine
  • Fetal growth chart - monitor for macrosomia
  • Monitor for maternal complications i.e. recurrent vulvovaginal candidiasis, UTI
  • Decide timing of delivery
  • Decide mode of delivery


2. In the case of newly-diagnosed GDM, there are less concerns of long-term complications. Eye assessment and renal profile is not routinely done. The patient is usually admitted once upon diagnosis. (Even this is not mandatory but it gives us the chance to introduce the patient to the dietitian, nurse, do an ultrasound scan, get a full history, etc while the patient goes through her 4-point BSP). All other principles of management as mentioned above remains.

Take note that a detailed fetal anomaly scan is offered on a selective basis due to limitations inherent in the public healthcare system. Fetal anomaly scan should be routinely offered to ALL pregnant women at 18-22 weeks. Thats the ideal situation.

Got it?

3 comments:

Azman said...

Dear Dr Sara,

My apologies for not responding in due time.

Everything here is rather 'baik'. "Baik siapkan portfolio cepat-cepat." "Baik pergi ward, kalau tak confirm kantoi." And when all fails, we go "Baiklah, Tuan Doktor."

But I'm hanging there.

And I will certainly frequent your blog and tell others to do the same. I think it's a wonderful job you've done here, Dr Sara. Everything is described in detail, easily understandable and neatly packaged in a casual-coloured wrapping paper.

For the time being, I hope you could advice me on HO posting. At the back of my head, there's a soft voice telling me to go to Sabah. That, and the extra RM1000. If I'm to go there, what should I expect, as far as working and living there is concerned.

Regards,
Azman.

p.s: I'm now writing on azmanstudies.blogspot. The other blog is on hold.

Dr Saravanen Velu said...

Hi!

Good choice you made there.

Very 'enlightening' in terms of gaining sound experience and getting over your mental-block. You will be faced with many do or die situations, where you find no one to turn to during situations of crisis. You learn to handle things on your own. Makes you more mature, cool and confident.

District posting provides excellent opportunity to attempt your Part I.

Downside- you may find yourself 'stuck' there longer than you hoped. The state pengarah may not release you for masters. And even if you get into masters program, they'll retain you in Sabah for first 2 years.

imu said...

You got me at 'cool' but shot me down at 'stuck'.