Enviar búsqueda
Cargar
pre existing DM in pregnancy
•
8 recomendaciones
•
826 vistas
Aboubakr Elnashar
Seguir
Aboubakr Elnashar
Leer menos
Leer más
Salud y medicina
Denunciar
Compartir
Denunciar
Compartir
1 de 29
Descargar ahora
Descargar para leer sin conexión
Recomendados
GESTATIONAL DM
GESTATIONAL DM
Aboubakr Elnashar
CONTROVERSIES IN MANAGEMENT OF IUGR
CONTROVERSIES IN MANAGEMENT OF IUGR
Aboubakr Elnashar
Infertility treatment related to PCOS
Infertility treatment related to PCOS
Aboubakr Elnashar
Role of ovum donation, surrogacy & Adoption in Fertility treatment- Dr. Kaber...
Role of ovum donation, surrogacy & Adoption in Fertility treatment- Dr. Kaber...
Kaberi Banerjee
ENDOMETRIAL PREPARATION IN FROZEN EMBRYO TRANSFER CYCLES
ENDOMETRIAL PREPARATION IN FROZEN EMBRYO TRANSFER CYCLES
Aboubakr Elnashar
Adenomyosis associated infertility
Adenomyosis associated infertility
Aboubakr Elnashar
Recurrent implantation failure: British fertility society Guidelines2020
Recurrent implantation failure: British fertility society Guidelines2020
Aboubakr Elnashar
what is new in controlled ovarian stimulation?
what is new in controlled ovarian stimulation?
Aboubakr Elnashar
Recomendados
GESTATIONAL DM
GESTATIONAL DM
Aboubakr Elnashar
CONTROVERSIES IN MANAGEMENT OF IUGR
CONTROVERSIES IN MANAGEMENT OF IUGR
Aboubakr Elnashar
Infertility treatment related to PCOS
Infertility treatment related to PCOS
Aboubakr Elnashar
Role of ovum donation, surrogacy & Adoption in Fertility treatment- Dr. Kaber...
Role of ovum donation, surrogacy & Adoption in Fertility treatment- Dr. Kaber...
Kaberi Banerjee
ENDOMETRIAL PREPARATION IN FROZEN EMBRYO TRANSFER CYCLES
ENDOMETRIAL PREPARATION IN FROZEN EMBRYO TRANSFER CYCLES
Aboubakr Elnashar
Adenomyosis associated infertility
Adenomyosis associated infertility
Aboubakr Elnashar
Recurrent implantation failure: British fertility society Guidelines2020
Recurrent implantation failure: British fertility society Guidelines2020
Aboubakr Elnashar
what is new in controlled ovarian stimulation?
what is new in controlled ovarian stimulation?
Aboubakr Elnashar
Unnecessary investigations in reproductive medicine
Unnecessary investigations in reproductive medicine
Aboubakr Elnashar
ART PREGNANCY COMPLICATIONS Prof. Aboubakr Elnashar
ART PREGNANCY COMPLICATIONS Prof. Aboubakr Elnashar
Aboubakr Elnashar
update on PCOS
update on PCOS
Aboubakr Elnashar
Management of pregnancy of unknown location
Management of pregnancy of unknown location
Aboubakr Elnashar
F.G.R. PANEL DISCUSSION AT FOGSI BOH CONFERENCE
F.G.R. PANEL DISCUSSION AT FOGSI BOH CONFERENCE
NARENDRA MALHOTRA
update on poor responder
update on poor responder
Aboubakr Elnashar
Management of diabetes during pregnancy
Management of diabetes during pregnancy
Aboubakr Elnashar
agonist trigger state of art
agonist trigger state of art
Aziza Negm
Fresh or frozen embryos – which are better
Fresh or frozen embryos – which are better
Dr Aniruddha Malpani
Emergency Contraception-Whats New?
Emergency Contraception-Whats New?
Dr.Laxmi Agrawal Shrikhande
Hormonal assay in clinical gyn
Hormonal assay in clinical gyn
Aboubakr Elnashar
Cesarean Scar Ectopic Pregnancy Current Management Strategies
Cesarean Scar Ectopic Pregnancy Current Management Strategies
Aboubakr Elnashar
Fet endometrial preparation
Fet endometrial preparation
Fatih Karaosmanoglu
Induction of labor
Induction of labor
kr
Aboubakr elnashar lectures on ART
Aboubakr elnashar lectures on ART
Aboubakr Elnashar
Optimizing IUI Outcome
Optimizing IUI Outcome
Dr.Laxmi Agrawal Shrikhande
Ohss
Ohss
Sundar Narayanan
COVID 19 infection and pregnancy RCOG2021
COVID 19 infection and pregnancy RCOG2021
Aboubakr Elnashar
Embryo grading
Embryo grading
sunitafeme
Reurrent Miscarriage
Reurrent Miscarriage
Aboubakr Elnashar
Preexisting DM in pregnancy
Preexisting DM in pregnancy
Aboubakr Elnashar
GESTATIONAL DIABETES MELLITUS
GESTATIONAL DIABETES MELLITUS
SangeethaVijian
Más contenido relacionado
La actualidad más candente
Unnecessary investigations in reproductive medicine
Unnecessary investigations in reproductive medicine
Aboubakr Elnashar
ART PREGNANCY COMPLICATIONS Prof. Aboubakr Elnashar
ART PREGNANCY COMPLICATIONS Prof. Aboubakr Elnashar
Aboubakr Elnashar
update on PCOS
update on PCOS
Aboubakr Elnashar
Management of pregnancy of unknown location
Management of pregnancy of unknown location
Aboubakr Elnashar
F.G.R. PANEL DISCUSSION AT FOGSI BOH CONFERENCE
F.G.R. PANEL DISCUSSION AT FOGSI BOH CONFERENCE
NARENDRA MALHOTRA
update on poor responder
update on poor responder
Aboubakr Elnashar
Management of diabetes during pregnancy
Management of diabetes during pregnancy
Aboubakr Elnashar
agonist trigger state of art
agonist trigger state of art
Aziza Negm
Fresh or frozen embryos – which are better
Fresh or frozen embryos – which are better
Dr Aniruddha Malpani
Emergency Contraception-Whats New?
Emergency Contraception-Whats New?
Dr.Laxmi Agrawal Shrikhande
Hormonal assay in clinical gyn
Hormonal assay in clinical gyn
Aboubakr Elnashar
Cesarean Scar Ectopic Pregnancy Current Management Strategies
Cesarean Scar Ectopic Pregnancy Current Management Strategies
Aboubakr Elnashar
Fet endometrial preparation
Fet endometrial preparation
Fatih Karaosmanoglu
Induction of labor
Induction of labor
kr
Aboubakr elnashar lectures on ART
Aboubakr elnashar lectures on ART
Aboubakr Elnashar
Optimizing IUI Outcome
Optimizing IUI Outcome
Dr.Laxmi Agrawal Shrikhande
Ohss
Ohss
Sundar Narayanan
COVID 19 infection and pregnancy RCOG2021
COVID 19 infection and pregnancy RCOG2021
Aboubakr Elnashar
Embryo grading
Embryo grading
sunitafeme
Reurrent Miscarriage
Reurrent Miscarriage
Aboubakr Elnashar
La actualidad más candente
(20)
Unnecessary investigations in reproductive medicine
Unnecessary investigations in reproductive medicine
ART PREGNANCY COMPLICATIONS Prof. Aboubakr Elnashar
ART PREGNANCY COMPLICATIONS Prof. Aboubakr Elnashar
update on PCOS
update on PCOS
Management of pregnancy of unknown location
Management of pregnancy of unknown location
F.G.R. PANEL DISCUSSION AT FOGSI BOH CONFERENCE
F.G.R. PANEL DISCUSSION AT FOGSI BOH CONFERENCE
update on poor responder
update on poor responder
Management of diabetes during pregnancy
Management of diabetes during pregnancy
agonist trigger state of art
agonist trigger state of art
Fresh or frozen embryos – which are better
Fresh or frozen embryos – which are better
Emergency Contraception-Whats New?
Emergency Contraception-Whats New?
Hormonal assay in clinical gyn
Hormonal assay in clinical gyn
Cesarean Scar Ectopic Pregnancy Current Management Strategies
Cesarean Scar Ectopic Pregnancy Current Management Strategies
Fet endometrial preparation
Fet endometrial preparation
Induction of labor
Induction of labor
Aboubakr elnashar lectures on ART
Aboubakr elnashar lectures on ART
Optimizing IUI Outcome
Optimizing IUI Outcome
Ohss
Ohss
COVID 19 infection and pregnancy RCOG2021
COVID 19 infection and pregnancy RCOG2021
Embryo grading
Embryo grading
Reurrent Miscarriage
Reurrent Miscarriage
Similar a pre existing DM in pregnancy
Preexisting DM in pregnancy
Preexisting DM in pregnancy
Aboubakr Elnashar
GESTATIONAL DIABETES MELLITUS
GESTATIONAL DIABETES MELLITUS
SangeethaVijian
Gestational Diabetes Mellitus.pptx
Gestational Diabetes Mellitus.pptx
Md. Redwan Jannah
Gestational Diabetes Endocrine course .pdf
Gestational Diabetes Endocrine course .pdf
Elhadi Miskeen
Diabetes in Pregnancy management all.pptx
Diabetes in Pregnancy management all.pptx
Saivenkat Kumbham
Gestational Diabetes Mallets that is metabolic diseases in pregnancy ppt
Gestational Diabetes Mallets that is metabolic diseases in pregnancy ppt
sonal patel
Diabetes in pregnancy
Diabetes in pregnancy
Brian Shiluli
GDM
GDM
Kapila Gunawardana
Gestational diabetes
Gestational diabetes
DrNawras
DIABETES IN PREGNANCY FOR MIDWIVES_ .pptx
DIABETES IN PREGNANCY FOR MIDWIVES_ .pptx
TabithaGorlekuOforiw
DM IN PREGN.pdf
DM IN PREGN.pdf
Fatima117039
Lecture_15._Diabetes_in_Pregnancy.ppt
Lecture_15._Diabetes_in_Pregnancy.ppt
Lawrenceshamboko
DM in pregnancy .pdf
DM in pregnancy .pdf
MuhamadAznorAqwaAzma
Presentation 28.pptx
Presentation 28.pptx
DrTejaswini7
Diabetes in pregnancy segamat 2012
Diabetes in pregnancy segamat 2012
Dr Zharifhussein
Diabetes in pregnancy
Diabetes in pregnancy
Kishore Rajan
GESTATIONAL DM.pptx
GESTATIONAL DM.pptx
Snehlata Parashar
DM IN PREGNANCY
DM IN PREGNANCY
Snehlata Parashar
emesis .ppt
emesis .ppt
rizwan250810
Hyperemesis Gravidarum
Hyperemesis Gravidarum
Joisy S. Joy
Similar a pre existing DM in pregnancy
(20)
Preexisting DM in pregnancy
Preexisting DM in pregnancy
GESTATIONAL DIABETES MELLITUS
GESTATIONAL DIABETES MELLITUS
Gestational Diabetes Mellitus.pptx
Gestational Diabetes Mellitus.pptx
Gestational Diabetes Endocrine course .pdf
Gestational Diabetes Endocrine course .pdf
Diabetes in Pregnancy management all.pptx
Diabetes in Pregnancy management all.pptx
Gestational Diabetes Mallets that is metabolic diseases in pregnancy ppt
Gestational Diabetes Mallets that is metabolic diseases in pregnancy ppt
Diabetes in pregnancy
Diabetes in pregnancy
GDM
GDM
Gestational diabetes
Gestational diabetes
DIABETES IN PREGNANCY FOR MIDWIVES_ .pptx
DIABETES IN PREGNANCY FOR MIDWIVES_ .pptx
DM IN PREGN.pdf
DM IN PREGN.pdf
Lecture_15._Diabetes_in_Pregnancy.ppt
Lecture_15._Diabetes_in_Pregnancy.ppt
DM in pregnancy .pdf
DM in pregnancy .pdf
Presentation 28.pptx
Presentation 28.pptx
Diabetes in pregnancy segamat 2012
Diabetes in pregnancy segamat 2012
Diabetes in pregnancy
Diabetes in pregnancy
GESTATIONAL DM.pptx
GESTATIONAL DM.pptx
DM IN PREGNANCY
DM IN PREGNANCY
emesis .ppt
emesis .ppt
Hyperemesis Gravidarum
Hyperemesis Gravidarum
Más de Aboubakr Elnashar
WHAT IS NEW IN ESHRE 2022 AND FIGO 2022 FOR GENERAL GYNAECOLOGIST
WHAT IS NEW IN ESHRE 2022 AND FIGO 2022 FOR GENERAL GYNAECOLOGIST
Aboubakr Elnashar
hepatitis B.pdf
hepatitis B.pdf
Aboubakr Elnashar
hepatitis c2022.pdf
hepatitis c2022.pdf
Aboubakr Elnashar
Endometriosis associated infertility: ESHRE2022
Endometriosis associated infertility: ESHRE2022
Aboubakr Elnashar
Adenxal mass guidelines2020
Adenxal mass guidelines2020
Aboubakr Elnashar
Aesthetic gynecology controversy
Aesthetic gynecology controversy
Aboubakr Elnashar
FIRST TRIMESTER ANC OF IVF
FIRST TRIMESTER ANC OF IVF
Aboubakr Elnashar
Infertility prevention
Infertility prevention
Aboubakr Elnashar
Individualisation of controlled ovarian stimulation
Individualisation of controlled ovarian stimulation
Aboubakr Elnashar
Female infertility
Female infertility
Aboubakr Elnashar
Maternal near miss
Maternal near miss
Aboubakr Elnashar
THE MANAGEMENT OF SEVERE PET/ECLAMPSIA
THE MANAGEMENT OF SEVERE PET/ECLAMPSIA
Aboubakr Elnashar
cesarean birth: procedural aspects: NICE2021
cesarean birth: procedural aspects: NICE2021
Aboubakr Elnashar
CAESAREAN SCAR DEFECT
CAESAREAN SCAR DEFECT
Aboubakr Elnashar
Aerobic Vaginitis
Aerobic Vaginitis
Aboubakr Elnashar
Imaging in pregnancy 2 in1
Imaging in pregnancy 2 in1
Aboubakr Elnashar
PREECLAMPSIA‐ECLAMPSIA SPECTRUM
PREECLAMPSIA‐ECLAMPSIA SPECTRUM
Aboubakr Elnashar
Ovarian cysts and infertility
Ovarian cysts and infertility
Aboubakr Elnashar
Heterotopoic pregnancy
Heterotopoic pregnancy
Aboubakr Elnashar
COVID 19 infection and pregnancy RCOG2021
COVID 19 infection and pregnancy RCOG2021
Aboubakr Elnashar
Más de Aboubakr Elnashar
(20)
WHAT IS NEW IN ESHRE 2022 AND FIGO 2022 FOR GENERAL GYNAECOLOGIST
WHAT IS NEW IN ESHRE 2022 AND FIGO 2022 FOR GENERAL GYNAECOLOGIST
hepatitis B.pdf
hepatitis B.pdf
hepatitis c2022.pdf
hepatitis c2022.pdf
Endometriosis associated infertility: ESHRE2022
Endometriosis associated infertility: ESHRE2022
Adenxal mass guidelines2020
Adenxal mass guidelines2020
Aesthetic gynecology controversy
Aesthetic gynecology controversy
FIRST TRIMESTER ANC OF IVF
FIRST TRIMESTER ANC OF IVF
Infertility prevention
Infertility prevention
Individualisation of controlled ovarian stimulation
Individualisation of controlled ovarian stimulation
Female infertility
Female infertility
Maternal near miss
Maternal near miss
THE MANAGEMENT OF SEVERE PET/ECLAMPSIA
THE MANAGEMENT OF SEVERE PET/ECLAMPSIA
cesarean birth: procedural aspects: NICE2021
cesarean birth: procedural aspects: NICE2021
CAESAREAN SCAR DEFECT
CAESAREAN SCAR DEFECT
Aerobic Vaginitis
Aerobic Vaginitis
Imaging in pregnancy 2 in1
Imaging in pregnancy 2 in1
PREECLAMPSIA‐ECLAMPSIA SPECTRUM
PREECLAMPSIA‐ECLAMPSIA SPECTRUM
Ovarian cysts and infertility
Ovarian cysts and infertility
Heterotopoic pregnancy
Heterotopoic pregnancy
COVID 19 infection and pregnancy RCOG2021
COVID 19 infection and pregnancy RCOG2021
Último
Night 7k to 12k Chennai City Center Call Girls 👉👉 7427069034⭐⭐ 100% Genuine E...
Night 7k to 12k Chennai City Center Call Girls 👉👉 7427069034⭐⭐ 100% Genuine E...
hotbabesbook
Call Girls Aurangabad Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Aurangabad Just Call 9907093804 Top Class Call Girl Service Available
Dipal Arora
(👑VVIP ISHAAN ) Russian Call Girls Service Navi Mumbai🖕9920874524🖕Independent...
(👑VVIP ISHAAN ) Russian Call Girls Service Navi Mumbai🖕9920874524🖕Independent...
Taniya Sharma
Call Girls Bareilly Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Bareilly Just Call 9907093804 Top Class Call Girl Service Available
Dipal Arora
Call Girls Visakhapatnam Just Call 9907093804 Top Class Call Girl Service Ava...
Call Girls Visakhapatnam Just Call 9907093804 Top Class Call Girl Service Ava...
Dipal Arora
Premium Call Girls Cottonpet Whatsapp 7001035870 Independent Escort Service
Premium Call Girls Cottonpet Whatsapp 7001035870 Independent Escort Service
vidya singh
Best Rate (Hyderabad) Call Girls Jahanuma ⟟ 8250192130 ⟟ High Class Call Girl...
Best Rate (Hyderabad) Call Girls Jahanuma ⟟ 8250192130 ⟟ High Class Call Girl...
astropune
VIP Hyderabad Call Girls Bahadurpally 7877925207 ₹5000 To 25K With AC Room 💚😋
VIP Hyderabad Call Girls Bahadurpally 7877925207 ₹5000 To 25K With AC Room 💚😋
TANUJA PANDEY
Call Girls Gwalior Just Call 8617370543 Top Class Call Girl Service Available
Call Girls Gwalior Just Call 8617370543 Top Class Call Girl Service Available
Dipal Arora
Book Paid Powai Call Girls Mumbai 𖠋 9930245274 𖠋Low Budget Full Independent H...
Book Paid Powai Call Girls Mumbai 𖠋 9930245274 𖠋Low Budget Full Independent H...
Call Girls in Nagpur High Profile
Call Girls Ludhiana Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Ludhiana Just Call 9907093804 Top Class Call Girl Service Available
Dipal Arora
VIP Service Call Girls Sindhi Colony 📳 7877925207 For 18+ VIP Call Girl At Th...
VIP Service Call Girls Sindhi Colony 📳 7877925207 For 18+ VIP Call Girl At Th...
jageshsingh5554
Call Girls Cuttack Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Cuttack Just Call 9907093804 Top Class Call Girl Service Available
Dipal Arora
Top Rated Bangalore Call Girls Mg Road ⟟ 9332606886 ⟟ Call Me For Genuine S...
Top Rated Bangalore Call Girls Mg Road ⟟ 9332606886 ⟟ Call Me For Genuine S...
narwatsonia7
(Low Rate RASHMI ) Rate Of Call Girls Jaipur ❣ 8445551418 ❣ Elite Models & Ce...
(Low Rate RASHMI ) Rate Of Call Girls Jaipur ❣ 8445551418 ❣ Elite Models & Ce...
parulsinha
Best Rate (Patna ) Call Girls Patna ⟟ 8617370543 ⟟ High Class Call Girl In 5 ...
Best Rate (Patna ) Call Girls Patna ⟟ 8617370543 ⟟ High Class Call Girl In 5 ...
Dipal Arora
Night 7k to 12k Navi Mumbai Call Girl Photo 👉 BOOK NOW 9833363713 👈 ♀️ night ...
Night 7k to 12k Navi Mumbai Call Girl Photo 👉 BOOK NOW 9833363713 👈 ♀️ night ...
aartirawatdelhi
Call Girls Haridwar Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Haridwar Just Call 9907093804 Top Class Call Girl Service Available
Dipal Arora
VIP Call Girls Indore Kirti 💚😋 9256729539 🚀 Indore Escorts
VIP Call Girls Indore Kirti 💚😋 9256729539 🚀 Indore Escorts
aditipandeya
Call Girls Bangalore Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Bangalore Just Call 9907093804 Top Class Call Girl Service Available
Dipal Arora
Último
(20)
Night 7k to 12k Chennai City Center Call Girls 👉👉 7427069034⭐⭐ 100% Genuine E...
Night 7k to 12k Chennai City Center Call Girls 👉👉 7427069034⭐⭐ 100% Genuine E...
Call Girls Aurangabad Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Aurangabad Just Call 9907093804 Top Class Call Girl Service Available
(👑VVIP ISHAAN ) Russian Call Girls Service Navi Mumbai🖕9920874524🖕Independent...
(👑VVIP ISHAAN ) Russian Call Girls Service Navi Mumbai🖕9920874524🖕Independent...
Call Girls Bareilly Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Bareilly Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Visakhapatnam Just Call 9907093804 Top Class Call Girl Service Ava...
Call Girls Visakhapatnam Just Call 9907093804 Top Class Call Girl Service Ava...
Premium Call Girls Cottonpet Whatsapp 7001035870 Independent Escort Service
Premium Call Girls Cottonpet Whatsapp 7001035870 Independent Escort Service
Best Rate (Hyderabad) Call Girls Jahanuma ⟟ 8250192130 ⟟ High Class Call Girl...
Best Rate (Hyderabad) Call Girls Jahanuma ⟟ 8250192130 ⟟ High Class Call Girl...
VIP Hyderabad Call Girls Bahadurpally 7877925207 ₹5000 To 25K With AC Room 💚😋
VIP Hyderabad Call Girls Bahadurpally 7877925207 ₹5000 To 25K With AC Room 💚😋
Call Girls Gwalior Just Call 8617370543 Top Class Call Girl Service Available
Call Girls Gwalior Just Call 8617370543 Top Class Call Girl Service Available
Book Paid Powai Call Girls Mumbai 𖠋 9930245274 𖠋Low Budget Full Independent H...
Book Paid Powai Call Girls Mumbai 𖠋 9930245274 𖠋Low Budget Full Independent H...
Call Girls Ludhiana Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Ludhiana Just Call 9907093804 Top Class Call Girl Service Available
VIP Service Call Girls Sindhi Colony 📳 7877925207 For 18+ VIP Call Girl At Th...
VIP Service Call Girls Sindhi Colony 📳 7877925207 For 18+ VIP Call Girl At Th...
Call Girls Cuttack Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Cuttack Just Call 9907093804 Top Class Call Girl Service Available
Top Rated Bangalore Call Girls Mg Road ⟟ 9332606886 ⟟ Call Me For Genuine S...
Top Rated Bangalore Call Girls Mg Road ⟟ 9332606886 ⟟ Call Me For Genuine S...
(Low Rate RASHMI ) Rate Of Call Girls Jaipur ❣ 8445551418 ❣ Elite Models & Ce...
(Low Rate RASHMI ) Rate Of Call Girls Jaipur ❣ 8445551418 ❣ Elite Models & Ce...
Best Rate (Patna ) Call Girls Patna ⟟ 8617370543 ⟟ High Class Call Girl In 5 ...
Best Rate (Patna ) Call Girls Patna ⟟ 8617370543 ⟟ High Class Call Girl In 5 ...
Night 7k to 12k Navi Mumbai Call Girl Photo 👉 BOOK NOW 9833363713 👈 ♀️ night ...
Night 7k to 12k Navi Mumbai Call Girl Photo 👉 BOOK NOW 9833363713 👈 ♀️ night ...
Call Girls Haridwar Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Haridwar Just Call 9907093804 Top Class Call Girl Service Available
VIP Call Girls Indore Kirti 💚😋 9256729539 🚀 Indore Escorts
VIP Call Girls Indore Kirti 💚😋 9256729539 🚀 Indore Escorts
Call Girls Bangalore Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Bangalore Just Call 9907093804 Top Class Call Girl Service Available
pre existing DM in pregnancy
1.
PRE-EXISTING DIABETES MELLITUS Prof. Aboubakr Elnashar Benha ubiversity Hospital, Egypt elnashar53@hotmail.com ABOUBAKR ELNASHAR ABOUBAKR ELNASHAR CONTENTS 1. PHYSIOLOGICAL CHANGES 2. PREVALENCE 3. EFFECT OF PREGNANCY ON DM 4. EFFECT OF DM ON PREGNANCY 5. COMPLICATIONS OF DM IN PREGNANCY 6. MANAGEMENT 1. PREPREGNANCY 2. ANTENATAL CARE 3. INTRAPARTUM 4. POSTPARTUM ❑ CONCLUSION
2.
1. PHYSIOLOGICAL CHANGES 1. Insulin resistance & relative glucose intolerance. ▪ Increasing after the first trimester ▪ Due to diabetogenic(anti-insulin)hormones secreted by placenta ▪ Human placental lactogen ▪ Cortisol ▪ Glucagon ▪ Oestrogen ▪ Progesterone ▪ Insulin requirements increase throughout, maximal at term. ABOUBAKR ELNASHAR 2. Renal tubular threshold for glucose falls: ▪ Glycosuria ▪ Glycosuria is not a reliable diagnostic tool for impaired glucose tolerance or diabetes in pregnancy. 3. Starvation: early breakdown of triglyceride: Liberation of fatty acids&ketone bodies: increased risk of ketoacidosis. ▪ This is most marked in the third trimester. ABOUBAKR ELNASHAR
3.
ABOUBAKR ELNASHAR 2. PREVALENCE ▪ 1–2% of pregnancies. ▪ In the UK, ▪ type 1 is about 0.5% ▪ type 2 about 3%–4% (lower in women of childbearing age, but higher in Afro- Caribbean and 10% in Asian ethnicities). ▪ pre-existing diabetes in pregnancy 0.4% (0.27% type 1 and 0.1% type 2). ABOUBAKR ELNASHAR
4.
3. EFFECT OF PREGNANCY ON DIABETES 1. Insulin requirements ▪ {normal pregnancy is associated with an increase in insulin production & insulin resistance} ▪ Type 1 diabetes require increasing doses of insulin as pregnancy progresses. ▪ Maximum requirements at term usually reach at least 2 fold pre-pregnancy doses. ▪ Type 2 diabetes often need the addition of insulin to their therapy or increasing doses of insulin. ▪ Rapid increases in insulin requirements between 28& 32 w, when the fetus is growing rapidly. ABOUBAKR ELNASHAR 2. Hypoglycaemia ▪ More common in pregnancy {intensified diabetic control ‘hypoglycaemia unawareness}’. ▪ Many maternal deaths caused by diabetes are due to hypoglycaemia. ▪ For every 1% fall in HbA1C, there is a 33% increase in hypoglycaemic attacks. ABOUBAKR ELNASHAR
5.
3. Ketoacidosis: ▪Rare ▪may be associated with ▪Hyperemesis ▪Infection ▪Tocolysis ( β sympathomimetics), or ▪Steroid therapy. ABOUBAKR ELNASHAR 4. Retinopathy: ▪Two-fold increased risk of development or progression of existing disease. ▪Rapid improvement in glycaemic control: increased retinal blood flow, which can cause retinopathy. ▪All diabetic women should have assessment for retinopathy in pregnancy, and proliferative retinopathy requires treatment. ▪Early changes usually revert after delivery. ABOUBAKR ELNASHAR
6.
5. Nephropathy: ▪5–10%. ▪Renal function & proteinuria may worsen during pregnancy. ▪usually temporary. ▪increased risk of ▪pre-eclampsia ▪IUGR ▪ increased surveillance is required. ABOUBAKR ELNASHAR 6. Ischaemic heart disease: ▪{Pregnancy increases cardiac workload}. ▪Women with symptoms should be assessed by a cardiologist before conception. 7. Women with autonomic neuropathy&gastric paresis often experience deterioration of their symptoms in pregnancy. ABOUBAKR ELNASHAR
7.
4. EFFECT OF DIABETES ON PREGNANCY I. Maternal hyperglycaemia: fetal hyperglycaemia. II. Fetal hyperglycaemia: hyperinsulinaemia (through β –cell hyperplasia in fetal pancreatic cells). Insulin acts as a growth promoter: ▪ Macrosomia ▪ Organomegaly ▪ Increase erythropoiesis ▪ Fetal polyuria (polyhydramnios). ABOUBAKR ELNASHAR ABOUBAKR ELNASHAR
8.
III. Neonatal hypoglycaemia: {removal of maternal glucose supply at birth from a hyperinsulinaemic fetus}. Respiratory distress syndrome: ▪More common {surfactant deficiency occurring through reduced production of pulmonary phospholipids}. ABOUBAKR ELNASHAR 5. COMPLICATIONS OF DIABETES IN PREGNANCY I. Maternal •Infections: UTI., recurrent vulvovaginal candidiasis, respiratory, endometrial, wound infections • Pregnancy-induced hypertension/pre-eclampsia. • Retinopathy (15%). • Nephropathy. • Cardiac disease. ▪Obstructed labour. • Operative deliveries: CS & assisted vaginal deliveries. ABOUBAKR ELNASHAR
9.
II. Fetal • Miscarriage* • Congenital abnormalities: In diabetics with poor control ▪ The specific: sacral agenesis, but this is very rare ▪ More common: congenital heart defects, skeletal abnormalities, NTD. • Preterm labour. • Polyhydramnios (25%). • Macrosomia (25–40%). • IUGR. • Unexplained IUD. ABOUBAKR ELNASHAR ▪ Congenital abnormalities. ▪ Incidence: 4% (double background) ▪ 3 fold increase of NTD and congenital heart disease. ▪ Risk: directly related to ▪ glycaemic control around the time of conception ▪ HbA1C. ▪ <8%: risk of 5% ▪ >10%: risk is as high as 25%. ▪ Normal: risk is eliminated ▪ Recommendation at the time of conception. ▪ HbA1C should be <7% (USA) <6.1%in (UK) ABOUBAKR ELNASHAR
10.
▪ Macrosomia ▪ B wt>4.5 kg or >90th percentile for g age. ▪ Insulin is an anabolic, growth-promoting hormon ▪ Baby is fat, plethoric, with all organs enlarged particularly the liver ▪ More common with poor diabetic control, but may also occur in cases of excellent control. ▪ incidence increases significantly when mean maternal blood glucose >7.2 mmol/L(130mg/dl) ▪ incidence of b wt >4 kg was 21% ▪ incidence of shoulder dystocia: 8%. ▪ Often associated with polyhydramnios {fetal polyuria}: preterm PROM and cord prolapse. ▪ increases the risk of traumatic delivery, particularly shoulder dystocia. ABOUBAKR ELNASHAR ▪ Sudden unexplained IUD ▪ inversely related to the degree of diabetic control ▪ highest after 36w. ▪ Chronic hypoxia (more common in macrosomic babies in the presence of hyperglycaemia & lactic acidosis. ▪ Not predicted from CTG, Doppler velocimetry or FBP. ▪ Maternal hyperglycaemia, and particularly ketoacidosis ▪ detrimental to the fetus, high (10%–25%) fetal mortality ▪ In contrast, maternal hypoglycaemia is well tolerated by fetus. ABOUBAKR ELNASHAR
11.
III. Neonatal • Polycythaemia. • Jaundice. • Hypoglycaemia. • Hypocalcaemia. • Hypomagnesaemia. • Hypothermia. • Cardiomegaly. • Birth trauma: shoulder dystocia, fractures, Erb’s palsy, asphyxia. • Respiratory distress syndrome. ABOUBAKR ELNASHAR ▪ Fetal hyperinsulinaemia ▪ may lead to chronic fetal hypoxia: stimulates extramedullary haemopoiesis, fetal polycythaemia & neonatal jaundice. ▪ In the presence of fetal hyperinsulinaemia, when the cord is clamped, the neonate is ‘cut off’ from its supply of glucose from the mother and is at risk of neonatal hypoglycaemia. ABOUBAKR ELNASHAR
12.
▪ Perinatal & neonatal mortality rates ▪ can be increased five- to tenfold in babies ▪ relate to HbA1C at conception and in early pregnancy. ▪ perinatal mortality rate for both type 1 and type 2 diabetes was about 3%. ABOUBAKR ELNASHAR 7. MANAGEMENT I. Prepregnancy care ▪ This is one of the most important aspects 1. Achievement of optimal control: ▪ FBS: between 63-106mg/dl ▪ 1h post-prandial <140 mg/dl (increased risk of miscarriage and congenital abnormalities with poor control). ABOUBAKR ELNASHAR
13.
2 . Assessment of severity of diabetes: check for ▪Hypertension ▪Nephropathy ▪U&E ▪Urinalysis ▪urinary protein: creatinine ratio ▪24h urine for protein. Proteinuria should be documented and quantified prior to pregnancy with an ACR or PCR. ▪Creatinine clearance {PET is increased in the presence of microalbuminuria (30– 300 mg/day) although to a lesser degree than in those with frank nephropathy (>300 mg/day). ABOUBAKR ELNASHAR ▪Retinopathy ▪fundoscopy, ophthalmology assessment. ▪If necessary, proliferative retinopathy may be treated with photocoagulation prior to conception ▪Neuropathy ▪clinical assessment ▪Cardiac disease. ABOUBAKR ELNASHAR
14.
3. Education ▪Good control: ▪Decreased F congenital abnormalities& preeclampsia ▪Improved pregnancy outcome ▪Effects of hyperglycaemia on fetus ▪Need for tight control ▪To inform doctor as soon as pregnancy confirmed ▪Some drugs may need stopping (ACEIs). 4. General health: ▪Stop smoking ▪Optimize weight (aim for a normal BMI), ABOUBAKR ELNASHAR 6. Medications ▪ Folic acid: {Increased risk of NTD}: 1mg. ▪ Rubella status: offer vaccination if not rubella immune. ▪ Contraception: until good control achieved ▪ Unplanned pregnancy is a risk factor for LFGA ▪ Contraindications to pregnancy ▪ Ischaemic heart disease ▪ Untreated proliferative retinopathy, ▪ Severe gastroparesis ▪ Severe renal impairment (CKD 4/5; creatinine >250 μmol/L). ABOUBAKR ELNASHAR
15.
II. Antenatal care ▪Multidisciplinary team with a diabetologist. 1. Medical management 1. Control of DM ▪ Diet: ▪ Strict adherence to a low-sugar, low-fat, high-fibre diet ▪ Low glycaemic index. ▪ Starvation and severe calorie restriction should be avoided because of the risk of ketoacidosis ▪ HbA1c every month: ▪ reflects control over the preceding 2mths. . ABOUBAKR ELNASHAR ▪ Home blood glucose monitoring (HBGM) ▪ using ▪ Glucose oxidase strips and glucose meters or ▪ Ideally a continuous glucose monitoring sensor (CGMS) (such as the Freestyle Libre®). ▪ spend more time within target glucose levels. ▪ lower rate of LGA babies, and improved neonatal outcome ▪Test blood glucose levels at least 4 times/d ▪Usually before meals but post-meal glucose may give tighter control ▪Before going to bed at night. ABOUBAKR ELNASHAR
16.
▪ Target capillary blood glucose ▪ Fasting: 3.5–5.3 mmol/L (63-95mg/dl) ▪ 1 H PP: <7.8 mmol/L (140mg/dl) (the same for types 1, 2 and gestational diabetes). ▪ Outcomes such as b wt & neonatal hypoglycaemia correlate better with postprandial than with preprandial glucose levels. ▪ Using postprandial targets: better improvements in maternal HbA1C levels. ABOUBAKR ELNASHAR ▪ Insulin Types ▪ Lispro and Aspart benefits: 1. Fewer hypoglycaemic episodes 2. Better control
17.
▪Calculation of insulin dose: 1. Initial insulin dose: TDD 2. Adjustments acc to ▪ meal and blood glucose diaries ▪ results of point-of-care Hb A1c measurements. For patients receiving 2 injections per day – 2/3 of the dose in the morning: Regular: Intermediate =1:2 – 1/3 of dose in the evening: Regular: Intermediate =1:2 to1:1. Preprandial capillary blood level for adjusting the dose of regular or rapid acting insulin using sliding scale (Inzucchi,1999)
18.
▪ Supplemental-Short acting Insulin Scale (SSIS) (ADA 1999) Prepr. Capillary g. (mg/dl) Additional SSIS(regular or lispro) < 100 0 100-140 2 141-160 3 161-180 4 181-200 5 201-250 6 251-300 8 > 300 10 Additional suplem.= 1 unit for every 20mg above 100 ▪ Management of type 1 diabetes ▪ Increasing doses of insulin throughout pregnancy, although insulin requirements may fall or be variable in 1 st trimester. ▪ The inevitable result of tighter control is an increased risk of hypoglycaemic attacks. ▪ Women should be warned about risks of hypoglycaemia& unawareness of hypoglycaemia particularly in 1st trimester. ▪ Usually require a ‘snack’ mid-morning, mid-afternoon, and before retiring at night. ▪ Women should be provided with concentrated glucose solution for use in the event of hypoglycaemia. ▪ Relatives or partners may be taught how to administer IM glucagon injections to avert profound hypoglycaemia in situations where the woman is unable or unwilling to eat or drink. The woman should be advised that glucagon provides only temporary relief from hypoglycaemia and should always be followed by oral intake of glucose-containing food or drink. ABOUBAKR ELNASHAR
19.
▪ Most women are managed with basal bolus regimens using fast-acting insulin analogues (Humalog® insulin lispro, Novorapid® insulin aspart) taken with meals. ▪ The long-acting insulin analogues detemir and glargine are the long-acting insulins of choice in pregnancy. ▪ Glargine dose is often divided into a BD regime from ws 16 to 20 in order to achieve good preprandial control. ▪ In some countries NPG (isophane) insulin is still used in pregnancy and this is also often used as a BD regime. ▪ Insulin often need to be increased in the presence of infection, use of corticosteroids ▪ Women should be offered blood ketone testing strips and a meter and advised to test for ketonaemia if they become hyperglycaemic or unwell. ABOUBAKR ELNASHAR ▪ Management of type 2 diabetes ▪ Most women require tt with insulin during pregnancy. ▪ Metformin ▪ biguanide can be used as an adjunct or alternative to insulin (NICE). ▪ Thiazolidinediones ▪ e.g., rosiglitazone, pioglitazone ▪ reduce peripheral insulin resistance. ▪ Out with pregnancy they are used as 2 nd line therapy added to either metformin or sulphonylureas ▪ Their use is avoided in pregnancy. ▪ Sitagliptin ▪ dipeptidyl peptidase-4 (DPP-4) inhibitor increasing the production of insulin and decreasing the production of glucagon by the pancreas. ▪ It is also avoided in pregnancy. ▪ Glucagon-like peptide-1 (GLP-1) receptor agonists and SGLT2 inhibitors are also avoided in pregnancy. ABOUBAKR ELNASHAR
20.
2. Prevention of Diabetic complications ▪ Retinopathy: ▪ Ophthalmological examination with digital imaging of the retina with mydriasis using tropicamide pre-pregnancy and in early pregnancy if their annual assessment occurred more than 3 months previously and at 28 weeks. If diabetic retinopathy is present, the next assessment should be at 16–20 weeks. Laser photocoagulation can be used either to treat or prevent proliferative retinopathy in pregnancy. ▪ Diabetic retinopathy is not a contraindication to rapid optimization of glycaemic control nor to vaginal delivery. ▪ Women with pre-proliferative diabetic retinopathy should have ophthalmological follow up for at least 6 months postpartum. ABOUBAKR ELNASHAR ▪ Nephropathy: ▪ Referral to a nephrologist pre-pregnancy or in early pregnancy if the serum creatinine is ≥120 μmol/L or the protein leak is >0.5 g/day or albumin creatinine ratio [ACR] > 30 mg/mmol. ▪ Women with diabetic nephropathy: ▪ Regular monitoring of renal function ▪ Quantification of proteinuria (protein creatinine ratio [PCR] or albumin creatinine ratio ABOUBAKR ELNASHAR
21.
▪ Hypertension ▪ 30% of women with diabetic nephropathy ▪ 75% will develop hypertension by the end of pregnancy. ▪ Strict control of hypertension in pregnancy is important to prevent ongoing renal damage. ▪ Therefore in hypertensive or nephropathic women with diabetes, a low threshold for antihypertensive therapy (e.g., 135/85) is used. ABOUBAKR ELNASHAR 2. Obstetrical management Antenatal 1. Regular BP and urinalysis checks to detect PET 2. US: 1. Dating & viability scan: early 2. NT scan: at 11–13 w 3. Anomaly scan at 18–20 w’, including 4-chambered assessment of f heart. 4. Regular scans for f growth and liquor volume in the third trimester (e.g. 28, 32, and 36 w) to detect macrosomia and polyhydramnios ABOUBAKR ELNASHAR
22.
3. Low-dose aspirin to all women with diabetes {increased risk of PET}. 4. Corticosteroids ▪ to induce fetal lung maturation ▪ additional insulin prescribed ▪ close monitoring to avoid severe hyperglycaemia and DKA. ABOUBAKR ELNASHAR II. Intrapartum ❑ Timing and mode of delivery ▪Should be individualized, based on ▪EFW ▪obstetric factors ▪previous mode of delivery ▪Gestation ▪glycaemic control ▪antenatal complications ▪Balance the risks of ▪PTL and its associated complications ▪late IUD and macrosomia with its complications. ABOUBAKR ELNASHAR
23.
❑Timing of delivery (NICE) ▪ Induction of labour or elective CS if indicated between 37 and 38 + 6 w for women with ▪ No maternal or fetal complications ▪ Good glycaemic control. ▪ Delivery should be expedited if complications occur. ABOUBAKR ELNASHAR ❑Mode of delivery ▪Vaginal delivery is preferred. ▪Continuous electronic fetal monitoring ▪Shoulder dystocia ▪More common at all birth weights than in the non-diabetic population. ABOUBAKR ELNASHAR
24.
▪ CS: (both elective & emergency) are increased ▪ Overall: 67% ▪ Emergency: 38%. ▪ {high rate of macrosomia (21% of babies weighed more than 4 kg; 6% >4.5 kg), this high rate may be unavoidable. ▪Elective CS if ▪EFW is >4.5kg. ▪EFW is 4–4.5kg use obstetric factors to influence decision. ▪Antibiotic & thromboprophylaxis ABOUBAKR ELNASHAR Glycaemic control • Diet controlled: check blood glucose hourly. If glucose (>108 mg/dl)>6.0mmol/L,start sliding scale. • Insulin dependent: ▪continue SC insulin until in established labour, then convert to insulin sliding scale (Table). ▪If induction of labour or CS, continue normal insulin until day of procedure, then start sliding scale in early morning. ABOUBAKR ELNASHAR
25.
Insulin rate (mL/h) Blood glucose (mg/dl) 0 54 0.5 55-72 1.0 73-108 1.5 109-144 2 145-198 3 199-270 Call doctor ≤271 Prescription: 50 U human actrapid in 50mL normal saline (sodium chloride 0.9%), via a continuous infusion pump. ABOUBAKR ELNASHAR ❑ Glycaemic control ▪ Type 2 diabetes An insulin infusion is not usually required ▪ Type 1 diabetes ▪ Sliding scale/variable rate insulin infusion. ▪ IV infusions of short-acting insulin and dextrose are administered throughout active labour and delivery via separate giving sets, to allow acceleration of glucose infusion and cessation of insulin in the event of hypoglycaemia. ▪ women using insulin pumps: continue these in labour but to discontinue for CS. ABOUBAKR ELNASHAR
26.
▪ The capillary blood glucose should be estimated hourly, and the insulin infusion rate altered according to a sliding scale determined by the individual daily insulin requirements. ▪ The usual dose range is 2–6 U/hr. ▪ The target glucose level during labour and delivery is 4–7 mmol/L (72-126mg/dl), the aim being to avoid hypoglycaemia. ▪ The dextrose infusion (5% or 10%) should provide 500 mL of fluid every 8 hours. ▪ Insulin drives extracellular potassium into the cells. It is important, therefore, to include potassium replacement with the i.v. dextrose to avoid hypokalaemia which may otherwise result especially if glucose levels are high. ABOUBAKR ELNASHAR III. Post-partum care ▪Baby ▪early feeding ▪glucose monitoring. ▪Breast-feeding ▪Encourage ▪Avoid oral hypoglycaemic drugs if breastfeeding ▪metformin and insulin are safe. ABOUBAKR ELNASHAR
27.
▪ Type 1 diabetes ▪ Following delivery of the placenta, the rate of infusion of insulin is halved ▪ Postpartum, insulin requirements return rapidly to pre-pregnancy levels. ▪ Once women are eating normally, SC insulin at either the pre-pregnancy dose or at a 25%–40% lower dose if the women intends to breastfeed, which is associated with increased energy expenditure. ABOUBAKR ELNASHAR ▪ Type 2 diabetes ▪ who are breastfeeding can resume or continue taking metformin or glibenclamide (glyburide). ▪ Other oral hypoglycaemic drugs are avoided in breast feeding. ABOUBAKR ELNASHAR
28.
▪Contraception • Avoid the COCP if ▪breast-feeding or ▪vascular complications. ▪Progesterone-based contraception Safe ▪No contraindications to an IUCD. ▪should be fitted from 6w post-partum onwards. ▪Sterilization or vasectomy ▪should be considered if the family is complete. ABOUBAKR ELNASHAR CONCLUSIONS ▪ The increased risk of congenital abnormalities is related to the degree of periconception diabetic control. ▪ Insulin requirements increase during pregnancy. ▪ Oral hypoglycaemics (metformin, glibenclamide) may be used in type 2 diabetes. ▪ Thiazolidinediones&DPP-4 inhibitors (sitagliptin) are avoided. ▪ Retinopathy may deteriorate during pregnancy. ▪ Women with diabetes, especially those with nephropathy and hypertension, have a greatly increased risk of PET&should be offered LDA. ▪ Neonatal and perinatal morbidity and mortality are increased ABOUBAKR ELNASHAR
29.
▪ Complications relate to the degree of maternal hyperglycaemia, fetal hyperinsulinaemia and macrosomia and may be decreased with tight diabetic control. ▪ Pregnant women with diabetes should be managed in joint pregnancy diabetic clinics by obstetricians and physicians with expertise in the care of such women. ▪ The most important goal of management is to achieve maternal near normoglycaemia. ▪ Outcome is improved if four-times-daily basal bolus regimes of insulin or insulin pumps are used, and target blood glucose levels are based on postprandial capillary glucose estimations. ABOUBAKR ELNASHAR
Descargar ahora