Babies born to mothers with a history of GDM will be more prone to develop diabetes

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 Maternal & Child Health Session during IDEC 2016

Babies born to mothers with a history of
GDM 
will be more prone to develop diabetes

Proper antenatal care is lacking at primary care level

KARACHI: Dr. Musarrat Riaz and Dr. Asmat Nawaz from BIDE were the facilitators during the Meet the Experts Session on the second day of International Diabetes & Endocrine Conference 2016 organized by BIDE from August 19-21st 2016.  Members of the Experts panel included Prof. Akhtar Hussain from Norway, Prof. Shabeen Naz Masood, Prof. Sadaqat Jabeen, Dr.Mahjabeen and Dr. Romaina Iqbal all from Pakistan and others.

During the discussion it was pointed out that fetal wellbeing prevents diabetes mellitus. Unfortunately medical profession was part of the problem rather than solution. Nutritional deficiency adds to the problem and prevalence of diabetes. Maternal nutrition was extremely important because low birth weight babies as well as malnourished are likely to develop diabetes. Weight itself was not a risk factor for diabetes but Pakistani women has lot of fat.

 

Some of the panelists in the Meet the Experts Session which discussed
issues related to Maternal and Child Health during IDEC 2016.

Girl’s educaiotn about diet, taking care of pregnant women, taking care during the pregnancy and taking care of pregnant women were extremely important. Micronutrients deficiency also needs to be looked into.  Anaemia was very common. Proper feeding in pre-conception stage and antenatal period was also highlighted. Folic acid deficiency has been highlighted in numerous studies hence Folic acid supplements will avoid Neuro tubal abnormalities.

It was also pointed out that antenatal care was not proper at primary care level. Not many women in rural areas were aware of the concept of pre-conception counselling. Early marriages, multi gravida, multiparty were some other important issues. It is essential to counsel the couples at the time of marriage. Women should be advised not to put on too much weight during pregnancy. Babies born to mothers with a history of gestational diabetes mellitus will be more prone to develop diabetes. In rural areas there is no concept of antenatal care. Ideally pre-concept counselling will reduce the prevalence of gestational diabetes mellitus and thus reduce the overall burden of diabetes in the society. Dais and Midwives working in rural areas should be educated to prevent GDM as counselling of pregnant women and creating awareness was important. All those who are involved in conducting deliveries should be educated. The participants also emphasized the importance of making a specific platform for Gestational Diabetes Mellitus to tackle this problem. We need to find out the risk factors as there is lot more diabetes during pregnancy. Good history taking was essential to identify the risk factors. Since doctors do not have enough time to take history, ask for risk factors because they have to examine too many patients in overcrowded Out Patients Departments of public hospitals, some arrangements should be made, may be involving the nurses in taking history.


It was also suggested that high risk pregnant women should be advised to check and monitor their blood glucose in the evening during Ramadan. Best thing is to ask them to check blood glucose after  eight hour fasting or after taking 75mg of glucose and then check blood glucose after two hours to find out the  OGTT. Pregnant women should be further advised to take 75mg of glucose in five minutes instead of taking it at once otherwise they will vomit it out. Complications of GDM are low. Try to manage the patients with diet and exercise at primary care level but if it is not possible, then refer the patient to tertiary healthcare facilities. All those ladies with GDM if they cannot be managed at primary care level should be referred to tertiary care centers. It is important that one should counsel the patient as to what is the problem. Remember insult to fetus has already occurred when it is diagnosed. Maternal problems should be avoided. First half hour is much more important for fetal health. For patients with GDM better choice is tertiary care hospitals. Breast feeding is also important. If the patient is already on insulin, its dose might have to be adjusted. Almost 85% of babies born to GDM mothers are likely to develop diabetes at later stager. Education plays a vital role in the management of diabetes hence  educating all those looking after the mothers i.e. midwives, lady health visitors, GPs, Nurses, quality of educaiotn and quality of antenatal care were all extremely important.


Dr. Uzma Khan from USA demonstrating  FNAC Thyroid technique on olives
embedded in chicken breast during  IDEC 2016 conference organized by BIDE.

Postpartum care is also important. Children born to diabetic mothers should be weighed. Measurement of 50mg of blood glucose is good for a newborn baby. Begin screening of women as soon as possible soon after delivery and if it is high, repeat it after forty eight hours and then after six weeks. Nursing staff should manage it and examine the new born soon after birth.  Reliable scientific approach, it was pointed out, was essential for better outcome.

Anaemia in Pregnancy

Prof. Sadaqat Jabeen from Lady Reading Hospital Peshawar made a presentation on iron deficiency anaemia. She opined that blood transfusion was not the answer to iron deficiency anaemia in our set up. Iron deficiency anaemia increased morbidity and mortality. The prevalence of IDA is between 40-90% and this is an important cause of maternal deaths. She then talked about classification of iron deficiency anaemia. Nutritional deficiency anaemia could be due to folate deficiency and Vitamin B12 deficiency. There is increased risk of haemorrhage which may lead to the death of the patient.

Continuing Prof. Sadaqat Jabeen said that mild to moderate anaemia does not affect baby but chronic anaemia in mothers will have adverse effects on the baby. It could lead to pre-term birth, Intra Uterine Growth Retardation, multiple pregnancy, palpation, chest pain, headache, lethargy, shortness of breath. These are some of the symptoms of anaemia as well as of pregnancy. One should always look for blood loss, drugs being used, nutritional deficiency, and reversal of predisposing factors as well as  dietary advice and routine supplementations. The objective is to have a healthy baby at the end of the pregnancy. Parenteral therapy like iron dextran and blood transfusion is indicated in those patients who cannot take oral therapy.


Dr. Romaina Iqbal’s presentation was on life style interventions trials in women with gestational diabetes mellitus. She talked about the prevention programme in GDM while Prof. Abdullah Umar talked about Polycystic Ovarian Syndrome during pregnancy.

Assessment of Cardiovascular risk

Prof. Liaquat Ali from Bangladesh in his presentation on Assessment of cardiovascular risk among low resource and underserved communities pointed out that risk should be assessed in each individual population groups. Comprehensive risk assessment for CVD risk factors, he further stated, was a better guide as compared to individual risk factor based approach. Studies have revealed that people of Bangladesh has one of the highest CVD risk among the South Asian countries.


Prof. Liaquat Ali

We have also found that risk factors for CVD were quite high even in the villages. Most of those at high risk are female. A much less proportion of these patients require drug treatment. In our studies we also studied short term predictive ability of various predictive tools .The two lab based tools i.e. Framingham Risk Scoring and WHO/ISH Risk Prediction Chart showed almost similar predictive ability compared to two non-lab based tools. The non-lab based tools seems to have slightly better performance particularly in females which may be potentially useful in low resource settings, he remarked.

Stem Cell Therapy in Diabetes

Prof. Liaquat’s other presentation during the conference was on Stem cell therapy in diabetes: Reality and myths? He pointed out that intensive research is going on to find out the possibility of use of stem cell in the treatment of Type 1 diabetes. However, initial euphoria has been contained and now challenges are becoming more clearer. At present there is no proven treatment for diabetes using stem cells. The major challenge is protecting the cells from being attacked by the immune system once they have been transplanted. One of the approach under study encourages the cells already present in the patient pancreas to make new beta cells.

Here the challenge is to find a drug which can activate the beta cells progenitors or which can reprogram other cells to produce beta cells in the labs. Lot of experiments are going on in this regard and various pharmaceutical firms are trying to create a capsule which will protect beta cells from immune attack but will not obstruct the outward movement of insulin. As regards Type 2 diabetes, evidence is very scare. Various experiments are using adult bone marrow stem cells for the treatment of diabetes as well as its complications which are being targeted. However, further intensive studies are needed to determine whether stem cell treatment was safe and effective, Prof. Liaquat Ali remarked.

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