Exercise:

• Walk 2 miles/day
• Health Club
• Swim 2/3 miles/day

Diet:

• Ideal Body Weight (IBW) = 100 lbs 1st 5 feet, then 5 lbs for each inch
• Abnormal 3º - START Low Carb diet x 2 weeks
  • ADA Diet: 40% carbo, 35% protein, 20% fat
    Max 2800-3000 calories
    Min 1800 calories
  • If Obese (BMI >29) then give 25 kcal/kg of IBW
  • If Normal (BMI 20-26) then give 30 kcal/kg of IBW
  • If Underweight (BMI <20) then give 35 kcal/kg of IBW

Other method of ADA diet is use current body weight with max ADA diet of 2800-3000 calories.

Desired wt gain: (Weeks gestation - 12) x 0.9 = desirable wt

• 0-12 weeks - 0 lb/wk gain
• 13-26 weeks - 0.9 lbs/wk gain
• 27-40 weeks - 0.9 lbs/wk gain

Oral Agent:

• x > 200 mg/dl/wk -> insulin
• x < 200 mg/dl/wk -> GLYBURIDE start with 2.5 mg (Evaluate q wk)
  

  	start	next	next	next	max
  AM	2.5	5	5	10	10
  PM			5	5	10

Insulin:

• 30 min before breakfast and 30 min before dinner
• Initial dose 0.7 - 1.0 U/kg/day
• 2/3 in am, 1/3 in pm
  • AM: 1/3 Reg, 2/3 NPH
  • PM: 1/2 Reg, 1/2 NPH

Dosing	AM	5PM
Reg	1/3	1/2
NPH	2/3	1/2
Time of Action
Reg	30 min - >2 hrs
NPH	6 hr - >12 hrs
Blood glucose adjustment
	< 80	Decrease 1-2 U
	140-200	Increase 1 U
	201-250	Increase 2 U
	251-300	Increase 3 U
	> 301	Increase 4 U
If Hyperglycemia: Majority BG elevated - increase total insulin 20% 1-2 BG elevated - increase corresponding dose by 10% FBG >95 - increase pm NPH by 10-20%
If Hypoglycemia: FBG <60 - decrease pm NPH by 10% Pre-supper/post prandial <60 - decrease pm Reg by 10%

Pregestional DM then order:

• HbA1C - initial intake and at 32 wks
• Fasting Lipid Profile (FLP), TSH
• Kidney Profile - creatine clearance, uric acid, urea, microalbumin (each trimester)
• C peptide
• Eye exam - initial and 3rd trimester
• EKG
• Sonogram: Initial visit
  • Level II at 26-30 wks
  • 37 wks
• NST: Weekly after 32 wks

Fetal Growth:

• 30 gm/day - good control
• 60 gm/day - poor control

Some indications for urodynamic testing include:

1. Stress / Urge / Mixed Incontinence 
2. Complete Procidentia, Cystocele, Rectocele
3. Incomplete emptying
4. Symptoms with hx of previous  incontinence surgery, XRT, or radical pelvic surgery

Before starting Uroflow testing, check name, consent and urine culture.  If + culture, treat infection and reschedule patient (preferably before clinic day).

Urodynamics Procedure: Sterile prep done, place catheter in urethra and catheter in vagina.  Start flow with 100ml/min.  Pt to report when she feels her FIRST SENSATION to use the rest room and when she HAS to immediately go to the restroom ( TOTAL CAPACITY) .  Pt also is asked to cough at each 100ml filling.  Once pt reaches her TOTAL CAPACITY, she is asked to cough.  To test for detrusor instability, the sound of water running is made by pouring water from one jar to another and/or the pt’s hand is placed in the water.

Write NAME and DATE on PRINT OUT
Reading the PRINT OUT (Graph):

1. Uroflow ( box = sec)
2. Cystometrogram (CMG)
3. Pressure Abdomen (Pa)
4. Pressure Detrusor (Pd)
5. Pressure Urethra (Pu)
6. Urethral Closure Pressure (Ucp) = (Pu-Pb) = 0.5cm /block -horizontally, 20cm H20/box -vertical)

What is Synchronous Void?: 
Relax in urethral pressure with concomitant increase in abdominal pressure and/or increase in detrusor pressure.

URODYNAMIC PEARLS

• Average 1st sensation – 150ml
• Average Total Sensation- 350
• Average Post Void Residual- <50ml or 80% of total  (UOP and residual)

URODYNAMICS- SAMPLE NOTE

1. Uroflow:     
1. VV (volume voided): 400 ml,  
2. PVR (post void residual)  40 ml,
3. Qmax (max flow)- 22 ml/sec,
4. TIME (11 sec)
2. CMG (Cystometrogram): 
1. 1st sensation:  150 ml
2. TC (Total Capacity): 350 ml
3. DI (Detrusor Instability): No
4. Leak: No   
3. UPP (Urethral Pressure Profile)
1. FUL (functional urethral length) – 1.5 mm (each block is 5mm)
   (length where urethral pressure exceeds intravesical pressure)
2. MUCP (measured urethral closure pressure – 170cm H2O (each block is 20cm H2O)
3. PE (pressure equalization) – Yes
   (Signifies genuine stress incontinence - in the absence of a detrusor contraction)
4. Leak - Yes
4. Voiding Study

Assessment:  Cystocele/Rectocele, Genuine Stress Incontinence
Plan:     a) F/U with Pre OP clinic and b) UTI prophylaxis: Macrobid 1 po this am and pm.