DIABETES IN PREGNANCY

DR. SALWA NEYAZI

CONSULTANT OBSTETRICIAN GYNECOLOGIST

PEDIATRIC & ADOLESCENT GYNECOLOGIST

PHYSIOLOGICAL CHANGES OF GLUCOSE

METABOLISM IN PREGNANCY
Pregnancy is a state of insulin resistance &

relative glucose intolerance

This is due to placental production of antiinsulin hormones : hPL, cotisol, and glucagon
FBS
Postprandial glucose
Insulin production 2 folds in N women
Insulin requirements in diabetic women
renal threshold for glucose glycosuria

DIAGNOSIS OF GESTATIONAL
DIABETES MELLITUS
Women in whom the criteria of DM are met in

pregnancy include a gp of diabetics who

were undiagnosed before pregnancy
FBS > 7 mmol/L on 2 occasions
Or
RBS > 11.1 mmol/L on 2 occasions
Borderline cases GTT DM is Dx if FBS
> 7 mmol/L or 2 hrs > 11.1 mmol/L
Impaired glucose tolerance 2hrs G 8-11
mmol/L with a N FBS

EFFECT OF PREGNANCY ON DM
Insulin requirement in pregnancy reaching a

max at term & being at least 2 X the prepregnancy requirement

Pt with diabetic nephropathy deterioration in

renal function with in creatinine clearance &

proteinuria
this deterioration in renal function is usually
reversed after delivery

EFFECT OF PREGNANCY ON DM
2 X in retinopathy

rapid improvement in glycemic control

worsening retinopathy due to retinal blood
flow
icidence of hypoglycemia
Ketoacidosis is rare unless associated with

hyperemesis, infections, tocolytic &

corticosteroid Rx

EFFECTS OF DM ON PREGNANCY
incidence of congenital abnormalities
The risk is related to the degree of glycemic

control 5% with Hb A1c > 8%

25% with Hb A1c > 10% with risk
of abortions
Sacral agenesis, congenital heart defects,
skeletal abnormalities & neural tube defects
Perinatal & neonatal mortality 2-4 X
Unexplained IUFD at term / more in
macrosomic babies

EFFECTS OF DM ON PREGNANCY
Macrosomia the incidence is with poor

diabetic control
not eliminated by tight control
associated with risk of operative delivery,
birth trauma, & shoulder dystocia
Hyperglycemia fetal polyuria
polyhydramnios PROM, preterm delivery
Prematurity pose an added problem as
pulmonary surfactant production is slightly
delayed in babies of diabetic mothers

EFFECTS OF DM ON PREGNANCY
Postnatally, babies are at risk of hypoglycemia

& jaundice
risk of PET especially in pt with pre-existing
hypertension & nephropathy where it reaches
almost 30%

MANAGEMENT
Multidisciplinary team including obstetricians,

endocrinologists, dieticians, & midwives

optimize outcome
Preconception councelling
To achieve normoglycemia as far as possible
FBS < 5 mmol/L
PP < 7.5 mmol/L
Dietary advice on a low sugar, low fat, high fiber
diet
Regular capillary glucose series (7 point profile)
Combined short acting & intermediate acting
insulin

MANAGEMENT
Regular assessment of Hb A1c
Ophthalmologic examination & Rx of

retinopathy
Regular monitoring of renal function in Pt with
diabetic nephropathy
Detailed U/S screening for congenital
malformations in the 2nd trimester (20wk) to
exclude NTD, sacral agenesis, & cardiac
defects
Frequency of antenatal visits needs to be
individualized

ANTENATAL FETAL SURVELANCE

incidence of IUFD justify close monitoring in

the 3rd trimester

Serial U/S biometry to detect macrosomia,
hydramnios, IUGR
Umbilical artery doppler in Pt with IUGR
CTG
BPP

LABOR & DELIVERY

With well controlled DM with appropriately

grown fetus pregnancy is allowed to proceed

till term
When there is concern about fetal well being or
macrosomia the risk of IUFD must be
weighed against the risk of RDS
of the babies are >90th centile CS rate of
50-60%
Intrapartum care should focus on meticulous
diabetic control & continuous electronic fetal
monitoring . Blood glucose should be 4-7
mmol/L achieved by 5% Dextrose infusion &
insulin infusion

LABOR & DELIVERY

After delivery mternal insulin requirement

rapidly returns to the pre-pregnancy level

If abnormal glucose tolerance was 1st Dx in
pregnancy GTT should be done 6 wk postpartum

Gestational diabetes
Carbohydrate intolerance of variable severity 1st

Dx in pregnancy will include women with

undiagnosed DM
There is no consensus on the optimal screening
for GDM
Universal screening
Screening pt > 25 Y
Clinical risk factors: previous GDM, family Hx ,
previous macrosomic baby, previous
unexplained IUFD, obesity, glycosuria,
polyhdramnios, LGA in current pregnancy
The timing of screening also contraversal

Implications of GDM
perinatal mortality & morbidity but to a lesser

extent than DM
No risk of congenital malformations
Macrosomia is the main risk factor for adverse
outcome
risk of operative deliveries
incidence of PET
Women with GDM have a significantly risk of
DM later in life (50% over 10-15 Y)

Management
Combined diabetic obstetric approach
Initial approach by dietery modification including

caloric reduction in obese Pt

The need for insulin is manifested by persistent
PP hyperglycemia (7.5-8 mmol/l) or persistant
fasting hyperglycemia (>5.5-6 mmol/L)
Regular U/S scans to assess fetal growth & well
being
Early delivery is not advised unless there is a
complicating factor

Management
Intrapartum management

Depends on whether the pt is on diet control

alone or on insulin
Pt on insulin need to be on sliding scale
Following delivery insulin must be discontinued
GTT should be done 6 wks postpartum

MACROSOMIA
Fetal Wt >4000-4500 gm regardless of

gestational age
Risks of macrosomia include shoulder
dystocia, erbs palsy, 5 min APGAR score,
admission to NICU & obesity later in life
Risk factors for the development of
macrosomia:
prior HX of macrosomia
maternal pre-pregnancy Wt
excessive Wt gain in pregnancy
multiparity

MACROSOMIA (risk factors)

male fetus
gestational age >40wks
race
maternal birth Wt
maternal Ht
maternal age
+ve GCT with-ve GTT
GD, DM

MACROSOMIA
How macrosomic infants of diabetic mothers

differ from those without diabetes?

How is macrosomia predicted?
How does it affect the management of labor &
delivery?
When is CS recommended for macrosomia?
What is the role of induction of labor?