DIABETES IN PREGNANCY

BY
DR ROEDA SHAMS
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DEFINITION
NORMAL GLUCOSE METTABOLISM
METABOLIC CHANGES DURING
PREGNANCY
CLASSIFICATION
EPIDEMIOLOGY
PATHOPHYSIOLOGY
Gestational Diabetes

DEFINITION:Clinical syndrome characterized by

deficiency or insensitivity to insulin.
NORMAL GLUCOSE METABOLISM: Glucose enters blood stream from
food source insulin aids in storage of
glucose as fuel for cells.
Insulin resistance results in increased
levels of glucose in blood
stream.HPL,CORTISOL
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METABOLIC CHANGES DURING PREGNACY

Caloric Requirements for a pregnant
women is 300 kcal than a non pregnant
lady
PLACENTAL HORMONES( Growth
hormone, human placental lactogen,
progesterone and corticotrophin releasing
hormone) affect glucose and lipid
metabolism.

Transient maternal hyperglycemia occurs

after meals because of insulin resistance.

Hypoglycemia occurs because of

proliferation of pancreatic beta cells leads to
increased insulin secretion

CLASSIFICATION:Diabetes in
pregnancy

Pre-existing
diabetes
IDDM
(Type1)

NIDDM
(Type2)

Gestational
diabetes
Pre-existing
diabetes

True GDM

TYPE 1 DIABETES MELLITUS (IDDM)

Autoimmune process that destroys
pancreatic beta cells.
The disease is typically diagnosed during
an episode of hypoglycemia , ketosis and
dehydration .

TYPE II DIABETES MELLITUS (NIDDM)

Acquired insulin resistance to obesity.

DIABETES IN PREGNANCY EPIDEMIOLOGY

Preexisting diabetes complicates 1% of
pregnancies.
4% of all pregnancies are affected by
diabetes
88% due to gestational diabetes mellitus
8% due to Type 2 diabetes mellitus
4% due to Type 1 diabetes mellitus

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PATHOPHYSIOLOGY
Lack of Insulin

Fatigue
Vulvitis

Hyperglycemia

Glycosuria

Polyuria
Polydypsia

Osmotic Diuresis

Tachycardia
Hypertension

Salt and Water

depletion

Increased secretion:
Glucagon
Cortisol
Catecholamines
Growth Hormone

Increased Catabolism

Glycogenolysis
gluconeogenesis
lipolysis

Wasting
Weight
loss

Hyperketonemia

Acidosis(DKA)

HPL, PROLACTIN,ESTROGEN & PROGESTERONE- DIABETOGENIC

Peripheral
vasodilatation
Hyperventillation
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GESATIONAL DIABETES

DEFINITION:Carbohydrate intolerance of variable

severity first recognized during the present
pregnancy.

RISK FACTORS:Age>25yrs
BMI >25
Previous GDM

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Family history of DM in first degree relative

Previous macrsomic baby
Polyhydromias
Large for date baby in current pregnancy
Previous unexplained stillbirth.

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SCREENING AND DIAGNOSIS:The test is performed b/w 24-28wks because

at this point in gestation the diabetogenic
effect of pregnancy is manifest and there is
sufficient time remaining in pregnancy for
therapy to exert its effect.

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DIAGNOSTC AND SCREENING CRITERIA

DIAGNOSTIC CRITEIA:1- Symptoms of Diabetes

Polyuria

Polydipsia

Unexpected weight loss

2-Fasting plasma glucose>126mg/dl or
randomized blood glucose >200mg/dl
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SCREENING TESTS:

50gm 1 hour glucose challenge test(GCT)

SCREENING THRESHOLDS:130mg/dl :90% sensitivity (23% screening

positive)
140mg/dl:80% sensitivity (14% screen
positive)

IF PATIENT SCREENS POSITIVE SHE

GOES ON TO TAKE A 3-HOUR GLUCOSE
TOLERANCE TEST(GTT)
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ORAL GLUCOSE TOLERANCE TEST

Patients undergoing oral glucose tolerance

testing for gestational diabetes should
undertake carbohydrate loading for 3 days
preceeding the test (>150g carbohydrates)
and over night fast of 8-14 hours the night
before
Time

100 g Glucose Load,

mg/dL (mmol/L)

Fasting

95 (5.3)

1 hour

180 (10.0)

2 hours

155 (8.6)

3 hours

140 (7.8)

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EFFECT OF PREGNANCY ON DIABETES

FIRST TRIMESTER:
Hyperemesis -- Hypoglycemia &
ketosis
SECOND TRIMESTER:
Inc in counter regulatory hormoneprogressive peripheral resistance to
insulin

Decreased renal threshold--glycosuria

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THIRD TRIMESTER---Inc level of

placental hormones-inc need of insulin.

DURING LABOUR--Inc consumption of

carbohydrates by uterine activity reduces the
insulin need

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EFFECTS OF DIABETES ON PREGNANCY

MATERNAL RISKS:_
1DIABETIC RETINOPATHY:Diabetic retinopathy is the leading cause of
blindness in women aged 24-64yrs.

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Half of patients with preexisting retinopathy

experienced deterioration during pregnancy
all the patients had partial regression
following delivery and returned to their
prepregnant state by 6 months postpartum.
Consider an ophthalmologic evaluation in the
first trimester.

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2-RENAL DISEASE: Patients with underlying nephropathy can

expect varying degrees of deterioration of
renal function during a pregnancy.

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Perinatal complications are greatly

increased in patients with diabetic
nephropathy .

Preterm births, growth restriction and

preeclampsia are more common

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3-ELAVATED BLOOD PRESSURE:Chronic hypertension complicates 1 in 10

diabetic pregnancies overall.
Patients with chronic hypertension and
diabetes are at increased risk of intrauterine
growth restriction, superimposed
preeclampsia, abrutio placentae
and maternal stroke.
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FOETAL EFFECTS
1MISCARRIAGES: Frequency directly related to degree of
maternal glycemic control.
Up to 44% with poorly controlled Diabetes
mellitus.
2---PRETERM DELIVERY: Increases birth defects (1-2%)
Two thirds of birth anomalies involve the
cardiovascular and central nervous system
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Neural tube defects occur 13-20 times more

frequently in diabetic pregnancies and
genitourinary, gestrointestinal and skeletal
anomalies are also more common.

3---GROWTH RESTRICTION:Growth restriction is fairly common among

Type 1 diabetic mothers
Best predictor is presence of maternal
vascular disease.

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4---OBESITY:Maternal obesity common in diabetes

appears to significantly accelerate the risk of
LGA

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5---MACROSOMIA:Defined as birth weight >4000grams

occurs in 15-45% of diabetic pregnancies, a
4 fold increase over normal
Carries many morbidities including birth
trauma, RDS, neonatal jaundice and severe
jaundice

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6-POLYCYTHEMIA : Hypoglycemia stimulates fetal erythropoetin

production

Can lead to tissue ischemia and infection.

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7---HYPOGLYCEMIA: Baby is used to having lots of maternal

glucose so it makes lots of insulin. when born
maternal glucose is no longer available but
insulin remains high--.hypoglycemia

Can lead to seizures, coma and brain

damage.
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8---POSTNAL HYPERBILLRUBINEMIA:Occurs in approx 25%, double that of normal

Thought to be due to polycythemia.
9----RESPIRATORY DISTRESS SYNDROME: 5-6 fold increased frequency
May be due to delay in lung maturation or
simply due to increased frequecy of preterm
deliveries.

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10---TRAUMATIC DELIVERY

e.g shoulder dystocia

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11----OPERATIVE VAGINAL DELIVERY:

Vaccum assisted
Forceps assisted

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12POLYHYDROMIAS:

Amniotic fluid volume >2000ml

Increased risk of placental abruption and
preterm

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MANAGEMENT
KNOWN

DIABETES

A---PREPREGNANCY CARE :
In patients with preexisting diabetes
nutritional and metabolic intervention must be
initiated well before pregnancy .

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Prepregnancy HbA1C level should be 6.1 to

reduce structural malformation
Commence Follic acid suppliments
Switch to short acting insulin analogue
Continue contraception if HbA1C >10 %
Continue oral hypoglcemic like
sulphonylureas and metformin

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BPRENATAL
Screen for gestational diabetes and do oral
glucose tolerance test
Do antenatal visit and commence foetal
growth monitoring

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 DIETARY

THERAPY:-

Low carbohydrate diet ,high fibre with caloric

restriction
Frequent small snacks may be needed
between 3 major meals
Avoid starvation

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 INSULIN

THERAPY:-

Gold standard, does not cross placenta

GDM on diet control will require insulin if
fasting glucose >95mg% or post parendial
>130mg%.
Insulin lispro ,aspart ,regular and
neutral potamine hagedor (NPH)
are safe and effective .

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Advise about management of hypoglycemia.

Advice women how to suspect early DKA and
how to self monitor for ketonemia or ketonuria.
Admit the pregnant lady with DKA in multi
disciplinary unit.
Follow up retinal scans based on initial findings.
Refer to nephrology if serum creatinine
>120micro mol/L

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Arrange anomaly scan at 18-21 wks

Include cardiac outflow tracts in anatomy
scan.
Refer for fetal echocardiography selectively
Scan for fetal growth scan and amniotic fluid
index at 4 wk interval from 26 wks gestation
Review and intensify hypoglycemic regime if
inpatient macrosomia

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Initiate tests of fetal wellbeing if IUGR is

diagnosed
Offer induction of labour/elective c section
Monitor fetal wellbeing weekly in women who
wish to continue their pregnancy beyond 38
wks

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Avoid beta sympathomimetics in preterm

labour

Elective preterm birth in maternal diabetes

should be in a unit with neonatal ICU
facilities

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LABOUR AND DELIVERY

Standeredized i/v Protocol & Insulin & Dextrose
Therapy
Nil by mouth until after the birth of baby.
Start i/v Dextrose in 500ml .100ml/hr by
electronic pump.
Hourly blood glucose estimation.
If initial blood glucose is 4-7mmol/L commence
insulin infusion at 1 unit/hr.
If blood glucose is more then 7mmol/L start
insulin infusion at 2 unit/hr.
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If glucose is less then 4mmol/L decrease insulin

rate by 1 Unit/hr & increase by 0.5Unit/hr when
glucose increases > 7mmol/Litre.
After delivery of placenta half the insulin to a
minimum of 0.5Unit/hr to maintain blood glucose
at 4-7mmol/Litre.

POSTNATAL
Return to prepregnancy insulin/hypoglycemia
therapy
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Discontinue hypoglycemic therapy in women

with GDM and monitor blood glucose levels
for evidence of type 2 diabetes
Offer contraceptive advice
Check fasting plasma glucose at 6 wk post
delivery and annually to exclude a new
diagnosis of type 2 diabetes

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RCOG GUIDE LINES

Pre-conception Care

Education: risks / diet / exercise / weight

loss if BMI>27
folic acid supplements (5 mg/day)
blood glucose meter for self-monitoring
monthly HbA1c
retinal assessment by fundoscopy
renal assessment

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SAFETY OF MEDICATIONS BEFORE AND

DURING PREGNANCY

Metformin (and Glibenclamide ) and insulin

may be used before and during pregnancy.

Isophane insulin is the first-choice longacting insulin during pregnancy.

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BEFORE OR AS SOON AS PREGNANCY IS

CONFIRMED:

Stop oral hypoglycaemic agents, apart from

metformin, and commence insulin if required
Stop angiotensin-converting enzyme
inhibitors and angiotensin-II receptor
antagonists and consider alternative
antihypertensives
Stop statins.

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POST NATAL CARE

Advise women with gestational

diabetes:

To stop taking hypoglycaemic medication

immediately after birth
On weight control, diet and exercise
On the risks of gestational diabetes in
subsequent pregnancies and screening for
diabetes when planning pregnancy.
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THANK YOU
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