Diabetes in pregnancy Dr.

Wasan 28/2/2016

Diabetes in pregnancy

General Consideration
Definition :
abnormalities of carbohydrate metabolism
Incidence : 4% ( 10%overt, 90%gestational)

• Pregnancy itself is diabetogenic through :

- insulin resistance
o Increased production of cortisol, estriol,
progesterone
o Increased insulin destruction by kidney&
placenta
o Production of placental somato- mmotropin
- Increased lipolysis: mother use fat for calories &
saves glucose for fetus
- Changes in gluconeogensis: fetus use alanine &
other a.a & depraves mother
• Detection ( screening) of GD :
High risk patients ( risk factors) :
1-positive family history of DM
2-Poor obstetric hx (neonatal death)
3-Polyhydromnia in recent preg.
4-Previous delivery of a large baby.
5-Obese woman
6-Advanced maternal age ( more than 25 years)

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Diabetes in pregnancy Dr.Wasan 28/2/2016

Screening :
• Random blood sugar test: 50 gm. Oral glucose, all
preg woman between ( 24-28) wk. without diet
prepartion
- 1 hour plasma glucose = 140 mg/dl ( cutoff value) = or
less than 7 mmol/l.
- 2 hour plasma glucose = 120 mg/dl= (4-6 mmol/l)
• General urine examination for sugar :
if it more than 1+
• OGTT (75 g) ( prepared patient) modified WHO used

normal IGT DIABETIC

fasting Less than 7 Less than 7 More than 7

2 hours Less than7.8 More than More than

7.8 11

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Diabetes in pregnancy Dr.Wasan 28/2/2016

Effect of diabetes on pregnancy

1. on the mother :
• Increase incidence of PE & eclampsia espicially in pre-
existing DM.
• Increase incidence of infection
• Increase incidence of traumatic delivery & C/S.
• Increase incidence of poly hydromna( fetal osmotic
diuresis) induced by materno- fetal hyper glycemia
• Increase PPH

2. ON the fetus :
• Intrauterine death ( sudden death of fetus in late
pregnancy) due to hypoxia & metabolic acidosis
• Neonatal death
• Neonatal morbidity ( birth injury esp. brachial plexuses
in shoulder dystocia)
• Neonatal hypo-glycemia, hypo-calcemia
• Congenital anomalies( sacral agenesis , CNS
anomalies)
• RDS ( respiratory distress syndrome): due to
inhibition effect of cotisol on enz. System responsible
for production of surfactant in fetal lung

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Diabetes in pregnancy Dr.Wasan 28/2/2016

Management
Antenatal measurement :
• Early U/S ( for dating, viable)
• Folic acid supplement ( 3 months before& 1st
trimester)
• Advice on hyperglycemic prevention
• HbA1C ( less than 6.5)
• Screening for diabetic complication

2nd trimester :
• Detailed U/S to exclude any congenital
abnormalities
• Assessment fetal growth & amniotic fluid from 28
wks of preg / 2 weeks
• Surveillance for medical obstetric complications :
increased risk for PIH
• Optimization of glycaemic control :
- By diet ( 3 meals& 3 snacks)
- 1800 cal /day
- Diet ( CHO 40- 60%),(PROT 20-30% )& remaining
fat.

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Diabetes in pregnancy Dr.Wasan 28/2/2016

• If 2 weeks no response . Start insulin :

- Regular 3 short acting & intermediate acting at
bed time.
- Aim FBS 4-6 mmol/l , 2 hour post prandial 7
mmol/l.
- Or dose : insulin ( unit) = BWT * 0.6 ( 1st trimester)
- Total dose divided 2/3 before breakfast ( 2
intermediate : 1 soluble)
- 1/3 dinner 1 ( intermediate) :1( soluble)

Third trimester :
1) Optimization of glycaemic control
2) Assessment of fetal growth ( at the end of the second
trimester & every 4 weeks)
3) Timing & mode of delivery

Protocol for insulin during labour & delivery

Intrapartum ( day of induction) :
• ½ dose of insulin at the morning & light breakfast
• labour establish 500cc of 10% dextrose ( 100cc/hr)
& in other 6 unit of insulin in 60 cc of normal saline
( 1 unit / 10 cc/ hr)
• Aim is blood sample = 4-6 mmol/l after ½ hr. if Bs
less than 4 mmol/l then 5cc/hr ( ½ unit). If Bs more
than 6 mmol/l then 20 cc/hr (2 unit/hr). Then should
mointer Bs every hour.

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Diabetes in pregnancy Dr.Wasan 28/2/2016

After delivery ( post partum) :

• adjustment of insulin dosage :Halve infusion rate until
eating then stop.
• Return to pre-pregnancy dose ( moniter blood sugar 2
hours & then post pranidal for 48 hours .
• Discussing contraception
• OGGT 6 weeks after delivery
THE END
BY:
TAHER ALI TAHER