DIABETES MELLITUS IN

PREGNANCY
I zyan Mohammad
DEFINITIONS
Diabetes Mellitus in Pregnancy falls
into 2 categories:
 Gestational Diabetes Mellitus (GDM) — Any
degree of glucose intolerance with onset or first
recognition during pregnancy. Does not exclude
possibility that unrecognised glucose
intolerance may have been present before onset
of pregnancy.

2. Pre-gestational Diabetes Mellitus —

diagnosed when the woman has diabetes
before pregnancy.
GESTATIONAL DIABETES MELLITUS
(GDM)
Physiology
0 Pregnancy -5 T HPL + cortisol (insulin antagonists)
O Mother -5 relative insulin resistance esp trimester
0 Maternal pancreas -5 T insulin to maintain carbohydrate
metabolism -5 PPG
0 Carbohydrate intake t glucose than non-pregnant lady

0 Glucose crosses placenta by facilitated diffusion and the fetal

blood glucose level closely follows the maternal level
0 Therefore, fetal glucose levels therefore is normally
maintained within normal limits, as in mother.
Modified Penderson Theory: Impact of
Maternal Hyperglycaemia During Pregnancy
MATERNAL PLACENTA FOETAL
Birth weight t
I Insulin release
glucose utilisation
? Altered
structure and/or
function
Hyperglycaemia t Insulin
(hyperinsulinaemia)

Hyperglycaemia
GDM IN FIRST TRIMESTER
o Women found to have fasting hyperglycaemia
or abnormal glucose intolerance in the first
trimester might have pre-existing diabetes o
Should be treated as women with glucose
intolerance before pregnancy o First trimester
hyperglycaemia high risk of congenital
abnormalities in foetus
SCREENING FOR GDM
o Women with high risk of GDM:
o BMI >30kg/m2
 o First degree relative with Diabetes
o Personal history of GDM
o Previous macrosomic baby 24.5kg
o Family origin with high diabetes prevalance (South
Asian, African-Caribbean, Middle-Eastern)
o *Previous poor obstetrics outcomes usually associated
with diabetes
PRE-GESTATIONAL DIABETES TYPE
1 AND TYPE 2 DIABETES
o Pre-conception care is essential o If untreated in
first few weeks gestation, associated With:
 o Spontaneous abortions
o Birth defects o If untreated during 218 or 3rd
trimester, associated with:
o Foetal macrosomia and metabolic abnormalities
o Birth injury
o Maternal hypertension and pre-eclampsia
o Future diabetes and/or obesity in child
PRE-PREGNANCY COUNSELLING
o To assess suitability for pregnancy o To
look for complications of diabetes, evaluate
and treat complications prior to onset of
pregnancy o To achieve optimal control prior
to and during very early pregnancy o To
provide an opportunity for pre-pregnancy
advice and folate supplements
MEDICAL ASSESSMENT IN
PRECONCEPTION CARE
o Duration and type of diabetes o Medical
history and current medical management
plan o Chronic diabetes complications:
o Retinopathy
o Nephropathy
 o Neuropathy o Co-morbid conditions (in
addition to diabetic complications)
o Hypertension (ideal blood pressure <120/80)
o Coronary Artery Disease
o Hyper- or Hypothyroidism
o Other auto-immune disease
PREVENTING RETINOPATHY
PROGRESSION
o Rapid normalization
of blood glucose
during pregnancy can
trigger retinopathy progression o Retinal status
should stabilized prior to conception o Reassess
retinal status each trimester (more frequently if
retinopathy is present)
RECOMMENDATIONS
o Plan pregnancies o Attain a pre-conception
HbA1c of < 7% o If planning pregnancy:
o Needs retinal screening prior to conception
o Screen for diabetic retinopathy and coronary heart
disease
o Discontinue oral hypoglycaemic agents and attain
glycaemic targets using insulin, if possible
 o Replace ACEI and ARBs to other hypertensives that
are safe to take in pregnancy
o Stop statins
POSSIBLE CONTRA-INDICATIONS
TO PREGNANCY
o Ischaemic Heart Disease o Active,
unrelated proliferative retinopathy o Renal
insufficiency
0 Severe Gastroparesls
• Inability or unwillingness to use Insulin
RISKS TO MOTHER WITH
GESTATIONAL DIABETES
O Increased risk of Caesarian Section
0 Pre-eclampsia (2-4 x esp with co-existing
microalbuminuria/frank nephropathy)
O Polyhydramnios
O Pre-term labour
O Post-Partum Haemorrhage
O Temporary worsening of renal function
O Progression Of retinopathy
O t incidence of infection, severe hyperglycaemia/hypoglycaemia,
DKA
O In future:
 • Recurrent GDM Pregnancies
• Risk of developing T2DM (50% in 5 - 10 years)
POTENTIAL COMPLICATIONS IN
INFANTS OF MOTHERS WITH
DIABETES

o Intra-uterine
demise
o Spontaneous abortions
 o Stillbirth (10-30%) o Congenital malformations
o Neural tube defects
o Cardiac defects
o Caudal Regression syndrome (rare)
POTENTIAL COMPLICATIONS IN
INFANTS OF MOTHERS WITH
DIABETES
o Macrosomia o
Visceromegaly
o Cardiac enlargement
o Hepatic enlargement
0 Respiratory Distress
Syndrome o Asphyxia o Birth injury
• Shoulder Dystocia
• Erb's Palsy
• Diaphragmatic paralysis
• Facial paralysis
MACROSOMIA
POTENTIAL COMPLICATIONS IN INFANTS
OF MOTHERS WITH DIABETES
o Metabolic complications
o Hypoglycaemia (high insulin production in immediate
neonatal period due to recent foetal hyperglycaemia)
0 Mothers encouraged to breastfeed ASAP; monitor
baby's blood glucose; formula-fed or glucose infusion prn
Hypocalcaemia, magnesium deficiency apnoeic episodes and
fits
o Polycythaemia -5 hyperbilirubinaemia jaundice
0 Partial exchange transfusion
Management:
Obstetrics
o Nuchal Traslucency Scan o Detailed US for
foetal anomalies o Foetal echocardiography 0
Serial growth scan o Monitor foetal well-being
(doppler US & CTG) o Aim: vaginal delivery
between 38 — 40 weeks
0 50% Ceasarian section because of macrosomia,
pre-eclampsia and failed induction of labour
Management:
preterm labour &
polyhydramnios
o Difficult
o Tocolytics (e.g. ritodrine, salbutamol) are
diabetogenic o I/M steroid for foetal lung
maturation destabilize diabetic control oIN
Management:
insulin / glucose infusion if required to ensure
normoglycaemia
Intrapartum
o Induced/Spontaneous labour sliding scale of
insulin to maintain normoglycaemia o Test
maternal blood glucose hourly o Continuous
foetal monitoring advised o Foetal scalp blood
sampling if CTG abnormal
Management:
Post-delivery
o Insulin requirements return to pre-pregnant
levels o If GDM, stop insulin o OGTT 6/52
post-delivery to ensure diabetes has resolved
THANK YOU FOR LISTENING