DIABETES IN PREGNANCY

Pregnancy is a diabetogenic state

ü State of insulin resistance is due to;
1. Insulin antagonists:
o á Oestrogen o á Cortisol
o á Progesterone o á Prolactin
o á HPL (Human placental lactogen)
2. Increased body weight, increased calorie intake.
3. Increased lipolysis and altered carbohydrate metabolism to fulfil nutritional demands of the growing
foetus.
ü Changes in Insulin resistance occur to have enough glucose for transport across the placenta to ensure
normal fetal growth and development.
ü Transfer of glucose across the placenta stimulates fetal pancreatic insulin secretion and insulin acts as an
essential growth hormone.
ü Now, If resistance to maternal insulin action becomes too pronounced, maternal hyperglycemia occurs and
gestational diabetes mellitus (GDM) is diagnosed
ü As period of gestation increases – Insulin Resistance also increases

Risk Factors for GDM:

1. BMI > 30Kg/m2
2. Family History of DM (In Parents/siblings)
3. Previous GDM
4. Previous Macrosomic Baby ≥ 4.5kg
5. Minority ethnic family origin with high prevalence of DM

ü Screening and diagnosis

1. Internationally: Screening is done @ 24 – 28 weeks
( At booking- only if patient is high risk)
2. In India: Screening is done at the time of booking or at 1st ANC visit
(if Negative Repeated @ 24 – 28 weeks)
2 STEP APPROACH

o Step 1: Glucose challenge test (GCT)

Patient given 50g glucose

RBS after 1hr

<140mg/dl >140mg/dl

No further test needed Do confirmatory test , OGTT

o Step 2: Oral Glucose tolerance test (OGTT)

§ Overnight fasting of 8 hours
§ Patient is given 100 gm glucose
â
§ RBS checked after 1hr, 2 hr, 3hr
o Carpenter / Coustan Criteria is used for diagnosing GDM. Normal values are less than following (in
mg/dl):
§ Fasting – 95
§ 1 hour – 180
§ 2 hour – 155
§ 3 hour – 140

1 STEP APPROACH

1. As per Diabetes in Pregnancy Study Group of India (DIPSI)

2. As per WHO / International Association of Diabetes and Pregnancy Study Groups (IADPSG)

MOSTLY THIS 1 STEP APPROACH (WHO/ IADPSG) IS FOLLOWED FOR ALL PRACTICAL PURPOSES
 Congenital malformation in babies of diabetic females
1ST Trimester HbA1C levels: (BEST PREDICTOR)
ü < 6.5%: No greater risk of malformation than non-diabetic
mothers
ü 6.5% - 8.5%: 5% Risk of malformation
ü >10 %: 22% Risk of malformation

o IOC to predict anomaly risk – HBA1C

o IOC to detect anomaly – level 2 scan at 18-20wk
o Mc system involved – CVS ( Mc anomaly VSD , most specific anomay -TGA)
o 2nd MC system, involved – CNS ( mc anomaly – anencephaly , most specific
anomaly – caudal regression syndrome )
o Overall most specific anomaly – caudal regression syndrome

COMPLICATIONS OF DIABTES IN PREGNANCY-

FETAL COMPLICATIONS
1st TM -
• Spontaneous abortion (25%) – in uncontrolled sugar
• Congenital malformation(11%)
nd
2 TM -
• Hydramnios
• Preterm birth
• Intra-uterine death
rd
3 TM -
• LGA , Shoulder dystocia, birth injuries
• Neonatal hypoglycemia, hypocalcemia , polycythemia.

MATERNAL COMPLICATIONS
• Pre-eclampsia (aspirin prophylaxis given)
• Prolonged labor *No risk of congenital malformation occur with GDM
• Obstructed labor *Except diabetic retinopathy long-term course of diabetes does
• Caesarean section not appear to be affected by pregnancy.
• Uterine atony
• Post-partum hemorrhage

MANAGEMENT
 DOC in Diabetes in pregnancy: INSULIN

1. Maintain a good glycaemic control

Diet and Exercise:

o High protein / low carbohydrate diet

o Atleast 30 min of mild to moderate exercise daily
o Ideal BMI: ≤ 27 Kg/m2

Glucose monitoring:

o Atleast 4 times a day:

o Measure FBS and 1 or 2 hr post meals
o Aim: Fasting < 95, 1 h PP < 140, 2h PP < 120
§ HBA1C ≤ 6% ( since level of HBA1C is reduced in pregnancy)

2. Maternal surveillance:

OVERT DIABETES -

1ST TRIMESTER -

o Start Folic Acid 4mg/d till 13 weeks.

o Start ecospirin 75-100mg , daily
o Stop drugs mother has been taking already ( ACE inhibitors , AT antagonist , statins )

o Measure HBA1C (1st trimester)

o Renal Function Test
o Retinal Scan (Repeated at 28 weeks)
o Joint DM – ANC consultation, every 1-2 weekly - Measure BP at every visit as there is 2 x á risk of
pre-eclampsia
o Aneuploidy screening (Level 1 Scan @11-13th Weeks +Dual Marker (PAPPA + Beta- HCG)

2ND TRIMESTER –
o Level II scan & fetal echo
o S.AFP
rd
3 TRIMESTER –
o Intermittent BPP , CTG & DFMC ( Starting from 32-34wk)
o 4 weekly scan from 28 weeks onwards

GESTATIONAL DIABETES
 o Regular maternal surveillance , besides that a Fetal growth scan should be performed at 28-30
weeks gestation & repeated at 34-36 weeks gestation.

DELIVERY -

• Watch out for Shoulder Dystocia (esp. in macrosomic baby > 4.5 kg)

• Overall Vaginal delivery is always preferred.

• If Mother has GDM / overt Diabetes + Macrosomic Baby (> 4.5 Kg): Ceasarean Section is Preferred

POSTPARTUM MANAGEMENT
1. Breastfeed the baby within 30 min of delivery
2. Evaluated for immediate hypoglycemia (<45 mg/dL) within first hour of birth and at 4 hours interval using
glucometer till four stable readings glucose values are achieved (≥45 mg/dL).
3. Reduce dosage of insulin / metformin post-delivery according to sugar levels
4. Measure OGTT , 6 – 13 weeks postpartum
5. If > 13 weeks postpartum measure HBA1C- if its high refer to endocrinologist

v DRUGS USED IN DIABETES IN PREGNANCY

o Insulin is the drug of first choice and Metformin can be considered after 20 weeks of gestation for medical
management of GDM
o If the woman's blood sugar is not controlled with the maximum dose of metformin (2 gm/day) and MNT,
Insulin is to be added
o Actrapid or Mixtard Iinsulin given in pregnancy. (30:70)
o 1st Trimester - .7 unit /kg 2nd Trimester - .8 unit /kg 3rd Trimester - .9 unit /kg At Term - 1 unit/kg
o Based on sugar levels –
2hr PPBS Insulin used
120-160 4U
160-200 6U
>200 8U

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