Diabetes in Pregnancy

Dr Richard A Greene
 Diabetes in Pregnancy

• Gestational Diabetes

• Pre-gestational diabetes
– Insulin dependent
– Non-insulin dependent (uncommon)
 Normal Maternal Glucose
Regulation

• Tendency for maternal hypoglycemia

between meals - fetal demand
• Increasing tissue insulin resistance during
pregnancy  diabetogenic placental steroid
 Oestrogen, Progesterone,
 Chorionic sommatomammotrophin
• Increased insulin production (= 30% mean)
 Maternal Hyperglycemia

• Causes fetal hyperglycemia

• Leading to fetal hyperinsulinaemia
• Fetal hyperinsulinaemia - even short periods
(1-2hours) lead to detrimental consequences
in:
– fetal growth
– fetal well-being
 Fetal Hyperinsulinaemia
• Promotes storage of excess nutrients -
macrosomnia
• Increased catabolism of excess nutrients - energy
usage and  fetal oxygen storage
• Episodic fetal hypoxia catecholamines causing:
- hypertension,
- cardiac remodelling and hypertrophy,
 Erythropoietin, RBC’s, haematocrit causing
poor circulation and hyperbilirubinaemia
 Congenital Anomalies

Cardiac defects x18 8.5%

• CNS defects x16 5.3%
• Anencephaly x 13
• Spina Bifida x 20
• All Anomalies x8 18.4%

• Background major defects 1-2%

 Congenital Anomalies and
Diabetic Control

Maternal HbA1c levels

< 7.2 Nil
7.2-9.1 14%
9.2-11.1 23%
> 11.2 25%
Critical periods - 3-6 weeks post conception
Need pre-conceptional metabolic care
 Macrosomnia

(Greater than 90 precentile, 4200 grammes)

Increased hyperbilirubinaemia
Increased hypoglycemia
Increased acidosis
Increased birth trauma
Macrosomnia as a child and glucose
intolerance in adulthood
 Gestational Diabetes

Risk Factors: < 25 years old

Previous macrosomnic infant
Unexplained fetal demise
Previous GDM
Family hx - GDM/NIDDM
Obesity > 90Kg
FG>7.8/2 hr >11.1
 Glucose Challenge Test

• Non fasting
• 50g glucose dose
• Value > 7.8mmol/l - needs a OGTT

10-15% need a OGTT

20-40% have GDM (2-7% of pop screened)
(Risk factor screening fails to detect 43% of GDM)
 Gestational Diabetes

Dietary advice
Glucose monitoring
Insulin if necessary (Hypoglycemic agents?)
2-weekly visits to Diabetic service/antenatal
service & Growth Monitoring (scan)
Delivery based on obstetric issues
Delivery gestation dep on insulin usage
 Perinatal Mortality/Morbidity

• Miscarriage
• IUGR
• Macrosomia
• Birth Injury
 Neonatal Morbidity and
Mortality

• Polycythemia and hyperviscosity

• Neonatal hypoglycemia
• Neonatal hypocalcemia
• Hyperbilirubinaemia
• Hypertrophic and congestive
cardiomyopathy
• RDS
• Childhood impaired glucose tolerance
 Maternal Complications

• Chronic hypertension
• Pre-eclampsia
• Diabetic ketoacidosis
• Maternal hypoglycemia
• Maternal trauma
• Higher C Section rate
• Retinal disease/renal disease not affected
significantly by pregnancy
 Management

• Pre-conceptional care
Thight glucose control (HbA1c)
Assessment and treatment of associated
medical problems - hypertension, renal,
retinal and/or heart disease
Folic acid
Assessment of family. Financial and
personal resourses to help achieve a
successful pregnancy
 Management

• Multidisciplinary approach
• Antenatal visits - 2-weekly after 24 weeks
• Diabetic service 2-weekly
• Scans - Anomaly scan at 20-weeks
Growth scans from 26-28 weeks
• Delivery - around term if insulin dependent
unless complications, diet only control as
normal antenatal patients
 Intrapartum management

• IV fluids (5% dextrose) + KCL + insulin

• Hourly glucose monitoring
• CTG
• Manage labour as normal
 Management - Postpartum

• Use pre pregnancy insulin levels when on

diet and monitor. If GDM monitor sugars
only
• Breast feeding v Bottle feeding?
• GDM - OGTT at 6 weeks
• GDM - long term risk of NIDDM
• Contraception
The End