DIABETES

MELLITUS IN
PREGNANCY
RENIERE I. LAGAZO
 Diabetes Mellitus
refers to a group of common metabolic disorders
that share the phenotype of hyperglycemia
 reduced insulin secretion
decreased glucose utilization
increased glucose production
 Epidemiology
Worldwide: from an estimated 30 million cases in 1985 to 382 million
in 2013.
Lifetime risk of diabetes
◦ Males: 33 percent
◦ Females: 39 percent

422 million people worldwide have diabetes (WHO, 2020)

In the Philippines, it is the 6th leading cause of death among Filipinos
(2013 Philippine Health Statistics) and over 6 million Filipinos are diagnosed to
have diabetes (Philippine Center for Diabetes Education Foundation, 2016)
 Classification
•Type 1 DM
can begin at any age
Onset: before age 30
after age 30 (5-10%)

•Type 2 diabetes- with

increasing age
Classification
 Classification
Pregestational or overt DM
diabetes before pregnancy

Gestational DM
diagnosed during pregnancy
Pathophysiology
Pathophysiology
What happens in diabetes
mellitus?
 MUSCLE CELLS AND
OTHER TISSUES ARE
RESISTANT TO
INSULIN

LIVER PUTS TOO

MUCH SUGAR IN
THE BLOOD

PANCREAS CAN’T
MAKE ENOUGH
INSULIN
Normal Glucose Metabolism in
Pregnancy
Normal Glucose Metabolism in
Pregnancy

mild fasting
hypoglycemia,
ensure a
pregnancy-induced sustained
postprandial
state of peripheral hyperglycemia, postprandial
insulin resistance supply of glucose
hyperinsulinemia
to the fetus
Normal Glucose Metabolism in
Pregnancy

mild fasting
hypoglycemia,
ensure a
pregnancy-induced sustained
postprandial
state of peripheral hyperglycemia, postprandial
insulin resistance supply of glucose
hyperinsulinemia
to the fetus
Normal Glucose Metabolism in
Pregnancy
Normal Glucose Metabolism in
Pregnancy

Hyperglycemia

Hyperinsulinemia

Glucagon suppression
Normal Glucose Metabolism in
Pregnancy
Normal Glucose Metabolism in
Pregnancy

Peripheral
insulin
resistance
Normal Glucose Metabolism in
Pregnancy
Maternal Insulin Resistance: causes
1. Growth hormone (GH)
2. Corticotropin Releasing Hormone (CRH)
3. Human Chorionic Somatomammotropin (HCS) or Human
Placental Lactogen (HPL)
4. Progesterone
Mechanism for progressive insulin
resistance in pregnancy:
Cytokines from Adipose tissues (Adipokines)
 Leptin, adiponectin, tumor necrosis factor-a, interleukin-6,
resistin

Inflammatory mediators derived from the placenta

 TNF
 Diabetes Mellitus in Pregnancy

mild fasting
hypoglycemia,
ensure a Maternal
pregnancy-induced sustained hyperglycemia!
postprandial
state of peripheral postprandial
insulin resistance
hyperglycemia, Fetal hyperglycemia!
hyperinsulinemia
supply of glucose
to the fetus
Increased glucose Increased insulin
production & resistance,
storage decreased
glucose utilization
Increased glucose Increased insulin
production & resistance,
storage decreased
glucose utilization
Increased glucose Increased insulin
production & resistance,
storage decreased
glucose utilization
Increased glucose Increased insulin
production & resistance,
storage decreased
glucose utilization
Increased glucose Increased insulin
production & resistance,
storage decreased
glucose utilization
Complications
Maternal Effects Diabetic Diabetic
Nephropathy Retinopathy

Diabetic
Preeclampsia
Acidosis

Infections
 Malfor-
Fetal Effects mation
Miscarriage

Altered
Preterm
delivery fetal
growth

Unexplained
Hydramnios
fetal death

Respiratory
distress
Hypo-
syndrome glycemia
Diagnosis of Diabetes during Pregnancy
 Gestational
Overt DM
diabetes

diabetes before pregnancy Diabetes during pregnancy

RBS >200 mg/dL plus classic

carbohydrate intolerance of
signs and symptoms (polydipsia,
variable severity with onset or
polyuria, and unexplained weight
first recognition during
loss or a fasting glucose: 126
pregnancy
mg/dL)
 Criteria for the Diagnosis of Overt DM
and GDM
Overt DM GDM

FBS >/= 126 mg/dL >/= 92mg/dL but

<126 mg/dL
First hour plasma >/= 180mg/dL
glucose
Second hour plasma >/= 200 mg/dL >/= 153mg/dL
glucose
Criteria for the Diagnosis of Overt DM
and GDM
FBS greater or equal to 126mg/dL (7.0 mmol/L)
OR
2-hr PG greater or equal 200mg/dL (11.1 mmol/L) during OGTT
OR
AIC greater or equal to 6.5% (48mmol/mol)
OR
Random plasma glucose equal or greater to 200mg/dL (11.1
mmol/L)
Screening and Detection
Screening and Detection
Screening and Detection
Screening and Detection
 Screening and Detection
Risk Factors Associated with Gestational Diabetes Mellitus (POGS, 2018)
BMI >/= 25 kg/m2
Previous macrosomic baby (above 4.5 kg)
Previous GDM
Family history of diabetes
Ethnic origin (Asian)
HbA1c greater than or equal to 5.7%, IGT or IFG on previous test
History of cardiovascular disease
Hypertension (greater than or equal 140/90 or on therapy for hypertension)
HDL 35mg/dL and/or triglyceride greater than or equal to 250 mg/dL
Women with PCOS
Physical inactivity
Other conditions associated with insulin resistance (severe obesity)
Previously elevated blood glucose level
Age >/= 40
Medication: Corticosteroids, antipsychotic
 Screening and Detection
Risk Factors Associated with Gestational Diabetes Mellitus (POGS, 2018)
BMI >/= 25 kg/m2
Previous macrosomic baby (above 4.5 kg)
Previous GDM
Family history of diabetes
Ethnic origin (Asian)
HbA1c greater than or equal to 5.7%, IGT or IFG on previous test
HDL 35mg/dL and/or triglyceride greater than or equal to 250 mg/dL
History of cardiovascular disease
Hypertension (greater than or equal 140/90 or on therapy for hypertension)
Women with PCOS
Physical inactivity
Other conditions associated with insulin resistance (severe obesity)
Previously elevated blood glucose level
Age >/= 40
Medication: Corticosteroids, antipsychotic
 Screening and Detection
Risk Factors Associated with Gestational Diabetes Mellitus (POGS, 2018)
BMI >/= 25 kg/m2
Previous macrosomic baby (above 4.5 kg)
Previous GDM
Family history of diabetes
Ethnic origin (Asian)
HbA1c greater than or equal to 5.7%, IGT or IFG on previous test
HDL 35mg/dL and/or triglyceride greater than or equal to 250 mg/dL
Previously elevated blood glucose level
History of cardiovascular disease
Hypertension (greater than or equal 140/90 or on therapy for hypertension)
Women with PCOS
Physical inactivity
Other conditions associated with insulin resistance (severe obesity)
Age >/= 40
Medication: Corticosteroids, antipsychotic
 Universal screening for GDM is
recommended for Filipino gravida
At first prenatal visit, determine if the gravida
is high risk or not based on historical and
pregnancy risk factors.
All Filipino gravidas should be
considered “high risk by race and should
be screened for type 2 DM
Algorithm for women low risk for Diabetes Mellitus
Algorithm for women low risk for Diabetes Mellitus
Algorithm for women high risk for Diabetes Mellitus
 Management
Diet
Exercise
Glucose monitoring
Insulin
Oral hypoglycemic agents
 Management

Antepartum Management
Intrapartum Management
Postpartum Management
 Antepartum Management
What are the caloric requirements for pregnant patients
with diabetes mellitus/GDM?
1800kcal- 2500kcal/day

Target weight gain during Pregnancy

Underweight 12.5-18 Kg
Normal 11.5-16 Kg
Overweight 7-11.5 Kg
Obese 5-9 Kg
 Antepartum Management
What specific dietary items/plans, as part of MNT, can be
prescribed for DM/GDM pregnant patients?
DASH
Diet rich in fruits, vegetables, whole grains and low-fat
dairy products
 Antepartum Management
What blood glucose targets are associated with a reduction
in maternal and perinatal complications?
Blood glucose should be lowered during pregnancy to the
following parameters:
Fasting blood glucose <95 mg/dL (5.3 mmol/L) AND
One-hour postprandial blood glucose < 140 mg/dL (7.8
mmol/L) OR
Two-hour postprandial blood glucose < 120 mg/dL (6.7
mmol/L)
 Antepartum Management
How should blood glucose be managed when glycemic
targets are NOT achieved with medical nutrition therapy and
lifestyle changes?
Insulin versus Oral hypoglycemic agents
Subcutaneous insulin should be used to achieve glycemic targets. (POGS, 2018)
The American College of Obstetricians and Gynecologists (2001) has not
recommended oral hypoglycemic agents during pregnancy.
 It is usually recommended that metformin be discontinued once pregnancy is
diagnosed because it is long known to reach the fetus. (Williams)
There is increasing support for the use of glyburide as an alternative to insulin in
the management of gestational diabetes. (Williams)
 Antepartum Management
What is the role of oral anti-diabetic pharmacotherapies
during pregnancy?
There is insufficient evidence on the benefits and potential
harms of oral anti-diabetic pharmacological therapies
(Metformin, Glibenclamide, Acarbose) on short-term
maternal health outcomes.
 Antepartum Management
Fetal Surveillance
Is there a need to do antenatal fetal surveillance in
pregnant patients with DM?
Pregestational DM 28 weeks
GDM with poor glycemic control AOG
On insulin or oral hypoglycemic agents

37 weeks
GDM well-controlled AOG
 Antepartum Management
Fetal Surveillance
What tests are available for fetal surveillance in pregnant
patients with DM?
Fetal movement count
Complete evaluation of maternal and fetal status (eg
NST or BPS)
Fetal growth monitoring
When and how often do we test pregnant patients with Diabetes
mellitus?
 Intrapartum Management
When should delivery occur in pregnancies complicated by
DM?
Pregestational DM 37 weeks
GDM with poor glycemic control AOG
On insulin or oral hypoglycemic agents

40 weeks
GDM well-controlled AOG
 Intrapartum Management
How should delivery be carried out in pregnancies
complicated by DM?

Macrosomia
Outright CS if with Birth injury
EFW of 4Kg and above
Shoulder
dystocia
 Intrapartum Management
How should blood glucose be managed during intrapartum
period?

Dextrose 5% solution
Prevent maternal hypoglycemia
 Postpartum Management

Women with GDM should discontinue blood

glucose-lowering therapy immediately after
birth.
Women with pregestational DM– monitor
blood glucose level
 Postpartum Management

Follow-up:
75-gram OGTT at 4-12 weeks post-partum

Use of hypoglycemic during lactation

 Infants of Diabetic Mother
AKALA NIYO I AM OKAY,
BUT THE TRUTH IS I AM
NOT.
 Prognosis
GDM may progress to Type 2 Diabetes Mellitus!
The incidence of Type 2 DM in those with Previous GDM:
3.7% 9 months postpartum
4.9% 15 months postpartum
13.1% 5 years postpartum
18.9% 9 years postpartum
50-70 15 to 25 years
Risk Factors:
 Waist circumference and BMI strongest
predictors of development of DMT2 among those
with previous GDM
DMT2 develops in 50-75% of obese (BMI >/=
30kg/m2)
Other major risk factors for the development of DMT2:
1. Insulin- requiring GDM
2. Onset early on pregnancy (<24 wks AOG)
3. Presence of autoantibodies (insulinoma antigen)
4. High FBS levels during pregnancy and early postpartum
5. Presence of neonatal hypoglycemia
6. GDM in more than 1 pregnancy
 Prevention
Preconception counselling
Folic acid supplementation
Prevent excessive weight gain
Continuing lifestyle modification
Prevention
Thank you for listening!