DIABETES MELLITUS

Dr. Aldilyn J. Sarajan

2nd year OB-GYNE resident
“Diabetes may exist bore the inception of
pregnancy, or may not appear until labour. The
prognosis is generally believed to be ominous for
mother and child, but a review of the literature
shows that less than 25 percent of the mothers died
from diabetic coma, while premature labour
occurred in only one third of the cases. “
-J . Whitridge Williams (1903)
TYPES OF DIABETES
CLASSIFICATION DURING PREGNANCY
 Before pregnancy – pre-gestational or overt

 During pregnancy - gestational diabetes

WHITE CLASSIFICATION IN PREGNANCY
DIAGNOSIS
IMPACT ON PREGNANCY
IMPACT ON PREGNANCY
FETAL EFFECTS
 Spontaneous Abortion
 Preterm Delivery
 Malformations
 Altered Fetal Growth
 Unexplained Fetal Demise
 Hydramnios
Fetal Effects

 Neonatal Effects
 Respiratory Distress Syndrome
 Hypoglycemia
 Hypocalcemia
 Hyperbilirubinemia and Polycythemia
 Cardiomyopathy
 Long-Term Cognitive Development
 Inheritance of Diabetes
Maternal Effects

 Pre-eclampsia
 Diabetic Nephropathy
 Diabetic Retinopathy
 Diabetic Neuropathy
 Diabetic Ketoacidosis
 Infections
MANAGEMENT OF DIABETES IN PREGNANCY
PRECONCEPTIONAL CARE
 Optimal glycemic control:
HbA1c < 6.5% in women with pre-gestational diabetes

 Optimal pre-conceptional glucose control using insulin:

Self-monitored preprandial glucose levels of 70 to 100 mg/dL, peak 2-hour
postprandial values of 100 to 120 mg/dL, and mean daily glucose
concentrations < 110 mg/dL.

 Folate 400 ug/d orally, is given periconceptionally and during early

pregnancy to decrease the risk of neural-tube defects.
First Trimester
 Insulin Treatment
First Trimester
 Monitoring
First Trimester
Diet
 Nutritionalplanning includes appropriate weight gain
through carbohydrate and caloric modifications based on
height, weight, and degree of glucose intolerance

 Minimum of 175 g/d of carbohydrates

First Trimester
Hypoglycemia

 Fasting glucose values > 120 mg/dL, was

associated with greater risks for preeclampsia,
cesarean delivery, and birth weight above

 Women with overt diabetes who have glucose

values that are viewed by some as "considerably
above" this 90 mg/dL threshold can expect good
pregnancy outcomes.
Second Trimester

 Euglycemia with self-monitoring

Third Trimester and Delivery

 Fetal movement counting

 Periodic fetal heart rate monitoring
 Intermittent biophysical
 Profile evaluation
 Contraction stress testing
Puerperium

 May require virtually no insulin for the first 24

hours or so postpartum
 Insulinrequirements may fluctuate markedly
during the next few days
 Infection must be promptly detected and treated
 Effective contraception or birth control
GESTATIONAL DIABETES
SCREENING AND DIAGNOSIS
 Maternal and Fetal Effects
 Fetal Macrosomia - primary effect attributed to gestational
diabetes
 Perinatal goal is to avoid difficult delivery from macrosomia and
concomitant birth trauma associated with shoulder dystocia

 Neonatal Hypoglycemia - Hyperinsulinemia may provoke severe

hypoglycemia within minutes of birth
 Occurs in the first 6 hours
 Recommended clinical thresholds ranging from 35 to 45 mg/dL

 Maternal Obesity
Management

 Diabetic Diet
 Carbohydrate-controlled diet
 Daily caloric intake of 30 to 35 kcal/kg

 Exercise
 regular physical activity that incorporates aerobic and
strength-conditioning exercise during pregnancy and
extends this to women with gestational diabetes
 Management
 Glucose Monitoring
 The American College of Obstetricians and Gynecologist and the
ADA (2017) recommend glucose assessment four times daily.
 The first check is performed fasting, and the remainder are done 1
or 2 hours after each meal

 Insulin Treatment
 The American College of Obstetricians and Gynecologists (2017)
also recommends that insulin be considered in women with 1-hour
postprandial levels that persistently exceed 140 mg/dL or those
with 2-hour levels > 120 mg/dL
 Management
 Oral Hypoglycemic Agents
 The Food and Drug Administration has not approved glyburide and
metformin use for treatment of gestational diabetes.
 However, the American College of Obstetricians and Gynecologists
(2017) recognizes both as reasonable choices for second-line
glycemic control in women with gestational diabetes.
Obstetrical Management
 Fetal surveillance in women with gestational diabetes and
poor glycemic control

 Inpatient admission after 34 weeks' gestation, and

antepartum monitoring is performed three times each week

 Routine labor induction in women with diet-treated

gestational diabetes should not occur before 39 weeks'
gestation

 Prophylactic caesarean delivery may be considered in

diabetic women with an estimated fetal weight >4500 g
Postpartum Evaluation
Recurrent Gestational Diabetes

 Lifestyle and behavioral changes that include

weight control and exercise between pregnancies
would seem likely to prevent gestational diabetes
recurrence
THANK YOU!