Diabetes in

Pregnancy
Supervisor: Dr Rathimalar
By: Dr Ashwini Arumugam & Dr Laily Mokhtar
 Types of DM in pregnancy
PRE-EXISTING DM GESTATIONAL DM
• Type 1 DM • 90% of cases
• Genetic Predisposition • Glucose intolerance occurs in 2nd half of
• Autoantibodies that targets the B- pregnancy
cells • Asymptomatic
• Type 2 DM • Disappear after delivery
• Genetic Predisposition • however
• Insulin Resistance - 80% GDM IN NEXT PREGNANCY
- 50% DM IN 5 YEARS
 Pathophysiology
• Characterised by hyperinsulinemia and insulin Resistance (IR), caused by increased Human
Placental Lactogen, Leptin, cortisol, progesterone and prolactin.

Pregnancy = Diabetogenic
 Implication
GDM
• - increased risk of fetal
macrosomia
• -risk of metabolic syndrome
and type 2 DM later (50%)
• -Risk of obesity, glucose
tolerance and diabetes to babies
later on
Pre-existing diabetes
• -Higher risk of congenital
malformation and miscarriage
• -Recurrent urinary tract
infection/vulvovaginal infection
• -Associate with pre-eclampsia,
polyhydramnios, PPROM,
Preterm labour, fetal
macrosomia, IUGR, risk of
operative delivery
 Fetal complication
• Fetal macrosomia result in shoulder dystocia during delivery, brachial plexus
injury, clavicular fracture
• Increased risk of stillbirth and IUGR
• Metabolic complication likes neonatal hypoglycaemia, hypocalcemia
• Hematologic complication such as hyperbilirubinemia and polycythemia
• Respiratory complication: RDS

ORAL GLUCOSE TOLERANCE TEST (OGTT)
Who should be screen (RF)
1. BMI > 27 kg/m2
2. Previous GDM
3. 1st degree family hx with DM
4. Glycosuria > 2+ on two occasions
5. History of macrosomic baby (>4kg)
6. Bad obstetric history [unexplained
intrauterine death, congenital
anomalies shoulder dystocia]
7. Current obstetric problems (essential
hypertension, pregnancy induced
hypertension, polyhydramnios and
current use of corticosteroids)
Diagnosis
When?
For women with risk factor,
As early as possible.
Women age >25 with no risk
factor: at 24-28 weeks
gestation
*If initial test is negative for
high risk women, it should be
repeated at 24-28 weeks of
gestation
HOW?
1. maintain normal diet (~3 days)
2. Fasting for the whole midnight
until next morning or at least 8H
3. Blood sample will be collected
in morning (FBS)
4. Drink 75g of glucose in 200ml
of water (10-15m)
5. Advice patients to rest
6. Take blood for after 2H
7. Interpret the reading
 Overt DM
• Overt DM is suspected in the presence of at least one of the following:
• Fasting plasma glucose ≥7.0 mmol/L
• Random plasma glucose ≥11.1 mmol/L with symptoms
• However, the diagnosis of overt DM is confirmed with a second test
(FPG/RPG/OGTT)
• Overt diabetes in pregnancy should be managed as pre-existing diabetes.
Management of
diabetes in
pregnancy
 Preconceptional care
•Discussion on timeline for pregnancy planning
•Lifestyle advice (diet, physical activities, smoking cessation and optimal body weight)
•Folic acid supplementation (5mg/day, start 3 months prior until 12w of gestation is effective in
preventing neural tube defects (NTDs)
• Appropriate contraception
•Full medication review (discontinue potentially teratogenic medications)
•Retinal and renal screening
•Patient education regarding glycaemic control
 Preeclampsia prophylaxis
• Pregnant woman with pre-existing diabetes has five-fold increased risk of PE
compared to woman without diabetes
• Low dose aspirin (75-150 mg daily) should be given to prevent preeclampsia in
women with pre-existing diabetes from 12 weeks of gestation until term.
• High dose CALCIUM 1g daily from 20 weeks of gestation until term
 Fetal surveilance
Due to risk of congenital malformation, women with pre-existing diabetes should be
offered USG scan at:
• 11-14 weeks of gestation for dating and assessment of major structural
malformation
• 18-20 weeks of gestation for detailed structural anatomy scan (by a trained
specialist or sonographer)
• • In pregnant women with pre-existing diabetes and GDM, serial growth scan
should be performed every four weeks from 28 to 36 weeks of gestation.
 Medical Nutritional Therapy
• If It mainly focuses on carbohydrate controlled meal plan, monitoring of gestational
weight gain, combined with Self Blood Glucose Monitoring
• MNT should be given to pregnant women with these conditions:
 at risk of GDM
 pre-existing diabetes
 at diagnosis of GDM
• MNT should be INDIVIDUALIZED according to nutritional needs and cultural
preference to ensure positive maternal and fetal outcomes
 Oral Anti-Diabetic Agent/ Oral Hypoglycemic Agent

• Based on two recent systematic review and meta-analysis, use of metformin in GDM leads to
better maternal and fetal outcomes, in terms of total weight gain, pregnancy induced hypertension,
neonatal hypoglycaemia.
• Metformin should be offered when blood sugar is not controlled by diet and exercise within 1-2
weeks (NICE Guideline recommendation)
Insulin Therapy
Actrapid yellow
Humulin R yellow-
orange

Lispro/Humalog purple

Insulatard green
Humulin N green

Mixtard orange-coklat
Humulin 70/30 orange
Novomix (pen) blue

Peakless 24H, unlicensed

for pregnancy use
Levemir/ detemir
turquoise
Lantus/ glargine purple
 Timing and mode of delivery
For women with pre-existing diabetes:
• without complications, delivery between 37+0 and 38+6 weeks
• with maternal or fetal complications, delivery before 37+0 weeks
For women with GDM:
• On diet alone, delivery before 40+0 weeks
• On oral antidiabetic agent or insulin, delivery between 37+0 and 38+6 weeks
• With maternal or fetal complications, deliver before 37+0 weeks
Mode of delivery should be individualised, taking into consideration the estimated
fetal weight and obstetric factors.
Intrapartum Blood Glucose Monitoring
 Postpartum
• Insulin requirement dropped after delivery by 60-75%
• If glycemic control is inadequate, insulin can be continued at lower
dose
• Counselling regarding contraception
• OGTT at 6 weeks post partum, then yearly
• Annual screening for diabetes
Thank You : )