DIABETESMELLITUS

AND
PREGNANCY

10/20/2016 Mrs. Heera KC Parajuli, BN 1

 Background
Prevalence
• About 1-14 % of all pregnancies are complicated by
Diabetes mellitus and 90% of them are gestational
Diabetes Mellitus.

• Nearly 50% of women with GDM will become

overt Diabetes over a period of 5 to 20 years.

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 BRAINSTMORMING
• Mrs, Sabita Devi Shah, 37 years old , G8P7AoL6Still
birth 1 IUFD 1, SVD with Episiotomy done at 37
completed weeks.
Her history reveals that at 20 weeks she had her
fasting Blood glucose 200 mg/dl and PP 233 mg/dl.
On subsequent check up also her blood sugar were
found above normal that is FBS 150mg/dl and PP
287mg/dl. Urine test shows glycosuria. She had a
positive history of Dm before pregnancy for which
she took ayurvedic medicines as well.
a) What would be her diagnosis?

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You got a handover from OT about a case.
• Mrs Sushma Bastola age 24 years, Emergency
LSCS done at 38 weeks of gestation for
prolonged labor with Gestational Dm. She gave
a birth of a male baby weighing 4kg. Baby was
born normal with no defects. ON medicines
along with the antibiotics protocal Inj. GIK
should be started as well.RBS should be
monitored every 2 hourly and also of Babys’
RBS at 0. 2. 4, 6, 8, 12, to then 48 hours of life.
a) What do you mean by GDM?
b) Why the RBS is monitored frequently for
both the baby’s and mother?

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 Diabetes Mellitus
• Diabetes mellitus is a chronic metabolic disorder
due to either insulin deficiency (relative or
absolute) or due to peripheral tissue resistance
(decrease sensitivity) to the action of insulin.

• The pathophysiology involved are:

 Insulin resistance and
 Inadequate secretion of insulin(B cell
dysfunction)

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 Diabetes in

pregnancy
Pre-existing Gestational
diabetes diabetes

IDDM NIDDM Pre-existing

True GDM
(Type1 (Type2 diabetes
) )

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 ICD 10 (Chapter I- XXII)
Chapter XV: Pregnancy, child birth and the puerperium (O00-O99)

O 24 : DM In Pregnancy

Title: Client attending BPKIHS in the Year 2014 Source: MRC, BPKIHS

Typ Number
e
O24.0= preexisting DM, Insulin dependent 2

O24.1= Preexisting DM Non insulin dependent 1

O24.2= Preexisting malnutrition -related DM 1

O24.3= Preexisting DM unspecified 2

O24.4= DM arising in pregnancy (GDM) 1

O24.9= DM in pregnancy, unspecified 87

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Tota 94
 Type
s
• Type 1 (IDDM)
 Young onset(juvenile) and absolute insulinopenia.
Genetic predisposition with presence of autoantibodies.

• Type 2 (NIDDM)
 Late age onset
 Overweight women
 Peripheral tissue insulin resistance(hyperinsulinaemia)

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 GESTATIONAL DIABETES MELLITUS

• Gestational Diabetes Mellitus is carbohydrates

intolerance of variable severity with onset or first
recognition during the present pregnancy.

• The entity usually presents in the second or

during the third trimester.

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 OVERT DIABETES
• A patient with symptoms of Diabetes Mellitus
(polyuria, Polydipsia, weight loss) and random
plasma glucose concentration of 200 mg/dl or
more is overt diabetes.

• It may be detected for the first time in pregnancy.

• According to ADA, FBS >126mg/dl and

PP(75gm)> 200 mg/dl.
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 EFFECT OF PREGNANCY ON DIABETES

 During pregnancy, due to altered carbohydrate

metabolism and an impaired insulin action, it is
difficult to stabilise the blood glucose.

 The insulin antagonism is due to the combined

effect of HPL, estrogen, progesterone, free cortisol
and degradation of the insulin by the placenta.

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• The insulin requirement during pregnancy increases
as pregnancy advances.

• During pregnancy, renal threshold is diminished,

due to the combined effect of increased glomerular
filtration and impaired tubular reabsorption of
glucose. Glucose leaks out in the urine even though
the blood sugar level is well below 180mg/100 ml .

• Hence, repeated blood glucose test

becomes
mandatory.
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• With the accelerated starvation, there is
rapid activation of lypolysis with short period of
fasting.
• Ketoacidosis canbe precipitated during early
hyperemesis pregnancy, infections
in fasting of and
labor.
• It can be iatrogenically induced by certain drugs
like corticosteroids used in management of pre term
labor.

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• Insulin requirements fall significantly
in puerperium.

• Vascular changes, especially retinopathy

nephropathy, CAD and , may
worsened duringneuropathy
pregnancy. be

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 Effect of diabetes on pregnancy

To the Mother
During pregnancy:
Abortion: recurrent spontaneous abortion may be
associated with uncontrolled DM.
Preterm labor(20%)- infection or polyhydramnious
Infection- UTI and vulvo vaginitis
Increased incidence of pre-eclampsia
Polyhydramnios (25-50%)
Maternal distress
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• Diabetic retinopathy

• Diabetic nephropathy

• ketoacidosis

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 During Labor

Increase incidence of:

• Prolong labor due to big baby
• Shoulder dystocia
• Perineal injuries
• Postpartum haemorrhage
• Operative interferences

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 Puerperium

• Puerperial sepsis
• Lactation failure
• PPH

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 Fetal and Neonatal Hazards

FETAL MACROSOMIA:(30-40%)

Elevation of
maternal
free fatty
acids

Maternal
hyperglycemi
a
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• Congenital malformation(6-10%)
• Neonatal hypoglycaemia(<37mg/dl)
• Respiratory distress syndrome
• Hyperbillirubinaemia
• Polycythemia
• Hypocalcemia(<7mg/dl)
• cardiomyopathy

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Longterm effects:
• Childhood obesity

• Neuropsychological effects and diabetes

• Stillbirth

Perinatal mortality(2-3 times)

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 GDM

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 WHO ARE THE POTENTIAL CANDIDATES ?

• Positive family history of diabetes (parents

or siblings).
• Previous birth of an overweight baby of 4 kg or
more
• Previous stillbirth with pancreatic disease..
• Unexplained perinatal loss.
• Presence of polyhydramnios or recurrent vaginal
candidiasis in present pregnancy.

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 WHO ARE THE POTENTIAL CANDIDATES ?

• Persistent glycosuria
• Age over 30 years
• Obesity
• Ethnic group (East Asian, Pacific Island
Ancestry)

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 Whom should you plan for screening for
GDM??
• Low risk- absence of any risk factors mentioned
above.

• Average risk- some risk factors

• High risk- blood glucose test as soon as feasible.

• (50gm oral glucose challenge test without regard to
time of day or last meal, between 24-28 weeks of
pregnancy.)

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 Hazards of GDM

• Increased perinatal loss associated with

fasting hyperglycaemia .
• Increased incidence of macrosomia
• Polyhydramnios
• Birth trauma
• Reoccurence of GDM in subsequent pregnancy is
about 50 %.

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 Management
Aim

Achieve maternal near normoglycemic

level prevent adverse
to perinatal
outcomes
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 Management
• Close antenatal supervision.
• Periodic FBS/PP . FBS < than 90mg/dl.
• Maintenance of mean plasma blood
glucose between 105 and 110 mg/dl.
• Diet, exercise with or without insulin.
• Human Insulin should be started if FBS exceeds
90mg/dl and 2 hours postprandial value is
greater than 120 mg/dl(repetitive) even on diet
control.
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 Management con….

• Diet- normal woman (2000-2500kcal/day) and

restriction to 1200-1800 kcal/day for over weight
woman is recommended.
• Exercise (aerobic, brisk walking) programmes
are safe in pregnancy.

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 Obstetric management

 Spontaneous labor for good glycaemic control.

 Elective delivery for uncontrolled GDM, requiring

insulin or with complications (macrosomia) at
around 38 weeks.

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 Thank
You

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