DIABETES MELLITUS

BY: GEORGIE MAY L. ALMACEN M.D

1ST YEAR RESIDENT
EPIDEMIOLOGY

• Affects 3-4% of low risk patients

• Affects 38% in high risk patients
TYPES OF DIABETES
• Type 1: Beta cell destruction, usually absolute
insulin deficiency
• Type 2: Ranges from predominantly insulin
resistance to an insulin secretory defect with insulin
resistance
CLASSIFICATION DURING
PREGNANCY

• Gestational diabetes
• Pregestational/Overt Diabetes
RISK FACTORS
• Increasing abdominal obesity
• Sedentary lifestyle and a diet • Low birth weight and
with high glycemic index undernutrition in utero
• Cigarette smoking • Infections: Hep B and
• Genetic susceptibility Tuberculosis
• Inadequate b cell response to • Exposure to environmental
increasing insulin resistance irritants
• Hemoglobinopathies
PREGESTATIONAL DIABETES
OVERT DIABETES
DIAGNOSIS
Measure of Glycemia Threshold

FPG 7.0 mmol/L (126mg/dL)

HBA1C >6.5 %

RPG 11.1 mmol/L (200 mg/dL) plus

signs and symptoms
IMPACT ON PREGNANCY
FETAL EFFECTS MATERNAL EFFECTS
Spontaneous abortion Preeclampsia
Preterm Delivery Diabetic Nephropathy
Malformations; Cardiomyopathy Diabetic Retinopathy
Altered Fetal Growth Diabetic Neuropathy
Unexplained Fetal Demise Diabetic Ketoacidosis
Hydramnios; Inheritance of Diabetes Infections
Respiratory Distress Syndrome
Hypoglycemia;
Hyperbilirubinemia and
Polycythemia
MANAGEMENT OF DIABETES IN
PREGNANCY

• Preconceptional Care
• First Trimester
• Insulin treatment
MONITORING AND DIET

55% Carbohydrate, 20% Protein, 25% fat (<10% saturated fat)

SECOND TRIMESTER

• Matrenal serum alpha-fetoprotein

• Sonographic Evaluation
• Fetal Echocardiography
• Self glucose monitoring
THIRD TRIMESTER AND DELIVERY
• Third Trimester
• Fetal movement counting
• Periodic Fetal Heart Monitoring
• Intermittent Biophysical Profile
• Contraction Stress Testing
• Labor Induction
• Reducing or withholding long-acting insulin
PUERPERIUM

• Adjusting insulin requirements

• Infections must promptly detected and treated
• Birth Control
GESTATIONAL DIABETES
SCREENING AND DIAGNOSIS

• Single step approach

• Two-step approach
RECOMMENDATIONS ON DETECTION AND DIAGNOSIS
OF DIABETES MELLITUS AMONG FILIPINO PREGNANT
WOMEN

• Classified as GDM or ODM based on plasma glucose levels

• Universal screening for GDM is recommended for Filipino gravidas
• At the first prenatal visit, determine if the gravida is high risk or
not based on historical and pregnancy risk factors
• All Filipino gravidas are considered “high risk” by race or ethnic
group and should be screened for type 2 diabetes mellitus in the
first prenatal visit.
• For Filipino gravidas with no other risk factors aside from
race or ethnicity and the initial test (FBS, HBA1c or RBS) is
normal, screening for GDM should be done at 24-28
weeks using 75g OGTT. If there are other risk factors
identified, screening should proceed immediately.
• If the OGTT at 24-28 weeks is normal, the woman should
be re-tested at 32 weeks or earlier if signs and symptoms
of hyperglycemia are present in the mother and fetus.
• The OGTT should be performed in the morning after an
overnight fast of 8 hours following the general instructions
for the test.
OVERT DIABETES GESTATIONAL POGS-CPG
MELLITUS DIABETES MELLITUS

FBS >126 mg/dL FBS >92 mg/dL FBS >92 mg/dL

(7mmol/L)

RBS >200 mg/dL (11.1 1 hour >180 mg/dL

mmol/L)

HBA1c >6.5% 2 hour >153 mg/dL 2 hour >140 mg/dL

2 hour 75g OGTT

>200 mg/dL
MATERNAL AND FETAL EFFECTS

• Fetal Macrosomia
• Neonatal Hypoglycemia
• Maternal Obesity
ANTEPARTUM FETAL SURVEILLANCE

• FETAL SURVEILLANCE CAN BE DIVIDED INTO:

• SCREENING FOR CONGENITAL ANOMALIES
• MONITOR FOR FETAL WELL-BEING (FETAL MOVEMENT
COUNTING, NST, CST, DOPPLER VELOCIMETRY, BPP)
• ULTRASOUND ASSESSMENT FOR ESTIMATED FETAL
WEIGHT
MANAGEMENT
• Diabetic Diet
• Exercise
• Glucose Monitoring
• Insulin Treatment
• OHAs (Glyburide and Metformin)
TIMING AND MODE OF DELIVERY
•The optimal time for delivery of most diabetic pregnancies is typically on or after the 38th week.
•Patients with well-controlled diabetes mellitus and no complicating factors may wait
spontaneous labor and be allowed to progress to their expected date of delivery.
•Pregnant women with DM who have a normally grown fetus should be offered elective birth
through induction of labor or cesarean section if indicated after 38 completed weeks.
•Routine induction of women with diabetes mellitus on or before 39th weeks gestation may
reduce the risk of macrosomia.
•If elective cesarean section is to be performed it should be at 39 weeks to reduce neonatal
respiratory morbidity
MODE OF DELIVERY BASED ON ESTIMATED
FETAL WEIGHT
<4000 g 4000-4499 g >/ = 4500g
Trial of labor Consider past delivery Cesarean section may
history, clinical be considered
pelvimetry, evidence
of body to head
disproportion and
progression of labor
POSTPARTUM EVALUATION

• GDM should be screened for diabetes mellitus 6-12 weeks

postpartum using non-pregnant oral glucose tolerance
test criteria.
• Women with a history of GDM should have lifelong
screening for the development of DM atleast every 3 years