Diabetes Mellitus in Pregnancy

JI Larracas | JI Laureano | JI Laureles | JI Ledda | PGI Lusung

Group B2
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CLINICAL HISTORY
 PATIENT’S PROFILE

27 years old

Regular prenatal checkup

Gravida 1 Para 0

Pregnancy Uterine 38
weeks and 1 day
HISTORY OF PRESENT
History of presentPREGNANCY
pregnancy | 1st
1STtrimester
TRIMESTER |
2nd TRIMESTER | 3RD TRIMESTER

❏ Nausea and vomiting

❏ Breast tenderness
❏ Missed menses

❏ 9 weeks AOG:
● Consulted for her first prenatal check up with no
subjective complaints
 9 weeks aog

CBC BLOOD TYPE

RBC 4.99 x 10^12/L B+

Hemoglobin 145 g/L

Hematocrit 0.41
HEPATITIS B SURFACE
ANTIGEN
Platelet Count 377 non-reactive

WBC 13.81 x 10^9/L

Neutrophils 0.73 RAPID PLASMA REAGIN

Lymphocytes 0.19 non-reactive
 9 weeks aog
TRANSVAGINAL
URINALYSIS
ULTRASOUND
Color yellow Single live intrauterine pregnancy 9 weeks and 1
day by crown rump length with good cardiac
Transparency slightly hazy activity (FHT: 170 bpm). Normal ovaries with
corpus luteum on the left.
Protein negative

Glucose +4

pH 6.0

Specific Gravity 1.015 ❏ Started on prenatal medications to which

WBC 16-25 she complied.

RBC 1-3

Epithelial Cells moderate

Bacteria few
 19 weeks aog

75g OGTT
Threshold
Patient’s Result
POGS* IADPSG** ADA**

FBS 145.96 mg/dL 92 92 95

1st Hour 322.93 mg/dL 180 180 180

2nd Hour 288.14 mg/dL 140 153155

❏ Advised diet modification and capillary blood glucose monitoring 4x a day.

❏ After a week, she came back with the following results:

CBG MONITORING
Patient’s Result ADA

Pre-breakfast 115-181 mg/dL < 100

1 hour post meals 134-232 mg/dL < 140

❏ Prescribed with Aspirin 80 mg/tab, 1 tablet OD until 36 weeks.

❏ Referred to Endocrinology service.
❏ Started on Insulin Mixtard 70/30
❏ 24 units SQ pre-breakfast & 12 units SQ pre-dinner
 23 weeks aog

PRENATAL CHECK-UP
Vital Signs stable

Fundic Height 23 cms.

FHT 150 bpm

CBG MONITORING QID

Patient’s Result ADA

Pre-breakfast 114-170 mg/dL < 100

1 hour post meals 143-216 mg/dL < 140

 23 weeks aog
Insulin was modified to the following:
Insulin Mixtard
❏ 28 units SQ pre-breakfast
❏ 8 units SQ pre-lunch
❏ 16 units SQ pre-dinner

Congenital Anomaly Scan was also performed showing:

❏ Single live intrauterine pregnancy, 23 weeks age of gestation, in
breech presentation
❏ Posterior grade I placenta
❏ Adequate amniotic fluid volume (AFI: 6.08 cm)
❏ No gross congenital anomalies noted at the time of scan
 SUBSEQUENT PRENATAL CHECK-UPS
AOG FH/FHT UTZ CBG Insulin
QID
24 cm Insulin Mixtard 70/30:
25 weeks - preBF: 77-113 mg/dL
150 bpm 32-12-20 u premeals
2h postmeals: 107-121 mg/dL

QID
Unremarkable Insulin Mixtard 70/30:
28 cm preBF: 69-105 mg/dL (2 elevated
28 weeks Biometry + 32-12-20 u premeals
140 bpm episodes)
BPS 8/8
2h postmeals: 76-115 mg/dL

TID Insulin Mixtard 70/30:

30 cm
30 weeks BPS 8/8 preBF: 74-89 mg/dL 32-12-20 u premeals
150 bpm
2h postmeals: 68-119 mg/dL

Unremarkable TID Insulin Mixtard 70/30:

31 cm
34 weeks Biometry + preBF: 63-89 mg/dL 32-12-20 u premeals
130 bpm
BPS 8/8 2h postmeals: 98-117 mg/dL

Unremarkable BID Insulin Mixtard 70/30:

31 cm
36 weeks Biometry + preBF: 70-84 mg/dL 32-12-20 u premeals
140 bpm
BPS 8/8 2h postmeals: 93-118 mg/dL
 38 weeks and 1 day aog

❏ She came back for her prenatal check-up and was

subsequently admitted for induction of labor.
PAST MEDICAL HISTORY

❏ No history of measles, mumps, chicken pox

❏ Non-hypertensive, non-asthmatic, non-diabetic prior
to pregnancy
❏ No history of trauma, hospitalizations, major illnesses
FAMILY HISTORY

❏ Father: died at 56 years old, due to

complications of diabetes mellitus
❏ Mother: 53 years old, apparently well
❏ 2 siblings: apparently well

❏ Denies heredofamilial diseases such as heart,

lungs, kidney diseases, malignancies
 PERSONAL & SOCIAL HISTORY

❏ College undergraduate
❏ Call Center agent
❏ Living-in with her 30-year-old partner for 2 years now
❏ Non-smoker, occasional alcoholic beverage drinker
❏ Denies any history of illicit drug use
OBSTETRICAL HISTORY | GYNECOLOGIC history | sexual
history | method of contraception
❏ Primigravid
❏ Gravida 1 Para 0
M 13 years old
I 28-30 days
D 4-5 days
A 3-4 moderately soaked pads/day
S occasional dysmenorrhea

❏ She denies any history of dyspareunia, post-coital bleeding, leucorrhea or exposure to sexually
transmitted diseases.
OBSTETRICAL HISTORY | GYNECOLOGIC history | sexual
history | method of contraception

❏ Coitarche: 20 years old

❏ 1 lifetime sexual partner
❏ Currently in a monogamous relationship

❏ No history of contraceptive use

 REVIEW OF SYSTEMS

Constitutional No fever, no chills, no malaise, no weight loss

Hematology No easy fatigability, no easy bruisability

CNS No headache, no seizure, and no loss of consciousness

HEENT No blurring of vision, no hearing loss, and no tinnitus

Respiratory No dyspnea, no cough, no colds, and no apnea

CVS No orthopnea, no palpitations

GIT No diarrhea, no constipation

GUT No dysuria, no frequency, no urgency

NMS No malaise, no arthralgia, no myalgia, no numbness

PHYSICAL EXAMINATION
 GENERAL SURVEY | VITAL SIGNS

conscious; coherent; not in distress

BP 120/80 mmHg Height 5’1”

CR 84 bpm Weight 70 kg

RR 20 cpm
Temp 29.2 kg/m2
36.9 C
BMI
Obese class I
O2 Sat 98%
 PHYSICAL EXAMINATION

HEENT Pink palpebral conjunctivae, anicteric sclerae, no NAD, no tonsillopharyngeal congestion

Neck Supple, no neck vein engorgement, no palpable lymph nodes

Chest Symmetrical chest expansion, no retractions, no lagging

Lungs Vesicular breath sounds, no crackles no wheezes

Heart Adynamic precordium, tachycardic with regular rhythm, no murmurs

Breasts Symmetrical in contour, no dimpling, no palpable mass or abnormal nipple discharge

 PHYSICAL EXAMINATION
Globular enlarged abdomen, with fundic height of 32 cms, fundus occupied by breech, fetal
Abdomen back on the left, fetal small parts on the right, cephalic, unengaged, with FHT of 130s best
heard at the lower left quadrant, estimated detail weight of 3000-3200 grams

Speculum Clean-looking cervix with scanty mucoid, non foul smelling discharge

Normal looking external genitalia, nulliparous introitus, vagina admits 2 fingers with ease,
Internal Exam cervix is closed, midposition, medium in consistency, beginning effacement, adnexa cannot be
assessed due to enlarged uterus

Extremities No gross deformities, no edema on both upper and lower extremities, full pulses
INITIAL IMPRESSION
& PLAN
 INITIAL IMPRESSION

Gravida 1 Para 0
Pregnancy Uterine 38 weeks and 1 day
Cephalic, not in labor
Overt Diabetes Mellitus - controlled
T/C Urinary Tract Infection
Obese class I
 INITIAL PLAN

❏ Admit the patient to LR/DR

❏ Hook to PNSS
❏ For Induction of Labor
❏ For CBG monitoring every 4-6 hours
❏ Insulin Therapy: Regular Insulin 4 units SQ as needed for CBG ≥ 140
mg/dL
❏ Continuous Electronic Fetal Monitoring
❏ For Vaginal Delivery
❏ Refer to Internal Medicine - Endocrinology service
SALIENT FEATURES
 SALIENT FEATURES
❏ 27 years old
❏ Gravida 1 Para 0
❏ Pregnancy Uterine 38 weeks and 1 day
❏ Filipino (Asian race)
❏ Non-diabetic prior to pregnancy
❏ First degree history of Diabetes Mellitus
❏ Obese Class I (BMI: 29.2 kg/m2)

Urinalysis:
9 weeks AOG
● Glucose +4
75g OGTT
● FBS: 145.96 mg/dL
19 weeks AOG
● 1st Hour: 322.93 mg/dL
● 2nd Hour: 288.14 mg/dL
 SALIENT FEATURES
❏ Capillary Blood Glucose
- taken 4 times days

Pre-breakfast: 115 - 181 mg/dL

19 weeks AOG
1 hour post-meals: 134 - 232 mg/dL
Pre-breakfast: 114 - 170 mg/dL
23 weeks AOG
1 hour post-meals: 143 - 216 mg/dL
Pre-breakfast: 77 - 113 mg/dL
25 weeks AOG
2 hour post-meals: 107 -121 mg/dL
Pre-breakfast: 69 - 105 mg/dL
28 weeks AOG
2 hour post-meals: 76 - 115 mg/dL
DIFFERENTIAL DIAGNOSIS
 Differential diagnoses
Asymptomatic Overt Diabetes
Gestational Diabetes
Bacteriuria (Pre-gestational)

>25 years old

>25 years old
Asian Race
Asian Race
(-) dysuria, frequency of Strong family history of type II diabetes
Obesity
urination, urgency Obesity
Family History of diabetes
(-) fever (+) Glucosuria, ketoacidosis
Non-diabetic prior to pregnancy
(+) polydipsia, polyuria
(+) Glucosuria
(+) unexpected weight loss

Increased WBC
FBS ≥ 7.0 mmol/L (≥126 mg/dL)
(+) Urine culture &
FBS ≥ 5.1 mmol/L (≥92 mg/dL) 1hr OGTT ≥200mg/dL
sensitivity
1hr OGTT ≥10 mmol/L (≥190 mg/dL) 2hr OGTT (>200 mg/dL)
(+) Bacteria
2hr OGTT ≥8.5 mmol/L (≥153mg/dL) HbA1c ≥ 6.5%
(+) Epithelial cells
RP Glucose >11.1 mmol/dL (>200 mg/dL)
(+) Leukocyte esterase/nitrite
 Differential diagnoses
Asymptomatic Overt Diabetes
Gestational Diabetes
Bacteriuria (Pre-gestational)

>25 years old

>25 years old
Asian Race
Asian Race
Strong family history of type II diabetes
Obesity
Obesity
Family History of diabetes
(+) Glucosuria, ketoacidosis
CASE CORRELATION Non-diabetic prior to pregnancy
(+) polydipsia, polyuria
(+) Glucosuria
(+) unexpected weight loss
Less Likely:
● No urine culture &
sensitivity
● (-) Leukocyte
esterase/nitrite FBS ≥ 7.0 mmol/L (≥126 mg/dL)
● Poor specimen catch FBS ≥ 5.1 mmol/L (≥92 mg/dL) 1hr OGTT ≥200mg/dL
1hr OGTT ≥10 mmol/L (≥190 mg/dL) 2hr OGTT (>200 mg/dL)
2hr OGTT ≥8.5 mmol/L ≥(153mg/dL) HbA1c ≥ 6.5%
RP Glucose >11.1 mmol/dL (>200 mg/dL)
 Differential diagnoses
Gestational Diabetes
CASE CORRELATION
Likely:
● 27 years old (>25)
● Filipino (Asian Race)
● Obese Class I
● Strong family history of DM
● Non-diabetic prior to pregnancy
9 weeks AOG, Urinalysis
● Glucose: +4
Less Likely:
19 weeks AOG, 75g OGTT results:
● FBS: 145.96 mg/dL
● 1st hr: 322.93 mg/dL
● 2nd hr: 288.14 mg/dL
Overt Diabetes
(Pre-gestational)
>25 years old
Asian Race
Strong family history of type II diabetes
Obesity
(+) Glucosuria, ketoacidosis
(+) polydipsia, polyuria
(+) unexpected weight loss
FBS ≥ 7.0 mmol/L (≥126 mg/dL)
1hr OGTT >200mg/dL
2hr OGTT (>200 mg/dL)
HbA1c ≥ 6.5%
RP Glucose >11.1 mmol/dL (>200 mg/dL)
Differential diagnoses
Overt Diabetes
(Pre-gestational)

CASE CORRELATION
● 27 years old (>25)
● Filipino (Asian Race)
● Obese Class I
● Strong family history of DM
● Non-diabetic prior to pregnancy
9 weeks AOG, Urinalysis
● Glucose: +4
19 weeks AOG, 75g OGTT results:
● FBS: 145.96 mg/dL
● 1st hr: 322.93 mg/dL
● 2nd hr: 288.14 mg/dL
 ADMITTING DIAGNOSIS

Gravida 1 Para 0
Pregnancy Uterine 38 weeks and 1 day
Cephalic, not in labor
Overt Diabetes Mellitus - controlled
Obese Class I
COURSE IN THE WARD
 INTRAPARTUM

❏ Hooked to continuous electronic fetal monitor

❏ Capillary blood glucose level was obtained every 4-6 hours
❏ Regular Insulin 4 units was given SQ as needed for CBG > 140 mg/dL

❏ Delivery: Normal Spontaneous Delivery

● Term, birth living girl
● APGAR Score: 9 and 10
● BW: 3230g, appropriate for gestational age.
DIABETES MELLITUS
IN PREGNANCY
 INTRODUCTION

❏ Most common medical complication in pregnancy

❏ Development of carbohydrate intolerance
❏ Easily managed but it should be closely monitored

A1GDM GDM that is adequately controlled with diet

A2GDM GDM that is adequately controlled with medication

 INCIDENCE | PREVALENCE

Williams Obstetrics 25th Ed

❏ In the US, 258,000 (6.5%)

gravidas coexist with some form
of diabetes.
 INCIDENCE | PREVALENCE
International Diabetes Federation, 2019

❏ 223 million women (20-79 years)

● Projected increase: 343 million by 2045
❏ 20 million (16%) of live births had some form of hyperglycemia in pregnancy
● 84% GDM
❏ 1 in 6 births was affected by gestational diabetes
❏ More prevalent in low- and middle-income countries.
 INCIDENCE | PREVALENCE
International Diabetes Federation, 2020

❏ The Philippines is one of the 39 countries and territories of the IDF WP region.
❏ Worldwide: 463 million people
❏ Western Pacific: 163 million people

Total Adult Population 63,265,700

Prevalence of Diabetes in Adults 6.3%

Total Cases of Diabetes in Adults 3,993,300

 ETIOLOGICAL CLASSIFICATION OF diabetes
mellitus
Insulin Deficiency

Insulin Resistance

Diabetes
Mellitus

Other Types

Gestational
 RISK FACTORS FOR DIABETES AMONG
PREGNANT WOMAN
❏ Prior history of GDM
❏ Glucosuria
❏ Family history of diabetes
❏ First-degree relative with type 2 diabetes
❏ Prior macrosomic baby
❏ Age >25 years old
❏ Diagnosis of polycystic ovary syndrome
❏ Overweight/Obese before pregnancy
❏ Macrosomia in current pregnancy
❏ Polyhydramnios in current pregnancy
❏ Intake of drugs affecting carbohydrate metabolism
 RISK FACTORS FOR DIABETES AMONG
PREGNANT WOMAN

❏ Glucosuria
❏ Family history of diabetes
❏ First-degree relative with type 2 diabetes

❏ Age >25 years old

 Diabetes Mellitus in
Pregnancy

Pre-gestational (Overt) Gestational Diabetes Mellitus

Diabetes (GDM)

Known to have Diabetes Mellitus Those who are diagnosed during

before pregnancy pregnancy

Fetal
● Spontaneous Abortion
● Preterm Delivery
● Malformations
● Altered Fetal Growth
● Unexplained Fetal Demise
● Hydramnios
PATHOphysiology
Pregnancy
❏ Human Placental Lactogen
❏
❏
❏
Cortisol
Progesterone
Estrogen
↑
↑ Glucose
Insulin Resistance
❏ Hyperglycemia
❏ Hyperinsulinemia
Neonatal Maternal
● Respiratory Distress Syndrome ● Preeclampsia
● Hypoglycemia ● Diabetic Nephropathy
● Hypocalcemia ●
● Hyperbilirubinemia & Polycythemia
Diabetic Retinopathy
● Diabetic Neuropathy
● Cardiomyopathy
● ● Diabetic Ketoacidosis
Long-term Cognitive Development
● Inheritance of Diabetes ● Infections
 IMPACT ON PREGNANCY
Fetal Neonatal Maternal
❏ Respiratory Distress
❏ Syndrome
Spontaneous Abortion ❏ Hypoglycemia ❏
❏ Preeclampsia
Preterm Delivery ❏ Hypocalcemia ❏
❏ Diabetic Nephropathy
Malformations ❏ Hyperbilirubinemia and ❏
❏ Diabetic Retinopathy
Altered Fetal Growth ❏
❏ Polycythemia Diabetic Neuropathy
Unexplained Fetal ❏ Cardiomyopathy ❏ Diabetic Ketoacidosis
Demise ❏ Long-term Cognitive ❏
❏ Hydramnios Infections
Development
❏ Inheritance of Diabetes
 IMPACT ON PREGNANCY
Fetal

❏ Spontaneous Abortion ❏ Early miscarriage & poor glycemic control

❏ Preterm Delivery
❏ Malformations ❏ Elevated risk:
❏ Altered Fetal Growth ● HbA1C of >12%
❏ Unexplained Fetal ● Preprandial glucose of >120 mg/dL
Demise
❏ Hydramnios ❏ Glucose Kinase Gene (CKG) mutation
 IMPACT ON PREGNANCY
Fetal

❏ Spontaneous Abortion
❏ Preterm Delivery
❏ Malformations ❏ Prone to infection
❏ Altered Fetal Growth ❏ Polyhydramnios
❏ Unexplained Fetal ❏ Fetal macrosomia
Demise
❏ Hydramnios
 IMPACT ON PREGNANCY
Fetal

❏ Spontaneous Abortion ❏ Women with Type 1 DM

❏ Preterm Delivery ● 2x incidence
❏ Malformations ● Almost half of perinatal deaths in
❏ Altered Fetal Growth
❏ Unexplained Fetal diabetic pregnancies
Demise ❏ Cardiovascular malformations
❏ Hydramnios ❏ Caudal regression sequence
 IMPACT ON PREGNANCY
Fetal
❏ From congenital malformations or advanced
❏ Spontaneous Abortion maternal vascular disease
❏ Preterm Delivery
❏ Malformations ❏ Fetal overgrowth
❏ Altered Fetal Growth ❏ Excessive fat deposition on shoulders or
❏ Unexplained Fetal trunk
Demise
❏ Hydramnios ● Shoulder dystocia
● Cesarean delivery
 IMPACT ON PREGNANCY
Fetal ❏ Risk of fetal death
● Three to four times higher in women
with pregestational diabetes
❏ Spontaneous Abortion
❏ “Unexplained”
❏ Preterm Delivery ● Unidentified factors
❏ Malformations ❏ Large for gestational age
❏ Altered Fetal Growth
❏
❏ Poor glycemic control
Unexplained Fetal
Demise ❏ Findings:
❏ Hydramnios ● Elevated lactic acid levels
● Lower umbilical venous blood pH
 IMPACT ON PREGNANCY
Fetal

❏ Spontaneous Abortion
❏ Preterm Delivery ❏ AFI of >24 cm
❏ Malformations ❏ Elevated HbA1c levels in the third trimester
❏ Altered Fetal Growth
❏ Unexplained Fetal ❏ Fetal hyperglycemia → polyuria →
Demise hydramnios
❏ Hydramnios
 IMPACT ON PREGNANCY
Neonatal

❏ Respiratory Distress
Syndrome
❏ Hypoglycemia
❏ Hypocalcemia
❏ Hyperbilirubinemia and ❏ Gestational age rather than overt diabetes
Polycythemia
❏ Cardiomyopathy
❏ Long-term Cognitive
Development
❏ Inheritance of Diabetes
 IMPACT ON PREGNANCY
Neonatal

❏ Respiratory Distress
Syndrome ❏ <45 mg/dL
❏ Hypoglycemia ❏ Rapid drop in plasma glucose concentration
❏ Hypocalcemia
❏ Hyperbilirubinemia and after delivery
Polycythemia ❏ Hyperplasia of fetal β-islet cells
❏ Cardiomyopathy
❏ Long-term Cognitive ❏ Frequent blood glucose measurements and
Development active early feeding
❏ Inheritance of Diabetes
 IMPACT ON PREGNANCY
Neonatal

❏ Respiratory Distress
Syndrome ❏ <8 mg/dL in term newborns
❏ Hypoglycemia ❏ Unexplained cause:
❏ Hypocalcemia
❏ Hyperbilirubinemia and ● Aberrations in magnesium-calcium
Polycythemia economy
❏ Cardiomyopathy ● Asphyxia
❏ Long-term Cognitive
Development ● Preterm birth
❏ Inheritance of Diabetes
 IMPACT ON PREGNANCY
Neonatal

❏ Respiratory Distress
Syndrome
❏ Hypoglycemia
❏ Hypocalcemia
❏ Hyperbilirubinemia ❏ Increased bilirubin load
and Polycythemia ● Fetal response to relative hypoxia
❏ Cardiomyopathy
❏ Long-term Cognitive
Development
❏ Inheritance of Diabetes
 IMPACT ON PREGNANCY
Neonatal
❏ Insulin excess
❏ Respiratory Distress
❏ First trimester: fetal diastolic dysfunction
Syndrome ❏ Third trimester: thicker fetal
❏ Hypoglycemia interventricular septum and right
❏ Hypocalcemia
❏ Hyperbilirubinemia and
ventricular wall
Polycythemia ❏ Most are asymptomatic
❏ Cardiomyopathy ❏ Hypertrophy resolves in the months after
❏ Long-term Cognitive delivery
Development
❏ Inheritance of Diabetes
 IMPACT ON PREGNANCY
Neonatal
❏ Autism spectrum disorders
❏ Respiratory Distress
Syndrome
❏ Developmental delay
❏ Hypoglycemia ❏ Younger children:
❏ Hypocalcemia ● Diminished cognitive and language
❏ Hyperbilirubinemia and
Polycythemia
development
❏ Cardiomyopathy ❏ Confounding factors = unconfirmed link
❏ Long-term Cognitive between maternal diabetes, glycemic
Development control, and long-term neurocognitive
❏ Inheritance of Diabetes
outcome
 IMPACT ON PREGNANCY
Neonatal
❏ Respiratory Distress
Syndrome
❏ Hypoglycemia ❏ Type 1 Diabetes
❏ Hypocalcemia ● Infection, diet, or toxins
❏ Hyperbilirubinemia and
Polycythemia
❏ Cardiomyopathy ❏ Type 2 Diabetes
❏ Long-term Cognitive ● Much stronger genetic component
Development ● Both parents → 40%
❏ Inheritance of
Diabetes
 IMPACT ON PREGNANCY
Maternal

❏ Preeclampsia ❏ Developed 3-4x more often in women with

❏ Diabetic Nephropathy overt diabetes
❏ Diabetic Retinopathy ❏ Those with coexistent chronic hypertension
❏ Diabetic Neuropathy
❏ Diabetic Ketoacidosis ● 12x more likely to develop
❏ Infections preeclampsia
 IMPACT ON PREGNANCY
❏ Diabetes is the leading cause of end-stage renal
Maternal disease
❏ Microalbuminuria
● 30 - 300 mg/24hr
❏ Preeclampsia ● As early as 5 years after onset
❏ Diabetic Nephropathy ❏ Macroalbuminuria
❏ Diabetic Retinopathy
❏ Diabetic Neuropathy ● >300 mg/24hr
❏ Diabetic Ketoacidosis ● In patients destined to have ESRD
❏ Infections ❏ Hypertension
❏ Renal failure
❏ Women with glomerulopathies, hypertension or
substantial proteinuria before or during
pregnancy
 IMPACT ON PREGNANCY
Maternal ❏ Highly specific complication of both type 1
and type 2 diabetes
❏ Visual impairment in working-aged adults
❏ Nonproliferative retinopathy
❏ Preeclampsia ● Small microaneurysms → blot
❏ Diabetic Nephropathy hemorrhages → hard exudates
❏ Diabetic Retinopathy
❏ ❏ Preproliferative retinopathy
Diabetic Neuropathy
❏ Diabetic Ketoacidosis ● Occlusion → retinal ischemia and
❏ Infections infarction (cotton wool exudates) →
neovascularization
❏ Pregnant women with preexisting diabetes
should be routinely be offered retinal
assessment after the first prenatal visit
 IMPACT ON PREGNANCY
Maternal
❏ Diabetic gastropathy
❏ Preeclampsia ● Nausea and vomiting
❏ Diabetic Nephropathy ● Nutritional problems
❏ Diabetic Retinopathy ● Difficulty with glucose control
❏ Diabetic Neuropathy
❏ Diabetic Ketoacidosis ❏ Women with gastroparesis
❏ Infections ● High risk of morbidity and poor
perinatal outcome
 IMPACT ON PREGNANCY
Maternal ❏ From insulin deficiency combined with an excess in
counter-regulatory hormones such as glucagon →
gluconeogenesis and ketone body formation
❏ May develop with the ff:
❏ Preeclampsia ● Hyperemesis gravidarum
❏ Diabetic Nephropathy ● Infection
❏ Diabetic Retinopathy ● Insulin noncompliance
❏ Diabetic Neuropathy ● Β-mimetic drugs for tocolysis
❏ Diabetic Ketoacidosis ● Corticosteroids
❏ Infections
❏ Noncompliance
 IMPACT ON PREGNANCY
Maternal ❏ Candidal vulvovaginitis
❏ Urinary and respiratory tract infections
❏ Puerperal pelvic sepsis
❏ Asymptomatic bacteriuria
❏ Preeclampsia ● Minimize complications by screening
❏ Diabetic Nephropathy
❏ Diabetic Retinopathy and eradication
❏ Diabetic Neuropathy ❏ Women with pregestational diabetes
❏ Diabetic Ketoacidosis ● Postoperative wound complications
❏ Infections
following cesarean delivery
RECOMMENDATIONS FOR FILIPINO WOMEN
BASED ON POGS CPG CONSENSUS 2011
First Prenatal Visit

FBS, HbA1c or RBS

FBS >92 mg/dL (5.1 mmol/mL)

and
<126 mg/dL (7 mmol/mL)

GDM
No further testing
RECOMMENDATIONS FOR FILIPINO WOMEN
BASED ON POGS CPG CONSENSUS 2011
First Prenatal Visit

FBS ≥126 mg/dL (7 mmol/mL)

or
FBS, HbA1c or RBS RBS ≥200 mg/dL (11.1 mmol/mL) or
HbA1c ≥6.5%

Overt DM
No further testing
 RECOMMENDATIONS FOR FILIPINO WOMEN
BASED ON POGS CPG CONSENSUS 2011
First Prenatal Visit

FBS <92 mg/dL (5.1 mmol/mL)

or
RBS <200 mg/dL (11.1 mmol/mL) FBS, HbA1c or RBS
or
HbA1c <6.5%

NORMAL
 RECOMMENDATIONS FOR FILIPINO WOMEN
BASED ON POGS CPG CONSENSUS 2011
If initial screening is
NORMAL

NORMAL
Proceed immediately to 2h 75g
2h 75g OGTT at 24-28 weeks
OGTT if with other risk
If with NO other risk factors
factors

NORMAL

Repeat 2h 75g OGTT at 32 weeks or anytime in the presence of

maternal/fetal signs of diabetes mellitus
(polyhydramnios, macrosomia, polyphagia, etc.)
RECOMMENDATIONS FOR FILIPINO WOMEN
BASED ON POGS CPG CONSENSUS 2011
If initial screening is
NORMAL

2h 75g OGTT at 24-28 weeks

If with NO other risk factors

NORMAL

Repeat 2h 75g OGTT at 32 weeks or anytime in the presence of

maternal/fetal signs of diabetes mellitus
(polyhydramnios, macrosomia, polyphagia, etc.)
 RECOMMENDATIONS FOR FILIPINO WOMEN
BASED ON POGS CPG CONSENSUS 2011

HIGH RISK PATIENT

1 hr value </= 180 mg/dL

2 hr value </=153 mg/dL 2h 75g OGTT >/= 200 mg/dL

NORMAL Overt DM
 HIGH-RISK PATIENTS

❏ Severe obesity
❏ Strong family history of Type 2 Diabetes Mellitus
❏ Previous history of GDM, impaired glucose metabolism, or glucosuria
SCREENING | DIAGNOSIS FOR OVERT DM IN
PREGNANCY

CASE 75g OGTT (9 weeks AOG)

●
CORRELA ● FBS: 145.96 mg/dL
1st Hour: 322.93 mg/dL
TION ● 2nd Hour: 288.14 mg/dL
One-STEP VS Tw0-STEP STRATEGY
MANAGEMENT
 Management

3rd Trimester
Pre-conceptional Care 1st Trimester 2nd Trimester
& Delivery
Pre-CONCEPTIONAL CARE
Management

3rd Trimester
Pre-conceptional Care 1st Trimester 2nd Trimester
& Delivery

❏ HbA1C of < 6.5% in pregestational diabetes

❏ preprandial glucose: 70-100 mg/dL

❏ peak 2-hr postprandial glucose: 100-120 mg/dL
❏ mean daily glucose concentrations: <110 mg/dL

❏ Folate 400 mcg/day

 FIRST TRIMESTER
Management

3rd Trimester
Pre-conceptional Care 1st Trimester 2nd Trimester
& Delivery

❏ Insulin Treatment
❏ Glucose Monitoring
❏ Diet Modification
 INSULIN TREATMENT
❏ The overtly diabetic gravida is best
treated with Insulin.
❏ Second line:
● Metformin or Glyburide
❏ Initial dose:
● 1st Trimester: 0.7-0.8 U/kg
● 2nd Trimester: 1 U/kg
● 3rd Trimester: 2 U/kg
**NPH: ⅔ before breakfast & ⅓ before
dinner

CASE
Insulin Mixtard 70/30
CORRELA [combination of short-acting & long-acting insulin]
TION
INSULIN TREATMENT

POSTPRANDIAL POSTPRANDIAL

BASAL BASAL
 GLUCOSE MONITORING
ADA POGS
RECOMMENDATION RECOMMENDATION
❏ GDM on diet treatment alone to monitor 4x a
❏ Fasting (before breakfast) day.
❏ Postprandial (1 or 2 hours after meals) ❏ Women on pharmacological therapy may
monitor 4-6 times a day.
 GLUCOSE MONITORING

CASE CORRELATION
Pre-breakfast 115 - 181 mg/dL
19 weeks AOG
1 hour post meals 134 - 232 mg/dL

Pre-breakfast 114 - 170 mg/dL

23 weeks AOG
1 hour post meals 143 - 216 mg/d

Pre-breakfast 77 - 113 mg/dL

25 weeks AOG
2 hours post meals 107 -121 mg/dL

69-105 mg/dL
28 weeks AOG Pre-breakfast
(2 elevated episodes)
 GLUCOSE MONITORING
AOG FH/FHT UTZ CBG Insulin
QID
24 cm Insulin Mixtard 70/30:
25 weeks - preBF: 77-113 mg/dL
150 bpm 32-12-20 u premeals
2h postmeals: 107-121 mg/dL

QID
Unremarkable Insulin Mixtard 70/30:
28 cm preBF: 69-105 mg/dL (2 elevated
28 weeks Biometry + 32-12-20 u premeals
140 bpm episodes)
BPS 8/8
2h postmeals: 76-115 mg/dL

TID Insulin Mixtard 70/30:

30 cm
30 weeks BPS 8/8 preBF: 74-89 mg/dL 32-12-20 u premeals
150 bpm
2h postmeals: 68-119 mg/dL

Unremarkable TID Insulin Mixtard 70/30:

31 cm
34 weeks Biometry + preBF: 63-89 mg/dL 32-12-20 u premeals
130 bpm
BPS 8/8 2h postmeals: 98-117 mg/dL

Unremarkable BID Insulin Mixtard 70/30:

31 cm
36 weeks Biometry + preBF: 70-84 mg/dL 32-12-20 u premeals
140 bpm
BPS 8/8 2h postmeals: 93-118 mg/dL
 DIET MODIFICATION

Carbohydrate & Caloric Minimum of 175g/d

Modifications carbohydrates ideally provided

❏ Height ❏ 55% CHO

❏ Weight ❏ 20% CHON
❏ Degree of glucose intolerance ❏ 25% Fat (<10% saturated)

Caloric restriction may be

appropriate for overweight or
obese women
SECOND TRIMESTER
Management

3rd Trimester
Pre-conceptional Care 1st Trimester 2nd Trimester
& Delivery

❏ a-fetoprotein
❏ Targeted UTZ
scan/Congenital
Anomaly Scan
❏ Fetal 2D Echo

CASE Congenital Anomaly Scan (23 weeks AOG):

CORRELA ❏ No gross congenital anomalies noted at the time of
scan.
TION
 THIRD TRIMESTER
Management

3rd Trimester
Pre-conceptional Care 1st Trimester 2nd Trimester
& Delivery

❏ Fetal Surveillance
❏ Blood Glucose
Management
❏ Timing & Mode of
Delivery
FETAL SURVEILLANCE
32-34 weeks AOG

❏ Fetal Movement counting

❏ Periodic Fetal Heart Rate Monitoring (3x/week)
❏ Intermittent Biophysical Profile Evaluation (2x/week)
❏ Contraction Stress Testing
❏ Delivery usually planned at 38 weeks AOG
 BLOOD GLUCOSE MANAGEMENT
DURING LABOR

❏ Last insulin dose given SQ night before or that morning

❏ Plasma glucose monitoring every 1-4 hours
❏ Give short-acting insulin via IV infusion at a dose of 0.5-1 unit per hour for
plasma glucose above 120 mg/dL
❏ Targets of control during labor are
● Plasma glucose: 80-120 mg/dL
● Capillary glucose: 70-110 mg/dL
❏ Discontinue IV insulin immediately prior to delivery
 BLOOD GLUCOSE MANAGEMENT
CESAREAN SECTION PATIENTS
❏ Last insulin dose given SQ night before
❏ Determine random plasma glucose immediately prior to CS
❏ Infuse short acting insulin (0.5-1 unit/hr) if plasma glucose is above 120 mg/dL
❏ Discontinue IV insulin immediately prior to delivery
❏ Check plasma glucose 2 hours post-CS up to 24 hours

PERIOD OF IMMEDIATE POSTPARTUM

❏ Monitor plasma glucose every 4-6 hours for 24 hours
❏ Administer insulin SQ when indicated
 TIMING & MODE OF DELIVERY
When should delivery occur in pregnancies complicated by
diabetes mellitus?

❏ Optimal: On or after the 38th week

❏ Before the 38th week:
● only for compelling maternal or fetal indications, without documenting
fetal lung maturity
❏ Patients with well-controlled DM and no complicating factors may await
spontaneous labor .

CASE
38 weeks and 1 day AOG
CORRELA Induction of labor
TION
 TIMING & MODE OF DELIVERY
How should delivery occur in pregnancies complicated by
diabetes mellitus?
< 4000g 4000 - 4499 g > 4500 g
Consider past delivery history,
clinical pelvimetry, evidence of Cesarean section may
Trial of Labor
body to head disproportion & be considered
progression of labor

CASE
3,230 g
CORRELA Induction of labor successful and delivered via NSD
TION
 FINAL DIAGNOSIS

Gravida 1 Para 1 (1001)

Pregnancy Uterine, term, Cephalic - Delivered via Normal Spontaneous Delivery; to a live
baby girl, term, birth
APGAR Score of 9 and 10
Birth Weight of 3,230 grams
Appropriate for Gestational Age
Overt Diabetes Mellitus - Controlled
Obese Class I
DISPOSITION &
FUTURE PLANS
 Disposition | future plans

❏ 24-48 hours:
Screening ● Continue glucose monitoring even without
insulin
● Refer to Endocrinologist

❏ Women diagnosed with overt DM in pregnancy

should be monitored using FBS 1-3 days after
delivery and 75 gram OGTT at 4-12 weeks
postpartum
 Disposition | future plans
Plans
Proper instructions
❏ Proper daily perineal hygiene and proper wound care
if episiotomy is done
Upon Discharge ❏ Lifestyle modification such as proper diet and
exercise
❏ Watch out for urinary retention and bladder
overdistention

All women, including those with prior GDM, should be actively

encouraged to exclusively breastfeed to the greatest extent possible
during the first year of life
Breastfeeding ● Benefits: postpartum maternal glucose values Type 2 DM and
Metabolic syndrome are lower among breastfed children
 Disposition | future plans

❏ Patient should be advised of

Desirous of Future Pregnancy preconceptional glucose control
before allowing to get pregnant

Contraception
❏ Both copper and levonorgestrel-releasing
IUD’s can be safely used in women with
prior GDM
❏ Low dose OCPs are safe
 REFERENCES
Cunningham, G. F., Leveno, K., Bloom, S., Spong, C., Dashe, J.,
Hoffman, B., & Casey, B. (2018). Williams Obstetrics(25th ed.).
McGraw-Hill Education / Medical.

Gestational Diabetes Mellitus: ACOG Practice Bulletin: Clinical

Management for Obstetrian-Gynecologists. (2017).
https://journals.lww.com/greenjournal/FullText/2017/07000/Practice_Bul
letin_No__180__Gestational_Diabetes.51.aspx#:~:text=The%20ADA%2
0and%20ACOG%20recommend,risk%20of%20macrosomia%20(20)
.
Unite for Diabetes:Philippine Practice Guidelines for the Diagnosis and
Management of Diabetes Mellitus (2011).
http://www.pcdef.org/Documents/Diabetes-United-for-Diabetes-Phil.pdf
 Thank you
Post-Graduate Interns:
Javate Johnson Lusung Marasigan

Junior Interns:

for listening!
Hornilla Hubilla Ibarra Ibay
Ida Ilagan Jorge Juanitez
Kabiling Kenept Lacanlale
acasandile
Lagman Lalata Lalia Larracas
Laureano Laureles Ledda

Group B2