Case

A 35-year-old married women, G1 P0 (gravidity,

parity) at 28 weeks’ gestation
PE: weight 70Kg, BP 110/80mmHg, Fundal
height 28cm, LOA, The fetal heart rate140bpm
1. What is the likely diagnosis ?
- The size of uterus?
2. What is the next diagnostic step?

3. What is the most likely diagnosis?

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Diabetes in pregnancy

Xiaomin Xiao （肖小敏） , Ph D. Prof.

Dept. of Gynecology & Obstetrics
First Affiliated Hospital of Jinan University

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What is diabetes?

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Diabetes, hyperglycemia, high
serum glucose

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 Diabetes
The pancreas produces the insulin
hormone, which help the organism to take
advantage of glucose
Diabetes: A clinical syndrome characterized
by deficiency of or insensitivity of insulin
and exposure of organs to chronic
hyperglycemia
Diabetes is the growing heath problem in
China

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 Diabetes in pregnancy
Diabetes is the most common medical
complication of pregnancy. It affects 1-14%
of pregnancies, and is associated with many
complications, and a perinatal mortality 2-3
times average
Optimal management (tight control of
blood glucose) is generally associated with a
good outcome

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 Learning objectives
1. Understand the definition of diabetes in
pregnancy
2. Understand the fetal and maternal effects of
diabetes
3. Understand the screening strategy and the
diagnose GDM
4. Understand the classification of diabetes
5. Understand the principles of management of
diabetes in pregnancy
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 Case
A 35-year-old married women, G1 P0 (gravidity,
parity) at 28 weeks’ gestation
PE: weight 70Kg, BP 110/80mmHg, Fundal height
28cm, LOA, The fetal heart tones140bpm
What is the likely diagnosis ?
− The size of uterus?
What is the next diagnostic step?
OGTT (5.4-10.5-7.8)--- Diagnosis of GDM
What is your next step in the management?
The timing of delivery?
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 Screening and diagnosis of GDM

Fasting glucose≥7.0mmol/L Fasting glucose <5.1mmol/L

HA1C≥6.5%

Pregestational diabetes OGTT, 24-28 weeks

Fasting glucose 1 hour 2 hour

5.1mmol/L 10.0mmol/L 8.5mmol/L

≥ 1 abnormal values
Management
of diabetes Diagnosis of GDM
 Management of diabetes

Dietary
control

Timely
termination
of pregnancy exercise

3-5 days,
Blood glucose

medication Self-easurement
of BG
FG 5.3
2h 6.7 mmol/L
、
Thanks

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 Definition during pregnancy
Diabetes in pregnancy being divided into:
1. Gestational diabetes mellitus (GDM)
− Diabetes onset or first recognition during
pregnancy
− Why ?
2. Pregestational diabetes
− Have diabetes antedating pregnancy
① Type 1 diabetes (Insulin-dependent)
② Type 2 diabetes (Non-insulin dependent)
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 Pathophysiology
1. Placenta → Placental lactogen→ Insulin resistance
− With placental growth, larger amounts of
contra-insulin hormone are synthesized
2. Marked increase in weight in the abdominal region
during pregnancy
Pregnancy is associated with increased tissue
resistance to insulin → Diabetogenic state
Normal pregnancy: Insulin release is enhanced in
an attempt to maintain normal glucose level
If endogenous insulin inadequate (produce by
pancreatic β–cell), resulting in GDM
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 Adverse fetal consequences
1. Fetal pancreatic hyperplasia → fetal
hyperinsulinaemia →Macrosomia, neonatal
hypoglycemia, RDS
2. Fetal anomalies: hyperglycemia around the time
of early organogenesis, 6-fold
3. Intrauterine fetal hypoxia
At a greater risk for perinatal death
Over the last decade associated perinatal
morbidity and mortality have been reduced from
60% to less than 5%
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 Maternal hyperglycaemia

Congenital ↓ Placenta
abnormalies ← Fetal hyperglycaemia
(NTD, Heart)
↓ Decreased
Macrosomia ← Fetal hyperinsulinaemia → surfactant
production

Organomegaly Increased Neonatal

e.g.cardiac erythropoesis hypoglycaemia

Traumatic Delivery NRDS

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 Congenital anomalies
① Correlated to high blood glucose

Blood glucose level in pregnancy Rate of anomalies

Higher than normal 9.2%
Control → optimal level 4.9%
Health women 2.1%

② Other factors → fetal anomalies

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 Adverse maternal effects
1. Require more insulin

2. Increased the need for cesarean delivery

3. Polyhydramnios

4. Increased frequency of hypertension

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 Screening for gestational diabetes

When and Who?

At the first perinatal visit: Risk assessment
1. For low-risk women: testing between 24-28 weeks
2. For high-risk women
Screening for GDM as soon as feasible
If results of testing normal, retested between 24-
28 weeks gestation age

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 High-risk women

1. History of GDM
2. First-degree relative with diabetes
3. Marked obesity
4. Previous unexplained stillbirth
5. Macrosomia
6. Advanced maternal age

Age <25yo 25-35yo 35 ～ >40yo

40yo
GDM risk 2.9-fold 5.2-fold 8.2-fold
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Diagnosis of pregestational diabetes
At the first perinatal visit
Diagnosed as pregestational diabetes---if any one
of the following
1. Fasting plasma glucose ≥ 7.0mmol/L
2. Glycosylated hemoglobin (HbA1c) ≥ 6.5%
3. Symptoms of hyperglycemia and random serum
glucose ≥ 11.1mmol/L
If no symptoms of hyperglycemia but random
serum glucose ≥ 11.1mmol/L --- next morning
Fasting plasma glucose and HbA1c
How to screening?--Screening procedure
1. A diagnostic OGTT (Oral glucose tolerance test )
2. Clinical screening
Urine: Glucosuria → Serum glucose
− It is a common finding in normal pregnancy
− The increase of filtration rate in pregnancy
Clinical findings:
− The size of uterus bigger than normal
− Excessive maternal weight gain
Ultrasound findings:
− Fetal weight ≥70% for gestational age
− Polyhydramnios (AFI ≥ 25cm)
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 Diagnostic criteria for GDM
Oral glucose tolerance test (OGTT)
OGTT is the golden test for the diagnosis of GDM
Using a 75g loading dose of glucose →
Fasting, 1 hour , 2hour serum glucose
≥ 1 abnormal values → GDM

Fasting 1h 2h
WHO (DM) ≥7.8 ≥11.1
WHO (GDM ) ≥5.1 ≥10.0 ≥8.5
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 White classification of diabetes
Class A: Fasting 2h after meal Insulin
Ａ 1 ： Dietary control ＜ 5.3mmol/L ＜ 6.7mmol/L No
Ａ 2 ： Dietary control ≥ 5.3mmol/L 　＞ 6.7mmol/L Yes

Class Age of onset Duration Vascular disease

B ＞ 20(yr) ＜ 10(yr) None
Ｃ 10 － 19 10 － 19 None
Ｄ ＜ 10 ＞ 20 Benign retinopathy
Ｅ : Associated with calcification of limb vessels
F: Diabetic nephropathy
G: The present of proliferating diabetic retinopathy
 Perinatal management
1. Pre-pregnancy--- good control of glucose
− Oral hypoglycaemic agents → Insuline
2. Prenatal treatment
− Tight control of blood glucose
− Maternal assessment
− Fetal assessment
3. Labor treatment
− Timing and mode of delivery
4. Postnatal treatment
5. Neonatal management
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 Tight control of blood glucose
1. What is optimal control?
− Before breakfast: 3.3-5.3mmol/L
− 2 hr after meal: 4.4-6.7mmol/L
− At 0Am: 4.4-6.7mmol/L
2. How?
− Dietary control and exercise (even short
exercise periods have a major benefit)
− Medicine: Insulin

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 Maternal assessment
1. The frequency of antenatal visits
− Every 2 weeks or even weekly depending
upon the stage of the pregnancy and the
blood sugar
2. Maternal assessment: Self-measurement of
blood glucose , 5 or 7 times daily
3. Prevention of infection, pre-eclampsia

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 Fetal assessment
1. Fetal development
− Routine clinical examinations
− Serial ultrasound scans → Size of fetus, AFI,
Exclude fetal anomalies
2. Fetal well-being → Prevention of stillbirth
Make daily assessments of fetal movements
Biophysical profiles, NST weekly
3. Fetal lung maturity:
Amniotic fluid L/S (Lecithin: sphingomyelin)
ratio ≥3 – maturity
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 Labor/Delivery
1. Timing of delivery *
−If good diabetic control is achieved and there is
no other complications, timing of deliver→
≦40 weeks
−If blood glucose is not optimal control or there
are complications, delivery when the fetus is
found to be mature
2. Accelerated fetal lung maturation – if immature
−Administer corticosteroids
−Side effect: increase maternal glucose levels
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 Mode of delivery
1. Vaginal delivery can be achieved
− Regulate blood glucose levels carefully *
− Continuous fetal monitoring during delivery
− Risk of shoulder dystocia
2. CS is performed for obstetric indication
− There is any evidence of fetal distress
− Delay in the progress of labor
− Blood glucose → dissatisfactory or there are
complications
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 The timing of delivery
Classification Glucose Delivery

White A1 Optimal
≤40W(40+6)
control
Pregestational DM Optimal
White A2 38-39W(39+6)
control
There are fetal mature
Abnormal
complications
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 Postnatal
1. Reduced insulin requirement: usually fall rapidly to
prepregnancy levels after delivery
2. Long-term counselling:
Patients with GDM should be evaluated 6-12 weeks
postpartum by OGTT to ensure it reverts to normal
(exclude pregestational diabetes)
Developing diabetes mellitus:
 If require insulin→ 50% risk, within 5 years
 If only diet → 60% risk, within 10-15 years
Reassessed OGTT at a minimum of 3-yr intervals
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 Neonatal
Prevention of hypoglycemia
−Use glucose within 30min after birth
Prevention of respiratory distress syndrome
Long term effect:
−Intrauterine environment →Fetal pancreatic
hyperplasia
−Make an impact on the child into adulthood
with an increased risk of diabetes
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 Dietary control
1. Initially try to control with diet rather than insulin
2. Soluble fiber is invaluable to improve insulin receptor
numbers and sensitivity
3. The caloric intake should be about 30kcal/kg/day,
divided into 3 meals and 3 snacks
4. The diet should contain:
− 50% carbohydrate
− 20-30% protein
− 20-30% fat
5. The patient checks her glucose 5 or 7 times daily
− 7 times: Before and 2hr after 3 meals, 0Am
− 5 times: Fasting, 2hr after 3 meals, 0Am
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 Insulin
When?
1. When standard dietary management does not
consistently maintain the blood glucose
2. All women taking oral hypoglycaemic agents
should be changed to insulin treatment
How?
1. Short acting insulin with each meal
2. A small doses of intermediate acting insulin in the
evenings
3. Continuous insulin pump therapy → women with
difficult diabetes
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Atrial septal defect Spinal bifida

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Macrosomia

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Shoulder dystocia *

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Self-measurement of blood glucose
(Capillary blood sampler)

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 Amniotic fluid circulation

The source of amniotic fluid :

−Early pregnancy: an dialysate of the fetal and
maternal extracellular compartments
−After 20 weeks: composed largely of fetal urine
The amniotic fluid be absorbed by:
−Fetal swallow and reabsorption by intestine
−Fetal membrane and skin

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 Fundal height

Fundal height (cm) ≈ (Gestational months + 1) Χ 3

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 Regulate blood glucose levels
 Optimal level ： 4.4-6.7mmol/L
 Measure blood glucose erery 2hours
 ACOG recommended
BG Insuline Fluid Insuline (5
(mmol/L) (IU/hr) (125ml/h) 00ml)
≤5.6 0 5%GNS
5.6-7.8 1 5%GNS 4u
7.8-10 1.5 NS 6u
10-12.2 2 NS 8u
≥12.2 2.5 NS 10u41