DIABETES IN PREGNANCY

Dr Habibah Abdul Hamid

O&G Lecturer, FPSK UPM
 Physiological change to CHO and glucose metabolism
 Know the effect of diabetes to pregnancy vice-versa
 Screening of diabetes in pregnant lady
 Management of diabetes in pregnancy
 Counseling and contraception
 How to clerk cases related to diabetes in pregnancy
DIABETES IN PREGNANCY
 Incidence : 1.3%
 Diabetes complicates 4/1000 pregnancies
 90% Gestational DM (GDM) + 10% Pre-existing DM
WHY WORRIED ABOUT
DIABETIC IN PREGNANCY?
 It cause complications to:
 Mother(2-4 folds higher)
 Baby (congenital anomalies – 4 folds higher,
perinatal mortality 5x higher)
 It causes problems to the family
 Also common case medical student get for the
exam!
HISTORY
 Before introduction of insulin,
 life expectancy was short
 Children alive up to two yrs
 Adults up to 6 yrs
 Few women conceived, mortality high
 Perinatal mortality between 40 to 60%
 After introduction of insulin:
 Incidence pregnant women increased
 Maternal mortality decreased
 Perinatal mortality improved
 CLASSIFICATION
 Pregestational diabetes:
 Pregnancy in a known or overt diabetes
 Type I: Insulin dependent diabetes mellitus
 Type 2:Non- insulin dependent diabetes mellitus

 Gestational diabetes (GDM)

 carbohydrate intolerance of variable degree with onset or first
recognition during pregnancy
 50% develop Diabetes later in life

 Other types:
 Monogenetic diabetes (MODY)
 Mitochondrial diabetes
 Secondary diabetes
PREGNANCY IS A DIABETOGENIC STATE

 Why this occur??

 What are the physiological changes that make pregnant
women diabetogenic state?
PREGNANCY: A DIABETOGENIC EVENT
 The woman is transformed from a physiological point
of view by:

• Nutritional demands by the fetus

• Metabolic changes in the mother
• Placenta as a site of exchange and
it’s hormonal effects:
Islets of Langerhans - Insulin -Progesterone
- Glucagon -Eostrogen
- Somatotropic Hormone
- Cortisol
- Adrenaline
- Thyroxine
- Placental lactogen
- GH,CRH,HPL ( major culprit)
CHANGES IN CARBOHYDRATE METABOLISM
DURING PREGNANCY

Pregnancy

Placenta hormones + cortisol Pancreas

HPL, estrogen, progesterone,

prolactin

Lipolysis insulin
Antagonism to insulin
Free fatty acids (used for and peripheral
mother’s metabolism) resistance

Glucose spared for fetus Maternal blood sugar

 CHANGES IN INSULIN AND
GLUCOSE LEVEL IN NORMAL
PREGNANCY

Responses in normal preg women to a 75g oral glucose load during non-pregnant and late preg.
During non-pregnant state there is a normal plasma insulin response with a relative reduction in
plasma glucose concentrations compared to the non-pregnant state.
In contrast, during late pregnancy plasma glucose concentrations reach higher levels after a delay
, despite a considerably enhanced plasma insulin response, a pattern which could be explained by
relative resistance to insulin.
 COMPLICATIONS
Maternal
• Recurrent infection (UTI,
• Macrosomia
moniliasis)
• Pyelonephritis
• Pre-eclampsia
• Polyhydromnios
• Preterm labour
• Operative delivery
Pre-existing
• Difficult sugar control
• Ketosis
• Hypoglycemic attacks
• Diabetic vasculopathy
Postpartum thyroiditis
Fetal Neonatal
• Hypoglycemia
• Sudden IUD • Hyaline membrane disease
• Shoulder dystocia • Hypomagnesemia
• Hyperbilirubinemia
• Hypocalcemia
• Hypertrophic
cardiomyopathy
• Hyperviscosity syndrome
(NEC, Renal vein
• Congenital anomalies thrombosis)
• Miscarriage (9-14%) • Transient tachypnoea
• IUGR • Birth injuries
• Birth asphyxia
Late effects
• Obesity
• Type 2 DM
AN EXPANDED MODIFICATION OF THE
PEDERSEN HYPOTHESIS
 PREVENTION AND EARLY
DETECTION IS IMPORTANT

 All pregnant mother at risk should have screening for diabetic status
 Then subject to MGTT

 Known diabetes mellitus:

 no need MGTT,
 do BSP and change to insulin immediately
SCREENING & DIAGNOSIS OF
GDM
 None
 Clinical risk factor based
 Urine test
 2 Step

Screen: Fasting, random glucose or 50 g GCT

Diagnosis: 75 g or 100 g OGTT
 1 Step OGTT
GDM: SCREENING &
DIAGNOSIS
 No international agreement

 No national agreement

 No local agreement
SCREENING FOR DIABETES
UNIVERSAL SCREENING SELECTIVE SCREENING
 Most effective means in  Target high risk population
identifying cases
 May miss 50% cases
 No data to support the
advantage MALAYSIA
 Not cost effective
(Luesley, 2004)
Glucose Challenge Test (GCT)
50g of oral glucose
Irrespective of time or meal
Blood glucose 1 H later
If plasma value > 7.8mmol- diagnostic test
INDICATIONS FOR SCREENING IN PREGNANT
WOMEN

Malaysian CPG : Management of type II DM (2009)

 DIAGNOSTIC TEST
Venous plasma values in mmol/l
OGTT Oral glucose Fasting 1 hr 2 hr 3 hr
(gms)
NDDG* 100 >5.3 >10 >8.6 >7.8
WHO 75 <6.1** <7.8

*NDDG: National Diabetes Data Group guidelines (ACOG)

(2 out of 4 value abnornal- DM)
** ADA uses 5.6 mmol/l

Screening is done using the 75g OGTT and performed at least once at ≥24 weeks
of gestation. Screening at an earlier stage of gestation depends on the degree of
suspicion and at the physician’s/ obstetrician’s request.
DIAGNOSTIC TEST FOR GDM
(NICE GUIDELINE 2015)
 Diagnose gestational diabetes if the woman has either:
 a fasting plasma glucose level of 5.6 mmol/litre or above or
 a 2-hour plasma glucose level of 7.8 mmol/litre or above. [new 2015]

Diagnosis FBG 2-HPP

GDM ≥ 5.6 ≥ 7.8

DIAGNOSTIC TEST FOR GDM
(from latest CPG 2015)
Diagnosis FPG (mmol/L) 2-h Value (mmol/L)

GDM ≥ 5.1* ≥ 7.8**

 * Adapted from the American Diabetes Association (ADA)–

Standards of Medical Care in Diabetes–2015,4 (Level III), The
International Federation of Gynecology and Obstetrics (FIGO),
International Association of Diabetes and Pregnancy Study
Groups (IADPSG) and World Health Organization (WHO).
 ** Adapted from NICE Guidance on Diabetes in Pregnancy:
Management of Diabetes and its Complications from
Preconception to the Postnatal Period, 2015. 421 (Level III) .
MANAGEMENT OF PREGNANCY
COMPLICATED BY DIABETES
PRE-PREGNANCY CARE

Ensure blood sugar 4-6 mmol/l, HbA1c 4-5.8%

 HISTORY
 Known diabetes
 Risk factors
 Duration
 HOPP
 Medication(prev n current)
 POH
 Follow-up
 Medical and Family Hx
 Control
 Complications  Dietary habit

 GDM  Social history

 When it was diagnosed
 Diet/medication
 Monitoring
 complications
 PHYSICAL EXAMINATION
 General
 Vital signs
 BMI
 Pallor (chronic anemia), oedema
 Acanthosis nigrican, dermopathy
 Insulin injection sites
 Abdominal examination
 Skin infections
 SFH
 Neurological examination
 Speculum:vulvovaginitis, moniliasis

 Fundoscopy  Bedside urine test: glucose and

protein
 Lungs/CVS examination
 Thyroid and breasts
RELATIONSHIP BETWEEN HBA1C AND
CONGENITAL MALFORMATIONS
HbA1c ≤14 W POG Congenital
(%) malformations
< 5.6 1/47
5.6–6.8 7/170
6.9–8.0 8/252
8.1–9.3 6/133
≤ 9.3 3/99 (3%)
9.4–11.0 4/77 (5.2%)
11.1–12.7 2/46 (4.3%)
12.8–14.4 7/18 (38.9%)
> 14.4 4/10 (40%)
 MANAGEMENT OF PREGNANCY
COMPLICATED BY DIABETES

 Team care (special diabetic clinics)

 physician, nutritionist, obstetrician, neonatologist.
 Objective
 A good glycemic control
 Antepartum fetal surveillance
 Delivery at appropriate time
 Optimal neonatal support
INVESTIGATIONS
Maternal Fetal
• Blood Sugar Profile • MSAFP- 16-20w
• Urine FEME • USG- booking, 18-20w
• Urine C&S • 3rd trimesters: serial scans
for growth and amniotic
fluids
Pregestational • Echocardiography- 22w
• Proteinuria • Umbilical Artery Doppler &
• Ketonuria BPP (>32w if indicated)

Every trimester
• HbA1c
• Fundoscopy
• Renal Function test
FREQUENCY OF IX IN
PREGNANCY

(Chaudry et al., 2007)

MONITORING OF GDM
 Pre-prandial?

 Post-prandial
 1 hour?
 2 hour?

 Pre and Post-prandial?

POSTPRANDIAL VS PREPRANDIAL
LEVELS IN DIET TREATED GDM
 Better glycemic control
 (HbA1c value 6.5 versus 8.1 percent)
 A lower incidence of large-for-gestational age infants
 (12 versus 42 percent)
 A lower rate of cesarean section for cephalopelvic
disproportion
 (12 versus 36 percent)

de Veciana M, Major CA, Morgan MA, Asrat T, Toohey JS, Lien JM, Evans AT. N
Engl J Med 1995 Nov 9;333(19):1237-41.
SELF BLOOD GLUCOSE MONITORING (SBGM)
TARGETS FOR PREGNANT WOMEN
(MALAYSIAN CPG MAY 2009)
 TREATMENT
1. Diet modification
2. Exercise
3. Hypoglycemic therapy
 DIET TREATMENT OF GDM
 Diet – energy intake
 30 Cal/kg (prepregnant weight): Normal BMI
 25 Cal/kg (BMI >25-35)
 20 Cal/kg (BMI > 35)
 Dietary recommendations (Bahado-Singh et al.)
 Plan : three meals, three snacks
 Diet : 30–35kcal/kg normal body weight, 2000–2400 kcal/day
 Composition: carbohydrate 40–50% complex, high fiber;
protein 20%; fat 30–40% (<10% saturated).
 Weight gain:
 22–25 lb (10–11 kg) for established DM
 20lb (9 kg); 16 lb (7.25 kg) for very obese
DIET TREATMENT
EXERCISE AND GDM
 Light exercise: lower FFA and increase blood flow to insulin sensitive ts.
 Involving upper part of the body (sufficient, safe and effective)
 Watch for injuries
 Practical in pregnancy?
SAFETY OF MEDICATIONS
BEFORE AND DURING
PREGNANCY
 Metformin may be used before or during pregnancy
 Rapid- acting insulin analogue (aspart and lispro) is safe in pregnancy
 Evidence on long-acting insulin analogues during pregnancy is limited.
 Isophane (NPH) insulin is the first choice long-acting insulin during
pregnancy
BEFORE OR AS SOON AS
PREGNANCY IS CONFIRMED
 Stop OHA and commence insulin if required
 Stop ACE-I and ARB
 Stop statins
HYPOGLYCEMIC THERAPY
 Indication:
 If lifestyle changes do not maintain glucose targets over 1-2 weeks
 Incipient fetal macrosomia
INSULIN: DURATION OF ACTION
GDM: OBSTETRIC
INTERVENTION
WHEN TO DELIVER
 Diet controlled
 No specific intervention
 Deliver at about EDD

 Insulin therapy
 Type 1 / Type 2 DM
 Deliver 38 weeks
 ?Earlier if established maternal vasculopathy
 GDM
 Deliver 38 weeks
HOW TO DELIVER
 Vaginal delivery
 LSCS for usual obstetric indications
 Elective LSCS if EFW > 4.5 kg (ACOG)
 IN LABOUR
 Maternal management
 Labour ass. With reduced insulin requirement
 Omit morning dose insulin
 Blood Glucose monitoring hourly (maintain 4-6 mmol/l)
 DIK regime if Dextrostix > 7 mmol/l
 5 to 10% dextrose infusion- different drip
 Partogram
 Adequate analgesia
 Ketonuria 4 hourly

 Fetal management:
 Continous CTG
 Inform peadiatrician
POSTPARTUM
 Neonatal care  Postpartum care
 Early cord clamping  Pregestational DM:
 commenced pre-pergnancy regime
 NICU admission
 Continuous diabetic care
 Dextrostix monitoring
 Eye assessment
 Encourage early
 GDM on insulin: stop insulin, monitor
breastfeeding
BSP
 Repeat MGTT 6/52 and annually
 Advice on prevention of DM (diet and
exercise)
CONTRACEPTION
 POP:
 No effect on CHO or lipid metabolism, suitable for breast feeding
mothers

 COCP:
 Low dose little effect on CHO or lipid metabolism
 May produce impaired glucose tolerance
 Women with IGTT/GDM should repeat MGTT 3-6months after use

 IM progestogen:
 No contraindication

 IUCD/IMPLANT:
 Can be use
 Women with IGTT/GDM should repeat MGTT 3-6months after use
LONG TERM PROGNOSIS
 Mother: 50% dev. DM over 5 – 10 years
 (Higher in older, increased weight, higher glycaemic)
 Recrrent GDM 30 – 50%

 Baby:1: 100 chance IDDM

 Normal population: 1: 1000 chance
 CONCLUSION
 Student should know:

 Physiological change to CHO and glucose metabolism

 Know the effect of diabetes to pregnancy vice-versa
 Screening of diabetes in pregnant lady
 Management of diabetes in pregnancy
 Counseling and contraception
 How to clerk cases related to diabetes in pregnancy