SUBJECT -

OBSTETRICS
Diabetes Mallitus & Pregnancy OR GDM

Topic By Drashti Mehta

3 rd Year BHMS
1. Introduction of Diabetes
◦ Definition
◦ “ DM is chronic metabolic disorder due to either insulin deficiency or decreased
sensitivity to action of insulin “

◦ PATHOPHYSIOLOGY INVOLED

1)Insulin resistance(decreased sensitivity of skeletal muscles & liver to insulin

{gluconeogenesis} .The liver plays a central role in the systemic regulation of glucose
and lipid metabolism
2)Beta cell dysfunction
◦ IL-6 & CRP Inhance insulin resistance ultimate effect is hyperglycemia

1. TYPES OF DIABETES
◦ Type 1 IDDM – young age onset juvenile( genetic pre- disposition)
◦ Type 2 NIDDM – late age,over weight woman,
◦ GDM(gestational diabetes mellitus
◦ Others – genetic,drugs,etc...
Carbohydrate metabolism In pregnancy
◦ Fetus is totally depend on mother Glucose requirements
◦ Fetus extract all glucose from the mother placenta,fetus always needs glucose
◦ With this also fat diposition also in mother body limited to the first 2 trimesters
◦ When complication occurs !!..
◦ When insulin resitence increase glucose will absorb from diet will not be able
Move to the cells of mother,various hormones contributing to insulin
resistance
◦ Resistence hormones – Human placental
lactogen,estrogen,progesteron,Cortisol,prolactin

◦ Beacause of insulin resitance glucose From the blood stream can’t move to
maternal cells Instead of cause POST PRANDIAL HYPERGYLCEMIA

◦ When mother is Overnight , not eating At that time baby not sleeping , so fetus
still extracting glucose maternal blood
◦ it cause fasting HYPOGLYCEMIA

◦ Insulin resitence also contributing hyperinsulinemia

◦ Hyperinsulenimia beacuse of insulin resitance

Increase tri glycerides Fat diposition

In 3rd trimester onwards lipolysis Increased , free fatty acid are realsed used by
mother for her own energy & glucose diverts towrads the fetus
Baby size increased ,most of glucose of mother towards the fetus
Diabetes in pregnancy

1. Gestational diabetes
◦ 1st diagnosed during during pregnancy
◦ Usually develop after 24 weeks

2.Overt diabetes in pregnancy

(Pre gestational diabetes inpregnancy)
◦ Abnormal glucose level 1st trimester (pre Conceptional)
◦ Increased risk of Abortions & co genital anomalies
 ◦ GESTATIONAL DIABETES MELLITUS
◦ A form of high blood sugar affecting pregnant women.
◦ Those who develop gestational diabetes are at higher risk of developing type 2
diabetes later in life.
◦ The entity usually presents late in the 2nd or during the 3rd trimester

◦ CONSIDERED FOR GDM (POTENTIAL CANDIDATES FOR GDM ARE)

1. +ve family history of Diabetes (parents or sibling),family history should be
include uncle,aunts & grandparents.
2. Having a previous birth of an overweight baby of 4 kg or more ,
3. Previous stillbirth with pancreatic islet hyperplasia revealed on autopsy
4 . Age over 30 yrs
5 obestiy
6 Presence of polyhydraamnios(too much Amniotic fluid in around the baby during pregnancy in uterus)

SCREENING
Screening tests for diabetes include risk scoring tools and biochemical
tests: urine glucose, random blood glucose (RBG), fasting plasma glucose
(FPG), glycated hemoglobin (HbA1c), fructosamine, and a 75-g oral glucose
tolerance test (OGTT).
◦ routinely to all pregnant mothers, others reserve for the potential candidates. Screening strategy for detection of
GDM are:

◦ (a) Low risk—Absence of any risk factors as mentioned above → blood glucose testing is not routinely required

◦ (b) Average risk—Some risk factors → perform screening test

◦ (c) High risk—Blood glucose test as soon as possible. The method employed is by using 50 gm oral glucose
challenge test without regard to time of day or last meal, between 24 weeks and 28 weeks of pregnancy. A
plasma glucose value of 140 mg% or that of whole blood of 130 mg% at 1 hour is considered as cut off point
for consideration of a 100 gm (WHO– 75 gm) glucose tolerance test.(20.3 & 20.5)
The National Diabetes Data
Group (NDDG)

versus Carpenter-Coustan
Criteria to Diagnose
Gestational Diabetes
DIPSI GUIDELINE (diabetes in
pregnancy socites of india
◦ Women not need be for fasting for screening test
◦ 75 gm oral glucose test
◦ 75 gm glucose Dissolved in 300 ML of water Than drink that
over 10mins.
◦ Than after 2hours sample was taken
◦ It does’t matter fasting status
◦ After 2 hour if Blood sugar value( 2hr>140) consideres as DM
ONE STEP SCREENING TEST BY
W.H.O
◦ International association of diabetes in pregnancy study group
◦ Women done fasting
◦ 75 gm of GTT GLUCOSE TOLERANCE TEST
Overt diabetes
EFFECTS OF PREGNANCY ON
DIABETES - introduction
◦ It is difficult to stabilize the blood glucose during pregnancy due to altered
carbohydrate metabolism
◦ an impaired insulin action. The insulin antagonism is due to the combined
effect of human placental lactogen, estrogen, progesterone, free cortisol and
degradation of the insulin by the placenta. The insulin requirement during
pregnancy increases as pregnancy advances.
◦ As more glucose leaks out in the urine due to renal glycosuria, control of
insulin dose cannot be made by urine test and repeated blood glucose
estimation becomes mandatory.
EFFECTS OF DIABETES ON
PREGNANCY
◦ Complications of diabetes (Hyperglycemia and adverse pregnancy outcome):
◦ 1 Maternal
◦ 2 Fetal and Neonatal
MaternaL During pregnancy
◦ Abortion
◦ Pre term labour
◦ Infection
◦ Polyhydramnios (25–50%) is a common association. large baby, large placenta,
fetal hyperglycemia leading to polyuria, increased glucose concentration of liquor
irritating the amniotic epithelium or increased osmosis, are some of the
probabilities.
◦ Diabetic nephropathy (Class F) is diagnosed when creatinine clearance is
reduced or there is persistent proteinuria (≥300 mg/24 hours) during the first 20
weeks of gestation.

◦ Coronary artery disease (Class H): Th ese women run the high risk for ischemic
heart disease especially when the disease is long standing.
◦ Ketoacidosis
◦ During labor: There is increase incidence of: shoulder dystocia

◦ Puerperium: (1) Puerperal sepsis.(2) lactation failure.

Early detection of fetal anomalies :
◦ Estimation of glycosylated hemoglobin A (HbA1c)
◦ Maternal serum α-fetoprotein level at 16 weeks and a detailed high resolution
ultrasonography of the fetus including fetal echocardiography at 20–22 weeks
are advocated
◦ A comprehensive ultrasound examination
◦ Birth injuries
◦ Growth restriction
◦ Fetal death has got multifactorial pathogenesis
◦ Neonatal Complication include : Hypoglycemia, Respiratory distress
syndrome, Hyperbilirubinemia, Cardiomyopathy, Hypomagnesemia (<7 mg/dl)
PPPG = post prandial plasma glucose
Examination of the placenta and cord: Placenta is large, the
cord is thick and there is increased incidence of a single
umbilical artery.

◦ Diabetic ketoacidosis: Pathology is insulin resistance → lipolysis → enhanced

ketogenesis → fall in plasma HCO3 and pH (< 7.30).
◦ Management is done in an acute care unit where both neonatal care is also
available. Parameters to assess are: Degree of acidosis, alterations in the level
of arterial blood gas, blood glucose, ketones and electrolytes.
◦ IV insulin → 0.1–0.2 units/kg (loading dose) → 0.1 U/kg/hr. (to adjust with
frequent capillary glucose estimation) → to keep plasma glucose levels
between 100 and 150 mg/dl
◦ Fluids—NaCl total: 4-6l in fi rst 12 hours. 5% dextrose with 0.45% NaCl at
150 ml/hr.
◦ IV Potassium: if reduced—infusion 15-20 mEq/hr until serum K+ > 3.3 but
<5.3 mEq/l
◦ Bicarbonate: if PH < 7.0: NaHCO3(50 mmol) in 200 ml water over 1 hr →
repeat serum NaHCO3 levels.
◦ CONTRACEPTION : Barrier method of contraceptives is ideal for spacing of
births. low dosecombined oral pills containing third generation progestins, are
effective and have got minimal effect on carbohydrate metabolism.
◦ Main worry is their effect on vascular disease (thromboembolism and myocardial
infarction)
◦ Progestin only pill may be an alternative long acting progestins are not used as a
first line method.
◦ The IUCD may be used once diabetes is well controlled. Permanent sterilization is
considered when family is completed.KEY POINTS Gestational Diabetes
Mellitus (GDM) is defi ned as carbohydrate intolerance of
◦THANK YOU