1

Suniti Rawal
Dept of OBGYN
DIABETES
is a state of carbohydrate intolerance resulting
from
1. Inadequacy of Insulin secretion or

2. Resistance to the Insulin action.

The imbalance between insulin supply and
demand leads to abnormal metabolism of
carbohydrates, proteins and fats.

GESTATIONAL DIABETES MELLITUS

Is a carbohydrate intolerance of variable severity with
onset or first recognition during pregnancy.
2
 Undoubtedly, some women with gestational
diabetes have previously unrecognized overt
diabetes i.e. type 2 diabetes unmasked or
discovered during pregnancy

3
 Incidence
 Gestational diabetes mellitus (GDM) accounts for
90% of the cases.
 Type 2 diabetes mellitus accounts for 8% of the
cases and
 Preexisting diabetes mellitus Type 1 affects 1% of
all pregnancies.

Baptiste-Roberts K et al. Risk factors for type 2 diabetes among women with
gestational diabetes: a systematic review. Am J Med. Mar 2009;122(3):207-
214.e4

4
Many placental hormones are secreted during
pregnancy which are thought to be responsible.
These are
 Human Placental lactogen
 Estrogen
 Progesterone
 Cortisol

5
 Congenital Malformation
 In normoglycemic pregnancy the risk of congenital
malformation is 1 – 2 % whereas it is increased to 6 –
10% in pregestational diabetes
 No significant increase in malformation with GDM
 Hyperglycemia at the time of organogenesis is thought
to be the culprit.
 Risk of structural anomalies are increased rather than
chromosomal
 Progressive rise with rates of congenital malformation
exceeding 8% where the HbA1c level is > 10%.
6
 Specific malformations
1.Skeletal malformation: Caudal regression syndrome
2. CNS (4.2 fold): Spina bifida, Anencephaly,
encephalocele, microcephaly, meningomyelocele,,
3.Cardiovascular (3.4 fold): Transposition of great
vessels, VSD, ASD, hypoplastic left ventricle,
anomalies of aorta
4.Genitourinary: Absent kidneys (Potter syndrome),
Polycystic kidneys, Double ureter
5. Gastrointestinal: TOF, Bowel atresia, Imperforate
anus

7
8
SPONTANEOUS MISCARRIAGE

 Established DM - increase rate of abortion

UNEXPLAINED FETAL DEATH IN UTERO

 Increase risk of stillbirth by approximately fourfold,

that too in the later part of pregnancy
Macrosomia:

 Reported incidence: 8 – 43 %
 Pederson hypothesis: Maternal hyperglycemia
leading to fetal hyperglycemia causes increase
insulin secretion.

This leads to accelerated growth of insulin sensitive

tissues in the fetus such as bone, muscle and
adipose tissues
6050-gm macrosomic infant was to a woman with gestational diabetes.
IUGR:

Especially associated with the presence of

micro vascular complications like Nephropathy,
Retinopathy and Preeclampsia
Polyhydraminos:

 A likely explanation is that fetal hyperglycemia

causes polyuria

 Associated congenital anomalies like Anencephaly

and Tracheo Oesophageal fistula.
RESPIRATORY DYSFUNCTION
Fetal hyperinsulinism

decrease pulmonary Phospholipid production

( Phosphatidylglycerol )

Surfactant deficiency

RDS
 TTN is also more common among the newborn
 More insulin might be necessary to achieve metabolic
control
 Increased risk of death for patients with diabetic
cardiomyopathy
 Placenta Previa
 Infection – chorioamnionitis, postpartum endometritis
 Postpartum bleeding – caused by exaggerated uterine
distension and high incidence of infection

 C.S.- high incidence, 16.7% in HAPO study

16
 ADA ACOG NICE ( U.K)
( Based on HAPO Based on W.H.O
Study) recommendatio
n
Who should Screen High risk All pregnant Selective screening
be women at 1st visit women between based on High risk
screened for for elevated 24-28 weeks factors
GDM glucose.
If previous GDM,
use 75 g OGT at
If normal, again
16-18 weeks.
screen at 24 – 28
weeks.

No need to screen
low risk women.

17
When a selective screening is used following
risk factors are considered:

 BMI > 30 kg/m2

 Previous macrosomic infant
 Previous pregnancy complicated by GDM
 Family history of diabetes in first degree relatives
 Multiple pregnancy losses and term IUFD

18
19
 Screening in OBG/GYN dept is carried in 2 steps.

 I Step – GCT with 50 g glucose at 24-28 weeks

 2 Step - followed by OGTT with 100 g glucose, if

GCT is positive or more than 7.8 mmol/l

20
 50 g glucose is dissolved in 200 ml water was
taken irrespective of fasting or fed status.

 Blood samples were taken 1 h after the intake

and subjected to the test.

21
Blood glucose level Result

>= 11 mmol/l GDM

>= 7.8 mmol/l Screen positive

< 7.8 mmol/l Screen negative

22
 Screen positive women are subjected to 100 g
OGTT

 Screen negative women are considered to be

non GDM

23
 The test should be performed in the morning
after an overnight fast of at least 8 h but not
more than 14 h and after at least 3 days of
unrestricted diet (150 g carbohydrate/day) and
physical activity.
 The first glucose measurement is done in fasting
state. Thereafter subjected to 100 g glucose
dissolved in 200-400 ml water is given over 10
min and blood sample is drawn
24
To confirm the diagnosis of GDM by OGTT:

2 or more value should be raised:

Fasting 5.3 mmol/l;
1-h, 10.0 mmol/l;
2-h, 8.6 mmol/l;
3-h, 7.8 mmol/l

25
WHO recommendation of carrying out the one
step test for screening as well as diagnosis with
75 g OGTT is being considered in TUTH as well
and a new study is in progress……

75 g plasma glucose level (1 or more values

need to elevated)
Fasting: 5.3 mmol/l
2-hr: 7.8 mmol/l
26
Other methods for screening………..
Glycosuria
 Testing urine at each ANC visit – a cheap, simple
& established method
 Sensitivity – low ; Specificity – high
Random blood sugar
 Sensitivity – 40% ; specificity – 90%
Fasting blood sugar
 Sensitivity – 90% ; specificity 50%
Fructosamine
 Measurement of glycated protein, represents glucose
status prior to 3 wks
27
 Diagnosis of overt diabetes:

 Fasting plasma glucose ≥ 126 mg/dL (7.0

mmol/L),
OR
 HbA1c ≥ 6.5%
OR

 Random plasma glucose ≥ 200 mg/dL (11.1

mmol/L) with symtoms of polyuria, polydypsia
and polyphagia.

28
29
 Proper nutrition is the most important component of
the care of Diabetes.

 The objective is to provide the calories and nutrients

necessary for the mother and the fetus without
causing postprandial hyperglycemia and excessive
weight gain.

 Though difficult to achieve the target blood sugar, this

intervention should be the first line of management.
30
ADA recommendation on calorie intake based on BMI of
prepregnant bodyweight
Body mass Calorie Total
Index intake allowable
weight gain
in pregnancy
Underweight <18.5 Kg/m2 36 – 40 12. 5 – 18 kg
kcal/kg
Normal 18.5 – 24.9 30 Kcal/kg 11.5 – 16 kg
Kg/m2
Overweight 25 – 29.9 24 Kcal/kg 7 – 11.5 kg
Kg/m2
Obese ≥ 30 Kg/m2 12 Kcal/kg 5 – 9 kg
ADA guideline on Diabetic care, 2009
Rasmussen KM. Weight gain during pregnancy. The National Academy
31 Press; 2009
 Diet should be evenly distributed:
55% from the carbohydrates
20% from the protein
30% from the fats with < 10% saturated fats

 Three main meals and three snacks

 Diet should be as she normally takes, that is to be

divided

Williams Obstetrics 23rd ed.

32 Pg 1120
33
 The target should be a preprandial glucose of 90
mg/dl or less and a peak postprandial of 120
mg/dl.

 Once diagnosis is made, meal plan is advised

initially for two weeks.

 If MNT fails to achieve control the blood sugar

level, insulin may be initiated.

34
 Insulin Therapy

Indication of Insulin therapy

 If MNT fails and if the blood glucose level is still

high despite 2 weeks of MNT, insulin therapy is
started.

35
 Once the women is diagnosed with GDM , she is
admitted and a sugar profile is done 6-7 times
throughout the day.
1. Fasting
2. Post breakfast
3. Pre lunch
4. Post lunch
5. Pre dinner
6. Post dinner
7. Midnight
36
Types and Action of various Insulin

37
 Starting Daily Insulin dose during Pregnancy

Week of Gestation Total Daily Insulin

requirement
1 – 18 week POG 0.7 U/kg of actual body
weight
18 – 26 week POG 0.8 U/kg of actual body
weight
26 – 36 week POG 0.9 U/kg of actual body
weight
36 – 40 week POG 1.0 U/kg of actual body
weight
38
Frequency of blood sugar monitoring

GDM: ≥ 4 times/day

1 fasting + 3 postprandial

39
 Goals for glycemic control in GDM is

Achieve a target maternal capillary glucose

Concentrations of :
 Fasting: ≤ 95 mg/dL (5.3 mmol/L),
 1-h postmeal: ≤ 140 mg/dL (7.8 mmol/L)
 2-h postmeal: ≤ 120 mg/dL (6.7 mmol/L)

Fifth International Workshop Conference on Gestational

Diabetes

40
41
 Metformin used as a treatment for PCOD has
been reported to reduce the incidence of GDM,
and can now is advised to be continued in
pregnancy too.

42
Principle of Obstetric care in a GDM
 Strict control of blood sugar levels
 Timing the delivery to improve maternal and
fetal outcome
 Choosing the correct mode of delivery and
 Adequate intrapartum and postpartum
management

43
 REFERRAL TO A COMBINED MULTIDISCIPLINARY
DIABETIC & OBSTETRIC ANTENATAL CLINIC

 Pregnancy outcomes are improved when women with

diabetes attend a multidisciplinary diabetic obstetric
antenatal clinic.
 This team should comprise of an obstetrician,
diabetologist and dietician who are jointly involved.

44
 Ideally a dating scan should be performed within
the first 10 weeks following conception as this
allows to know the viability of fetus, confirm the
gestational age and detect early congenital
anomalies if any ,esp. anencephaly.

 Measurement of HbA1c and

 Optimizing blood glucose levels during the

organogenesis has been shown to decrease the
fetal malformations rate
45
Screening for Congenital abnormalities:
 Detailed anomaly scan should be done between
18 and 20 weeks’ gestation to look for major
congenital abnormalities esp. spine, skull, kidneys
and heart.

 Fetal echocardiography at around 24 weeks’

gestation

46
Surveillance for medical obstetric complications:

 Women with GDM have an increased risk of

hypertension in pregnancy, including PE.

 So, routine blood pressure and urine albumin

should be monitored

47
Assessment of Fetal growth

 Ultrasound scans for assessment for fetal growth

usually starts at the end of the second trimester
and is repeated thereafter every 4 weeks, or
more frequently if needed.

 Measurement of liquor volume should also be

serially recorded, as polyhydramnios is more
common in diabetic pregnancies.

48
Optimization of Glycemic status:

 When glucocorticoid are required for lung

maturation insulin requirements over the next
72 h may need to double. This may lead to
profound hyperglycemia and even DKA.

49
Assessment of fetal Growth

 Serial ultrasound should be done every 2-3 week or

less if indicated.
 Umbilical artery Doppler is helpful in identifying infant
with IUGR.
 Such growth patterns are indicative of utero-placental
insufficiency and are frequently seen in overt diabetic
women with renal impairment, vascular disease or
hypertension.

50
 When glucose control is good and no other
complications supervene, pregnancy can be
prolong up to 40 weeks of gestation.

51
 Expectant management beyond the estimated
due date is generally not recommended.

ACOG Practice Bulletin. Clinical management guidelines for obstetrician-gynecologists,

Number 30, September 2001. Obstet. Gynecol. 98,525-538 (2001).

52
 Suspected fetal macrosomia is related to traumatic
delivery including shoulder dystocia and brachial plexus
injury which can be prevented by elective Caesarean
section.
 But Caesarean delivery results in higher rates of
maternal morbidity and two- to four-fold greater risk of
maternal mortality compared with vaginal delivery.

 Vaginal delivery is much safer in a well-controlled

patient with a normal-sized fetus before term, either by
induction of labor or spontaneous delivery.

 But the chances of failed induction is higher if induced

before term.
Hen Y. Sela et al. Managing Labor and Delivery of the Diabetic Mother: Expert
53Rev of Obstet
Gynecol. 2009;4(5):547-554.
 Therefore, frequent evaluation between 37 and
39 weeks of gestational age is indicated and
timely induction of labor is a better option
where macrosomia seems to be likely.

 Elective Caesarean delivery may be indicated in

women with GDM whose EFW is 4500 g or
greater;

54
Insulin Management During Labor and Delivery

 Usual dose of insulin is given at bedtime.

 Morning dose of insulin is withheld.
 Intravenous infusion of normal saline is begun.
 At TUTH, G I K regimen with 10 U of regular insulin
with 10 meq of KCL in 10% Dextrose is started at
the onset of active labour and glucose and
sodium/potassium is monitored every 4 hour

55
 Following delivery, insulin requirement fall
immediately.

 In women with GDM, Insulin and OHA should be

discontinued and blood glucose monitoring
extended into postpartum period.

56
At TUTH
 Following vaginal delivery or Cesarean delivery,
G I K regimen is continued until patient eats
normal diet.

 Patient is also kept in a sliding scale of Insulin.

 Glucose is monitored every 6 hour and sodium

and potassium every 12 hour

57
 It should be remembered that

 Women with previous GDM have 66% risk of GDM in

future pregnancies

 40% to 60% risk of developing type 2 diabetes in next 5 to

15 years

Jovanovic L, ed in chief. Medical Management of Pregnancy Complicated by Diabetes. 3rd ed. Alexandria, Va: American Diabetes
58
Association; 2000:151
 Contraception

 Lactational Amenorrhoea
 Barrier method
 Low dose OCP
 IUCD in cases of GDM
 Sterilization

Progestarone containing contraception should be

avoided due to their diabetogenic potency
59
 Take home message
 Pregnancy related insulin resistance leading to
hyperglycemia is the cause of all the Maternal and
fetal effect of diabetes.
 Screening will help detect all high risk pregnancy so
that they can be evaluated and managed as early as
possible.
 Principle in the management is to achieve the
euglycemia throughout the pregnancy.
 Even a diabetic mother can deliver a healthy baby with
the help of multidisciplinary approach/team.

60
 References
 Williams Obstetrics.23rd edition ; Diabetes, 1169-1184
 High Risk Pregnancy. DK James 4 th edition; Diabetes in Pregnancy, 665-
681
 Avery’s Disease of the Newborn 8 th ed. Endocrine disorders in
pregnancy, pg:71-82
 Dewhurst’s Textbook of obstetrics & Gynecology 6 th edition; Diabetes &
endocrine disorders in pregnancy, 197-209
 Practical Guide to High risk pregnancy & Delivery. Fernando Arias 3r d
edition,; Diabetes & Pregnancy, 280-297
 Medical Disorders in Obstetrics Practice. Michael de Sweit, 4 th edition;
Diabetes, 386-409
 Progress in Obstetrics & Gynaecology. John Studd vol 16. GDM re-
appraised, 57-70
 Harrison’s Principles of Internal Medicine 17 th edition; Diabetes Mellitus,
2152-2180
 Pharmacology. Goodman & Gillman . Hypoglycaemic agents & the
pharmacology of the endocrine pancreas, 1679-1711

61
62