Diabetes In

Pregnancy
DR TIVAGARAN
KK SELAMA
Diabetes in Pregnancy
A: Preexisting diabetes
◦Type 1
◦Type 2

B: Gestational diabetes melitus (GDM)

Gestational diabetes mellitus (GDM) is any degree

of glucose intolerance which is first recognized
during pregnancy, whether or not the condition
persisted after pregnancy.
 Risk of Diabetes in Pregnancy
to the mother
❑Increase risk of C-section
❑ Traumatic delivery
❑Increase risk of retino/neuro/nephopathy (established
DM)
❑ 2-fold increased risk of preeclampsia (established DM)
❑Development of type 2 DM later in life (GDM)
❑Polyhydramnios
❑ Infections –urinary, vaginal
 Risks of Diabetes in Pregnancy
to the fetus
Pre-existing diabetes Gestational
miscarriage neonatal hypoglycaemia
congenital malformation perinatal death
stillbirth
neonatal death
fetal macrosomia
birth trauma (to mother and baby)
induction of labour or caesarean section
transient neonatal morbidity
obesity and/or diabetes developing later
in the baby’s life
 Macrosomia

• Birth weight >4kg or >90th centile

Increase in maternal blood

sugar

Hyperplasia of fetus pancreas

and Increase in fetal insulin
production

Growth stimulating effect of

insulin
• Much of the excess weight is truncal fat, hence
shoulder dystocia.

• Macrosomia occurs in 25% of infants of type 1

diabetic mothers

• Excessive insulin secretion persists after birth

--🡪 hypoglycaemia
WHO TO SCREEN?
Screening - risk factors

1. BMI >27 kg/m2

2. Age >25-year-old
3. Previous macrosomia baby weighing ≥4 kg
4. Previous gestational diabetes mellitus
5. First-degree relative with diabetes
6. History of unexplained intrauterine death
7. History of congenital anomalies
8. Glycosuria ≥ 2+ on 2 occasions
9. Current obstetric problems (essential hypertension,
pregnancy-induced hypertension, polyhydramnios and
current use of steroids)
 DIAGNOSIS of GDM
75g Oral Glucose Tolerance Test
(mOGTT)

150g carbohydrate perday diet

3 days
before test.
Fasted for 10hrs overnight.
Venous blood samples at 0 and
2h after
oral glucose load.
0h PGL ≥5.1mmol/L OR
2h PGL ≥7.8mmol/L
= diagnostic of GDM
Based on different authorities’ recommendation, patient with criteria as below
should be treated as pre-existing diabetes.

i.GDM diagnosed during first trimester if they are fulfilling the diagnosis criteria
of diabetes outside pregnancy (ADA 2014)

i.If
a. Fasting blood is ≥ 7.0 mmol/l, or
b. 2h post glucose load ≥11.1 mmol/l, or
c. HbA1c is ≥ 6.3%, or
d. random blood glucose ≥ 11.1 mmol/l in the presence of symptom. (WHO
2013, IADPSG 2010)

Suggested documentation: to document the diagnosis as:-GDM (likely pre-

existing diabetes). This is to make sure that we are tuned to treat this patient
as pre-existing diabetes rather than merely as GDM.
MANAGEMENT OF DIABETES
IN PREGNANCY
Pre-conception counselling
Women with pre-existing DM : good pre-
conception glycaemic control are more
likely to have good pregnancy outcomes

Multidisciplinary team : physician/ FMS,

obstetrics, dietitian, diabetes nurse
educator, & other health care providers
 Counselling
Well-planned pregnancy
Only when she has good glycaemic control
Discontinue unsafe medications during
pregnancy
Smoking cessation
Time, commitment and effort required by the
patient in both self-Mx and engagement with the
health care team
Importance of notifying the health care team
without delay once confirmed pregnant
Pre-pregnancy Management
Keep HbA1c < 6.5% (CPG 2017, NICE)
◦ If HbA1c > 10%, advised not to get pregnant
Weight reduction in those overweight & obese
before pregnant
Folic acid – start 3 months prior to planning
pregnancy
Women on OAD can be switched to insulin for
better glycaemic control before planning
pregnancy
Patient who are already on metformin may
continue treatment during pregnancy
Pre-pregnancy Management
Screen for diabetic retinopathy,
nephropathy, hypertension, cardiovascular
risks prior to pregnancy
 Medication review
▪ Women with T2DM who are planning a pregnancy should switch
from oral antidiabetic agent (OAD) to insulin for glycaemic
control.
▪ Patients who are already on metformin may continue treatment.
▪ Women with pre-existing diabetes who also have
ovarian syndrome may continue metformin for polycystic
induction. ovulation
▪ Prior to conception or upon detection of pregnancy, the following
medications should be discontinued: angiotensin-converting
enzyme inhibitors, angiotensin II receptor blockers and statins.
 SMBG during Pregnancy
Timing of SMBG & treatment Breakfast Lunch Dinner

Pre Post Pre Post Pre Post

Diet only √ √ √ √

OAD or single dose insulin √ √ √ √

Multiple dose insulin √ √ √ √ √ √

Fetal Monitoring By Ultrasound Scan

• Pregnant women with pre-existing diabetes should be

offered ultrasound scan at:
◦11-14 weeks of gestation for dating and major structural
malformation
◦18-20 weeks of gestation for detailed structural anatomy
scan (by a trained specialist or ultra sonographer)

• In women with pre-existing diabetes and gestational

diabetes mellitus, serial growth scan should
be performed every four weeks from
28 to 36 weeks of gestation.
 Nutrition and Weight Management
Important to receive medical nutrition therapy defined as a
carbohydrate controlled meal plan that promotes:
◦Adequate nutrition with appropriate weight gain
◦Normoglycaemia, and
◦Absence of ketosis.
 MANAGEMENT OF
DIABETES IN PREGNANCY
ANTENATAL
Nutrition :
◦ Refer dietitian
◦ Medical nutrition therapy (MNT / diet control),
for 1-2 weeks
◦ Carbohydrate intake limited to 45% of total
calories
Weight management
◦ Normal pre-preg wt, caloric prescription :
35kcal/kg body weight
◦ Overweight/obese : moderate caloric restriction
25kcal/kg
Exercise In Pregnancy

• 15-30 min exercise, mainly

upper body and not
involving the trunk.
• Effect of exercise
evident
only after 4 wks.
• Daily exercise can
decrease insulin
requirement.
Women at risks of GDM (mostly
BMI>25), should receive MNT (dietary
intervention and counselling) as needed,
preferably by dietitian, beneficially before
15 weeks of gestation
◦ (CPG 2017-Diabetes in pregnancy)
Exercise
 Eg. of safe physical activities during pregnancy
are :
◦ Brisk walking
◦ Swimming
◦ Stationary cycling
◦ Low impact aerobics
◦ Modified yoga or pilates
◦ Strength training
◦ Racquet sport
 GLYCAEMIC CONTROL
Monitor :
◦ Preferably patient has self-monitoring of blood
glucose be done at home (SMBG), performed
over a few days :
◦ Fasting ( 8 hr of overnight fast) & pre-meal
◦ 1 or 2 hr after the start of each meal (post-
prandial)
◦ Bedtime & during the night (3-4am) if indicated
GLYCAEMIC CONTROL
Monitoring is preferably done at home
Traditional BSP performed in hospital
may not reflect the actual day-to-day
sugar levels
When SMBG is not feasible, clinic-based
BSP may be done
Frequency of BSP is once in 2 weeks
until delivery or more frequent
 There is NO EVIDENCE on
the effectiveness of HbA1c
monitoring in predicting
adverse outcomes in pregnancy
(CPG 2017)
Thus…
HbA1c ONLY to do during booking /
first or early second trimester (when
detected DM)
ONLY do once
DO NOT monitor HbA1c each trimester
 Blood glucose targets
Timing of blood glucose Target value* (mmol/L)

Fasting or pre-prandial ≤ 5.3

1 hour after start of a meal ≤ 7.8

2 hours after start of a meal ≤ 6.7

( CPG Malaysia 2017 )

* Pregnant women who are on insulin or OAD should maintain their capillary
blood glucose > 4.0 mmol/L
* Plasma calibrated values ( capillary whole blood reading is 12% lower than
venous plasma glucose )
Oral Anti-Diabetic (OAD)
Published data suggest :
◦ Metformin in GDM is not a/w birth defects,
pre-eclampsia or adverse maternal or fetal
outcome
◦ Better maternal outcome in weight gain, post-
prandial blood glucose, PIH
◦ Better fetal outcome in hypoglycaemia, but
worse in preterm birth
◦ In pt w PCOS, reduce risk of miscarriage and
GDM
OAD…
Metformin is labelled as FDA pregnancy
category B while glibenclamide is in
category C (CPG Malaysia 2017)
Glibenclamide (Daonil) can be used in
pregnancy, but less effective if GDM
diagnosed before 25 week or FPG
>6.2mml/L
Glibenclamide should only be used if
potential benefit outweighs the risk
 Insulin therapy
Refer hosp for insulin commencement, if blood
glucose targets are not met 1-2 weeks after
MNT or metformin therapy
Basal-bolus regime
Patients who get steroid or dexa injection,
should be monitored closely
Eg. Actrapid & insulatard
If pre-prandial actrapid exceed 16units tds,
consider adding 6-10 units insulatard in the
morning & titrate accordingly until targets are
achieved
(CPG 2017) insulin therapy could be
initiated in the outpatient setting if pt is
agreeable, able to monitor SMBG & able
to titrate the required insulin doses to
achieve glycaemic targets without
hypoglycaemia
Types of insulin
Insulin treated women should be on
multiple daily doses (basal-bolus)
◦ Basal-bolus doses of short-acting human
insulin have been used safely & effectively
◦ Rapid acting insulin analogues may be used to
achieve better 1hr PP glycaemic control with
less hypoglycaemia although perinatal
outcomes are similar to human insulin (CPG
Malaysia 2015)
Insulin preparation Type of insulin Used in Used in
pregnancy breastfeeding

Fast-acting Rapid analogue Safe Safe

-Aspart(Novorapid)
-Lispro (Humalog)

Human regular Safe Safe

-Actrapid
-Humulin R

Intermediate Human NPH insulin Safe Safe

acting -insulatard
-Humulin N

Long-acting Analogue Not proven Not proven

-Glargine (not licence)
-Detemir
Premixed insulins Mixtard 30/70 Category B, but Not excreted in
Humulin 30/70 not recommended breast milk
ANC follow up…
GDM :
◦ Refer dietitian for 1-2 weeks diet control
◦ If blood glucose not well-controlled with diet
control, for metformin or insulin commencement
◦ No need detail scan, as GDM usually no effect on
organogenesis (less likely to have congenital
defects)
Issue : GDM on MNT, never s/b dietitian yet or
counselled for MNT, on normal diet, BSP after 2
wk deranged, refer for insulin commencement…
Start insulin at 6 units (never start with 4 units)
 ANC follow up…
Pre-existing DM :
◦ Refer dietitian
◦ If pre-pregnancy on OAD (low dose), for diet control 1-2
weeks. If blood glucose targets not achieved, start insulin
◦ High dose OAD, multiple drugs, or insulin, refer
specialist
◦ HbA1C during booking
◦ Assess kidney (renal profile), eyes (refer opthal), cardiac,
hypertension
◦ Detail scan at 18-22 weeks
◦ T. Aspirin?
 HIGH RISK
MODERATE RISK
(any ONE of the following)
(any TWO of the following)
1. Hypertensive disease in
1. Primigravida
previous pregnancy
2. 40 yo and above
2. Chronic renal disease
3. Pregnancy interval > 10 yrs
3. Autoimmune disease
4. BMI > 35 at booking
(SLE, APS)
5. Family history of PE
4. Chronic hypertesion
6. Multiple pregnancy
5. Type I or II DM

1. Start T. Aspirin 75mg-150mg OD at 12 weeks, preferably

before 16 weeks, bt may still be beneficial up to 24 weeks

2. Start T. Calcium Carbonate 1g TDS from 20 weeks, may be

still beneficial if started from up to 34 weeks
Pre-existingdiabetes – retinal assessment at
booking, then at 28 weeks

Renal assessment at booking,

◦ Refer nephro if :
 Serum creat ≥ 120чmol/L
 Urine albumin : creatinine ratio > 30mg/mmol
 Total protein excretion > 0.5g/day

Thromboprophylaxis should be considered

if proteinuria > 5g/day
Corticosteroids in antenatal patient:
Corticosteroid or Dexamethasone is known
to elevate plasma glucose level and worsen
glycaemic control of diabetes in pregnancy
For pt on insulin, most of them had to
increase the insulin doses to less than double
of their regular doses
Need regular plasma glucose monitoring (at
least 4 times a day, for 48 hours from the
first dose) & adjustment of their insulin dose
accordingly (CPG 2017)
Timing & mode of delivery:
Intrapartum
Monitor capillary plasma glucose every
hour to maintain blood glucose levels
between 4 – 7 mmol/L
Start insulin infusion if > 7 mmolL
Post - partum
Insulin requirements drop immediately
after delivery by 60-75%

Most women diagnosed with GDM

should be able to discontinue their insulin
immediately post delivery
Post-partum – in hospital
GDM on diet control
◦ GM in ward controlled, discharge with repeat
OGTT after 6 weeks

GDM on low dose insulin

◦ Discontinue insulin, monitor GM in ward,
discharge w repeat OGTT after 6 wk
Post - partum
GDM on high dose insulin
◦ Insulin therapy should be continued at lower
dose (reduce 50%)
◦ Monitor GM in ward (aim GM 4-6mmol/L),
discharge and continue monitor GM in KK
◦ Repeat OGTT 6 weeks later
◦ Eg. GDM on s/c Actrapid 20/20/24
antenatally, post delivery s/c actrapid 10/10/12
Post – partum (GDM)
RepeatOGTT 6 weeks later
NICE guideline :
◦ Postnatal FPG < 6.0mmol/L (100% sensitivity)
◦ If FPG ≥ 6.0 mmol/L, then only proceed with
full OGTT
◦ Cost-effective
CPG 2017:
Post - partum
Pre-existing DM
◦ In non-breastfeeding mothers, OAD agents
can be continued
◦ Low dose metformin can be safely used in
nursing mothers
◦ Glipizide & glibenclamide – not detected in
breast milk, safely used in BF mothers
◦ Other OAD agents – not in BF
◦ Mixtard – not excreted into breast milk
Post - partum
Counsel for appropriate contraception
Informed reg the risk of GDM in future
pregnancies and advised :
◦ Check OGTT when planning pregnancy
◦ Have annual screening for diabetes
◦ Lifestyle modifications to prevent DM in
future
Postpartum Care

⮚ Low dose metformin can be safely used in nursing mothers.

⮚ Patients should be counseled regarding appropriate

contraception.

⮚ Women with GDM should be informed of the risk of GDM in

future pregnancies and advised to have an OGTT when
planning future pregnancies.

⮚ MGTT at the 6-week postnatal appt.

⮚ Women with a history of GDM should have annual screening for
diabetes.
Case 2

o 1st visit
o 35 y.o Indian woman, executive recently married, is
seen at the ANC at 15 weeks gestation.
o No prior medical illness
o Her pre-conception BMI was 31 kg/m2
o FH both parents have T2DM
Question
At 15 weeks gestation, should you screen for
GDM in her?
Question
At 15 weeks gestation, should you screen for
GDM in her?

She has RF for GDM (age, BMI, FH), so she should be

screened early for it.
Laboratory results

❖ OGTT results:
FPG 5.3 mmol/L
2PPG 7.9 mmol/L
 Questions
• What is her glucose status?
• What management is required?
 Questions
• What is her glucose status?
• What management is required?

GDM
Lifestyle modification advice
Monitor blood glucose at fasting and post-prandial 2-4
weekly
 On Follow - up
▪ At 30 wks gestation, her SBGM are:
FPG 6.2, 2PPG 9.1
HbA1c 7%
Fetal USG Normal
 QUestions
▪ What is her glucose status?
▪ What management is required?
▪ How should her BG be monitored now?
 Questions
▪ What is her glucose status?
▪ What management is required?
▪ How should her BG be monitored now?

SBGM are all elevated as is her HbA1c

Full insulin therapy for her BG control as well as
counselling from dietician and DE.
SBGM monitoring while on insulin is FPG and Post
prandial BG twice or weekly
 Summary
❖ Diabetes in pregnancy is associated with maternal and fetal
outcomes.
❖ Important to screen at the right time.
❖ Pre-conception counselling is important in pre-existing
diabetes.
❖ It is important to achieve the glucose targets without
hypoglycaemia.
❖ Insulin therapy is still the mainstay of treatment.
❖ During post partum, adjustment of insulin and OHA should be
done with a repeat OGTT in women with GDM.
THANK YOU