Asresach D.(M.

D+)
DEFINITION
Diabetes mellitus;
abnormal metabolism of carbohydrates which results
in elevated blood glucose level.
Prevalence
 increasing globally
-marked shift in dietary intake
-reduced physical activity
Classification During Pregnancy
PREGESTATIONAL (overt) DIABETES
 Existing before pregnancy
Type 1
 juvenile-onset diabetes
 Autoimmune destruction of beta cells
 Absolute insulin deficiency,
 Requirement of exogenous insulin
Cont..
Type 2
 Maturity onset or Adult type
 Abnormal insulin secretion / insulin resistance
 Hereditary pattern
 Associated with risk factors such as obesity
 usually classified as class B diabetes according to the
White classification system.
Cont..
Gestational Diabetes
o CHO intolerance of variable severity with onset or first
recognition during pregnancy
More than half of women with GDM ultimately develop
overt DM in the ensuing 20 years.
White Classification in Pregnancy
Metabolic changes in pregnancy in healthy pregnant
women
1. Serum glucose
– Fasting hypoglycemia
– Post prandial hyperglycemia
2. Insulin secretion
– Increases progressively across GA & B-cells required
to produce more Insulin because of Insulin Resistance
– B-cell Hyperplasia
• if B-cell cant produce enough more → GDM
 Cont…
3. Insulin sensitivity
– 50% decrease in sensitivity in late 3rd TM
– Insulin Resistance peak at 36 wks
4. Insulin Resistance
– High level of maternal/Placental hormones:
• HPL, Estrogen, Progesterone, Cortisol, Leptin, Prolactin
– Metabolic Inflammation :
• TNF Alpha, CRP, IL-6, Macrophages
– Insulin Receptor Signaling Dysfunction at skeletal
muscle
 Metabolic changes in pregnancy with DM
 1. Serum glucose
– Increase b/c insulin don’t inhibit hepatic glucose
production
 2. Insulin secretion
– B-cells don’t produce the needed amount of insulin
 3. Insulin sensitivity
– decreases as GA increase
– The level of decrease in Insulin Sensitivity is similar to
normal pregnancy
Metabolism in normal and diabetic pregnancy
Insulin is an anabolic hormone with essential roles in
carbohydrate, fat, and protein metabolism.

1. CHO metabolism:

– Stimulates hepatic glucose uptake and use by cells
– Inhibits gluconeogenesis and glycogenolysis
– Blood sugar↓
 Cont…
2. Fat metabolism:
– Improves fatty acid transportation and fat anabolism
– Inhibits fat catabolism
– Inhibits fatty acid and acetone body generation
3. Protein metabolism:
– Improves amino acid transportation
– Inhibits protein catabolism and amino acid
utilization in the liver
4. Potassium:
– Stimulates K+ entering cells → blood K+↓
 Cont…
The lack of insulin results in
hyperglycemia
lipolysis
↑ed free fatty acids
 increase in the formation of ketone bodies,
acetoacetate and B-hydroxybutyrate.
 Cont…
– When BGL exceed the renal threshold for absorption of filtered glucose,
glycosuria occurs and causes an osmotic diuresis with dehydration and
electrolyte losses.
 Insulin sensitivity decreases as gestation advances, due to
anti-insulin signals produced by the placenta
In the first TM,
↑ing maternal estrogen and progesterone levels
 decrease in FBS.
 Cont…
In the 2nd TM,
higher fasting and postprandial glucose levels facilitates
transfer of glucose from mother to fetus.
--occurs via a carrier-mediated active transport system
↓ed amino acid due to active placental transfer to the
fetus.
Lipid metabolism continued storage until midgestation,
 then enhanced mobilization (lipolysis) as fetal fuel
demands increase.
 Cont…
Human placental lactogen (hPL);
--responsible for insulin resistance and lipolysis.
–decreases the hunger sensation
--diverts maternal CHO to fat metabolism.
–reduces the insulin affinity to insulin receptors.
–>favors placental transfer of glucose to the fetus
and to reduce the maternal use of glucose.
– The hPL levels rise steadily during the 1st and 2nd
trimesters, with a plateau in the late 3rd TM.
 Cont…
Cortisol levels rise during pregnancy
 stimulate endogenous (hepatic)glucose production and
glycogen storage and decrease glucose utilization.
– The "dawn phenomenon" (elevated fasting glucose to
facilitate brain metabolism).
 Cont…
Prolactin
increased 5 to 10-fold during pregnancy and may
impact CHO metabolism
Overall, pregnancy results in
fasting hypoglycemia,
postprandial hyperglycemia, and
 hyperinsulinemia
 Cont…
Insulin resistance leads to-
 Reduced maternal glucose utilization
 Increased lipolysis
 Reduced Glycogen synthesis
 Increased gluconeogenesis
 Elevated maternal serum glucose. etc
 Renal threshold for glycosuria drops
from non pregnant level of 180mg/dl
Screening strategy for detecting GDM

Risk assessment should be ascertained at the first

prenatal visit.
• Low risk: testing is not routinely required if:
 Member of an ethnic group with a low prevalence of
GDM
 No known diabetes in first-degree relatives
 Age <25 years
 Weight normal before pregnancy
 No history of abnormal glucose metabolism
 No history of poor obstetric outcome
 Cont…

• Average risk:
 Perform blood glucose testing at 24 to 28 weeks by
one of the following methods:
 Two-step procedure: A 50-g GCT followed by a
diagnostic oral GTT in those who meet the threshold
value in the GCT.
 One-step procedure: Diagnostic oral GTT
performed on all subjects.
 Cont…
High risk: Perform blood glucose testing as soon as
feasible if one or more of these are present:
• Severe obesity
• Strong family history of type 2 diabetes
• Previous hx of GDM, impaired glucose metabolism,
or glucosuria
• Hx of unexplained Stillbirth, Congenital
Malformation, Macrosomia
 Cont…
If GDM is not diagnosed, it should be repeated at 24
to 28 wks or anytime a pt has sx/sn suggestive of
hyperglycemia.
Whom to screen?
Selective vs universal
 When to screen?
at 24 to 28 wks’ gestation, the “diabetogenic state” of
px has been established
 Methods of screening and diagnosis of
GDM:
One step strategy
Screen all pregnant mothers
The OGTT should be performed in the morning after
an overnight fast of 8 hr.
GDM can be diagnosed when any single threshold
value was met or exceeded (see next table).
 Cont….

Based on a universal, 75-g, 2-hr glucose tolerance test.

Diagnosis of GDM is made if one value is met or exceeded
 Cont…
Two step test
 50 gm challenge test
Administer 50 gm of glucose orally irrespective of
time and meal
then determine plasma level after one hr.
If its above 135-140 gm/dl, do diagnostic test
 Cont…
Diagnostic test(100gm OGTT):
 after overnight fasting, in the morning
 1st take FBS sample,
100gm glucose taken per os, then 1hr, 2hrs, 3hrs
blood sugar determined:
 GDM diagnosed, if 2 or more abnormal:-
Normal results are:-
see on the next table
Cont…
 Diagnosis
Overt DM:
Previous history
Symptom complex: the “polys”
Signs and symptoms of end organ damage
High plasma glucose levels and/or glycosuria
 Cont…
RBS ≥200 with classic poly symptoms
OR
FBS ≥126 mg/dl
OR
OGTT 2hr post prandial(2hr Post 75g Oral Glucose Load)
test>200mg/dl
OR
HbA1c level ≥6.5%.
 Impact on pregnancy
Fetal effects
Congenital anomalies
CHD (35 to 40%); tetralogy of Fallot, transposition of
the great arteries, septal defects, and anomalous
pulmonary venous return,
CNS defects (anencephaly, spina bifida, encephalocele,
hydrocephaly, anotia/microtia) and
defects in the urogenital system.
 Cont…
Sacral agenesis/caudal dysplasia is rare.
two major causes of fetal death
• congenital malformations and
• unexplained fetal death
Miscarriage
Preterm Delivery
Altered Fetal Growth: macrosomia, IUGR
Unexplained Fetal Demise
Hydramnios
Neonatal Mortality and Morbidity
Respiratory Distress Syndrome
 excess level of fetal insulin blocks the action of cortisol.
 Cortisol activates type II pneumocytes
Hypoglycemia
 blood glucose < 35 -40 mg/dL during the first 12 hrs of
life,
 rapid drop in plasma glucose following clamping of the
umbilical cord.
 Hypocalcemia
–total serum calcium conc < 8 mg/dL in term infants.
 Cont…
Hyperbilirubinemia and Polycythemia
increased red cell production b/c of relative hypoxia
in utero and break down of red cells
Cardiomyopathy
Long-Term Cognitive Development
Inheritance of Diabetes
Birth trauma
 Maternal effects
except diabetic retinopathy, the long-term course of
diabetes is not affected by pregnancy
Diabetic Nephropathy
–reduced cr clearance or proteinuria of at least 500 mg
in 24 hours during the first 20 wks of gestation
Diabetic Retinopathy
– Retinal vasculopathy is a highly specific complication of
both type 1 and type 2 diabetes
– progression of eye disease during px despite intensive
glucose control.
 Cont…
-proliferative retinopathy, represents
neovascularization or growth of new retinal
capillaries.
may cause vitreous hge with scarring and retinal
detachment vision loss.
In labor, avoid the Valsalva maneuver to reduce the
risk for retinal hge.
 Cont…
Diabetic Neuropathy
–known as diabetic gastropathy,
--causes nausea and vomiting, nutritional problems,
and difficulty with glucose control.
Preeclampsia
Diabetic Ketoacidosis
Infections (recurrent vulvovaginal candidiasis, UTI)
Operative delivery
Increased insulin dose
 Mgt of pregestational DM
PRECONCEPTION CARE
Requires multidisciplinary approach
Evaluate and treat diabetic complications before px
Measure and optimize thyroid hormone levels in type 1 diabetes.
Review all current medications
Measure HbA1C monthly until < 7%.
 Cont…
Monitor blood glucose level to achieve the target blood
sugar level:
• FBS: 80 -110 mg/dL
• 2 hr postprandial blood glucose: < 150 mg/dL
Folic acid supplementation.
Provide counseling
effective contraception until target blood glucose control is
achieved
 Cont…
ANTENATAL mgt
Initial evaluation:
Screen, monitor and manage for maternal medical complications of DM
baseline investigations ( RFT, urine protein, LFT)
Follow up
 every 2 – 3 wks during the first two trimesters, every 1-2 wks until 36
wks then wkly until delivery.
 Cont…
Ultrasound
low-dose aspirin after 12 weeks of gestation to
prevent preeclampsia
Monitor Blood Glucose
The goal is to maintain capillary glucose levels as
close to normal as possible,
 Cont…
FBS; <95 mg/dL
Premeal values of; <100 mg/dL
1-hour postprandial levels; < 140 mg/dL , and
2-hour postprandial values; < 120 mg/dL.
During the night, glucose levels should not <60
mg/dL.
Mean capillary glucose levels should be maintained at
an average of 100 mg/dL with Hb A1C < 6%
 Cont…
An ideal typical glucose monitoring involves capillary glucose
checks
on rising in the morning, 1 or 2hr after breakfast, before & after
lunch, before dinner & at bed time.
Dietary management
Exercise
Insulin Therapy
Timing and route of delivery
 Cont….
balancing the risk of IUFD with the risks of
PTB.
delivery at 37wks:
vasculopathy, nephropathy, poor glucose
control, or a prior stillbirth after confirmation
of fetal pulmonary maturity.
reassuring antenatal testing; 38 – 39 wks. But
not beyond 40 wks.
 Cont….
Delivery b/n 34 and 36 wks 6 days;
failure of in hospital glycemic control or
 abnormal fetal testing.
• Cesarean section for obstetric indications
 Cont…
 INTRAPARTUM MANAGEMENT
 Patient is kept NPO after midnight
 Usual dose of intermediate-acting insulin at bedtime.
 Withhold morning (AM) insulin injection.
 glucose infusion (5% dextrose in water) at 100 – 150 mL/hr
 Add 10 U RI to 1000 mL of solution containing 5% DW.
 infusion of regular insulin if capillary glucose >80 mg/dL.
 Cont…
Use fluid without dextrose if capillary glucose > 180
mg/dL.
 Begin oxytocin as needed.
Monitor maternal glucose levels hourly. Adjust
insulin infusion.
Intermittent Subcutaneous Injection Method
Cont….
 Management of GDM
Antenatal
Identification of risk factors
 Risk assessment at the first prenatal visit and screening.
 Ultrasound evaluation
 Diet and Exercise
 Insulin
 for pts treated with nutrition and exercise therapy when
 1hr postprandial > 130–140 mg/dL or
 2hr postprandial >120mg/dL or
 FBS >92mg/dL persistently over 2wks.
 Cont…
Metformin
Timing and route of delivery
Delivery, b/n 39 and 40wks, but not later than 40wks.
Poor glycemic control-- Induction at 38wks
If delivery is indicated <39wk
check lung maturity
CS is done only for obstetric indications
 Postpartum follow up
Determine RBS within 4 hours of delivery
If FBS >126 mg/dL or RBS >200mg/dL, insulin in a
lower dose or metformin
was on insulin in the antenatal period, adjust the dose
to pre pregnant doses in those with type 2 DM.
 Cont…
GDM, no treatment is required and usually maintained
on diet alone.
OGTT at 6 - 12 wks postpartum to exclude overt DM.
FBS> 140 mg/dl and
2 hr plasma glucose > 200mg/dl-- overt DM
preproliferative diabetic retinopathy or any form of
referable retinopathy
ophthalmological follow-up for at least 6 months
after the birth of the baby
 Cont…
Family planning
All reliable method of family planning can be used
COC and DMPA
avoided in women with pregestational DM who have
vascular complications
Permanent methods of contraception are ideal if
family size is complete.
THANK YOU