Diabetes in PregnancyDiabetes in Pregnancy

L.Sekhavat MDL.Sekhavat MD

Diabetes in PregnancyDiabetes in Pregnancy

Gestational Diabetes

Pre-gestational diabetes (overt)Insulin dependent (type1)

Non-insulin dependent (type 2)

DefinitionDefinition

Gestational diabetes mellitus (GDM) is defined as any degree of glucose intolerance with onset onset or first first recognition recognition during pregnancy

Diabetes in pregnancy

Pre-existing diabetes Gestational diabetes

Pre-existing diabetesIDDM

(Type1)NIDDM(Type2) True GDM

Gestational diabetes typically is 3rd trimester disorder

Overt diabetes is 1st trimester

Some general characteristic of type1 Some general characteristic of type1 and type 2 diabetesand type 2 diabetes

Characteristic type1 type2

genetic ch 6 unknown

Age at onset <40 >40

Habitus normal to wasted obese

Plasma insullin low to absent normal to high

Insullin therapy responsive R/resistant

Classification of diabetesClassification of diabetesClass onset FBS 2hpp therapyA1 gestational <90 <120 dietA2 gestational >90 >120 insullinClass age of onset duration V diseasesB >20 10-19 noneC 10-19 10-19 none

D <10 >20 B retionopathyF any any nephropathyR any any P retionopathyH any any heart D

Normal Maternal Glucose Normal Maternal Glucose RegulationRegulation

Tendency for maternal hypoglycemia between meals - fetal demand

Increasing tissue insulin resistance during pregnancy

Diabetogenic placental steroid

Estrogen, Progesterone

HPL

Increased insulin production

(= 30% mean)

Fetalhyperinsulinemia

Fetus

Fetal pancreas stimulated

MotherPl

acen

ta

Insulin

Maternal hyperglycemia

The Impact of Maternal Hyperglycemia The Impact of Maternal Hyperglycemia During Pregnancy During Pregnancy

Maternal HyperglycemiaMaternal Hyperglycemia

Causes fetal hyperglycemia

Leading to fetal hyperinsulinemia

Fetal hyperinsulinemia - even short periods (1-2 hours) lead to detrimental consequences in:

fetal growth

fetal well-being

Fetal HyperinsulinemiaFetal HyperinsulinemiaPromotes storage of excess nutrients - macrosomnia

Increased catabolism of excess nutrients - energy usage and low fetal oxygen storage

Episodic fetal hypoxia

Increased catecholamines causing: hypertension

cardiac hypertrophy

Increased Erythropoietin:Hyperbilirubinaemia

Diagnosis:Diagnosis:

Glucosuria is common in pregnancy (Renal glycosuria)

so not diagnosticso not diagnostic.

Fasting and 2 hours postprandialFasting and 2 hours postprandialvenous plasma sugar during pregnancy.venous plasma sugar during pregnancy.

Diabetic>120 mg/ dl.>95 mg/dl

Not diabetic< 120mg/ dl.<95 mg/dl

Result2h postprandialFasting

Risk Factors:Risk Factors:> 25 years old

Previous macrosomnic infant

Unexplained fetal demise

Previous GDM

Family hx - GDM/NIDDM

Obesity > 90Kg

Smoking

50-g oral glucose challenge50-g oral glucose challengeThe screening test for GDM, a 50-g oral

glucose challenge, may be performed in the fasting or fed state. Sensitivity is improved if the test is performed in the fasting state .

A plasma value above 130-140130-140 mg/dl one hour afterone hour after is commonly used as a threshold for performing a 3-hour OGTT.

If initial screening is negative, repeat If initial screening is negative, repeat testing is performed at 24 to 28 weeks.testing is performed at 24 to 28 weeks.

3 hour Oral glucose tolerance test3 hour Oral glucose tolerance test 3 hour Oral glucose tolerance test3 hour Oral glucose tolerance test

PrerequisitesPrerequisites::

Normal diet for 3 days before the test.

No diuretics 10 days before.

At least 10 hours fast.

Test is done in the morning at rest.

Giving 100 gm (75 gm by other authors) glucose in 250 ml water orally

Criteria for glucose tolerance testCriteria for glucose tolerance testCriteria for glucose tolerance testCriteria for glucose tolerance test The maximum blood glucose values during

pregnancy:

fasting 95 mg/ dl,

one hour 180 mg/dl,

2 hours 155 mg/dl,

3 hours 140 mg/dl.If any 2 or more of these values are elevated, the If any 2 or more of these values are elevated, the

patient is considered to have an impaired glucose patient is considered to have an impaired glucose tolerance test.tolerance test.

Pregnancy ComplicationPregnancy ComplicationPregnancy ComplicationPregnancy Complication

Hydramnios

Spontaneous abortions

Congenital malformations

Macrosomia

Diabetic ketoacidosis

Neonatal metabolic complications

Macrosomia -PathogenesisMacrosomia -PathogenesisMacrosomia -PathogenesisMacrosomia -Pathogenesis

MacrosomniaMacrosomnia

(Greater than 90 precentile, 4200 grammes)

Increased birth trauma

Macrosomnia as a child and glucose intolerance in adulthood

Congenital AnomaliesCongenital AnomaliesCardiac defects 8.5%

CNS defects 5.3%Anencepha

Spina Bifida

All Anomalies 18.4%

Specially overt diabetes Specially overt diabetes

The most risk is HgA1c >10The most risk is HgA1c >10

Maternal ComplicationsMaternal ComplicationsPre-eclampsia

Diabetic ketoacidosis

Maternal hypoglycemia

Maternal trauma

Higher C/S rate

Retinal disease/renal disease not affected significantly by pregnancy

Perinatal Mortality/MorbidityPerinatal Mortality/Morbidity

Miscarriage

IUGR

Macrosomia

Birth Injury

Neonatal Morbidity and MortalityNeonatal Morbidity and Mortality Neonatal Morbidity and MortalityNeonatal Morbidity and Mortality

Neonatal hypoglycemiaPolycythemiaHyperbillirubinemiaHypertrophic and congestive cardiomyopathyARDS

Development of obesity and diabetes in childhood

Treatment of Gestational DiabetesTreatment of Gestational Diabetes Treatment of Gestational DiabetesTreatment of Gestational Diabetes

Diet and exercise

Glucose monitoring

Insulin if necessary (Hypoglycemic agents?)

2-weekly visits to Diabetic service/antenatal service & Growth Monitoring (scan)

Delivery based on obstetric issues

Diet TherapyDiet Therapy

Goals of an Effective diet: Normoglycemia

Adequate weight gain

Good fetal health

Medical nutrition therapy should include the provision of adequate calories and nutrients to meet the needs of pregnancy

( Diet: 50% carb, 20% prot, 30% fat)

Exercise TherapyExercise Therapyexercise diminishes peripheral resistance to insulin cardiovascular conditioning increase affinity and receptor bindingReduction in both fasting and postprandial glucose

may decrease need for other may decrease need for other therapies in Gestational Diabetestherapies in Gestational Diabetes

insulin therapy is recommended when medical nutrition therapy fails to maintain self-monitored glucose at the following levels:

Fasting blood glucose <95 mg/dL or1-hour postprandial blood glucose <140

mg/dL or2-hour postprandial blood glucose <120

mg/dL

Insulin therapyInsulin therapy

The total first dose of insulin is calculated according to the patient’s weight as follow:

In the first trimester .......... weight x 0.7

In the second trimester........ weight x 0.8

In the third trimester........... weight x 0.9

Insulin therapyInsulin therapy

Insulin Therapy (dosage)Insulin Therapy (dosage)Divide the injections:

60% Regular insulin30% before breakfast15% before lunch15% before dinner

40% NPH30% before breakfast10% before bed

One study demonstrated that the 4 injection a day as compared to 2 injections a day improved glycemic control and perinatal outcome

ManagementManagementTest AFP at 16-20 weeks

Antenatal visits – 2 weekly after 24 weeks

NST weekly (starting at 28-30 wks)

Anomaly scan at 16- 20-weeks and

Growth scans from 26-28 weeks

Delivery Around term if insulin dependent unless complications

Diet only control as normal antenatal patients

When antepartum testing suggests

fetal compromise, delivery must be

considered.

Intrapartum managementIntrapartum management

IV fluids (5% dextrose) + insulin

Hourly glucose monitoring

Manage labor as normal

The need of insulin typically decreased after delivery so:

Avoid of NPH and used Regular Avoid of NPH and used Regular insulininsulin

Management - PostpartumManagement - Postpartum

Use pre pregnancy insulin levels when on diet and monitor.

Breast feeding?

GDM - long term risk of NIDDM

Contraception

After delivery After delivery nearly all postpartum women will become normoglycemic

1/3 to 2/3 will have recurrent GDM in subsequent pregnancies

Over than 50%

of gestational diabetes

lead to overt diabetes