Diabetes in Pregnancy L.Sekhavat MD

Diabetes in Pregnancy Gestational Diabetes Pre-gestational diabetes (overt) Insulin dependent (type1) Non-insulin dependent (type 2)

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

Gestational diabetes typically is 3rd trimester disorder Overt diabetes is 1st trimester

Some general characteristic of type1 and 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 diabetes Class onset FBS 2hpp therapy A1 gestational <90 <120 diet A2 gestational >90 >120 insullin Class age of onset duration V diseases B >20 10-19 none C 10-19 10-19 none D <10 >20 B retionopathy F any any nephropathy R any any P retionopathy H any any heart D

Normal Maternal Glucose Regulation 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)

Maternal hyperglycemia The Impact of Maternal Hyperglycemia During Pregnancy Maternal hyperglycemia Fetal pancreas stimulated Placenta Fetal hyperinsulinemia Insulin Fetus Mother

Maternal 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 Hyperinsulinemia Promotes 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: Glucosuria is common in pregnancy (Renal glycosuria) so not diagnostic.

Fasting and 2 hours postprandial venous plasma sugar during pregnancy. 2h postprandial Result <95 mg/dl < 120mg/ dl. Not diabetic >120 mg/ dl. Diabetic >95 mg/dl

Risk Factors: > 25 years old Previous macrosomnic infant Unexplained fetal demise Previous GDM Family hx - GDM/NIDDM Obesity > 90Kg Smoking

50-g oral glucose challenge The 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 130-140 mg/dl one hour after is commonly used as a threshold for performing a 3-hour OGTT. If initial screening is negative, repeat testing is performed at 24 to 28 weeks.

3 hour Oral glucose tolerance test Giving 100 gm (75 gm by other authors) glucose in 250 ml water orally Prerequisites: 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.

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

Pregnancy Complication Hydramnios Spontaneous abortions Congenital malformations Macrosomia Diabetic ketoacidosis Neonatal metabolic complications

Macrosomia -Pathogenesis

Macrosomnia Increased birth trauma (Greater than 90 precentile, 4200 grammes) Increased birth trauma Macrosomnia as a child and glucose intolerance in adulthood

Congenital Anomalies Specially overt diabetes Cardiac defects 8.5% CNS defects 5.3% Anencepha Spina Bifida All Anomalies 18.4% Specially overt diabetes The most risk is HgA1c >10

Maternal Complications Pre-eclampsia Diabetic ketoacidosis Maternal hypoglycemia Maternal trauma Higher C/S rate Retinal disease/renal disease not affected significantly by pregnancy

Perinatal Mortality/Morbidity Miscarriage IUGR Macrosomia Birth Injury

Neonatal Morbidity and Mortality Neonatal hypoglycemia Polycythemia Hyperbillirubinemia Hypertrophic and congestive cardiomyopathy ARDS Development of obesity and diabetes in childhood

Treatment 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 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 Therapy exercise diminishes peripheral resistance to insulin cardiovascular conditioning increase affinity and receptor binding Reduction in both fasting and postprandial glucose may decrease need for other therapies in Gestational Diabetes

Insulin therapy insulin therapy is recommended when medical nutrition therapy fails to maintain self-monitored glucose at the following levels: Fasting blood glucose <95 mg/dL or 1-hour postprandial blood glucose <140 mg/dL 2-hour postprandial blood glucose <120 mg/dL

Insulin 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 Therapy (dosage) Divide the injections: 60% Regular insulin 30% before breakfast 15% before lunch 15% before dinner 40% NPH 10% before bed One study demonstrated that the 4 injection a day as compared to 2 injections a day improved glycemic control and perinatal outcome

Management Growth scans from 26-28 weeks Test 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 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 insulin

Management - Postpartum Use pre pregnancy insulin levels when on diet and monitor. Breast feeding? GDM - long term risk of NIDDM Contraception

After delivery nearly all postpartum women will become normoglycemic 1/3 to 2/3 will have recurrent GDM in subsequent pregnancies

of gestational diabetes lead to overt diabetes Over than 50% of gestational diabetes lead to overt diabetes