1. DIABETES IN PREGNANCY Dr Chippy Tess Mathew

2. CLASSIFICATION OVERT DIABETES Seen in women known to be diabetic before the onset of pregnancy. Seen in women known to be diabetic before the onset of pregnancy. IDDM mostly IDDM mostly GESTATIONAL DIABETES

3. EFFECT OF PREGNANCY ON DIABETES Diabetogenic state Insulin requirement increases Insulin requirement increases Ketosis can occur Ketosis can occur Lowered renal threshold Lowered renal threshold Retinal changes are aggravated Retinal changes are aggravated

4. EFFECT OF DIABETES ON PREGNANCY Abortion Abortion Fetal malformations* Fetal malformations* Preterm delivery* Preterm delivery* PIH PIH Fetal macrosomia-birth trauma Fetal macrosomia-birth trauma Hydramnios Hydramnios Maternal infections Maternal infections Unexplained fetal deaths* Unexplained fetal deaths*

5. GESTATIONAL DIABETES INCIDENCE 1 % 1 %DEFINITION Carbohydrate intolerance of variable severity with onset or first detected during the present pregnancy Carbohydrate intolerance of variable severity with onset or first detected during the present pregnancy

6. RISK FACTORS FOR SCREENING FOR GDM Family history of diabetes -1 st degree relative Family history of diabetes -1 st degree relative Having a previous baby of wt >4kg Having a previous baby of wt >4kg Previous stillbirth Previous stillbirth Unexplained perinatal loss Unexplained perinatal loss Polyhydramnios Polyhydramnios Persistent glycosuria Persistent glycosuria Age> 30 Age> 30 obesity obesity

7. SCREENING TEST OGCT 24-28 weeks 24-28 weeks Cut off – 140mg% Cut off – 140mg% Procedure Procedure DEFINITIVE TEST OGTT OGTT

8. OGTT GTT GTT TIME WHOLE BLOOD PLASMA mg% Fasting90105 1 hr 165190 2 hr 145165 3 h 125145

9. White’s classification ClassOnsetTherapy A1GestFbs<105Ppbs>120Diet A2Gest>105>120insulin DurationComplication B>20yrs<10Noneinsulin C10-1910-19NoneInsulin D<10>20RetinopathyInsulin FAnyAnyNephropathyInsulin RAnyAny Prolif retinopathy insulin Hanyanyheartinsulin

10. MANAGEMENT AIMS To control diabetes To control diabetes Timing of delivery Timing of delivery Management in labor Management in labor Care of the newborn Care of the newborn

11. MANAGEMENT CONTD ANTENATAL CARE ANTENATAL CARE Maintain blood sugar at FBS <95 / PPBS< 120 mg% Regular blood checkups at 3 weeks interval (post prandial better than pre-prandial) Management options- Diet Diet exercise exercise Diet + insulin Diet + insulin

12. Contd.. Diet in pregnant diabetics Total calories- 30 -35 kcal/kg of ideal body weight Total calories- 30 -35 kcal/kg of ideal body weight Given in split meals of 3 meals and 3 snacks Given in split meals of 3 meals and 3 snacks Ideal diet – 55% carbohydrates Ideal diet – 55% carbohydrates 20% proteins 20% proteins 25% fat- < 10% saturated fat 25% fat- < 10% saturated fat

13. contd INSULIN If PPBSL >150 mg% in spite of dietary regulations start on insulin/ FBS > 105 mg% plasma If PPBSL >150 mg% in spite of dietary regulations start on insulin/ FBS > 105 mg% plasma Plain insulin in 3 divided doses pre meals Optimize the insulin dose Sometimes combination of lente and regular OHA usually not used –more chance of fetal hyperinsulinemia/?fetal defects Trials on glyburide

14. CONTD OBSTETRIC MANAGEMENT In general, women with gestational diabetes who do not require insulin seldom require early delivery or other interventions. Well controlled diabetes delivery at 40 weeks Well controlled diabetes delivery at 40 weeks ACOG 2001 suggested that cesarean delivery should be considered in women with a sonographically estimated fetal weight of 4500 grams or more.

15. Contd.. Induction of labor with Oxytocin or after priming with prostaglandin Induction of labor with Oxytocin or after priming with prostaglandin Prophylactic antibiotics given Prophylactic antibiotics given Strictly monitor in labor Strictly monitor in labor

16. CONTD.. Women who require insulin therapy for fasting hyperglycemia, however, typically undergo fetal testing and are managed as if they had overt diabetes. POSTPARTUM CONSEQUENCES Women diagnosed with gestational diabetes undergo evaluation with a 75-g oral glucose tolerance test at 6 to 12 weeks after delivery. Women whose 75-g test is normal should be reassessed at a minimum of 3-year intervals

17. CONTD.. Patients with GDM don’t require insulin after delivery.antibiotics given. CONTRACEPTION Low-dose hormonal contraceptives may be used safely by women with recent gestational diabetes.

18. OVERT DIABETES DEFINITION Women known to have diabetes before pregnancy is called pregestational or overt diabetes.

19. contd DIAGNOSIS OF OVERT DIABETES DURING PREGNANCY Women with high plasma glucose levels, glucosuria, and ketoacidosis women with a random plasma glucose level greater than 200 mg/dL plus classic signs and symptoms such as polydipsia, polyuria, and unexplained weight loss or Fasting plasma glucose of 126 mg/dL

20. Effects Fetal effects Fetal effects Abortion/ PTL / malformation / IUD / hydramnios Neonatal effects Neonatal effects respiratory distress / hypoglycemia /hypocalcaemia /hyperbilirbinemia /macrosomia / cardiac hypertrophy /inheritance of diabetes

21. Contd.. Maternal effects Nephropathy Nephropathy Retinopathy Retinopathy Neuropathy Neuropathy Pre eclampsia Pre eclampsia Ketoacidosis Ketoacidosis Infection Infection

22. MANAGEMENT PRECONCEPTION To prevent early pregnancy loss as well as congenital malformations in infants of diabetic mothers ADA has defined optimal preconceptional glucose control using insulin to include selfmonitored preprandial glucose levels of 70 to 100 mg/dL and postprandial values of less than 120 at 2 hours. Hemoglobin A1 or A1c measurement -- circulating glucose for the past 4 to 8 weeks, is useful to assess early metabolic control. The most significant risk for malformations is with levels exceeding 10%

23. Contd… Folate, 400 ug/day, is given periconceptionally and during early pregnancy

24. Contd.. Obstetric management maternal serum alpha feto proteins at 16 – 20 weeks maternal serum alpha feto proteins at 16 – 20 weeks Target USG at 18 - 20 weeks Target USG at 18 - 20 weeks Fetal echo at 24 – 26 weeks to r/o cardiac anomaly Fetal echo at 24 – 26 weeks to r/o cardiac anomaly Regular ANC- Regular ANC- Hospitalise if poor control of diabetes Hospitalise if poor control of diabetes

25. Contd.. Ante partum surveillance –biophysical profile / NST -start at 32 weeks Ante partum surveillance –biophysical profile / NST -start at 32 weeks TIMING OF DELIVERY In overt diabetes pregnancy terminated at 37 – 38 weeks if he fetus is otherwise normal. In all other situations TOP is based on fetal well-being/POG/ neonatal facilities

26. Contd.. Cesarean section is performed if baby is large or if there are other obstetrical indications such as fetal distress. Cesarean section is performed if baby is large or if there are other obstetrical indications such as fetal distress.

27. contd… Management in labor Omit morning dose of insulin- do FBS, urine sugar and ketone. Omit morning dose of insulin- do FBS, urine sugar and ketone. i/v saline/ dextrose with insulin During labor the woman should be hydrated adequately -i/v saline/ dextrose with insulin IOL with Oxytocin / PG IOL with Oxytocin / PG Constant insulin infusion by calibrated pump is most satisfactory.

28. Contd.. Capillary or plasma glucose levels should be checked 2 hourly and regular insulin should be administered accordingly. Antibiotics Antibiotics Strict monitoring/ ARM in active labor Strict monitoring/ ARM in active labor

29. Contd.. PUERPERIUM PUERPERIUM Dose of insulin required decrease --and so adjusted according to blood sugar levels.. CONTRACEPTIONBarrier.