1. DIABETES IN PREGNANCY
AHMED ABDULWAHAB

2. CLASSIFICATION:
INSULIN DEPENDANTDIABETES.I.D.D
Diagnosis before pregnancy ,patient already in insulin usually young with little or no insulin.
Non insulin dependant DM ,patient on oral hypoglycemic agents

3. STANDARD TEST FOR DIAGNOSIS:
75 gm of glucose –orally after over night fast.
Fasting < than 6 mmol one hour less than 11mmol . 2hour < hour should back to fasting level

4. GESTIONAL DIABETES:
Diabetes occurs during pregnancy , will come to normal after delivery:
INDICATION OF GTT;
High GCT more than 7.8 mmol
Potential diabetes.
Unexplained IUFD
History of congenital anomalies

5. Glucose in urine more than twice
Maternal weight more than 90 KG
Previous big babies

6. WHY?
Pregnancy has diabetogenic effect .
There is a decreased sensitivity of insulin due to antagonizing effect by cortisone –estrogen –progesterone HPL , and degradation of insulin by placenta

7. GLUCOSE AND INSULIN RELATIONSHIP IN MOTHER AND FETUS.
Glucose cross placenta by facilitated diffusion.
Fetal pancreatic beta cell hypertrophy will increase the release of insulin.
Insulin is a potent stimulus to growth .

8. EFFECT OF PREGNANCY ON DIABETES.
Difficult to control
Lowered renal threshold and diminished sensitivity to insulin
Retinopathy. Need careful ophthalmic assessment , there is increase prolifrative retinopathy
Nephropathy may be confused with hypertension and edema ,assess renal function

9. EFFECT OF DIABETES ON PREGNANCY.
Abortion.
Infection UTI fungal infection.
Pre eclampsia
Polyhydramnios
Prenatal death RDS – anomalies
Macrosomia.

10. Cont.
Congenital anomalies –poor control at early pregnancy, mainly CVS and CNS.
Caudal regression syndrome is specific.
Lung maturity, fetal insulin antagonize the effect of cortisone on surfactant .

11. MAAGEMENT
Combined care ,obstetrician and physician.
Without complication wait till 40 weeks
Food plan. 50% carbohydrate 20% protein 20% fat , fiber
Majority need insulin –short acting 2 or 3 doses may be required ..
Doses rise progressively with advancing pregnancy.
Oral hypoglycemic never to be used
Keep FBS between h postprandial below 8 mmol
HbA1C REFLECT average plasma glucose normal 6%

12. OBSTETRIC CARE
Early pregnancy control reduce anomalies.
Late control reduce PET polyhydramnios and macrosomia .
Early booking for accurate dating.
Detailed USS ANOMALIES WEEKS
Alpha fetoprotein
Regular follow up

13. DELIVERY.
Normal pregnancy wait 40 weeks
DM alone is not an indication for caesarian section
Induction of labor IOL Insulin infusion , hourly checking of blood sugar (sliding scale)
Close fetal heart monitoring .

14. POST PARTUM CARE .
Insulin requirement fall rapidly after delivery
Infant of diabetic mother has the following problems.
Over weight, plethoric ,RDS, hypoglycemic.
Hyperbilurbinaemia hypocalcaemia.