1. Diabetes Mellitus It is a syndrome characterized by disturbance of carbohydrates, fats, proteins, minerals and water caused by absolute or relative deficiency or decreased sensitivity of insulin either congenital or acquired.

2. Incidence  Second commonest medical disorder in pregnancy.  Generally the incidence is reported to be 1%.

3. Classification of Diabetes Complicating Pregnancy (A.C.O.G May 1986) Class Age of Onset Duration Vascular Disease Therapy AAny NoneDiet Only B> 20< 10NoneInsulin C10 – 19 NoneInsulin D< 19> 20BenignInsulin RetinopathyInsulin FAny NephropathyInsulin RAny ProfiferaiveInsulin RetinopathyInsulin HAny Heart DiseaseInsulin

4. Gestational Diabetes WHO: Diabetes in pregnancy when fasting glucose >7.9mmol or > 11 mmol/L 2hours after a 75 gm glucose load. Gestational Diabetes: Meets the WHO criteria for diabetes during pregnancy but reverting to normal after puerperium

5. Potential Diabetes  Strong family H/O diabetes  A child with birth weight of 4kg or more  A stillborn child with pancreatic islet cell hyperplasia or other congenital anomalies  Maternal weight > 90 kg.  Previous unexplained IUD or early neonatal death or recurrent abortion. Risk of developing diabetes at some age in woman’s life.

6. Pregnancy & Carbohydrate Metabolism  Pregnancy is diabetogenic.  Pregnancy alters carbohydrates metabolism but adaptation occurs and there is no effect on mother and fetus, as insulin secretion also increases.  When there is abnormal maternal response, there is increased fetal risk.  Decreased sensitivity to insulin with increasing gestation due to cortisole, estrogen, progesterone, hPL and degradation of insulin by placenta.

7. Pregnancy & Carbohydrate Metabolism (Contd.)  Early pregnancy: fasting serum insulin and Peak after glucose intake are equal to non- pregnant state.  Late pregnancy levels are higher at 28 weeks.  There is tendency to post parendial hypoglycaemia.  For normal glucose homeostasis more insulin is to be secreted adequate reserve of  cell.  Pregnancy can reveal a tendency to carbohydrate in tolerance 30%  Maternal age parity and genetics also has its effects.

8. Effects of Pregnancy on Diabetes  Lowered renal threshold for glucose.  Increase in Progesterone, H.P.L, cortisole, placental insulinase and insulin antibodies.  Insulin requirement increases steadily.  Control is difficult.  Increased tendency of acidosis ketosis  Increased risk of complications such as nephropathy and retinopathy

9. Effect of Diabetes on Pregnancy  Infertility  Spontaneous abortions  Infection  Candidiasis  Pre-eclampsia  Polyhydramnios  Pre-term labour  Macrosomia  Sudden intrauterine death  Perinatal death  Post-partum hemorrhage  Congenital malformations

10. Management Aims  To maintain euglycaemia and prevent complications.  To deliver at appropriate time.  Intensive neonatal care.

11. Diet Control  30 – 30k cal/kg body weight for the non- obese patients  25k cal/kg body weight for obese patients CHO50 – 55% Proteins 15 – 20% Fat 20 – 30%

12. Antenatal Management  Early booking.  Ultrasound in early pregnancy and at 20 weeks for anomaly scan.  Fortnight visits to estimate maternal complications and assess fetal well-being  After 24 weeks monthly ultrasound for fetal growth.  In last trimaster fetal kick count, CTG and biophysical profile.  Late pregnancy admission to hospital to plan delivery.

13. Medical Management  Insulin therapy (maintain glucose between 4 – 6 mmol/L).  Insulin requirement increases steadily.  Never use oral hypoglycaemics.  Self monitoring with glucometer.  Patients education regarding insulin injections, symptoms of hypoglycaemia, urine testing, dietary advice and to report immediately if any complication occurs.

14. Admissions To The Hospital If:  Inadequate control of Diabetes.  Condition is newly diagnosed.  An intercurrent Infection.  Any medical or obstetric complication.

15. Obstetric Management  Plan normal delivery if every thing is OK  Induction and augmentation.  Omit morning insulin.  IV insulin therapy.  Monitor uterine contractions and fetal heart rate and CTG  Adequate analgesia.  Maintain partogram.  Second stage shortened by ventous or forceps.  Supervised by the senior.  Watch for diabetic ketoacidosis.

16. Neonatal Management  Nursery care.  Blood glucose estimation.  Treatment of hypoglycaemia, hypocalcaemia and jaundice.

17. Neonatal Complications  Hypoglycaemia  Hypocalcaemia  Hypomagnecaemia  Hyperbilirubinaemia  Polycythemia  Respiratory distress syndrome  Cardimyopathy  Late inherent diabetes mellitus

18. Maternal hyperglycaemia & hyperacidaemia Fetal pancreatic hyperplasia Fetal hyperinsulinaemia Macrosomia Decreased surfactant Organomegaly Neonatal hypoglycaemia Fetal hyperglycaemia & hyperacidaemia Increased erythropoisis

19. Post-Natal Management  Blood glucose level after delivery.  Insulin requirement decreases.  Prevention of wound infection.  Breast feeding.  Post-natal checkup after 6 weeks.  Contraceptive advice.

20. Thank You