1. Diabetes in Pregnancy
L.Sekhavat MD

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

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

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

6. Some general characteristic of type1 and type 2 diabetes
Characteristic type type2
genetic ch unknown
Age at onset < >40
Habitus normal to wasted obese
Plasma insullin low to absent normal to high
Insullin therapy responsive R/resistant

7. Classification of diabetes
Class onset FBS hpp therapy
A gestational < < diet
A gestational >90 > insullin
Class age of onset duration V diseases
B > none
C none
D < > B retionopathy
F any any nephropathy
R any any P retionopathy
H any any heart D

8. 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)

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

10. 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

11. 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

12. Diagnosis: Glucosuria is common in pregnancy (Renal glycosuria)
so not diagnostic.

13. 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

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

15. 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 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.

16. 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.

17. Criteria for glucose tolerance test
The maximum blood glucose values during pregnancy:
fasting mg/ dl,
one hour mg/dl,
2 hours mg/dl,
3 hours mg/dl.
If any 2 or more of these values are elevated, the patient is considered to have an impaired glucose tolerance test.

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

19. Macrosomia -Pathogenesis

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

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

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

24. Perinatal Mortality/Morbidity
Miscarriage
IUGR
Macrosomia
Birth Injury

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

26. 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

27. Diet Therapy Goals of an Effective diet: Normoglycemia
Adequate weight gain
Good fetal health

28. 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)

29. 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

30. 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

31. 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

32. 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

33. Management Growth scans from 26-28 weeks Test AFP at 16-20 weeks
Antenatal visits – 2 weekly after 24 weeks
NST weekly (starting at wks)
Anomaly scan at weeks and
Growth scans from weeks
Delivery
Around term if insulin dependent unless complications
Diet only control as normal antenatal patients

34. When antepartum testing suggests fetal compromise, delivery must be considered.

35. Intrapartum management
IV fluids (5% dextrose) + insulin
Hourly glucose monitoring
Manage labor as normal

36. The need of insulin typically decreased after delivery so:
Avoid of NPH and used Regular insulin

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

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

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