1. Diabetes in pregnancy Dr. Lubna Maghur MRCOG

2. Diabetes is a common medical disorder effecting 2-5% of pregnancies. Diabetes is a common medical disorder effecting 2-5% of pregnancies. It is associated with maternal morbidity and mortality. It is associated with maternal morbidity and mortality. Good antenatal care and blood sugar control is associated with major reduction in its complications. Good antenatal care and blood sugar control is associated with major reduction in its complications.

3. Objectives To understand the changes of glucose metabolism in pregnancy. To understand the changes of glucose metabolism in pregnancy. Te be able to list the different methods used to diagnose diabetes in pregnancy. Te be able to list the different methods used to diagnose diabetes in pregnancy. To be able to define gestational diabetes. To be able to define gestational diabetes. To list the effect of diabetes on pregnancy. To list the effect of diabetes on pregnancy. To list the effect of pregnancy on diabetes. To list the effect of pregnancy on diabetes. To understand the management of diabetes in pregnant women. To understand the management of diabetes in pregnant women.

4. Physiological changes In normal pregnancy fasting blood sugar is slightly reduced. In normal pregnancy fasting blood sugar is slightly reduced. In normal pregnancy renal threshold for glucose increases leading to glucoseurea. In normal pregnancy renal threshold for glucose increases leading to glucoseurea. Pregnancy is a state of insulin resistance and glucose intolerance. Pregnancy is a state of insulin resistance and glucose intolerance. This is due to increase in anti-insulin hormones. This is due to increase in anti-insulin hormones. The insulin resistance increases with increased gestation. The insulin resistance increases with increased gestation.

5. This does not effect normal pregnancy as insulin levels will increase. This does not effect normal pregnancy as insulin levels will increase. Patients with relative glucose intolerance will develop gestational diabetes. Patients with relative glucose intolerance will develop gestational diabetes. Patients who are established diabetics may require increase dosage of their medication. Patients who are established diabetics may require increase dosage of their medication.

6. Definition Complex disease characterized by Carbohydrate intolerance of variable degree of severity. Complex disease characterized by Carbohydrate intolerance of variable degree of severity.

7. Types of diabetes in pregnancy Type I( IDDM): There is absolute insulin deficiency, usually effects children and young adults. Type I( IDDM): There is absolute insulin deficiency, usually effects children and young adults. Type II diabetes(NIDDM): There is increase insulin resistance, usually effects adults. Type II diabetes(NIDDM): There is increase insulin resistance, usually effects adults. Gestational diabetes: Diabetes occurring for the first time during pregnancy. Gestational diabetes: Diabetes occurring for the first time during pregnancy.

8. Screening for diabetes in pregnancy History and examination : risk factors. History and examination : risk factors. Glucose urea. Glucose urea. Random blood sugar. Random blood sugar. Fasting blood sugar. Fasting blood sugar. Oral GGT Oral GGT When to screen? When to screen?

9. Risk factors for gestational diabetes Previous history of diabetes. Previous history of diabetes. Positive family history. Positive family history. Age and parity. Age and parity. History of IUFD. History of IUFD. History of recurrent abortion. History of recurrent abortion. History of Large size babies (>4Kg). History of Large size babies (>4Kg). Polyhydramnious. Polyhydramnious. Obesity. Obesity.

10. Diagnosing gestational diabetes Should be performed in all high risk patients or if screening is positive. FBS > 100mg/dl FBS > 100mg/dl Glycosylated haemoglobin????? Glycosylated haemoglobin????? GTT. GTT.

11. How to perform GTT Normal diet for 3 days. Normal diet for 3 days. Over night fasting 8 – 12 hours. Over night fasting 8 – 12 hours. Obtain fasting blood sample. Obtain fasting blood sample. Drink 75 g glucose solution within 5 min. Drink 75 g glucose solution within 5 min. Obtain blood sample 2 hour later. Obtain blood sample 2 hour later.

12. Blood sugar results Fasting blood sugar should be < 100mg/dl. Fasting blood sugar should be < 100mg/dl. Blood sugar at 2 hours should be <140mg/dl. Blood sugar at 2 hours should be <140mg/dl. Impaired glucose if 2 hours level 140- 200mg/dl. Impaired glucose if 2 hours level 140- 200mg/dl. Diabetic if fasting >100 and 2 hours level >200mg/dl Diabetic if fasting >100 and 2 hours level >200mg/dl

13. Effect of pregnancy on diabetes Insulin requirement increases 2 folds especially between 28-32 weeks. Insulin requirement increases 2 folds especially between 28-32 weeks. Hyperemesis and infection increase the risk of diabetic ketoacidosis. Hyperemesis and infection increase the risk of diabetic ketoacidosis. Nephropathy, retinopathy and neuropathy may deteriorate in pregnancy. Nephropathy, retinopathy and neuropathy may deteriorate in pregnancy.

14. Effects of diabetes on pregnancy Maternal; Increase risk of pre-eclampsia. Increase risk of pre-eclampsia. Increase risk of infection; UTI, candidiasis, and postpartum. Increase risk of infection; UTI, candidiasis, and postpartum. Increase cesarean section rate. Increase cesarean section rate.

15. Fetal complications Early pregnancy: Early pregnancy: Miscarriage, congenital abnormalities, Late pregnancy: Late pregnancy: Macrosomia, polyhydramnious, unexplained intrauterine fetal death, IUGR, increase perinatal mortality, shoulder dystocia. Neonatal: Neonatal: Hypoglycemia, hypomagnisemia, hypokalemia, hyperbilirobinemia, RDS, polycythemia.

16. Congenital anomaly and diabetes Hyperglycemia is teratogenic. Hyperglycemia is teratogenic. Chromosomal abnormalities are not increased. Chromosomal abnormalities are not increased. The commonest abnormality is congenital heart disease and neural tube defects. The commonest abnormality is congenital heart disease and neural tube defects. Other abnormalities may occur. Other abnormalities may occur. Sacral agenesis is characteristic but rare Sacral agenesis is characteristic but rare

17. Fetal macrosomia Fetus >90 centile. Fetus >90 centile. Occurs due to maternal hyperglycemia. Occurs due to maternal hyperglycemia. May lead to prolonged labour, increase risk of instrumental delivery, increase risk of C/S, and shoulder dystocia. May lead to prolonged labour, increase risk of instrumental delivery, increase risk of C/S, and shoulder dystocia. Large babies are more likely to suffer from hypoglycemia. Large babies are more likely to suffer from hypoglycemia.

18. Management of diabetes in pregnancy Pre-pregnancy counseling. Pre-pregnancy counseling. Antenatal care. Antenatal care. Controlling blood sugar. Controlling blood sugar. Management of diabetes in labour. Management of diabetes in labour. Postpartum management. Postpartum management.

19. Pre-pregnancy counseling Most important in the management of diabetes. Most important in the management of diabetes. Good diabetic control is essential before pregnancy to prevent early complications. Good diabetic control is essential before pregnancy to prevent early complications. Diabetic control is measured by glycosylated Hb. Diabetic control is measured by glycosylated Hb. Folic acid to reduce NTD 3 months before. Folic acid to reduce NTD 3 months before. If uncontrolled use contraception. If uncontrolled use contraception. If on oral hypoglycemic change to insulin. If on oral hypoglycemic change to insulin. Advice healthy diet and life style. Advice healthy diet and life style. May advice against pregnancy in some cases. May advice against pregnancy in some cases.

20. Antenatal care. Should be managed in a joint clinic. Should be managed in a joint clinic. Early booking. Early booking. Anomaly scan at 18-22 weeks. Anomaly scan at 18-22 weeks. Frequent antenatal follow up with U/S to monitor fetal growth. Frequent antenatal follow up with U/S to monitor fetal growth. Check blood pressure and urine albumen at every visit. Check blood pressure and urine albumen at every visit. Avoid delivery before 38 weeks unless other complications. Avoid delivery before 38 weeks unless other complications. Pregnancy should not go beyond 40 weeks. Pregnancy should not go beyond 40 weeks.

21. Controlling blood sugar. Good control of blood sugar improves maternal and fetal complications. Good control of blood sugar improves maternal and fetal complications. Good diet control but avoid starvation (3 meals and 3 snacks). Good diet control but avoid starvation (3 meals and 3 snacks). Patients with newly diagnosed with gestational diabetes is can be first treated with diet control. Patients with newly diagnosed with gestational diabetes is can be first treated with diet control.

22. The aim is to keep blood sugar near normoglycemia (<100mg/dl fasting and 140mg/dl post-brandial). The aim is to keep blood sugar near normoglycemia (<100mg/dl fasting and 140mg/dl post-brandial). Usually blood sugar is controlled with 2 doses of mixed inslulin. Usually blood sugar is controlled with 2 doses of mixed inslulin. Better control is achieved with 4 doses. Better control is achieved with 4 doses. Self control is ideal. Self control is ideal. The patient may need to be admitted to hospital for blood sugar control at some stage. The patient may need to be admitted to hospital for blood sugar control at some stage.

23. Management of diabetes in labour. C/S is for obstetric indications. C/S is for obstetric indications. Patient is kept NPO. Patient is kept NPO. Dextrose infusion is set up. Dextrose infusion is set up. Insulin infusion at rate of 2-6 units per hour. Insulin infusion at rate of 2-6 units per hour. If patient is having a cesarean section morning dose of insulin is omitted. If patient is having a cesarean section morning dose of insulin is omitted. Continous electronic fetal monitoring. Continous electronic fetal monitoring.

24. Postpartum management. Reduce the insulin to pre-pregnancy dose or half the pregnancy dose. Reduce the insulin to pre-pregnancy dose or half the pregnancy dose. Breast feeding mothers have lower insulin requirements. Breast feeding mothers have lower insulin requirements. If delivered by C/S continue insulin infusion until the patient is eating then retern to subcutanous insulin. If delivered by C/S continue insulin infusion until the patient is eating then retern to subcutanous insulin.

25. Patients with gestational diabetis may improve after delivery but the have increase risk of developing GD in next pregnancies and NIDDM later in life (40-60%). Patients with gestational diabetis may improve after delivery but the have increase risk of developing GD in next pregnancies and NIDDM later in life (40-60%).

26. Summary The ultimate goal of our management is ….. Healthy mother and healthy baby