1. DIABETES IN PREGNANCY DR. SALWA NEYAZI CONSULTANT OBSTETRICIAN GYNECOLOGIST PEDIATRIC & ADOLESCENT GYNECOLOGIST

2. PHYSIOLOGICAL CHANGES OF GLUCOSE METABOLISM IN PREGNANCY  Pregnancy is a state of insulin resistance & relative glucose intolerance  This is due to placental production of anti- insulin hormones : hPL, cotisol, and glucagon  FBS   Postprandial glucose ↑ ↑  Insulin production ↑ ↑ 2 folds in N women  Insulin requirements ↑ ↑ in diabetic women   renal threshold for glucose  glycosuria

3. DIAGNOSIS OF GESTATIONAL DIABETES MELLITUS  Women in whom the criteria of DM are met in pregnancy  include a gp of diabetics who were undiagnosed before pregnancy  FBS  > 7 mmol/L on 2 occasions  Or  RBS  > 11.1 mmol/L on 2 occasions  Borderline cases  GTT  DM is Dx if FBS  > 7 mmol/L or 2 hrs > 11.1 mmol/L  Impaired glucose tolerance  2hrs G 8-11 mmol/L with a N FBS

4. EFFECT OF PREGNANCY ON DM  Insulin requirement ↑ ↑ in pregnancy reaching a max at term & being at least 2 X the pre- pregnancy requirement  Pt with diabetic nephropathy  deterioration in renal function with  in creatinine clearance & proteinuria  this deterioration in renal function is usually reversed after delivery

5. EFFECT OF PREGNANCY ON DM  2 X ↑↑ in retinopathy  rapid improvement in glycemic control  worsening retinopathy due to ↑↑ retinal blood flow  ↑↑ icidence of hypoglycemia  Ketoacidosis is rare unless associated with hyperemesis, infections, tocolytic & corticosteroid Rx

6. EFFECTS OF DM ON PREGNANCY  ↑↑ incidence of congenital abnormalities  The risk is related to the degree of glycemic control  5% with Hb A1c > 8%  25% with Hb A1c > 10% with ↑↑ risk of abortions  Sacral agenesis, congenital heart defects, skeletal abnormalities & neural tube defects  Perinatal & neonatal mortality ↑↑ 2-4 X  Unexplained IUFD at term / more in macrosomic babies

7. EFFECTS OF DM ON PREGNANCY  Macrosomia  the incidence is ↑↑ with poor diabetic control  not eliminated by tight control  associated with ↑↑ risk of operative delivery, birth trauma, & shoulder dystocia  Hyperglycemia  fetal polyuria  polyhydramnios  PROM, preterm delivery  Prematurity pose an added problem as pulmonary surfactant production is slightly delayed in babies of diabetic mothers

8. EFFECTS OF DM ON PREGNANCY  Postnatally, babies are at risk of hypoglycemia & jaundice  ↑↑ risk of PET especially in pt with pre-existing hypertension & nephropathy where it reaches almost 30%

9. MANAGEMENT  Multidisciplinary team including obstetricians, endocrinologists, dieticians, & midwives  optimize outcome  Preconception councelling  To achieve normoglycemia as far as possible  FBS < 5 mmol/L  PP < 7.5 mmol/L  Dietary advice on a low sugar, low fat, high fiber diet  Regular capillary glucose series (7 point profile)  Combined short acting & intermediate acting insulin

10. MANAGEMENT  Regular assessment of Hb A1c  Ophthalmologic examination & Rx of retinopathy  Regular monitoring of renal function in Pt with diabetic nephropathy  Detailed U/S screening for congenital malformations in the 2 nd trimester (20wk)  to exclude NTD, sacral agenesis, & cardiac defects  Frequency of antenatal visits needs to be individualized

11. ANTENATAL FETAL SURVELANCE  ↑↑ incidence of IUFD justify close monitoring in the 3 rd trimester  Serial U/S biometry  to detect macrosomia, hydramnios, IUGR  Umbilical artery doppler in Pt with IUGR  CTG  BPP

12. LABOR & DELIVERY  With well controlled DM with appropriately grown fetus  pregnancy is allowed to proceed till term  When there is concern about fetal well being or macrosomia  the risk of IUFD must be weighed against the risk of RDS  ½ of the babies are >90 th centile  CS rate of 50-60%  Intrapartum care should focus on meticulous diabetic control & continuous electronic fetal monitoring. Blood glucose should be 4-7 mmol/L achieved by 5% Dextrose infusion & insulin infusion

13. LABOR & DELIVERY  After delivery mternal insulin requirement rapidly returns to the pre-pregnancy level  If abnormal glucose tolerance was 1 st Dx in pregnancy  GTT should be done 6 wk post- partum

14. Gestational diabetes  Carbohydrate intolerance of variable severity 1 st Dx in pregnancy  will include women with undiagnosed DM  There is no consensus on the optimal screening for GDM  Universal screening  Screening pt > 25 Y  Clinical risk factors: previous GDM, family Hx, previous macrosomic baby, previous unexplained IUFD, obesity, glycosuria, polyhdramnios, LGA in current pregnancy  The timing of screening also contraversal

15. Implications of GDM  ↑ perinatal mortality & morbidity but to a lesser extent than DM  No ↑ risk of congenital malformations  Macrosomia is the main risk factor for adverse outcome  ↑ risk of operative deliveries  ↑ incidence of PET  Women with GDM have a significantly ↑ risk of DM later in life (50% over 10-15 Y)

16. Management  Combined diabetic obstetric approach  Initial approach by dietery modification including caloric reduction in obese Pt  The need for insulin is manifested by persistent PP hyperglycemia (7.5-8 mmol/l) or persistant fasting hyperglycemia (>5.5-6 mmol/L)  Regular U/S scans to assess fetal growth & well being  Early delivery is not advised unless there is a complicating factor

17. Management  Intrapartum management  Depends on whether the pt is on diet control alone or on insulin  Pt on insulin need to be on sliding scale  Following delivery insulin must be discontinued  GTT should be done 6 wks postpartum

18. MACROSOMIA  Fetal Wt >4000-4500 gm regardless of gestational age  Risks of macrosomia include  shoulder dystocia, erb’s palsy,  5 min APGAR score, admission to NICU & obesity later in life  Risk factors for the development of macrosomia:  prior HX of macrosomia  ↑ maternal pre-pregnancy Wt  excessive Wt gain in pregnancy  multiparity

19. MACROSOMIA (risk factors)  male fetus  gestational age >40wks  race  maternal birth Wt  maternal Ht  maternal age  +ve GCT with-ve GTT  GD, DM

20. MACROSOMIA  How macrosomic infants of diabetic mothers differ from those without diabetes?  How is macrosomia predicted?  How does it affect the management of labor & delivery?  When is CS recommended for macrosomia?  What is the role of induction of labor?