1. Josephine Carlos-Raboca, MD
DIABETES IN PREGNANCY
Josephine Carlos-Raboca, MD

2. Pregnancy is a time when serial metabolic changes in the mother are carefully regulated to provide optimum substrate to mother and fetus.

3. GOALS: Normal outcome of index pregnancy.
Decrease risk for abnormal glucose and insulin homeostasis.
Mother (before, during, after pregnancy).
Infant subsequent generations.

4. Gestational Diabetes Mellitus (GDM)
Any degree of glucose in tolerance with onset or first recognition during pregnancy.
4th International Workshop-Conference on GDM, 1998.

5. Pregestational Diabetes Mellitus
Diabetes diagnosed before pregnancy.

6. Prevalence of GDM 1 – 14% USA--- 3-5%
MMC (Asian Population) – Raboca et al 13.4%

7. Perinatal Complications:
Macrosomia
Respiratory Distress Syndrome (RDS)
Hypocalcemia
Hyperbilirubinemia
Hypoglycemia
Polycythemia

8. Congenital Malformations
Skeletal
Cardiac (septal and outflow tract lesions)
CNS and neural tube defects
Gastrointestinal Defects
Genitourinary Tract lesions

9. Maternal and Fetal Factors of Teratogenesis
Genetic Background
Teratological Period
Disturbances in Maternal-Fetal Transport
Concentrations of Metabolites
Hyperglycemia
Hyperketonemia
Somatomedin inhibitors
Arachidonic/myoinositol deficiency
Generation of free oxygen radicals
Genotoxity
Teratology 1997

10. Objectives: Recognize GDM Know how to provide nutritional plan
Know how to give insulin
Discuss preconception and postpartum care
Recognize special problems of pregestational diabetes

11. Case I 31 year old female G1 PO, Age of Gestation 20 weeks
Weight gain of 5 kg in the last 4 weeks
BMI (pre-pregnant) = 30
Height: 165 cm
actual body weight 90 kg
Family History (+) DM in mother

12. Would you recommend. testing for GDM at this
Would you recommend testing for GDM at this time or later at 24th to 28th weeks of gestation

13. Risk Factors of GDM Age > 25 years of age
Obesity – BMI > 27 kg/m2 or > 20% over DBW
Family History of diabetes in first degree relative
Ethnicity (Hispanic American, Native American, Asian American, Pacific Islander)

14. ADA 2001 ASGODIP Low risk – no test
Average risk – test at 24th-28th week
High risk – test at 1st visit if negative repeat at 24 – 28 weeks.
ASGODIP
Test at 1st visit and every trimester if negative in previous test

15. 50 gm glucose challenge test was 150 mg/dl
100 gm OGTT F=102; 1H=192; 2H=155; 3H=140
Does this patient have GDM?

16. Diagnosis of GDM 100 gm OGTT 75 gm OGTT mg/dl mml/L mg/dl mml/L1H 2H 3H
> 2 values met = GDM
ASGODIP, WHO
European Diabetes
Policy Group gm OGTT, 2H >140

17. Prescribe diet for this patient
For normal weight – 30 kcal/kg of Present BW
For overweight – 24 kcal/kg of Present BW
For morbidly obese – 12 kcal/kg Present BW
3 meals, 3 snacks, 40% of total calories = CHO
Medical Management of Pregnancy Complicated by Diabetes

18. With diet, preprandial capillary blood glucose level were 70 - 80 mg/dl,2HPPCBG 95 – 115 mg/dl
Would she require insulin?

19. ADA 2001 Insulin Required if diet fails to maintain glucose
at following levels.
Fasting whole blood glucose < 95 mg/dl (5.3 mml/L)
Fasting Plasma Glucose < 105 mg/dl (5.8 mml/L) OR
1H Postprendial whole blood glucose < 140 mg/dl (7.8 mml/L)
1H Postprendial Plasma Glucose < 155 mg/dl (8.6 mml/L)
2H Postprandial whole blood glucose < 120 mg/dl (6.7 mml/L)
2H Postprandial Plasma Glucose < 130mg/dl (7.2 mml/L)

20. How would you follow up this patient Postpartum?
What are her chances of developing diabetes?

21. 75 gm OGTT > 6 wks. postpartum
FPG every year x 3 years

22. 50% in 20 years time Predictors of DM
maternal obesity
fasting hyperglycemia
duration of time from index pregnancy

23. TRIPOD

24. Case 2
28 years old Go Po
diabetic X 1 year
desires pregnancy

25. When is the best time for patient to get pregnant?
What advise would you give her?

26. Counseling about risk of malformation with poor control
Use of low dose estrogen progestogen
contraceptive till good metabolic control is
achieved.
Goals:
HBA is 1% above normal
Preprandial CBG mg/dl ( mml/L) CPG mg/dl ( mml/L)
2H Postprandial CBG < 140 mg/dl (7.8mml/L) CPG < 155 mg/dl (8.6mml/L)

27. 4-7 X / day preprandial 1 hour or 2 hour post prandial

28. What other medical. problems should you. consider in a diabetic
What other medical problems should you consider in a diabetic pregnant?

29. Acceleration of retinopathy
Pregnancy induced hypertension
Progression of Nephropathy

30. What is your goal for glycemic control during labor?

31. 120 mg/dl
D NSS at ml/hour
CBG every 1-4 hours
Insulin infusion to start at 1unit/hour of regular insulin if CBG > 120 mg/dl

32. THANK YOU.

33. HYPERGLYCEMIA AND ADVERSE PREGNANCY OUTCOME STUDY (HAPO)
Background: Overt diabetes clearly increases the risk of adverse pregnancy outcome
What level of glucose intolerance short of diabetes increases the risk of adverse pregnancy outcome?

34. Study protocol 75gm OGTT 24-32 weeks (average 28) 0,1,2 hours
Venous plasma, enzymatic method
Results provided if FPG> 105 (5.8)
2 hour > 200 (11.1)
any value <45(2.5)
otherwise blinded to caregivers

35. Endpoints Relationship between maternal hyperglycemia and
cesarian rate
macrosomia rate
fetal hyperinsulinemia
neonatal obesity (skinfold thickness)
neonatal hypoglycemia rate
other morbidities

36. Study Protocol Routine prenatal care Daily kick count from 28 weeks
Random venous plasma glucose at weeks if > 160 mg/dl (8.9) or <45
Umbilical cord glucose and C-peptide levels
Routine neonatal care
Neonatal blood glucose at 1-2 hours of age
First feeding 2 hours after birth (may nurse earlier if desired)

37. Interim Study Report Enrollment: 9396 women Deliveries:5282
primary CS 14.5%
repeat CS %
prenatal loss 5.5/1000
Number of OGTT: 7160
Unblinded: 158 (2.2%)

38. Interim… Glucose levels FPG 10% > 90 1 hour 15% > 160

39. Summary
Preliminary data from HAPO enrollees confirm the safety of the study protocol and yielded the predicted prevalence of “lesser degrees”of glucose intolerance that should permit an adequate test of the study hypothesis.

40. Study Hypothesis
Hyperglycemia in pregnancy less severe than overt diabetes is associated with increased risk of adverse maternal fetal and neonatal outcomes that is independently related to the degree of metabolic disturbance.