Diabetes in Pregnancy

Introduction

• Affects up to 3% of all pregnancies

• 90% due to gestational diabetes

• Perinatal mortality around 2-5%

Pathophysiology• Normal pregnancy:• glucose homeostasisis affected by increased

estrogen, progesterone &HPL which lead to B cell hyperplasia and increased insulin secretion. Lower maternal fasting glucose levels.

• Increased: glycogen deposition, fatty acids, triglycerides & ketones

• Decreased: circulating amino acids

• Maternal response is to increase protein catabolism and accelerate renal gluconeogenesis

Pathophysiology• Normal pregnancy:• lipids become an important fuel as pregnancy advances, fat

storage increases.

• With the rise of HPL, lipolysis is stimulated in adipose tissue. The release of glycerol and fatty acids reduces both maternal glucose and amino acid utilization and sparing them for the fetus

• This action of HPL is responsible for the “diabetogenic state of pregnancy”along with increased cortisol. Estrogen and progesterone.

• Fetal glucose level is similar to the mothers by facilitated diffusion, insulin dose not cross the placenta. Persistant elevated levels of glucose will stimulate the pancreas resulting in β-cell hyperplasia and fetal hyperinsulinemia

Maternal classification and risk assessment

Modified white classification of pregnant diabetic women

class

Onset age duration

Vascular dis Insulin need

A1 Any any 0 0

A2 any Any 0 +

B >20 <10 0 +

C 10-19 10-19 0 +

D <10 >20 + +

F Any Any + +

R Any Any + +

T Any Any + +

H any Any + +

Gestational diabetes

Pre-gestational diabetes

Effect of pre-existing diabetes on pregnancy

Pre-eclampsia and eclampsia Diabetic ketoacidosis Worsening pre-existing nephropathy Worsening pre-existing retinopathy Infection: genital > monilial Polyhydramnios/ oligohydramnios Cesarean delivery Post partum hemorrhage mortlaity

Fetal Morbidity and Mortality

1-miscarriage2-teratogenecity , drug related3- Congenital Malformation

Caudal regressionNeural tube defectCVS

4- Macrosomia / IUGR5-Fetal Death

Diabetes Mellitus and Gestational Diabetes

Summery of Management Options1- Pre-Pregnancy Explain general risks and management of

diabetes in pregnancy Evaluate any additional risks with appropriate

specialist referral (e.g. renal, ophthalmologic) Optimize blood glucose control Discuss effective contraception until good glucose

control (avoid estrogen containing-preparations with vascular disease)

Folate supplementation(4-5 mg daily) for at least 2 months before or during first trimester

B- prenatal

1- Detection of Diabetes in Pregnancy

2- Treatment of the Insulin-Dependent Patient

3- Fetal Surveillance

4- Management of Gestational Diabetes

Pregnancy is diabetogenic1. Occurrence of GDM2. Unmasking latent DM3. Worsening of existing DM4. Shift of GTT upward5. Need of more insulin in

pregnancy6. Need of less insulin after

labour7. High female to male ratio

Now we screen all gravid womenAt bookingAt 28 weeks

High risk patientsPositive family history (mother, father,

siblings)Maternal obesity (BMI > 30 kg/m2, trunkal

obesity)Aged gravidaPoor obstetric historyPersistent glycosuria MacrosomiaHydramnios

Screening for DM

high risk patients should undergo glucose testing

A fasting plasma glucose level >125mg/dL or a casual plasma glucose >200 mg/dL meets the threshold for the diagnosis of diabetes

In the absence of this degree of hyperglycemia, evaluation for gestational diabetes mellitus in women with average or high-risk characteristics is by glucose tolerance test .

Risk assessment

Methods of screening

Method Sensitivit

y

Specifici

ty

Family history

Random glucose

Glucose load

(WHO)

Glycated Hb

50 %

40 %

79 %

40 %

66 %

90 %

83 %

90 %

Fasting and 2 hours postprandial venous plasma sugar during

pregnancy.

Border line indicates glucose tolerance test.

125-200 mg/dl.100-125 mg/dl

Diabetic>200 mg/ dl.>125 mg/ dl

Not diabetic< 145mg/ dl.<100 mg/dl

Result2h postprandial

Fasting

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 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.

130 - 140 mg/dl

3 hour Oral glucose tolerance test

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.

Giving 75 gm (100 gm by other authors) glucose in 250 ml water orally

Criteria for glucose tolerance test:The maximum blood glucose values during pregnancy:- fasting 90 mg/ dl, - one hour 165 mg/dl,- 2 hours 145 mg/dl, - 3 hours 125 mg/dl.If any 2 or more of these values are elevated, the patient is considered to have an impaired glucose tolerance test.

Team care

The patient is the most important member of the team by her compliance

The patient

Control of diabetes in pregnancy

Diet Exercise

Insulin

Antenatal careRegular visitsTight glucose control

Pre-meal glucometery

Diet and insulinMedical conditionComplications

MedicalObstetric

Fetal assessmentMaturityWellbeing

Initial visit1. Careful dating

2. White’s staging

3. Obstetric history

4. Funduscopy **

5. Blood pressure

6. Urinalysis & culture **

7. HbA1c **

3- Fetal Surveillance

Ultrasound scan

CTG

Biophysical Profile

Starting 32 week gestation, weekly

Diet control25-35 kcal/kg ideal wt

50% carbohydrate20% protein30% fat Adjust for work

3 meals and 3 snacksTest for sugar before mealsArtificial sweeteners, high-fiber, low

salt diet

What worsen diabetes

1. Infection

2. Lack of exercise

3. Drugs

4. Stress of life

5. Smoking

Your aim is not weight reduction, but proper glycemic control

Proper weight gain is 1 Ib/mo in first half & 1 Ib/wk in second half

Exercise for diabeticsAdvantage

Exercising muscle utilizes glucose without insulin

Synergistic with insulin

Improves metabolic control

Improve the mood and well-being

DisadvantageExercise-induced

hypoglycemiaVigorous exercise

worsen metabolic control precipitates lactic acidosis

Strenuous exercise diverts blood to the muscles; it can cause IUGR

Regular exercise improves the outcome of pregnancy in diabetics but strenuous one disproves it

Contraindication for exercise in pregnant diabetics

MedicalCVS diseases

Retinopathy

Nephropathy

ObstetricPIH

Over distended uterus

History of premature labour

Insulin therapyHuman insulin (Actrapid, Initard 1/1,

Mixatard 2/1)Intermittent dosing

Twice daily doses (Lewis) Before breakfast 2/3 dose (NPH: Regular 2:1)Before dinner 1/3 dose (NPH: Regular is 1:1)

Thrice daily doses (Jovanovic) Before breakfast 2/3 dose (NPH: Regular 2:1)Before lunch 1/6 dose (Regular)Before dinner 1/6 dose (NPH)

Continuous insulin infusion pump (CII pump)

Daily dosage is calculated according to gestational age, severity of diabetes and actual body weight.

2- Prenatal Screen for gestational diabetes ideally in all

pregnancies ( controversy over which test and whether just at 24-28 weeks): OGTT is diagnostic test

Regular capillary glucose series Avoid oral hypoglycemic agent Appropriate diet Amend insulin regimen to keep capillary

glucose values as normal as possible Instruct partners/relatives in glucagon use for

hypoglycemic attacks

2- Prenatal Baseline renal and possibly cardiac function Randomized trials of low dose aspirin in women

with vascular disease are awaited Regular ophthalmologic review Monitor for hypertensive disease Fetal surveilance - Normality -Growth -Well-being(NST,BPS) -

Umbilical artery blood flow Gestational diabetics: initially try to control with

diet rather than insulin; otherwise, as for established diabetics

Vaginal Spontaneous or inducedShoulder dystocia develops at lower birth

weights

Caesarean sectionPlanned Urgent

Neonatologist should be available

DeliveryInduction of labor at 38 weeks, as PNM

starts to increase steadily afterward, for IDDM and GDM on treatment

If GDM on diet control with no complication allow till term

Timing of delivery depends on

Mother FetusVascular diseaseGlycemic controlObstetric history

MaturityEFWBPP

Intrapartum careTwo infusion sets

G.I.K. 10% glucose + 10 I.U insulin + 10 mmol K

1-2 hourly blood sugar check and infusion adjustment according to level

keep the blood sugar 90-120 mg/dlCTG during labor & delivery

Post-partum careReadjust the dose of insulinEncourage breast feedingReassess the glycemic statusGive a suitable contraceptiveWeight reduction to delay

NIDDMFollow-up for NIDDM

Hypoglycemia

Respiratory Distress Syndrome

Hypocalcemia

Hypomagnesemia

Jaundice

Requiring admission to nursery for monitoring and Rx