DIABETES

IN
PREGNANCY

PRESENTER : DR LEONG YUH YANG (MD UKM)

SUPERVISOR : DR NORAZA AZMEERA
CLASSIFICATION

Diabetes and
Pregnancy
Diabetes in
Pregnancy Gestational
Diabetes
mellitus

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DEFINITION OF GDM
 GDM is defined as any degree of glucose intolerance with
onset or first recognition during pregnancy.

 The definition applies regardless of whether insulin or only

diet modification is used for treatment or whether the
condition persists after pregnancy.

 It does not exclude the possibility that unrecognized glucose

intolerance may have antedated or begun concomitantly
with the pregnancy.

Source: American Diabetes Association 2009

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 GLOBAL SCENARIO OF GDM
 GDM complicates ∼4% of all pregnancies in the U.S.,
resulting in ∼135,000 cases annually.

 The prevalence may range from 1 to 14% of pregnancies,

depending on the population studied.

 GDM represents nearly 90% of all pregnancies complicated

by diabetes.

 Deterioration of glucose tolerance occurs normally during

pregnancy, particularly in the 3rd trimester.
Source: American Diabetes Association 2009
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MALAYSIA SCENARIO OF GDM
 Diabetes prevalence had increased from 8.3% (1996) to
14.9% (2006) (NHMS III 2006).

 Diabetes admission based on type of diabetes (1994-2004):

GDM represent ≈ 30% of total admission (Ministry of Health
Malaysia 2007).

 Prevalence of GDM:
 Year Author Study Location Prevalence of GDM (%)
1993 Chan UMMC 12.7
2001 Shamsuddin et al. UKMMC 24.9
2009 Idris et al. Alor Setar 18.3

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MALAYSIA SCENARIO OF GDM (2)
Demographic Data of Patients with GDM
GDM & ETHNICITY GDM & AGE (YEARS)

3.0% 1.5%
3.0%
10.4%
50.7% 46.3%
85.1%

Malay Chinese Indian Others Less than 25 25-34 35 & above

Figures modified from Idris et al. (2009) 6

MALAYSIA SCENARIO OF GDM (3)
Demographic Data of Patients with GDM
GDM & PARITY

4.5%
19.4%

76.1%

Nulliparious Parity 1-4

Parity 5 & above

Figure modified from Idris et al. (2009) 7

PATHOPHYSIOLOGY
 levels of placental steroid and peptide hormones
(eg, estrogens, progesterone, and chorionic
somatomammotropin) rise linearly throughout the
second and third trimesters.

 insulin resistance increases and the demand for

increased insulin secretion with feeding escalates
progressively during pregnancy.

 Twenty-four–hour mean insulin levels are 50% higher

in the third trimester compared to the nonpregnant
state. Hospital Pakar Sultanah Fatimah 2011 8
 Inadequate maternal pancreatic insulin response
 fetal hyperglycemia results - manifests as recurrent
postprandial hyperglycemic episodes.
 These postprandial episodes are most significantly
accountable for the accelerated growth exhibited by
the fetus.
 Reflex hyperinsulinaemia by the fetus
– promoting excess nutrient storage  macrosomia

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Antenatally

 Identify risk factors

 Screening
 Diagnosis
 Monitoring
 Targets
 Other screening tests

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RISK FACTORS OF GDM

 BMI >27kg/m2
 Previous macrosomic baby weighing 4kg or
above
 Previous gestational diabetes mellitus (GDM)
 First-degree relative with diabetes
 Bad obstetric history
 Glycosuria at the first prenatal visit

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 Current obstetric problems
(essential hypertension, pregnancy induced
hypertension, polyhydramnios and current
use of steroids)

 Age above 25

Source : CPG MX of DM 4th edition

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 Screening
2-hour 75 g oral glucose tolerance test (OGTT)
Malaysia At least once at or more than 24 weeks
Screening at an earlier stage of gestation
depends on the degree of
suspicion and at the
physician’s/obstetrician’s request

WHO Screen high-risk population

groups during the first trimester of
pregnancy in order to detect previously
undiagnosed
diabetes mellitus.
Women at high risk who screen
negatively and average risk women
should be tested between 24 and 28
weeks of gestation

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Screening
2-hour 75 g oral glucose tolerance test (OGTT)
(Malaysia)
Fasting 6.1 / 5.6 (ADA) mmol/l

2 hours 7.8 mmol/l

Source : CPG MX of DM 4th edition

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 Screening
ADA/WHO ACOG NICE

High risk women should be screen all 16–18

screened as soon as feasible pregnant women (universal weeks if prior GDM;
screening) 24–28
weeks if risk factors

If normal, to repeat at 24 – 28
weeks

100 g glucose 100 g glucose 75 g glucose

(2 or more elevated) (2 or more elevated) 1 or more elevated
Fasting 5.3 mmol/l Fasting 5.3 mmol/l Fasting 7.0 mmol/l
1-h 10.0 mmol/l 1-h 10.0 mmol/l 2-h 7.8 mmol/l
2-h, 8.6 mmol/l 2-h, 8.6 mmol/l
(only 2 h if 75-g (only 2 h if 75-g
glucose used) glucose used)
3-h, 7.8 mmol/l 3-h, 7.8 mmol/l

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Frequency of Monitoring

 Frequency should be individualized

 Ideal to have self blood glucose
monitoring(SBGM)

 On diet control:
pre-breakfast,1 hour PPG levels
(weekly – fortnightly)

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 On insulin therapy:
premeal (breakfast, lunch, dinner) and
pre-bed glucose levels
(weekly – fortnightly).

 Once premeal glucose levels are achieved,

PPG testing is
recommended for fine-tuning of insulin dose.
Source : CPG MX of DM 4th edition
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 WHO MALAYSIA CPG
Hba1c can be falsely altered (increased or 4-6 weekly
decreased) in patients with
haemoglobinopathies/ recent
blood loss

Fructosamine Not an adequate substitute for Reflect control in the past

HbA1c, but fulfils 2-3 weeks
some of the same functions.

It may be used when there is --

coexisting haemoglobin
abnormalities falsely affecting the
level of HbA1c
(i.e. thalassemia)

- during pregnancy
for early detection of
deteriorations in glycaemic
control

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Hba1c Vs Fructosamine
Fructosamine HbA1c
(µmol) %
200 5
258 6
288 6.5
317 7
346 7.5
375 8
435 9
494 10
552 11
611 12
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Targets
Timing Level (mmol/l)

Pre breakfast 3.5 – 5.9

Pre prandial 3.5 – 5.9

Post prandial < 7.8

Source : CPG MX of DM 4th edition

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The Hyperglycemia and Adverse
Pregnancy Outcome (HAPO) Study

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Other screenings for pregnancy with
diabetes mellitus
 Detail scan at 18 – 20 weeks of gestation
 Regular US scan to monitor fetal growth and
amniotic fluid index

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Definition of Diabetes and Pregnancy

 Known case of diabetes patient if pregnant is

not known as GDM
 Diabetes mellitus and pregnancy

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Pre Conception Care

 Counseling is important
 Pregnancy should be planned
 Achieve good glycaemic control before
conception, aim for HbA1c <6.5%
 Insulin therapy may be necessary before
conception

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Measures
Joint clinic (obstetrician and physician)
Good glycaemic control preconception
and throughout pregnancy
Avoid unplanned pregnancies
Source: NICE guideline 2008-DM in Pregnancy
significance
Better control of pre morbidities
-reduces risk of complications
-Assessed by Hba1c level
( Hba1c < 6.1% reduces risk of congenital
malformation)
-risks associated with pregnancies
complicated by diabetes increase with
the duration of diabetes
-glycaemic targets, monitoring,
medications for diabetes and medications
for complications of diabetes will need to
be reviewed before and during pregnancy
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Measures Significance

Role of diet, exercise, body weight -To refer dietician

-reduce weight if preconception BMI >
27kg/m2
-medical nutrition therapy
-T.folate 5mg OD for 1st trimester

Assessment for diabetic nephropathy -Serum creatinine > 120 umol/l

-Total protein excretion > 2g/ day
-Estimated GFR < 45 ml/min
*to refer nephrologist
**if already pregnant, eGFR is not used

- Thrombophylaxis needed if excretion >

5g/day

Source: NICE guideline 2008-DM in Pregnancy 26

 Significance
Assessment for diabetic -Retinopathy tends to get worsen during pregnancy
retinopathy
- Preconception and during -assessment by digital imaging with mydriasis
pregnancy following first antenatal clinic appointment and again
at 28 weeks if the first assessment is normal.
-If any diabetic retinopathy is present, an additional
retinal assessment should be performed at 16–20
weeks.

-pre proliferative diabetic retinopathy diagnosed

during pregnancy should have ophthalmological
follow-up for at least 6 months following the birth

-should not be considered a contraindication to

vaginal birth.

Source: NICE guideline 2008-DM in Pregnancy 27

General management

 Diet control and lifestyle modification for all

-Medical Nutrition Therapy
-moderate amount of exercise
 If conservative mx fails to maintain
satisfactory blood sugar profile after 1-2
weeks

Insulin commencement
-insulin needs variable
-Requirements increase through pregnancy 28
-average
0.8 units/kg/day first trimester
1.0 unit/kg/day  second trimester
1.2 units/kg/day  third trimester

s/c Humulin R tds

s/c Humulin N on

Source :http/ /bestpractice.bmj.com

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ROLE OF ORAL ANTIDIABETIC IN
PREGNANCY
 The American College of Obstetricians and
Gynecologists has not recommended these
agents during pregnancy
 Glyburide/ Glibenclamide
 Metformin

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Timing of Delivery

 Diet control
 allow up to EDD and then IOL

 Insulin therapy
IOL at 38 weeks
If complications anticipated---ELLSCS

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Intrapartum Management

 On diet control
 manage as normal labour

 On insulin therapy
 insulin infusion sliding scale +
dextrose/potassium maintenance

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 Investigations
4 Houly urine ketone
Hourly GM
baseline BUSE and then 4 Hly

 NBM
 Maintain 1 pint D5% + 1 g KCl (100 mls/H)
 Insulin infusion sliding scale

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Post Partum (maternal)

 Insulin requirement drops immediately after

delivery by 60 -75%
 In breast-feeding, if glycaemic control is
inadequate with diet therapy alone, insulin
therapy should be continued at a lower
dose.
 In non-breast-feeding mothers, OAD agents
can be continued

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 If GDM  off insulin therapy and then
monitor GM regularly
 If pre existing diabetes  to continue pre-
pregnancy insulin/OAD
 Repeat OGTT 6/ 52 post delivery
- DM/IFG/IGT

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Post Partum (Baby)

 Blood glucose testing should be carried out

routinely in babies of women with diabetes at
2–4 hours after birth.

 should feed as soon as possible after birth

(within 30 minutes) and then at frequent
intervals (every 2–3 hours)

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 If blood glucose values are below 2.0 mmol/l
on two consecutive readings despite maximal
support for feeding, if there are abnormal
clinical signs or if the baby will not feed orally
effectively, additional measures such as tube
feeding or intravenous dextrose should be
given.

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Complications – antenatally

MOTHER FETUS

 Miscarriage  Fetal malformations

 Stillbirths  Growth accelerations/
 Pre eclampsia restrictions
 Pre term  Macrosomic baby
 Polyhydramnions
 Prone to infections
 Deterioration of diabetic
retinopathy/nephropathy

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Hospital Pakar Sultanah Fatimah 2011 40
Complications – intrapartum

MOTHER FETUS

 Polyhydramnions  Macrosomic baby

 Obstructed labour  birth injury
 Increase risk of operative  Polyhydramnions
interventions  unstable lie
 abruptio placenta
during ROM

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Complications – post partum

MOTHER FETUS

 PPH  Birth injury

 Risk of future type 2 DM  Respiratory distress
syndrome
 Hypoglycaemia
 Hypocalcemia
 Hypomagnesaemia
 Polycythaemia
 Hyperbilirubinaemia
 Risk of metabolic
syndrome
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REFERENCES
 American Diabetes Association. 2009. Diagnosis and classification of diabetes mellitus.
Diabetes Care 32 (supplement 1):88-90.
 Kulenthran, A. 2006. A practical approach to obstetric problems for the undergraduate. Third
edition. Page 87.
 Ministry of Health Malaysia. Diabetes Mellitus. The Third National Health and Morbidity Survey,
2006 (NHMS III): Executive Summary. Kuala Lumpur: Institute of Public Health (IPH), Malaysia;
2008, p. 55-7.
 Ministry of Health Malaysia. Diabetes Admission and Death by Type of Diabetes for Malaysia.
Putrajaya: Ministry of Health Malaysia; 2007, p. 18.
 Chan S. Prevalence of GDM in Malaysia. ASGODIP Report: ASEAN, 7th Congress of ASEAN
Federation of Endocrine Society, 1993.
 Shamsuddin K, Mahdy ZA, Rafiaah SI, Jamil MA. Risk Factor screening for abnormal glucose
tolerance in pregnancy. International Journal of Gynecology and Obstetric 2001;75:27-32.
 Idris N, Che Hatikah CH, Murizah MZ, Rushdan MN. Universal versus selective screening for
detection of gestational diabetes mellitus in a Malaysian population. Malaysian Family
Physician. 2009;4(2&3):83-87.
 Siti Rohana, S. 2010. Risk factors of gestational diabetes mellitus in Gombak district, Selangor-
A case-control study. Paper presented in 5th International Case-mix Conference Malaysia in Park
Royal Hotel, Kuala Lumpur, Malaysia, December 2010.

Hospital Pakar Sultanah Fatimah 2011 43

 NICE Clinical Guideline. Diabetes in Pregnancy March 2008
 Gestational Diabetes Mellitus: NICE for the
U.S.? Diabetes Care 33:34–37, 2010

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 thank you…
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