DIABETES

MELLITUS
TYPES OF DIABETES
 CLASSIFICATION DURING PREGNANCY
• Diabetes before pregnancy
PREGESTATIONAL OR OVERT • Diabetes diagnosed
during pregnancy
GESTATIONAL DIABETES
AMERICAN DIABETES ASSOCIATION (ADA)
 PREGESTATIONAL DIABETES
Fasting <100 mg/dL 110-125 ≥ 126
DIAGNOSIS plasma
glucose
mg/dL mg/dL

75 g OGTT
2nd hour
<140 mg/dL 140-199 ≥ 200
plasma mg/dL mg/dL
Symptom
s of
diabetes
mellitus
and
• Polydipsia, polyuria and plasma
unexplained weight loss glucose
• (without
regard to
time of
last meal)
> 200
mg/dL
PREGESTATIONAL DIABETES

RISK FACTORS FOR IMPAIRED

CARBOHYDRATE METABOLISM

• Strong familial history of

diabetes
• Prior delivery of a large
newborn
• Persistent glucosuria
• Unexplained fetal losses
 IMPACT ON PREGNANCY

Spontaneous Abortion Respiratory Distress Syndrome

Preterm Delivery Hypoglycemia

Cardiac Malformations Hypocalcemia

Altered Fetal Growth Hyperbilirubinemia and Polycythemia

Unexplained Fetal Demise Cardiomyopathy

Hydramnios Long-term Cognitive Development

Inheritance of Diabetes
 FETAL EFFECTS

SPONTANEOUS ABORTION PRETERM DELIVERY

• HbA1c >12% • Overt diabetes – undisputed
• Preprandial glucose >120 risk factor
mg/dL
 FETAL EFFECTS

MALFORMATIONS ALTERED FETAL GROWTH

• Cardiovascular • May result from congenital
• Caudal regression malformations or from substrate
sequence deprivation
• Increased HbA1c • Maternal hyperglycemia  fetal
hyperinsulinemia  excessive
somatic growth
• Glucose chronically exceed 130
mg/dL
•

•
 FETAL EFFECTS

UNEXPLAINED FETAL DEMISE HYDRAMNIOS

• Poor glycemic control
• Elevated lactic acid levels
• Maternal ketoacidosis
• Placental insufficiency
• Women with hypertension and
pregestational diabetes
• Women with advanced diabetes
and vascular complications
• AFI >24 cm in the 3rd
trimester
• Elevated HbA1c
• Fetal hyperglycemia 
polyuria
 NEONATAL EFFECTS

RESPIRATORY DISTRESS HYPOGLYCEMIA

SYNDROME
• Gestational age is the most • Rapid drop in plasma glucose
significant factor concentration after delivery
• • Hyperplasia of the β-islet cells
• Low glucose concentration <45
mg/dL
 HYPOCALCEMIA HYPERBILIRUBINEMIA AND
POLYCYTHEMIA
• Total serum calcium • Polycythemia  increase
concentration <8 mg/dL bilirubin
• Aberrations in magnesium- •
calcium economy, asphyxia,
and preterm birth
 LONG-TERM COGNITIVE
CARDIOMYOPATHY DEVELOPMENT
• Hypertrophic • Autism spectrum disorders or
cardiomyopathy developmental delay
• May lead to obstructive •

cardiac failure
• Usually resolves in months INHERITANCE OF DIABETES
after delivery • Type 2 DM has stronger genetic
•
component
• Complex interplay between genetic
predisposition and environmental
factors
• Breastfeeding reduces risk
MATERNAL EFFECTS

Diabetic Nephropathy

Diabetic Retinopathy

Diabetic Ketoacidosis

Infections
 MATERNAL EFFECTS

DIABETIC
Most often forces preterm delivery
NEPHROPATHY
•

• Risk factors: vascular complication and

preexisting nephropathy
• MICROalbuminuria 30-300
• May be related to oxidative stress mg/24 hrs
• MACROalbuminuria >300
mg/24hrs

PREECLAMPSIA
 DIABETIC RETINOPATHY
• Small microaneurysms  blot
hemorrhages
• Background/Nonproliferative
retinopathy
• Preproliferative retinopathy -
Cotton wool exudates
• Laser photocoagulation before
hemorrhage
• Retinal assessment after first
prenatal visit
DIABETIC NEUROPATHY

• Diabetic gastropathy
• Associated with high risk or
morbidity and poor perinatal
outcome
• Metoclopramide and D2-
receptor antagonists
• Hyperemesis gravidarum –
continuous insulin infusion
 DIABETIC KETOACIDOSIS
• Most often encountered in type 1 diabetes
• May develop with hyperemesis gravidarum, infection, insulin
noncompliance, β -mimetic drugs given for tocolysis, corticosteroids
given to induce fetal lung maturation
• Results from insulin deficiency + excess in counter-regulatory
hormones (glucagon)  gluconeogenesis and ketone body formation
• Serum or plasma assays for β-hydroxybutyrate more accurately
reflect true ketone body levels
 DIABETIC KETOACIDOSIS

• Parkland Hospital:
mean glucose level
380 mg/dL and mean
HbA1c 10%
• Euglycemic
ketoacidos is possible
but rare
INFECTIONS

• Candidal vulvovaginitis
• Urinary and respiratory tract infections
• Puerperal pelvic sepsis
• Asymptomatic bacteruria
• Postoperative wound complications following
CS
 MANAGEMENT OF DIABETES IN PREGNANCY

PRECONCEPTIONAL CARE
• Should begin before pregnancy and include specific goals during each trimester
• Optical medical care and education are recommended before conception
• Optimal glycemic control
•

• HbA1c <6.5%
• ADA – insulin use
•

• Preprandial: 70-100 mg/dL

• 2-hr postprandial: 100-120 mg/dL
• Mean daily glucose concentration <100 mg/dL
• Evaluation and treatment of diabetic complications
• Folate 400 microgram/d orally – decrease the risk of neural tube defects
 MANAGEMENT OF DIABETES IN PREGNANCY

FIRST TRIMESTER
• Careful monitoring of glucose control
• INSULIN TREATMENT MONITORING
•
 MANAGEMENT OF DIABETES IN PREGNANCY

DIET HYPOGLYCEMIA st
• Appropriate weight gain through • Incidence peaks during 1
carbohydrate and caloric trimester
modifications • Blood glucose <40 mg/dL (Chen
• Minimum of 175 g/d carbohydrates and coworkers)
• Weight loss is not recommended
• FBS >120 mg/dL – associated with
• Modest caloric restriction greater risk for preeclampsia, CS,
and BW > 90%
• Ideal dietary composition
• Glucose level considerably above
•
90 mg/dl – good pregnancy
• 55% carbohydrate outcomes
• 20% protein •
• 25% fat – 10% saturated
•
 MANAGEMENT OF DIABETES IN PREGNANCY

SECOND TRIMESTER
THIRD TRIMESTER
• Maternal serum alpha-fetoprotein • AND DELIVERY
Fetal surveillance at 32-34 weeks AOG
determination at 16-20 weeks AOG – •

used in association with targeted • Fetal movement, periodic FHB

sonographic examination monitoring, intermittent BPP
• Levels may be lower in diabetic evaluation and CST
pregnancies • Fetal kick counts
• Fetal echocardiography • 34 weeks – admission
• Euglycemia with self-monitoring – goal • 38 weeks - delivery
• • Labor induction – fetus not excessively
• large and favorable cervix
• CS delivery at or near term
•
MANAGEMENT OF DIABETES IN PREGNANCY
MANAGEMENT OF DIABETES IN PREGNANCY

PUERPERIUM
• No insulin for the first 24 hours
• Infection – promptly detected and treated
• Restart oral agents when appropriate
• Counseling – discussion of birth control
•

• Effective contraception
•
GESTATIONAL DIABETES
• GESTATIONAL – diabetes induced by pregnancy due to
exaggerated physiological changes in glucose metabolism
•

• Carbohydrate intolerance of variable severity with onset or

first recognition during pregnancy
•
 SCREENING AND DIAGNOSIS

24 to 28 weeks AOG

50g, 1-hour oral glucose

challenge test

Diagnostic 100g, 3-hour

OGTT

130 mg/dl
135 mg/dl
140 mg/dl
SCREENING AND DIAGNOSIS
ALGORITHM FOR DIAGNOSIS OF DM IN PREGNANT
FILIPINO WOMEN
 MATERNAL AND FETAL EFFECTS

• Do not appear to have fetuses with

higher rates of anomalies
• Unexplained stillbirths
• Higher frequency of hypertension and
cesarean delivery
 FETAL MACROSOMIA
• Perinatal goal: avoid difficult delivery and concomitant birth trauma
• Cheng and associates (2013)
•

• ≥ 4200 g: 76x greater risk for shoulder dystocia

• Excessive shoulder and trunk fat
• Fetal-growth regulation
•

• Insulin-like growth factors

• C-peptide
• Epidermal growth factor
• Fibroblast growth factor
• Platelet-derived growth factor
• Leptin
• Adiponectin
NEONATAL HYPOGLYCEMIA
• Hyperinsulinemia may provoke severe
hypoglycemia within minutes of birth
• 35-45 mg/dL
• Correlates with umbilical cord C-peptide levels
• Risk rises with birthweight, independent of
maternal diabetes diagnosis
 MATERNAL OBESITY
• BMI –risk factor for fetal macrosomia
• LGA neonates – maternal obesity + excessive
gestational weight gain
• Weight distribution – truncal obesity
• Increased maternal abdominal subcutaneous fat
thickness measured by sonography at 18-22 weeks
AOG – better predictor of gestational diabetes
MANAGEMENT
•

• Pharmacological methods - if diet modification

does not consistently maintain
•

• FBS <95 mg/dL

• 2 hr postprandial glucose <126 mg/dL
• Lower incidence of preeclampsia, shoulder
dystocia, and macrosomia
•

•
 MANAGEMENT

DIABETIC DIET • MEDICAL NUTRITION THERAPY

(MNT)
Carbohydrate controlled diet • GDM DIET
It meets the dietary principles for
Daily caloric intake of 30-35 kcal/kg 1.

diabetes mellitus management

Carbohydrate intake 40% of total 2. It provides for the nutritional
calories requirements of pregnancy
It is individualized for maternal pre-
20% protein and 40% fat 3.

gravid body mass index (BMI) and

weight gain goals
4. It is culturally acceptable
 EXERCISE
•

• Regular physical activity (aerobic and strength-

conditioning exercise)
• Diminish weight gain during pregnancy
• Reduce risk of developing gestational diabetes
• Lowers glucose levels
•
 GLUCOSE MONITORING

• Daily blood-glucose self

monitoring - significantly fewer
macrosomic newborns FASTING
• Less weight gain
• Glucose assessment 4x a day 1st HOUR

2nd HOUR
 INSULIN TREATMENT

• Standard therapy
FBS >95 mg/dL
• Does not cross the placenta
1-hour postprandial level >140 mg/dL • Tight glycemic control
2 hr >120 mg/dL

⅔ is given before before

breakfast (⅓ regular insulin
Starting dose: 0.7-1.0 units/kg/d and ⅔ are NPH)
Given in divided doses
A combination of intermediate-acting ⅓ is given before dinner (½
and short-acting insulin insulin and ½ NPH)
 ORAL HYPOGLYCEMIC AGENTS
Second-line glycemic control
GLYBURIDE
• •
• Higher BW, more macrosomia,
more frequent neonatal
hypoglycemia
• Crosses the placenta
• Reaches concentration in fetus >2/3
of maternal levels
• Increased rates of NICU admission,
respiratory distress and neonatal
hypoglycemia
METFORMIN
• Less maternal weight gain, more preterm
birth, less severe neonatal hypoglycemia,
lower BW, less macrosomia
• Reaches fetal serum concentrations =
maternal levels
• Neonatal hypoglycemia, RDS,
phototherapy, birth trauma, 5 minute
Apgar score ≤ 7 and preterm birth
 OBSTETRICAL MANAGEMENT
• Early delivery or other interventions are seldom required
• Fetal surveillance – women with gestational diabetes and poor glycemic control
• Daily fetal kick counts in the third trimester
• Insulin-treated women
•

• Inpatient admission after 34 weeks AOG

• Antepartum monitoring 3x a week
• ACOG – routine labor induction in women with diet-treated gestational diabetes
should not occur before 39 weeks AOG
• Prophylactic cesarean delivery in diabetic women with EFW ≥4500 g
 POSTPARTUM EVALUATION
•
Fasting glucose or 75-g, 2-
hour OGTT at 4-12 weeks
postpartum
• Testing at least every 3
years – women with history
of gestational diabetes but
normal postpartum glucose
screening
• At risk for metabolic
syndrome
•

•
 RECURRENT GESTATIONAL DIABETES

RISK FACTORS PREVENTION

•
•

• Maternal BMI • Lifestyle behavioral

• Insulin use changes including weight
• Fetal macrosomia control and exercise
• Weight gain between between pregnancies
pregnancies •

•
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