DIABETES AND PREGNANCY

• The increasing prevalence of type 2 diabetes/

Diabetes in younger people has led to an
increasing number of pregnancies with this
complication
• Many women found to have gestational
diabetes are likely to have type 2 diabetes that
has previously gone undiagnosed
• mini-environment of the uterus
– believed that early imprinting can have effects later in life
• Example:
• in utero exposure to maternal hyperglycemia leads to
fetal hyperinsulinemia, causing an increase in fetal fat
cells, which leads to obesity and insulin resistance in
childhood)
• This in turn leads to impaired glucose tolerance and
diabetes in adulthood. Thus, a cycle of fetal exposure
to diabetes leading to childhood obesity and glucose
intolerance is set in motion
 Classification During Pregnancy
• most common medical complication of
pregnancy
• diabetes before pregnancy—pregestational or
overt.
• during pregnancy—gestational.
• the focus is on whether diabetes is first
diagnosed during pregnancy or antedates
pregnancy.
 DIAGNOSIS OF DIABETES DURING
PREGNANCY
• Overt Diabetes
• Women with high plasma glucose levels, glucosuria, and ketoacidosis
• random plasma glucose level >200 mg/dL + classic signs and symptoms:
– polydipsia, polyuria, and unexplained weight loss or a fasting glucose
exceeding 125 mg/dL
• The diagnostic cutoff value for overt diabetes:
– fasting plasma glucose of 126 mg/dL or higher
• The likelihood of impaired carbohydrate metabolism is increased
appreciably in women who have :
– a strong familial history of diabetes
– given birth to large infants
– demonstrate persistent glucosuria
– have unexplained fetal losses
• Gestational Diabetes
• carbohydrate intolerance of variable severity with
onset or first recognition during pregnancy
– applies whether or not insulin is used for treatment
• some women with gestational diabetes have
previously unrecognized overt diabetes
• Fasting hyperglycemia early in pregnancy almost
invariably represents overt diabetes.
• Screening
• no consensus regarding the optimal approach to screening for
gestational diabetes
• recommendations are now for selective screening using the
guidelines:
• Low Risk: Blood glucose testing not routinely required if all the
following are present:
– Member of an ethnic group with a low prevalence of GDM
– No known diabetes in first-degree relatives
– Age 25 years
– Weight normal before pregnancy
– Weight normal at birth
– No history of abnormal glucose metabolism
– No history of poor obstetrical outcome
• Average Risk: Perform blood glucose testing at 24
to 28 weeks
• High Risk: Perform blood glucose testing as soon
as feasible if one or more of these are present:
– Severe obesity
– Strong family history of type 2 diabetes
– Previous history of GDM, impaired glucose
metabolism, or glucosuria. If GDM is not diagnosed,
blood glucose testing should be repeated at 24 to 28
weeks or at any time there are symptoms or signs
suggestive of hyperglycemia.
• Diagnosis
• Recommended criteria for interpretation of the 100-g
diagnostic glucose tolerance test:
 GESTATIONAL DIABETES
• Gestational:
– implies that diabetes is induced by pregnancy—
ostensibly because of exaggerated physiological
changes in glucose metabolism
– type 2 diabetes unmasked or discovered during
pregnancy
• Important perinatal concern:
– is excessive fetal growth, which may result in both
maternal and fetal birth trauma
• MATERNAL AND FETAL EFFECTS
• women with elevated fasting glucose levels
have increased rates of unexplained stillbirths
similar to women with pregestational diabetes
• fasting hyperglycemia 105 mg/dL may be
associated with an increased risk of fetal
death during the last 4 - 8 weeks of gestation
• Macrosomia
– birthweight exceeds 4500 g
• Except for the brain, most fetal organs are
affected by the macrosomia that commonly
characterizes the fetus of a diabetic woman.
• Macrosomic infants of diabetic mothers:
– anthropometrically different from other large-for-
gestational age infants
– excessive fat deposition on the shoulders and trunk,
which predisposes them to shoulder dystocia or
cesarean delivery
• maternal obesity is an important confounding
factor in the diagnosis of gestational diabetes.
• Management
– standard dietary management
– Insulin therapy
• Maternal capillary glucose levels be kept 95
mg/dL in the fasting state
• Diet
• an average of 30 kcal/kg/d based on prepregnant body
weight for nonobese women
• obese women with a body mass index (BMI) 30 kg/m2
may benefit from a 30-percent caloric restriction
• Exercise
• physical activity during pregnancy reduced the risk of
gestational diabetes
• resistance exercise diminished the need for insulin
therapy
• Insulin
• A total dose of 20 to 30 units given once daily, before
breakfast >> initiate therapy.
– The total dose is usually divided into two-thirds intermediate-
acting insulin and a third short-acting insulin.
• Oral Hypoglycemic Agents
• the use of glyburide as an alternative to insulin in the
management of gestational diabetes
– glyburide as first-line therapy for diet failure with gestational
diabetes ( 13%)
• Metformin has been reported to reduce the incidence of
gestational diabetes in women who use the drug
throughout pregnancy
• women with gestational diabetes to
metformin or insulin treatment:
– neonatal hypoglycemia
– respiratory distress
– Phototherapy
– birth trauma
– 5-minute Apgar score of 7 or less
– preterm birth
• Obstetrical Management
• In general, women with gestational diabetes
who do not require insulin seldom require
early delivery or other interventions
• women who require insulin are managed as if
they had overt diabetes
• Postpartum Evaluation
 PREGESTATIONAL DIABETES
• The embryo, the fetus, and the mother
commonly experience serious complications
directly attributable to diabetes
• Fetal Effects
• Miscarriage
– early abortion is associated with poor glycemic
control
• Preterm Delivery
– Overt diabetes is an undisputed risk factor for preterm
birth
• Malformations
• Altered Fetal Growth
– consistently heavier birthweights compared with that
of normal pregnancies
• Unexplained Fetal Demise
– factors such as obvious placental insufficiency,
abruption, fetal-growth restriction, or
oligohydramnios are not apparent
• Hydramnios
– result of increased amnionic fluid glucose
concentration.
 Neonatal Mortality and
Morbidity
• Respiratory Distress Syndrome
– gestational age rather than overt diabetes is likely the most significant associated factor with
respiratory distress
• Hypoglycemia
– neonatal hypoglycemia—blood glucose levels < 45 mg/dL before the second feeding—was
related to maternal blood glucose levels > 145 mg/dL during labor
• Hypocalcemia
– total serum calcium concentration 8 mg/dL in term infants
• Hyperbilirubinemia and Polycythemia
– Factors implicated have included preterm birth and polycythemia with hemolysis
– Renal vein thrombosis is also reported to result from polycythemia.
• Cardiomyopathy
– may have hypertrophic cardiomyopathy that occasionally progresses to congestive heart
failure
• Long-Term Cognitive Development
• Inheritance of Diabetes
– breast feeding by diabetic mothers in the genesis of childhood diabetes.
 Maternal Effects
• Diabetic Nephropathy
– no long-term sequelae of pregnancy on diabetic nephropathy
• Diabetic Retinopathy
– With increasingly severe retinopathy, the abnormal vessels of background eye disease become
occluded, leading to retinal ischemia and infarctions that appear as cotton wool exudates.
• Diabetic Neuropathy
– Causes nausea and vomiting, nutritional problems, and difficulty with glucose control
• Preeclampsia
– major complication that most often forces preterm delivery in diabetic women
• Diabetic Ketoacidosis
– affects only approximately 1 percent of diabetic pregnancies
– unique to type 1 diabetes, and it may develop with hyperemesis gravidarum, -mimetic drugs
given for tocolysis, infection, and corticosteroids given to induce fetal lung maturation
• Infections
– pregestational diabetes is associated with a two- to threefold increase in wound complications
after cesarean delivery
– candida vulvovaginitis, urinary infections, respiratory tract infections, and puerperal pelvic
infections
 Management of Diabetes in
Pregnancy
• Preconceptional Care
– glucose control using insulin
– folate, 400 μg/d, is given periconceptionally and during early
pregnancy to decrease the risk of neural-tube defects.
• First Trimester
– Careful monitoring of glucose control by hospitalizing.
– Insulin Treatment
– Noninvasive Monitoring
– Diet of caloric intake with:
• normal 30 to 35 kcal/kg
• underweight women, 40 kcal/kg/d.
• more than 120 percent above ideal weight, 24 kcal/kg/d
– dietary composition:
• 55 percent carbohydrate, 20 percent protein, and 25 percent fat with less than
10 percent as saturated fat.
• Second Trimester
– Sonographic examination at 18 to 20 weeks in an attempt to
detect neuraltube defects and other anomalies
– increased insulin requirement after approximately 24 weeks
(results from the increased production of pregnancy hormones,
which are insulin antagonists)
• Third Trimester and Delivery
– cesarean delivery has commonly been used to avoid traumatic
birth
– considerably reduce or delete the dose of long-acting insulin
given on the day of delivery
– During labor and after delivery, the woman should be
adequately hydrated intravenously and given glucose in
sufficient amounts to maintain normoglycemia