DIABETES MELITUS IN

PREGNANCY
• Types
• Risk factors for GDM
• Screening
• Diagnostic criteria
• Complications
• Management
 TYPES
GESTATIONAL DIABETES MELLITUS (GDM)
Carbohydrate intolerance of variable severity with onset or first recognition
during the present pregnancy (National Diabetes Data Group,1985) It includes
women with pre-existing but previously unrecognized diabetes
PRE-EXISTING DIABETES MELLITUS (TYPE 1)

Insulin-dependent diabetes mellitus – juvenile onset

PRE-EXISTING DIABETES MELLITUS (TYPE 2)

Non-insulin-dependent diabetes mellitus- maturity onset

Risk factors for screening gdm
• BMI above 30 kg/m2
• Previous baby weighing 4.5 kg or above
• Previous gestational diabetes
• First degree relative with diabetes
• Family origin from high prevalence area (South Asian, black Caribbean and
middle eastern)
Screening for GDM

Assessment of risk factors at

booking

Risk factor (+) No Risk factors

Self monitoring of OGTT at 16-18 weeks 2 hr 75 g oral glucose

blood glucose If normal, repeat tolerance test (OGTT)
monitoring at home at 24-28 weeks at 24-28 weeks
MODIFIED Oral glucose tolerance test
(MALAYSIA)
• Fasting from 12 am till the next morning
• Take blood for fasting blood sugar
• Give patient to drink 75 g glucose + 250 ml water, drink in 10-15
min
• After 2 hours, take blood again for 2 hr postprandial blood sugar
DIAGNOSTIC CRITERIA
• There is no international consensus on diagnostic criteria for GDM.

WHO criteria Diabetes outside of GDM

pregnancy

Fasting >=7.0 mmol/L >5.6 mmol/L

2 hour >=11.1 mmol/L >=7.8 mmol/L

• In Malaysia GDM – Fasting >5.6 mmol/L, 2 hr >7.8 mmol/L

Maternal complications
PRE-EXISTING DIABETES GDM
Pre-eclampsia Pre-eclampsia
Hypoglycaemia Hypoglycaemia
Infection Recurrent infections
Ketoacidosis
Deterioration in retinopathy
Increased proteinuria and oedema
(nephropathy)
Miscarriage
Polyhydramnios Polyhydramnios
Induction of labour Induction of labour
Shoulder dystocia Shoulder dystocia
Increased caesarean section rate Increased caesarean section rate
Birth trauma Birth trauma
Fetal complications
PRE-EXISTING DIABETES GDM
Congenital abnormalities no increase in congenital abnormality (exception in
unrecognized DM pre-dating pregnancy and
hyperglycaemia in 1st trimester)
macrosomia macrosomia
Late stillbirth Late stillbirth
Neonatal hypoglycaemia Neonatal hypoglycaemia
Polycythaemia Polycythaemia
Respiratory distress syndrome Respiratory distress syndrome
Neonatal jaundice Neonatal jaundice
Birth trauma Birth trauma
Perinatal death Perinatal death
Preterm delivery
Obesity and/or diabetes developing later in baby’s Obesity and/or diabetes developing later in baby’s
life life
Pathophysiology of fetal effects (modified Pederson)
Maternal hyperglycaemia

Fetal hyperglycaemia

Fetal pancreatic beta cell

hyperplasia

Fetal hyperinsulinaemia

Macrosomia Organomegaly Polycythaemia Hypoglycaemia RDS

Jaundice
Effects of pregnancy on diabetes
• Change in eating pattern
• Increase in insulin dose requirements
• Greater importance of tight glucose control
• Increased risk of severe hypoglycaemia
• Risk of deterioration of pre-existing retinopathy
• Risk of deterioration of established nephropathy
Management of GDM
• Medical manangement
• Obstetric management
• Antenatal management
• Intrapartum management
• Postnatal management
Medical management of GDM
• Multidisciplinary diabetes pregnancy clinic
• Diet control , refer to dietician
• Regular exercise
• Monitoring – home based glucose monitoring (HBGM) / Blood sugar profile (BSP) (4
times/ day)
• Aim of glucose control – BSP – 4-6 mmol/ L
• FBS - <5.3 mmol/L, 1HPP – 7.8 mmol/L, 2HPP – 6.4 mmol/L
• If not control with diet and lifestyle changes for 2 weeks – Insulin / Metformin
• Insulin- 4 times daily basal bolus insulin regime (rapid acting insulin)
• in more severe case, rapid acting insulin 3 times+ intermediate acting at night
Obstetric management

• Regular check of BP, urinalysis to assess PE

• Regular monitoring for complications ( infection,
polyhydramnios)
• Reular USG assessment of fetal growth, amniotic fluid
• Any concern for fetal well being- Cardiotocography, Doppler
ultrasound
Antenatal • Elective birth after 38 weeks by induction of labour (on diet
control -40 wk, control with insulin- 38 wk) as there is risk
of unexplained still birth in late pregnancy
• EL caesarean section if indications are present
Obstetric management
• Women on larger doses of insulin – IV dextrose and insulin
• Target blood glucose level- 4-7 mmol/ L
• Following delivery insulin infusion should be discontinued.
Intrapartum All oral hypoglycaemic drugs should be stopped.

• Check blood glucose level prior to transfer to community

care
• FBS at 6 weeks and annually to screen diabetes
Postnatal
Management of pre-existing diabetes
mellitus
• Pre-pregnancy management
• Medical management and management of complications
• Obstetric management
• Antenatal management
• Intrapartum management
• Postnatal management
Pre-Pregnancy management
• Counselling
• Folic acid high dose (5 mg) before conception to prevent neural
tube defect
• Diabetes therapy should be intensified and adequate
contraception used until glucose control is good.
• Targets – HbA1c at <6.5%, pre- meal glucose level -4-7 mmol/L
• Retinal assessment (refer to opthamologist)
• Renal assessment
Medical management
• Multidisciplinary diabetes pregnancy clinic
• Diet control , refer to dietician
• Type 1 -Insulin- 4 times daily basal bolus insulin regime (rapid
acting insulin) achieve better glycaemic control compared with
regimes using mixed insulins
• Type 2- most women require treatment with insulin
• Monitoring – self monitoring
• Target – HbA1c <6%,
• pre-meal glucose – 3.5-5.5 mmol/L
• 2 hr postprandial -4-6.5 mmol/L
Management of complications
• Retinal assessment
• Refer to opthamologist
• Renal assessment
• Refer to nephrologist
• Strict control of hypertension
Obstetric management

• Early dating and viability scan

• Detailed anomaly scan of fetus at 18-20 wks, including
four chambered assessment of fetal heart
• Regular check of BP, urinalysis to assess PE
• Regular USG assessment of fetal growth, amniotic fluid
• Any concern for fetal well being- Cardiotocography,
Doppler ultrasound
Antenatal • Elective birth after 38 weeks by induction of labour (on
diet control -40 wk, control with insulin- 38 wk) as there
is risk of unexplained still birth in late pregnancy
• EL caesarean section if indications are present
Obstetric management
• Women on larger doses of insulin – IV dextrose and insulin sliding scale
• Target blood glucose level- 4-7 mmol/ L
• Following delivery rate of infusion is halved in type 1
• Type 1 -once normal eating start, subcutaneous insulin with pre pregnancy dose
Intrapartum • Type 2- can resume metformin or glibenclamide

• Check blood glucose level prior to transfer to community care

• FBS at 6 weeks and annually to screen diabetes
• back to routine diabetes care.
Postnatal
THANK YOU