DIABETES WITH

PREGNANCY
Definition:

 Diabetes mellitus, is a group of metabolic

diseases in which a person has high blood sugar,
either because the pancreas does not produce
enough insulin (insulin deficiency), or because
cells do not respond to the insulin that is
produced (insulin resistance).
 This high blood sugar produces the classical
symptoms of polyuria, polydipsia and polyphagia.
 : Incidence

 2-12% of pregnancies are complicated by diabetes mellitus.

 90% are gestational diabetes (onset of diabetes or first time

recognition during pregnancy).

 10% had diabetes mellitus before pregnancy (pregestational

or preconceptional diabetes mellitus).
CLASSIFICATION DURING
PREGNANCY

•Known to have diabetes before pregnancy;

pregestational or overt.

•Diagnosed during pregnancy; gestational.

CLASSIFICATION ACCORDING TO
SEVERITY

The White classification

 Why pregnant women (in women with impaired or
borderline pancreatic function) develop impaired
glucose tolerance (gestational diabetes ) without
previous history of diabetes?

 Why pregnancy make blood glucose control more

worse in known diabetic patient?
 Pregnancy is diabetogenic

 Human placental lactogen,

Antagonize insulin
 prolactin, (reduce the number
 estrogens, and sensitivity of
insulin receptors in
 progesterone and target cells).
 cortisol

 The placental enzyme insulinase

that destroys insulin.
 Diabetes becomes difficult to control in
pregnancy
 Early pregnancy→ nausea and vomiting → maternal
hypoglycemia.

 After the third month until term → increase anti-

insulin hormones → increase insulin requirements.

 During labor → uterine activity → hypoglycemia.

 After delivery → drop in placental hormones →

decrease insulin requirements.
CONFIRMATION
Prediabetic become diabetic-1 

Diabetic pt,controlled on dietbefor-2 

pregnancy,need insulin during pregnancy

increase insulin requierment during pregnancy-3 

,Decrease insulin requierment in missed abortion 

.IUFD,post partum 
Also we conclude :
 We cannot depend on urine glucose (gestational
glucosuria). Blood glucose is the only method for
diagnosis and follow up (capillary blood glucose is
the optimal).

 Blood glucose level in pregnant women is different

of non pregnant women . (it is 10 – 20% lower in
fasting and higher in post prandial level )
.RISK FOR DIABETES M
.Family history of D-1 

Obesity-2 

Grand multipara-3 

past history of macrosomic baby-4 

past history of repeated IUFD,abortionof -5 

unknown cause
Why we should control blood sugar
during pregnancy?

 Diabetes is associated with increasing morbidity of

the mother and fetus .
Fetal complication of diabetic mother:

With Miscarriage
pregestational
diabetes only

Congenital anomalies
cardiac most common,
sacral agenesis pathognomonic,
neural tube defects.
 Fetal complication of diabetic mother:

With pregestational
Macrosomia
and gestational
diabetes

Shoulder dystocia

IUFD
Stillbirth Prematuriry
 Fetal complication of diabetic mother:

With pregestational Neonatal hypoglycemia

and gestational
diabetes

Neonatal death Respiratory distress

Fetal birth injuries

Risk of inheritance of diabetes

Maternal complication of diabetes with
pregnancy:

 Hypoglycemia Rare with type 2 and

gestation diabetes
 Diabetic ketoacidosis
 Worsening of pre-existing retinal and renal disease
 Increased liability to infection as urinary tract
infection and vulvo -vaginal mycosis.
 Pre-eclampsia
 Increased incidence of polyhydramnios
 Operative delivery and birth tract injuries
Our target:

Selective screening to
pregnant women with
risk factors who are
prone to develop
gestational diabetes

Control blood glucose level in

known diabetic pregnant
women in order to decrease
the risk of fetal and maternal
complication
:Diagnosis

Pregestational
DM
 Fasting hyperglycemia (>125mg/dl)
125 early in
pregnancy.
 Random plasma glucose level >200 mg/dL
 Classic signs and symptoms such as polydipsia,
polyuria, unexplained weight loss and ketoacidosis
:Diagnosis

Gestational DM

Selective screening

For whom? By what?

When?
For whom? .... When?

 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
For whom? .... When?

 Average Risk: Perform blood glucose testing at 24

to 28 weeks using :

 Two-step procedure: 50-g oral glucose challenge test

(GCT), followed by a diagnostic 100-g oral glucose
tolerance test (GTT) for those meeting the threshold
value in the GCT.
For whom? .... When?

 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.
By what?..... The two-step procedure

 50-g oral glucose challenge test: Plasma glucose

level is measured 1 hour after a 50-g glucose load
without regard to the time of day or time of last meal.

 A value of 140 mg/dL or higher is considered

positive→

 Followed by a diagnostic 100-g oral glucose

tolerance test.
By what?..... The two-step procedure

3 hours 100gm GTT

 Fasting blood sugar is measured then patient is given
100 gm glucose then blood sugar is measured after 1, 2
& 3 hours

Plasma Glucose Criteria for Gestational Diabetes

If two or more results are abnormal, the patient is diagnosed as

a diabetic.
 Pregestational
:Management diabetes

1. Before Pregnancy:

 Good control of blood glucose level.

 Keep HBA1c < 6% before conception (pregnancy is better
avoided if level > 9.5%).increase congenital anomalies.
 The diabetic woman should take folic acid 5 mg daily before
conception and for the first 12 weeks of pregnancy to reduce
the incidence of neural tube defects.
 Early booking for antenatal care when pregnancy occurs.
 Pregestational
:Management diabetes

2. During Pregnancy:

a)Medical Control of D.M.:

Diet:
 Average caloric intake (2200 - 2400 Kcal/day)
 50-60% CHO, 15-20 % proteins &the remaining fat
 Divided in 3 main meals & 3 snacks in between.
 Pregestational
:Management diabetes

2. During Pregnancy:
a)Medical Control of D.M.:
Insulin:
 Start by 0.7 u/kg in 1st trimester, 0.8 u/kg in 2nd trimester and
0.9 u/kg in 3rd trimester.
 Given in 2 doses, 2/3 in the morning (2:1 NPH:regular)
and 1/3 at evening (1:1 NPH:regular).
 Keep FBS between 60 and 90 mg/dl & 2hrs PP ≤120 mg/dl.
 Pregestational
:Management diabetes

2. During Pregnancy:
b) Antepartum assessment:

Maternal assessment:
 Preeclampsia
 Ophthalmologic, cardiac, and renal function
 Urine culture in every trimester for asymptomatic bacteruria
 Pregestational
:Management diabetes

2. During Pregnancy:
b) Antepartum assessment:

Fetal assessment:
 Sonography: viability, fetal anomalies, fluid volume and fetal
growth.
 Fetal well-being: Daily kick count and non-stress test done
twice weekly (testing starts at 28-30 weeks).
 Pregestational
:Management diabetes

2. During Pregnancy:
c) Timing of delivery:

 With good metabolic control and assuring

antepartum surveillance→ delivery at term
(complete 38 weeks) or at the onset of spontaneous
labor.
 Pregestational
:Management diabetes

2. During Pregnancy:
c) Timing of delivery:

 Fetal hypoxia, PE or previous history of IUFD → delivery

before 38 weeks → amniocentesis to determine lung
maturity (presence of phosphatidylglycerol) → If no evidence
of lung maturity, dexamethazone for 48 hours (6 mg IM
every 12 hours for 4 doses) then deliver.
 Pregestational
:Management diabetes

3. During Labor:
 Blood glucose is determined every 2 hours.
 Urine is checked for ketones every 2 hours.
 Continuous monitoring of the fetal heart rate.

4. During Puerperium
:
 The patient is given one -third to one-half her dose of insulin.
 Encourage breast feeding.
 Infection if present should be treated.
 Pregestational
:Management diabetes

5. The Newborn :

 Managed as a preterm baby irrespective of its weight.

 Liable to develop respiratory distress syndrome (RDS),
hypoglycemia, hypocalcaemia (tetany), hyperbilirubinemia,
or polycythemia.

6. Contraception
 Gestational
:Management diabetes

 Usually controlled by diet only.

 If insulin is needed, dose and follow up as in pregestational
DM.

 Delivery may be safely delayed in most cases until term or

the onset of spontaneous labor.
 GTT should be done 6-12 wks after delivery

 Recurrence : GDM has 70% risk of recurrence in

subsequent pregnancy.
 20-50% of GDM will develop overt D.M. within 5-10
years.
Case study
Case
 A 30 years old women G2P0020 present to the obstetrician for
pre-conception counseling to an 8-year history of diabetes
mellitus.
 She has been treated with multiple oral hypoglycemic
medication (glyburide, metformin ) in order to achieve glycemic
control
 She denies hypertension ,retinopathy and renal disease.
 Her obstetric history is significant for two first trimester losses.
 The patient and her husband are contemplating a pregnancy , she
is concerned about her pregnancy loss and other potential effect
of diabetes on her pregnancy .
What is needed as a pre-conception
preparation and counseling for this patient ?

Discuss with the patient the increased risk of

complication to her and her fetus and how to
reduce this risk and the importance of the
scheduled antenatal care and investigation needed
for this patient
What is needed as a pre-conception
preparation and counseling for this patient ?

 Complete history taking and physical examination

 Review diet and weight loss
 Retinal examination
 Renal function

 Discuss with the patient symptoms of hypoglycemia and how

to deal
 Discuss with the patient the risk of diabetic ketoacidosis and
the precaution and mangment
What is needed as a pre-conception
preparation and counseling for this patient ?

 5 mg folic acid pre-conception

 Change oral hypoglycemic to insulin
 Optimization of blood glucose before conception , the HbA1c
6.1 percent is the goal
 What are the expected maternal
complications if she got pregnant ?
What are the expected fetal
complications ?
What are the precautions that should be done to
avoid further miscarriages ?

 Optimization of pre-pregnancy blood glucose control.

Our aim is to achieve glycosylated haemoglobin below
7 % ( the optimum is to achieve Hba1c at 6.1%).

 Prescribing folic acid 5mg daily starting pre-

conception and during the 1st three months of the
pregnancy.

N.B: diabetes is one of the causes of recurrent

miscarriage.
If this patient got pregnant what is the plan of
? antenatal care

Three main lines of management :

 Glycemic control.

 Fetal monitoring .

 Monitoring for expected maternal complication .

?When to deliver this patient

 With good glycemic control delivery at 38

completed weeks .
MCQ
The infant of a diabetic mother is at
:increased risk of

a) Polycythemia.
b) Hypermagnesaemia.
c) Traumatic delivery.
d) Neonatal jaundice.
e) Hypoglycaemia.
The infant of a diabetic mother is at
:increased risk of

a) Polycythemia.
b) Hypermagnesaemia.
c) Traumatic delivery.
d) Neonatal jaundice.
e) Hypoglycaemia.
:Diabetes mellitus in pregnancy

A. During labor, glucose should be given as a vehicle

for an oxytocin infusion.

B. In pregnancy, there is an increased glucose

concentration in the vaginal epithelium.

C. Pre-eclampsia is seen in 8 per cent of pregnant

patients with diabetes mellitus.
ANSWER

 A. False. Insulin should be administered as an intravenous

infusion combined with intravenous glucose.

 B. True. This, in association with glycosuria, predisposes

the patient to monilial vaginitis and vulvitis.

 C.True.