Pregnancy & diabetes mellitus

Contents
 Introduction
 Gestational diabetes mellitus
 Risk factors
 Complications
 Approch for GDM
 Pregestational DM
 Diagnostic criteria
 Approch for pregestational DM
 Introduction
 Diabetes mellitus is the most common medical complication of pregnancy
 Preexisting (type 1 or type 2) diabetes mellitus affects approximately 1–3 per 1000 pregnancies
Types diabetes during pregnancy:

1 Gestational Diabetes Mellitus (GDM)

Diabetes diagnosed during pregnancy
=>accountes for 80% of DM in pregnancy
2 Pre gestational DM
Detected before pregnancy
=>Accounts for 20% of DM in pregnancy
Could be:
type 1 or
type 2
 GESTATIONAL DIABETES

 GDM is defined as any degree of glucose intolerance with onset or first recognition during
pregnancy.
 The risk of recurrence in future pregnancies is at least 60%.
 GDM complicates approximately 4% of pregnancies.
 Women with GDM have an approximately 50% risk of developing type 2 diabetes over the
next 10 years
 Phatophysiology is similar to type 2 DM
 In the majority of GDM cases, glucose levels return to normal after delivery.
 Maternal Risk factors
 obesity (nonpregnant body mass index 30),
 prior history of GDM,
 heavy glycosuria (> 2+),
 Presence of polyhydraminos
 Having a previous birth of an overweight baby of 4kg or more
 unexplained stillbirth,
 prior infant with major malformation, and
 family history of diabetes in a first-degree relative.

 Risk assessment for GDM is performed at the first prenatal visit in all women who do
not already have diagnosed diabetes.
 women with low risk
The low-risk group comprises women who fulfill all of the following criteria:
 age less than 25 years,
 normal body weight,
 no family history (first-degree relatives) of diabetes,
 no history of abnormal glucose metabolism or poor obstetric outcome,
 and not a member of an ethnic/racial group with a high prevalence of diabetes (eg, Hispanic
American, Native American, Asian
 Complications

Diabetic ketoacidosis (DKA)

spontaneous abortion
 Fetal cx
 Elevated glucose levels are toxic to the developing fetus,
 miscarriages and major malformations
 leading to macrosomia and also to enlargement of internal organs.
 shoulder dystocia, and
 birth trauma.

 They are preventable by preconceptional glucose control. Because malformations occur within the first 8
weeks of gestation.
 Infants --- increased risk of hypoglycemia, hypocalcemia, RDS, polycythemia,jaundice

 Offspring of mothers with GDM appear to be at increased risk of obesity and impaired glucose tolerance
later in life
 They might also have…

 Cardiac- Atrial septal defects, Ventricular septal defects

 Cns- Neural tube defects, Anencephaly
 Renal - Hydronephrosis, Renal agenesis
 Gastrointestinal – Duodenal atresia
 Spinal- sacral agenesis
 Approch for GDM
 History- rull out all the risk factors
 Physical examination – BMI index

 Universal vs Risk based screening

 Early detection:
 Screening starts: as early as possible
 All women of ordinary or high risk should be screened between 24 and 28 weeks' gestation.
 If results of testing do not demonstrate diabetes, these women should be retested between 24
and 28 weeks' gestation.
,
 NB: Risk based screening detects only 50%
 Universal screening at first ANC visit with OGTT for
 In those who meet the following criteria
 Maternal age > 35 yrs.
 Previous macrosomic infant ( ≥ 4000gm)
 Previous unexplained fetal death
 History of pregnancy with GDM
 Strong immediate family history of diabetes.
 Obesity ( > 90kg)
 Previous congenital abnormal fetus
 Glucosuria.
 determination 1 hour after the ingestion of a 50-g glucose load. If the blood glucose concentration
exceeds 140 mg/dl, a 3-hour oral GTT has been recommended
 Diagnostic test:
100gm OGTT, it is done after overnight fasting, in the morning
 1st take FBS sample,
 100gm glucose taken PO
 then 1hr, 2hrs, 3hrs blood sugar is determined:
 GDM diagnosed, if 2 or more abnormal results are seen
 Normal results are:-
FBS <95mg/dl
1hr BS<180mg/dl
2hr BS<155mg/dl 2 or more abnormal results are needed
3hr BS<140mg/dl
Management & follow up

GDM once diagnosed: Main stay of management

 Exercise
 Diet Dietary counseling: patients are prescribed diabetic diet.
 Initiate insulin IF FBS>95mg/dl or 2hrs post-prandal >120mg/dl
 : 0.5-u/kg in the first half pregnancy and increase to 0.7u/kg in the second half subcutaneously
 2/3rd (NPH) in the morning and 1/3rd(regular Insuline) in the evening from total dose
 Medical mgt for complication

 Oral hypoglycemic agents are contraindicated as they cause prolonged neonatal hypoglycemia
and congenital anomalies because they cross the placenta.
Obstetric Mgt.

 Management of comlication
 Antepartum Fetal Surveilance:
 In excellent glycemic control achieved by diet alone, fetal follow up with BPP.
 and ultrasound assessment of fetal growth are advised.
 Planned delivery:
 anticipate intrapartum compln.
 induction vs c/s
 Intrapartum care
 Insulin infusion method
 Withhold the morning Regular insulin injection.
 Give ½ the usual insulin dose in AM.
 Begin & continue glucose infusion (5%DW) (RI 0.5 unit/hr )at 100ml/hr
throughout labor.
 monitor glucose levels every 2 hours in early labor and every 1hours in
active labor.
 Follow feto-maternal condition
 Mode of delivery induction vs c/s
 Timing of delivery b/n 38& 40wks
Postpartum Care

 GDM - No therapy required as is blood glucose monitoring.

 All patients with GDM should have a 2-hour, 75-g OGTT approximately 6 weeks postpartum.
 Those with normal glucose tolerance should be reassessed every 3 years.
 For Pre-existing DM restart as protocol
 Recommended Contraception
- Barrier methods are safe & without metabolic side effects
- Permanent sterilization should be made available to women with diabetes who have completed
childbearing

- preexisting diabetes, who do not have serious vascular disease

---- lowest dose combination or progestin only contraceptive
--- Breast feeding
 Target glucose levels
 Pre-meal glucose 70-95mg/dl
 PP glucose <130mg/dl at 1hr. or <120mg/dl at 2hrs.
 No significant hypoglycemia
Pregestational diabetes

Type 1 diabetes mellitus (T1DM)

 results from beta cell destruction, usually leading to absolute insulin deficiency.
 Onset often occurs in the young
 T1DM may appear in older persons and may rarely present during pregnancy.
 Profound thirst, increased urination, and weight loss or even overt ketoacidosis
are the usual symptoms prompting medical evaluation.
TYPE 2 DIABETES (NONINSULIN DEPENDENT)
 is characterized by insufficient insulin receptors to effect proper glucose control after
insulin is released (insulin resistance).
 Women with T2DM typically have a body habitus consisting of increased abdominal
girth, often described as an "apple shape."
 T2DM is a multifactorial illness that is influenced by heredity, environment, and lifestyle
choices
 Diagnostic Criteria for Diabetes Mellitus Prior to Pregnancy

However, if the fasting plasma glucose value is > 126 mg/dL and if confirmed on repeat test, there is no need to
perform GTT as the woman is diabetic
 SEVERE HYPERGLYCEMIA & KETOACIDOSIS
 During pregnancy, severe hyperglycemia and ketoacidosis are treated exactly the same as
in the nonpregnant state.
 Insulin therapy, careful monitoring of potassium level, and fluid replacement are crucial
Thank you!