DM with Pregnancy

• Associate Professor
• Dr Ahmed Hussein
• O6U – OB/GYN Dep
 Definition Incidence
Disorder in carbohydrate metabolism 1: 350
Characterized by One of the most common endocrine
• Hyperglycemia and glucosuria disorders during pregnancy
• Impaired CHO & protein & fat
metabolism
• Microangiopathy
Maternal adaptation Consequences
1- Rapid uptake of glucose from GIT 1- Alimentary glycosuria
Decrease uptake by cells 2- Increased liability to Ketoacidosis
2- Increased lipolysis to increase 3- Renal glucosuria
delivery of FFAs to the fetus
4- Fasting hypoglycemia
3- Decreased renal glucose threshold
5,6,7- Hyperglycemia
4- Rapid transfer of glucose to fetus
(facilitated diffusion)
5- anti insulin effect of placental
hormones (HPL, E, P, CCs)
6- placental Insulinase
7- Glycogenolysis
 Types Classifications
• Priscilla White Classification
• GDM (late in • A
pregnancy) • A1 – FBS normal– DIET CONTROL
• Usually develop overt DM within • A2 – FBS elevated – Require Insulin
5 – 10 yrs later 35% • B – ONSET after age of 20 and
• Overt DM duration less than 10 years.
• C – start in age (10-19 yrs) – and
• Diagnosed duration (10-19 yrs)
Classifications (preconceptionally) • D – onset less than age 10 and
& types duration more than 20 yrs
• Type I (insulin dependent –
• E – calcified pelvic vessels
Juvenile onset)
• Type II (adult onset – insulin • F - nephropathy
resistant) • R - retinopathy
• Undiagnosed
 PDFs = high risk group

Elderly Grand Bad Obst

Obesity Macrosomia
gravida multipara History

Recurrent
Repeated Unexplained
RPL PROM &
CFMF IUFD
PTL
 Side effects Effect of pregnancy Effect of DM on
(complications) on DM pregnancy

On mother

On fetus

On neonate
 Effect of pregnancy on
diabetes

Pregnancy is a diabetogenic
condition

• If on oral TTT – parenteral

• If controlled – uncontrolled
Worsen the DM – ONE • If controlled on insulin –
STEP increase the dose
• If uncomplicated – become
complicated
Effect of DM on pregnancy
On mother

• Abortion – RPL – why ??

• Pruritus – why ??
• Difficult control – why ??
• DKA – why ??
• May develop PET – why ??
• PROM & Chorioamnionitis – why ??
• PTL - why ??
• Polyhydramnios – why ??
• Instrumental delivery & maternal
birth tract injury
• Puerperal sepsis & wound infection –
why
On fetus
• CFMF
• Most common ???
• Most pathognomonic ???
• Fetal macrosomia ?????
• Fetal birth injury
• Un explained fetal
death
On neonate
/ ‫ مورم‬/ ‫ مخبوط‬/‫ كبير‬/‫بيبي‬
‫ملون‬

• Hypoglycemic
• Hypocalcemia
• Polythematic
• Hyperbilirubinemia
• RDS
Who to screen & how to diagnose?
Target population ??

• Non high risk - WHEN?

• High risk – WHEN ?

Sequence

• Screening
• One hour test (50 g) Then test
• If > 200 mg/dl - ….
• If < 140 mg/gl - ……
• If in between - …..
• Diagnostic
• FBS
• OGTT
• Abnormal two values
• Tested in blood & urine
Management

PRECONCEPTIONAL
• Counselling
• Control blood sugar level
• Folic acid (what dose)?

During pregnancy
• Aim
• 1- Euglycemic control (since
early pregnancy)
• Diet & exercise
• Oral hypoglycemic
• Insulin
• 2- Fetal surveillance ( FCA,
Macrosomia, Polyhydramnios)
• 3- Timing & route of labor
Glycemic control
FBS - < 90 MG/DL
1hr PPBS - < 140 MG/DL
• A1 – DIET & EXERCISE
• 30 Kcal/ Kg/ day
• A2
• Oral hypoglycemics
• B & other categories (Or Failed previous steps to control
blood sugar levels)
• Insulin
• Frequent monitoring (4 times daily)
• Dose
• 1 unit/ Kg
• Divided
• 2/3 in the morning
• 1/3 in the evening

N.B: -
• HbA1c
• < 7%
• Importance ?????
 Anomalies
• Ultrasound anomaly scan
• (1st trimester)
• NTD, Anencephaly, Nuchal
Translucency
• (2nd trimester)
• Cardiac (sacral agenesis)
Fetal surveillance • Trisomies & NTD
• Double Marker test (11-13
Wks)
• Triple test (16-18 Wks)

Fetal growth FWB

• Ultrasound in 3rd • NST
trimester • BPP
• Macrosomia,
polyhydramnios
• IUGR
N.B. Timing of ending the pregnancy
• CCs

Euglycemic, Controlled, No
complications, No macrosomia

Yes No

Once proved fetal

lung maturity
Continue up to => 37 Wks GA
4o Wks GA , VD OR
complication /
fetal distress
 When to
perform C.S.

IUGR
Macrosomia
(intrapartum
(truncal obesity Other obstetric
hypoxia,
– shoulder indication
cerebral palsy ,
dystocia)
still birth)

Care of the newborn

• Infant of diabetic
mother
• Hypoglycemia
• RDS

Puerperium
• Readjust insulin dose
• Care against infection
Thyroid disease with
pregnancy
Maternal adaptation

Physiological goiter

Decreased plasma iodine –

why ??

Increased thyroid binding

globulin result in increased total
T3, T4 (UNDER EFFECT OF ??)

Normal Free T3, T4

 Etiology
Hyperthyroidism • Gravis disease – the commonest (Autoimmune) –
associated with fetal hyperthyroidism ????
• Nodular goiter (toxic)
• Molar pregnancy ??????

C/P

• Failure to gain weight

• Tachycardia
• Thyroid enlargement – debate !!
• Exophthalmos

Diagnosis

• Normal or low TSH

• Marked increased T3, T4
• N.B. ( in case of GRAVES Disease)
• Anti thyroid antibodies is elevated
 Effect on pregnancy
Hyperthyroidism • If controlled – NO EFFECT
• Uncontrolled
• RPL
• PTL
• IUGR
• PNMR increased

Treatment

• Propylthiouracil (50-200 ug/d)

• B- blocker
• Steroids & iodine in sever / autoimmune
cases
• Toxic – thyroidectomy
 Hypothyroidism
Etiology

• An autoimmune disorder (Hashimoto's disease)

• Hormonal changes in pregnancy
• Genetics
• older age
• higher body mass index
• a diet low in iodine2.
• Endemic iodine deficiency
• Chronic autoimmune thyroiditis

Effect on pregnancy

• Mild OR controlled – NO EFFECT

• IF sever – usually anovulation & infertility OR RPL
Hypothyroidism
Diagnosis

• Elevated TSH

Treatment

• Oral thyroid hormone

Thank you