Diabetes mellitus in

pregnancy
Dr.manal naseh
CABOG ,FICMS,DOG
TYPES

type 1 diabetes mellitus

 type 2 diabetes mellitus
 impaired glucose tolerance develops
during the course of her pregnancy
(GDM).
 Prepregnancy counselling

 The aim of prepregnancy counselling is to achieve the best possible glycaemic

control before pregnancy and to educate diabetic women about the
implications of pregnancy.
Advice includes:
 Optimization of glycaemic control to achieve an HbA1c of <42 mmol/mol
without inducing hypoglycaemia.
 High-dose folic acid (5 mg daily) to reduce the risk of neural tube defects.
 Planning periconception adjustments to other medications such as statins and
angiotensin-converting enzyme (ACE) inhibitors before pregnancy.
Poor glycaemic control

 is associated with a significantly increased risk of congenital anomalies,

particularly neural tube defects and cardiac anomalies.
The most critical period for the embryo is therefore the period of organogenesis,
which occurs in the first 42 days of pregnancy, and this is often before the
pregnancy is medically confirmed.
 The level of HbA1c in early pregnancy also correlates with the risk of early
fetal loss.
 An HbA1c of >85 mmol/mol is associated with a fetal loss during pregnancy of
around 30%.
Management

In the preconception period, diabetes therapy should be

intensified and adequate contraception encouraged until
glucose control is good.
Targets for therapy prepregnancy are premeal glucose levels
of 4–7 mmol/l. Improved glycaemic control may be achieved
with newer insulin delivery systems such as continuous
subcutaneous insulin infusion pumps and glucose sensors
Management of complication
 Diabetic vascular complications are common in women of
reproductive age and women with significant retinopathy,
nephropathy and/or neuropathy benefit from multidisciplinary
team review prior to pregnancy.
 It is important that a plan for medication adjustment is made and
women are counselled regarding the additional potential
complications associated with diabetic microvascular disease. This
is particularly important for women with nephropathy, which is
associated with a significantly increased risk of complications
arising in pregnancy that would necessitate preterm delivery as for
women with other types of renal disease (80% chance if 125–180
μmol/l; 75% chance if 180–220 μmol/l; and 60% chance if >220
μmol/l). There is also a risk that retinopathy can progress in
pregnancy and during the postpartum period.
Maternal and fetal complications of
types 1 and 2 diabetes mellitus
 Congenital abnormality is an important cause of mortality and morbidity in
diabetic pregnancies and is seen 2–4 times more often than in pregnancies
without diabetes, with a threefold excess of cardiac and neural tube defects.
 structural malformations
 fetal macrosomia , frequently contributes to a traumatic birth and shoulder
dystocia.
 Stillbirth, particularly in the third trimester, remains too common in
pregnancies complicated by maternal diabetes, being five times higher than in
the general population.
 Concerns regarding fetal wellbeing, particularly in the presence of fetal
macrosomia, frequently prompt early term delivery in women with diabetes,
which in turn increases the likelihood of neonatal unit admission and reduces
breastfeeding rates
 maternal morbidity in diabetic pregnancies is related to
the severity of diabetic-related vascular disease preceding
the pregnancy. The risk of preeclampsia is increased
threefold in women with diabetes, and particularly in
those with underlying microvascular disease. All women
with diabetes should be offered low-dose aspirin from 12
weeks’ gestation to reduce the risk of preeclampsia.
Women with diabetic retinopathy are at risk of progression
of the disease and should be kept under careful
surveillance (retinal screening at booking, 16–20 weeks’
and 28 weeks’ gestation).
Other maternal complications

 increased incidence of infection, severe

hyperglycaemia or hypoglycaemia, diabetic
ketoacidosis and the complications that may arise
from the increased operative delivery rate.
Management of types 1 and 2 diabetes
in pregnancy
 Women with diabetes should be managed throughout
their pregnancy by a multidisciplinary team involving
diabetic specialist midwives and nurses, a dietician, an
obstetrician and a physician. The primary goal of the
team is to support the woman and her family during the
pregnancy to safely optimize glycaemic control. Blood
glucose monitoring is encouraged 7 times a day (before
and 1 hour after meals) with targets of with targets of
<5.3 mmol/l and 1-hour postprandial levels of <7.8
mmol/l.
 If not given before pregnancy, women require additional
support and education regarding diet, use of oral
hypoglycaemic agents such as metformin
where appropriate, insulin adjustments for hyperglycaemia
and management of hypoglycaemia, which is much more
common and potentially very dangerous in pregnancy,
particularly in women with reduced hypoglycaemic
awareness.
 Insulin resistance increases dramatically
over the course of pregnancy and therefore
women with type 1 and type 2 diabetes are
usually required to increase their dose of
insulin or metformin during the second half
of pregnancy.
A plan for the pregnancy should be set out in early
pregnancy and should include renal and retinal
screening, fetal surveillance and a plan for delivery.
Women with diabetes should be offered a fetal
anomaly scan at 19–20 weeks with an assessment of
the cardiac outflow tracts. Serial growth scans are
also recommended to assess fetal growth and
.diagnose macrosomia and polyhydramnios
 If antenatal corticosteroids are indicated, additional
insulin therapy is required to maintain normoglycaemia,
often requiring inpatient admission. Timing and mode of
delivery should be determined on an individual basis. In
general, provided the pregnancy has gone well, the aim
would be to achieve a vaginal delivery at between 38 and
39 weeks. However, the development of macrosomia or
maternal complications such as pre-eclampsia, together
with the rate of failed induction, is such that the
caesarean section rate amongst diabetic women often is
as high as 50%.
 For women with type 1 diabetes and those with type 2
diabetes requiring insulin, a sliding scale of insulin and
glucose should be commenced in labour, and maternal
blood glucose levels maintained at 4–7 mmol/l to reduce
risk of neonatal hypoglycaemia. Insulin requirements
return to prepregnancy levels immediately following
delivery and insulin doses should be adjusted accordingly
 Women should be informed of the increased risk of
hypoglycaemia in the postnatal period, particularly if they
are breastfeeding