DR FARAH DEEBA NASRULLAH

ASST PROF DEPT OF OBGYN UNIT II

CHK/DUHS

Pregnancy is a state of insulin resistance & relative

glucose intolerance
This is due to placental production of anti-insulin
hormones : hPL, cotisol, and glucagon
FBS
Postprandial glucose
Insulin production 2 folds in N women
Insulin requirements in diabetic women
renal threshold for glucose glycosuria

Pregnancy may be complicated by diabetes

in two distinct forms:

Gestational diabetes mellitus (GDM) is defined as

glucose intolerance of varying severity with onset or
first recognition during pregnancy. This constitutes 90%
of women with pregnancies complicated by diabetes.
The most important perinatal complication in this group
is macrosomia with resulting birth trauma. More than
 50% women ultimately develop diabetes in the next 20
years and majority of them are obese.
Pre-gestational diabetes is diabetes that antedates
pregnancy. Pregnancies complicated by pre-
gestational diabetes, type-1 or type-2, carry an
additional risk to both mother and fetus beyond the
effects on fetal growth and congenital anomalies.

Pregestational diabetes: A woman with known

diabetes who conceives while on treatment with diet,
oral hypoglycemic agents or insulin.
Type 1 DM, Type 2 DM, Secondary DM
Gestational diabetes mellitus is defined as glucose
intolerance of variable degree with onset or first
recognition during pregnancy.

Risk Factors for gestational diabetes screening

1. Strong family history of diabetes

2. History of birth to large infants (>4 kg; 8 lbs 13 oz)
3. History of recurrent fetal loss
4. Persistent glycosuria
5. Age > 25 years
6. Past history of glucose intolerance or diabetes in a
previous pregnancy

Obesity; overweight women (>15% of non-pregnant ideal

body weight)
8. Ethnic group with a high prevalence of diabetes (e.g. Pima
Indians, Asians, Hispanic)
9. History of stillbirth, unexplained neonatal death, congenital
malformations, prematurity.
10. History of pre-eclampsia or polyhydraminos
11. Chronic hypertension
12. Recurrent severe candidiasis or urinary tract infection
13. History of traumatic delivery with an associated
neurological disorder in the baby

Risk Assessment
Low risk: no screening
Average risk: at 24-28 weeks
High risk: as soon as possible
Screening is usually initiated b/w24th and 28th weeks of
pregnancy or earlier in the presence of risk factors .

Low risk for GDM

Age <25 years
normal BMI before pregnancy
Ethnic group with a low prevalence of GDM
No H/O diabetes in first-degree relatives
No H/O abnormal glucose tolerance
No H/O obstetric complication

HIGH RISK FOR GDM

Marked obesity
Prior GDM
Glycosuria
Strong family history
Ethnic group with high diabetes prevalence

Screening test
Glucose Challenge Test (GCT): best screening test
for gestational diabetes. It includes measurement of
plasma glucose 1 hour after ingesting 50 g of glucose
 without dietary preparation between 24-28 weeks of
gestation.
cut-off value > 140 mg/dl identifies 80% women with GDM
cut-off value > 130 mg/dl identifies 90% women with GDM
Women with elevated GCT values require a diagnostic test
(OGTT)
Oral Glucose Tolerance Test (OGTT): After an overnight
fast measurement of plasma glucose after ingesting 100 g
of glucose.
Timing of National Carpenter and
measurement Diabetes Data Coustan (CC)
Group (1979) 1982
Fasting 105 mg/dl 95 mg/dl
1 hour 190 mg/dl 180 mg/dl
2 hour 165 mg/dl 155 mg/dl
3 hour 145 mg/dl 140 mg/dl

Women in whom the criteria of DM are met in

pregnancy include a gp of diabetics who were
undiagnosed before pregnancy
FBS > 7 mmol/L on 2 occasions
Or
RBS > 11.1 mmol/L on 2 occasions
Borderline cases GTT DM is Dx if FBS > 7
mmol/L or 2 hrs > 11.1 mmol/L
Impaired glucose tolerance 2hrs G 8-11 mmol/L with
a N FBS
 Effects of GDM on the fetus

Congenital abnormalities
Neonatal hypoglycemia
Macrosmia (big baby syndrome > 4 Kg or >8 lb 13 oz)
Jaundice
Polycythemia / hyperviscosity syndrome
Hypocalcemia, hypomagnesemia
Birth trauma (due to macrosmia and shoulder
dystocia)
Prematurity
Hyaline membrane disease
Apnea and bradycardia

The risk of fetal anomalies is not increased in GDM patients.

However, the risks of unexplained still births (during the last
4-8 weeks of gestation) are similar to pre-gestational
diabetes.

Effects of GDM on neonates

Hypoglycemia
Hypocalcemia
Hyperbilirubinemia
RDS
Cardiac Hypertrophy
Long term effects on cognitive development

Macrosomic infant
Macrosomia (large for gestational age or big baby
syndrome)
(birth weight >90% percentile for gestational age)
persistent maternal hyperglycemia leadS to fetal
hyperglycemia and prolonged fetal hyperinsulinism. This
stimulates excessive somatic growth mediated by insulin-like
 growth factors (IGFs). Macrosomia affects all organs except
the brain.

Cardiac (most common): transposition of great vessels,

Ventricular septal defect, Atrial septal defect
Central nervous system (7.2%): spina bifida,
Anencephaly, hydrocephalus
Skeletal: cleft lip/palate, caudal regression syndrome
Genitourinary tract: ureteric duplication
Gastrointestinal: anorectal atresia
Renal agenesis, Duplex ureters, Cystic Kidney
Situs inversus

Poor glycemic control at time of conception: risk

factor Caudal regression syndrome
(abnormal development of lower spine)

Effects of GDM on the

mother
Pre-eclampsia: 10-25% of all pregnant women with GDM
 Infections: high incidence of chorioamnionitis and
postpartum endometritis
Postpartum bleeding: caused by uterine overdistension
Cesarian section more common due to fetal macrosmia and
cephalo-pelvic disproportion
Weight gain
Hypertension
Miscarriages
Third trimester fetal deaths
Long term risk of type-2 diabetes mellitus

Effect of pregnancy on diabetes

More insulin is necessary to achieve metabolic control

Progression of retinopathy: esp. severe proliferative

retinopathy

Progression of nephropathy: especially if renal failure +

Increased risk of Coronary artery disease, and a high

risk of maternal death in post MI patients

Cardiomyopathy

Instruct mother about maternal and fetal complications

Medical Nutrition therapy
Glycemic monitoring: teach mother about self
monitored blood glucose measurement and glycemic
targets
Pre-conception counseling
Fetal monitoring: ultrasound
Planning on delivery
 Long term risks
Glycemic control targets
Tight glycemic control can reduce fetal risk. But, strict
glycemic control p increaseds risk of hypoglycemic
events and the fetus at risk of being small-for-
gestational age.
American Diabetes Association Recommendations:
Fasting whole blood <95 mg/dl
glucose
1 hr postprandial blood <140 mg/dl
glucose
2 hr postprandial blood <120 mg/dl
glucose

in type-1 patients with pregnancy

Fasting blood sugar Macrosomia

>105 mg/dl 28.6 %

95-105 10%
<95 mg/dl 3%

4 times/day minimum, fasting and 1 to 2 hours after start

of meals
Maintain record
Calibrate the glucometer frequently
 Medical Nutrition and Exercise therapy
provide necessary nutrients for mother and fetus to
ensure adequate gestational weight gain
control glucose levels
prevent starvation ketosis
aerobic exercise, exercise that does not stress the
trunk
Current weight in Daily caloric Recommended
relation to ideal intake pregnancy
body weight (kcal/kg) weight gain (kg)
<80-90% 36-40 28-40
80-120% (ideal) 30 25-35
120-150% 24 15-25
>150% 12-18 15-25

Approximately 30 kcal/kg of ideal body weight

> 40-45% should be carbohydrates

6-7 meals daily (3 meals, 3-4 snacks). Bed time snack

to prevent ketosis

Calories guided by fetal well being/maternal weight

gain/blood sugars/ ketones

Energy requirements during the first 6 months of

lactation require an additional 200 calories above the
pregnancy meal plan

Insulin in GDM
Insulin used if fasting blood glucose >105 mg/dl or 1 hr
postprandial blood glucose >120 mg / dl on a diet
Use basal bolus regime or pre-mixed insulin
Short acting insulins (e.g. Lispro and Aspart) can be used to
achieve postprandial control
Insulin requirements increase by 50% from 20-24 weeks to 30-32
weeks, after which insulin needs often stabilize.

Oral Hypoglycemic agents

Glyburide is a clinically effective alternative to insulin in GDM

(Langer et al. 2000)
Metformin may be effective in GDM (Ratner et al., 2008;
Coustan, 2007)

Preconception counseling
All women with pre-existing type-1 or type-2 diabetes, when
planning on pregnancy, should receive pre-conception
counseling so that they understand the importance of
achieving near-normal blood glucose before conception to
reduce the risk of congenital malformations and
spontaneous miscarriage.

Assess maternal and fetal risk

Mother should learn self-administration of insulin and
regular monitoring of blood glucose.
Target: HbA1c < 7%
Emphasize diet and exercise
Folic acid supplementation: 5 mg/day
Ensure no transmissible diseases: HBsAg, HIV, rubella
Try and achieve normal body weight: diet/exercise
Stop drugs: oral hypoglycemic drugs, ACE inhibitors,
beta blockers and potentially teratogenic drugs
 Medications
Pre-pregnancy weight
Weight gain
Edema
Pallor
Thyroid enlargement
Blood pressure
Fundal height

Laboratory parameters to be
monitored at antenatal visit

Hemoglobin
Blood Sugar
HbA1C
Urine microscopy and albumin

Baseline ultrasound : fetal size

Ultrasound evaluation of neural tube defects and other congenital
malformations should begin by 15-21 weeks of
At 18-22 weeks: fetal anatomic survey, major malformations
At 20-22 weeks: fetal echocardiogram for cardiac defects
At 26 weeks onwards: ultrasound to evaluate fetal growth and
amniotic fluid volume Third trimester: Fetal surveillance to reduce
risk of still birth: include non-stress test, biophysical profile, maternal
monitoring of fetal activity, frequent USG for accelerated growth
abdominal: head circumference
 Small risk of late intra-uterine death even with good glycemic
control
Delivery usually at 38 weeks
Beyond 38 weeks, increased risk of intrauterine death without an
increase in RDS

Management of labor and delivery

Vaginal delivery: preferred

Cesarian section only for routine obstetric indication
GDM alone is not an indication !
> 4.5 Kg fetus: Cesarean delivery may reduce the likelihood of
brachial plexus injury in the infant
Unfavorable condition of the cervix is a problem
Maintain euglycemia during labor
Maternal hyperglycemia in labor: fetal hyperinsulinemia and worsen
fetal acidosis
Maintain sugars: 80-120 mg/dl (capillary: 70-110mg/dl )
Feed patient the routine GDM diet
Maintain basal glucose requirements
Monitor sugars 1-4 hrly intervals during labour
Give insulin only if blood sugar >120 mg/dl

GLYCEMIC MANAGEMENT DURING LABOUR

Later stages of labour: start dextrose to maintain basal nutritional

requirements: 150-200 ml/hr of 5% dextrose
Elective Cesarian section: check fasting blood sugar; if within target
range no insulin is needed; start dextrose drip
Continue hourly self monitored blood glucose
Post delivery keep patients on dextrose-normal saline till fed
 No insulin unless sugars more than normal ( not GDM targets ! )

Post partum follow up

Check blood sugars before discharge
Breast feeding: helps in weight loss
Lifestyle modification: exercise, weight reduction
Oral glucose tolerance test at 6-12 weeks postpartum: classify
patients into normal/impaired glucose tolerance and diabetes
Preconception counseling for next pregnancy
Increased risk of cardiovascular disease,future diabetes and dyslipidemia

Immediate management of neonate

Hypoglycemia: 50 % of macrosomic infants
515 % optimally controlled GDM
Starts when the cord is clamped
Exaggerated insulin release secondary to pancreatic -cell
hyperplasia
Increased risk: blood glucose during labor and delivery exceeds 90
mg/dl
Anticipate and treat hypoglycemia in the infant

Hypoglycemia <40 mg/dl

Encourage early breast feeding
If symptomatic give a bolus of 2- 4 ml/kg, IV, 10% dextrose
Check after 30 minutes, start feeding
IV dextrose : 6-8 mg/kg/min infusion
Check for calcium, if seizure/irritability/RDS
Examine infant for other congenital abnormalities
 Increased risk of obesity and abnormal glucose tolerance due to
changes in fetal islet cell function
Encourage breast feeding: less chance of obesity in later life
Lifestyle modification

Conclusion

Gestational diabetes is a common problem in worldwide

Risk stratification and screening is essential in all pregnant women,

particularly those from ethnicities with increased risk

Tight glycemic targets are required for optimal maternal and fetal
outcome

Patient education is essential to meet targets

Long term follow up of the mother and baby is essential

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