DIABETES IN PREGNANCY

DR. ANMOL DEEP

 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. The most important perinatal
concern in this group is macrosomia with resulting birth trauma. More than 50% women
ultimately develop diabetes in the ensuing 20 years and this is linked with obesity.
 Pre-gestational diabetes is diabetes that antedates pregnancy. Pregnancies which are
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 development in mid and late
pregnancy.
 CLASSIFICATION
• Pregestational diabetes: A lady 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. Women found early in
pregnancy to have gestational diabetes are a high-risk subgroup.
 Risk Factors for gestational diabetes screening
1. Strong family history of diabetes
2. Past history of glucose intolerance or diabetes in a previous pregnancy
3. Obesity; overweight women (>15% of non-pregnant ideal body weight)
4. Ethnic group with a high prevalence of diabetes (e.g. Indians, Asians, Hispanic)
5. Persistent glycosuria
6. Age > 30 years
7. Women who have given birth to large infants (>4 kg; 8 lbs 13 oz)
8. History of recurrent fetal loss
9. History of traumatic delivery with an associated neurological disorder in the infant
 Risk Factors for gestational diabetes screening

10. History of stillbirth, unexplained neonatal death, congenital malformations,

prematurity.
11. History of pre-eclampsia or polyhydraminos
12. Chronic hypertension
13. Recurrent severe candidiasis or urinary tract infection
 PATHOPHYSIOLOGY:

• Caused by placental production of human placental lactogen (HPL) and progesterone.

• Other hormones that may contribute include prolactin and cortisol.
• Early in pregnancy, relatively higher levels of estrogen enhance insulin sensitivity.
• As placenta develops, estrogen decreases as HPL and progesterone rise, resulting in increased insulin
resistance at the end organs.
• Insulin resistance is most marked in the third trimester at which time GDM most often occurs.

Insulin
• is the major fetal growth hormone .
• produces excessive fetal growth particularly in fat, the most insulin-sensitive tissue.
GROWTH ABNORMALITIES(1)
TWO EXTREMES OF GROWTH ABN:
 WHOM TO SCREEN?
Risk stratification

• Low risk: no screening

• Average risk: at 24-28 weeks

• High risk: as soon as possible

Screening is done between the 24th and 28th weeks of pregnancy or
earlier if any of the risk factors are present.
 Low risk for GDM

• Age <25 years

• Weight normal before pregnancy

• Member of an ethnic group with a low prevalence of GDM

• No known diabetes in first-degree relatives

• No history of abnormal glucose tolerance

• No history of poor obstetric outcome

Intermediate risk for GDM
• Women of south east Asian origin ,including Indian
• Women of Native American,African

HIGH RISK FOR GDM

• Marked obesity • Polyhydraminos
• Prior GDM • Poor reproductive history ( >3
• Glycosuria spontaneous abortions in first and second
• Strong family history trimester)
• Ethnic group with high diabetes prevalence • Recurrent UTI and candidiasis
• History of still birth • Age>30 years
• History of congenital anomaly
• History of delivery of large infant (>4kg)
 Screening test
Oral Glucose Tolerance Test (OGTT): Measurement of plasma glucose after
ingesting 75 g of glucose in 200ml of water in 10-15 mins.
 Screening test
 Glucose Challenge Test (GCT): An excellent screening test for gestational diabetes is
the measurement of plasma glucose 1 hour after ingesting 50 g of glucose.
A value of <140 mg/dl is takes as normal
a value of 140 -199 mg/dl identifies 80% women with GDM and is taken as cut off point for
Glucose tolerance test
Using a cut-off value > 200 mg/dl taken as overt diabetes
Gluocse tolerance test – 100 gm glucose ingestion with 3 hour measurement of plasma
gluscose. Two or more values should exceed the cut off for diagnosis of GDM
 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
 Effects of GDM on neonates
Respiratory distress
Hypoglycemia
Hypocalcemia
Hyperbilirubinemia
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)
Macrosomia is a result of persistent maternal hyperglycemia
leading 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.
INFANT OF A DIABETIC MOTHER WITH
SACRAL AGENESIS
• Cardiovascular anomalies: ASD,
VSD,TGA
• Skeletal anomalies: sacral
agenesis
• CNS anomalies
• Genitourinary anomalies: renal
agenesis, polycystic kidneys
 CONGENITAL ABNORMALITIES DUE TO GDM
• 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: affects 10-25% of all pregnant women with GDM
 Infections: high incidence of chorioamnionitis
 Postpartum bleeding: high incidence caused by exaggerated uterine distension
 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
 MANAGEMENT:

• The goal is to prevent adverse pregnancy outcomes.

• A multidisciplinary approach is used.
• Patient is seen every 1-2 wks until 36 wks gestation and then weekly.
• Patient is asked to keep an accurate diary of their blood glucose concentration.
• Aim – to keep fasting plasma glucose - <95mg/dl and 2 hr pp plasma glucose at <
120mg/dl.
DIETARY THERAPY:

• Dietary restriction – 1200-1800 kcal/day for obese ( BMI > 30kg/m2)

• ACOG recommends 55% carbs, 20% protiens, 25% fats of total calories
• Exercise
• Recommend a complex, high fiber diet
• Avoid concentrated sweets
WHEN DIETARY THERAPY FAILS:

• Insulin
• Oral Hypoglycemic Agents:
-Glyburide
-Metformin
INSULIN REGIMEN:

• If the fasting value is > 105 mg/dL, or 2 hr value >140 mg/dL despite diet therapy. insulin
therapy needs to be initiated. A total dose of 20 to 30 units divided into 2/3 rd morning
( 2/3rd intermediate acting and 1/3rd short acting insulin) and 1/3rd night (1/2 intermediate
½ short acting) is started
 PATIENT EDUCATION
CORNERSTONE IN GDM MANAGEMENT

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
 Management of labor and delivery
Vaginal delivery: preferred
Cesarean 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
Monitor sugars 1-2 hrly intervals during labour
Give insulin only if blood sugar >100 mg/dl
DELIVERY:

Early delivery may be indicated for:

• women with poor glycemic control
• pregnancies complicated by fetal abnormalities
Otherwise, pregnancies are allowed to go to term.
INTRAPARTUM:

The goal is to maintain normoglycemia in order to prevent neonatal hypoglycemia.

• Check patient’s glucose q1-2 hours.
• Start insulin drip to maintain a glucose level of 100 mg/dL.
• Observe infant closely for hypoglycemia, hypocalcemia, and hyperbilirubinemia after
birth.
GLYCEMIC MANAGEMENT DURING LABOUR
Later stages of labor: start dextrose to maintain basal nutritional
requirements: 150-200 ml/hr of 5% dextrose
Elective Cesarean 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 ! )
 Immediate management of neonate

Hypoglycemia: 50 % of macrosomic infants

Starts when the cord is clamped
Exaggerated insulin release secondary to pancreatic ß-cell
hyperplasia
Increased risk: blood glucose during labor and delivery
exceeds 90 mg/dl

Anticipate and treat hypoglycemia in the infant

MANAGEMENT OF NEONATE

 Hypoglycemia <45 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
 POSTPARTUM CARE:

After delivery:
• Measure blood glucose.
-fasting blood glucose concentrations should be <105 mg/dL and one hour postprandial concentrations should be
< 140 mg/dL.
• Administer one half of the pre-delivery dose before starting regular food intake.
Follow up:
• If the pt’s postpartum GTT is normal, she should be re-evaluated at a minimum of 3 years interval with a fasting
glucose.
• All pts should be encouraged to exercise and lose wt.
• All pts should be evaluated for glucose intolerance or DM before a subsequent pregnancy.
 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
 LONG TERM RISK: OFFSPRING

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

17 pound baby born to Brazilian diabetic mother Courtesy: MSNBC News Services
Jan. 24, 2005