Diabetes in Pregnancy

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 subset constitutes 90% of women with
pregnancies complicated by diabetes. 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. Some patients with fasting
hyperglycemia detected early in pregnancy may be missed
cases of diabetes that predated 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. Women who have given 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
 Risk Factors for gestational diabetes screening
7. 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 moniliasis or urinary tract infection
13. History of traumatic delivery with an associated neurological
disorder in the infant
 Pathophysiology:
 Caused by placental production of human
placental lactogen (HPL) and progesterone.
 Other hormones that may contribute include
prolactin and cortisol.
 Pathophysiology-cont:
 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.
 Pathophysiology-cont:
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 ideally initiated 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
Must exhibit one risk factor from the list in slide 5.

High risk for GDM

 Marked obesity
 Prior GDM
 Glycosuria
 Strong family history
 Ethnic group with high diabetes prevalence
 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 plasma glucose level obtained one hour after a 50 g glucose
load administered at any time of the day without regard to the time
since the last meal, has become a well validated and widely
applied screening procedure for women between 24 and 28 weeks
of gestation.
Using a cut-off value > 140 mg/dl identifies 80% women with GDM
Using a cut-off value > 130 mg/dl identifies 90% women with GDM
Women with elevated GCT values require a diagnostic oral
glucose tolerance test
 Screening test
Oral Glucose Tolerance Test (OGTT): Measurement of plasma
glucose after ingesting 100 g of glucose.
Timing of National Diabetes Carpenter and
measurement Data Group (1979) Coustan (CC) 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
> 2 values must be abnormal; for at least 3 days prior to the test, the patient should have an
unrestricted diet and unlimited physical activity. The patient should fast for 8 hours before the
test. The CC criteria detects 54% more women with GDM than the NDDG criteria

Classification: and diagnosis of diabetes mellitus and other categories of glucose intolerance: National
Diabetes Data Group. Diabetes 1979;28:1039–1057
Carpenter MW, Coustan DR. Criteria for screening tests for gestational diabetes. Am J Obstet Gynecol.
1982;144:768-73.
 Urine monitoring

Urine glucose monitoring is not useful in gestational diabetes

mellitus

Urine ketone monitoring may be useful in detecting insufficient

caloric or carbohydrate intake in women treated with calorie
restriction
 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
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
 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)
Caudal regression syndrome
 Effects of GDM on the mother
 Pre-eclampsia: affects 10-25% of all pregnant women with
GDM
 Infections: high incidence of chorioamnionitis and postpartum

endometritis
 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.
 Dietary Therapy:
 Refer to a dietitian
 Recommend a complex, high fiber CHO diet
 Avoid concentrated sweets
 When Dietary Therapy Fails:
 Insulin
 Oral Hypoglycemic Agents:

-Glyburide
-Metformin
 Insulin Regimen:
 Pt should check their fasting glucose and a 1
hour or 2 hour postprandial glucose level
after each meal, for a total of four
determinations each day.
 If the fasting value is > 95 mg/dL, or 1 hr
value > 130-140 mg/dL or 2 hr value > 120
mg/dL, insulin therapy needs to be initiated.
 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
 Maintain basal glucose requirements
 Monitor sugars 1-4 hrly intervals during labour
 Give insulin only if blood sugar >120 mg/dl
 Timing of delivery
 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

 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 between 80 - 110 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
 5–15 % optimally controlled GDM
 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 <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
 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.
 Postpartum Care-cont:
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.
 Self monitored blood glucose (SBMG)

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

meals
 Maintain log book

 Use a memory meter

 Calibrate the glucometer frequently

 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