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Diabetes in pregnancySupervised via:

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Diabetes in pregnancy

Pre-existing diabetes Gestational diabetes

Pre-existing diabetesIDDM

(Type1)

NIDDM

(Type2)True GDM

Preexisting diabetes in pregnancy

Type 1 DM ( IDDM)

Type 2 DM (NIDDM)

Preexisting DM in pregnancyEffect of pregnancy on pre-existing DM

• Increase requirement for insulin doses

• Nephropathy , autonomic neuropathy may deteriorate

• Progress in diabetic retinopathy Hypoglycemia

• Diabetic ketoacidosis

Preexisting DM In PregnancyEffect of preexisting DM on pregnancy

(1) Maternal

1. increase risk of miscarriage

2. increase risk of preclampsia

3. increase risk of infeaction eg vaginal candidiasis, UTI, endometrial or wound infection

Preexisting DM in Pregnancy(2) Fetal

1. increase risk of congenital abnormalities

sacral agenesis, congenital heart disease,

neural tube defects

Hba1c level Risk

normal not increased

<8% 5%

>10% 25 %

Preexisting DM in Pregnancy2. Perinatal mortality (excluding

congenital abnormality ) 2 fold increased

3. Increase risk of sudden unexplained intrauterine fetal death.

Complications of pregnancy in pre-existing DMMaternal:

Increase insulin requirment’

Hypoglycemia

Infection

Ketoacidosis

Deterioration in retinopathy’

Increased proteinuria+edema

Miscarriage

Polyhydramnio

Preeclampsia

Increased caesarean rate

Fetal:

Congenital abnormalities

Increased neonatal and perinatal mortality

Macrosomia

Late stillbirth

Neonatal hypoglycemia

Polycythemia

Shoulder dystocia

jaundice

Maternal hyperglycemia

|

Fetal hyperglycemia

|

Fetal pancreatic beta-cell hyperplasia

|

Fetal hyperinsulinaemia

|

Macrosomia,organomegaly, polycythaemia, hypoglycemia, RDS

Management Aim

Achieve maternal near normoglycemic level to prevent adverse perinatal

outcomes

DietLow-carbohydrate diet , high fibre with

caloric restriction

Frequent small snacks may be needed between meals

Avoid starvation

Insulin3 pre-meal short acting insulin

(actrapid) +/- intermediate-acting insulin (protophane) as it allows maximum flexibility

Target blood glucose:

fasting < 5mmol/L

2 hr <7 mmol/L

Oral Hypoglycemic agents Implicated as teratogeneic in animal

studies esp first generation sulfonyureas

In humans, scattered case reports of congenital abnormality

Risk of congenital abnormality related to maternal glycemic control rather than mode of the anti-DM agents

Oral hypoglycemic agentsFor Type 2 DM patients,

to stop oral hypoglycemic agents and change to insulin

Reassure that the risk of congenital abnormality due to drug is small

Oral hypoglycemic agents Biguanides ( metformin)

Commonly used in Polycystic Ovarian Disease (PCOD) to treat insulin resistance and normalize reproductive function

Not teratogeneic

Reduce first trimester miscarriage

10X reduce gestational diabetes

Oral hypoglycemic agentsSulfonylureas1st generation drug increase risk of

neonatal hypoglycemia2nd generation drug (Glyburide) no

such effect and other morbidities . 4%-20% patients failed to achieve

glucose control with maximum dose of drugIncrease risk of preeclampsia and need

for phototherapy

Insulin Analogues 1. rapid-acting insulin analogs

(lispro)

majority of evidence showed that it does not cross placenta, and has no adverse maternal or fetal effects

Insulin Analogues2. Long acting analogs

glargine

Not well studied systemically

MonitoringRegular home glucose monitoring with

h’stix

Insulin may be need to be adjusted as gestation advances

Hba1c monitoring

Fetal monitoring with USG

Refer ophthamologist

DeliveryTiming and mode of delivery

individualised

Intrapartum insulin infusion with glucose monitoring

no contraindication for Breast feeding either with insulin or oral hypoglycemic agents

Pre-conception Counselling Allows for optimisation of diabetic control prior to

conception, and assessment of the presence of complications like hypertension, nephropathy, and retinopathy

Should counsel that good control and lower hba1c lower the risk of congenital abnormalities and improve outcome

If necessary, proliferative retinopathy may be treated with photocoagulation prior to conception

Contraindications to pregnancy only :ischemic heart dx, untreated proliferative retinopathy, severe renal impairment(creatinine>250 mmol/L)

Gestational diabetesDefinition

Carbohydate intolerance of variable severity first recognised during the present pregnancy.

This includes women with preexisting but previously unrecognised diabetes

Gestational diabetes Screening and diagnosis

In general, the test is performed btn 24-28 wk

because at this point in gestation the diabetogenic effect of pregnancy is manifest and there is sufficient time remaining in pregnancy for therapy to exert its effect

Gestational diabetes Screening and diagnosis

In general, risk factor includes:1. age>25y2. BMI > 253. previous GDM4. Family hx of DM in 1st degree relative5. previous macrosomic baby (<4 kg)6. polyhydramnio7. large for date baby in current pregnancy8. previous unexplained stillbirth

Gestational diabetesScreening

Fasting / random glucose/ glucose challenge test(50gm)

Diagnosis

Glucose challenge test

(75gm/100gm ?)

Gestational diabetes Diagnosis

WHO criteria 1998,

75 gm glucose

fasting 2 hr (mmol/L)

Impaired fasting glucose 6.1-6.9

IGT <or =7 and 7.8-11

DM >or = 7 or > or=11.1

Gestational diabetesIncidence

2-9%

more common in Asian and Indian women

In developed countries, increasing trend because of epidemic of obesity

Gestational diabetesClinical significance of GDM

1. High incidence of macrosomia, and adverse pregnancy outcomes,

2. A significant proportion(30%) identified as GDM in fact have DM before pregnancy

Gestational diabetesWomen with glucose intolerance just

above normal range are at low risk for pregnancy complications, those with more severe glucose intolerance approaching the criteria of diabetes are at risk of neonatal complications

Fetal complicationsMacrosomia (>4 kg)

risk is 16-29% as compared to 10% in control

Increase in caesarean delivery, instrumental deliveries ( forceps/vacuum), birth trauma, such as brachial plexus injuries , clavicular fractures

Increase in neonatal hypoglycemia (24% ), hyperbilirubinemia, hypocalcemia, polycythemia

Children are at risk of type 2 DM and obesity in life

Maternal complications Increase risk of hypertensive disorders

Increase risk of caesarean and intrumental deliveries

Increased Risk (40-60%) of developing type 2 DM within10-15 yr.

Gestational diabetes

Management Management similar as preexisting DM

Need for glucose monitoring

Start with Diet control

Commence insulin for poor control

Delivery plan individualised

Gestational diabetesIn view of risk of developing type 2 DM

the woman should be screened annually for DM on yearly basis.

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