Diabetes in PregnancyDiabetes in PregnancyRyan Agema MS IIIRyan Agema MS III

Diabetes in PregnancyDiabetes in Pregnancy

EpidemiologyEpidemiology ClassificationClassification PathophysiologyPathophysiology MorbidityMorbidity

FetalFetal MaternalMaternal

DiagnosisDiagnosis Treatment and ManagementTreatment and Management ReferencesReferences

EpidemiologyEpidemiology

4-6% of pregnancies in the U.S are 4-6% of pregnancies in the U.S are complicated by DM, accounting for complicated by DM, accounting for 50-150 thousand babies per year.50-150 thousand babies per year. 88% GDM, 8% Type II DM, 4% Type 1 88% GDM, 8% Type II DM, 4% Type 1

DMDM Prevalence also varies by racePrevalence also varies by race

1.5-2% in Caucasians, 5-8% in 1.5-2% in Caucasians, 5-8% in Hispanic, Asian and African Americans, Hispanic, Asian and African Americans, and up to 15% in some SW Native and up to 15% in some SW Native American groups.American groups.

ClassificationClassification

PathophysiologyPathophysiology

Normal pregnancy is Normal pregnancy is characterized by: characterized by: Mild fasting hypoglycemiaMild fasting hypoglycemia Postprandial Postprandial

hyperglycemiahyperglycemia HyperinsulinemiaHyperinsulinemia

Due to peripheral insulin Due to peripheral insulin resistance which resistance which ensures an adequate ensures an adequate supply of glucose for the supply of glucose for the baby.baby.

PathophysiologyPathophysiology

Human Placental Lactogen (HPL)Human Placental Lactogen (HPL) Produced by syncytiotrophoblasts of Produced by syncytiotrophoblasts of

placenta.placenta. Acts to promote lipolysis Acts to promote lipolysis increased increased

FFA and to decrease maternal glucose FFA and to decrease maternal glucose uptake and gluconeogenesis. “Anti-uptake and gluconeogenesis. “Anti-insulin”insulin”

Estrogen and ProgesteroneEstrogen and Progesterone Interfere with insulin-glucose Interfere with insulin-glucose

relationship.relationship. InsulinaseInsulinase

Placental product that may play a minor Placental product that may play a minor role.role.

A Vicious Cycle???A Vicious Cycle???

Fetal MorbidityFetal Morbidity

MiscarriagesMiscarriages Frequency directly related to Frequency directly related to

degree of maternal glycemic degree of maternal glycemic control.control.

Up to 44% with poorly controlled Up to 44% with poorly controlled DM (HbADM (HbA11C >12).C >12).

Preterm DeliveryPreterm Delivery Increase in both spontaneous and Increase in both spontaneous and

indicated preterm labor (<35 wks).indicated preterm labor (<35 wks).

Fetal MorbidityFetal Morbidity

Birth DefectsBirth Defects 1-2% risk among the general 1-2% risk among the general

population.population. 4-8 fold increased risk among 4-8 fold increased risk among

preexisting diabetics.preexisting diabetics. Most common defects are CNS and Most common defects are CNS and

CV, but also an increase in renal and CV, but also an increase in renal and GI abnormalities.GI abnormalities.

Up to a 600 fold increase in caudal Up to a 600 fold increase in caudal regression syndrome.regression syndrome.

Fetal MorbidityFetal Morbidity

MacrosomiaMacrosomia Defined as birthweight above 90Defined as birthweight above 90thth

% or >4000 grams.% or >4000 grams. Occurs in 15-45% of diabetic Occurs in 15-45% of diabetic

pregnancies, a 4-fold increase over pregnancies, a 4-fold increase over normal.normal.

Carries many morbidities including Carries many morbidities including birth trauma, RDS, neonatal birth trauma, RDS, neonatal jaundice and severe hypoglycemia.jaundice and severe hypoglycemia.

Fetal MorbidityFetal Morbidity

Growth RestrictionGrowth Restriction Although we typically associate Although we typically associate

maternal DM with macrosomia, maternal DM with macrosomia, growth restriction is fairly common growth restriction is fairly common among Type 1 diabetic mothers.among Type 1 diabetic mothers.

Best predictor is presence of Best predictor is presence of maternal vascular disease.maternal vascular disease.

Fetal MorbidityFetal Morbidity

Fetal MorbidityFetal Morbidity

PolycythemiaPolycythemia Hyperglycemia stimulates fetal erythropoeitin Hyperglycemia stimulates fetal erythropoeitin

production.production. Can lead to tissue ischemia and infarction.Can lead to tissue ischemia and infarction.

HypoglycemiaHypoglycemia Think of as an “overshoot” mechanism.Think of as an “overshoot” mechanism. Baby is used to having lots of maternal Baby is used to having lots of maternal

glucose so it makes lots of insulin. When glucose so it makes lots of insulin. When born, maternal glucose is no longer available born, maternal glucose is no longer available but insulin remains high but insulin remains high hypoglycemia. hypoglycemia.

Can lead to seizures, coma and brain Can lead to seizures, coma and brain damage.damage.

Fetal MorbidityFetal Morbidity

Postnatal hyperbilirubinemiaPostnatal hyperbilirubinemia Occurs in appox. 25%, double that of Occurs in appox. 25%, double that of

normal.normal. Thought to be due in large part to Thought to be due in large part to

polycythemia.polycythemia. Respiratory distress syndromeRespiratory distress syndrome

5-6 fold increased frequency.5-6 fold increased frequency. May be due to a delay in lung May be due to a delay in lung

maturation or simply due to the maturation or simply due to the increased frequency of preterm increased frequency of preterm deliveries.deliveries.

Fetal MorbidityFetal Morbidity

PolyhydramniosPolyhydramnios Amniotic fluid volume >2000 mL.Amniotic fluid volume >2000 mL. Occurs in 10% of diabetics.Occurs in 10% of diabetics. Increased risk of placental Increased risk of placental

abruption and preterm labor.abruption and preterm labor.

Maternal MorbidityMaternal Morbidity

Increased risk of DKA due to Increased risk of DKA due to increasingly resistant DM.increasingly resistant DM.

Increased incidence of UTI due to Increased incidence of UTI due to glucose-rich urine and urinary glucose-rich urine and urinary stasis.stasis. Glucosuria is a normal finding of Glucosuria is a normal finding of

pregnancy but may be much higher in pregnancy but may be much higher in diabetics.diabetics.

Diabetic retinopathyDiabetic retinopathy Diabetic nephropathyDiabetic nephropathy

Maternal MorbidityMaternal Morbidity

Diabetic neuropathyDiabetic neuropathy PreeclampsiaPreeclampsia

2-fold increase2-fold increase

DiagnosisDiagnosis

Glucose Challenge Test (24-28 Glucose Challenge Test (24-28 wks)wks) 50 gram glucose load with blood 50 gram glucose load with blood

level 1 hour later.level 1 hour later. Does NOT require fasting state.Does NOT require fasting state. Normal finding is <140 mg/dl.Normal finding is <140 mg/dl. If >140, need to do a 3 hour If >140, need to do a 3 hour

glucose tolerance test.glucose tolerance test.

DiagnosisDiagnosis

Glucose Tolerance TestGlucose Tolerance Test Draw a fasting glucose level Draw a fasting glucose level

(normal<95).(normal<95). Give 100 gram glucose load with Give 100 gram glucose load with

glucose levels drawn after 1, 2 and 3 glucose levels drawn after 1, 2 and 3 hours.hours.

Normal levels vary widely depending on Normal levels vary widely depending on who you ask but should be in the who you ask but should be in the following ranges:following ranges: 1 hr:<180 2 hr:<155 3 hr:<1401 hr:<180 2 hr:<155 3 hr:<140

2 or more abnormal values = GDM.2 or more abnormal values = GDM.

Treatment and Treatment and ManagementManagement

Obviously the main goal is to Obviously the main goal is to maintain good glycemic control.maintain good glycemic control. Typically controlled with insulin but Typically controlled with insulin but

oral hypoglycemic agents like oral hypoglycemic agents like glyburide are also showing promise.glyburide are also showing promise.

Treatment and Treatment and ManagementManagement

Obstetrical managementObstetrical management Serial US to trend fetal growth, AFI and Serial US to trend fetal growth, AFI and

fetal anatomyfetal anatomy Fetal well-being monitored with kick Fetal well-being monitored with kick

counts, NSTs, BPPscounts, NSTs, BPPs Postpartum, 95% of GDM mothers Postpartum, 95% of GDM mothers

return to normal glucose tolerance, return to normal glucose tolerance, and require no further insulin.and require no further insulin. Glucose tolerance screen 2-4 mo. Glucose tolerance screen 2-4 mo.

postpartum to detect those that remain postpartum to detect those that remain diabetic.diabetic.

ReferencesReferences

www.acog.org Current Obstetric & Gynecologic Current Obstetric & Gynecologic

Diagnosis & Treatment (2003)Diagnosis & Treatment (2003) Williams Obstetrics (2005)Williams Obstetrics (2005)