Diabetes in Pregnancy

1. Diabetes in Pregnancy

2. Classification • Pregestational diabetes Type 1 DM Type 2 DM Secondary DM • Gestational diabetes

3. Definition Gestational diabetes (GDM) is defined as glucose intolerance of variable degree with onset or first recognition during the present pregnancy. Pregestational diabetes precedes the diagnosis of pregnancy.

4. Magnitude of problem: GDM • GDM varies worldwide and among different racial and ethnic groups within a country • Variability is partly because of the different criteria and screening regimens

5. Whom to screen ? Risk stratification based on certain variables • Low risk : no screening • Average risk: at 24-28 weeks • High risk : as soon as possible

6. Low risk for GDM To satisfy all these criteria • 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

7. High risk Intermediate risk At least one of the criteria in the list • Marked obesity • Prior GDM • Glycosuria • Strong family history

9. Screening and Diagnosis of GDM in the U.S. • Use the 50 g oral glucose challenge with BS taken 1 hour later • Screen all pregnant women @ 24-28 weeks • Test earlier in selected patients • Threshold of 130 mg/dL or greater

10. How to screen? Oral glucose tolerance test ( OGTT) with 100 gm glucose • Overnight fast of at least 8 hours • At least 3 days of unrestricted diet • and unlimited physical activity • > 2 values must be abnormal

11. 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

12. Problems of GDM: fetal • Increases the risk of fetal macrosomia • Neonatal hypoglycemia • Jaundice • Polycythemia • Hypocalcemia, hypomagnesemia • Birth trauma • Prematurity

13. Problems: fetal • Cardiac( including great vessel anomalies) : most common • Central nervous system: 7.2% • Skeletal: cleft lip/palate, caudal regression syndrome • Genitourinary tract: ureteric duplication • Gastrointestinal : anorectal atresia Poor glycemic control at time of conception: risk factor

14. Caudal regression syndrome

15. Caudal regression syndrome

16. Problems of GDM: maternal • Weight gain • Maternal hypertensive disorders • Miscarriages • Third trimester fetal deaths • Cesarean delivery (due fetal growth disorders) • Long term risk of type 2 diabetes mellitus

17. Pregnancy in diabetic mother: risks • Progression of retinopathy: esp. severe proliferative retinopathy • Progression of nephropathy: especially if renal failure + • Coronary artery disease: Post MI patients: high risk of maternal death

18. Management

19. Preconception counselling • Diabetic mother : glycemic control with insulin/SMBG Target: HbA1c < 7% • 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

20. Clinical parameters: checked at each visit • medications • pre-pregnancy weight • weight gain • edema • pallor • blood pressure • Fundal height

21. Patient educationCornerstone in GDM management • Maternal complication • Fetal complication • Medical Nutrition therapy • Glycemic monitoring: SMBG and targets • Fetal monitoring: ultrasound • Planning on delivery • Long term risks

22. Glycemic targets • Fasting venous plasma < 95 mg/dl • 2 hour postprandial <120 mg/dl • 1 hour postprandial <130 mg/dl (140) • Pre-meal and bedtime: 60 to 95 mg/dl If diet therapy fails to maintain these targets > 2 times/week, start insulin These are venous plasma targets, not glucometer targets

23. Why these tight glycemic targets? Prospective study in type1 patients with pregnancy

24. GDM Medical nutrition therapy Failure to maintain glycemic targets INSULIN THERAPY

25. Medical nutrition therapy • Promote nutrition necessary for maternal and fetal health • Adequate energy levels for appropriate gestational weight gain, • Achievement and maintenance of normoglycemia • Absence of ketones • Regular aerobic exercises

26. Medical nutrition therapy • 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.

27. Self monitored blood glucose • 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

28. Fetal monitoring • Baseline ultrasound : fetal size • At 18-22 weeks: major malformations fetal echocardiogram • 26 weeks onwards: growth and liquor volume • III trimester: frequent USG for accelerated growth ( abdominal: head circumference)

29. Timing of delivery • Small risk of late IUD even with good control • Delivery at 38 weeks • Beyond 38 weeks, increased risk of IUD without an increase in RDS • Vaginal delivery: preferred • Caesarian section only for routine obstetric indication just GDM is not an indication ! • Unfavorable condition of the cervix is a problem • 4500 grams, cesarean delivery may reduce the likelihood of brachial plexus injury in the infant (ACOG)

30. Management of labor and delivery • Maternal hyperglycemia in labor: fetal hyperinsulinemia, 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 sugars more than 120 mg/dl

31. Glycemic management during labour • Later stages of labour: start dextrose to maintain basal nutritional requirements: 150-200 ml/hr of 5% dextrose • Elective LSCS: check FBS, if in target no insulin, start dextrose drip • Continue hourly SMBG • Post delivery keep patients on dextrose-normal saline till fed • No insulin unless sugars more than normal ( not GDM targets ! )

32. Post partum follow up • Check blood sugars before discharge • Breast feeding: helps in weight loss • Lifestyle modification: exercise, weight reduction • OGTT 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

33. 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

34. Management of neonate • Hypoglycemia <40 mg/dl • Encourage early breast feeding • If symptomatic give a bolus of 2- 4 cc/kg, IV, 10% dextrose • Check after 30 minutes, start feeds • IV dextrose : 6-8 mg/kg/min infusion • Check for calcium, if seizure/irritability/RDS • Examine infant for other congenital abnormalities

35. 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

36. Conclusion • Gestational diabetes is a common problem • Risk stratification and screening is essential in all pregnant women • Tight glycemic targets are required for optimal maternal and fetal outcome • Patient education is essential to meet these targets • Long term follow up of the mother and baby is essential

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

38. thank you