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Diabetes in Pregnancy

Diabetes in Pregnancy. L.Sekhavat MD. Diabetes in Pregnancy. Gestational Diabetes Pre-gestational diabetes (overt) Insulin dependent (type1) Non-insulin dependent (type 2). Definition.

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Diabetes in Pregnancy

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  1. Diabetes in Pregnancy L.Sekhavat MD

  2. Diabetes in Pregnancy • Gestational Diabetes • Pre-gestational diabetes (overt) • Insulin dependent (type1) • Non-insulin dependent (type 2)

  3. Definition Gestational diabetes mellitus (GDM) is defined as any degree of glucose intolerance with onset or first recognition during pregnancy

  4. Gestational diabetes typically is 3rd trimester disorder • Overt diabetes is 1st trimester

  5. Some general characteristic of type1 and type 2 diabetes • Characteristic type1 type2 • genetic ch 6 unknown • Age at onset <40 >40 • Habitus normal to wasted obese • Plasma insullin low to absent normal to high • Insullin therapy responsive R/resistant

  6. Classification of diabetes • ClassonsetFBS2hpp therapy • A1 gestational <90 <120 diet • A2 gestational >90 >120 insullin • Classage of onsetduration V diseases • B >20 10-19 none • C 10-19 10-19 none • D <10 >20B retionopathy • F any any nephropathy • R any any P retionopathy • H any any heart D

  7. Normal Maternal Glucose Regulation • Tendency for maternal hypoglycemia between meals - fetal demand • Increasing tissue insulin resistance during pregnancy  Diabetogenic placental steroid  Estrogen, Progesterone HPL • Increased insulin production (= 30% mean)

  8. Maternal hyperglycemia Insulin Fetal pancreas stimulated Fetal hyperinsulinemia The Impact of Maternal Hyperglycemia During Pregnancy Placenta Fetus Mother

  9. Maternal Hyperglycemia • Causes fetal hyperglycemia • Leading to fetal hyperinsulinemia • Fetal hyperinsulinemia - even short periods (1-2 hours) lead to detrimental consequences in: • fetal growth • fetal well-being

  10. Fetal Hyperinsulinemia • Promotes storage of excess nutrients - macrosomnia • Increased catabolism of excess nutrients - energy usage and low fetal oxygen storage • Episodic fetal hypoxia • Increased catecholamines causing: • hypertension • cardiac hypertrophy • Increased Erythropoietin: • Hyperbilirubinaemia

  11. Diagnosis: • Glucosuria is common in pregnancy (Renal glycosuria) so not diagnostic.

  12. Fasting and 2 hours postprandialvenous plasma sugar during pregnancy. Fasting 2h postprandial Result <95 mg/dl < 120mg/ dl. Not diabetic >120 mg/ dl. Diabetic >95 mg/dl

  13. Risk Factors: • > 25 years old • Previous macrosomnic infant • Unexplained fetal demise • Previous GDM • Family hx - GDM/NIDDM • Obesity > 90Kg • Smoking

  14. 50-g oral glucose challenge The screening test for GDM, a 50-g oral glucose challenge, may be performed in the fasting or fed state. Sensitivity is improved if the test is performed in the fasting state . A plasma value above 130-140 mg/dl one hour afteris commonly used as a threshold for performing a 3-hour OGTT. • If initial screening is negative, repeat testing is performed at 24 to 28 weeks.

  15. 3 hour Oral glucose tolerance test Giving 100 gm (75 gm by other authors) glucose in 250 ml water orally • Prerequisites: • Normal diet for 3 days before the test. • No diuretics 10 days before. • At least 10 hours fast. • Test is done in the morning at rest.

  16. Criteria for glucose tolerance test The maximum blood glucose values during pregnancy: • fasting 95 mg/ dl, • one hour 180 mg/dl, • 2 hours 155 mg/dl, • 3 hours 140 mg/dl. • If any 2 or more of these values are elevated, the patient is considered to have an impaired glucose tolerance test.

  17. Pregnancy Complication • Hydramnios • Spontaneous abortions • Congenital malformations • Macrosomia • Diabetic ketoacidosis • Neonatal metabolic complications

  18. Macrosomia -Pathogenesis

  19. Macrosomnia (Greater than 90 precentile, 4200 grammes) • Increased birth trauma • Macrosomnia as a child and glucose intolerance in adulthood

  20. Congenital Anomalies • Cardiac defects 8.5% • CNS defects 5.3% • Anencepha • Spina Bifida • All Anomalies 18.4% • Specially overt diabetes • The most risk is HgA1c >10

  21. Maternal Complications • Pre-eclampsia • Diabetic ketoacidosis • Maternal hypoglycemia • Maternal trauma • Higher C/S rate • Retinal disease/renal disease not affected significantly by pregnancy

  22. Perinatal Mortality/Morbidity • Miscarriage • IUGR • Macrosomia • Birth Injury

  23. Neonatal Morbidity and Mortality • Neonatal hypoglycemia • Polycythemia • Hyperbillirubinemia • Hypertrophic and congestive cardiomyopathy • ARDS Development of obesity and diabetes in childhood

  24. Treatment of Gestational Diabetes • Diet and exercise • Glucose monitoring • Insulin if necessary (Hypoglycemic agents?) • 2-weekly visits to Diabetic service/antenatal service & Growth Monitoring (scan) • Delivery based on obstetric issues

  25. Diet Therapy Goals of an Effective diet: • Normoglycemia • Adequate weight gain • Good fetal health

  26. Medical nutrition therapy should include the provision of adequate calories and nutrients to meet the needs of pregnancy ( Diet: 50% carb, 20% prot, 30% fat)

  27. Exercise Therapy • exercise diminishes peripheral resistance to insulin • cardiovascular conditioning increase affinity and receptor binding • Reduction in both fasting and postprandial glucose may decrease need for other therapies in Gestational Diabetes

  28. Insulin therapy insulin therapy is recommended when medical nutrition therapy fails to maintain self-monitored glucose at the following levels: Fastingblood glucose <95 mg/dL or 1-hour postprandialblood glucose <140 mg/dL or 2-hour postprandialblood glucose<120 mg/dL

  29. Insulin therapy The total first dose of insulin is calculated according to the patient’s weight as follow: • In the first trimester .......... weight x 0.7 • In the second trimester........ weight x 0.8 • In the third trimester........... weight x 0.9

  30. Insulin Therapy (dosage) • Divide the injections: • 60% Regular insulin • 30% before breakfast • 15% before lunch • 15% before dinner • 40% NPH • 30% before breakfast • 10% before bed • One study demonstrated that the 4 injection a day as compared to 2 injections a day improved glycemic control and perinatal outcome

  31. Management • Test AFP at 16-20 weeks • Antenatal visits – 2 weekly after 24 weeks • NST weekly (starting at 28-30 wks) • Anomaly scan at 16- 20-weeks and Growth scans from 26-28weeks • Delivery • Around term if insulin dependent unless complications • Diet only control as normal antenatal patients

  32. When antepartum testing suggests fetal compromise, delivery must be considered.

  33. Intrapartum management • IV fluids (5% dextrose) + insulin • Hourly glucose monitoring • Manage labor as normal

  34. The need of insulin typically decreased after delivery so: Avoid of NPH and used Regular insulin

  35. Management - Postpartum • Use pre pregnancy insulin levels when on diet and monitor. • Breast feeding? • GDM - long term risk of NIDDM • Contraception

  36. After delivery • nearly all postpartum women will become normoglycemic • 1/3 to 2/3 will have recurrent GDM in subsequent pregnancies

  37. Over than 50% of gestational diabetes lead to overt diabetes

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