Diabetes Mellitus in Pregnancy

By Dr Samuel,Gynecologist

DM in Pregnancy
Diabetes mellitus is the most common
medical complication of pregnancy

By Dr Samuel,Gynecologist

DM in Pregnancy
DM in pregnancy can be separated into two;
1. Pregestational or overt Diabetes
diagnosed before pregnancy
Type I, Type II, Other forms
2. Gestational Diabetes (GDM)
any degree of glucose intolerance
diagnosed during pregnancy.

By Dr Samuel,Gynecologist

By Dr Samuel,Gynecologist

Modified Whites Classification Scheme of

Diabetes Complicating Pregnancy
Class

Onset

A1
A2
Class

Fbs

2hrpp

Rx

Gestational <105

<120

Diet

Gestational >105

>120

Insulin

Onset age

Duration

Vascular
disease

Rx

B
C
D
F
R

>20

<10

None

Insulin

10-19

10-19

None

Insulin

<10

>20

Benign rpthy

Insulin

Any

Any

Nephropathy

Insulin

Any

Any

Proliferative
rrtinopathy

Insulin

Any

Heart
Any
By Dr Samuel,Gynecologist

Insulin

By Dr Samuel,Gynecologist

Effects of Pregnancy On Carbohydrate

Metabolism
Pregnancy is characterized by increased
insulin resistance and reduced sensitivity to
insulin action.
Late in the first trimester, relatively higher
levels of estrogen enhance insulin sensitivity
and,
when associated with nausea and vomiting,
increase the risk for maternal hypoglycemia.

By Dr Samuel,Gynecologist

Effects of Pregnancy On Carbohydrate

Metabolism
The increase in insulin resistance is largely
the result of a mixture of placental
hormones, including;

hPL, progesterone, prolactin, placental

growth hormone, and cortisol.
More recently, TNF and Leptin have been
implicated as contributors to the insulin
resistant state of pregnancy
Insulin resistance is greatest in the 3rd TMx.
By Dr Samuel,Gynecologist

Effects of pregnancy on CH Metabolism

In the 1st trimester, increasing maternal estrogen
and progesterone levels are associated with: a decrease in fasting glucose levels, which
reach a nadir by the 12th week
The decrease averages 15 mg/dL; thus, fasting
values of 7080 mg/dL are common by the 10th
week of pregnancy
Insulin sensitivity decreases as gestation
advances in all pregnant women, mainly due to
anti-insulin signals produced by the placenta.
By Dr Samuel,Gynecologist

Effects of pregnancy on CH Metabolism

In the 2nd trimester, as the placenta increases
secretion of anti-insulin hormones,
higher fasting and postprandial glucose levels
occur;
that facilitate transfer of glucose from mother
to fetus.

Glucose transfer occurs via a carrier-mediated

active transport system that becomes saturated
at 250 mg/dL.
Fetal glucose levels are 80% of maternal levels.
By Dr Samuel,Gynecologist

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Effects of pregnancy on CH Metabolism

In contrast, maternal amino acid levels are

lowered due to active placental transfer to the

fetus.

Lipid metabolism in the second trimester

shows continued storage until midgestation,

then enhanced mobilization (lipolysis) as fetal

fuel demands increase
By Dr Samuel,Gynecologist

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Effects of pregnancy on CH Metabolism- Hormones

HPL

Resembles GH
Major culprit of insulin resistance and lipolysis
Decreases affinity of receptors to insulin
Diverts CHO metabolism to fat metabolism +
decreases mat. Hunger sensation
NET Effect:-maternal glycemia+Glucose use
se placental transfer to fetus.
The hPL levels rise steadily during the first and
second trimesters, with a plateau in the late third
trimester.
By Dr Samuel,Gynecologist

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Effects of pregnancy on CH Metabolism- Hormones

Cortisol: Its levels rise during pregnancy and

stimulate endogenous glucose production
and glycogen storage and decrease glucose
utilization.

Prolactin
increased 5- to 10-fold during pregnancy
and may impact CH metabolism.
Thus, women with hyperprolactinemia also
should undergo early glucose screening.
By Dr Samuel,Gynecologist

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I. Pregestational/ Overt DM

By Dr Samuel,Gynecologist

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Pregestational/ Overt DM
Observed in 1% of all pregnancies
Type 2 PGDM is most common and is
characterized by;
onset later in life;
peripheral insulin resistance;
relative insulin deficiency;
obesity; and the development of vascular,
renal, and neuropathic complications
By Dr Samuel,Gynecologist

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Pregestational/ Overt DM
Diagnosis:
Random plasma glucose level > 200 mg/dL
plus polydipsia, polyuria, and unexplained
weight loss or;
Fasting glucose level > 125 mg/dL (ADA (2012))

Incidence
>

1% of all pregnancies
By Dr Samuel,Gynecologist

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 aApply to women without known diabetes antedating Px.

The decision to perform blood testing for evaluation of glycemia
on all pregnant women or only on women with characteristics
indicating a high risk for diabetes is based on the background
frequency of abnormal glucose metabolism in the population
and on local circumstances----- Williams 24th
By Dr Samuel,Gynecologist

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Pregestational DM-Impact on pregnancy

Outcome of pregnancy depends on;

Degree of glycemic control

Poor control poor outcome

the stage/ Whites Class

Advanced stage less favorable
outcome
By Dr Samuel,Gynecologist

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Pregestational DM-Impact on pregnancy

Fetal Effects

Neonatal Effects

Respiratory distress
syndrome
Hypoglycemia
Hypocalcaemia
Hyperbilirubinemia
Polycythemia
Hypertrophic
cardiomyopathy

Spontaneous abortion
Preterm delivery
Malformations
Growth abnormalities
IUGR
Macrosomia

Unexplained fetal
demise
Hydramniosis

By Dr Samuel,Gynecologist

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 The frequency of major congenital malformations

in newborns of women with Pregestational
diabetes stratified by hemoglobin A1c levels at
first prenatal visit. (Data from Galindo,
2006.)
By Dr Samuel,Gynecologist

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 Congenital Anomalies in Fetuses of 91 Women with Type 1 Diabetes between

1999 and 2004 in Norway

Cardiovascular system is the most involved organ.

By Dr Samuel,Gynecologist

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Pregestational DM-Impact on pregnancy

Maternal Effects
Vascular complications
Retinopathy progression worsened by;

Pregnancy independent risk factor for Rpathy

poor early pregnancy glycemic control
Hypertension
Rapid tight glycemic normalization
long duration DM , advanced rpathy,

Nephropathy
Pregnancy has no effect on progression of preexisting
or dvt of new Npathy.
By Dr Samuel,Gynecologist

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Maternal effect
Preeclampsia (3-4X increased risk, ~12x risk if
there is CHTN)
Diabetic neuropathy
in the form of Gastropathy (N, V, malnutrition,
difficult Glucose control)

DKA- in `~1% of pregnancies with DM

Infections
candidia vulvovaginitis, UTI, Respairatory Tract
Infections, puerperial sepsis
By Dr Samuel,Gynecologist

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Pregestational DM- Management

Preconception Care

Conception with uncontrolled glycemic level- increased risk of

early pregnancy loss and congenital malformations
Optimal preconceptional self monitored Glucose control using
insulin (ADA- 2012)
Pre-prandial: 70-100mg/dl
Peak postprandial 100- 129mg/dl
Mean daily glucose level < 110 mg/dl
HGB A1C < 7%*
*Reflects an average of circulating glucose for the past 4 to 8 weeks, is useful to
assess early metabolic control. Substantially fourfold increased risk for
malformations at HGB A1clevels > 10 %

If indicated, evaluation and treatment for diabetic complications

such as retinopathy or nephropathy should also be instituted
before pregnancy.
Folate, 400 g/day orally is given periconceptionally and during
early pregnancy to decrease the risk of neural-tube defects.
By Dr Samuel,Gynecologist

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Pregestational DM- Management

Management during pregnancy
Treatment with insulin
Careful monitoring of glucose control to attain
glycemic goals
US for fetal anatomy at 18-20wks
Testes for anomalies- maternal serum analytes
Fetal well being tests initiated at 32-34 weeks
of GA.
By Dr Samuel,Gynecologist

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Antepartum care
Maternl glycemic control evaluation by SMBG
Eye exam( laser rx if needed)
RFT( creat./ 24hr urine p/urine alb: creat ratio)
Electrocardiography( if age>30 + disease >5yr)
TFT for those with Type I preg.DM
Urine culture & rx( 3x risk of asymp. Bacterutria)
Early US for GA
Fetal growth US
US for fetal anatomy at 18-20wks
Testes for anomalies( 1st trim NT, serum
screening, 2nd trim. Triple/ quadriple tests)
By Dr Samuel,Gynecologist

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Pregestational DM Rx
Blood Glucose Goals in pregnancy

By Dr Samuel,Gynecologist

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Action Profiles of Commonly Used Insulins

By Dr Samuel,Gynecologist

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Pregestational DM-Management
Delivery
Timing- balance of risks i.e, IUFD vs prematurity
Early delivery may be indicated in some patients
with vasculopathy, nephropathy, poor glucose
control, or a prior stillbirth.
patients with well-controlled diabetes and
reassuring antenatal testing may be allowed to
progress to their EDD.
Expectant management beyond the estimated
due date generally is not recommended.
For EFW > 4500gm cesarean delivery may be
considered to prevent traumatic birth injury
(ACOG 2014)

By Dr Samuel,Gynecologist

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Pregestational DM-Postpartal Management

No insulin needed for the 1st 24 hrs
Breast feeding should be encouraged
Calorie intake- 500kcal in excess of the
Prepregnancy requirement.
Contraception
Low dose OCP-if non smoker and no vasculopathy
POPs- if there is vasculopathy
IUCD- may have increased infection risk
Sterilization for those with serious vasculopathy
and in those who have completed their family.
By Dr Samuel,Gynecologist

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II.Gestational Diabetes Mellitus (GDM)

By Dr Samuel,Gynecologist

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GDM
Gestational diabetes is defined as
carbohydrate intolerance of variable

severity with onset or first

recognition during pregnancy (ACOG,
2013).
By Dr Samuel,Gynecologist

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GDM-Epidemiology
GDM complicates approximately 4% of
pregnancies.
90% of diabetes cases encountered during
pregnancy are GDM
> 40% will have recurrent GDM in subsequent
pregnancy.
more than one half of women with GDM
eventually develop type 2 PGDM later in life
(in 10-20yrs).(ACOG 2014)
By Dr Samuel,Gynecologist

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GDM risk assessment

Risk factors
Obesity (nonpregnant body mass index > 30),
Prior history of GDM( > 60% recurrence)
Heavy glycosuria (> 2+),
Unexplained stillbirth,
Prior infant with major malformation, and
Family history of diabetes in a first-degree
relative
By Dr Samuel,Gynecologist

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Screening
A.Universal or
B. selective screening

By Dr Samuel,Gynecologist

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Selective screening
Screening Strategy Based on Risk Assessment for
Detecting GDM (Recommendation by 5th
International Workshop-Conference on GD)

A. Low risk
Routine screening is not required
Ethnic group with low GDM prevalence
Age < 25,
No diabetic 10 relative
Normal birth weight, normal prepregnant wt.
No hx of glucose intolerance
No hx of poor obstetric outcome
By Dr Samuel,Gynecologist

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Selective screening
B. Moderate risk
screen at 24-28 week using either the 2 step
(50gm GCt---threshold---100g- 3hr OGTT) or 1 step
test ( 75gmOGTT)

C. High Risk
screen as soon as possible,
if ve repeat at 24-28wk and whenever SS suggest
hyperglycemia
severity sign are: Severe obesity
Strong Family Hx of type 2 DM
Dr Samuel,Gynecologist
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Hx of GDM, IG Bymetabolism,
glucosuria

screening one step vs Two step tests

I. One-step procedure:
diagnostic ,OGTT performed on all subjects
II. Two step Procedure
1. 50 gm glucose administered regardless of timing of prior
meal;

Blood Sugar is checked after 1hr screening test

No strict cut off is set for abnormal value (usually 130140 are acceptable+ the lower the cutoff the higher the
sensitivity)

2. 3hr100gm OGTT/ 75gm 2hrOGTT preceded by

obtaining the FBS Diagnostic test
After unrestricted diet, at least 150gm CH,for 3 days
to avoid CH depletion and subsequent spurious GTT
values
By Dr Samuel,Gynecologist
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Screening-one step vs Two step tests

WHO (1998) and the American Diabetes

Association (ADA ,2013) recommend the 75-g

2-hour oral glucose tolerance test (one step).

In the US , however, the 100-g, 3-hour OGTT

test performed after an overnight fast is

recommended by ACOG (2013).

By Dr Samuel,Gynecologist

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Screening - 0ne step procedure*

aOne or more of these values from a 75-g OGTT must be equaled

or exceeded for the diagnosis of gestational diabetes.
Recommended by IADPSG Consensus Panel (2010) and ADA
(2013)
*Not accepted by ACOG and NIHIt would increase the
prevalence of GDM in US to 17.8% the No of women with
mild GDM would increase almost threefold with no evidence of
treatment benefit(Cundy,
By Dr2012).
Samuel,Gynecologist
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5th International Workshop Conference on

GDM Diagnostic Criteria of GDM by OGTT.

aThe test should be performed in the morning after an overnight fast of at

least 8 hr but not more than 14 hr and after at least 3 days of unrestricted
diet ( >150 g/d) and physical activity.
The subject should remain seated and should not smoke during the test.
bTwo or more of the venous plasma glucose concentrations listed must be
met or exceeded for a positive diagnosis.
Data from Metzger, 2007.

By Dr Samuel,Gynecologist

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GDM- complications
Unlike overt diabetes, rates of fetal anomalies do
not appear to be substantially increased in
GDM(Sheffield, 2002).
Excessive fetal size (macrosomia)
Excessive trunk and shoulder fat predisposing for
shoulder dystocia and CD

Neonatal Hypoglycemia
Women with a history of gestational diabetes are
also at risk for cardiovascular complications
associated with dyslipidemia, hypertension, and
abdominal obesitythe metabolic syndrome
The women also have increased cardiovascular
morbidity risk in the long-term.
By Dr Samuel,Gynecologist

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GDM- Management
Glycemic control can be achieved via;

1. Life style modification

Diet modification, moderate exercise

2. Pharmacologic rx.
if diet modification doesnt result in the target
glucose level
Insulin - preferred
Oral hypoglycemic- studies show safety and
efficacy of either glyburide (Micronase) or
metformin (Glucophage)
By Dr Samuel,Gynecologist

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GDM-Management
Target Glucose levels in GDM treatment
Fasting plasma glucose levels < 95 mg/dL
1hr postprandial plasma glucose< 140mg/dl
The 2-hour postprandial plasma glucose <

120 mg/dL (ACOG, 2013).

By Dr Samuel,Gynecologist

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GDM- Obstetric Management

Often expectant management as long as
glycemic control is good.
Fetal surveillance ; not routine-may be used
only when there is poor glycemic control
Elective induction to prevent shoulder
dystocia??? Controversial.
EFW > 4500gm elective CD to avoid
shoulder dystocia and brachial plexus injury.

By Dr Samuel,Gynecologist

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GDM- Postpartum Evaluation

By Dr Samuel,Gynecologist

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By Dr Samuel,Gynecologist

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