When Two Lives are at Stake :

Diabetes in Pregnancy

Diagnosis and
Classification of Diabetes
in Pregnancy
Scientific Exchanges in Endocrinology and Diabetes
Philippine Society of Endocrinology, Diabetes and
Metabolism
 Imelda Soberano-Antonio, MD, FPCP, FPSEDM
Monica Therese Cating-Cabral, MD, FPCP, FPSEDM
Margarita Holgado-Galicia, MD, FPCP, FPSEDM
Cristina Jaring, MD, FPCP, FPSEDM
Paulette Nacpil-Dominguez, MD, FPCP, DPSEDM
Queenie Ngalob Samonte, MD, FPCP, DPSEDM
 Learning Objectives
After this session, attendees should be able to:
1. Understand the pathogenesis of diabetes in
pregnancy and its complications in both the
mother and fetus
2. Screen for and diagnose diabetes in
pregnancy
3. Differentiate between pre-gestational
diabetes/overt diabetes and gestational
diabetes mellitus
 Outline
Insulin resistance and pregnancy
Classification of diabetes mellitus (DM) in
pregnancy
Complications of DM in pregnancy
 Period from conception to birth with
physiologic adaptations to maintain an
environment conducive for the fetus
State of insulin resistance

Mohammed Chyad Al-Noaemi and Mohammed Helmy Faris Shalayel (2011). Pathophysiology of Gestational Diabetes Mellitus:
The Past, the Present and the Future, Gestational Diabetes, Prof. Miroslav Radenkovic (Ed.), ISBN: 978-953-307-581-5, InTech
 Increased estrogen,
progesterone
Increased
pancreatic B cell
hyperplasia
Increased insulin
release

Mohammed Chyad Al-Noaemi and Mohammed Helmy Faris Shalayel (2011). Pathophysiology of Gestational Diabetes Mellitus:
The Past, the Present and the Future, Gestational Diabetes, Prof. Miroslav Radenkovic (Ed.), ISBN: 978-953-307-581-5, InTech
 Fetoplacental hormones!!!
Decreased maternal insulin
sensitivity

Mohammed Chyad Al-Noaemi and Mohammed Helmy Faris Shalayel (2011). Pathophysiology of Gestational Diabetes Mellitus:
The Past, the Present and the Future, Gestational Diabetes, Prof. Miroslav Radenkovic (Ed.), ISBN: 978-953-307-581-5, InTech
Classification of Diabetes Mellitus (DM)
in Pregnancy
Pre-Existing Pregnancy

Gestational
Pre-Gestational
Diabetes
Diabetes Overt Diabetes
(GDM)

IADPSG. Diabetes Care. 2010; 33(3): 676-682

Management of Diabetes in Pregnancy, ADA Diabetes Care 2016, 39 (Suppl.1): 594-598
 Mrs. P, 40F
PU 7 wks AOG
G1P0
Diabetic for 4 years
Gliclazide MR 30 mg
Metformin 1500 mg
Classification of Diabetes Mellitus (DM)
in Pregnancy
Pre-Existing Pregnancy

Gestational
Pre-Gestational
Diabetes
Diabetes Overt Diabetes
(GDM)

IADPSG. Diabetes Care. 2010; 33(3): 676-682

Management of Diabetes in Pregnancy, ADA Diabetes Care 2016, 39 (Suppl.1): 594-598
WHAT ARE THE COMPLICATIONS
OF PREGESTATIONAL DIABETES?
 Fetal Malformations
1.9 to 7 - fold higher risk
3rd to 7th weeks AOG embryogenesis &
organogenesis
Rates similar between Type 1 & 2
Toxic metabolites may be teratogenic
Pathogenesis is poorly understood

Boulot P, et al., Diabetes Care 26:29902993, 2003

Lapolla A., et al. Nutr Metab Cardiovasc Dis. 2008 May;18(4):291-7
Persson M, et al., Diabetes Care. 2009 Nov;32(11):2005-9
Eriksson UJ, et al., . Rev Endocrinol Metabol Dis 2003;4:7993.
Kousseff BG. Diabetic embryopathy. Curr Opin Pediatr 1999;11:348
Bell R., et al., BJOG. 2008 Mar;115(4):445-52.
 Congenital Malformations

The poorer the glycemic control

periconceptionally or early in pregnancy, the
greater the risk for congenital anomalies

Towner D, et al., Diabetes Care 1995;18:144651.

Langer O, et al., J Mat Fet Med 2000;9:3541.
Temple R, et al., BMJ 2002;325:12756.
Schaefer-Graf UM, et al., Am J Obstet Gynecol 2000;182:31320.
Suhonen L, et al., Diabetologia 2000;43:7982.
Spontaneous Abortions

4-fold increased
risk
Risk rises with
poor glycemic
control

Temple R., BMJ. 2002 Nov 30;325(7375):1275-6

Perinatal Mortality

2.3 to 6-fold increased

risk
Intrauterine stillbirth
(>24 weeks AOG) or
neonatal death (within
28 days of life)

Feig, et al., Diabetes Care. 2014 Apr 4. [Epub ahead of print]

Boulot P, et al., Diabetes Care 26:29902993, 2003
Dunne R, et al., Diabet Med. 2003 Sep;20(9):734-8
Lapolla A., et al. Nutr Metab Cardiovasc Dis. 2008 May;18(4):291-7
Persson M, et al., Diabetes Care. 2009 Nov;32(11):2005-9
Other Adverse Perinatal Outcomes

MACROSOMIA FETAL DISTRESS

OR 11.45 OR 11.45
(95% CI 10.61 12.36) (95% CI 10.61 12.36)

PRETERM RESPIRATORY DISTRESS

OR 4.86 SYNDROME
(95% CI 4.47-5.28) OR 4.65
(95% CI 2.2-9.84)

Perrson M, et al., Diabetes Care 32:20052009, 2009

 Effect of Pregnancy on the
Diabetic Mother

Obstetric
DM Complications
Outcomes
 DM Retinopathy

No to mild retinopathy
Small risk for progression

Established retinopathy
can rapidly progress during Effects of pregnancy on
and up to 1 year after retinopathy eventually
pregnancy, more so in diminish after the first year
poorly controlled
DCCT group. Diabetes Care 23:10841091, 2000
Boulot P, et al., Diabetes Care 26:29902993, 2003
D. Thompson et al., Can J Diabetes 37 (2013) S168eS183
Chew EY, et al., Diabetes Care. 1995 May;18(5):6
DM Retinopathy
Patients with higher levels of HBA1C
were at greater risk for progression

Chew EY, et al., Diabetes Care. 1995 May;18(5):631-7

 DM Nephropathy

Normal creatinine
albuminuria and creatinine
clearance is preserved during
pregnancy

Microalbuminuria
may worsen but typically Moderate to severe
modest and reversible can significantly deteriorate and
(BP and blood sugar are well- may not be reversible
controlled)

Rossing K, et al., Diabetologica 2002, 45: 36-41

Miodovnik M, et al., Am J Obstet Gynecol 1996;174:1180-91
Biesenbach, et al., Nephrol. Dial. Transplant. (1992) 7 (2): 105-109
Purdy LP, et al., Diabetes Care. 1996 Oct;19(10):1067-74.
 Obstetric Outcomes

PREECLAMPSIA CESAREAN SECTION VACUUM

OR 4.47 OR 5.31 EXTRACTION/FORCEP
(95% CI 3.77 to 5.31) (95% CI 4.97 TO 5.69) S
OR 1.41
(95% CI 1.25 TO 1.58)

Perrson M, et al., Diabetes Care 32:20052009, 2009

 Mrs. Q, 32 F
PU 10 wks AOG
G1P0
BMI 26 kg/m2
No known illnesses
Routine prenatal care
detected glucosuria on
urinalysis
Classification of Diabetes Mellitus (DM)
in Pregnancy
Pre-Existing Pregnancy

Gestational
Pre-Gestational
Diabetes
Diabetes Overt Diabetes
(GDM)

IADPSG. Diabetes Care. 2010; 33(3): 676-682

Management of Diabetes in Pregnancy, ADA Diabetes Care 2016, 39 (Suppl.1): 594-598
#1 Screening for Diabetes in Pregnancy
All pregnant women should be screened for
gestational diabetes
Evaluate for risk factors for gestational
diabetes/diabetes at the first prenatal visit

Blumer I, et al., J Clin Endocrinol Metab 98: 42274249, 2013

Unite for Diabetes. www.endo-society.org.ph
ADA 2015 Standards of Care
Risk Factors for Diabetes in Pregnancy
Prior GDM (OR 23)
Glucosuria (OR 9)
Family history of DM (OR 7)
Prior macrosomic (>8lbs) baby (OR 5.6)
Macrosomia in current pregnancy (PPV 40%)
Age 25 years old (OR 1.9)
PCOS (OR 2.9)
Overweight or obese (OR 2.3-2.7)
Polyhydramnios in current pregnancy (PPV 40%)
Intake of drugs affecting carbohydrate metabolism

Unite for Diabetes. www.endo-society.org.ph

 #2 Diagnosis of GDM
1st Prenatal Visit
Screen for risk
factors
(+) (-)
Test at booking
(FBS, RBS, A1C, 75 gm OGTT at
repeated twice if
asymptomatic 24 - 28 wks AOG
75gm OGTT )
Blumer I, et al., J Clin Endocrinol Metab 98: 42274249, 2013
IADPSG. Diabetes Care. 2010; 33(3): 676-682
Unite for Diabetes. www.endo-society.org.ph
 # 2 Diagnosis of GDM
1st Prenatal Visit (<13 weeks AOG)
Diagnosis FBS, RBS, HBA1C*
mg/dl (mmol/l) mg/dl (mmol/l) %

Overt 126 200 6.5

Diabetes** ( 7.0) ( 11.1)
Gestational 92-125 na na
Diabetes ( 5.1 6.9)
*NGSP certified & standardized to the DCCT reference assay
** repeated on another day
If criteria not met, repeat testing at 24-28 weeks AOG using 75gm OGTT

ADA 2014,WHO 2013, EndoSoc 2013, IADPSG 2010

 #2 Diagnosis of GDM
1st Prenatal Visit (<13 weeks AOG)
Diagnosis FBS, RBS, HBA1C*
mg/dl (mmol/l) mg/dl (mmol/l) %

Overt 126 200 6.5

Diabetes** ( 7.0) ( 11.1)
Gestational 92-125 na na
Diabetes ( 5.1 6.9)
Patient 130 7.5
154

ADA 2014,WHO 2013, EndoSoc 2013, IADPSG 2010

Classification of Diabetes Mellitus (DM)
in Pregnancy
Pre-Existing Pregnancy

Gestational
Pre-Gestational
Diabetes
Diabetes Overt Diabetes
(GDM)

IADPSG. Diabetes Care. 2010; 33(3): 676-682

Management of Diabetes in Pregnancy, ADA Diabetes Care 2016, 39 (Suppl.1): 594-598
WHAT ARE THE COMPLICATIONS
OF OVERT DIABETES?
 Effect DM on the conceptus

Fetal Spontaneous Perinatal

malformation abortion mortality

Effect of DM on the mother

DM Obstetric
Complications Outcomes
 Mrs. R, 22F
PU 24 wks AOG
G2P1
no risk factors
75 gm OGTT at 24wks AOG
FBS : 89 mg/dl
1 hr : 190 mg/dl
2 hr : 150 mg/dl
 #1 Diagnosis of GDM
24th to 28th week AOG using 75 gm OGTT

Diagnosis FBS, 1st hour 2nd hour

mg/dl (mmol/l) mg/dl (mmol/l) mg/dl (mmol/l)

Overt 126 na 200

Diabetes** ( 7.0) ( 11.1)
Gestational 92-125 180 153-199
Diabetes (5.1 6.9) ( 10.0) (8.5-11.0)

ADA 2014,WHO 2013, EndoSoc 2013, IADPSG 2010

 #1 Diagnosis of GDM
24th to 28th week AOG using 75 gm OGTT

Diagnosis FBS, 1st hour 2nd hour

mg/dl (mmol/l) mg/dl (mmol/l) mg/dl (mmol/l)

Overt 126 na 200

Diabetes** ( 7.0) ( 11.1)
Gestational 92-125 180 153-199
Diabetes (5.1 6.9) ( 10.0) (8.5-11.0)
Patient 89 190 150
Classification of Diabetes Mellitus (DM)
in Pregnancy
Pre-Existing Pregnancy

Gestational
Pre-Gestational
Diabetes
Diabetes Overt Diabetes
(GDM)

IADPSG. Diabetes Care. 2010; 33(3): 676-682

Management of Diabetes in Pregnancy, ADA Diabetes Care 2016, 39 (Suppl.1): 594-598
 #1 Diagnosis of GDM

75 g OGTT IADPSG* ACOG POGS*

FBS 92 95 92
1-hour 180 180 NA
2-hour 153 155 140
3-hour NA 140 N.A
* Any one value meeting threshold is considered GDM
** Two values must meet thresholds to be considered GDM
IADPSG International Association of Diabetes & Pregnancy Study Group;
ACOG American College of Obstetrics & Gynecology;
POGS Philippine Obstetrics & Gynecology Society
WHAT ARE THE COMPLICATIONS
OF GESTATIONAL DIABETES?
 Effect DM on the conceptus

Fetal Spontaneous Perinatal

malformation abortion mortality

Effect of DM on the mother

DM Obstetric
Complications Outcomes
 Effect DM on the conceptus
Fetal: Increased birthweight, hypoglycemia, birth
injuries, shoulder dystocia,
NICU admission, hyperbilirubinemia
Children : Abnormal glucose tolerance and
obesity
Effect of DM on the mother
Maternal : Increased cesarean delivery &
preeclampsia
Classification of Diabetes Mellitus (DM)
in Pregnancy
Pre-Existing Pregnancy

Gestational
Pre-Gestational
Diabetes
Diabetes Overt Diabetes
(GDM)

IADPSG. Diabetes Care. 2010; 33(3): 676-682

Management of Diabetes in Pregnancy, ADA Diabetes Care 2016, 39 (Suppl.1): 594-598
 Thank You

Scientific Exchanges in Endocrinology and Diabetes

Philippine Society of Endocrinology, Diabetes and
Metabolism
 References
Blumer I, et al., Diabetes and Pregnancy: An Endocrine
Society Clinical Practice Guideline. J Clin Endocrinol Metab,
November 2013, 98(11):4227 4249
Philippine Practice Guidelines on the Diagnosis and
Management of Diabetes Mellitus, UNITE for Diabetes
Philippines 2011
Joslin Diabetes Center and Joslin Clinic. Guideline for
Detection and Management of Diabetes in Pregnancy. 2010
Reader, DM. Medical Nutrition Therapy and Lifestyle
Interventions. Diabetes Care 30 (Suppl. 2): S188-S193, 2007.
Hernandez, TL et al. Strategies in the Nutritional
Management of Gestational Diabetes. Clin Obstet Gynecol.
56(4): 803-815. 2013
 References
Much D, et al., Beneficial effects of
breastfeeding in women with gestational
diabetes mellitus. Molecular Metabolism 3
(2014) 284292.
Ziegler AG, et al., Long-Term Protective Effect
of Lactation on the Development of Type 2
Diabetes in Women With Recent Gestational
Diabetes Mellitus. Diabetes 2012,
61(12):31673171.