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DIABETES & PREGNANCY

JEHAD AL-HARMI
DEPARTMENT OF OBS & GYN
FACULTY OF MEDICINE/ KUWAIT UNIVERSITY
DEFINITION
• Persistent state of hyperglycemia due to
lack, or diminished effectiveness, of
endogenous insulin

• Very common medical complication of


pregnancy; variable incidence from 0.5 –
15%
TYPES-1

Abnormal glucose metabolism in pregnancy:


1. Overt, pregestational, or pre-existing DM
2. Gestational diabetes (GDM):
• First diagnosed during pregnancy
• May persist after delivery
• May include a small group of overt DM
• Has many similarities to NIDDM
1. Impaired glucose tolerance test (IGTT)
TYPES-2
Pregestational DM:
1. Type I or IDDM:
• Usually juvenile onset
• May be associated with autoimmune disease

1. Type II or NIDDM:
• Usually adult onset
• Occurs more frequently in the obese
• Has a stronger familial component
CLASSIFICATION
MODIFIED WHITE CLASSIFICATION:
 A1 GDM on diet
 A2 GDM on insulin
 B Onset after age 20 years, or duration less than 10 years
 C Onset &/or duration between 10-20 years
 D Onset before age 10 years, or duration more than 20 years
 F Nephropathy
 R Proliferative (not background) retinopathy
 H Coronary artery disease
 T Renal transplant
RISK FACTORS-1
WHAT ARE THE RISK FACTORS OF
GDM?
RISK FACTORS-2

1. Family h/o DM (1st degree relative)


2. Previous h/o GDM
– Recurrence rate is 60-70%. Why not 100%?
What are the predictors?
3. Glycosuria
– Before 16/52
– >2 occasions
4. Polyhydramnios (AFI > 25 cm)
RISK FACTORS-3
5. Age > 30 years
6. Obesity (BMI > 27 kg/m²)
7. Polyuria
8. Polydypsia
9. Excessive weight gain (> 18 kg)
RISK FACTORS-4
10. Previous h/o:
1. Recurrent spontaneous abortions
2. Unexplained SB or NND
3. Baby with major congenital anomalies (CNS,
cardiac, skeletal)
4. Big baby (> 4500 g)
5. Recurrent PE
6. Recurrent candidaiasis
DIAGNOSIS - 1
SCREENING:
– Why?

– Whom?

– How?

– When?
DIAGNOSIS - 2

SCREENING:
• Glucose loading/challenge test (GLT):
– No special preparation
– 50 g glucose; measure plasma BS after 1
hour
– For low-risk: screen at 26-28/52
– For high-risk: screen at booking & if result
negative repeat at 26-28/52
DIAGNOSIS - 3

• If GLT > 10 or FBS > 7.2 mmol/l no


need for further testing; patient is diabetic

• If GLT 7.3-10 mmol/l proceed to oral


glucose tolerance test (OGTT)
OGTT
– 3 days on diet containing 150 g CHO daily
– Fasting 8 - 14 hours. 100 g glucose load
– Measure plasma levels
– No smoking or excessive activity
• Normal values:
– FBS 5.3 mmol/l
–1h 10 1 high value = IGTT
–2h 8.6 2 high values = GDM
–3h 7.8
GLUCOSE METABOLISM IN
PREGNANCY
• GLYCOSURIA:
– Often seen during pregnancy due to ↓ renal
threshold of glucose excretion & incomplete re-
absorption in the renal tubules
• GLYCEMIA:
– FBS usually lower by 0.5 mmol/l; PPBS higher
– Higher highs & lower lows
EFFECTS OF DIABETES ON
PREGNANCY - 1
WHAT ARE THE MATERNAL
COMPLICATIONS OF DM?
EFFECTS OF DIABETES ON
PREGNANCY - 2
MATERNAL - 1:
1. DKA  fetal & / or maternal death
2. Hypoglycemia (if severe & prolonged) may
lead to fetal death. But usually better
tolerated than hyperglycemia
3. Polyhydramnios  PROM, & unstable lie
4. PET especially in presence of renal
impairment (20-40%, up to 60%)
EFFECTS OF DIABETES ON
PREGNANCY - 3
MATERNAL - 2:
5. Macrosomia (25% of IDM have BW
>4000 grams; 60% are LGA with BW >90th
percentile) CPD, operative delivery,
shoulder dystocia, trauma, & PPH
6. UTI & pyelonephritis
7. Vulvovaginal candidaiasis
EFFECTS OF DIABETES ON
PREGNANCY - 4
WHAT ARE THE FETAL/NEONATAL
COMPLICATIONS OF DM?
EFFECTS OF DIABETES ON
PREGNANCY - 5
FETAL & NEONATAL - 1:
1. Spontaneous abortion
2. Macrosomia  shoulder dystocia  asphyxia
&/or trauma
1. Erb’s palsy, Klumpke’s palsy
2. Facial palsy, Horner’s syndrome
3. Clavicular or humeral fractures
3. IUFD in late pregnancy
4. Prematurity (double)
EFFECTS OF DIABETES ON
PREGNANCY - 6
FETAL & NEONATAL - 2:
5. FD during labor; secondary to acute &
chronic hypoxia
6. Hypoglycemia especially in 1st 48 hours
after delivery
• Maternal hyperglycemia  fetal hyperglycemia  fetal
hyperinsulinemia  hyperplasia & hypertrophy of fetal
pancreatic islets of Langerhans  neonatal
hypoglycemia (Pederson hypothesis)
• Check RBS frequently and start early feeding
EFFECTS OF DIABETES ON
PRGNANCY - 7
FETAL & NEONATAL - 3:
7. RDS or HMD
8. Hypocalcemia
9. Polycythemia & neonatal jaundice
10. Congenital anomalies:
1. Sacral agenesis & caudal regression
2. CNS : open NTD. Role of folic acid?
3. CVS : TOGV, VSD, ASD
4. Renal
INFANT OF DIABETIC
MOTHER
EFFECTS OF PREGNANCY ON
DIABETES
• NIDDM patients will require insulin
because oral hypoglycemic agents
relatively contraindicated. Why?
• IDDM patients will require higher doses of
insulin
• Existing retinopathy & nephropathy may
worsen
PROGNOSIS-1
• PNM associated with DM has decreased
10 X in the past 40 years because of
better glycemic control, reduction of early
IOL, & advances in neonatal care
• Benefits of tight glycemic control:
– Early pregnancy: decrease possibility of
abortions & fetal anomalies
– Later pregnancy: decrease the rate of
macrosomia & PNM
PROGNOSIS-2
RULE OF 15:
– 36% of women with GDM develop DM within 15
years
– 15% of pregnant patients have abnormal GLT
– 15 % of those have abnormal OGTT
– 15 % of those require insulin therapy
– 15% of patients with GDM have macrosomic babies
(BW> 4000 grams)
MANAGEMENT - 1
PRECONCEPTION COUNSELING - 1:
– Timing of pregnancy & importance of Hb A1c levels
in detecting control over the past 30-40 days
• Hb A1c produced by slow glycosylation
• Normal range 3-4%
• If level > 12% associated with increased risk of
complications
– Postponement of pregnancy till later age not
advisable. Why?
MANAGEMENT - 2
PRECONCEPTION COUNSELING - 2:
– Re-education
– Ideal control:
• Glucose home monitoring by capillary sampling
• Patient injects herself with insulin
• Close relatives able to deal with emergencies
– Long-term effects on off-spring:
• Childhood obesity
• Early-onset type II DM
MANAGEMENT - 3

ANC - 1:
– Team approach (obstetrician, physician, nurse,
dietician)
– Additional testing:
• RFT, 24-hour urine collection for total protein &
creatinine clearance rate
• Fundoscopy
• MSU for C&S
• Fetal echocardiography
MANAGEMENT - 4

ANC - 2:
– Insulin dose & frequency may have to be
increased (up to 2-3 X in later pregnancy)
– Glucose home monitoring (as opposed to
repeated hospital admissions) increases
compliance, improves results, & reduces cost
– Visits every 2/52 till 32/52, then weekly till
delivery
MANAGEMENT - 5
ANC - 3:
– U/S in T1 for viability & confirmation of GA
– U/S at 20-24/52 for anomalies
– U/S at 32-36/52 for growth
– Daily FKC starting at 32/52
– Weekly NST starting at 32/52; increase to
twice weekly at 34-36/52
– Weekly BPP may also be carried out
MANAGEMENT - 6

GDM:
– Diabetic diet for 1/52
– BSP: 7 readings
– If controlled with diet, recheck FBS & PPBS
every 1-2/52
– If insulin is needed, admit to hospital
MANAGEMENT - 7
DIET:
– 30-35 kcal/kg of ideal body weight (range =
1800-2800 kcal/ day)
– 3 meals + 3 snacks
– 50 % CHO (complex & high fiber) + 30 % fat +
20 % protein
– 25 % breakfast + 30 % lunch & dinner + 5 %
each snack
– Consistency in dietary intake and activity level
MANAGEMENT - 8
INSULIN THERAPY - 1:
– If initial FBS > 9 mmol/l
– If diet does not provide satisfactory control
within 1-2/52
• FBS < 5.3 mmol/l
• Pre-prandial < 6 THIS IS
• 1-hour PPBS < 7.8 “TIGHT GLYCEMIC
• 2-hour PPBS < 6.7 CONTROL”
• Not less than 4
MANAGEMENT - 9
INSULIN THERAPY - 2:
– Total dose:
• T1  0.5 units/kg actual body weight
• T2  0.6
• T3  0.7
– Dose divided into 2/3 in am + 1/3 in pm
– AM dose further divided into 1/3 short-acting + 2/3
intermediate- acting
– PM dose divided in 1/2
MANAGEMENT - 10
INSULIN THERAPY - 3:
– Alternative regimen:
• 3 pre-prandial doses of short-acting insulin
• 1 dose of intermediate-acting insulin at bedtime if FBS high
– Reduced compliance but better glycemic control
– What is the role of continuous subcutaneous insulin infusion
pumps?
MANAGEMENT - 11
INSULIN THERAPY - 4:
– HR / Actrapid:
• Onset of action after 30 minutes
• Peak effect within 2 hours

– HN / Monotard:
• Onset of action after 2 hours
• Peak action within 10 hours
MANAGEMENT - 12
JAMEELA
– 24 year old
– G1
– GA = 26/5
– GLT = 11 mmol/l
– Weight = 100 kg
MANAGEMENT - 13
• IGTT:
– Repeat OGTT after 4/52 if test was done before 28/52
– Dietary advice; especially for those with high FBS.
Occasional FBS & PPBS
– FKC & NST as for normal pregnancy
• Others:
– Oral hypoglycemic drugs (Glyburide)
– Exercise (upper body CV training)
MANAGEMENT - 14
LABOR & DELIVERY - 1:
– DM on insulin IOL at 38-39/52
– GDM A1 IOL at 40/52
– IGTT IOL at 41-42/52 (overdue )
– Aim for vaginal delivery. But LCSC rates are
higher for diabetics (up to 60%) because of
FD & macrosomia
MANAGEMENT - 15
LABOR & DELIVERY - 2:
– On day of delivery:
• Reduce am dose of intermediate-acting insulin (1/3-1/2
usual dose)
• Start IV fluids D5% in NS at 125 cc/h
• RBS 1-2 hourly. Check urine each void for glucose &
ketones
• Start IV insulin if RBS > 6.7 mmol/l
• Continuos FHR monitoring
• Pediatrician to examine baby after delivery
MANAGEMENT - 16
PNC - 1:
– Insulin requirements decrease after delivery
– GDM A1  normal diet, FBS & PPBS after 2
days. 75-gram, 2-hour OGTT 6/52 later
– GDM A2  diabetic diet, BSP after 2 days,
OGTT 6/52 later
MANAGEMENT - 17
PNC - 2:
– 5-20% of GDM patients continue to have DM
after delivery
– Pre-existing diabetics can go back to pre-
pregnancy regimen
MANAGEMENT - 18
PNC - 3:
– Breast-feeding should be encouraged; take
into account increased caloric demand. How
much?
– 30-50% of patients with GDM develop type II
DM within 20 years; especially if obese
– Diabetogenic effect of pregnancy increased
by repeated pregnancies & obesity
MANAGEMENT - 19
FAMILY PLANNING:
– Advice regarding limiting size of family in
presence of retinopathy or nephropathy
– Low-dose OCP if young, non-obese, &
normotensive
– IUCD
– Barrier methods
– Sterilization
CASE - 1

SALMA
– 22 year old lady. MF 2/12
– IDDM since the age of 9 years
– Had renal transplant last year
– Attends for pre-conceptual counseling

– Outline management
CASE - 2
NADIA
– 30 year old lady. MF 5 years
– G6 P0+2+3+2. Previous LSCS X 2
– IDDM since the age of 22 years
– GA = 6/52
– Attends for her booking ANC visit

– Outline management
CASE - 3
FAWZIA
– 40 year old lady. MF 18 years
– G7 P5+1+0+7. Previous LSCS
– GDM on insulin
– GA = 37/52. Breech presentation
– EFW by U/S +/- 4000 g

– Outline management
CASE - 4
NAEEMA
– 30 year old lady. MF 5 years
– Juvenile DM. G6 P2+0+3+2
– G 4: LSCS for failed VE. BW = 3700g
– G 5: VBAC. BW = 3200g
– GA = 37/52. SFH = 42 cm. EFW = 4000g. Hb A1c = 12%

– Outline plan for delivery


CASE - 5

RIHAB
– 22 year old lady. MF 1 year
– G1 P1+0+0+1
– Delivered 3 days ago. FTND after IOL for
GDM A1. BW = 3200 g
– She plans to breast-feed her baby

– She seeks contraceptive advice


THE END