Diabetes and Pregnancy

Dr. Mohammadeid Mohtaseb

Diabetes in pregnancy

Pre-existing diabetes

IDDM
(Type1)

NIDDM
(Type2)

Gestational diabetes

Prediabetes

True GDM

Diabetes and
Pregnancy
1. Preexisting DM and pregnanc
y
2. Gestational diabetes

Preexisting diabetes in pregnancy

Type 1 DM ( IDDM)
Type 2 DM (NIDDM)

Preexisting DM in pregnancy
Effect of pregnancy on pre-existing DM
Increase requirement for insulin doses
Nephropathy , autonomic neuropathy ma
y deteriorate
Progress in diabetic retinopathy (2X)
Hypoglycemia
Diabetic ketoacidosis

Preexisting DM In Pregnancy
Effect of preexisting DM on pregnancy
Maternal
1. increase risk of miscarriage
2. increase risk of preclampsia
3. increase risk of infection eg vaginal candidi
asis, UTI, endometrial or wound infection
4. increase LSCS rate

Preexisting DM in Pregnancy
(2) FETAL
1. increase risk of congenital abnormalities
sacral agenesis, congenital heart disease,
neural tube defects

Hba1c level
normal
<8%
>10%

Risk
not increased
5%
25 %

Preexisting DM in Pregnancy

Perinatal mortality (excluding congenital. 2

abnormality ) 2 fold increased
Increase risk of sudden unexplained intr. 3
.auterine fetal death

Complications of pregnancy in p
re-existing DM
Maternal:

Increase insulin requirment

Hypoglycemia
Infection
Ketoacidosis
Deterioration in retinopathy
Increased proteinuria+edema
Miscarriage
Polyhydramnio
Shoulder dystocia
Preeclampsia
Increased caesarean rate

Fetal:
Congenital abnormalities
Increased neonatal and perinatal m
ortality
Macrosomia
Late stillbirth
Neonatal hypoglycemia
Polycythemia
jaundice

Maternal hyperglycemia
|
Fetal hyperglycemia
|
Fetal pancreatic beta-cell hyperplasia
|
Fetal hyperinsulinaemia
|
Macrosomia,organomegaly,
polycythaemia, hypoglycemia, RDS

Management

Aim
Achieve maternal near normoglycemic level t
o prevent adverse perinatal outcomes

Diet

Low-carbohydrate diet , high fibre with caloric

restriction
Frequent small snacks may be needed betwee
n meals
Avoid starvation

Insulin
3 pre-meal short acting insulin (actrapid) +/- int
ermediate-acting insulin (protophane) as it allo
ws maximum flexibility
Target blood glucose:
fasting < 5mmol/L
2 hr
<7 mmol/L

Oral Hypoglycemic agents

Implicated as teratogeneic in animal studies esp first

generation sulfonyureas
In humans, scattered case reports of congenital abno
rmality
Risk of congenital abnormality related to maternal gly
cemic control rather than mode of the anti-DM agen
ts

Oral hypoglycemic agents

For Type 2 DM patients,

to stop oral hypoglycemic agents and change to ins
ulin
Reassure that the risk of congenital abnormality due
to drug is small

Oral hypoglycemic agents

Biguanides ( metformin)
Cat B drug
Commonly used in Polycystic Ovarian Disea
se (PCOD) to treat insulin resistance and no
rmalize reproductive function
Not teratogeneic
Reduce first trimester miscarriage
10X reduce gestational diabetes

Oral hypoglycemic agents

Sulfonylureas
1 st generation drug increase risk of neonatal hypo
glycemia
2 nd generation drug (Glyburide) no such effect and
other morbidities .
Cat C drug
4%-20% patients failed to achieve glucose control
with maximum dose of drug
Increase risk of preeclampsia and need for photot
herapy

Insulin Analogues

1. rapid-acting insulin analogs

(lispro) Cat B

concerns about teratogenesis, antibodies

formation, growth-promoting properties
majority of evidence showed that it does not cross plac
enta, and has no adverse maternal or fetal effects

Insulin Analogues

2. Long acting analogs

glargine
Cat C drug
Not well studied systemically

Monitoring

Regular home glucose monitoring with hstix

Insulin may be need to be adjusted as gestation a
dvances
Hba1c monitoring
Fetal monitoring with USG
Refer ophthamologist

Delivery

Timing and mode of delivery individualised

Intrapartum insulin infusion with glucose mon
itoring
no contraindication for Breast feeding either
with insulin or oral hypoglycemic agents

Pre-conception Counselling
Allows for optimisation of diabetic control prior to con
ception, and assessment of the presence of complicati
ons like hypertension, nephropathy, and retinopathy
Should counsel that good control and lower hba1c low
er the risk of congenital abnormalities and improve out
come
If necessary, proliferative retinopathy may be treated
with photocoagulation prior to conception
Contraindications to pregnancy only :ischemic heart dx
, untreated proliferative retinopathy, severe renal impa
irment(creatinine>250 mmol/L)

Gestational diabetes

Definition
Carbohydate intolerance of variable severity fir
st recognised during the present pregnancy.
This includes women with preexisting but previ
ously unrecognised diabetes

Gestational diabetes
Should all pregnant women be screened or onl
y those with risk factors?
Is it safe to screen all?
Which screening test and which diagnostic test
are the most reliable?
Which cut-off values should we use?
What are the risk for mothers and babies and c
an treatment improve outcome?
What are the connection between gestational d
iabetes and type 2 DM?

Gestational diabetes

Screening and diagnosis

In general, the test is performed btn 24-28 wk
because at this point in gestation the diabeto
genic effect of pregnancy is manifest and ther
e is sufficient time remaining in pregnancy for
therapy to exert its effect

Gestational diabetes

PREGNANCY IS A DIABETOGENIC STATE FOR THE FOLLOWING RE

ASONS:
human placental lactogen has anti-insulin and lipolytic effect
s. It increases the glucose levels in maternal plasma and thus
makes more glucose available to the fetus
steroid hormones have an anti-insulin effect (especially corti
costeroids and progesterone)
some insulin may be destroyed by the placenta

Gestational diabetes
Screening and diagnosis

In general, risk factor includes:

1. age>25y
2. BMI > 25
3. previous GDM
4. Family hx of DM in 1st degree relative
5. previous macrosomic baby (>4 kg)
6. polyhydramnios
7. large for date baby in current pregnancy
8. previous unexplained stillbirth

Gestational diabetes

Screening and diagnosis

9.metabolic abnormalities HDL <35mg/dl ,TAG >250mg/
dl
10. PCO
11.HbA1c >5.7
12.Evidance of insulin resistance (acanthosis nigricans or
sever obesity )

Criteria for the Diagnosis of Diabete

s
A1C 6.5%
OR

Fasting plasma glucose (FPG)

126 mg/dL (7.0 mmol/L)
OR

2-h plasma glucose 200 mg/dL

(11.1 mmol/L) during an OGTT
OR

A random plasma glucose 200 mg/dL

(11.1 mmol/L)
ADA. I. Classification and Diagnosis. Diabetes Care 2014;37(suppl 1):S15; Table

Gestational diabetes

Incidence
2-9%
more common in Asian and Indian women
In developed countries, increasing trend because of
epidemic of obesity

Gestational diabetes
Clinical significance of GDM
1. High incidence of macrosomia, and adverse
pregnancy outcomes,
2. A significant proportion(30%) identified as G
DM in fact have DM before pregnancy

Gestational diabetes

Women with glucose intolerance just above no

rmal range are at low risk for pregnancy compl
ications, those with more severe glucose intole
rance approaching the criteria of diabetes are
at risk of neonatal complications

Fetal complications

Macrosomia (>4 kg)

risk is 16-29% as compared to 10% in control
Increase in caesarean delivery, intrumental deliv
eries ( forceps/vacuum), birth trauma, such as br
achial plexus injuries , clavicular fractures
Increase in neonatal hypoglycemia (24% ), hyperb
ilirubinemia, hypocalcemia, polycythemia
Children are at risk of type 2 DM and obesity in li
fe

Maternal complications

Increase risk of hypertensive disorders

Increase risk of caesarean and
Increased Risk (40-60%) of developing type 2 D
M within10-15 yr.

Gestational diabetes

Does treatment improves outcomes

Conflicting results
1. Cochrane datebase systemic review 2005 (3 studies only)
no difference in outcomes except neonatal hypoglycemia
2. Australian Carbohydrate Intolerance Study in Pregnant Wo
men (ACHOIS study) 2005 ( 490/510 subjects)
treatment of diabetes reduces serious perinatal morbility a
nd may
improve the womans health-related quality of life

Gestational diabetes

Management
Management similar as preexisting DM
Need for glucose monitoring
Start with Diet control
Commence insulin for poor control
Delivery plan individualised

Gestational diabetes

In view of risk of developing type 2 DM

the woman should be screened annually for D
M on yearly basis.

Diabetes and Pregnancy

Conclusion

(1)
(

Preexisting DM in pregnancy

Insulin is still the gold standard of tx in pregnancy

Increasing evidence for clincial effectiveness for treatment with oral

hypoglycemic agents

Good glucose control is important for decreasing morbidities

Diabetes and pregnancy

conclusion
(2) Gestational diabetes
no consensus
The morbidities increases as glucose level approac
hing the diagnosis as DM
Possible that treatment improves outcomes
Overlap with preexisting DM, esp type2
Long term implication for health of the mother and
baby

!!Thank
Thank you very much