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DIABETES

MELLITUS IN
PREGNANCY
SOLEDAD CHU-CRISOSTOMO, MD, FPOGS
Department of Obstetrics and Gynecology
OUTLINE
 Classification during pregnancy
 Pathophysiologic alterations in pregnancy
 Diagnosis
 Maternal and fetal effects
 Management
 Postpartum follow up
CLASSIFICATION DIABETES
DURING PREGNANCY

 PREGESTATIONAL
 Diabetes antedates pregnancy
 GESTATIONAL DIABETES
 Onset of first recognition during pregnancy
CLASSIFICATION

 Based on underlying pathogenesis (National Diabetes Data Group)

Nomenclature Old Name Clinical Features


Type I Juvenile-onset Ketosis prone, insulin-deficient
Insulin-dependent DM
DM (IDDM)
Type II Adult-onset DM Ketosis-resistant, insulin-resistant;
Non-insulin- obesity, family history& age are
dependent DM common risk factors
(NIDDM)
Type III Gestational Occurs only during pregnancy;
Gestational diabetes established by glucose tolerance
diabetes (GDM) test; obesity and age are common
risk factors
CLASSIFICATION

 Based on degree of glycemia, on the onset and duration of the


disease and presence of secondary vascular and other end organ
complications (White Classification)

Class Onset Fasting Plasma 2-hour postprandial Therapy


Glucose glucose
A1 Gestational <105 mg/dl <120 mg/dl Diet
A2 Gestational >105 mg/dl >120 mg/dl Insulin

Class Age of onset Duration (yr) Vascular disease Therapy


B Over 20 <10 None Insulin
C 10-19 10-19 None Insulin
D Before 10 >20 Benign retinopathy Insulin
F Any Any Nephropathy Insulin
R Any Any Proliferative retinopathy Insulin
H Any any Heart Insulin
PATHOPHYSIOLOGY
 Type 1- insulin dependent diabetes
 Developsin genetically susceptible person
 Immune mediated
 Predisposition triggered by viral infection →
inflammatory insulitis with lymphocytic infiltration of
islets → immune stimulation of antibodies against
the B-cell → cellular destruction → insulin
deficiency → hyperglycemia → Diabetes
PATHOPHYSIOLOGY

 Type 1- insulin dependent diabetes


 When fasting blood glucose levels are low →they are
more prone to ketonemia
 Glucose reserved for the fetus, while maternal
metabolic needs are served by the breakdown of
fats into fatty acids and ketones
 → ketones easily transported across the
placenta causing neuropsychiatric defects in
the offspring
 → high maternal ketone level causes metabolic
acidosis
 → if uncorrected, the dehydration and
electrolyte imbalance lead to cardiac
dysrhythmias, hemodynamic collapse and
death
PATHOPHYSIOLOGY

 Type 1- insulin dependent diabetes


 Clinicalonset typically abrupt and severe
 Associated with weight loss, fatigue, polyuria,
polydipsia, blurring of vision and dehydration
 Individuals are insulinopenic and dependent on
exogenous insulin for life
PATHOPHYSIOLOGY

 Type 2- non-insulin dependent diabetes


 With 3 defects noted:
1. Impaired insulin secretion
2. Increase hepatic glucose output
3. Inefficient peripheral tissue glucose utilization
 Reduction in insulin with increase glucagon draining
into the liver → increases hepatic glucose
production but there is absence of insulin response
to intravenous or oral glucose
PATHOPHYSIOLOGY

 Gestational diabetes
 Carbohydrate intolerance with onset of recognition
during pregnancy regardless of whether or not
insulin is used in the treatment
 Hyperglycemia due to:
1. Increase hepatic glucose production
2. Peripheral tissue insulin resistance
DIAGNOSIS:
OVERT DIABETES
 Fasting plasma glucose of 126 mg/dl or higher
 Glucosuria
 Ketoacidosis
 Random plasma glucose level greater than 200mg/dl
 Presence of the classic signs and symptoms-
polydipsia, polyuria and unexplained weight loss
 High index of suspicion if with the following- strong
family history of diabetes, having delivered large
baby, unexplained fetal losses, persistent glycosuria
DIAGNOSIS:
GESTATIONAL DIABETES
 WHY SCREEN?
 GDM is one of the most common medical problems in
pregnancy
 GDM is an in-utero risk factor for spontaneous
abortion, prematurity, fetal malformation, and
metabolic derangement
 Risk for fetal macrosomia which leads to an increased
risk for operative delivery by CS, vacuum or forceps
and birth trauma (shoulder dystocia, clavicle fracture,
peripheral nerve injury)
DIAGNOSIS: GESTATIONAL DIABETES

 WHY SCREEN?

 Neonatal risk factor for hypoglycemia, hypocalcemia,


hyperbilirubinemia, respiratory distress syndrome,
and congenital malformation
 Women with GDM are at increased risk for developing
the following complications later in life: metabolic
complications, coronary heart disease, CVA,
polyneuropathy, blindness, non traumatic amputations
and end stage renal disease
DIAGNOSIS: GESTATIONAL DIABETES

 WHOM TO SCREEN: UNIVERSAL OR


SELECTIVE SCREENING?
Risk Factors for Gestational Diabetes Mellitus
 >25 years of age
 <25 years of age and obese (>20% over desired BW or BMI
>27 kg/m2
 Family history of diabetes in first degree relatives
 Members of ethnic/racial group with high prevalence of
diabetes ( Hispanic-American, Native Americans, Asian-
American, African-American, or Pacific Islander)
LOW RISK if Pregnant women meeting none of the
criteria
DIAGNOSIS: GESTATIONAL DIABETES

 HIGH RISK
 Historical risk factors
 Past pregnancy – Abnormal glucose tolerance
Macrosomia (BW>8lbs
Congenital malformation
Recurrent abortions
Unexplained intrauterine deaths
 Present pregnancy –
Family history (first degree relative)
Maternal obesity ( >180 lbs or BMI > 2 kg/m2)
Drugs affecting carbohydrate metabolism
(steroids, betamimetic, etc.)
Age ≥ 30 years
Racial predilection (Indian)
DIAGNOSIS: GESTATIONAL DIABETES


HIGH RISK
 Obstetric risk factors
 Polyhydraminos

 Macrosomis babies

 Fetal abnormality

 Recurrent genital tract infection


DIAGNOSIS: GESTATIONAL DIABETES

 WHEN TO SCREEN ?
 LOW RISK – 24th to 28th weeks of gestation
 HIGH RISK – immediately at first prenatal visit
 If initial test are normal- repeat test at 24-28 weeks

and again later at 32-34 weeks due to increasing


glucose sensitivity as pregnancy progresses
DIAGNOSIS: GESTATIONAL DIABETES

 HOW TO SCREEN ?
 TWO-STEP TESTING
1. Screening test – OGCT
 50 grams oral anhydrous glucose load
followed by plasma glucose determination 1
hour later
 No fasting needed
 Value > 140 mg/dl (7.8 mmol/l) or >130 mg/dl

( 7.5 mmol/l) need confirmatory test


DIAGNOSIS: GESTATIONAL DIABETES

 HOW TO SCREEN ?
 TWO-STEP TESTING
1. Confirmatory test – OGTT
 100 grams 3 hour oral glucose tolerance test

 Fast for 10-16 hours, not less or more

 + GDM if obtain any 2 abnormal values of the


4 plasma glucose values
DIAGNOSIS: GESTATIONAL DIABETES

Carpenter & O’Sullivan &


Coustan Mahan / NDDG
OGCT 130 mg/dl 140 mg/dl

OGTT
Fasting 95 mg/dl 105 mg/dl
1 hour 180 mg/dl 190 mg/dl
2 hour 155 mg/dl 165 mg/dl
3 hour 140 mg/dl 145 mg/dl
DIAGNOSIS: GESTATIONAL DIABETES

 HOW TO SCREEN ?
 ONE-STEP TESTING
 WHO,ASEAN
 75 grams anhydrous glucose load followed by I blood
sugar value measured after 2 hours
 Value >140 mg% considered abnormal and treatment is
began
 Fourth International Workshop-Conference on
GDM
 75 grams glucose load followed by OGTT using the
criteria of Carpenter and Coustan
DIAGNOSIS: GESTATIONAL DIABETES

 HOW TO SCREEN ?
 REMINDERS: (OGTT)
 Do not do on patients who have an acute or
chronic illness that can affect the test.
 Discontinue all drug therapy hat can affect the test
for at least 3 days prior to the test ( see table).
 Have a patient eat a carbohydrate intake of at
least 150 grams/day for 3 days prior to the test
 Fast for 10 to 16 hours, not less or more
DIAGNOSIS: GESTATIONAL DIABETES

 HOW TO SCREEN ?
 REMINDERS (OGTT)
 Have patient drink the glucose solution within 15
minutes. The first swallow is time zero.
Discontinue the test if patient develop nausea and
vomiting. Collect samples at 0, 1 and 2 hours.
 Have patient abstain from tobacco, coffee, tea,
food and alcohol during the test.
 Slow walking is permitted but vigorous exercise
should be avoided.
DIAGNOSIS: GESTATIONAL DIABETES

Drugs That May Impair Glucose Tolerance


 Diuretics & Antihypertensives – chlorthalidone, furosemide,
thiazides, diazoxide, metazolone, propanolol, bumetamide,
ethacrynic acid, clonidine, calcium channel blockers
 Hormones – corticosteroids, adrenocorticotropic hormone,
glucagon, oral contraceptives thyroid hormones
 Psychoactive agents – haloperidol, lithium, tricyclic
antidepressants
 Cathecholamines and their neurologically active agent –
Phenytoin, epinephrine, isoproterenol, levedopa,
norepinephrine
 Antineoplastic agents – Alloxas, streptozotocin, L-
asparginase
 Miscellaneous – caffeine, indomethacin, isonizid, nicotinic
acid, acetaminophen, morhine, cimetidine
MATERNAL & FETAL EFFECTS
OF DIABETES
 FETAL EFFECTS OF GESTATIONAL
DIABETES
 Fetal anomalies are not increased
 Unexplained stillbirth is observed with elevated fasting
glucose (Class A2)
 Increased risk of fetal death during the last 4 to 8
weeks of gestation if with fasting hyperglycemia
(> 105mg/dl)
MATERNAL & FETAL EFFECTS OF DIABETES

 ADVERSE MATERNAL EFFECTS OF


GESTATIONAL DIABETES
 Increasedfrequency of hypertension and the need for
cesarean delivery
MATERNAL & FETAL EFFECTS OF DIABETES

 FETAL EFFECTS OF OVERT DIABETES


 2-4 % perinatal losses with improved fetal
surveillance, neonatal intensive care and maternal
metabolic control
 Abortion in patients with poor glycemic control during
first trimester especially among type 1 diabetes with
initial glycohemoglobin A1 concentration above 12%
or persistent preprandial glucose concentration above
120 mg/dl
 Preterm delivery at 34 weeks or less in 9% of women
with pregestational diabetes
MATERNAL & FETAL EFFECTS OF DIABETES

 FETAL EFFECTS OF OVERT DIABETES


 Increased incidence of fetal anomalies among type 1
diabetes although diabetes is not associated with
increased risk for fetal chromosomal abnormalities
 Unexplained fetal death
 Increased frequency of placental insufficiency in
association with severe preeclampsia
 Hydraminos possibly due to fetal polyuria caused by
fetal hyperglycemia
MATERNAL & FETAL EFFECTS OF DIABETES

 NEONATAL EFFECTS OF OVERT DIABETES


 Respiratory distress due to prematurity
 Hypoglycemia due to hyperplasia of the fetal B-islet cells
induced by chronic maternal hyperglycemia
 Hypocalcemia
 Hyperbilirubinemia
 Cardiac hypertrophy due to hyperinsulinemia
 Altered fetal growth/macrosomia
Long term cognitive development and inheritance of diabetes
– not greatly affected by maternal diabetes
MATERNAL & FETAL EFFECTS OF DIABETES

 MATERNAL EFFECTS OF OVERT DIABETES


 10-fold increase in maternal mortality due to ketoacidosis,
underlying hypertension, preeclampsia and pyelonephritis
 Diabetic nephropathy
 Diabetic retinopathy
 Diabetic neuropathy
 Preeclampsia causing preterm delivery
 Ketoacidosis
 Infections like candida vulvovaginitis, UTI, puerperal pelvic
infections, respiratory tract infections causing preterm
delivery
MANAGEMENT
 PRENATAL CHECK UP
 Gestational Diabetes
 Frequency of visits – every 2 weeks for glycemic
control and asses obstetric complications
(macrosomia, intrauterine growth retardation,
preeclampsia, hydraminos)
 Ultrasound – at first visit to determine AOG

at 20-22 weeks to detect


malformations
at 32-34 weeks to monitor growth
MANAGEMENT

 PRENATAL CHECK UP
 Pregestational Diabetes
 Frequency of visits – every 2 weeks or more often
to asses glycemic control and obstetric
complications
 Ultrasound – as in GDM

 At 36th week – creatinine, uric acid and electrolytes


MANAGEMENT

 DIET
 Total calories/day – 1800 to 2000 calories
 Frequency of meals – 3 main meals, 3 snacks
 Distribution of calories:
 Carbohydrate – 50-60% of total calories, no simple sugars
but complex, high fiber type
 Proteins – 18-20% of total calories
 Fats – equal to or less than 30% of total calories
MANAGEMENT

 EXERCISE
 Improves glycemic control when compared with diet
alone
 Do exercises that use upper body muscles with less
mechanical stress on the trunk region during exercise
 Effects on glucose levels only become apparent after
4 weeks of exercise
MANAGEMENT

 INSULIN
 Gestational Diabetes should be placed on insulin
when:
 1-2 weeks of diet fails to control blood glucose
 Pre-breakfast blood glucose is 100mg% or more and when 2
hours blood glucose is 140mg% or more
 Pregestational diabetics should discontinue their oral
hypoglycemic agents and be shifted to insulin
 Type of insulin – highly purified human insulin
MANAGEMENT

 ANTENATAL FETAL MONITORING


 In general, GDM’s who are well controlled on diet
alone, normotensive and have normal fetal growth do
not require additional tests of fetal well being before
30 completed weeks of gestation
MANAGEMENT

 ANTENATAL FETAL MONITORING


 Additional tests of fetal well being indicated in the
following:
 GDM’s on insulin, well controlled

 GDM’s on insulin, poorly controlled

 Presence of maternal hypertension

 Fetal macrosomia +/- polyhydraminos

 Fetal IUGR
MANAGEMENT

 ANTENATAL FETAL MONITORING


 Limitation of tests in predicting sudden intrauterine
death
 Antenatal tests of fetal well being:
 Fetal movements charted from 34 weeks
 Antenatal cardiotocographs (CTG) done bi-weekly from 36
weeks for pregestational diabetics and GDM’s on insulin
therapy
 Biophysical Profile Scoring in all GDM’s on insulin therapy
and pregestational diabetics from 36 weeks
MANAGEMENT

 DELIVERY
 Should be accomplished at 38 weeks when
gestational age is certained.
 If uncertained, lecithin-sphingomyelin ratio is measured and if
2.0 or greater, delivery is done.
 If severe hypertension develops, delivery is carried out even
if the ratio is less than 2.0
 Earlydelivery if diabetic control is poor or in the
presence of other complications where continuation of
pregnancy may be detrimental to the mother or fetus
MANAGEMENT

 DELIVERY
 Caution on the use of B-sympathomimetic drugs as
tocolysis in preterm labor and glucocosteroid as these
can worsen maternal glucose control and cause
ketoacidosis
 In the absence of other obstetric complications,
vaginal delivery is the aim.
MANAGEMENT

 DELIVERY
 Labor induction may be tried provided the fetus is not
very large and the cervix is favorable for induction
 Active management of labor is practiced - with labor
augmentation when necessary, glucose monitored,
adequate hydration
 Diabetes is not an indication for cesarean section but
is commonly used in the overtly diabetic women
within class B or C White classification to avoid
traumatic delivery of large infant at or near term
MANAGEMENT

 INFANTS OF DIABETIC MOTHERS


 Admitted to ward nursery for neonatal pediatric care
 Blood sugar obtained half to one hour after birth to
check for hypoglycemia and feed baby as early as
possible
 Repeat blood glucose monitoring just before the
second feed and third feed and more frequently if
indicated
MANAGEMENT

 INFANTS OF DIABETIC MOTHERS


 Infantsof pregestational diabetics should be screened
for congenital malformations associated with diabetes
 Look for other associated morbidity – polycythemia,
hyperbilirubinemia, hypocalcemia, and respiratory
problems
POSTPARTUM FOLLOW UP
 POSTNATAL ASSESSMENT
 75 grams oral glucose tolerance test at 6-12 weeks
after delivery for women with gestational diabetes
POSTPARTUM FOLLOW UP

 CONTRACEPTION
 Estrogen in OCP can increase risk of
thromboembolism, myocardial infarction and stroke in
diabetic women already at risk for vascular disease
 Low dose OCP which do not increase cardiovascular
risk maybe used but only by women without
vasculopathy or additional risk factors such as history
of ischemic heart disease
POSTPARTUM FOLLOW UP

 CONTRACEPTION
 Progestin-only contraceptives can be used because
of minimal effect on carbohydrate metabolism
 Intrauterine devices are not recommended because
of possible increased risk of pelvic infections
POSTPARTUM FOLLOW UP

 PRE-PREGNANCY COUNSELLING
 Should be impressed on all young diabetic female so
that they may be educated on good control of
diabetes before contemplating pregnancy
 Patients who may be well controlled on oral
hypoglycemics should be advised to change to insulin
therapy for fine control and maintain normoglycemia
at time of conception and during early gestation
GET READY FOR
THE QUIZ BEE
CASE
A 30 year old woman presents 8 weeks
pregnant. She is not obese and does
not have a history of any medical
problem. Her father has type 2 diabetes
mellitus requiring insulin. Vital signs and
physical examination are normal. There
is no protein or glucose in her urine.
Questions
1. The most appropriate screening test for
gestational diabetes in this patient is
a. Fasting blood sugar as soon as possible
b. 1 hour post 50 grams glucose as soon as possible
c. 1 hour post 50 grams glucose with the first
appearance of glycosuria
d. 1 hour post 50 grams glucose at 24-28 weeks of
gestation
e. 3 hour glucose tolerance test at 24-28 weeks of
gestation
Questions
1. The screening test revealed a value of 129
mg/dl. The next step is to
a. Treat the patient with insulin
b. Do a 100 grams OGTT as soon as possible
c. Do a 100 grams OGTT at 24-28 weeks
AOG
d. Repeat the OGCT at 24-28 weeks AOG
e. Do nothing since patient is not diabetic
Questions
1. At 22 weeks AOG the patient complained of
puritus vulva and curd like vaginal discharge.
She has glycosuria on urinalysis. The next step
is to
a. Treat the patient with insulin
b. Do a OGCT immediately
c. Do a OGCT at 24-28 weeks AOG
d. Do a 100 grams OGTT at 24-28 weeks AOG
e. Do nothing since patient is not diabetic
Questions
1. The patient has been found to have gestational
diabetes mellitus. You start her on a diabetic
diet and plan to begin insulin therapy if
a. Her fetus becomes macrosomic
b. She gains more than 3 lbs per week
c. Glucose is detected in her urine
d. Her 2 hour post prandial glucose consistently rises
above 120 mg/dl
e. As soon as diagnosed
Questions
1. The patient asked about her perinatal and
neonatal risks after being diagnosed to have
gestational diabetes. You will tell her that she
has an increased risk of the following except
a. Macrosomia
b. Structural anomalies
c. Operative delivery
d. Fetal hypocalcemia
e. Fetal hyperbilirubinemia
Questions
1. The patient is now 38 weeks AOG and has maintained
good control of her blood sugar with diet alone. She
asked regarding the mode of delivery. It is appropriate
to tell her that
 In the absence of other obstetric complications,
vaginal delivery is aimed.
 She will be delivered by cesarean section once she
goes into labor
 She can choose any date for her scheduled
cesarean section
 Labor should be induced now that she reached 38
weeks.

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