Professional Documents
Culture Documents
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
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?
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
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
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
HOW TO SCREEN ?
TWO-STEP TESTING
1. Confirmatory test – OGTT
100 grams 3 hour oral glucose tolerance test
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
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
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
Fetal IUGR
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
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.