DIABETES MELLITUS

&
PREGNANCY

G.M Punarbawa

Introduction
Most common medical complication of
pregnancy
The Centers for Disease Control and
Prevention estimated: 20.8 million
persons (USA) had diabetes in 2005.
Diabetes is undiagnosed: 1/3 of adults
Preexisting (type 1 or type 2) DM
affects 13/1000 pregnancies

GDM
Def: any degree of glucose intolerance with first
recognition during pregnancy
Complicates: 4% of pregnancies
Women + GDM: 50% risk of developing T2DM over
the next 10 years
DM during pregnancy: significant risks to the
mother & fetus

GDM..
- Poorly controlled diabetes:
risk of spontaneous abortion
rate of major congenital anomalies is 612%
among women with pregestational diabetes.

-Diabetic ketoacidosis (DKA) is an

immediate
threat to maternal and fetal life:
Fetal death (10% ), 3050% in the past

GDM
GDM:
risk fetal macrosomia operative delivery,
shoulder dystocia, birth trauma
risk neonatal complications (hypoglycemia,
RDS, hypocalcemia, & hyperbilirubinemia
Before insulin (1922): diabetic patients often
died during the course of their pregnancy
20 years ago, delivery of an unexplained
stillbirth from a mother with type 1 diabetes
>>>. Today this tragedy is rare, with a
reduction in perinatal mortality rate to less
than 5%.

Diabetic patients receive preconception care:

medical nutrition therapy
insulin therapy
achieve near-normal glycemic goals
morbidity % mortality uncomplicated
pregnancies
Accessibility of self-monitoring of blood glucose
level with its concomitant effect on glycemic
control << prolonged hospitalization
Priorities for diabetes care providers are:
identify & control diabetes prior to conception
Appropriately screen & treat even mild GDM
during pregnancy

Fetal Effects
Elevated glucose levels toxic (developing fetus):
miscarriages & major malformations
Birth defects: fatal or seriously deleterious QOL;
preventable by preconceptional glucose control
Malformations (first 8 weeks): preconceptional care:
essential for women with diabetes
Hb A1c level: reflects blood glucose concentration over
previous 2 months, can predict the risk for
malformations when measured in the first trimester
Fetus continues experience effects of hyperglycemia
beyond the period of organogenesis glucose crosses
the placenta; insulin does not fetal insulin
production (compensate hyperglycemic environment)
Higher insulin levels fetal somatic growth
(macrosomia & central fat deposition; & enlargement
of heart)

Diagnostic Criteria for

Diabetes Mellitus Prior to
Pregnancy
1. Symptoms of diabetes + random plasma
glucose > 200 mg/dL. Classic symptoms
(polyuria, polydipsia, unexplained weight
loss)
2. Fasting plasma glucose (FPG) > 126
mg/dL
3. Two-hour postload glucose level >200
mg/dL during an oral glucose tolerance test
(OGTT); glucose load (75 g anhydrous
glucose in water)

Diagnostic Criteria for GDM

Risk assessment for GDM is performed atthe first
prenatal visit in all women who do not already
have diagnosed diabetes
Women with risk factors should be screened as
soon as feasible
Risk factors: obesity (nonpregnant BMI 30),
history of GDM, heavy glycosuria (> 2+),
unexplained stillbirth, prior infant with major
malformation, family history of diabetes in a firstdegree relative.
If the results of testing (-) retested (24 & 28
weeks)
All women should be screened between 24 and 28
weeks

 USA: 2-step approach;

1st step: screening test (50-g oral
glucose challenge test/GCT). Serum
glucose measured 1 hour later
The GCT can be performed at any
time of day and without regard to
time of prior meal. Cutoff: 140 mg/dL
(sensitivity 80%)
If the GCT >180 mg/dL FPG next
day

GDM
Screening for women with low risk:
<25 years, normal body weight, no family
history, no history of abnormal glucose
metabolism or poor obstetric outcome, and not
a member of an ethnic/racial group with a high
prevalence of diabetes (eg, Hispanic American,
Native American, Asian American, African
American, Pacific Islander).
The American Diabetes Association (ADA)
diagnoses GDM based on 2 abnormal results on
the 3-hour, 100-g OGTT or on the 2-hour, 75-g
OGTT

During ANC:
fetal weight 70% /> for gestational age; or
polyhydramnios (AFI 24 cm) re-evaluation
for GDM.
TYPE:
Type 1 DM (T1DM): results from beta cell
destruction, usually leading to absolute insulin
deficiency
Type 2 DM (T2DM): insufficient insulin
receptors to effect proper glucose control
after insulin is released (insulin resistance)

GDM
GDM: any degree of glucose intolerance with
onset or first recognition during pregnancy
Majority of GDM cases: glucose levels return to
normal after delivery
Risk of recurrence in future pregnancies: 60%
Risk of miscarriages, congenital malformations,
preterm birth, pyelonephritis, preeclampsia, in
utero meconium, fetal heart rate abnormalities,
cesarean deliveries, and stillbirths
Increasing obesity, metabolic syndrome, &
prediabetes incidence GDMPathophysiology
GDM: pathophysiologically similar to T2DM.
Women most likely develop GDM: overweight,
"apple shape."

APPROACH TO DIABETES IN
PREGNANCY
Prevention hyperglycemia /control of glucose
level: mainstay of treatment GDM.
Careful preconceptional counseling & normal
Hb A1c levels Pre- pregnancy (pregestational
diabetics), frequent (usually 45x per day)
home glucose level monitoring, adjustment of
diet, regular exercise.
Regular exercise: nonweight-bearing or lowimpact exercise initiated or continued. Short
episodes of exercise will sensitize the patient's
response to insulin for approximately 24 hours.
Diet: soluble fiber satiety & improves number
of insulin receptors & their sensitivity.

 Carbohydrate restriction. Calories: 2535 kcal/kg of

actual body weight, generally 18002400 kcal/day.
Diet: 4050% carbohydrate, 3040% fat, 20%
protein.
Morbidly obese women may have a lower
metabolism rate; therefore, begin low and increase
calories as needed. When postprandial values
exceed the targets, review all recent food intake to
adjust food choice, preparation, and portion size.
Self-monitoring of fasting, 1- or 2-hour postprandial,
and nighttime blood glucose levels using a glucose
meter provides instant feedback to assess the
patient's diet and behavior. Optimal glucose levels:
fasting 7095 mg/dL & 1-hour postprandial < 140
mg/dL or 2-hour postprandial values < 120 mg/dL.

 A minimum of 2 visits to a dietitian

improves education and active
participation regarding diet
Insulin therapy is added when
necessary to achieve goals
Insulin: rational step to achieving
worthwhile glycemic goals
Subcutaneous insulin pumps better
control of hyperglycemia Recent
evidence: glyburide or metformin are
safe & effective alternatives. Treatment
with oral hypoglycemics should be
limited & individualized

ANTEPARTUM CARE
Comprehensive eye examination for retinopathy:
performed annually. Renal function test. In
patients with T1DM, thyroid function test:
because of increased rates of thyroid disease.
ECG: > 30 years or have disease > 5 years
Supplemen: 0.4 mg of folate daily
Gestational age should be confirmed with a firsttrimester ultrasound examination
Pregestational diabetics: USG for anatomy
completed at 1820 weeks
Tests to screen anomalies (1st-trimester nuchal
translucency & serum screening; 2nd-trimester
triple or quadruple screening

ANTEPARTUM CARE
DMG: 3x rate of asymptomatic bacteriuria vs N
pregnant women.
Urine culture: at the initial visit. R/AB A a repeat
culture (test of cure). The development of edema
risk of preeclampsia
Evaluation of maternal glycemic control (selfmonitoring) & fetal growth (USG) are essential
Poor glycemic control (macrosomia / polyhydramnios)
risk poor outcome.
Fetal well-being begins 32 weeks': NST / modified BPP:
2x weekly
DMG with diet-controlled: testing at 3640 weeks until
delivered.
Maternal fetal movement monitoring ("kick counts"): a
count to 10 or similar method is recommended to
reduce stillbirth
When fetal assessment not reassuring mature fetus
delivered. Cases near term amniocentesis

ANTEPARTUM CARE
Assessment lung maturity recommended for
elective delivery < 38 weeks' or glycemic control
inadequate risk delay lung maturity
Preterm labor: >> among. R/ tocolysis
glucocorticoid (lung maturation over 48 hours).
Magnesium sulfate, Nifedipine
Adrenergic mimetics (terbutaline): avoided may
cause severe hyperglycemia &, rarely,
ketoacidosis
Glucocorticoids: cause hyperglycemia +
continuous iv insulin (maintain normal glucose
levels)
>> obstetricians induce at 39 weeks' gestation

SEVERE HYPERGLYCEMIA &

KETOACIDOSIS
Treated the same as in the
nonpregnant state. R/ Insulin, careful
monitoring of potassium level, fluid
replacement
CTG: often demonstrates recurrent
late decelerations, but improve as
maternal ketoacidosis is corrected

INTRAPARTUM
MANAGEMENT
Glucose infusion in labor (D5% in RL): 125 mL/h

(6.25 g of glucose per hour)

Monitor glucose levels @ 24 h (early labor) & @
12 h (active labor)
Patients requiring insulin: continuous infusion
(regular insulin), 25 U in 250 mL saline (0.1
unit/mL)
Continuous CTG: abnormalities scalp
stimulation / fetal oxygen saturation monitoring
Risk shoulder dystocia (adequate personnel,
obstetric anesthesia, neonatal resuscitation)
CS: evening insulin doses on the preceding night,
morning dose (-)
The morning of surgery, glucose level is monitored
with continuous intravenous insulin to maintain
glucose 70 - 120 mg/dL

POSTPARTUM CARE
Dose of insulin should be reduced (insulin
sensitivity increases markedly postpartum)
two-thirds of prepregnancy dose or onehalf of the present dose
If the patient underwent surgery: glucose
levels should be kept < 140150 mg/dL to
assist the patient in healing
Breastfeeding is encouraged, and snacks
can be used to decrease the risk of
hypoglycemia
Insulin is continued for those women who
are breastfeeding, whereas oral agents can
be used in nonbreastfeeding mothers

CONTRACEPTION
Contraceptive: DMG without vascular
complications = nondiabetic women
If increased risk for embolism, hormonal
contraception containing estrogen not
recommended, but progesterone-only
methods, including the levonorgestrel
intrauterine system, can be offered
Permanent sterilization should be made
available to women with diabetes who
have completed childbearing