Diabetes in Pregnancy

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Diabetes in Pregnancy
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• Pregnancy is DIABETOGENIC
• Insulin resistance related to placental hormones

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Classification

• established diabetes prior to pregnancy
• -IDDM
• -NIDDM
• Gestational diabetes

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Pre-existing diabetes in pregnancy

• IDDM
• NIDDM
• may be undiagnosed
• hyperglycaemia
• vascular disease

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Embryogenesis
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Diabetes and congenital malformations

• increased incidence 3-5x
• - major 2-6x or minor
• - multiple
• - congenital heart disease, neural tube defects,
  renal and urinary tract, gastrointestinal and
  skeletal
• effect on early embryo
• Cause HYPERGLYCAEMIA

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Data from Rosenn et al From   Taylor BMJ,
Volume 334(7596).April 7, 2007.742-745
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Preconceptual care

• good diabetic control first 7 weeks pregnancy
• monitor HbA1C or fructosamine
• folate 0.5mg
• assess and treat other complications

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How to treat diabetes in pregnancy

• NIDDM
• ? metformin
• Insulin
• IDDM
• Insulin
• All diabetics
• - diet
• - exercise
• - obstetric monitoring
• - fructosamine/HbA1C

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Hypoglycaemia

• not associated with teratogenesis
• severe prolonged hypos may be dangerous
• Ketoacidosis major risk to fetus

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Other fetal/neonatal complications of
pre-existing diabetes

• Macrosomia- 40 Type I
• associated birth trauma
• childhood obesity
• later onset NIDDM
• Stillbirth
• gtType II
• after 36 weeks
• Hypoglycaemia
• RDS

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Maternal complications of diabetes in pregnancy

• Increased risk of miscarriage
• Increased risk of pre-eclampsia
• Increased risk of worsening eye, renal or cardiac
  disease

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Diagnosis of GDM at RHW

• Previous GDM or high risk test at 12-14 weeks?
  75g GTT
• screening test 26-28 weeks
• 50g Glu load, non-fasting
• - 1hr ?7.8 mmol/l
• if abnormal ? 75gm GTT
• - F ?5.5 mmol/l, 2hr ?8.0 mmol/l

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Why does gestational diabetes matter?
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Why treat gestational diabetes in pregnancy?

• Reduce maternal complications
• reduce neonatal/fetal Cx
• identify at risk population for NIDDM in future
• - 36 over 25 years years postpartum
• - may be greater risk in certain populations

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Aims of treatment

• euglycaemia
• fasting lt5.5 postprandial 4-7
• avoid Cx of diabetes

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How to treat diabetes in pregnancy

• Gestational diabetes
• - diet
• - weight control
• - exercise
• - BSL monitoring
• - insulin preferred over oral hypoglycaemics
• - fructosamine

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Follow up

• hyperglycaemia usually resolves within 24 hours
• repeat GTT within 12 months annually
• high recurrence rate
• Aggressive risk factor management