DIABETES IN PREGNANCY

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DIABETES IN PREGNANCY

• DR. SALWA NEYAZI
• CONSULTANT OBSTETRICIAN GYNECOLOGIST
• PEDIATRIC ADOLESCENT GYNECOLOGIST

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PHYSIOLOGICAL CHANGES OF GLUCOSE METABOLISM IN
PREGNANCY

• Pregnancy is a state of insulin resistance
  relative glucose intolerance
• This is due to placental production of
  anti-insulin hormones hPL, cotisol, and
  glucagon
• FBS ??
• Postprandial glucose ? ?
• Insulin production ? ? 2 folds in N women
• Insulin requirements ? ? in diabetic women
• ?? renal threshold for glucose ? glycosuria

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DIAGNOSIS OF GESTATIONAL DIABETES MELLITUS

• Women in whom the criteria of DM are met in
  pregnancy ? include a gp of diabetics who were
  undiagnosed before pregnancy
• FBS ? gt 7 mmol/L on 2 occasions
• Or
• RBS ? gt 11.1 mmol/L on 2 occasions
• Borderline cases ? GTT ? DM is Dx if FBS ? gt 7
  mmol/L or 2 hrs gt 11.1 mmol/L
• Impaired glucose tolerance ? 2hrs G 8-11 mmol/L
  with a N FBS

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EFFECT OF PREGNANCY ON DM

• Insulin requirement ? ? in pregnancy reaching a
  max at term being at least 2 X the
  pre-pregnancy requirement
• Pt with diabetic nephropathy ? deterioration in
  renal function with ? in creatinine clearance
  proteinuria
• ? this deterioration in renal function is
  usually reversed after delivery

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EFFECT OF PREGNANCY ON DM

• 2 X ?? in retinopathy
• ? rapid improvement in glycemic control ?
  worsening retinopathy due to ?? retinal blood
  flow
• ?? icidence of hypoglycemia
• Ketoacidosis is rare unless associated with
  hyperemesis, infections, tocolytic
  corticosteroid Rx

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EFFECTS OF DM ON PREGNANCY

• ?? incidence of congenital abnormalities
• The risk is related to the degree of glycemic
  control ? 5 with Hb A1c gt 8
• ? 25 with Hb A1c gt 10 with ??
  risk
• of abortions
• Sacral agenesis, congenital heart defects,
  skeletal abnormalities neural tube defects
• Perinatal neonatal mortality ?? 2-4 X
• Unexplained IUFD at term / more in macrosomic
  babies

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EFFECTS OF DM ON PREGNANCY

• Macrosomia ? the incidence is ?? with poor
  diabetic control
• ? not eliminated by tight control
• ? associated with ?? risk of operative
  delivery, birth trauma, shoulder dystocia
• Hyperglycemia ? fetal polyuria ? polyhydramnios ?
  PROM, preterm delivery
• Prematurity pose an added problem as pulmonary
  surfactant production is slightly delayed in
  babies of diabetic mothers

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EFFECTS OF DM ON PREGNANCY

• Postnatally, babies are at risk of hypoglycemia
  jaundice
• ?? risk of PET especially in pt with pre-existing
  hypertension nephropathy where it reaches
  almost 30

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MANAGEMENT

• Multidisciplinary team including obstetricians,
  endocrinologists, dieticians, midwives ?
  optimize outcome
• Preconception councelling
• To achieve normoglycemia as far as possible
• ?FBS lt 5 mmol/L
• ?PP lt 7.5 mmol/L
• Dietary advice on a low sugar, low fat, high
  fiber diet
• Regular capillary glucose series (7 point
  profile)
• Combined short acting intermediate acting
  insulin

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MANAGEMENT

• Regular assessment of Hb A1c
• Ophthalmologic examination Rx of retinopathy
• Regular monitoring of renal function in Pt with
  diabetic nephropathy
• Detailed U/S screening for congenital
  malformations in the 2nd trimester (20wk) ? to
  exclude NTD, sacral agenesis, cardiac defects
• Frequency of antenatal visits needs to be
  individualized

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ANTENATAL FETAL SURVELANCE

• ?? incidence of IUFD justify close monitoring in
  the 3rd trimester
• Serial U/S biometry ? to detect macrosomia,
  hydramnios, IUGR
• Umbilical artery doppler in Pt with IUGR
• CTG
• BPP

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LABOR DELIVERY

• With well controlled DM with appropriately grown
  fetus ? pregnancy is allowed to proceed till term
• When there is concern about fetal well being or
  macrosomia ? the risk of IUFD must be weighed
  against the risk of RDS
• ½ of the babies are gt90th centile ? CS rate of
  50-60
• Intrapartum care should focus on meticulous
  diabetic control continuous electronic fetal
  monitoring . Blood glucose should be 4-7 mmol/L
  achieved by 5 Dextrose infusion insulin
  infusion

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LABOR DELIVERY

• After delivery mternal insulin requirement
  rapidly returns to the pre-pregnancy level
• If abnormal glucose tolerance was 1st Dx in
  pregnancy ? GTT should be done 6 wk post-partum

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Gestational diabetes

• Carbohydrate intolerance of variable severity 1st
  Dx in pregnancy ? will include women with
  undiagnosed DM
• There is no consensus on the optimal screening
  for GDM
• ?Universal screening
• ?Screening pt gt 25 Y
• ?Clinical risk factors previous GDM, family Hx ,
  previous macrosomic baby, previous unexplained
  IUFD, obesity, glycosuria, polyhdramnios, LGA in
  current pregnancy
• ? The timing of screening also contraversal

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Implications of GDM

• ? perinatal mortality morbidity but to a lesser
  extent than DM
• No ? risk of congenital malformations
• Macrosomia is the main risk factor for adverse
  outcome
• ? risk of operative deliveries
• ? incidence of PET
• Women with GDM have a significantly ? risk of DM
  later in life (50 over 10-15 Y)

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Management

• Combined diabetic obstetric approach
• Initial approach by dietery modification
  including caloric reduction in obese Pt
• The need for insulin is manifested by persistent
  PP hyperglycemia (7.5-8 mmol/l) or persistant
  fasting hyperglycemia (gt5.5-6 mmol/L)
• Regular U/S scans to assess fetal growth well
  being
• Early delivery is not advised unless there is a
  complicating factor

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Management

• Intrapartum management
• ?Depends on whether the pt is on diet control
  alone or on insulin
• ? Pt on insulin need to be on sliding scale
• ?Following delivery insulin must be discontinued
• GTT should be done 6 wks postpartum

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MACROSOMIA

• Fetal Wt gt4000-4500 gm regardless of gestational
  age
• Risks of macrosomia include ? shoulder dystocia,
  erbs palsy, ? 5 min APGAR score, admission to
  NICU obesity later in life
• Risk factors for the development of macrosomia
• ? prior HX of macrosomia
• ?? maternal pre-pregnancy Wt
• ?excessive Wt gain in pregnancy
• ?multiparity

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MACROSOMIA (risk factors)

• ?male fetus
• ?gestational age gt40wks
• ?race
• ?maternal birth Wt
• ?maternal Ht
• ?maternal age
• ?ve GCT with-ve GTT
• ?GD, DM

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MACROSOMIA

• How macrosomic infants of diabetic mothers differ
  from those without diabetes?
• How is macrosomia predicted?
• How does it affect the management of labor
  delivery?
• When is CS recommended for macrosomia?
• What is the role of induction of labor?