Diabetes and Pregnancy

1
Diabetes and Pregnancy
July 2006
2
Diabetes and pregnancy

• Session outline
• Normal metabolism in pregnancy
• Pre existing diabetes and pregnancy
• Gestational diabetes
• Antenatal management
• Postnatal follow up

3
Normal metabolismin pregnancy

• Decreased fasting BGL
• Increased post prandial BGL
• Increased fat metabolism
• Increased ketone production
• Decreased circulating amino acids
• Decreased glucose production in the liver

4
Normal foetal metabolism

• Foetal pancreas develops between 4 and 6 weeks
  after conception.
• Insulin is produced at 10-12 weeks.
• Foetus obtains glucose via the placenta and can
  not produce its own glucose supply even during
  maternal hypoglycaemia.
• 3rd trimester glycogen storage in the liver and
  triglyceride production increases under the
  influence of foetal insulin.

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Type 1 diabetes and pregnancy

• Preconception normoglycaemia (normal blood
  glucose level) is important.
• Peri-natal mortality (death in the womb) is 2 and
  3 .
• Insulin requirements initially fall, then
  increase by 2nd and 3rd trimester.
• Will need intensive insulin therapy and close
  monitoring.

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Type 2 diabetes in pregnancy

• Pre conception normoglycaemia is important.
• If on oral medication, may need to switch to
  insulin.
• Controlled with diet, exercise and often insulin
  therapy.

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Risks

• To mother
• Hypoglycaemia
• Ketoacidosis (type 1 only)
• Retinopathy
• Nephropathy
• Pre eclampsia
• Urinary tract infections
• Hydramnios

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Risks

• To baby
• Congenial abnormalities
• Macrosomia
• Spontaneous abortion
• Intrauterine growth retardation
• Foetal death in utero

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Post natal

• Risks to baby
• Prematurity
• Respiratory distress
• Birth trauma
• Hypoglycaemia
• Risks to mother
• Hypoglycaemia (if on insulin therapy)

10
Gestational diabetes (GDM)

• Risk factors
• Family history of diabetes
• GDM in previous pregnancy
• Older maternal age (over 30 yrs)
• Previous large babies (over 4kgs)
• Obesity
• High risk ethnic groups (eg South East Asian or
  Aboriginal)
• Complicated obstetric history

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Gestational diabetes (GDM)

• Routine screening at 26-28 weeks
• non fasting OGCT (Oral glucose challenge test)
• 50g glucose load
• proceed to 75g OGTT (Oral glucose tolerance test)
  if 1hr BGL ? 7.8
• for OGTT
• fast overnight (water only), non smoking, 150g
  CHO per day for preceding 3 days
• positive if fasting level is ? 5.5 mmol/L and/or
  a
• 2 hour ? 8.0 mmol/L.

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Risks associated with GDM

• Major complication is macrosomia and its
  associated problems.
• Other complications can occur as previously
  discussed for women who have pre-existing
  diabetes.

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Antenatal management

• Management aims are the same for type1, type 2
  and gestational.
• Aim is to maintain BGLs between 3.5 and 7.0
  mmol/L.
• Regular home blood glucose monitoring
• Dietary education.
• Daily activity recommended.
• Review by the obstetric physician, diabetes
  educator and dietitian.

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Postnatal management gestational diabetes

• Stop insulin as soon as baby is delivered.
• Recommence normal diet as tolerated.
• Up to day 4 - test fasting and 2 hour post
  prandial blood glucose levels at breakfast, lunch
  and dinner.
• 2 months - fasting plasma or if had insulin OGTT.
• 12 months - OGTT (routine 1-2 yearly tests
  thereafter).
• Screening prior to planning next pregnancy.