DIABETES IN PREGNANCY

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DIABETES IN PREGNANCY

• Josephine Carlos-Raboca, MD

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Pregnancy is a time when serial metabolic changes
in the mother are carefully regulated to provide
optimum substrate to mother and fetus.
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GOALS

• Normal outcome of index pregnancy.
• Decrease risk for abnormal glucose and
  insulin homeostasis.
• Mother (before, during, after pregnancy).
• Infant subsequent generations.

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Gestational Diabetes Mellitus (GDM)

• Any degree of glucose in tolerance with onset or
  first recognition during pregnancy.
• 4th International Workshop-Conference on GDM,
  1998.

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Pregestational Diabetes Mellitus

• Diabetes diagnosed before pregnancy.

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Prevalence of GDM

• 1 14
• USA--- 3-5
• MMC (Asian Population) Raboca et al 13.4

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Perinatal Complications

• Macrosomia
• Respiratory Distress Syndrome (RDS)
• Hypocalcemia
• Hyperbilirubinemia
• Hypoglycemia
• Polycythemia

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Congenital Malformations

• Skeletal
• Cardiac (septal and outflow tract lesions)
• CNS and neural tube defects
• Gastrointestinal Defects
• Genitourinary Tract lesions

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Maternal and Fetal Factors of Teratogenesis

• Genetic Background
• Teratological Period
• Disturbances in Maternal-Fetal Transport
• Concentrations of Metabolites
• Hyperglycemia
• Hyperketonemia
• Somatomedin inhibitors
• Arachidonic/myoinositol deficiency
• Generation of free oxygen radicals
• Genotoxity
• Teratology 1997

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Objectives

1. Recognize GDM
2. Know how to provide nutritional plan
3. Know how to give insulin
4. Discuss preconception and postpartum care
5. Recognize special problems of pregestational
   diabetes

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Case I

• 31 year old female
• G1 PO, Age of Gestation 20 weeks
• Weight gain of 5 kg in the last 4
  weeks
• BMI (pre-pregnant) 30
• Height 165 cm
• actual body weight 90 kg
• Family History () DM in mother

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Would you recommend
testing for GDM at this time
or later at 24th to 28th weeks of gestation
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Risk Factors of GDM

• Age gt 25 years of age
• Obesity BMI gt 27 kg/m2 or gt 20 over DBW
• Family History of diabetes in first degree
  relative
• Ethnicity (Hispanic American, Native American,
  Asian American, Pacific Islander)

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ADA 2001

• Low risk no test
• Average risk test at 24th-28th week
• High risk test at 1st visit if negative repeat
  at 24 28 weeks.
• ASGODIP
• Test at 1st visit and every trimester if
  negative in previous test

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• 50 gm glucose challenge test was 150 mg/dl
• 100 gm OGTT F102 1H192 2H155 3H140
• Does this patient have GDM?

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Diagnosis of GDM

• 100 gm OGTT 75 gm OGTT
• mg/dl mml/L mg/dl
  mml/L
• F 95 5.3 95
  5.3
• 1H 180 10.0 180
  10.0
• 2H 155 8.6 155
  8.6
• 3H 140 7.8
• gt 2 values met GDM
• ASGODIP, WHO
• European Diabetes
• Policy Group 1992-1998 75 gm OGTT, 2H gt140

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Prescribe diet for this patient

• For normal weight 30 kcal/kg of Present BW
• For overweight 24 kcal/kg of Present BW
• For morbidly obese 12 kcal/kg Present BW
• 3 meals, 3 snacks, 40 of total calories CHO
  
• Medical Management of Pregnancy Complicated
  by Diabetes

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1. With diet, preprandial capillary blood glucose
   level were 70 - 80 mg/dl,2HPPCBG 95 115 mg/dl
2. Would she require insulin?

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ADA 2001

• Insulin Required if diet fails to maintain
  glucose
• at following levels.
• Fasting whole blood glucose lt 95 mg/dl (5.3
  mml/L)
• Fasting Plasma Glucose lt 105 mg/dl (5.8 mml/L)
• OR
• 1H Postprendial whole blood glucose lt 140 mg/dl
  (7.8 mml/L)
• 1H Postprendial Plasma Glucose lt 155 mg/dl (8.6
  mml/L)
• OR
• 2H Postprandial whole blood glucose lt 120 mg/dl
  (6.7 mml/L)
• 2H Postprandial Plasma Glucose lt 130mg/dl (7.2
  mml/L)

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1. How would you follow up this patient Postpartum?
2. What are her chances of developing diabetes?

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• 75 gm OGTT gt 6 wks. postpartum
• FPG every year x 3 years

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50 in 20 years timePredictors of DM

• maternal obesity
• fasting hyperglycemia
• duration of time from index pregnancy

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TRIPOD
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Case 2

• 28 years old Go Po
• diabetic X 1 year
• desires pregnancy

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• When is the best time for patient to get
  pregnant?
• What advise would you give her?

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• Counseling about risk of malformation with
  poor control
• Use of low dose estrogen progestogen
• contraceptive till good metabolic control is
• achieved.
• Goals
• HBA is 1 above normal
• Preprandial CBG 70-110 mg/dl (3.9-5.6mml/L)
  CPG 80-110 mg/dl (4.4-6.1
  mml/L)
• 2H Postprandial CBG lt 140 mg/dl (7.8mml/L)
  CPG lt 155 mg/dl
  (8.6mml/L)

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4-7 X / day preprandial 1 hour or 2 hour
post prandial
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What other medical problems should you
consider in a diabetic pregnant?
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• Acceleration of retinopathy
• Pregnancy induced hypertension
• Progression of Nephropathy

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What is your goal for glycemic control during
labor?
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• 120 mg/dl
• D5 0.45 NSS at 100-125 ml/hour
• CBG every 1-4 hours
• Insulin infusion to start at 1unit/hour of
  regular insulin if CBG gt 120 mg/dl

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THANK YOU.
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HYPERGLYCEMIA AND ADVERSE PREGNANCY OUTCOME STUDY
(HAPO)

• Background Overt diabetes clearly increases
  the risk of adverse pregnancy outcome
• What level of glucose intolerance short of
  diabetes increases the risk of adverse pregnancy
  outcome?

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Study protocol

• 75gm OGTT 24-32 weeks (average 28) 0,1,2 hours
• Venous plasma, enzymatic method
• Results provided if FPGgt 105 (5.8)
• 2 hour gt 200 (11.1)
• any value lt45(2.5)
• otherwise blinded to caregivers

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Endpoints

• Relationship between maternal hyperglycemia and
• cesarian rate
• macrosomia rate
• fetal hyperinsulinemia
• neonatal obesity (skinfold thickness)
• neonatal hypoglycemia rate
• other morbidities

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Study Protocol

• Routine prenatal care
• Daily kick count from 28 weeks
• Random venous plasma glucose at 34-37 weeks if gt
  160 mg/dl (8.9) or lt45
• Umbilical cord glucose and C-peptide levels
• Routine neonatal care
• Neonatal blood glucose at 1-2 hours of age
• First feeding 2 hours after birth (may nurse
  earlier if desired)

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Interim Study Report

• Enrollment 9396 women
• Deliveries5282
• primary CS 14.5
• repeat CS 7.3
• prenatal loss 5.5/1000
• Number of OGTT 7160
• Unblinded 158 (2.2)

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Interim

• Glucose levels
• FPG 10 gt 90
• 1 hour 15 gt 160
• 2 hour 4 gt 140

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Summary

• Preliminary data from HAPO enrollees confirm the
  safety of the study protocol and yielded the
  predicted prevalence of lesser degreesof
  glucose intolerance that should permit an
  adequate test of the study hypothesis.

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Study Hypothesis

• Hyperglycemia in pregnancy less severe than overt
  diabetes is associated with increased risk of
  adverse maternal fetal and neonatal outcomes that
  is independently related to the degree of
  metabolic disturbance.