Important core knowledge about management of diabetic female in pregnancy and what are the possible fetal and neonatal complications and risk factors. book: Obstetrics by Ten teachers.

1. DIABETES &
PREGNANCY

2. Definition:-
► WHO has defined:
“Diabetes mellitus as either a raised fasting blood glucose level of >
7.8 mmol/L or a level of > 11.1 mmol/L 2 hrs following a 75g oral
glucose load.”

3. Introduction:-
► Diabetes may complicate a pregnancy either because a woman has
pre-existing (IDDM) or (NIDDM).
► Diabetes can also develop during the course of pregnancy due to
hormonal changes leading to impaired glucose tolerance/insulin
resistance as a result of hormonal changes.

4. Continued…
► Studies have shown that a direct relationship exists between blood
glucose level and maternal and fetal complications.
► For this reason, women should be advised to aim for optimal control
of their blood sugar levels prior to conception and throughout
pregnancy.

5. Risk factors
► Obesity (body mass index > 30)
► Family history of diabetes
► Previous baby > 4.5 kg
► Previous unexplained still birth
► Previous congenital abnormality in baby

6. Fetal and neonatal complications:-
► Miscarriage
► Congenital fetal abnormalities:
1. Neural tube defects
2. Congenital heart diseases
3. Spinal abnormalities (rare condition caudal regression syndrome)
► Macrosomia:
1. Birth asphyxia
2. Traumatic birth injury, e.g. brachial plexus injury
3. Shoulder dystocia

7. Continued…
► RDS
► Hypoglycemia
► Polycythemia
► Hyperbilirubinaemia
Congenital abnormalities is the most important cause of mortality and
morbidity in diabetic pregnancies and exact reasons for all of these
complications are not known

8. Maternal complications:-
► Nephropathy (temporary worsening)
► Retinopathy (progression)
► Coronary artery diseases
► Hyperglycemia/hypoglycemia/ketoacidosis
► Pre- eclampsia (risk increased by two-to-four fold)

9. Continued…
► Infections
► Thromboembolic disease
All these complications are accelerated and worsen if already present
and if not present chances of there development are increased or they
may be initiated during diabetic pregnancy.

10. Management:-
There are three aspects of management
1. preconception management
2. Management During pregnancy
3. Management During labor

11. Preconception management
► Review risks of uncontrolled diabetes during pregnancy
► Provide counseling on medications contraindicated during
pregnancy
► Statins, angiotensin-converting-enzyme (ACE) inhibitors,
angiotensin II receptor blockers (ARBs), and most non-insulin
antihyperglycemic agents

12. Continued…
► Advise patient to take high dose (5mg) of folic acid pre-conception
and for first 12 weeks
► Diabetes therapy should be intensified and appropriate
contraceptives should be taken until glucose control is good
► Recommended HBA1c level is 6.5% and pre-meal glucose levels of
4-7 mmol/L

13. During pregnancy
► Maintain close-to-normal glycemic control prior to and throughout
pregnancy
► It is done in a joint clinic with obstetrician and physician
► Input from dietician is also important to adjust the dose of insulin
► Insulin dose will increase in pregnancy due to physiological increase in
insulin resistance

14. Continued…
► Target is to achieve HBA1c level <6.5% with pre-meal glucose levels of
3.5-5.5 mmol/L and 2 hour postprandial levels of 4-6.5 mmol/L
► Appropriate screening tests (nuchal translucency scanning, detailed
ultrasound, fetal echocardiography, serial growth scans, etc. ) should be
performed for fetal well being
► Timing and mode of delivery should be determined on individual basis

15. During Labor:
► Normoglycaemia is maintained using sliding scale of insulin
administration
► Blood glucose levels should be tested at two-hourly intervals
► Continuous fetal monitoring is advised and fetal scalp blood
sampling should be done if CTG is abnormal

16. Continued…
► Following delivery insulin requirements fall to pre-pregnancy state
► Insulin may be stopped and a full glucose tolerance test is repeated
six weeks after delivery for women who became diabetic for first
time during pregnancy