pregnancy

1. Dr. Phyu Phyu Kyaing
Senior Consultant /Associate Professor
YCWH
DIABETES MELLITUS IN
PREGNANCY

2. - second commonest medical disorder in
pregnancy
Incidence – 1%
Physiology
hPL,cortisol,O&P (Insulin
antagonists --- relative
insulin resistance)
fasting glucose level
peak glucose following
carbohydrate challenge
insulin level (double)

3. Either a raised fasting blood glucose level of
>5.1 mmol/L or a level of >10 mmol/L , 8.5
mmol/l 1 and 2 hours following a 75 gram
glucose load (WHO).
Definition of Geatational Diabetes

4. The woman has pre-existing insulin-
dependent diabetes before her pregnancy
begins.
She may develop an impaired glucose
tolerance during the course of her pregnancy
Diabetes may complicate the pregnancy

5. Risk factors for the development
of diabetes in pregnancy
• Obesity (body mass index 30)
• Family history
• Previous baby >4.5 Kg
• Previous unexplained stillbirth
• Previous congenital abnormality

6. The effects of pregnancy on
diabetes mellitus
Control of diabetes becomes difficult
because of placenta hormones which are
diabetogenic.
Patients who are treated by diet alone may
need injection insulin. Insulin requirement is
increased.

7. May lead to diabetic nephropathy or
retinopathy and if these conditions are
already present, they may become worse.
Ketosis is more apt to occur.
Severe hyper or hypoglycaemia.

8. The effects of diabetes on mother
and fetus
Effects on mother
During pregnancy
• Easy to get infection – urinary tract infection,
vulval and vaginal candidiasis
• Pregnancy induced hypertension
• Polyhydramnios
• Abortion
• Preterm delivery

9. During labour
• Increased risk of operative delivery/caesarean
section because of fetal macrosomia and the
complications including thromboembolic
disease.
• Difficult labour or shoulder dystocia as a
result of fetal macrosomia and likely to have
genital tract injuries.
During puerperium
• Puerperal infection

10. Effects on fetus and neonate
Congenital abnormalities - Cardiac, Neural
tube defect.
Good diabetic control, particularly prior to
conception reduces these risks.
Hb A1C – retrospective assessment of
diabetic control
lncreased levels in early preg: associated
with NTD, Cong Ht, rare condition called
caudal regression syndrome.

11. Cardiac
• ASD
• VSD
• Coarctation of
aorta
• Transposition of
great vessels
Others
• Single umbilical
artery
Gastrointestinal
• anorectal atresia
• duodenat
atresia
• Tracheo-
esophageal
fistula
Skeletal &
central nervous
system
• anencephaly
• caudal
regression
syndrome
• microcephaly
• NTDs
Renal
• hydronephrosis
• renal agenesis
• ureteral
duplication
• polycystic
kidneys

12. Abortion
Prematurity
Macrosomia -Shoulder dystocia, birth asphyxia,
Traumatic birth injury e.g. brachial nerve injury
Sudden intrauterine fetal death – 10 -30% of
diabetic preg:, poorly controlled diabetes, those
with vascular disease, complicated by
macrosomia or polyhydramnios.

13. Respiratory distress syndrome – six times that
of normal infant, consequence of diminished
surfactant production as a result of fetal
hyperinsulinaemia.
Polycythaemia
Hyperbilirubinaemia and neonatal jaundice –
result of polycythaemia
Hypoglycaemia – in first 24 hours because the
fetus continues to excrete large amounts of
insulin in the immediate neonatal period.
Hypomagnesemia & hypocalcaemia – leads to
apnoeic attack and fits

14. Management of pregnancy with
diabetes mellitus
Prepregnancy care
Prepregnancy counselling and assess the
condition before pregnancy starts
If severe nephropathy or retinopathy is noted
advise against pregnancy
Good control preceding pregnancy
(HbA1c,normal) and in first trimester reduce
the incidence of congenital anomalies.

15. Antenatal care
Routine antenatal care + joint care with
diabetic physician and obstetrician close
cooperation is required.
More frequent antenatal visits.
Consists of two parts –
(1) Medical management
(2) Obstetric management

16. Medical management
• Control can be achieved by diet alone or by
injection insulin (short acting insulin
injection and in late pregnancy, short acting
insulin before each meal and intermediate
acting insulin at bed time are usually used)
• Oral hypoglycaemic agents are almost used
in pregnancy.
• Diet alone has to be readjusted or dose of
insulin has to be increased.

17. • Maternal blood sugar level and urine sugar
should be monitored 2 or 3 times a week.
• Preprandial plasma glucose between 4 to 6
mmol/L shows good control.
• Can check the control of DM by assessing Hb
A1c (Normal - 5% If > 10%, it shows poor
control in last 4 – 6 weeks.)

18. Obstetric management
Fetal monitoring
• Detailed USS at 18 weeks for – gestational
dating and structural abnormalities
• Serial USG to assess fetal growth -
BPD, HC, AC, HC : AC, FL
• In late pregnancy assess fetal wellbeing by
- daily fetal kick count
- FHS and CTG
- USG fetal biophysical profile scores
because danger of fetal death is still present in
late pregnancy

19. Maternal monitoring
• In addition to diabetic control
- Note for maternal weight gain
- Note for development of complications like
pre-eclampsia, polyhydramnios
- Symphysiofundal height, abdominal girth
- Early detection and treatment of infections

20. Maternal monitoring
• Admission to hospital
- When control is poor or at 36 -38 weeks of
gestation to keep under constant supervision
- BPD, HC, AC, HC : AC, FL
• Optimum timing of delivery - usually at 38 – 40
weeks and never allows to go post term.
• Decide mode of delivery
- Vaginal delivery is the aim
- on spontaneous onset of labour or
- by induction
- LSCS if there is any complications (e.g. Pre-
eclampsia, fetal distress, abnormal
presentation)

21. Intrapartum care
First stage
- oral intake
- 5% D/W drip 500 ml in 4 hours
- Soluble insulin 1-2 units per hour
- Maintain blood glucose level around 6.4 mmol/L
- Partogram – FHS every 15 minutes or CTG
continuously to detect fetal distress

22. Intrapartum care
Second stage
- Neonatologist should be present at the time of
delivery
- Instrumental delivery whenever required by
experienced obstetrician (be aware of shoulder
dystocia)

23. Intrapartum care
Third stage
- Active management to prevent PPH

24. Neonatal care
Baby should be nursed in special care baby
unit .
Early feeding is very important. Mother
should be encouraged to breastfeed straight
away.
Careful monitoring of baby’s blood sugar, if
necessary a glucose infusion commenced.
Watch out for the complications and give
appropriate treatment

25. Care in puerperium
Insulin requirement will reduce after delivery
and it should be adjusted.
- insulin requirement of established DM will
rapidly fall and return to pre-pregnancy
level.
- women who for the first time became
diabetic during pregnancy may stop their
insulin and a full glucose tolerance test is
repeated six weeks following delivery.