management of Diabestes in pregnancy for healthcare providers

1. Management of Diabetes in Pregnancy
In a practical view

2. Definitions
Management Post partum
01
Screening Diagnosis
02 03
04 05
CONTENTS

3. WHO??
WHAT??
HOW?
WHY??

5. Lorenzo, Petra I. et al (2019). Molecular Modelling of Islet β-Cell Adaptation to Inflammation in
Pregnancy and Gestational Diabetes Mellitus. International Journal of Molecular Sciences.

7. DEFINITION
Gestational Diabetes Mellitus (GDM)
Any degree of glucose intolerance which is first detected
during pregnancy, whether or not the condition persists after
pregnancy

8. Pre-existing Diabetes Mellitus In Pregnancy
Definition: Diabetes Mellitus diagnosed before
pregnancy
Overt diabetes in pregnancy should be managed as pre-
existing diabetes.

9. National Obstetric Report involving 14 tertiary
hospitals showed incidence of diabetes in
pregnancy was 8.66% in 2011 and 8.83% in 2012
- ~13% underwent Cesarean section
- ~16% babies born to diabetic mothers weighed
≥4kg

10. Screening for GDM
WHO?
**Presence of any risk factors:
• BMI >27 kg/m2
• Previous history of GDM
• First-degree relative with DM
• History of macrosomia baby (BW >4kg)
• Bad obstetric history
• Glycosuria ≥2+ on two occasions at any POG
• Current obstetric problems (essential hypertension, Pregnancy-
induced hypertension, polyhydramnios, and current use of
corticosteroids)

11. Overt DM is suspected in the
presence of at least one of the
following:
• FPG ≥7.0mmol/L
• RPG ≥11.1mmol/L
However, the diagnosis of overt
DM should be confirmed with a
second test (FPG/RPG/MOGTT)

12. Refer FMS/O&G
specialist for
initiation of
pharmacological
treatment
Refer dietitian, trial
of diet control &
exercise with 2
weekly 7PBSP
Diagnosed GDM
If deranged 7PBSP,
find out why;
• Non-compliant to
diet control
• Improper 4-
7PBSP checking
time
• Improper insulin
injection
time/technique
If Yes, recounsel.
If
No
GENERAL MANAGEMENT OF GDM
Reference: Management of DIabetes in Pregnancy. Clinical Practical Guidelines Malaysia 2017

13. Hyperglycemia

14. Hypoglycemia

15. Suku suku separuh DIET
Reference: https://kliniksabah.com/tips-pemakanan-yang-sihat-dengan-prinsip-suku-suku-
separuh/

16. Suku suku separuh DIET
Reference: https://kliniksabah.com/tips-pemakanan-yang-sihat-dengan-prinsip-suku-suku-separuh/

20. Can pregnant women exercise?

21. • Walking—Brisk walking gives a
total body workout and is easy
on the joints and muscles.
• Swimming and water workouts
• Yoga and Pilates
• Strength training
Exercise tips when you're pregnant:
•warm up and cool down afterward
•try to keep active on a daily basis – 30 minutes of walking each day can be enough
•avoid any strenuous exercise in hot weather
•drink plenty of water and other fluids
•if you go to exercise classes, make sure your teacher is properly qualified and knows that you're pregnant, as well as how
many weeks pregnant you are
•you might like to try swimming because the water will support your increased weight. Some local swimming pools provide
aqua-natal classes with qualified instructors.
•exercises that have a risk of falling, such as horse riding, downhill skiing, ice hockey, gymnastics, and cycling, should only be
done with caution. Falls carry a risk of damage to your baby
Start with a low level of exertion and work up to 30 minutes a day, three to five
times a week

22. WEIGHT MANAGEMENT
⮚ Energy prescription should be individualized based on pre-pregnancy body
weight
• Normal pre-pregnancy weight: 35 kcal/kg body weight.
• Overweight/obese woman: moderate caloric restriction 25 kcal/kg body weight.
⮚ Recommended weight gain during pregnancy:
Pre-pregnancy BMI (kg/m2) Total weight gain (kg) Mean rates of weight gain in 2nd
and 3rd trimester (kg/week)
Underweight (<18.5kg) 12.5-18.0 0.51
Normal weight (18.5-24.9) 11.5-16.0 0.42
Overweight (25.0 - 29.9) 7.0 - 11.5 0.28
Obese (>30) 5.0 - 9.0 0.22
Reference: Management of DIabetes in Pregnancy. Clinical Practical Guidelines Malaysia 2017

23. 03
02
SELF-MONITORING OF BLOOD GLUCOSE
Target Reading:
fasting or preprandial: ≤5.3 mmol/L
1-hour postprandial: ≤7.8 mmol/L
2-hour postprandial: ≤6.7 mmol/L
⮚ Provide BSP monitoring chart.
⮚ Educate patients on how to record 7PBSP readings.
⮚ Advise taking meals regularly (breakfast, lunch, dinner).
⮚ Check blood glucose using a glucometer before & 2hrs after each meal (Ensure correct timing).
⮚ If the patient is on insulin, take insulin after checking pre-meal blood glucose (to omit the insulin if blood sugar
<4.0mmol/L), take a meal after half an hour of insulin injection, and check blood sugar 2 hrs post-meal.
⮚ Repeat the steps for lunch, dinner, and pre-bed.
⮚ If a patient does not have her own glucometer: perform 7PBSP at the clinic as an outpatient/admit to the
maternity ward.
Reference: Management of DIabetes in Pregnancy. Clinical Practical Guidelines Malaysia 2017

25. COMPLICATIONS OF UNCONTROLLED GLUCOSE
Reference:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4404707/
Outcome Frequency in
GDM (%)
Frequency in non-
GDM (%)
Frequency
difference (%)
Pre-eclampsia 9.1 4.5 4.6
Delivery at <37 weeks 9.4 6.4 3.0
Primary caesarean delivery 24.4 16.8 7.6
Shoulder dystocia or birth injury 1.8 1.3 0.5
Intensive neonatal care 9.1 7.8 1.3
Clinical neonatal hypoglycaemia 2.7 1.9 0.8
Neonatal hyperbilirubinemia 10.0 8.0 2.0
Birth Weight >90th percentile 16.2 8.3 7.9
Cord C-peptide >90th percentile 17.5 6.7 10.8
Percent body adipose tissue content
>90th percentile
16.6 8.5 8.1

26. METFORMIN INSULIN
• In GDM, metformin(MTF) is offered when blood
glucose targets are not met by modification in
diet and exercise within 1–2 weeks.
• MTF is continued in women who are already on
the treatment prior.
• MTF is not associated with any birth defects or
adverse outcomes.
• MTF in GDM leads to better maternal outcomes
(total weight gain, postprandial blood glucose,
gestational hypertension) and fetal outcomes
(severe neonatal hypoglycemia)
• Insulin should be initiated when:
- blood glucose targets are not met after diet
control and MTF therapy
- MTF is contraindicated or unacceptable or
failed
- FPG ≥7.0 mmol/L at diagnosis (with or without
metformin)
- FPG of 6.0-6.9 mmol/L with complications such
as macrosomia or polyhydramnios (start insulin
immediately, with or without metformin).
PHARMACOLOGICAL TREATMENT
Reference: Management of DIabetes in Pregnancy. Clinical Practical Guidelines Malaysia 2017

29. TIMING OF DELIVERY
In pregnant women with pre-existing diabetes with:
- no complications, deliver between 37+0 and 38+6 weeks.
- maternal and fetal complications, deliver before 37+0 weeks.
In women with GDM:
- on diet alone with no complications, deliver before 40+0 weeks.
- on OHA or insulin, deliver between 37+0 and 38+6 weeks.
- with maternal or fetal complications, deliver before 37+0 weeks.
Mode of delivery should be individualised, taking into
consideration EFW and obstetric factors.
Reference: Management of DIabetes in Pregnancy. Clinical Practical Guidelines Malaysia 2017

30. Enter
title
POST PARTUM
⮚ Most women with GDM should be able to discontinue their insulin therapy immediately after
delivery.
⮚ When breastfeeding, if glucose control is inadequate with diet control alone, insulin therapy
should be continued at a lower dose.
⮚ Low-dose metformin can be safely used in breastfeeding.
⮚ For GDM women whose blood glucose normalized immediately after delivery;
• For OGTT at 6 weeks postpartum
• Early MOGTT during the next pregnancy
• For annual screening of diabetes and lifestyle modifications
• For PPC
Reference: Management of DIabetes in Pregnancy. Clinical Practical Guidelines Malaysia 2017

31. • DEFINITIONS
PRE-EXISTING DIABETES MELLITUS IN
PREGNANCY
Definition: Diabetes Mellitus diagnosed before pregnancy
Overt diabetes in pregnancy should be managed as pre-existing diabetes.
Reference: Management of DIabetes in Pregnancy. Clinical Practical Guidelines Malaysia 2017

32. Start
Refer FMS/O&G
specialist for initiation
of pharmacological
treatment
Refer dietitian, trial
of diet control &
exercise with 2
weekly 7PBSP
Pre-existing DM in
pregnancy
If deranged 7PBSP, find out
why;
• Non-compliant to diet
control
• Improper 7PBSP
checking time
• Improper insulin
injection time/technique
If Yes, recounsel.
If
No
In pre-existing DM,
additional work ups are
needed:
• Baseline creatinine
• Baseline HbA1c
• Ophthalmology referral
• Detailed scan referral
• Screening of
complications (cardiac
vasculopathy,
nephropathy, retinopathy,
dermopathy, neuropathy)
GENERAL MANAGEMENT
❖ Start PE prophylaxis (T Aspirin 150mg ON
at 12 weeks & T CaCO3 1g BD at 20
weeks)
❖ G/S with AFI: every 2-4 weeks from 28-36
weeks POG
❖ More frequent G/S (with Doppler) if there
is evidence of FGR
❖ If antenatal corticosteroid is indicated,
woman with diabetes should be monitored
closely (≥4 times a day, 48 hrs from the
1st dose) for abnormal glucose levels and
insulin should be initiated/titrated when
indicated
Reference: Management of DIabetes in Pregnancy. Clinical Practical Guidelines Malaysia 2017

33. PRE-PREGNANCY CARE FOR
PRE-EXISTING DM
Keep HbA1c <6.5%
Weight reduction in
obese/overweight
Folic acid supplement for 3
months prior to contraception
withdrawal
Screen for diabetic
retinopathy &
nephropathy
Satisfactory blood
pressure control
(<130/80)
Patients with multiple
cardiovascular risks should
undergo cardiovascular
assessment
Reference: Management of DIabetes in Pregnancy. Clinical Practical Guidelines Malaysia 2017

34. Reference: https://www.cdc.gov/reproductivehealth/contraception/pdf/summary-chart-us-medical-eligibility-criteria_508tagged.pdf

35. THANK YOU