Dr. Elioba J. Raimon

1. DIABETES
IN
PREGNANCY
DR. ELIOBA J. RAIMON
3RD YEAR RESIDENT OBGY
MENTOR
PROF. UBARNEL
Diabetes In Pregnancy By Dr. Elioba
01/09/2023 1

2. CARBOHYDRATES METABOLISM IN PREGNANCY
CARBOHYDRATES
METABOLISM
IN
PREGNANCY
Insulin resistance increases
Fasting hypoglycaemia
Postprandial
hyperglycaemia
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3. INTRODUCTION
Diabetes is the most common endocrine disorder in pregnancy
Overt diabetes Mellitus
Chronic metabolic disorder characterized by relative or absolute
luck of insulin resulting into hyperglycaemia, glycosuria, increased
protein and fat metabolism
Gestational diabetes
Abnormal glucose tolerance with onset or first recognition during
pregnancy that is not clearly overt.
Usually developed after 24 weeks of gestation
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4. EPIDEMIOLOGY
• GDM affect 14% of pregnancies worldwide (Kafle D. et al.,
2022).
• Prevalence is highest among non-Hispanic blacks, Mexican-
Americans, Puerto Rican-Americans, and Native Americans
(Powers, 2018).
• A study conducted in Isingiro, Uganda showed that 16.4% of the
pregnant women were hyperglycaemic higher than the sub
Saharan average of 12.6% (Nuwahereza et al., 2020).
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5. • A study at Kawolo hospital among women attending ANC
indicated a prevalence of 4.5% of GDM (Ochieng, C., 2022).
• Women of childbearing age are at increased risk of developing
gestational diabetes
• GDM increases the risk of adverse maternal and perinatal
outcome and also increases risk of future diabetes to the mother
and their child (Kafle D. et al., 2022).
EPIDEMIOLOGY
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6. CLASSIFICATION DURING PREGNANCY
PRISCILLA WHITE CLASSIFICATION
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7. CLASSIFICATION DURING PREGNANCY
AMERICAN DIABETIC ASSOCIATION, 2017
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8. PREGESTATIONAL DIABETES
 A known diabetic woman who become pregnant
5-10% of women with GDM are diagnosed with overt diabetes
immediately after pregnancy.
DIAGNOSTIC CRITERIA (WHO AND ADA 2019)
Random plasma glucose level >200 mg/dL plus classic signs
and symptoms
Fasting glucose level ≥ 126 mg/dL
HbA1c ≥ 6.5%
Plasma glucose level >200 mg/dL 2 hours after a 75g of oral
glucose
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9. EFFECT OF PREGNANCY ON DIABETES
PREGNANCY
Diabetogenic stage
Insulin antagonism-HPL, P,
E, Cortisol, Prolactin
Placental insulinase
Control of diabetes is more
difficult
Insulin requirements
decrease after delivery
More insulin is needed
during pregnancy
Progression of retinopathy
and Nephropathy
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10. EFFECT OF DIABETES ON PREGNANCY
FETUS
Congenital
abnormalities (11%)
Unexplained Fetal
Demise
Abortion (25%)
Polyhydromnios
Preterm birth
Altered foetal growth
(Pederson’s hypothesis)
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11. EFFECT OF DIABETES ON PREGNANCY
Association between foetal malformation rates and HbA1c values determined at initiation
of prenatal care in 1573 pregnancies in women with pre-gestational diabetes
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12. 6050g macrosomic neonate was born to a woman with gestational diabetes
EFFECT OF DIABETES ON PREGNANCY
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13. EFFECT OF DIABETES ON PREGNANCY
NEONATE
Polycythaemia
Hyperbilirubinemia
Cardiomyopathy
Hypoglycaemia
(<45 mg/dL/2.5mmol/L)
Cerebral palsy
Respiratory Distress
Syndrome
Hypocalcaemia
(<8 mg/dL)
Inheritance
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14. EFFECT OF DIABETES ON PREGNANCY
MOTHER
Preterm labour Operative delivery
Diabetic Ketoacidosis
Hypertensive disorders
Polyhydromnios
Infection
Progression to type 2 DM
Shoulder dystocia & Birth trauma
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15. DIABETIC KETOACIDOSIS
This is a serious complication that develops in approximately 1%
of diabetic pregnancies
Most often encountered in women with type 1 diabetes
(Ehrmann, 2020).
It is increasingly being reported in women with type 2 or even
those with gestational diabetes (Bryant, 2017; Sibai, 2014).
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16. DIABETIC KETOACIDOSIS
Pregnant women usually develop DKA at lower blood glucose
thresholds than when nonpregnant.
In a study from Parkland Hospital, the mean glucose level for
pregnant women with DKA was 380 mg/dL, and the mean HbA1C
value was 10 percent (Bryant, 2017).
Euglycemic ketoacidosis during pregnancy also is possible but is
rare (Sibai, 2014; Smati, 2020).
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17. DIABETIC KETOACIDOSIS - RISK FACTORS
Hyperemesis gravidarum
Infection
Insulin non-compliance
Insulin pump failures
β-mimetic drugs given or tocolysis
Corticosteroids given to induce fetal lung maturation
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19. MGT OF DKA DURING PREGNANCY
Laboratory Assessment
• Obtain arterial blood gases to
document degree of acidosis present.
• Measure glucose, creatinine, ketones,
and electrolyte levels at 1- to 2-hour
intervals
Insulin
• Low-dose, intravenous
• Loading dose: 0.2–0.4 U/kg
• Maintenance: 2–10 U/hr
Bicarbonate
• Add one ampule (44 mEq) to 1 L of
normal saline if serum pH is <7.1
Fluids
• Total replacement in first 12 hours of
4-6 L
• 1 L in first hour
• 500–1000 mL/hr for 2–4 hours
• 250 mL/hr until 80 percent replaced
Glucose
• Begin D5% in 0.45% saline when
glucose plasma level reaches 250
mg/dL (14 mmol/L)
Potassium
• If initially normal or reduced, an
infusion rate up to 15–20 mEq/hr may
be required
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20. OVERT DIABETES - PRECONCEPTIONAL CARE
To minimize early pregnancy loss and congenital malformations, glucose
levels should be controlled before conception.
Optimal glycaemic control
HbA1c level <6.5%
Self-monitored pre-prandial glucose levels of 70 to 100 mg/dL
Peak 2-hour postprandial values of 100 to 120 mg/dL
Mean daily glucose concentrations <110 mg/dL.
Folate, 400 μg/d orally, is given periconceptionally and during early
pregnancy to decrease the risk of neural-tube defects
Evaluation and treatment for diabetic complications such as retinopathy or
nephropathy should be instituted before pregnancy
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21. OVERT DIABETES – FIRST TRIMESTER CARE
Careful monitoring and glucose control is essential
Assessment of 24-hour urine protein excretion and serum
creatinine level, retinal examination, and echocardiogram if
chronic hypertension is comorbid.
Screening for aneuploidy
Pregnancy-associated plasma protein A (PAPP-A)
β-human chorionic gonadotropin (hCG)
Ultrasound measurement of foetal nuchal translucency
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22. INSULIN TREATMENT
The Gravida with overt diabetes is best treated with insulin.
Although oral hypoglycemics agents have been used successfully
for gestational diabetes, these agents are not currently
recommended for overt diabetes, despite some controversy
(ACOG, 2020c).
Maternal glycaemic control can usually be achieved with multiple
daily insulin injections and adjustment of dietary intake
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23. OVERT DIABETES – SECOND TRIMESTER CARE
Most women with pre-gestational diabetes require a higher total
daily insulin dose with advancing gestational age
Normoglycemia with self-monitoring continues to be the goal
Maternal serum alpha-fetoprotein at 16 to 20 WOG to detect
neural-tube defects
Fetal echocardiography is an important part of second-trimester
sonographic evaluation
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24. OVERT DIABETES – THIRD TRIMESTER CARE
• Fetal surveillance at 32 to 34 weeks’ of gestation.
• Fetal movement counting, periodic foetal heart rate monitoring, intermittent
biophysical profile evaluation, and contraction stress testing.
• With reassuring testing and no other complications, delivery is anticipated
between 390/7 and 396/7 weeks
At Parkland Hospital
Maternal-Fetal Medicine clinic every 2 weeks
Fetal kick counts beginning early in the third trimester
At 34 weeks’ gestation, admission to our High-Risk Pregnancy Unit is
offered to all insulin-treated women
With no other complications, delivery at Parkland is typically planned for
38 weeks
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25. OVERT DIABETES – LABOUR
•Pre-gestational DM
• 37-38+6Weeks
• Early termination only if complication
• Uncontrolled blood sugar
• PIH
• Vasculopathy
•Pre-gestational DM on insulin therapy
• Delivery after 38 completed weeks
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26. OVERT DIABETES – LABOUR CONT’D
• Reducing or withholding the dose of long-acting insulin on the day
of delivery is recommended
• Regular insulin should be used to meet most or all of the insulin
needs of the mother during labour
• For vaginal delivery, labor induction may be attempted when the
fetus is not excessively large and the cervix is considered favourable
• Caesarean delivery at or near term – EFW 4.5kgs.
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27. OVERT DIABETES – LABOUR CONT’D
Insulin Management for Labor Induction or Scheduled Caesarean Delivery
Give evening dose insulin.
Withhold morning dose.
Infuse intravenous normal saline at 100–125 mL/hr.
Regular insulin is infused at 1–1.25 units/hr if glucose levels
>100 mg/dL.
Measure glucose levels hourly.
With active labor or if glucose levels are >70 mg/dL, change
from intravenous saline to 5% dextrose given at 100–150 mL/hr
with a target glucose level of ∼100mg/dL.
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28. OVERT DIABETES -PUERPERIUM
Many diabetic women may require virtually no insulin for the first
24 hours or more postpartum
When appropriate, oral agents can be restarted for type 2
diabetes.
Infection must be promptly detected and treated
Counselling in the puerperium should include a discussion of birth
control
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29. GESTATIONAL DIABETES
Diabetes which is diagnosed in 2nd or 3rd trimester that was not
present prior.
Gestational diabetes is defined as carbohydrate intolerance of
variable severity with its onset or first recognition during
pregnancy (ACOG)
Due to exaggerated physiological changes in glucose metabolism
More than half of women with gestational diabetes ultimately
develop overt diabetes in the ensuing 20 years
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30. EPIDEMIOLOGY
In USA 6 percent of pregnancies
were complicated by gestational
diabetes (Deputy, 2018).
Worldwide, its prevalence differs
according to race, ethnicity, age,
and body composition and by
screening and diagnostic criteria
HIGH RISK FACTORS
Obesity
Strong family history of type 2
diabetes
Previous history of GDM
Impaired glucose metabolism,
or Glycosuria
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31. SCREENING OF GDM
ONE STEP PROTOCOL (WHO)
Done after fasting
75gm oral glucose tolerance test
Fasting >92mg/dl
1hr >180mg/dl
2hr>153mg/dl
Note that, derangement of
one value, diagnosis of GDM
can be made
TWO STEP PROTOCOL (ACOG)
1. Glucose challenge test with oral
50gm glucose irrespective of
meal
1hr >140mg/dl
2. Confirm with Glucose Tolerance
test with 100g Glucose
Fasting >95mg/dl
1hr >180mg/dl
2hr>155mg/dl
3hr>140mg/dl
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33. MATERNAL AND FETAL EFFECTS
MATERNAL
Progression to overt diabetes
Hypertension
Increased operative delivery
FETAL
Macrosomia
Unexplained stillbirths
Neonatal Hypoglycaemia
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34. MANAGEMENT OF GDM
• Blood sugar control
Most important for good pregnancy outcome
ANC visit as high risk group at least weekly with monitoring of blood
sugars level
• Ensure foetal wellbeing
Monitoring of foetus begin at 32 WOG, before that, DFMC
Regular NST
Regular USS
Foetal growth
AF volume
BPP regularly
• Watch for complications
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35. DIET + EXERCISE
Diabetic Diet (ACOG)
3 major meals per day
2 time snacks in between
meals
Restriction of Carbohydrate to
40%, Fats 40% and Proteins
20%
Exercise
At least 30 minutes of aerobic
exercises 5 times per week
GLUCOSE MONITORING
Self monitoring
recommended than clinics
visits
Target control
FBS ≤ 95mg/dl
1hr post meal ≤ 140mg/dl
2hr Post meal ≤ 120mg/dl
Average blood sugar ≤ 100mg/dl
HbA1C ≤ 6%
MANAGEMENT OF GDM CONT’D
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36. Initiate Insulin therapy
 FBS > 95mg/dl
 1hr post meal >140mg/dl
 2hr Post meal >120mg/dl
GLUCOSE PROFILE AFTER 1 WEEK OF
DIET + EXERCISE MODIFICATION
MANAGEMENT OF GDM CONT’D
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37. INSULIN RX
Started if fasting levels persist > 95 mg/dL
Or 1-hour postprandial levels that persistently > 140 mg/dL
Or 2-hour levels >120 mg/dL.
The starting insulin dose is typically 0.7 to 1.0 U/kg/day and is
given in divided doses
MANAGEMENT OF GDM CONT’D
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38. INSULIN THERAPY
• Regular insulin
• Short acting insulin
• Given pre meal
• NPH insulin (Neutral Protamine Hagedorn)
• Intermediate acting insulin
• Given usually bedtime
• Mixtard
• Combination of regular and NPH insulin
• Recent studies shows that; Ultra short
acting insulin
Aspart
Lispro
Consider safe in pregnancy
• Long acting insulin ( Not preferred)
Glargine
Determin
Limited safety profile during pregnancy
• Most commonly used in combination of
regular insulin and NPH
• Insulin is the drug of choice for DM in
Pregnancy
• Oral hypoglycaemic agents
contraindicated in pregnancy
previously
• Latest evidence shows Metformin and
Glyburide safe for use in 2nd and 3rd
Trimester in GDM
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39. PARKLAND HOSPITAL
The starting daily dose of
insulin is divided, 2/3 given in
the morning as pre-breakfast
and 1/3 in the evening pre-
dinner.
Morning dose, 1/3 is regular
insulin and 2/3 NPH insulin.
Evening dose, 1/2 is regular
insulin and the other 1/2 is
NPH
UNIVERSITY OF ALABAMA
Half of the calculated dose is given
at bedtime (long-acting glargine)
The other half is divided into 3
doses given as pre-breakfast, pre-
lunch and pre-supper (rapid-acting
insulin)
MANAGEMENT OF GDM CONT’D
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40. ORAL HYPOGLYCEMICS AGENTS
The FDA has not approved glyburide or metformin use for
treatment of gestational diabetes.
ACOG (2019a) recognizes both as reasonable choices for
second-line glycaemic control in women with gestational
diabetes
MANAGEMENT OF GDM CONT’D
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41. OBSTETRICAL MANAGEMENT
Women who do not require insulin, early delivery or other interventions
are seldom required. Deliver at 39 completed weeks
Insulin-treated women are offered inpatient admission after 34 weeks
gestation. Antepartum fetal monitoring is performed three times each
week.
Women with adequate glycaemic control are managed expectantly.
Deliver at 39 completed weeks
Prophylactic caesarean delivery may be considered in women with an
EFW ≥4500g.
MANAGEMENT OF GDM CONT’D
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42. TIMING OF DELIVERY - ACOG GUIDELINES
Controlled on diet ≥ 39 weeks
Expectant mgt up to 40 completed weeks is appropriate
Well controlled on medication
Deliver at 39 weeks 0 days to 39weeks 6 days
Poorly controlled
Expert guidance supports earlier delivery but data lucking regarding
precise timing
Delivery between 37weeks 0 days and 38weeks 6 days may be justified
Delivery between 34weeks 0 days and 36 weeks 6 days reserved for:-
 Failure of hospital glycaemic control
 Abnormal foetal testing
EFW ≥ 4500 counsel regarding risks and benefits of a scheduled C/S
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43. POSTPARTUM EVALUATION
ACOG (2019a) recommends either a fasting glucose
assessment or a 75-g, 2-hour OGTT at 4 to 12 weeks
postpartum for the diagnosis of overt diabetes.
The American Diabetes Association (2019) recommends
testing every 1 to 3 years in women with a history of
gestational diabetes but normal postpartum glucose
screening.
MANAGEMENT OF GDM CONT’D
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44. REFERENCE
1. American College of Obstetricians and Gynaecologists: Pregestational
diabetes mellitus. Practice Bulletin No. 201, November 2020c
2. American College of Obstetricians and Gynaecologists: Gestational
diabetes mellitus. Practice Bulletin No. 190, February 2018. Reaffirmed
2019a
3. Williams Obstetrics 26th edition 2022
4. Current obstetrics 12th Edition
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