3. Definition
Diabetes Mellitus in Pregnancy
• Metabolic disorder characterized by impaired
glucose tolerance.
• It may occur for the first time in pregnancy or
worsens if preexisting.
• Incidence -2-3%
4. Gestational diabetes.
What causes it?
Diabetes can develop in pregnancy in a woman
who initially doesn’t have it.
When:
• The body is unable to produce sufficient extra insulin.
• The hormones produced in pregnancy block the action of
insulin.
5. Who Criteria for diagnosis of
diabetes
Venous plasma glucose level
(mmol/l)
Fasting 2 hrs post gluc
Diabetes => 8.0 =>11.0
Impaired Gluc
tolerance
<8.0 =<8.0 to <11.0
Normal <6.0 <8.0
5
6. Classification of glucose disorders in
pregnancy
1. Clinical diabetes
2. Potential diabetics
3. Latent diabetics
Gestational diabetics
4. Chemical diabetics
7. Risk factors to diabetes Mellitus
• Maternal weight > 90 kg (obesity)
• History of diabetes in a first degree relative
• A previous unexplained intrauterine death or early neonatal
death.
• A previous baby weighing 4.5 kg or more.
• Glycosuria on two or more occasions.
• Age over 35 yrs during index pregnancy
• Congenital abnormality in a previous pregnancy especially
sacral agenesis.
8. Pregnancy and carbohydrate
metabolism
Pregnancy alters carbohydrate metabolism.
Decreased sensitivity to insulin with increasing
gestation age.
Impaired glucose tolerance
9. Pregnancy and carbohydrate
metabolism
Factors antagonising the action of
insulin;
Cortisol
Oestrogen
Progesterone
Human Placental Lactogen hPL
Insulinase enzyme
10. Effect of Diabetes on Pregnancy
• Spontaneous abortion
• UTI
• Monilial vaginitis
• Pre eclampsia
• Polyhydramnios
• Perinatal death
• Macrosomia congenital malformations
• Delayed lung maturity
11. Plan of Management of pregnancy
complicated by diabetes.
• Pre conceptual visit/counselling
• Combined care (Antenatal Care)
– Frequent visits every 2 wks up to 28 wks
once weekly thereafter.
• Food Plan
• Medical care
– Insulin
– 2 daily doses of a short and a long-acting
– Insulin doses increase progressively 50-100%
12. Insulin therapy
Indicated if :
• Gestational diabetes with failed diet control
persistent hyperglycemia >7.5 -8 mmol/l
FBS > 5.5-6mmol/l
•
13. Antenatal Care
Strict control of plasma glucose reduces the
incidence of congenital malformations.
Multi-disciplinary care/General advice
Early booking and dating of pregnancy is
Cardinal.
- U/S for gestational dating and anomaly at 16wk.
- Serum alpha-fetal protein
- Serial growth scan
14. Insulin dosage
• Initial calculation of dose
0.7 of insulin x actual body wt in Kg = Total
daily dose
The total daily dose is divided as follows:
TDD
2/3 TDD morning 1/3 TDD
at 5 pm.
1/3 Crystaline+2/3 NPH ½ Crystaline
½ NPH
15. Insulin dosage
The total first dose of insulin is calculated
according to the patient’s weight as follow:
the total dose of insulin increases with
gestational age.
• In the first trimester .......... weight x 0.7
• In the second trimester........ weight x 0.8
• In the third trimester........... weight x 0.9
16. Insulin Management during
Labor and Delivery
Usual dose of intermediate-acting insulin is given at
bedtime.
• Morning dose of insulin is withheld.
• Intravenous infusion of normal saline is begun.
• Once active labor begins or glucose levels fall below 70
mg/dl, the infusion is changed from saline to 5%
dextrose
• Glucose levels are checked hourly using a portable meter
allowing for adjustment in the infusion rate.
• Regular (short-acting) insulin in administered by
intravenous infusion if glucose levels exceed 140 mg/dl.
17. Delivery
• Timing of delivery should be tailored to the individual
patient.
• Good glucose control - pregnancy may be allowed to
continue up to 40 wks.
• Induction of labour/ caesarean section to be done on
obstetric indication
• Beware of shoulder dystocia
• Presence of Paediatrician
18. Timing of Delivery
• Delivery Earlier termination of pregnancy
- poor glycemic control
- Obstetric complications
19. Timing of Delivery
• Vaginal delivery
- Induction of labour according to Bishop score
- Caesarean section if EFW > 4.5 kg
• Maternal euglycemia during labour is
necessary to avoid neonatal hypoglycemia
• Continuous infusion of dextrose with insulin.
• Blood glucose should be checked hourly
during labour.
• Maintain serum sugar between 4-7
20. Care of the Baby
• Respiratory distress syndrome
• Hypoglycaemia
• Hyperbilirubinaemia – jaundice
• Hypocalcaemia
• Examination carefully for CFMF,birth trauma
• Carefully monitoring of Blood sugar levels
• Carefully monitor physiological jaundice
• Extreme precaution from infection
21. Post partum Care
Insulin requirements drop drastically during the first few
days of birth and doses of insulin should be adjusted
against frequent glucometer readings
• Recalculation of insulin needs
• Beware of PPH and infection
• Contraceptive advise
• Counselling as regards next pregnancy
• Later in life at risk of DM
22. Contraception
• A diabetic woman has to take care of her health more
than others.
• A large family should therefore be discouraged.
• Risk of offspring becoming diabetic is 1 in 100. ( 1 in
1000 in general population)
23. Family planning in a Diabetic women
Oral Combined Contraceptive pill
• Not contraindicated to uncomplicated diabetic patients.
• Marginally impairs carbohydrate tolerance but does not
increase insulin requirement.
Depo Medro Progesterone Acetate (DMPA)
• This causes considerable glucose intolerance and therefore
should only be used with caution in diabetic women without
vascular disease.
• This injection is given every 3 months.
24. Family planning in a Diabetic women
Noristerat
• This does not raise the blood glucose level as much as
Depo-provera. It is thus to be used in diabetic patients
when depot injection is the only choice of contraception.
• This injection is given every 2 months.
Implants
• These have similar effects as depot injections. They are
however better in that the implant can be removed if the
side effects become troublesome.
25. Family planning in a Diabetic women
Mini Pill
• These pills have only got a progesterone and were previously
recommended in diabetic women. They are however less
effective that the ordinary pill and spotting is higher.
Bilateral Tubal Ligation (BTL)
• Permanent sterilisation in the form of BTL is recommended
for diabetics who have satisfied parity or those with severe
form of the disease with frequent complications.
