pregnancy and diabetes

1. DIABETES MELLITUS
By SABAH SALIM
Under supervision of : Dr.Khalida Hassan

2. Diabetes Mellitus (DM) is abnormal carbohydrate
metabolism.
*most common medical condition during
pregnancy(0.5 - 5 %)
**90% is gestational DM, and 10% is pre-existing
DM.

3. A) pre-existing diabetes: type 1 and type 2.
Type 1(juvenile onset) is an autoimmune
destruction pancreatic islet cells
associated with HLA-DR3 and HLA-DR 4.
It is not associated with obesity.

4. Type 2 (maturity onset)
peripheral insulin resistance rather than deficiency.
incidence increases with age and body weight and there is a stronger
genetic component than in type 1.

5. B)Gestational diabetes (GDM)
defined as impaired carbohydrate tolerance resulting
in hyperglycaemia, which first develops or becomes
diagnosed during pregnancy.
Some of these women will, in fact, have previously
undiagnosed diabetes, usually type 2.

6. PHYSIOLOGICAL CHANGES IN PREGNANCY
1.Alteration in carbohydrate metabolism. Due to
hyperplasia of pancreatic islet cells which leads to a
doubling in insulin production between the first and
the third trimesters.

7. 2. Release of insulin-resistant hormones (human placental lactogen,
glucagons, progesterone and corticotrophin releasing hormone)
from the placenta results in progressive glucose intolerance
(insulin resistance) with advancing gestation.
3.increased glucose uptake of the fetus
4.The renal tubular threshold for glucose falls, such that glycosuria is
common.

8. Diagnosis
A)Screening performed prior to 24weeks of gestation
with a :
50-g 1-hour oral glucose challenge test (GCT), given
without regard to last oral intake.

9. Screening is advised :
 maternal age greater than 25 years.
 previous macrosomic infant.
 previous pregnancy with GDM.
family history of diabetes.
history of PCOD.
 obesity.
Ethnic origin : South Asia (India, Pakistan, Bangladest)
Middle Eastern (Saudi Arabia, Iraq)
Black Caribbean

10. * IF the first-trimester screen is negative, it should be repeated at
24 to 28 weeks.
**Glucose values above 130 to 140 mg/dL on a GCT are considered
abnormal and have an 80% to 90% sensitivity in detecting GDM.
***An abnormal GCT is followed with a diagnostic 3-hour 100-g oral
glucose tolerance test.
***If the 1-hour screening (50 -g oral glucose) plasma glucose
exceeds 200 mg/dL, a glucose tolerance test is not required .

11. Diagnostic:
3-hour 100-g OGTT
after an overnight fast, drinking a 100-g glucose drink,
and checking glucose levels hourly for 3 hours.
**If there are two or more abnormal values on the
3-hour GTT, the patient is diagnosed with GDM .

12. Management
1-Pre-pregnancy counselling:
The aim is achieving glycaemic control before
pregnancy and to educate diabetic women about the
implications of pregnancy.
*Targets for therapy pre-pregnancy should be to
maintain HbAlc at 6.5% and pre-meal glucose levels
of 72-126 mg/dL

13. 2-Antenatal Care
Pregnant women with diabetes should be managed in
a joint clinic with an obstetrician physician and a
dietician in order to make
A plan for the pregnancy and should include targets
for glycaemic control, renal and retinal screening,
fetal surveillance and plan for delivery

14. 3-ACHIEVING EUGLYCEMIA
For optimal outcome, the fasting blood glucose
should be less than 95 mg/dL, 1-hour postprandial
glucose level less than 140 mg/dL, and 2-hour
postprandial glucose level less than 120 mg/dL.

15. A)DIET: Caloric requirements are calculated on the basis of
ideal body weight:
-35-40 kcal/kg for <80% of ideal body weight
-30 kcal/kg for 80%-120% of ideal body weight
-24 kcal/kg for 120%-150% of ideal body weight.
diet comprises of 50% carbohydrate, 20% protein, and 20%
fat. The diet should also contain a generous amount of fiber.

16. intake is divided into 25% at breakfast, 30% at lunch,
30% at dinner, and 15% at a bedtime snack.
***National Institute for Health and Clinical Excellence
(NICE) guidance suggests that hypoglycaemic therapy
should be considered if diet and exercise fail to achieve
blood glucose targets over a period of 1-2 weeks

17. B)EXERCISE. Diabetic patients should be encouraged
to engage in mild to moderate aerobic exercise (e.g.,
brisk walking) for about half an hour after meals.

18. C)Medication:
Oral hypoglycemic agents have not been
recommended for pregnant women because of the
risks for teratogenesis and neonatal hypoglycemia.
Current NICE recommendations are that metformin
may be considered as an alternative to insulin
therapy in pregnant women with type 2 diabetes.

19. Insulin use is the gold standard
The peak action of
lispro insulin(rapid acting) is at 30 to 90 minutes,
regular insulin(short acting)at 2 to 3 hours,
NPH insulin(intermediate acting) at 6 to 10 hours.
A combination of rapid-acting or short-acting (lispro or
regular) and intermediate-acting (NPH) insulin is usually
given in split morning and evening doses or more
frequently to achieve euglycemia.

20. for calculating insulin dosage
I Insulin units = body weight (kg)
xO.6 (First trimester)
xO.7 (Second trimester)
xO.8 (Third trimester)
Dosage schedule: give 2/3 in AM and 1/3 in PM
Before breakfast: 2/3 NPH, 1 /3 regular or lispro

21. 4-ADMINISTRATION OF CORTICOSTEROIDS
Corticosteroids, given to reduce neonatal morbidity
and mortality associated with prematurity.

22. 5-Timing and mode of delivery
it depends on individual basis:
In general a well management aims to achieve a
vaginal delivery between 38 and 39 weeks.
However, the development of macrosomia or
maternal complications such as pre-eclampsia,
together with the rate of failed induction, is such that
the Caesarean section rate among diabetic women
often is as high as 50 per cent.

23. 6-Intrapartum Management
continuous infusion of regular insulin. Plasma glucose
levels are measured frequently, and insulin dosage is
adjusted accordingly to maintain a plasma glucose
level between 80 and 120 mg/dL.

24. 7-Postpartum Period
After delivery of the fetus and placenta, insulin requirements drops.
its treated accordingly:
GD patients frequently do not need insulin therapy postpartum
Diabetic Women can change from insulin back to their oral
hypoglycaemic agents.
A fasting BG or OGTT should be performed at 6 to 12 weeks
postpartum.

25. COMPLICATIONS OF DM:
A)MATERNAL COMPLICATIONS
Polyhydramnios
Preeclampsia
Infections, e.g., urinary tract infection
and candidiasis
Cesarean delivery
Genital trauma

26. PREGESTATIONAL DIABETES MELLITUS
Renal
Ophthalmic
Peripheral vascular
NEUROLOGIC
Peripheral neuropathy
Gastrointestinal disturbance

27. LONG-TERM OUTCOME
Type 2 diabetes
Metabolic syndrome
Cardiovascular disease

28. DIABETIC EMERGENCIES
Hypoglycemia
Diabetic coma
Ketoacidosis
Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state
(HHS) are the most serious and immediate threats to the life of the
mother and fetus. Immediate fluid resuscitation, insulin therapy and
correction of electrolyte abnormalities are the most important
cornestone treatments. They are treated the same way as
they are in the non-pregnant state.
Maternal hypoglycemia should be recognized early to give prompt
attention with either oral or intravenous glucose, or intramuscular
glucagon.

29. B)FETAL AND NEONATAL COMPLICATIONS
Macrosomia with traumatic delivery (shoulder
dystocia,Erb's palsy)
DELAYED ORGAN MATURITY
Pulmonary, hepatic, neurologic, pituitary-thyroid axis;
with respiratory distress syndrome, hypocalcemia

30. CONGENITAL DEFECTS
Cardiovascular anomalies (left septal hypertrophy)
Neural tube defects
Other defects,e.g.renal
FETAL COMPROMISE
IGR
IFD

31. Mechanism
Glucose crosses the placenta easily by facilitated
diffusion, causing fetal hyperglycemia, which
stimulates pancreatic B cells and results in fetal
hyperinsulinism.
Fetal hyperglycemia during the period of
embryogenesis is teratogenic

32. Contraception and follow up
Low-dose oestrogen containing pills have little impact
on diabetic control,
progesterone-only pills can be used in type 1 diabetes.
Contraceptive choices should be discussed with
individual women, with careful consideration of their
risk factors.

33. THANK YOU