Presentation at Monthly Seminar of Obstetrics and Gynaecology Eden Hospital< Medical College, Kolkata- July, 2012

2. OVERT DIABETESOVERT DIABETES

3.  Classic signs/ symptoms of DM
+
RBS >200 mg/dl
 FBS ≥126 mg/dl
 2 hr PPBS ≥200 mg/dl

5. PRE-CONCEPTIONAL CARE
PRECONCEPTIONAL COUNSELING
 Good glycaemic control before pregnancy can
reduce (but not eliminate) the risk of adverse
pregnancy outcomes
 Regular glucose monitoring
 Diet, body weight and exercise
 Weight reduction if BMI > 27 kg/m2
 The importance of planning of pregnancy and the
role of contraception
 Folic acid (5 mg/day) until 12 weeks of gestation to
reduce the risk of NTD

6. PRE-CONCEPTIONAL CARE (CONTD.)
GLYCAEMIC CONTROL
 Glucometer for self-monitoring of blood glucose
 Pre-conceptional Glucose level (ADA,1999a)
 FBS 70-100 mg/dl
 PPBS (1 hr) <140 mg/dl
 PPBS (2 hr) <120 mg/dl
 HbA1c
 ≤6%
 Within 3 SD of normal mean
 If ≥10%, strongly advised to avoid pregnancy (NICE, 2008)
 Testing of ketone by strips if they become
hyperglycaemic or unwell.

7. PRE-CONCEPTIONAL CARE (CONTD.)
DRUGS (NICE, 2008)
 Metformin- can be used in the pre-conception period and
during pregnancy, when the likely benefits from improved
glycaemic control outweigh the potential for harm
 All other OHAs- should be discontinued before pregnancy
except Glyburide
 Aspart & Lispro insulin- no adverse effects in pregnancy
 NPH insulin- the first choice for long-acting insulin in
pregnancy
 ACE inhibitors and ARBs- discontinued before conception
or as soon as pregnancy is confirmed
 Statins- discontinued before pregnancy or as soon as
pregnancy is confirmed

8. PRE-CONCEPTIONAL CARE (CONTD.)
RETINALASSESSMENT (NICE, 2008)
 Done at the first appointment
 Thereafter annually, if no diabetic retinopathy is found
 By digital imaging with mydriasis using tropicamide
 Women should defer rapid optimisation of glycaemic
control until after retinal assessment and treatment have
been completed

9. PRE-CONCEPTIONAL CARE (CONTD.)
RENALASSESSMENT (NICE, 2008)
 Includes measurement of microalbuminuria before
pregnancy
 Referral to a nephrologist should be considered
before discontinuing contraception if
 Serum creatinine ≥120 µmol/L
 Estimated GFR <45 ml/min/1.73 m2

10. MANAGEMENT IN FIRST TRIMESTER
DIETARY MANAGEMENT
 3 meals and 3 snacks per day
 Consistent timing with food intake
 To facilitate insulin dosage & avoid
hypoglycaemia
 Specially for NPH + Regular insulin
 Not so rigorous for Glargine + Aspart/ Lispro

11. MANAGEMENT IN FIRST TRIMESTER
(CONTD.)
INSULIN THERAPY
 Mainstay of management in type I DM
 To cover
 Basal needs (Basal Insulin)-
Intermediate/ Long acting Insulin-
To suppress hepatic neoglucogenesis
between meals & during fasting
 PP rise of sugar (Prandial Insulin)-
Short acting Insulin

12. PHARMACOKINETICS OF INSULIN
PREPARATIONS
ONSET PEAK
(Hrs)
DURATION
(Hrs)
SHORT ACTING
LISPRO <15 min 0.5-1.5 3-4
ASPART <15 min 0.5-1.5 3-4
REGULAR 30-60 min 2-3 4-6
INTERMEDIATE ACTING
ISOPHANE INSULIN (NPH) 1-3 hr 5-7 13-18
INSULIN ZINC SUSPENSION
(LENTE)
1-3 hr 4-8 13-20
LONG ACTING
EXTENDED INSULIN ZINC
SUSPENSION (ULTRALENTE)
2-4 hr 8-14 18-30
INSULIN GLARGINE 1-4 hr Peakless 24

13. INSULIN THERAPY (CONTD.)
I. Multiple daily SC injections
 Total daily requirement
0.6 U/kg current weight- 1st
trimester
0.7 U/kg current weight- 2nd
trimester
0.9 U/kg current weight- 3rd
trimester
 Regular + NPH – commonly used
 4/6 at breakfast (2/3 NPH, 1/3 Regular)
 1/6 before dinner- Regular
 1/6 at bed time- NPH
 To be administered >30 min before meal
 Mid-morning & mid-afternoon snacks necessary to
avoid hypoglycaemia
 Glargine + Lispro/ Aspart-
 Mimics physiological system
 Less rigorous timing of meals
 But Inj Lispro necessary before each meals

14. INSULIN THERAPY (CONTD.)
II. Subcutaneous insulin infusion pump
Only for those women who are
highly motivated,
where multiple daily injections are ineffective &
no disabling hypoglycaemia
Needs strict asepsis
Needs less Insulin (0.3-0.5 U/kg)
II. Inhaled Insulin
 Not well studied in pregnancy
 Needs PFT monitoring

15. INSULIN THERAPY (CONTD.)
 Insulin: Carbohydrate ratio:
One method to calculate prandinal Insulin
How many grams of CHO is covered by 1 U
Regular Insulin
Insulin : CHO = 500/ total daily requirement
Typically in the range of 10-15
 Insulin Sensitivity Factor
 Estimated drop in blood glucose per unit of Regular
Insulin
 Equal to 1500/ total daily requirement
 Amount of supplemental Insulin needed =
difference between actual and desired blood
glucose/ sensitivity factor
 Useful to make sliding scale

16. MANAGEMENT IN FIRST TRIMESTER
(CONTD.)
BLOOD SUGAR MONITORING
 Self-monitoring of capillary blood glucose (CBG)
 Finger-prick method using a Glucometer
 Noninvasive- by Iontophoresis
 Goals of glucose control (ACOG, 2005)
 Fasting ≤ 95 mg/dl
 Premeal ≤ 100 mg/dl
 1 Hr PP ≤ 140 mg/dl
 2 Hr PP ≤ 120 mg/dl
 02.00- 06.00 AM ≥ 60 mg/dl
 Mean (Average) 100 mg/dl
 HbA1c ≤ 6 %

17. BLOOD SUGAR MONITORING (CONTD.)
 Blood Sugar should be measured in fasting, 1 hr
before meals and at bed time (NICE, 2008)
 Rotine use of HbA1C in 2nd
and 3rd
trimester is not
recommended (NICE, 2008)
 Ketone should be measured if women feel unwell or
hyperglycaemic

18. MANAGEMENT IN SECOND TRIMESTER
 Congenital anomaly detection
 Vaginal probe USG at 10-14 weeks to detect NTD &
Nuchal tranlucency
 MSAFP (values lower in DM) at 16-20 weeks to
detect NTD
 Detailed sonographic examination at 18-20 weeks
 Fetal echocardiography for the four-chamber view
of the fetal heart and outflow tracts at 20-22 weeks
 Individualized glycaemic control
 Insulin requirement increases after 24 weeks
 Dietary management continues
 Regular antenatal visits

19. MANAGEMENT IN THIRD TRIMESTER
 Insulin and dietary control continues
 Fetal monitoring
 Ultrasound monitoring
Fetal growth and amniotic fluid volume
Every 4 weeks from 28 to 36 weeks
 Routine monitoring of fetal well-being
Not recommended before 38 weeks
 Indications of monitoring of fetal well-being
From 28 weeks
 Women at risk of IUGR (macrovascular disease and/or
nephropathy)
 Unstable DM
 Women requiring >100 U insulin/day

20. MANAGEMENT IN LABOUR
 Decision for delivery
 To be taken at 36 weeks- Induction vs CS
 Discussion with patient, keeping respect to her
decision
 CS often for macrosomia in White class B and C
 DM is not a contraindication to VBAC
 Timing of delivery
 Stable DM- at 38 weeks
 Unstable DM- as soon as fetal lung maturity is
attained

21. MANAGEMENT IN LABOUR (CONTD.)
 Preterm labour
 β-mimetics are to be avoided
 Nifedipine is preferred drug
 <32 weeks, intrauterine infections to be
excluded
 Steroids for lung maturity are not contraindicated
 Needs additional insulin
 Close monitoring
 Labour management
 IVF & insulin for glycaemic control
 Careful monitoring

22. MANAGEMENT IN PUERPERIUM
 CBG should be regularly monitored
 Often patient needs no insulin in 1st
24 hr
 Start with ½ to 2/3 of pre-delivery doses of insulin
 Breastfeeding should be encouraged
 Risk of hypoglycaemia during breast feeding
 Infections promptly detected and treated
 Contraceptive advices
 IUCD does not increase infection rate
 Hormonal contraceptives are avoided in vascular disease
 Puerperal sterilisation, if suitable
 Counseling regarding future pregnancy

24. INSULIN RESISTANCE
 Impaired metabolic response to endogenous or
exogenous insulin (ADA)
 Peak insulin levels in 3 hr GTT (µU/ml)
 <100- normal
 100-150- mild resistance
 150-300- moderate resistance
 >300- severe resistance
 FBS (mg/dl) : fasting insulin (µU/ml) <4.5
 C-peptide assay
 Glucose-clamp technique

25. METABOLIC SYNDROME
 Also called syndrome X, Insulin Resistance syndrome
or Deadly Quartet
 NCEPATP III definition-
At least three of the following
 FBS ≥110 mg/dl
 Abdominal obesity (waist circumference >35 inch. In
women, >40 inch in men)
 Triglycerides >150 mg/dl;
HDL <50 mg/dl in women,
<40 mg/dl in men
 BP ≥ 130/85 mm Hg

26. MANAGEMENT IN PREGNANCY
DIETARY MANAGEMENT
 Like GDM
 To maintain a calorie intake adequate for
pregnancy but with minimum weight gain
 Ideal weight gain
Normal weight 25-35 lb
Overweight 15-25 lb
Obese 11-20 lb
Underweight 28-40 lb

27. MANAGEMENT IN PREGNANCY
(CONTD.)
GLYBURIDE
 Normal weight/ moderately obese
 Good β-cell functions
 Duration of DM <5 years

28. MANAGEMENT IN PREGNANCY (CONTD.)
INSULIN THERAPY
Glyburide
+
NPH insulin at bed time
(to suppress hepatic neoglucogenesis to lower FBS)
Or
Glargine in the morning (less hypoglycaemia)
 Starting dose is 20 U SC usually
 If CBG values are still elevated, the dose may be ↑
by 5 U every 5 days until adequate control is
obtained

29. MANAGEMENT IN PREGNANCY
(CONTD.)
BLOOD SUGAR MONITORING
 Self-monitoring of CBG
 HbA1C
 Fructosamine <2.6 µmol/L

30. MANAGEMENT OF LABOUR AND
PUERPERIUM
 Similar to GDM

32. DIABETIC NEPHROPATHY
 Especially in type I
 Hypertension & proteinuria
 Risk of Preeclampsia and preterm labour, IUGR
 Renal assessment to be done in the first ANC visit
 Referral to a nephrologist - if
 Serum creatinine ≥120 µmol/L
 Total protein excretion >2 g/day
 Estimated GFR should not be used in pregnancy
 Thromboprophylaxis should be considered-
 If proteinuria >5 g/day (macroalbuminuria)

33. DIABETIC RETINOPATHY (DR)
 Both in type I & type II DM
 Pregnancy worsens retinopathy
 Acute rigorous metabolic control worsens
retinopathy
 Slows down progression of retinopathy in long term
 Insulin Lispro may worsen retinopathy (?)
 Retinopathy is associated with reduced fetal growth

34. RETINAL CHANGES IN DIABETES
 Beningn/ Background / Nonproliferative
retinopathy- (White class D)
 Microaneurysm
(first and commonest finding)
 Blot haemorrhage
 Serous leak → hard exudates
 Pre-proliferative retinopathy-
 Retinal ischaemia/ infarction
→ Cotton wool exudates
 Proliferative retinopathy-
(White class R)
 Neovascularisation on retinal surface & vitreous

35. MANAGEMENT OF RETINOPATHY

36. DIABETIC NEUROPATHY
 Peripheral sensory-motor neuropathy- uncommon in
pregnancy
 DIABETIC GASTROPATHY-
 More troublesome in pregnancy
 Nausea, vomiting, nutritional problems
 Difficult glucose control
 Needs Metoclopramide, H2 receptor blockers,
Erythromycin or Intermittent gastric intubation

37. INFECTIONS
 Urinary tract infections
 Associated with preterm labour
 May cause pyelonephritis
 Screening and treatment of asymptomatic
bacteruria to be done
 Respiratory tract infections
 Vulvovaginal infections
 Puerperal pelvic infections
 Wound infections after Caesarean Section
 Needs prompt diagnosis and treatment with
antibiotics

38. DIABETIC KETOACIDOSIS (DKA)
 Most serious complication
 Affects 1% of diabetic pregnancies
 Fetal loss 20%
 Unique to type I DM
 Precipitating factors
 Hyperemesis gravidarum
 Noncompliance to insulin therapy
 Tocolytics, corticosteroids
 Pregnant women usually develop DKA at
lower level of glucose than nonpregnant
individuals

39. DIAGNOSIS OF DKA
 Blood glucose >250 mg/dl usually
 Ketone bodies in urine & plasma
 Arterial pH <7.3
 Serum bicarbonate <15 mEq/L

40. MANAGEMENT OF DKA
(ACOG 2005)
 Laboratory assessment
 ABG, glucose, ketones, eletrolytes every 1-2 hr
 Insulin
 IV loading 0.2-0.4 U/Kg
 IV maintenance 2-10 U/hr
 Fluids
 Isotonic NaCl
 1 L in 1st
hr
 500-1000 ml/hr for next 2-4 hr
 250 ml/hr until 80% replaced
 Total replacement in 1st
12 hrs of 4-6 L

41. MANAGEMENT OF DKA (CONTD.)
 Glucose
 When CBG <250 mg/dl, 5%DNS infusion
 Potassium
 If initially normal/ low- 15-20 mEq/ hr
 If elevated, wait, until it becomes normal, then
20-30 mEq/ L IV solution
 Bicarbonate
 If pH < 7.1, add 1 amp (44 mEq) to 1 Lit of
0.45% NS

42. HYPEROSMOLAR NONKETOTIC COMA
 Peculiar to type II DM
 Severe hyperglycaemia (>600 mg/dl)
 Serum hyperosmolarity (>320 mOsm/L)
 No ketonaemia
 Management-
 Aggressive fluid therapy to combat severe
dehydration
 Insulin
 Potassium
Rarely seen in pregnancy

43. HYPOGLYCAEMIA
 Especially occurs in 1st
trimester with type I DM
 Peak incidence at 10-15 weeks
 Significant hypoglycaemia occurs when CBG
values are less than 35 mg/dl
 Woman should know symptoms of hypoglycaemia
 Management
 Oral glucose
 If unconscious- 20 ml of 50% dextrose, followed
by 10% dextrose drip
 If severe, injection Glucagon 1 mg IM/ SC

44. FASTING HYPERGLYCAEMIA
SOMOGYI’S PHENOMENON
 High fasting blood sugar & C/O nightmares/ nocturnal
sweating
 Nocturnal hypoglycaemia (01.00- 05.00 AM) →
exaggerated counter-regulatory response
 Treatment is to DECREASE the night dose of
intermediate/ long acting insulin
DAWN PHENOMENON
 High fasting blood sugar in absence of nocturnal
hypoglycaemia
 Cause not known exactly
 Treatment is to INCREASE the night dose of
intermediate/ long acting insulin

45. THANK YOUTHANK YOU