diabetis in pregnancy

1. DIABETES IN PREGNANCY
-Dr.p.Lydia
2nd year post graduate
Dept of OBGY

2. Introduction
• Definition:is a disorder of carbohydrate metabolism
characterized by high blood glucose levels as a
result of defective insulin production or insulin
resistance
• Prevalance: 22 million women between 20-39 yrs
have diabetes
• Expected to rise by 20% in next 10 years
• GDM has been found to be more prevalent in urban
areas than in rural areas
• Prevalance of diabetes varies from 1.5 to 15%

3. Diabetes in
pregnancy
Gestational
diabetes
Pre-existing
diabetes
IDDM (Type l)
NIDDM
(Type2)
True GDM
Pre-existing
diabetes

4. Gestational diabetes mellitus
Risk factors:
Factors in history:
• Age>30yrs
• Past history GDM
• Family history of DM
• Bad obstetric history
• Prior history of macrosomic
baby
• Previous stillbirth,previous
foetal anomalies
• Unexplained perinatal loss
• History of PCOS
factors in present pregnancy:
• Polyhydraminos
• Recurrent vaginal
candidiasis
• Recurrent UTI
• Obesity(>90kg)
• Congenital foetal anomalies
• Pre-eclampsia
• Persistant glycosuria

5. Pregnancy as a diabetogenic state
• Harmonal changes like increased placental
harmones acts as insulin antagonizers causing
insulin resistance and decreased insulin sensitivity
• Human placental lactogen promotes lipolysis
making free fatty acids available for mother own
metabolism ensuring availability of adequate
glucose for foetus
• GDM occurs when pancreas ,despite the
production of insulin fails to overcome the effect of
these contra-insulin harmones

6. Whom to screen and why to
screen?
• According to ACOG guidelines-Universal screening is now
recommended in all pregnancies.
Why to screen?
• Women with h/o GDM are increased risk of developing type
2 DM in their future
• Treatment of GDM reduces serious perinatal morbidity and
improves neonatal outcome

7. Which screening method ?
Diabetes in Pregnancy Study Group of India (DIPSI)
Criteria
• One step approach - The one step approach has been proposed
by the DIPSI and endorsed by the GOI .
• On 14th March 2007, Government of India issued the instructions
that universal screening of glucose intolerance during pregnancy
should be mandatory.
• The order recommends that all women should be screened in first
visit and if negative then done between 24 and 28 weeks of
gestation with 2 h 75 g oral glucose.

8. How to do it?
• 75 gms glucose with 300 ml water
• Irrespective of last meal
• Ingestion to be completed within 5-10 min
• Measure blood sugar after 2 hour
• If vomiting within 30 min of intake-repeat test next
day

9. Interpretation of DIPSI Test
• PG BSL (DIPS') > 200 mg %
at first visit - overt DM
• Look hypertension
• Retinopathy: Fundus examination
• Nephropathy: Serum creatinine

10. Advantages of DIPSI Criteria
• Fasting not required
• Causes least disturbance in a pregnant women’s activities
• Serves as both screening and diagnostic purpose

11. Two step(double step method)
1)Glucose challenge test(GCT):
• Irrespective of last meal 50gm of glucose is given
• Plama glucose is measured after 1hr
• Values:
<140mg/dl – normal
>= 200mg/dl – overt diabetes
140-199mg/dl -80% will have GDM and it is taken as
cutoff point For GTT

12. 2)Glucose tolerance test:
• Overnight fasting
• Fasting blood sample taken
• Then 100gm of glucose is given in 200ml of water,then
3 blood samples are taken hrly
• FBS>95
1hr>180
2nd hr>155
3rd hr>140
• If any two of the values is increased it indicates GDM

13. 1. Detection of Overt Diabetes
• To be performed at the initial antenatal visit
• FPG, HbA1c or random glucose can be used
• If results suggestive of overt diabetes (FPG ≥ 126
mg/dl;HbA1c ≥ 6.5% or random glucose≥200 mg/dl
with symptoms of hyperglycemia), start treatment
• If results not suggestive of overt diabetes
• And FPG between 92 and 125 mg/dl, diagnose
GDM
• And FPG <92 mg/dl, repeat screening at 24 to 28
weeks

14. Maternal complications
• Early pregnancy - spontaneous miscarriage
• Pregnancy – Pre-eclampsia, Gestational HTN, UTI, Macrosomia,
hydramnios,
• Delivery – stillbirth, increased risk of instrumental delivery and
Caesarean, shoulder dystocia and birth injuries, Postpartum infections,
PPH, maternal mortality/ morbidity
• Puerperium – subinvolution of uterus,peuperal sepsis, lactation failure
• Long term postpartum - weight retention , GDM in subsequent
pregnancy , DM, CVD

15. Fetal complictions
• Still birth / Neonatal deaths
• Macrosomia
• Preterm birth
• congenital malformations:(pregestational diabetes)
 CVS-transposition of great vessels,ASD,VSD,TOF,truncus arteriosus
 CNS-spina bifida,hydrocephalus,caudal regression syndrome,
encephalocele,meningocele
 GU-renal anomalies,ureteric duolication,polycystic kidney disease
 GI-rectal atresia
 Skeletal:caudal regression syndrome,sacral agenesishypoplasia of
caudal structures

16. • Intrapartum-
 birth injury(brachial plexuses injury,clavicular
fracture,humerus fracture)
 Fetal asphyxia
• Neonatal:
 Hypoglycemia
 Hyperbilirubinemia
 Polycythemia
 Hypomagnesemia
 Repiratory distress
 Neurodevelopmental delay

17. Management
• Aim: keep FBS<95mg/dl and 2hr PPBS<120mg/dl
• Primary management strategy for GDM: dietary
changes and exercise
• If uncontrolled hyperglycemia with lifestyle change:
• lnsulin should be first line therapy
• Use Metformin, if insulin cannot be used

18. GDM Diet
• Diet- 30 kcal/kg — normal weight women, 24 Kcal/kg for
overweight women, and 12 Kcal/kg for morbidly obese
women.
• Diet should contain carbohydrate 50%, protein 20% and fat
25-30%.
• Usually three meal regimen, with breakfast 25% of the total
intake, lunch 30%, dinner 30%.

19. • Receive nutrition counseling by registered dietician to
achieve their nutrition, weight and blood glucose goals
• Eat healthy diet and Replace high-Glycemic Index foods with
low-Glycemic Index foods to reduce need for insulin
initiation
• Discuss appropriate weight gain and healthy lifestyle
interventions throughout pregnancy

20. Medical Nutrition Therapy (MNT)
Therapeutic goals:
•adequate nutrition
•Adequate weight gain
•prevention of ketosis
•Prevention of postprandial hyperglycemia.

21. Individualized diet plan based on
level of activity and BMI

22. Physical Activity
• Unless contraindicated, physical activity should be included
in a pregnant woman's daily regimen
• Regular moderate-intensity physical activity (eg, walking)
can help to reduce glucose levels in patients with GDM
• Other appropriate forms of exercise during pregnancy
• Cardiovascular training with weight-bearing, limited to the upper
body to avoid mechanical stress on the abdominal region

23. OHA in pregnancy
Metformin- first line drug
• Insulin sensitizer
• Give with meal
• Start at 500 mg once or twice daily with
food
• Increase slowly weekly to 2000 mg per
day (2500 mg/day)
• No teratogenic risks demonstrated
• pregnancy risk factor: B (No evidence of
risk in studies)
• Not FDA approved for use in pregnancy
Glibenclamide:
• 2.5mg/day
• Max of20mg/day

24. Insulin initiation during pregnancy
• About 50% of women initially treated with diet alone will require
additional therapy, and insulin therapy usually is recommended.
• FBS>105mg/dl or 2hrs PPBS>140mg/dl
• Insulin management must be individualized, but most pregnant
women require about 0.7 units/kg daily.
• two thirds of the insulin is administered in the morning and one
third is administered in the evening, with a 1:2 ratio of short- to
intermediate- (or long-) acting insulin in 2-3 doses per day

26. Monitoring Blood Glucose
• At least 4 times-self monitoring
• Fasting(<95mg/dl)
premeal(100mg/dl)
1hr pp(<= 140mg/dl)
2hour postprandial(<=120mg/dl)
• After achieving target level, lab monitoring till 28wks- once in a month
• 28-32 weeks once in 2 weeks
• >32 once a week
• Other parameters to be monitored: fundus,micro albuminuria

27. Monitoring during pregnancy

28. Fetal monitoring
• Baseline ultrasound : foetal size
• At 18-22 weeks -major malformations & foetal
echocardiogram
• 26 weeks onwards -growth and liquor volume
• Ill trimester —frequent USG for accelerated growth
(abdominal: head circumference), weight gain, AFI

29. Care in labour & delivery
• LABOUR MANAGEMENT - FIRST STAGE
• Institutional delivery
• Presence of expert obstetrician
• Close electronic monitoring

30. Care in labour & delivery
• LABOUR MANAGEMENT - SECOND AND THIRD
STAGE
Close monitoring in second stage
W/F foetal distress
Vaginal delivery should be preferred and LSCS should be done for obstetric
indications only.

31. Indications of caesarian delivery
• Malpresentations
• Proliferative retinopathy
• Pregnancy complicated by pre-eclampsia
• Macrosomia(EFW>4.5kg)
• Previous caesarian
• Foetal distress prior to or during labour
• BOH in elderly patient
• Elderly primigravida
• Hba1c>6.4%

32. Insulin Management during Labour &
Delivery
• Usual dose of intermediate-acting insulin is given at bedtime
• Morning dose of insulin is withheld
• I.V infusion of normal saline is begun
• Once active labor begins or glucose levels fall below 70 mg/dl, infusion
is changed from saline to 5% dextrose & delivered at a rate of 2.5
mg/kg/min
• Glucose levels are checked hourly using a portable meter allowing for
adjustment in infusion rate
• Regular (short-acting) insulin is administered by iv infusion if glucose
levels exceed 140 mg/dl

33. Immediate postpartum care
GDM on OHAs
• In most women, glucose tolerance will normalize immediately after
delivery
• Cease pharmacological therapy immediately after delivery
• Continue pre prandial BGL monitoring QID for 24 hrs
• If preprandial BGL 72 — 126mg/dl — discontinue monitoring
• If BGL <72mg/dI or >126mg/dI — seek medical review and continue
monitoring
• 1 — 8% may continue to be glucose intolerant and need OHAs
• Metformin, glibenclamide / glyburide safe during lactation
Queensland clinical guideline 2015

34. Immediate postpartum care
GDM on Insulin
• Preprandial BGL monitoring QID for 24 hrs
• If BGL >126mg/dl —medical review & start OHAs
• Insulin therapy is generally not indicated unless marked
fasting hyperglycemia (200—250 mg/dL)

35. Risk factors for persistent diabetes
• Pregnancy fasting glucose levels greater than or equal to
126 mg/dL
• Diagnosis of GDM during the first trimester
• A prior history of GDM without documented normal glucose
tolerance outside of pregnancy

36. Monitor for persistent diabetes
• Recommend OGTT at 6 weeks postpartum to screen for
persistant diabetes
• Recommend lifelong screening for diabetes every 3 yrs
• Early glucose monitoring in future pregnancy

37. Breast feeding
• should be encouraged to breastfeed immediately after
delivery in order to avoid neonatal hypoglycemia
• to continue for at least 3-4 months postpartum in order to
prevent childhood obesity and diabetes in the offspring and
• to reduce risk of type 2 diabetes and hypertension in the
mother

38. Contraceptive choices
• Barrier
• IUCD
• POP / DMPA
• COC / implants/ rings - contraindicated with
macrovascular disease

39. Can we Prevent GDM ?
• In women at high risk for GDM based on pre- existing risk
factors, nutrition counseling should be provided on healthy
eating and prevention of excessive gestational weight gain
in early pregnancy, ideally before 15 weeks of gestation, to
reduce the risk of GDM

40. Thank u