diabetes is very common disorder in all age group i.e from infancy to secondary childhood age so intake of good healthy diet is very important for the production of insulin which is needed for body for regular activities

1. DIABETES
MELLITUS IN
PREGNANCY
Kusuma Neela Bolla, M.Sc,M.B.A
Asst.proof, S.D.M.S.M.Kalasala, Vijayawada.

2. CLASSIFICATION OF DIABETES IN
PREGNANCY

3. DEFINITIONS
Diabetes Mellitus in Pregnancy falls into 2 categories:
1. Gestational Diabetes Mellitus (GDM) – Any
degree of glucose intolerance with onset or first
recognition during pregnancy. Does not
exclude possibility that unrecognised glucose
intolerance may have been present before
onset of pregnancy.
2. Pre-gestational Diabetes Mellitus – diagnosed
when the woman has diabetes before
pregnancy.

4. WHITE’S CLASSIFICATION OF
DIABETES DURING PREGNANCY
CLASS DEFINITION
A1 Diet controlled gestational DM
A2 GDM requiring insulin
B Pre-existing DM without complications. Dur:<10yrs.
Onset: >20yrs
C Pre-existing DM without complications. Dur:10-19yrs,
Onset:<10-19yrs
D Pre-existing DM. Dur:>20yrs. Onset:<10yrs
F Pre-existing DM with Nephropathy
R Pre-existing DM with retinopathy
T Pre-existing DM with post op renal transplant status
H Pre-existing DM with heart diseases

5. GESTATIONAL DIABETES MELLITUS
(GDM)

6. Physiology
 Pregnancy  ↑ HPL + cortisol (insulin antagonists)
 Mother  relative insulin resistance esp 3rd
trimester
 Maternal pancreas  ↑ insulin to maintain carbohydrate
metabolism  ↓ FPG
 Carbohydrate intake  ↑ glucose than non-pregnant lady
 Glucose crosses placenta by facilitated diffusion and the
fetal blood glucose level closely follows the maternal level
 Therefore, fetal glucose levels therefore is normally
maintained within normal limits, as in mother.

7. Modified Penderson Theory: Impact of
Maternal Hyperglycaemia During Pregnancy
MATERNAL PLACENTA FOETAL
↓ Insulin release
↓ glucose utilisation
Hyperglycaemia Hyperglycaemia
↑ Insulin
(hyperinsulinaemia)
Birth weight ↑
↑ Lipid &
↑ Glycogen? Altered structure
and/or function

8. GDM IN FIRST TRIMESTER
 Women found to have fasting hyperglycaemia or
abnormal glucose intolerance in the first
trimester might have pre-existing diabetes
 Should be treated as women with glucose
intolerance before pregnancy
 First trimester hyperglycaemia  high risk of
congenital abnormalities in foetus

9. SCREENING FOR GDM
 Women with high risk of GDM:
 BMI >30kg/m2
 First degree relative with Diabetes
 Personal history of GDM
 Previous macrosomic baby ≥4.5kg
 Family origin with high diabetes prevalance (South
Asian, African-Caribbean, Middle-Eastern)
 *Previous poor obstetrics outcomes usually associated
with diabetes

10. TESTS FOR DIAGNOSIS OF GDM
Non challenge blood glucose test:
 Fasting glucose test
 2 hr post prandial test
 Random glucose test
Screening glucose challenge test
Oral glucose tolerance test

22. PRE-GESTATIONAL DIABETES

23. TYPE 1 AND TYPE 2 DIABETES
 Pre-conception care is essential
 If untreated in first few weeks gestation,
associated with:
 Spontaneous abortions
 Birth defects
 If untreated during 2nd
or 3rd
trimester, associated
with:
 Foetal macrosomia and metabolic abnormalities
 Birth injury
 Maternal hypertension and pre-eclampsia
 Future diabetes and/or obesity in child

24. PRE-PREGNANCY COUNSELLING
 To assess suitability for pregnancy
 To look for complications of diabetes, evaluate
and treat complications prior to onset of
pregnancy
 To achieve optimal control prior to and during
very early pregnancy
 To provide an opportunity for pre-pregnancy
advice and folate supplements

25. MEDICAL ASSESSMENT IN PRE-
CONCEPTION CARE
 Duration and type of diabetes
 Medical history and current medical
management plan
 Chronic diabetes complications:
 Retinopathy
 Nephropathy
 Neuropathy
 Co-morbid conditions (in addition to diabetic
complications)
 Hypertension (ideal blood pressure <120/80)
 Coronary Artery Disease
 Hyper- or Hypothyroidism
 Other auto-immune disease

26. PREVENTING RETINOPATHY
PROGRESSION
 Rapid normalization
of blood glucose
during pregnancy can
trigger retinopathy
progression
 Retinal status should
stabilized prior to
conception
 Reassess retinal
status each trimester
(more frequently if
retinopathy is
present)

27. RECOMMENDATIONS
 Plan pregnancies
 Attain a pre-conception HbA1c of < 7%
 If planning pregnancy:
 Needs retinal screening prior to conception
 Screen for diabetic retinopathy and coronary heart
disease
 Discontinue oral hypoglycaemic agents and attain
glycaemic targets using insulin, if possible
 Replace ACEI and ARBs to other hypertensives that
are safe to take in pregnancy
 Stop statins

28. POSSIBLE CONTRA-INDICATIONS
TO PREGNANCY
 Ischaemic Heart Disease
 Active, unrelated proliferative retinopathy
 Renal insufficiency
 Severe Gastroparesis
 Inability or unwillingness to use Insulin

29. RISKS TO MOTHER WITH
GESTATIONAL DIABETES
 Increased risk of Caesarian Section
 Pre-eclampsia (2-4 x esp with co-existing
microalbuminuria/frank nephropathy)
 Polyhydramnios
 Pre-term labour
 Post-Partum Haemorrhage
 Temporary worsening of renal function
 Progression of retinopathy
 ↑ incidence of infection, severe hyperglycaemia/hypoglycaemia,
DKA
 In future:
 Recurrent GDM Pregnancies
 Risk of developing T2DM (50% in 5 - 10 years)

30. POTENTIAL COMPLICATIONS IN
INFANTS OF MOTHERS WITH
DIABETES
 Intra-uterine demise
 Spontaneous abortions
 Stillbirth (10-30%)
 Congenital
malformations
 Neural tube defects
 Cardiac defects
 Caudal Regression
syndrome (rare)

31. POTENTIAL COMPLICATIONS IN
INFANTS OF MOTHERS WITH
DIABETES
 Macrosomia
 Visceromegaly
 Cardiac enlargement
 Hepatic enlargement
 Respiratory Distress
Syndrome
 Asphyxia
 Birth injury
 Shoulder Dystocia
 Erb’s Palsy
 Diaphragmatic
paralysis
 Facial paralysis

32. MACROSOMIA

33. POTENTIAL COMPLICATIONS IN INFANTS
OF MOTHERS WITH DIABETES
 Metabolic complications
 Hypoglycaemia (high insulin production in
immediate neonatal period due to recent foetal
hyperglycaemia)
 Mothers encouraged to breastfeed ASAP; monitor baby’s
blood glucose; formula-fed or glucose infusion prn
 Hypocalcaemia, magnesium deficiency  apnoeic
episodes and fits
 Polycythaemia  hyperbilirubinaemia  jaundice
 Partial exchange transfusion

34. Management: Obstetrics
 Nuchal Traslucency Scan
 Detailed US for foetal anomalies
 Foetal echocardiography
 Serial growth scan
 Monitor foetal well-being (doppler US & CTG)
 Aim: vaginal delivery between 38 – 40 weeks
 50% Ceasarian section because of macrosomia,
pre-eclampsia and failed induction of labour

35. Management: preterm labour &
polyhydramnios
 Difficult
 Tocolytics (e.g. ritodrine, salbutamol) are
diabetogenic
 I/M steroid for foetal lung maturation 
destabilize diabetic control
 I/V insulin / glucose infusion if required to ensure
normoglycaemia

36. Management: Intrapartum
 Induced/Spontaneous labour  sliding scale of
insulin to maintain normoglycaemia
 Test maternal blood glucose hourly
 Continuous foetal monitoring advised
 Foetal scalp blood sampling if CTG abnormal

37. Management: Post-delivery
 Insulin requirements return to pre-pregnant
levels
 If GDM, stop insulin
 OGTT 6/52 post-delivery to ensure diabetes has
resolved