12. Diet
• Low-carbohydrate diet , high fibre with caloric restriction
• Frequent small snacks may be needed between meals
• Avoid starvation
13. Insulin
• 3 pre-meal short acting insulin (actrapid) +/- intermediate-
acting insulin (protophane) as it allows maximum flexibility
• Target blood glucose:
fasting < 5mmol/L
2 hr <7 mmol/L
14. Oral Hypoglycemic agents
• Implicated as teratogeneic in animal studies esp first
generation sulfonyureas
• In humans, scattered case reports of congenital abnormality
• Risk of congenital abnormality related to maternal glycemic
control rather than mode of the anti-DM agents
15. Oral hypoglycemic agents
• For Type 2 DM patients,
to stop oral hypoglycemic agents and change to insulin
Reassure that the risk of congenital abnormality due to drug is
small
16. Oral hypoglycemic agents
• Biguanides ( metformin)
• Cat B drug
• Commonly used in Polycystic Ovarian Disease (PCOD)
to treat insulin resistance and normalize
reproductive function
• Not teratogeneic
• Reduce first trimester miscarriage
• 10X reduce gestational diabetes
Glueck, Fertil Steril 2002
Reece, Curr Opin Endocrinol Diabetes, 2006
Hague, BMJ, 2003
Glueck, Human Reprod, 2004
17. Oral hypoglycemic agents
Sulfonylureas
• 1st generation drug increase risk of neonatal
hypoglycemia
• 2nd generation drug (Glyburide) no such effect and other
morbidities .
• Cat C drug
• 4%-20% patients failed to achieve glucose control with
maximum dose of drug
• Increase risk of preeclampsia and need for phototherapy
Langer, N Eng Med J , 2000
Kremer, Am J Obst Gynaecol, 2004
Chmait, J Perinatol ,2004
Langer, Am J Obst Gynaecol, 2005
18. Insulin Analogues
• 1. rapid-acting insulin analogs
(lispro) Cat B
concerns about teratogenesis, antibodies formation,
growth-promoting properties
majority of evidence showed that it does not cross placenta,
and has no adverse maternal or fetal effects
20. Monitoring
• Regular home glucose monitoring with h’stix
• Insulin may be need to be adjusted as gestation advances
• Hba1c monitoring
• Fetal monitoring with USG
• Refer ophthamologist
21. Delivery
• Timing and mode of delivery individualised
• Intrapartum insulin infusion with glucose monitoring
• no contraindication for Breast feeding either with insulin or
oral hypoglycemic agents
22. Pre-conception Counselling
• Allows for optimisation of diabetic control prior to
conception, and assessment of the presence of
complications like hypertension, nephropathy, and
retinopathy
• Should counsel that good control and lower hba1c lower
the risk of congenital abnormalities and improve
outcome
• If necessary, proliferative retinopathy may be treated
with photocoagulation prior to conception
• Contraindications to pregnancy only :ischemic heart dx,
untreated proliferative retinopathy, severe renal
impairment(creatinine>250 mmol/L)
25. Gestational diabetes
• Should all pregnant women be screened or only
those with risk factors?
• Is it safe to screen all?
• Which screening test and which diagnostic test
are the most reliable?
• Which cut-off values should we use?
• What are the risk for mothers and babies and
can treatment improve outcome?
• What are the connection between gestational
diabetes and type 2 DM?
• Is it physiological or pathological ?
26. Gestational diabetes
Screening and diagnosis
In general, the test is performed btn 24-28 wk because at this
point in gestation the diabetogenic effect of pregnancy is
manifest and there is sufficient time remaining in pregnancy
for therapy to exert its effect
27. Gestational diabetes
• Screening and diagnosis
In general, risk factor includes:
1. age>25y
2. BMI > 25
3. previous GDM
4. Family hx of DM in 1st degree relative
5. previous macrosomic baby (<4 kg)
6. polyhydramnio
7. large for date baby in current pregnancy
8. previous unexplained stillbirth
31. Gestational diabetes
Clinical significance of GDM
1. High incidence of macrosomia, and adverse pregnancy
outcomes,
2. A significant proportion(30%) identified as GDM in fact have
DM before pregnancy
32. Gestational diabetes
• Women with glucose intolerance just above normal range are
at low risk for pregnancy complications, those with more
severe glucose intolerance approaching the criteria of
diabetes are at risk of neonatal complications
33. Fetal complications
• Macrosomia (>4 kg)
risk is 16-29% as compared to 10% in control
• Increase in caesarean delivery, intrumental deliveries
( forceps/vacuum), birth trauma, such as brachial plexus
injuries , clavicular fractures
• Increase in neonatal hypoglycemia (24% ),
hyperbilirubinemia, hypocalcemia, polycythemia
• Children are at risk of type 2 DM and obesity in life
34. Maternal complications
• Increase risk of hypertensive disorders
• Increase risk of caesarean and intrumental deliveries
• Increased Risk (40-60%) of developing type 2 DM within10-15
yr.
35. Gestational diabetes
Does treatment improves outcomes?
Conflicting results
1. Cochrane datebase systemic review 2005 (3 studies only)
no difference in outcomes except neonatal hypoglycemia
2. Australian Carbohydrate Intolerance Study in Pregnant Women (ACHOIS study)
2005 ( 490/510 subjects)
treatment of diabetes reduces serious perinatal morbility and may
improve the woman’s health-related quality of life
36. Gestational diabetes
• Large randomized study on going
HAPO trial in USA
(Hyperglycemia and Adverse Pregnancy Outcome study)
37. Gestational diabetes
Management
• Management similar as preexisting DM
• Need for glucose monitoring
• Start with Diet control
• Commence insulin for poor control
• Delivery plan individualised
38. Gestational diabetes
• In view of risk of developing type 2 DM
the woman should be screened annually for DM on yearly
basis.
39. Diabetesand Pregnancy
Conclusion
(1) Preexisting DM in pregnancy
• Good glucose control is important for decreasing
morbidities
• Insulin is still the gold standard of tx in pregnancy
• Increasing evidence for clincial effectiveness for treatment
with oral hypoglycemic agents
40. Diabetes and pregnancy
conclusion
(2) Gestational diabetes
• no consensus
• The morbidities increases as glucose level
approaching the diagnosis as DM
• Possible that treatment improves outcomes
• Overlap with preexisting DM, esp type2
• Long term implication for health of the mother
and baby
