Diabetes during pregnancy, also known as gestational diabetes, occurs when high blood sugar levels develop during pregnancy and can affect both mother and baby. It is defined as glucose intolerance that begins or is first recognized during pregnancy. Risk factors include family history of diabetes, high BMI, and advanced maternal age. An oral glucose tolerance test is used to screen for gestational diabetes. Treatment involves dietary changes, exercise, glucose monitoring, and possible insulin or metformin medication. Complications for both mother and baby can include preterm birth, high birth weight, preeclampsia, and future type 2 diabetes.

1. Diabetes Mellitus in
Pregnancy
By : Ozhin Araz

2. What is Diabetes Mellitus?
• A metabolic condition characterized by chronic
hyperglycemia as a result of defective insulin secretion,
insulin action or both.
• Diabetes is the most common medical complication of
pregnancy.
• Impact of elevated blood sugar:
1. Pregnancy complications
2. Multi-organ dysfunction
3. Excess mortality

4. Gestational Diabetes
• Defined as carbohydrate intolerance of variable severity with
onset or first recognition during pregnancy.
• The entity usually presents late in the second or during the
third trimester.
• Gestational diabetes affects 3–9% of pregnancies, affecting
1% of those under the age of 20 and 13% of those over the
age of 44.

5. Risk Factors
1. Strong familial history of diabetes
2. Body mass index >30 kg/m2
3. Previous gestational diabetes.
4. Have given birth to large infants (4 kg or more)
5. Previous polyhydromnios.
6. Previous unexplained fetal losses
7. Over the age of 30
8. Ethnic group (East Asian, pacific island ancestry)

6. Pathophysiology
Insulin Resistance

7. Insulin resistance is a normal phenomenon emerging in the
second trimester of pregnancy, which in cases of GDM
progresses thereafter to levels seen in a non-pregnant
person with type 2 diabetes.
Factors that mediate insulin resistance during pregnancy :
Cortisol and progesterone are the main culprits, but human
placental lactogen, prolactin and estradiol contribute, too
with tumor necrosis factor alpha which is named as the
strongest independent predictor of insulin sensitivity in
pregnancy.

8. Screening

9. Oral glucose tolerance test (OGTT)
Procedure :
• CHO intake of at least 150 g/day 3 days prior then Fast for 10 to 16 hours
• 100 grams or 75 grams of anhydrous dextrose powder
Drink within 5 minutes (first swallow is time zero)
Terminate test should nausea and vomiting occur
• Abstain from tobacco, coffee, tea, food and alcohol during test
• Sit upright and quietly during the test , Slow walking is permitted but avoid
vigorous exercise
• Collect samples at 0, 1 ,2 and 3 hours
Result:
 Fasting blood glucose level ≥95 mg/dl (5.33 mmol/L)
 1 hour blood glucose level ≥180 mg/dl (10 mmol/L)
 2 hour blood glucose level ≥155 mg/dl (8.6 mmol/L)
 3 hour blood glucose level ≥140 mg/dl (7.8 mmol/L)

10. 1- Diet :
• Recommendations are 30 kcal/kg for women with a BMI of 22
to 25, 24 kcal/kg for women with a BMI of 26 to 29, and 12 to
15 kcal/kg for women with a BMI above 30.
• The recommended overall dietary ratio is 33% to 40% complex
carbohydrates, 35% to 40% fat, and 20% protein.
• This calorie distribution will help 75% to 80% of GDM women
become normoglycemic.
Management :

11. • Avoid concentrated sweets and highly processed foods -contribute to
unwanted weight gain:
• soft drinks, ice cream, cakes and sweet.
• restrict CHO to those found in vegetables and dairy products like cheese and cottage cheese
• Small frequent meals (4 hourly) instead of fewer larger meals
• Breakfast should be especially small and low in carbs because insulin
resistance is highest in the morning.
• Foods rich in antioxidants have a role in reducing the incidence of
fetal anomalies therefore fruits and vegetables are recommended
Management :

12. 2- Exercise
3- Glucose Monitoring
• Daily self blood-glucose monitoring had fewer macrosomic
infants and gained less weight after diagnosis.
• Glycosylated hemoglobin should be determined at the end of
first trimester and three months thereafter. HBA1C level of 5-
6% is desirable.
Management :

13. 4- Medications
A- Insulin Therapy : Recommended when standard dietary management
does not consistently maintain fasting plasma glucose at <95 mg/dL or the
2hour postprandial plasma glucose < 120 mg/dL .
• Total dose of 20 to 30 units OD, before breakfast, is commonly used to
initiate therapy which is divided into two-thirds intermediate-acting
insulin and a third short-acting insulin.
• Alternatively, weight-based split-dose insulin is administered twice daily.
• During the stabilization process of insulin dose, frequent blood sugar
estimation especially at night may be necessary
Management :

14. B- Oral Hypoglycemic Agents (OHA): is usually avoided due to
fearful effects of these drugs on the fetus but now Metformin can be
used in certain circumferences due to its safety in pregnancy ,
especially if it was associated with Polycystic ovarian syndrome.
If blood glucose cannot be adequately controlled with a single agent,
the combination of metformin and insulin may be better than insulin
alone
Management :

15. 1. On initial calculation of insulin dose, especially in unreliable
patients
2. Patient with Pregnancy-induced Hypertension.
3. Sever vascular diabetic disease
4. At any time if there are concerns about glycaemic control,
especially if hyperemesis gravidarum develops
5. In cases of diabetic complications ,e.g,diabetic ketoacidosis
Indications of hospitalization

16. • Insulin requirements drop to prepregnancy values immediately
following delivery of the placenta.
• For women who had diabetes before pregnancy , can be restarted on
their appropriate medication following the pregnancy .
• Insulin (For women with type 1 DM) is not excreted into breast
milk and is considered completely safe for use during
breastfeeding. The use of Metformin (for women with type 2 DM)
by breastfeeding mothers is also considered safe, as very little of
the drug is excreted in breast milk.
• Schedule 75-g OGTT after 6 weeks
Post-partum Follow-up

17. Prognosis :
• 60-70% chance of developing GDM in subsequent pregnancies.
• 40-60% chance of developing type 2 diabetes in the future.
• A second pregnancy within 1 year of the previous pregnancy has a
high rate of recurrence.
• Children of women with GDM have an increased risk for childhood
and adult obesity and an increased risk of glucose intolerance and
type 2 diabetes later in life.
Prognosis and Complications :

18. Complications :
1- Maternal Complication
a. During Pregnancy:
1. Preterm labour (20%)
2. UTI
3. Increased incidence of preeclampsia (25%)
4. Polyhydramnios
5. Maternal distress
6. Diabetic retinopathy and Diabetic nephropathy
7. Ketoacidosis
Prognosis and Complications :

19. Complications :
1- Maternal Complication
b. During Labor
1. Prolongation of labour due to big baby
2. Shoulder dystocia
3. Perineal injuries
4. Postpartum hemorrhages
5. Operative interferences
c. Puerperium:
1. Puerperal sepsis
2. Lactation failure
Prognosis and Complications :

20. Complications :
2- Fetal and Neonatal Complication
a. Fetal complications
1. Fetal macrosomia (%30-40)
2. Congenital Malformations (%10) such as Neural tube defect or
VSD.
3. Birth injuries (brachial plexus)
4. Growth restriction (less common)
5. Unexplained fetal death
Prognosis and Complications :

21. Complications :
2- Fetal and Neonatal Complication
a. Neonatal complications
1. Hypoglycemia
2. Respiratory distress syndrome
3. Hyperbilirubinemia
4. Polycythemia
5. Hypocalcemia
6. Hypomagnesemia
7. Cardiomyopathy .
Prognosis and Complications :

22. Thank you!