diabetes in pregnancy definition and types

1. Diabetes in Pregnancy

2. • Diabetes mellitus disorder of carbohydrate metabolism
• Prevalence 6.4% in 2010 increases to 7.7% by 2030
• Reason for rise in prevalence
• Short and long term complication to mother and baby.

3. Classification of diabetes
Pregestational
• Type 1 diabetes mellitus
• Type 2 diabetes mellitus
Gestational
Others
• Genetic mutation (mody)
• Abnormality in insulin action
• Exocrine and endocrine abnormality
• Chromosomal abnormality
• Drug and infections

4. WHITE CLASSIFICATION
CLASS ONSET FASTING POSTPRANDIAL THERAPY
A1 GESTATIONAL <105mg/dl <120mg/dl DIET
A2 GESTATIONAL >105mg/dl >120mg/dl INSULIN
CLASS AGE OF ONSET (YR) DURATION (YR) VASCULAR DISEASE THERAPY
B OVER 20 <10 NONE INSULIN
C 10 TO 19 10 TO 19 NONE INSULIN
D BEFORE 10 >20 BENIGN RETINOPATHY INSULIN
F ANY ANY NEPHROPATHY INSULIN
R ANY ANY PROLIFERATIVE
RETINOPATHY
INSULIN
H ANY ANY HEART INSULIN

5. DEFINITION
GESTATIONAL DIABETES MELLITUS :
Carbohydrate intolerance resulting in hyperglycaemia of
variable severity with onset or first recognition during pregnancy.
• Type 1 diabetes mellitus: Absolute insulin deficiency.
• Type 2 diabetes mellitus: Absolute insulin resistance.

6. DIAGNOSIS OF OVERT DM IN PREGNANCY
FASTING PLASMA GLUCOSE >126 mg/dl.
hbA1c > 6.5%.
random plasma glucose >200 mg/dl.

7. CARBOHYDRATE METABOLISM
Diabetogenic state
Insulin resistance
(HUMAN PLACENTAL
LACTOGEN,
PROGESTERONE
,PROLACTIN ,CORTISOL)
Lipolysis
Changes in
gluconeogenesis

8. COMPLICATION
• ACUTE
• CHRONIC
• MICROVASCULAR
• MACROVASCULAR

9. PREGESTATIONAL COUNSELLING
• Information About Outcomes And Risk For Mother And Baby
• Diet , Body Weight.
• Blood Glucose And Ketone Monitoring.
• Target Blood Glucose And Hba1c Level .
• Safety Of Medications.
• Complication And Assessment.

10. EFFECTS OF DIABETES ON PREGNANCY
Diabetic nephropathy : 25 to 30 % with type 1 dm.
PATHOGENESIS :
ADVANCED GLYCOSYLATED END PRODUCTS.
RECEPTOR MEDIATED: RELEASE OF CYTOKINES TGF BETA
GENERATION OF ROS.
INCREASED PROCOAGULANTS.

11. NON RECEPTOR MEDIATED:
Stages
• Stage 1: early renal hypertrophy and hyperfunction
• Stage 2: renal lesion without clinical signs
• Stage 3: incipient nephropathy.
• Stage 4: overt diabetic nephropathy.
• Stage 5: esrd

12. • Microalbuminuria
Albumin to creatinine ratio >/3.5 mg/mmol
24 hr urinary collection urine albumin excretion of 30
-299 mg/24 hrs.
• Macroalbuminuria
Albumin to creatinine ratio >/30mg/mmol
24 hr urinary collection urine albumin excretion of
>300 mg/24 hrs.

13. PREECLAMPSIA:
• Diabetes with chronic hypertension 12 times likely to develop
preeclampsia.
• Dm with vascular complications -UPI
• DAPIT : Type 1 DM to antioxidant .
• Low dose aspirin : 81 mg oral daily dose between 12 and 28 weeks
and Continued until delivery (ACOG 2022).

14. Diabetic Retinopathy
STAGES RETINAL FINDING
MILD NPDR MICROANEURSYM ONLY
MODERATE NPDR RETINAL HEMORRAGE, HARD EXUDATES , COTTON
WOOL SPOT, VENOUS BEADING.
SEVERE NPDR 4-2-1 RULE (HEMORRAGE, VENOUS BEADING ,IRMA)
PDR NEOVASULARISATION .

15. Diabetic
retinopathy
• Non-proliferative diabetic
retinopathy
• Mild
• Screening and follow-up
• Moderate
• Fundoscopy prior to
consumption,
• first antenatal visit,
• 28 weeks,
• 16-20 weeks in pre-existing
lesions
• Severe
• Fundoscopy prior to
consumption,
• first antenatal visit,
• 28 weeks,
• 16-20 weeks in pre-existing
lesions
• Proliferative diabetic retinopathy

16. • NPDR : good glycaemic control.
• PDR: Pan retinal photocoagulation.
• Untreated proliferative retinopathy - intravitreal haemorrhage in
labour.
• Follow up at least 6 months after delivery.
• Intrapartum – chances of infection, increase chance of operative
delivery.
• Postpartum risk of PPH, puerperal sepsis, prolonged labour.
• Long term risk : type 2 dm , CVS disorders (18 to 30 %)

17. DIABETIC NEUROPATHY:
• DIABETIC GASTROPATHY
• TREATMENT: METACLOPROMIDE AND DOMPERIDONE.
DIABETIC KETOACIDOSIS :
• Stress – gluconeogenesis and ketone body – metabolic
acidosis, kussmaul breathing, dehydration.
Infections

18. FETAL EFFECTS
1) SPONTANEOUS ABORTION: 25 %
FBS>120mg/dl , hba1c >12% .
Mody ,gck mutation.
2) PRETERM DELIVERY :
3)MALFORMATIONS:
HBA1C <7% - NO GREATER RISK .
HBA1C 7 TO 8.5 - 5% RISK OF ANOMALY.
HBA1C >10% - 22 % RISK OF ANOMALY.

19. BIRTH DEFECT
CVS –TGA ,AV SEPTAL DEFECTS, HYPOPLASTIC LEFT
HEART.
NEURAL TUBE DEFECTS
SACRAL AGENESIS
RENAL AGENESIS
INTESTINAL –DUODENAL ATRESIA.
HYPOSPADIAS
ESOPHAGEAL CAUSE,SMALL LEFT COLON SYNDROME.

20. 4) FETAL GROWTH
PEDERSON HYPOTHESIS.
5)UNEXPLAINED FETAL DEMISE:
6) CHEMICAL IMBALANCES
7)RDS
8) LONG TERM COGNITIVE DEVELOPMENT
9)INHERITANCE.

21. GDM

22. Definition
• Carbohydrate intolerance of variable severity with onset or
first recognition during the present pregnancy, Thus, it
includes women with pre-existing but previously
unrecognized diabetes
• Incidence 6%
• prevalence of GDM 17.9% in TN

23. Risk factors
• Overweight/ obesity
• Excessive gestational wt gain
• Ethnicity
• Genetic polymorphism
• Advanced maternal age
• Family & personal history of GDM
• Diseases related to insulin resistance -PCOS

25. Screening
When to screen
Diagnostic test Week of gestation
1 At 12-16 weeks /1st visit to AN check up
2 At 24-28 weeks
3 At 32-34 weeks

26. Screening methods
Single step methods
• DIPSI method
• IADPSG criteria
• The WHO Method
Two step method

27. DIPSI METHOD
• 75 g glucose in 300 ml water irrespective of previous
meal
• Plasma glucose level after 2 hours
• Positive – 2 hour post glucose load > 140 mg/dl

28. IADPSG CRITERIA
• After overnight fasting – plasma glucose level checked
• 75 g glucose in 150 ml water/lime juice
• Plasma glucose at 1& 2 hours
–Cut off values
• Fasting-92 mg/dl
• 1 hour- 180mg/dl
• 2 hour- 153mg/dl

29. THE WHO METHOD
• AT 24-28 WEEKS
• Fasting plasma glucose
• 75 g glucose load – plasma glucose level after 2 hours
• Cut off value – 140 mg/dl

30. DIPSI IADPSG WHO
GLUCOSE 75g in 300ml
water
75g in 150 ml
water
75g in 300ml
water
Previous meal irrespectively fasting fasting
PPPG
monitoring
2 hours 1 hour & 2
hour
2 hour
Cut off 140 182 & 153 140

31. Two step method
• Screening test if positive diagnostic test
• STEP 1
50 g glucose irrespective of previous meal
1 hour plasma glucose - ≥ 140mg/dl second step carried out
• STEP 2
Fasting plasma glucose
100 G glucose OGTT plasma glucose at 1,2,3 hours
• Cut off values
Fasting- 95 mg/dl
1 hour – 180 mg/dl
2 hour – 155mg/dl
3 hour – 140 mg/dl

32. Management
• Glycemic control
ACOG and ADA recommended self-monitored glucose targets
from the Fifth International Workshop–Conference on GDM
• Goals
• Fasting glucose , 95 mg /dl
• PPPG 110-120 mg/dl

33. Dietary management - MNT
• Moderate exercise of 30 min daily
• Calorie intake should start at 30 kcal / day of the ideal body weight
• over weight women - 24 kcal / day
• Carbohydrate forms 40-50% of the diet
• 80- 100 g protein except diabetic nephropathy(60g) – 10-35%
of total enery intake by proteins
• Fat intake should constitute 30% of thr diet
• 30-35g of natural fibres should be included

34. • Divide the food intake to 3 meals and 3 snacks – to avoid nocturnal
and preprandial hypoglycemia
• GDM(deficiency in insulin secretion after breakfast)-so quantity to
be divided into portions
• Peak of plasma glucose higher with breakfast than
lunch,dinner(DAWN PHENOMENON)- so split of breakfast into 2
portins adviced
• All sugar items,tubers avoided

35. • Equations proposed by ICMR (1989) expert group can be used to
calculate adult energy requirement which are as follows:
• Energy requirement (K.cal/d)= BMR ×PAL
• *BMR= Basal metabolic rate *PAL= Physical activity level
• BMR (K.cal/d)for adult females (18-30yrs)= 14×B.W (Kg) + 471
• BMR (K.cal/d)for adult females (30-60yrs)= 8.3×B.W (Kg) + 788
• Ideal body weight can be taken in to consideration when calculating
the requirement.

36. • PAL values proposed by ICMR expert group (2009) are as
follows Level of activity
• Sedentary work PAL value 1.53
• Moderate work PAL value 1.8
• Heavy work PAL value 2.3
• An addition of 350 k. Cal can be made after calculating the
energy

37. Pharmacotherapy
• Insulin does not cross the placenta, is the most studied
pharmacologic class in pregnancy, and is preferred over other
therapies, including metformin and sulfonylureas
• Ideal to use – least immunogenic & reduces the risk of fetal beta
cell damage.
• Rapid acting insulin analogues-safe & effective
• Intermediate-acting insulin – if pre food values are high.
• Long acting insulin -avoided

39. • The starting insulin dose is typically 0.7 to 1.0 U/kg/d and is given in
divided doses (American College of Obstetricians and Gynecologists,
2019a).
• If women needs more than 16 units/day, then split dose is given in
the morning and evening.
• The starting daily dose is divided so that two thirds is given in the
morning before breakfast and one third in the evening before
dinner.
• In the morning dose, one third is regular insulin and two thirds are
NPH (neutral protamine Hagedorn) insulin.
• For the evening dose, one half is regular insulin and the other half
is NPH.

40. Metformin
• Inexpensive oral medication and is increasingly used in pregnancy
despite ADA and ACOG preference for insulin therapy.
• Even with its gastrointestinal side effects, study data suggest
women prefer metformin to insulin therapy.
• Although meta-analysis has been largely reassuring regarding
metformin versus insulin use in GDM, with less maternal weight
gain and the trend toward less neonatal hyperglycemia, some
studies show metformin results in more preterm delivery and
offspring with increased childhood weight gain.
• Metformin crosses the placenta.

41. • ADA recommends against metformin in pregnancies complicated by
hypertension, preeclampsia, or otherwise at risk for intra uterine
growth restriction (IUGR).
• ADA also cites a risk for acidosis and IUGR in the setting of
placental insufficiency with metformin use.
• Metformin in GDM is initiated at 500 mg once or twice daily with
food and adjusted based on tolerance to a maximal daily dose of
2500 mg.
• Metformin should not be used in renal insufficiency and should be
held in the event of major illness or surgery.
• Glucose should be closely monitored as failure of metformin is
common

42. Glyburide
• The sulfonylurea glyburide has been studied in pregnancy and offers the convenience of an
inexpensive oral therapy.
• Despite guideline preference for insulin from ACOG and ADA, glyburide use has increased.
According to studies of registry data, glyburide use in pregnancy surpasses insulin in the
United States.
• Glyburide crosses the placenta.
• Long-term outcome data in offspring of women who used glyburide through pregnancy is
lacking
• Glyburide in GDM is initiated at low doses, 1.25–2.5 mg daily, and titrated for effect to a
maximum dose of 10 mg twice daily.
• Hypoglycemia is reduced by dosing glyburide 1 hour prior to meals.
• Patients treated with glyburide should be educated on hypoglycemia recognition and
management.
• Treatment failure with the need for pro gression to insulin therapy occurred in 6–18% of
women in various trials

43. MANAGEMENT DURING LABOUR
• HIGH RISK CONSENT .
• ON EVENING PRIOR TO INDUCTION INSULIN DOSE AND MEAL TO BE TAKEN.
• MORNING DOSE OF INSULIN OMITTED AND DO FBS. AIM 72 TO 126 MG/DL.
• SECURE TWO IV LINE.
• IVF NS 100-125 ML/ HR.
• DEXTROSE INSULIN NEUTRILISING DRIP .
• 50 UNITS OF REGULAR INSULIN IN 50 ML NS. DOSE ADJUSTED ACCORDING TO
GLUCOSE LEVEL.
• MEASURE GLUCOSE LEVEL hourly.
• With active labour or rbs >70 mg/dl 5% dextrose 100-150ml/hr with target
blood glucose of 100 mg/dl.

44. Postpartum Management in Diabetes

45. Gdm mother
• Immediate postpartum care in women with GDM is not different
from women without gdm but these women are at risk of
developing of type 2 diabetes mellitus in 15 to 25 years
• Maternal glucose levels usually return to normal after delivery .
Nevertheless, fasting & postprandial blood sugar is performed on
3 rd day of delivery
• Subsequently, ANM to perform 75 g GTT at 6 weeks postpartum
to evaluate glycemic status of woman.

46. Normal cut off values
• Fasting plasma glucose: ≥ 126 mg/dl
• 75 g OGTT 2 hour plasma glucose
Normal: < 140 mg/dl
IGT: 140-199mg/dl
Diabetes: ≥ 200 mg/dl
• Test normal: Woman is counselled about lifestyle modifications, weight
monitoring & exercise.
• Test positive: Woman advised to consult a physician.

47. Fifth International Workshop-Conference: Metabolic
Assessments Recommended After Pregnancy with Gestational
Diabetes

48. Pre-conception care & counselling
• It is more important because recurrent gestational diabetes rate was 48%
• Woman with h/o GDM to be counselled about BMI & Plasma glucose
estimation before next pregnancy
• Desired Plasma glucose levels:
• Fast blood sugar level. - <100 mg/dl
• Postprandial blood sugar level - < 140 mg /dl
• Counselled to consult obstetrician as soon as she misses her period
.

49. Overt diabetes mellitus mother
• Often, many diabetic women may require virtually no insulin for the first
24 hours or more postpartum.
• Subsequently, insulin requirements may fluctuate markedly during the
next few days.
• Infection must be promptly detected and treated.
• When appropriate, oral agents can be restarted.
• For type 2 diabetic women who will be transitioned to oral agents, this can
be done on post op day1

50. Contraception in GDM
• Barrier methods are safe
• Low dose combined oc pills , injectable progestogens and
intrauterine devices can all be safely used

51. Breastfeeding , medicines titration in GDM & overt
dm mother
• Explain to women with insulin-treated pre-existing diabetes that they are
at increased risk of hypoglycaemia in the postnatal period (especially
when breastfeeding), and advise them to have a meal or snack available
before or during feeds
• Women with pre-existing type 2 diabetes who are breastfeeding can
resume or continue metformin immediately after birth, but should avoid
other oral blood glucose-lowering therapy while breastfeeding.
• Women with diabetes who are breastfeeding should continue to avoid
any medicines for their diabetes complications that were stopped for
safety reasons when they started planning the pregnancy.

52. Contraception in overt diabetes mother
• Barrier contraception is safe
• Progesterone in the hormonal contraception mau increase insulin
resistance but injectable progestogens can be used with caution in
well controlled diabetics
• Use of oc pills is contraindicated in women with cardiovascular
problems but not without these problems
• Intrauterine devices should be used in women with low risk of
sexually transmitted diseases as any infection can place her at risk for
septicaemia
• Diabetic women should be counselled to have their children early as
vascular complications are like with increasing age
• Sterilisation is best option who completed their family

53. POSTPARTUM SELF-CARE AND FOLLOW-UP FOR WOMEN
WITH PREEXISTING DIABETES
• Healthy eating
• Staying healthy
• Monitoring blood glucose
• Taking medication properly needed
• Problem solving
• Reducing risks
• Healthy coping

54. Reference
• Williams obstetrics,26 th edition ,chapter 60, p 2887
• 2015_CDAPP Sweet success Guidelines for care, California
department of public health ,p 24-26
• NHM guidelines for diagnosis & management of diabetes p.43 -46
• NICE guidelines for diagnosis & management of diabetes mellitus
(2015)P.42

55. Thank you