this presentation is mainly about gestational diabetes i also gave few informations regarding pregestational diabetes

1. Diabetes & Pregnancy
Dec.23.2013

2. • Gestational diabetes mellitus is
defined as glucose intolerance of
variable degree with onset or first
recognition during pregnancy

3. • Abnormal
maternal
glucose
regulation occurs in 3-10% of
pregnancies.
• Gestational
diabetes
mellitus
accounts for 90% of cases of diabetes
mellitus
in
pregnancy,
while
preexisting type 2 diabetes accounts
for 8% of such cases.

4. Maternal-Fetal Metabolism in Normal
Pregnancy
• Each meal sets in motion a complex series of
hormonal actions, including a rise in blood glucose
and the secondary secretion of pancreatic insulin,
glucagon,
somatomedins,
and
adrenal
catecholamines. These adjustments ensure that an ample, but not
excessive, supply of glucose is available to the mother and fetus.
• pregnant
women
tend
to
develop
hypoglycemia (plasma glucose mean = 65-75
mg/dL) between meals and during sleep.

5. • Levels of placental steroid and peptide
hormones (eg, estrogens, progesterone,
and chorionic somatomammotropin)
rise linearly throughout the second and
third trimesters.
• By the third trimester, 24-hour mean
insulin levels are 50% higher than in the
nonpregnant state.

6. Maternal-Fetal Metabolism in
Diabetes
• the maternal pancreatic insulin
response is inadequate, maternal and,
then, fetal hyperglycemia results.
• The energy expenditure associated with
the conversion of excess glucose into fat
causes depletion in fetal oxygen levels.

8. Maternal Complications
• Chronic hypertension
• Pre-eclampsia
• Diabetic ketoacidosis
• Maternal hypoglycemia
• Maternal trauma
• Higher C Section rate
• Retinal disease/renal disease not affected significantly
by pregnancy
• 50% lifetime risk in developing Type II DM
• Recurrence risk of GDM is 30-50%

9. • Hypertensive disorders are a major complication of
women with diabetes who become pregnant.
• Approximately 10% to 20% of women with
diabetes will experience hypertensive disease
related to pregnancy.
• This percentage is increased in women with
preexisting renal dysfunction; as 40% of women
with mild preexisting nephropathy and nearly 50%
with significant disease.

10. • women with diabetic retinopathy and chronic
hypertension experience rates of preeclampsia as
high as 60%.
• Often times it is hypertension and not
diabetes which leads to morbidity and
subsequent iatrogenic preterm delivery.

11. Fetal effects
• higher rates of fetal wastage which appears to be
related to the degree of glycemic control, . This
includes higher rates of first-trimester losses as
well as increased rates of stillbirth in later
trimesters.
• Fetal overgrowth or macrosomia is commonly
associated with poor maternal glycemic control.
• . Women with underlying vascular and/or renal
disease experience increased rates of fetal
growth restriction.

12. • Episodic fetal hypoxia leads to increased
catecholamines causing:
–Fetal hypertension
–Cardiac remodelling and hypertrophy
–Increased erythropoietin, RBC’s, hematocrit
–Poor fetal circulation and hyperbilirubinemia
–Stillbirth

13. Fetal macrosomia is
associated with
increased rates of
maternal and
neonatal birth trauma
and higher rates of
neonatal ICU
admissions.

14. Babies born to mothers with
suboptimal glycemic control
experience increased rates
of congenital anomalies.

15. Preexisting Diabetes
Congenital anomalies
CVS
:ASD/VSD, CoA
:Transposition,
:Cardiomegaly
CNS
:Anencephaly,
:NTD,
:Microcephaly
GI :duodenal atresia,
anorectal atresia, situs inversus
GU :renal agenesis
:Polycystic kidneys
MSK
:caudal regression

16. Neonatal Effects for All Diabetic Pregnancies:
• Polycythemia and hyperviscosity
• Neonatal hypoglycaemia
• Neonatal hypocalcaemia, hypomagnesaemia
• Hyperbilirubinemia
• Hypertrophic and congestive cardiomyopathy
• RDS
• Childhood impaired glucose tolerance
Keep in mind that just because your patient
have
GDM it does not mean that these
problems will occur.

17. •Infants of mothers with preexisting
diabetes mellitus experience double
the risk of serious injury at birth,
triple the likelihood of cesarean
delivery, and quadruple the incidence
of newborn intensive care unit (NICU)
admission.

18. PRINCIPLE DANGERS
GESTATIONAL DIABETES:
Fetal hyperinsulinemia
PREGESTATIONAL DIABETES:
Fetal Anomalies

19. Risk Factors For Gestational Diabetes
• maternal age >30
• BMI >25
• Family history
• Glucosuria
• PCOS
• Prior GDM
• prior macrosomia
• previous unexplained stillbirth
• ethnic group: Hispanic, Black, Asians
Low risk woman must not have any positive risk factor.

20. Gestational Diabetes Screening
• Its performed between 24-28 weeks of gestation.
• no need to fast.
• screen at 1st prenatal visit if hx of previous GDM.
• screen earlier (12-24 weeks ) in high risk groups.

21. Gestational Diabetes Screening
Universal screening is advisable.
• 1 hour 50 gm glucose load (GCT)
• Venous plasma glucose cut-offs
• 140 mg/dl
• 130 mg/dl

22. Diagnosis of Gestational Diabetes
Three Hour 100 gm glucose tolerance test (GTT)
Two abnormal values required for the diagnosis of gestational
diabetes

23. NDDG
Carpentar and Coustan
FBS
105
FBS
95
1 hour
190
1 hour
180
2 hour
165
2 hour
155
3 hour
145
3 hour
140

25. Treatment Plan for GDM
• Knowing your blood sugar (glucose) level and keeping it under
control
• Eating a healthy diet, as outlined by your health care provider
• Getting regular, moderate physical activity
• Maintaining a healthy weight gain
• Keeping daily records of your diet, physical activity, and glucose
levels

26. • Avoidance of large meals with high percentage of simple
carbohydrates
• Three small meals with three snacks are preferred
• Low glycemic index foods release calories from the gut slowly
and improve metabolic control
• Caloric content:
– 35 calories/Kg Ideal body
– No less than 1800 calories and no more than 2800 calories
– “Eyeball Technique”
- Small patient
1800 calories
- Medium patient
2200 calories
- Large patient
2400 calorie

28. Role of physical activity
• Women with gestational diabetes often need
regular, moderate physical activity to help
control their blood sugar levels by allowing
insulin to work better.
Caution
• Examples include:
• Walking
• Prenatal aerobics classes
• Swimming
• However, a consultation and approval by
a health care provider is needed before
beginning any physical activity during
pregnancy.
28
Keep in mind that
it may take 2 to
4 weeks before
physical activity
has an effect on
blood sugar
levels2006
PBRC .

29. Know your blood sugar level
& keep it under control

30. • Use insulin in patients with gestational diabetes
to achieve optimal glycemic control.
• Adjust insulin doses to achieve fasting whole-blood
glucose levels of 70 to 100 mg/dL and 2-hour
postprandial levels of <140 mg/dL.

31. Gestational Diabetes
INSULIN
If persistent hyperglycemia
after one week of diet
control proceed to insulin
• 6-14 weeks 0.5u/kg/d
• 14-26 weeks 0.7u/kg/d
• 26-36 weeks 0.9u/kg/d
• 36-40weeks 1 u /kg/d

32. Know your blood sugar level
& keep it under control
•
You may have to test four times a day:
1.
2.
3.
4.
•
In the morning before eating breakfast, referred to as the Fasting glucose level
1 or 2 hours after breakfast
1 or 2 hours after lunch
1 or 2 hours after dinner
You may also have to test your glucose level before you go to bed at night.
This is referred to as your nighttime or nocturnal glucose test.

33. Maintain a healthy weight
• Healthy weight gain can refer to your
overall weight gain or your weekly rate
of weight gain.
• Some health care providers
focus only on overall gain or
only on weekly gain, but some
keep track of both types of
weight gain.
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34. Maintain a healthy weight
Weekly Rate Of Weight Gain
Time Frame
Expected Weight Gain
In the first trimester of
pregnancy
(the first 3 months)
Three to six pounds for the
During the second and third
trimester
(the last 6 months)
Between ½ and 1 pound each
week
If you gained too much weight
early in the pregnancy
Limit weight gain to ¾ of a
pound each week (3 pounds each
month) to help get your blood
sugar level under control
entire three months
A weight gain of two pounds or more each
week is considered high.
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35. Maintain a healthy weight
Things to Keep in Mind
1. A weekly rate of weight gain may go up and down
throughout the pregnancy.
2. A physician can assess whether weight gain is
appropriate or not.
3. A weight loss can be dangerous during any part of
the pregnancy, therefore any weight loss needs to be
reported to a health care provider right away.
4. If weight gain slows or stop, and does not increase
again after one-to-two weeks, it should be reported
to a health care provider immediately. Adjustments in
your treatment plan may be necessary.
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36. Know the symptoms of hypoglycemia
If your blood sugar level drops below
60 at any time, you have
hypoglycemia. This can be very
dangerous. Hypoglycemia is already
common in all women with gestational
diabetes, but for women taking insulin
for this condition, they are at greater
risk.

37. Why does low blood sugar occur?
• Too much exercise
• Skipping meals or snacks
• Delaying meals or snacks
• Not eating enough
• Too much insulin

38. Symptoms of Hypoglycemia
• Very hungry
* Report any abnormal
blood sugar level to your
• Very tired
health care provider right
• Shaky or trembling
away, in case a change
• Sweating or clamminess
in your treatment plan is
• Nervous
needed.
• Confused
• Like you’re going to pass out or faint
• Blurred vision

39. Hypoglycemia
Prevention Strategies
Consistent Monitoring

Before All Meals & Snacks
 Pre/Post Exercise
 Bedtime
 3 a.m. (occasionally)

40. Fetal Surveillance and Delivery
• Women requiring pharmacologic therapy
for GDM and those with additional
comorbid conditions who do not require
medical therapy should undergo increased
surveillance to improve neonatal outcome.
• Early ultrasound evaluations are useful to
provide accurate dating, and anatomy
surveys performed between 18 and 20
weeks gestation are important to evaluate
for congenital anomalies.

41. • Antenatal testing should begin no later than 32
weeks’ gestation in women requiring insulin or
oral hypoglycemic therapy.
• Women treated with diet therapy alone may
wait for testing to begin later.
• Antenatal surveillance should be carried out at
least weekly with fetal non-stress tests or
biophysical profile evaluations

42. Timing of Delivery
GDM Diet controlled
• Same as non diabetic
• Offer induction at 41 weeks
if undelivered
GDM on Insulin/Type II/Type I
• If suboptimal control, deliver following
confirmation of lung maturity if <39
Weeks.
• Otherwise deliver by 40 weeks
• Generally do not allow to go postterm

43. Intrapartum management
• ABSOLUTE REQUIREMENTS:
–Maintain plasma glucose 80 – 110 mg/dl with iv
dextrose and insulin infusion
• Hourly glucose monitoring
• Continuous fetal heart rate monitoring
• Continuous tocodynametry
• Manage labor as normal

44. HYPOGLYCEMIA DURING AN INSULIN
DRIP
For Glucose <60
• Turn off Insulin drip for 30 minutes
• Continue D5W (or D5LR) at 100 – 125
cc/hr
• Recheck Glucose after 30 minutes
• If blood glucose on recheck is still <60
• Give 25 ml of D50 IV (or 10-12 grams
glucose)
• Recheck Blood Glucose every 30 minutes
• Restart insulin when glucose >101 mg/dl

45. What should I do after delivery?
• Six weeks after your
baby is born, you should
have a blood test to find
out whether your blood
sugar level is back to
normal.
• Based on the results
you will fall into one of
the three categories:
If your category is…
Normal
Impaired Glucose Tolerance
Diabetic
You should…
Get checked for diabetes
every 3 years
Get checked for diabetes
every year and talk with your
health care provider to learn
about ways to lower your risk
for developing diabetes.
Work with your health care
provider in setting up a
treatment plan for your
diabetes.
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46. Pre-Pregnancy Management
• Preconceptional care
– Tight glucose control (HbA1c)
– Assessment and treatment of associated medical problems
- Hypertension,
- Renal disease,
- Retinal disease
- Heart disease
– Folic acid

47. • Stop all oral diabetic medication 3 months
before conception.
• Switch all women with pregestational
diabetes on oral diabetic treatments to
insulin before conception.
• Use insulin in all pregnancies requiring
medication for glucose control.
• Stop ACE inhibitor therapy and review the
patient's other medications before
conception.

50. Thank You