Hyperglycemia in pregnancy, also known as gestational diabetes, occurs when glucose tolerance is impaired during pregnancy. It is diagnosed through screening tests and affects 3-10% of pregnancies. Risk factors include obesity, family history of diabetes, and previous gestational diabetes. Treatment involves lifestyle modifications like diet, exercise, glucose monitoring as well as possible medication like insulin or metformin. High blood sugar levels during pregnancy can increase risks for complications in both mother and baby such as preeclampsia, preterm birth, and excessive fetal growth. Post-delivery, women with gestational diabetes have increased risk of developing type 2 diabetes.

1. Session 4.8:Hyperglycaemia in
Pregnancy
Module 4: Management of
Patient with Diabetes
Mellitus

2. Learning Objectives
• At the end of this session participants are
expected to be able to:
 Explain hyperglycaemia in pregnancy and
its pathophysiology
 Identify risk factors for hyperglycaemia in
pregnancy
 Recognize clinical presentation of
hyperglycaemia in pregnancy
 Screen and diagnose hyperglycaemia in
pregnancy

3. Learning Objectives (2)
 Provide appropriate pharmacological and
non-pharmacological treatment
 Identify effects of hyperglycaemia in
pregnancy on the baby
 Provide health education and adherence
counselling for hyperglycaemia in pregnancy
• Conduct regular prenatal, natal and postnatal
follow up of the mother and the baby
• Prevent hyperglycaemia in pregnancy

4. Activity: Brainstorming
• What is hyperglycaemia in pregnancy?
• What is the pathophysiology of
hyperglycaemia in pregnancy?

5. Hyperglycemia in Pregnancy
 Hyperglycaemia in pregnancy or Gestational
Diabetes Mellitus (GDM) is any degree of
glucose intolerance first recognized in
pregnancy
 Diabetes in pregnancy refers to those with pre-
existing diabetes, whether diagnosed or not
 The patients may have previously
undiagnosed diabetes mellitus diagnosed
coincidentally during pregnancy or
 may have developed diabetes during
pregnancy

6. Hyperglycemia in Pregnancy (2)
 Gestational diabetes:
 Affects 3-10% of pregnancies, depending on
the population studied
 Usually shows up in the middle of pregnancy
 Doctors most often test for it between 24 and
28 weeks of pregnancy
 Usually goes away after pregnancy, but it
may persist as type 2 diabetes
 Many women who have had gestational
diabetes will develop type 2 diabetes later

7. Pathophysiology
 The hallmark of GDM is increased insulin
resistance
 It is a normal phenomenon emerging in the
second trimester of pregnancy
 More insulin is needed to overcome this
resistance
 The production of insulin is about 1.5-2.5
times more than in a normal pregnancy
 is thought to secure glucose supply to the
growing foetus

8. Pathophysiology (2)
 Women with GDM have an insulin resistance
which cannot be compensated by increased
insulin production in the β-cells of the
pancreas
 This causes inappropriately elevated blood
sugar levels, hormones and to a lesser
extent increased fat deposits
 To a lesser extent increased fat deposits
seem to mediate the insulin resistance
during pregnancy

9. Pathophysiology (3)
 In untreated gestational diabetes the foetus is
exposed to consistently higher glucose levels
• This leads to increased foetal levels of
insulin
• The growth-stimulating effects of insulin can
lead to excessive growth and a large body
• After birth, the high glucose environment
disappears, leaving the newborn with
ongoing high insulin production and
susceptibility to low blood glucose levels
(hypoglycaemia)

10. Activity:Buzzing
• What are the risk factors for
hyperglycaemia in pregnancy?

11. Risk Factors for Hyperglycaemia in
Pregnancy
• Risk factors for developing gestational
diabetes include:
• A previous diagnosis of gestational
diabetes, impaired glucose tolerance, or
impaired fasting glycaemia
• Maternal age - a woman's risk increases
as she gets older than 35 years of age
• Being overweight, obese or severely
obese increases the risk by a factor 2.1,
3.6 and 8.6, respectively

12. Risk Factors for Hyperglycaemia in
Pregnancy (2)
• A previous pregnancy which resulted in a
child with a birth weight >4kg
• Previous poor obstetric history
• Polycystic ovarian syndrome
• A relative with type 2 diabetes
• Africans and South Asians have a higher
risk
 About 40-60% of women with GDM have no
demonstrable risk factor; for this reason
many advocate to screen all women

13. Activity: Buzzing
• What is the clinical presentation of
hyperglycaemia in pregnancy?

14. Clinical Presentation
• Women with GDM exhibit no symptoms
(another reason for universal screening)
• It is most commonly diagnosed by
screening during pregnancy
• Some women may demonstrate increased
thirst, increased urination, fatigue, nausea
and vomiting, bladder infection, yeast
infections and blurred vision

15. Clinical Presentation
• Typically, women with GDM exhibit no
symptoms (another reason for universal
screening) and it is most commonly
diagnosed by screening during pregnancy.
• Some women may demonstrate increased
thirst, increased urination, fatigue, nausea
and vomiting, bladder infection, yeast
infections and blurred vision

16. Activity: Buzzing
• How do you screen and diagnose
hyperglycaemia in pregnancy?

17. Screening at First Antenatal Visit
• Perform screening in all women at the first
antenatal clinic attendance if they have:
• BMI > 25 kg/m2
• Previous history of GDM
• Previous big baby
• Poor obstetric history
• Family history of DM
• Known impaired glucose
tolerance/impaired fasting glucose
• Grand multipara
• Glycosuria

18. Screening Later in Pregnancy
• Routinely screen for GDM at 24-28 weeks
• All pregnant women over 30 years
• Pregnant women below 30 years if they
present with the above risk factors
• All women with risk factors should have a
75 g OGTT
• A fasting plasma glucose is recommended
in low-risk women

19. Diagnosis
• Normal blood glucose values:
• Fasting < 5.6 mmol/l
• 2-hour postprandial (2hr after a meal) <7.8
mmol/l
• Random glucose test <6.1 mmol/l
• Women in early pregnancy with the following
values which are diagnostic of diabetes should
be treated as having pre-existing diabetes
• HbA1c ≥6.5% or
• Fasting blood glucose ≥7.0 mmol/l or
• Two hour blood glucose ≥11.1 mmol/l

20. Diagnosis (2)
 Women with the following values should be
assessed to determine the need for
immediate home glucose monitoring
HbA1c 6.0–6.4%, or
Fasting glucose 5.1– 6.9 mmol/l, or
Two hour glucose 8.6–11.0 mmol/l
 If the diagnosis remains unclear, assess for
gestational diabetes by 75 g oral glucose
tolerance test (OGTT) at 24–28 weeks

21. Urinary Glucose Testing
• Increased glomerular filtration rates during
pregnancy contribute to some 50% of women
having glucose in their urine on dipstick tests
at some point during their pregnancy
• The sensitivity of glucosuria for GDM in the
first 2 trimesters is only around 10% and the
positive predictive value is around 20%

22. Activity: Brainstorming
• What are the effects of diabetes on the
health of the pregnant woman and the
baby?

23. Effects of Hyperglycaemia on the
Health of Pregnant Woman
• A woman with gestational diabetes whose
blood sugar stays high has an increased
chance of:
• Preeclampsia (high blood pressure, protein
in urine, increased swelling)
• Preterm birth (baby born before 37 weeks)
• Caesarean section

24. Effects of Hyperglycaemia on the
Health of Pregnant Woman (2)
• Blood sugar which remains high in a woman
with pre-existing diabetes can trigger or
worsen certain health problems, including:
• High blood pressure, Preeclampsia
• Kidney, nerve, heart disease, blindness
• Miscarriage, Preterm birth, or Stillbirth
• Deliveries using forceps, ventouse or
caesarean section or problems during
vaginal delivery (such as shoulder
dystocia)

25. Effect of Diabetes on the Child
• Blood sugar that remains high in a pregnant
woman with diabetes can cause the baby to
have health problems:
• Birth defects, especially of the brain, spine,
and heart
• Increased birth weight, if unmanaged (may
affect 12% of normal women compared to
20% of patients with GDM)
• Intrauterine growth retardation, if
managed

26. Effect of Diabetes on the Child (2)
• Nerve damage to the shoulder during delivery
• Low blood sugar after birth (may require
admission to a neonatal care unit)
• Jaundice
• Dysmature babies prone to respiratory
distress syndrome due to incomplete lung
maturation and impaired surfactant synthesis
• Off springs of GDM mothers are prone to
developing childhood overweight/obesity,
and/or type 2 diabetes later in life

27. Activity: Brainstorming
• What are the non-pharmacological and
pharmacological treatment of GDM?

28. Non-Pharmacological Treatments
• All women intending to become pregnant should:
• Be encouraged to achieve excellent glycaemic
control, monitoring both fasting and
postprandial glucose
• Take high-dose (5mg) pre-pregnancy folate
supplementation, up to 12 weeks’ gestation
• Have an eye exam and be informed of the risk
of developing and/or progression of retinopathy
• Have a kidney assessment (random urine
albumin/creatinine ratio and serum creatinine)
and referred if urine protein ≥ 1g

29. Non-Pharmacological Treatments (2)
 A combined healthcare team (obstetrician,
diabetologist or internist, diabetes educator,
paediatrician/neonatologist) is required
 Review SMBG, blood pressure and urine
protein and ketones by dipstick at each visit
 Eye examination in each trimester

30. Non-Pharmacological Treatments (3)
• Self-monitoring can be accomplished using
glucose meters
• Target ranges advised by the Australian
Diabetes in Pregnancy Society are as follows:
• fasting capillary blood glucose 3.5 - 5.5
mmol/L
• 1 hour postprandial capillary blood glucose
<8.0 mmol/L
• 2 hour postprandial blood glucose <6.7
mmol/L

31. Non-Pharmacological Treatments (4)
• Lifestyle management is the preferred means
of managing gestational diabetes.
• Diet is based on the principles of optimal
nutrition and controlled weight gain
• Diet needs to provide sufficient calories for
pregnancy with the exclusion of simple
carbohydrates so as to avoid peaks in blood
sugar levels

32. Non-Pharmacological Treatments (5)
• Spread carbohydrate intake over meals and
snacks throughout the day
• Use slow-release carbohydrate sources
• Ingesting more fiber in foods with whole grains
• Fruit and vegetables can also reduce the risk
of gestational diabetes
• Since insulin resistance is highest in
mornings, breakfast carbohydrates need to be
restricted more

33. Non-Pharmacological Treatments (6)
• Exercise can be helpful in lowering BG levels
• Regular moderately intense physical
exercise is advised
• The most acceptable form of exercise for
most women is walking in their normal
daily routine

34. Pharmacological Treatments
• Glucose-lowering therapy should be
considered in addition to diet where two or
more values per fortnight are:
• Fasting or preprandial ≥5.5 mmol/L, or
• 2 hours postprandial ≥7 mmol/L at ≤35
weeks
• 2 hours postprandial ≥8 mmol/L at >35
weeks
• Postprandial values are >9 mmol/L

35. Pharmacological Treatments (2)
• When pharmacologic treatment is indicated:
• Insulin and oral medications (metformin or
glibenclamide) are equivalent in efficacy,
and either can be an appropriate first-line
therapy
• Metformin (alone or combined with
insulin) 500 mg twice daily, maximum
2000mg in 2–3 doses or
• Glibenclamide 2.5mg once daily to a
maximum of 10mg daily

36. Pharmacological Treatments (3)
• Insulin
• The rapid-acting insulin analogs
• lower postprandial blood glucose
• decrease the risk of nocturnal
hypoglycemia
• Patients on lispro and aspart prior to
conception may continue them during
pregnancy

37. Pharmacological Treatments (4)
• Patients on regular insulin may be switched
to lispro or aspart if
• 1–hour postprandial blood glucose levels
are above target and/or
• the patient is also experiencing pre-meal or
nocturnal hypoglycemia

38. Health Education and Adherence
Counselling
• Plan for the pregnancy
• Follow up with the doctor regularly
• Monitor blood sugar often
• Control and treat low blood sugar quickly
• Continue to exercise and eat a healthy diet
after pregnancy to prevent or delay getting
type 2 diabetes

39. Postnatal Follow Up
• Women with gestational diabetes should be
screened
• At 6–12 weeks postnatal to ensure return to
normal glucose tolerance
• Thereafter, a 1–2 yearly follow up screening
• Metformin and glibenclamide may be used
even if a woman is breastfeeding
• Encourage to breastfeed – it possibly reduces
the risk of diabetes for both mother and child
• If retinopathy, check eyes 1 year postpartum

40. Prognosis
• Gestational diabetes generally resolves once
the baby is born
• The chances of developing GDM in a second
pregnancy are between 30 and 84%,
depending on ethnic background
• Risk of recurrence is high if
• If another pregnancy within 1 year
• In women who needed insulin treatment,
women with more than two previous
pregnancies, and women who were obese

41. Prognosis (2)
• Women requiring insulin to manage
gestational diabetes have a 50% risk of
developing diabetes within the next five years
• Children of women with GDM have
• Increased risk for childhood and adult
obesity
• Increased risk of glucose intolerance and
type 2 diabetes later in life
• This risk relates to increased maternal
glucose values

42. Key Points
 Gestational Diabetes Mellitus is any degree
of glucose intolerance first recognized in
pregnancy
 Diabetes in pregnancy refers to those with
pre-existing diabetes, whether diagnosed or
not
 diagnosed coincidentally during pregnancy
or
 may have developed diabetes during
pregnancy

43. Key Points (2)
 Gestational diabetes affects 3-10% of
pregnancies, depending on the population
 Risk factors include a family history of
diabetes mellitus
 Treatment includes non-pharmacological and
pharmacological
 Health education has to be on taking
medication and monitoring of blood glucose
 Monitoring has to include the baby to prevent
complications

44. Session Evaluation
 What is the clinical presentation of
hyperglycaemia in pregnancy?
 What are the pharmacological and non-
pharmacological treatment?
 What are the effects of hyperglycaemia in
pregnancy on the baby?
 How can you prevent diabetes during
pregnancy?