Download DR FARAH DEEBA NASRULLAH ASST PROF DEPT OF OBGYN

DR FARAH DEEBA NASRULLAH
ASST PROF DEPT OF OBGYN UNIT II
CHK/DUHS
• Pregnancy is a state of insulin resistance & relative
glucose intolerance
• This is due to placental production of anti-insulin
hormones : hPL, cotisol, and glucagon
• FBS 
• Postprandial glucose ↑ ↑
• Insulin production ↑ ↑ 2 folds in N women
• Insulin requirements ↑ ↑ in diabetic women
•  renal threshold for glucose  glycosuria
Pregnancy may be complicated by diabetes
in two distinct forms:
 Gestational diabetes mellitus (GDM) is defined as
glucose intolerance of varying severity with onset or
first recognition during pregnancy. This constitutes 90%
of women with pregnancies complicated by diabetes.
The most important perinatal complication in this group
is macrosomia with resulting birth trauma. More than
50% women ultimately develop diabetes in the next 20
years and majority of them are obese.
 Pre-gestational diabetes is diabetes that antedates
pregnancy. Pregnancies complicated by pregestational diabetes, type-1 or type-2, carry an
additional risk to both mother and fetus beyond the
effects on fetal growth and congenital anomalies.
• Pregestational diabetes: A woman with known
diabetes who conceives while on treatment with diet,
oral hypoglycemic agents or insulin.
Type 1 DM, Type 2 DM, Secondary DM
• Gestational diabetes mellitus is defined as glucose
intolerance of variable degree with onset or first
recognition during pregnancy.
Risk Factors for gestational diabetes screening
1. Strong family history of diabetes
2. History of birth to large infants (>4 kg; 8 lbs 13 oz)
3. History of recurrent fetal loss
4. Persistent glycosuria
5. Age > 25 years
6. Past history of glucose intolerance or diabetes in a
previous pregnancy
Obesity; overweight women (>15% of non-pregnant ideal
body weight)
8. Ethnic group with a high prevalence of diabetes (e.g. Pima
Indians, Asians, Hispanic)
9. History of stillbirth, unexplained neonatal death, congenital
malformations, prematurity.
10. History of pre-eclampsia or polyhydraminos
11. Chronic hypertension
12. Recurrent severe candidiasis or urinary tract infection
13. History of traumatic delivery with an associated
neurological disorder in the baby
Risk Assessment
Low risk: no screening
Average risk: at 24-28 weeks
High risk: as soon as possible
Screening is usually initiated b/w24th and 28th weeks of
pregnancy or earlier in the presence of risk factors .
Low risk for GDM
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Age <25 years
normal BMI before pregnancy
Ethnic group with a low prevalence of GDM
No H/O diabetes in first-degree relatives
No H/O abnormal glucose tolerance
No H/O obstetric complication
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HIGH RISK FOR GDM
Marked obesity
Prior GDM
Glycosuria
Strong family history
Ethnic group with high diabetes prevalence
Screening test
 Glucose Challenge Test (GCT): best screening test
for gestational diabetes. It includes measurement of
plasma glucose 1 hour after ingesting 50 g of glucose
without dietary preparation between 24-28 weeks of
gestation.
cut-off value > 140 mg/dl identifies 80% women with GDM
cut-off value > 130 mg/dl identifies 90% women with GDM
Women with elevated GCT values require a diagnostic test
(OGTT)
Oral Glucose Tolerance Test (OGTT): After an overnight
fast measurement of plasma glucose after ingesting 100 g
of glucose.
Timing of
National
Carpenter and
measurement Diabetes Data Coustan (CC)
Group (1979)
1982
Fasting
105 mg/dl
95 mg/dl
1 hour
190 mg/dl
180 mg/dl
2 hour
165 mg/dl
155 mg/dl
3 hour
145 mg/dl
140 mg/dl
• Women in whom the criteria of DM are met in
pregnancy  include a gp of diabetics who were
undiagnosed before pregnancy
• FBS  > 7 mmol/L on 2 occasions
• Or
• RBS  > 11.1 mmol/L on 2 occasions
• Borderline cases  GTT  DM is Dx if FBS  > 7
mmol/L or 2 hrs > 11.1 mmol/L
• Impaired glucose tolerance  2hrs G 8-11 mmol/L with
a N FBS
Effects of GDM on the fetus
 Congenital abnormalities
 Neonatal hypoglycemia
 Macrosmia (big baby syndrome > 4 Kg or >8 lb 13 oz)
 Jaundice
 Polycythemia / hyperviscosity syndrome
 Hypocalcemia, hypomagnesemia
 Birth trauma (due to macrosmia and shoulder
dystocia)
 Prematurity
 Hyaline membrane disease
 Apnea and bradycardia
The risk of fetal anomalies is not increased in GDM patients.
However, the risks of unexplained still births (during the last
4-8 weeks of gestation) are similar to pre-gestational
diabetes.
Effects of GDM on neonates
Hypoglycemia
Hypocalcemia
Hyperbilirubinemia
RDS
Cardiac Hypertrophy
Long term effects on cognitive development
Macrosomic infant
Macrosomia (large for gestational age or big baby
syndrome)
(birth weight >90% percentile for gestational age)
persistent maternal hyperglycemia leadS to fetal
hyperglycemia and prolonged fetal hyperinsulinism. This
stimulates excessive somatic growth mediated by insulin-like
growth factors (IGFs). Macrosomia affects all organs except
the brain.
• Cardiac (most common): transposition of great vessels,
Ventricular septal defect, Atrial septal defect
• Central nervous system (7.2%): spina bifida,
Anencephaly, hydrocephalus
• Skeletal: cleft lip/palate, caudal regression syndrome
• Genitourinary tract: ureteric duplication
• Gastrointestinal: anorectal atresia
• Renal agenesis, Duplex ureters, Cystic Kidney
• Situs inversus
Poor glycemic control at time of conception: risk
Caudal regression syndrome
factor
(abnormal development of lower spine)
Effects of GDM on the
mother
 Pre-eclampsia: 10-25% of all pregnant women with GDM
 Infections: high incidence of chorioamnionitis and
postpartum endometritis
 Postpartum bleeding: caused by uterine overdistension
 Cesarian section more common due to fetal macrosmia and
cephalo-pelvic disproportion
 Weight gain
 Hypertension
 Miscarriages
 Third trimester fetal deaths
 Long term risk of type-2 diabetes mellitus
Effect of pregnancy on diabetes
 More insulin is necessary to achieve metabolic control
 Progression of retinopathy: esp. severe proliferative
retinopathy
 Progression of nephropathy: especially if renal failure +
 Increased risk of Coronary artery disease, and a high
risk of maternal death in post MI patients
 Cardiomyopathy
 Instruct mother about maternal and fetal complications
 Medical Nutrition therapy
 Glycemic monitoring: teach mother about self
monitored blood glucose measurement and glycemic
targets
 Pre-conception counseling
 Fetal monitoring: ultrasound
 Planning on delivery
 Long term risks
Glycemic control targets
 Tight glycemic control can reduce fetal risk. But, strict
glycemic control p increaseds risk of hypoglycemic
events and the fetus at risk of being small-forgestational age.
 American Diabetes Association Recommendations:
Fasting whole blood
<95 mg/dl
glucose
1 hr postprandial blood
glucose
<140 mg/dl
2 hr postprandial blood
glucose
<120 mg/dl
in type-1 patients with pregnancy
Fasting blood sugar
Macrosomia
>105 mg/dl
28.6 %
95-105
10%
<95 mg/dl
3%
 4 times/day minimum, fasting and 1 to 2 hours after start
of meals
 Maintain record
 Calibrate the glucometer frequently
Medical Nutrition and Exercise therapy
 provide necessary nutrients for mother and fetus to
ensure adequate gestational weight gain
 control glucose levels
 prevent starvation ketosis
 aerobic exercise, exercise that does not stress the
trunk
Current weight in Daily caloric
Recommended
relation to ideal intake
pregnancy
body weight
(kcal/kg)
weight gain (kg)
<80-90%
36-40
28-40
80-120% (ideal) 30
25-35
120-150%
24
15-25
>150%
12-18
15-25
• Approximately 30 kcal/kg of ideal body weight
• > 40-45% should be carbohydrates
• 6-7 meals daily (3 meals, 3-4 snacks). Bed time snack
to prevent ketosis
• Calories guided by fetal well being/maternal weight
gain/blood sugars/ ketones
• Energy requirements during the first 6 months of
lactation require an additional 200 calories above the
pregnancy meal plan
Insulin in GDM
Insulin used if fasting blood glucose >105 mg/dl or 1 hr
postprandial blood glucose >120 mg / dl on a diet
 Use basal bolus regime or pre-mixed insulin
 Short acting insulins (e.g. Lispro and Aspart) can be used to
achieve postprandial control
Insulin requirements increase by 50% from 20-24 weeks to 30-32
weeks, after which insulin needs often stabilize.
Oral Hypoglycemic agents
Glyburide is a clinically effective alternative to insulin in GDM
(Langer et al. 2000)
Metformin may be effective in GDM (Ratner et al., 2008;
Coustan, 2007)
Preconception counseling
All women with pre-existing type-1 or type-2 diabetes, when
planning on pregnancy, should receive pre-conception
counseling so that they understand the importance of
achieving near-normal blood glucose before conception to
reduce the risk of congenital malformations and
spontaneous miscarriage.
Assess maternal and fetal risk
 Mother should learn self-administration of insulin and
regular monitoring of blood glucose.
 Target: HbA1c < 7%
 Emphasize diet and exercise
 Folic acid supplementation: 5 mg/day
 Ensure no transmissible diseases: HBsAg, HIV, rubella
 Try and achieve normal body weight: diet/exercise
 Stop drugs: oral hypoglycemic drugs, ACE inhibitors,
beta blockers and potentially teratogenic drugs
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Medications
Pre-pregnancy weight
Weight gain
Edema
Pallor
Thyroid enlargement
Blood pressure
Fundal height
Laboratory parameters to be
monitored at antenatal visit
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Hemoglobin
Blood Sugar
HbA1C
Urine microscopy and albumin
 Baseline ultrasound : fetal size
 Ultrasound evaluation of neural tube defects and other congenital
malformations should begin by 15-21 weeks of
 At 18-22 weeks: fetal anatomic survey, major malformations
 At 20-22 weeks: fetal echocardiogram for cardiac defects
 — At 26 weeks onwards: ultrasound to evaluate fetal growth and
amniotic fluid volume Third trimester: Fetal surveillance to reduce
risk of still birth: include non-stress test, biophysical profile, maternal
monitoring of fetal activity, frequent USG for accelerated growth
 abdominal: head circumference
 Small risk of late intra-uterine death even with good glycemic
control
 Delivery usually at 38 weeks
 Beyond 38 weeks, increased risk of intrauterine death without an
increase in RDS
Management of labor and delivery
 Vaginal delivery: preferred
 Cesarian section only for routine obstetric indication
GDM alone is not an indication !
 > 4.5 Kg fetus: Cesarean delivery may reduce the likelihood of
brachial plexus injury in the infant
 Unfavorable condition of the cervix is a problem
 Maintain euglycemia during labor
 Maternal hyperglycemia in labor: fetal hyperinsulinemia and worsen
fetal acidosis
 Maintain sugars: 80-120 mg/dl (capillary: 70-110mg/dl )
 Feed patient the routine GDM diet
 Maintain basal glucose requirements
 Monitor sugars 1-4 hrly intervals during labour
 Give insulin only if blood sugar >120 mg/dl
GLYCEMIC MANAGEMENT DURING LABOUR
 Later stages of labour: start dextrose to maintain basal nutritional
requirements: 150-200 ml/hr of 5% dextrose
 Elective Cesarian section: check fasting blood sugar; if within target
range no insulin is needed; start dextrose drip
 Continue hourly self monitored blood glucose
 Post delivery keep patients on dextrose-normal saline till fed
 No insulin unless sugars more than normal ( not GDM targets ! )
Post partum follow up
 Check blood sugars before discharge
 Breast feeding: helps in weight loss
 Lifestyle modification: exercise, weight reduction
 Oral glucose tolerance test at 6-12 weeks postpartum: classify
patients into normal/impaired glucose tolerance and diabetes
 Preconception counseling for next pregnancy
Increased risk of cardiovascular disease,future diabetes and dyslipidemia
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Immediate management of neonate
Hypoglycemia: 50 % of macrosomic infants
5–15 % optimally controlled GDM
Starts when the cord is clamped
Exaggerated insulin release secondary to pancreatic ß-cell
hyperplasia
Increased risk: blood glucose during labor and delivery exceeds 90
mg/dl
Anticipate and treat hypoglycemia in the infant
Hypoglycemia <40 mg/dl
Encourage early breast feeding
If symptomatic give a bolus of 2- 4 ml/kg, IV, 10% dextrose
Check after 30 minutes, start feeding
IV dextrose : 6-8 mg/kg/min infusion
Check for calcium, if seizure/irritability/RDS
Examine infant for other congenital abnormalities
 Increased risk of obesity and abnormal glucose tolerance due to
changes in fetal islet cell function
 Encourage breast feeding: less chance of obesity in later life
 Lifestyle modification
Conclusion
 Gestational diabetes is a common problem in worldwide
 Risk stratification and screening is essential in all pregnant women,
particularly those from ethnicities with increased risk
 Tight glycemic targets are required for optimal maternal and fetal
outcome
 Patient education is essential to meet targets
 Long term follow up of the mother and baby is essential
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