Nuredin

Mohammed(MRHN)
 INCIDENCE

 Affects2-3% of pregnancies
 The most common medical complication
of pregnancy
 90% are GDM

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 CLASSIFICATION

 PREGESTATIONAL

TYPE 1 : IDDM
TYPE 2: NIDDM
 GESTATIONAL

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 PHYSIOLOGIC CHANGE

 Pregnancy is characterized by insulin

resistance and hyperinsulinemia
 The resistance stems from placental
secretion of diabetogenic hormones
– Human placental lactogen
– Growth hormone
– Corticotropin-releasing hormone
– Progesterone
– Estrogen
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PREGESTATIONAL
DIABETES
 DIAGNOSIS

 FPG > 126 mg/dL (7.0 mmol/L)

 A two-hour value in a 75g OGTT (2-h PG)
> 200 mg/dL (11.1 mmol/L) or
 A random (or "casual") plasma glucose
concentration >200 mg/dL (11.1 mmol/L)
in the presence of symptoms
 This must be confirmed on a subsequent
day

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GESTATIONAL DIABETES
 DEFINITION

 Glucoseintolerance of variable degree

with onset or first recognition during
pregnancy

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 SCREENING
 At 24-28 weeks but earlier if there is high degree of suspicion
 Universal screening: All pregnant women
 Selective: based on risk factors
– Age >30 yrs
– Previous infant > 4 Kg
– History of GDM
– Family history Of diabetes
– Obesity
– Polyhydramnios
– Previous unexplained perinatal loss
– << birth of a malformed child
– Glycosuria
– Polycystic ovary syndrome
– Current use of glucocorticoids
9 – Personal birth weight of over 4.5kg
 SCREENING…

 SCREENING PROTOCOL
– 75 gm glucose is taken po after 8-14 hours of
fasting and diagnosed if
– FBG =92–125 mg/dL (5.1–6.9 mmol/L)
– If 1hr BGL = 180 mg/dL (10.0 mmol/L)
– 2hr BGL = 153–199 mg/dL (8.5–11.0 mmol/L)

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 COMPLICATIONS
 MATERNAL
– Abortion
– Pre-eclampsia
– Infection- wound, UTI ( 3-4X increased risk)
– Polyhydramnios
– APH & PPH
– DKA
– Retinopathy
– Nephropathy
– Peripheral neuropathy
– Hypo/ Hyper glycemia
– Increased risk of operative delivery
– Puerperal sepsis
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 COMPLICATIONS…

 FETAL & NEONATAL

– Fetal death
 Usually after 36 wks
 Usually In those having PE, poor glycemic control,
polyhydramnios & macrosomia
 Due to hypoxia & lactic acidemia

– Congenital anomaly
 Cardiac( most common)
 Neural tube defect
 Renal & GI

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 COMPLICATIONS…

 FETAL & NEONATAL…

– Macrosomia
– Birth trauma
– Shoulder dystocia- due to disproportionate growth
– Hypoglycemia
– RDS- due to reduced production of surfactant
– Hypo calcemia & hypo magnesemia
– Polycythemia & hyperbilirubinemia
– Diabetes in later life
– Cardiomyopathy

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 MGT of pregestational DM

PRECONCEPTION CARE
RX DM complication
Optimize thyroid hormones
Review current medication
Measure HbA1C

Target BGL
FBS=80-110mg/dl
2HR BGL<150mg/dl

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  Folicsuplimention/3month
 Counseling
 Diet
 Complication
 Effective contraception
 regular exercise and weight control

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 Pregnancy is not recommended if
ischemic heart disease
active proliferative retinopathy (untreated)
severe renal insufficiency
creatinine clearance 2.0 mg/dL or
heavy proteinuria (>2g/24hr.)
Hgb A1c >10%.

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 ANC of pregestational DM
Screening for medical complication
Baseline investigations (RFT, urine protein
level, RFT)
Follow up
oQ 2 – 3 weeks during the first 2TP
oQ1-2 weeks until 36 weeks
o weekly until delivery.
oU/S 1st,2nd and 3rd TP

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  Preclampsia prevention
 Blood Glucose Monitoring
 By combination of diet, exercise, and insulin
therapy

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 Target BGL
FBS= 95 mg/dL or less
 Premeal values of 100 mg/dL or less
 1-hour postprandial levels of 140 mg/dL or less
 2-hour postprandial values of 120 mg/dL or less.
During the night, glucose levels should not decrease to less than
60 mg/dL.
Hb A1C concentration no higher than 6%

NOTE
In resource poor settings FBS & 2hrs postprandial should be
checked at least twice weekly.

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 Dietary management
Total calories
30 Kcal/kg/day if ideal body weight
 24 Kcal/ Kg /Day if 20-25% above ideal weight,
12-18 Kcal/ Kg /Day if more than 50% above ideal body weight and
36-40 Kcal/ Kg /Day if more than 10% below ideal body weight].

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 Distribution of calories
Breakfast
The breakfast meal should be small (10% of total
calories)
Carbohydrate intake at breakfast is also limited since
insulin resistance is greatest in the morning.
Lunch: 30% of total calories, dinner: 30% of total
calories, snacks:30% of total calories are distributed, as
needed
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 Exercise
o Non strenuous exercise, 3 times per week for 30 – 60 minutes.
oUsing the upper body and walking appear to be more
appropriate.
oContraindications to exercise include PIH, PROM, preterm labor,
incompetent cervix, persistent 2nd or 3rd trimester bleeding and
IUGR.

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 INSULIN TERAPY
Starting insulin dose is 0.7-1.0 units/kg daily
A combination of short & intermediate acting
insulin is necessary to maintain glucose levels
Target BGL 70-130 mg/dl

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 MANAGEMENT …
 Insulin
– If FBG is > 105 mg/dl or 2hr BG is > 120 mg/dl
– Starting dose
 0.6u/Kg, 0.7u/Kg & 0.8u/Kg in the 1st , 2nd & 3rd trimester
– 2/3 in the morning & 1/3 in the evening
– For the morning
 2/3 intermediate acting & 1/3 short acting
– For the evening
 1/2 intermediate acting & 1/2 short acting
– Oral hypoglycemic agent is not recommended
 As it causes fetal & neonatal hypoglycemia
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 MANAGEMENT …

 Timing of delivery
– Depending on metabolic control & fetal
condition
– 38-40 wks
– Fetal monitoring especially for insulin
requiring
 Route of delivery
– C/S for macrosomia( wt > 4500g) and other
obstetric indications

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 MANAGEMENT …

 Labor
– Withhold morning insulin before an elective
induction or C/S
– Intrapartum 5% or 10% glucose & regular insulin
infusion at a rate of 0.5-2u/hr
 10u
regular insulin in 5%/10% DNS at a rate of 100-
125ml/hr
– Blood glucose measurement every 2 hrs

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 MANAGEMENT …

 Puerperium
– Honeymoon period with decreased insulin requirement
after delivery
– GDM patients usually don’t need insulin
– For pre-gestational diabetes 2/3 of the pre-pregnancy dose
or ½ of the present dose
– Blood glucose measurement every 6 hrs
– Breast feeding is encouraged
– 75g OGTT at 6th wks for GDM- diabetes diagnosed if
 FBS is > 126mg/dl or
 2hrs post challenge measurement is > 200mg/dl

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 MANAGEMENT …

 Contraception
– Tubal ligation if family is completed
– Barrier methods
– Low dose OCPs- in well controlled cases
– IUD
– DMPA & implant- not recommended why??

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  Management of gestational DM
Insulin indicated when
 1hr postprandial values exceed 130–140 mg/dL or
 2hr postprandial values exceed 120 mg/dL or
fasting glucose exceeds 92mg/dL persistently over
2weeks
 Metformin can be used if insulin is not appropriate

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 Timing and route of delivery
Delivery can be planned between 39 and 40wks, but
not later than 40wks. •
Induction of labor is recommended at 38wks in
patients with poor glycemic control. • If early delivery is
indicated (before 39wks) lung maturity should be
checked •
CS is done only for obstetric indications

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 Postpartum follow up
RBS 4 hours of delivery
If FBG exceed 126 mg/dL or RBS exceeds
200mg/dL, insulin in a lower dose (usually one third to
half of the antenatal dose) or metformin would be
required •
If the mother received insulin in the antenatal period,
the dose needs adjustments to pre pregnant doses in
those with type 2 diabetes mellitus

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  For those with GDM, no treatment is required and
usually maintained on diet alone.
 Note that determination of OGTT at 6 - 12 wks
postpartum is required to exclude overt diabetes.
 Ensure that women who have preproliferative
diabetic retinopathy or
 any form of referable retinopathy diagnosed during
pregnancy have ophthalmological follow-up for at
least 6 months

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 FAMILY PLANNING
All reliable method of family planning can be used
Combined hormonal contraceptives and DMPA
should be avoided in women with pregestational DM
who have vascular complications
Permanent methods of contraception are ideal if
family size is complete

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 KETO ACIDOSIS DURING
PREGNANCY

 Definition
– Plasma glucose >300mg/dl, HCO3<15mEq/l &
PH<7.3
 Risk factors
– Infection, volume depletion, failure to take insulin & C/S
 Management
– Lab assessment
– Insulin – regular insulin 10-20 u IV then 5-10 u/hr
– IV fluid( 4- 6L in the 1st 12 hrs)
– Potassium
– bicarbonate
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