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KABERA Ren,MD
PGY III Resident
Family and Community Medicine
National University of Rwanda
Diabetes and Pregnancy
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PLAN
Introduction
Physiopathology
Diagnosis
Management
Complications
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INTRODUCTION
Diabetes mellitus is a clinical syndrome characterized by deficiency of or
insensitivity to insulin and exposure of organs to chronic hyperglycemia.
Deterioration of glucose tolerance occurs normally during pregnancy.
Gestational diabetes mellitus (GDM) is defined as any degree of glucose
intolerance with first recognition during pregnancy.
Preexisting diabetes is diagnosed prior to pregnancy.
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INTRODUCTION
Type 1 diabetes, results from a cellular-mediated autoimmune destruction of
the b cells of the pancreas.
Type 2 diabetes is characterized by insufficient insulin receptors to effect
proper glucose control after insulin is released (insulin resistance).
Gestational diabetes is similar to type 2 diabetes. 90% of the personsidentified have a deficiency of insulin receptors or a marked increase in
weight in the abdominal region.
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PHYSIOPATHOLOGY
Significant metabolic changes are necessary to provide proper energy
delivery to the growing conceptus. Hormones associated with pregnancy such as human placental lactogen
(HPL) and cortisol lower glucose levels, promote fat deposition, and
stimulate appetite.
Rising serum levels of estrogen and progesterone increase insulinproduction and secretion while increasing tissue sensitivity to insulin.
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PHYSIOPATHOLOGY
The overall result is a lowering of the fasting glucose levels .
The decrease is on average 15 mg/dL; thus fasting values of 70-80 mg/dL
are normal in a pregnant woman by the 10th week of gestation.
Hormones associated with pregnancy facilitate maternal storage of energy in
the first trimester and then assist in the diversion of energy to the fetus inlater pregnancy as demand increases.
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There are three ways to diagnose preexisting diabetes mellitus and each way
must be confirmed by a follow-up test. Criteria for diagnosing diabetes mellitus
include:
Symptoms of diabetes (polyuria, polydipsia, and/or unexplained weight loss)
plus a casual plasma glucose concentration of equal to or greater than 200
mg/dL,
Fasting plasma glucose (at least 8 hours without eating) equal to or greater
than 126 mg/dL,
OGTT
DIAGNOSIS
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The gestational DM diagnostic criteria are based on O'Sullivan and Mahan
and modified by Carpenter and Coustan works.
All pregnant women should be screened for diabetes at 24-28 weeks unless
clinical indications exist for earlier screening.
Indications for obtaining an early screen:
Unexplained prior stillbirth or fetal anomalies
Maternal glycosuria (2+ or greater).
Polyhydramnios in the current pregnancy.
DIAGNOSIS
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DIAGNOSIS
Previous history of gestational diabetes.
Family history of diabetes, in a first degree relative.
Characteristics of insulin resistance (obesity, hypertension, hyperlipidemia)
Maternal obesity (BMI greater than 29.0)
Maternal age greater than 35 years. Maternal polycystic ovary syndrome (PCOS)
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DIAGNOSIS
Screening test procedure
The screen is a load followed by a plasma blood sugar one hour after
administration.
The test may be performed at any time during the day and the patient
does NOT need to be fasting.
She should refrain from eating, smoking or drinking during the hourbetween administration of the 50-gram oral glucose and drawing of the
blood sugar.
Patients with an abnormal screen require an OGTT.
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DIAGNOSIS
Interpretation
Screen less than 135, no further screening required
Screen greater than 135, but less than 200, proceed to OGTT
Screen greater than 200, obtain fasting glucose.
If fasting equal to or greater than 105, treat as gestational diabetes.
If fasting less than 105, proceed to OGTT
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DIAGNOSIS
3-hour OGTT- American College of Obstetricians and Gynecologists
Fasting state before the test is started.
A fasting plasma blood sugar is obtained.
Then the patient is given 100 gram glucose load followed by blood sugars at
one hour, two hours and three hours.
If the fasting plasma sugar is over 125 mg per dl or a random glucose is
greater than 200, then the 100 gram glucose load should be withheld.
The test should be considered abnormal and the rest of the test canceled.
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DIAGNOSIS
Interpretations of the results: Carpenter and Coustan
Fasting less than 95 mg per dl
One Hour less than 180
Two Hours less than 155
Three hours less than 140
Two or more abnormal values are considered a positive test.
One abnormal value is considered borderline.
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MANAGEMENT
Objectives:
To relieve symptoms. To correct associated health problems and to reduce morbidity, mortality and
economic costs of diabetes.
To prevent as much as possible acute and long-term complications; to
monitor the development of such complications and to provide timelyintervention.
To improve the quality of life and productivity of the individual with diabetes.
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MANAGEMENT
Management Based On 3-hour OGTT Results
o Fasting value greater than 110, proceed immediately to treatment as A2
GDM.
o Fasting value 95 -110, initiate diet therapy and reevaluate within one week.
o Fasting values remain greater than 95 and /or 1 hour postprandial greaterthan 140 initiate therapy with insulin or glyburide: See management of A2
GDM.
o Fasting values less than 95 and 1 hour postprandial less than 140, follow
diet controlled gestational diabetes treatment. See management of A1 GDM.
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Management Of Gestational Diabetes A1
A. Nutritional counseling:
1.Calories
Body weight Category & Weight gain guidelines
Category BMI Kcal / kg Ideal weight gain
Underweight Less than 19.8 36-40 28-40
Normal 19.8-26 30 25-35
Overweight 26.1-29 24 15-25
Obese Greater than 29 12-18 Equal to or greater than 15
2.Suggested macronutrient distribution: 40-50% carbohydrate, 20-25% protein, and 30-40% fat.
3.Meal plan: Recommend three small meals and two-four snacks based on blood glucose control andpatients lifestyle.
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MANAGEMENT
B. Prenatal visits: Following diagnosis weekly to every other week
C. Glucose monitoring: Prescribe a glucometers for fingersticks before breakfast andone hour after each meal.
D. Indications for initiation of Insulin or Glyburide
1. fasting blood sugar greater than 95 mg per dl.
2. 1 hour postprandial greater than 140 mg per dl (2 hour > 120 mg per dl)
3. Polyhydramnios or LGA, especially if abdominal circumference greater than 75th
percentile at 29-33 weeks.
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MANAGEMENT
E. Laboratory tests
Patients with GDM are at increased risk of developing preeclampsia:
Electrolytes, BUN and Creatinine, platelets, uric acid, LFTs.
Fasting triglycerides (TG)(should be checked at some time Postpartum before
giving estrogen containing OCPs postpartum, since a fasting TG greater than
400 is a relative contraindication to OCPs).
Screen for asymptomatic bacteriuria: urine analysis or urine culture.
F. Fetal Surveillance
Fetal movement record starting at 28 weeks (should be performed daily).
In uncomplicated A1 DM with no evidence of complications, no testing isindicated.
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MANAGEMENT
If EFW greater than 4500 grams, then C-section should be considered due to
risk of shoulder dystocia.
Notify neonatology before delivery.
Postpartum Management
Up to 60% of gestational diabetes will become diabetic with a subsequent
pregnancy or later in life.
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MANAGEMENT
Initiation Of Insulin In GDM A2
Initiate of insulin therapy in non-insulin dependent diabetics and gestational
diabetics as follows:
a. Initial dose determined by actual body weight and gestational age:
0.5-0.7 units per kg in first trimester
0.5-0.8 units per kg in second trimester
0.5-0.9 units per kg in third trimester
b. Divide insulin dose into 2 injections:
2/3 of total dose in am (prior to breakfast)
1/3 total dose in pm (prior to dinner)
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MANAGEMENT
c. Composition of insulin dose is:
morning - 2/3 NPH & 1/3 regular
evening - 1/2 NPH & 1/2 regular
d. Patients should initially be placed on BID insulin.
If nocturnal hypoglycemia becomes a problem, then consider administeringthe evening NPH at bedtime instead of 5 p.m.
Hypoglycemia is extremely dangerous in a diabetic due to hypoglycemic
unawareness and should be avoided.
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MANAGEMENT
Obstetrical
Allow the pregnancy to continue to 40 0/7 weeks gestation in patients withan unfavorable cervix and documentation of good glycemic control,
reassuring antepartum fetal testing and no other maternal or fetal
complications.
Consider elective induction at 39 weeks without an amniocentesis in apatient with a favorable cervix, good dating criteria, optimal glycemic control,
EFW less than 4500 gms.
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MANAGEMENT
Obstetrical
Earlier induction should be considered for
Classes C or greater,(D-benign retinopathy, F-nephropathy ,H-heart
complications, R-Diffuse retinopathy)
Patients with obstetric reasons including IUGR, oligo-or polyhydramnios,
Non-reassuring Doppler flow, poor glycemic control,
Failure to obtain appropriate fetal surveillance
Deterioration of maternal status. Amniocentesis should be offered in patients
who are electively induced prior to 39 weeks.
Consider hospitalization 24-48 hours prior to delivery to stabilize blood
sugars if control has been difficult.
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COMPLICATIONSFetal
Delayed fetal lung maturity
Neonatal hypoglycemia,Hyperbilirubinemia,Polycythemia
Organomegaly.
Preterm birth.
Malformations (high glucose environment in first 8 weeks)
Cardiac, Neural tube defects, Caudal regression syndrome
Higher incidence of developing Type 2 DM as a child or as an adolescent,if
glucose control was poor during pregnancy.
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COMPLICATIONS
Maternal
Increased rate of preeclampsia (4.5 times the usual rate). Increased incidence of intrauterine deaths.
Increased incidence of polyhydramnios.
Increased incidence of wound and urinary tract infections cystitis and
pyelonephritis and PROM.
Increased incidence of vulvovaginitis (esp. candidiasis).
Increased incidence of operative delivery.
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THANK YOU
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