Diabetes in Diabetes in PregnancyPregnancy
ClassificationClassification
Pregestational diabetesPregestational diabetes
Type 1 DMType 1 DM
Type 2 DMType 2 DM
Secondary DMSecondary DM Gestational diabetes Gestational diabetes
DefinitionDefinition
Gestational diabetes (GDM) is defined as glucose Gestational diabetes (GDM) is defined as glucose intolerance of variable degree with onset or first intolerance of variable degree with onset or first recognition during the present pregnancy. recognition during the present pregnancy.
Pregestational diabetes precedes the diagnosis of pregnancy.
Magnitude of problem: GDM Magnitude of problem: GDM
GDM varies worldwide and among different racial and GDM varies worldwide and among different racial and ethnic groups within a countryethnic groups within a country
Variability is partly because of the different criteria and Variability is partly because of the different criteria and screening regimens screening regimens
Whom to screen ?Whom to screen ?
Risk stratification based on certain variablesRisk stratification based on certain variables
Low risk : no screeningLow risk : no screening
Average risk: at 24-28 weeksAverage risk: at 24-28 weeks
High risk : as soon as possibleHigh risk : as soon as possible
To satisfy To satisfy allall these criteria these criteria
Age <25 years Age <25 years
Weight normal before pregnancy Weight normal before pregnancy
Member of an Member of an ethnic group with a low prevalence of GDMethnic group with a low prevalence of GDM
No known diabetes in first-degree relatives No known diabetes in first-degree relatives
No history of abnormal glucose tolerance No history of abnormal glucose tolerance
No history of poor obstetric outcomeNo history of poor obstetric outcome
Low risk for GDMLow risk for GDM
High riskHigh risk
Marked obesityMarked obesity Prior GDMPrior GDM GlycosuriaGlycosuria Strong family historyStrong family history
Intermediate risk
At least one of the criteria in the list
Screening and Diagnosis of Screening and Diagnosis of GDM in the U.S.GDM in the U.S.
Use the 50 g oral glucose Use the 50 g oral glucose challenge with BS taken 1 hour challenge with BS taken 1 hour laterlater Screen all pregnant women @ 24-28 Screen all pregnant women @ 24-28
weeksweeks Test earlier in selected patientsTest earlier in selected patients
Threshold of 130 mg/dL or greaterThreshold of 130 mg/dL or greater
How to screen?How to screen? Oral glucose tolerance Oral glucose tolerance
test ( OGTT) with 100 gm test ( OGTT) with 100 gm glucoseglucose
FastingFasting 95 mg/dl95 mg/dl
1-h1-h 180 mg/dl180 mg/dl
2-h2-h 155 mg/dl155 mg/dl
3-h3-h 140 mg/dl140 mg/dl
• Overnight fast of at least 8 hours
• At least 3 days of unrestricted diet and unlimited physical activity
• > 2 values must be abnormal
Urine glucose monitoring is not useful in gestational Urine glucose monitoring is not useful in gestational diabetes mellitusdiabetes mellitus
Urine ketone monitoring may be useful in detecting Urine ketone monitoring may be useful in detecting insufficient caloric or carbohydrate intake in women insufficient caloric or carbohydrate intake in women treated with calorie restrictiontreated with calorie restriction
Urine monitoring
Problems of GDM: fetalProblems of GDM: fetal
Increases the risk of fetal macrosomiaIncreases the risk of fetal macrosomia Neonatal hypoglycemiaNeonatal hypoglycemia JaundiceJaundice PolycythemiaPolycythemia Hypocalcemia, hypomagnesemiaHypocalcemia, hypomagnesemia Birth traumaBirth trauma PrematurityPrematurity
Problems: fetalProblems: fetal Cardiac( including great vessel anomalies) : Cardiac( including great vessel anomalies) : most commonmost common
Central nervous system: 7.2%Central nervous system: 7.2%
Skeletal: cleft lip/palate, Skeletal: cleft lip/palate, caudal regression syndromecaudal regression syndrome
Genitourinary tract: ureteric duplicationGenitourinary tract: ureteric duplication
Gastrointestinal : anorectal atresiaGastrointestinal : anorectal atresia
Poor glycemic control at time of conception: risk factor
Caudal regression syndrome
Caudal regression syndrome
Problems of GDM: maternalProblems of GDM: maternal
Weight gainWeight gain Maternal hypertensive disordersMaternal hypertensive disorders MiscarriagesMiscarriages Third trimester fetal deathsThird trimester fetal deaths Cesarean delivery (due fetal growth disorders) Cesarean delivery (due fetal growth disorders) Long term risk of type 2 diabetes mellitus Long term risk of type 2 diabetes mellitus
Pregnancy in diabetic mother: Pregnancy in diabetic mother: risksrisks
Progression of retinopathy: esp. severe proliferative Progression of retinopathy: esp. severe proliferative retinopathyretinopathy
Progression of nephropathy: especially if renal failure +Progression of nephropathy: especially if renal failure +
Coronary artery disease: Post MI patients: high risk of Coronary artery disease: Post MI patients: high risk of maternal death maternal death
ManagementManagement
Preconception Preconception counsellingcounselling
Diabetic mother : glycemic control with insulin/SMBGDiabetic mother : glycemic control with insulin/SMBG Target: HbA1c < 7% Target: HbA1c < 7%
Folic acid supplementation: 5 mg/day Folic acid supplementation: 5 mg/day
Ensure no transmissible diseases: HBsAg, HIV, rubellaEnsure no transmissible diseases: HBsAg, HIV, rubella
Try and achieve normal body weight: diet/exerciseTry and achieve normal body weight: diet/exercise
Stop drugs : oral hypoglycemic drugs, ACE inhibitors, Stop drugs : oral hypoglycemic drugs, ACE inhibitors, beta blockersbeta blockers
Clinical parameters: checked Clinical parameters: checked at each visitat each visit
medicationsmedications pre-pregnancy weight pre-pregnancy weight weight gainweight gain edemaedema pallorpallor blood pressure blood pressure Fundal height Fundal height
Patient educationPatient education
Cornerstone in GDM managementCornerstone in GDM management
Maternal complicationMaternal complication Fetal complicationFetal complication Medical Nutrition therapyMedical Nutrition therapy Glycemic monitoring: SMBG and targetsGlycemic monitoring: SMBG and targets Fetal monitoring: ultrasoundFetal monitoring: ultrasound Planning on deliveryPlanning on delivery Long term risksLong term risks
Glycemic targetsGlycemic targets
Fasting venous plasma < 95 mg/dlFasting venous plasma < 95 mg/dl 2 hour postprandial <120 mg/dl2 hour postprandial <120 mg/dl 1 hour postprandial <130 mg/dl (140)1 hour postprandial <130 mg/dl (140)
Pre-meal and bedtime: 60 to 95 mg/dlPre-meal and bedtime: 60 to 95 mg/dl
If diet therapy fails to maintain these targets > 2 times/week, start insulin
These are venous plasma targets, not glucometer targets
Why these tight glycemic Why these tight glycemic
targets?targets? Prospective study in type1 patients with pregnancyProspective study in type1 patients with pregnancy
FBSFBS MacrosomiaMacrosomia
>105 mg/dl>105 mg/dl 28.6 %28.6 %
95-105 95-105 10%10%
<95 mg/dl <95 mg/dl 3%3%
GDM
Failure to maintain glycemic targets
INSULIN THERAPY
Medical nutrition therapy
Medical nutrition therapyMedical nutrition therapy
Promote nutrition necessary for maternal and fetal healthPromote nutrition necessary for maternal and fetal health
Adequate energy levels for appropriate gestational weight Adequate energy levels for appropriate gestational weight
gain,gain,
Achievement and maintenance of normoglycemiaAchievement and maintenance of normoglycemia
Absence of ketones Absence of ketones
Regular aerobic exercisesRegular aerobic exercises
Medical nutrition therapyMedical nutrition therapy
Approximately 30 kcal/kg of ideal body weightApproximately 30 kcal/kg of ideal body weight
> 40-45% should be carbohydrates> 40-45% should be carbohydrates
6-7 meals daily( 3 meals , 3-4 snacks). Bed time snack to prevent 6-7 meals daily( 3 meals , 3-4 snacks). Bed time snack to prevent ketosis ketosis
Calories guided by fetal well being/maternal weight gain/blood Calories guided by fetal well being/maternal weight gain/blood sugars/ ketonessugars/ ketones
Energy requirements during the first 6 months of lactation Energy requirements during the first 6 months of lactation require an additional 200 calories above the pregnancy meal require an additional 200 calories above the pregnancy meal plan.plan.
Self monitored blood glucoseSelf monitored blood glucose
4 times/day minimum, fasting and 1 to 2 4 times/day minimum, fasting and 1 to 2 hours after start of mealshours after start of meals
Maintain log bookMaintain log book
Use a memory meterUse a memory meter
Calibrate the glucometer frequentlyCalibrate the glucometer frequently
Fetal monitoringFetal monitoring
Baseline ultrasound : fetal sizeBaseline ultrasound : fetal size At 18-22 weeks: major malformationsAt 18-22 weeks: major malformations
fetal echocardiogramfetal echocardiogram 26 weeks onwards: growth and liquor volume26 weeks onwards: growth and liquor volume III trimester: frequent USG for accelerated growthIII trimester: frequent USG for accelerated growth
( abdominal: head circumference) ( abdominal: head circumference)
Timing of deliveryTiming of delivery
Small risk of late IUD even with good controlSmall risk of late IUD even with good control Delivery at 38 weeksDelivery at 38 weeks Beyond 38 weeks, increased risk of IUD without an Beyond 38 weeks, increased risk of IUD without an
increase in RDSincrease in RDS Vaginal delivery: preferredVaginal delivery: preferred Caesarian section only for routine obstetric indicationCaesarian section only for routine obstetric indication just GDM is not an indication !just GDM is not an indication ! Unfavorable condition of the cervix is a problemUnfavorable condition of the cervix is a problem 4500 grams, cesarean delivery may reduce the likelihood of 4500 grams, cesarean delivery may reduce the likelihood of
brachial plexus injury in the infant (ACOG)brachial plexus injury in the infant (ACOG)
Management of labor and deliveryManagement of labor and delivery
Maternal hyperglycemia in labor: fetal hyperinsulinemia, Maternal hyperglycemia in labor: fetal hyperinsulinemia,
worsen fetal acidosisworsen fetal acidosis Maintain sugars: 80-120 mg/dl (capillary: 70-110mg/dl )Maintain sugars: 80-120 mg/dl (capillary: 70-110mg/dl ) Feed patient the routine GDM diet Feed patient the routine GDM diet Maintain basal glucose requirementsMaintain basal glucose requirements Monitor sugars 1-4 hrly intervals during labourMonitor sugars 1-4 hrly intervals during labour Give insulin only if sugars more than 120 mg/dlGive insulin only if sugars more than 120 mg/dl
Glycemic management during labourGlycemic management during labour
Later stages of labour: start dextrose to maintain basal Later stages of labour: start dextrose to maintain basal nutritional requirements: 150-200 ml/hr of 5% dextrose nutritional requirements: 150-200 ml/hr of 5% dextrose
Elective LSCS: check FBS, if in target no insulin, start Elective LSCS: check FBS, if in target no insulin, start dextrose dripdextrose drip
Continue hourly SMBGContinue hourly SMBG Post delivery keep patients on dextrose-normal saline till Post delivery keep patients on dextrose-normal saline till
fedfed No insulin unless sugars more than normal ( No insulin unless sugars more than normal ( not GDM not GDM
targets ! )targets ! )
Post partum follow upPost partum follow up Check blood sugars before dischargeCheck blood sugars before discharge
Breast feeding: helps in weight lossBreast feeding: helps in weight loss
Lifestyle modification: exercise, weight reductionLifestyle modification: exercise, weight reduction
OGTT at 6-12 weeks postpartum: classify patients into OGTT at 6-12 weeks postpartum: classify patients into normal/impaired glucose tolerance and diabetesnormal/impaired glucose tolerance and diabetes
Preconception counseling for next pregnancyPreconception counseling for next pregnancy
Increased risk of cardiovascular disease,future diabetes and dyslipidemia
Immediate management of neonateImmediate management of neonate
Hypoglycemia : 50 % of macrosomic infants Hypoglycemia : 50 % of macrosomic infants 5–15 % optimally controlled GDM5–15 % optimally controlled GDM
Starts when the cord is clamped Starts when the cord is clamped
Exaggerated insulin release secondary to pancreatic ß-cell Exaggerated insulin release secondary to pancreatic ß-cell hyperplasiahyperplasia
Increased risk : blood glucose during labor and delivery Increased risk : blood glucose during labor and delivery exceeds 90 mg/dlexceeds 90 mg/dl
Anticipate and treat hypoglycemia in the infant
Management of neonateManagement of neonate Hypoglycemia <40 mg/dl Hypoglycemia <40 mg/dl
Encourage early breast feeding Encourage early breast feeding
If symptomatic give a bolus of 2- 4 cc/kg, IV, 10% dextroseIf symptomatic give a bolus of 2- 4 cc/kg, IV, 10% dextrose
Check after 30 minutes, start feedsCheck after 30 minutes, start feeds
IV dextrose : 6-8 mg/kg/min infusionIV dextrose : 6-8 mg/kg/min infusion
Check for calcium, if seizure/irritability/RDSCheck for calcium, if seizure/irritability/RDS
Examine infant for other congenital abnormalitiesExamine infant for other congenital abnormalities
Long term risk: offspringLong term risk: offspring
Increased risk of obesity and abnormalIncreased risk of obesity and abnormal
glucose toleranceglucose tolerance
Due to changes in fetal islet cell function Due to changes in fetal islet cell function
Encourage breast feeding: less chance of obesity in later Encourage breast feeding: less chance of obesity in later lifelife
Lifestyle modificationLifestyle modification
ConclusionConclusion
Gestational diabetes is a common problem Gestational diabetes is a common problem
Risk stratification and screening is essential in all pregnant Risk stratification and screening is essential in all pregnant womenwomen
Tight glycemic targets are required for optimal maternal Tight glycemic targets are required for optimal maternal and fetal outcomeand fetal outcome
Patient education is essential to meet these targetsPatient education is essential to meet these targets
Long term follow up of the mother and baby is essential Long term follow up of the mother and baby is essential
17 pound baby born to Brazilian diabetic mother Courtesy: MSNBC News ServicesJan. 24, 2005
thank youthank you
