DIABETES IN PREGNANCY

Dr Chippy Tess Mathew

CLASSIFICATION
OVERT DIABETES Seen in women known to be diabetic before the onset of pregnancy. IDDM mostly

GESTATIONAL DIABETES

EFFECT OF PREGNANCY ON DIABETES

Diabetogenic state Insulin requirement increases Ketosis can occur Lowered renal threshold Retinal changes are aggravated

EFFECT OF DIABETES ON PREGNANCY

Abortion Fetal malformations* Preterm delivery* PIH Fetal macrosomia-birth trauma Hydramnios Maternal infections Unexplained fetal deaths*

GESTATIONAL DIABETES
INCIDENCE 1% DEFINITION Carbohydrate intolerance of variable severity with onset or first detected during the present pregnancy

RISK FACTORS FOR SCREENING FOR GDM

Family history of diabetes -1st degree relative Having a previous baby of wt >4kg Previous stillbirth Unexplained perinatal loss Polyhydramnios Persistent glycosuria Age> 30 obesity

SCREENING TEST
OGCT 24-28 weeks Cut off 140mg% Procedure DEFINITIVE TEST OGTT

OGTT

GTT
TIME Fasting WHOLE BLOOD 90 PLASMA mg% 105

1 hr
2 hr 3h

165
145 125

190
165 145

Whites classification
Class Onset Therapy

A1 A2

Gest Gest

Fbs<105 >105 Duration

<10 10-19 >20 Any Any any

Ppbs>120 >120 Complication

None None Retinopathy Nephropathy Prolif retinopathy heart

Diet insulin

B C D F R H

>20yrs 10-19 <10 Any Any any

insulin Insulin Insulin Insulin insulin insulin

MANAGEMENT
AIMS To control diabetes Timing of delivery Management in labor Care of the newborn

MANAGEMENT CONTD
ANTENATAL CARE Maintain blood sugar at FBS <95 / PPBS< 120 mg% Regular blood checkups at 3 weeks interval (post prandial better than pre-prandial) Management options Diet exercise Diet + insulin

Contd..
Diet in pregnant diabetics Total calories- 30 -35 kcal/kg of ideal body weight Given in split meals of 3 meals and 3 snacks Ideal diet 55% carbohydrates 20% proteins 25% fat- < 10% saturated fat

contd
INSULIN If PPBSL >150 mg% in spite of dietary regulations start on insulin/ FBS > 105 mg% plasma Plain insulin in 3 divided doses pre meals Optimize the insulin dose Sometimes combination of lente and regular OHA usually not used more chance of fetal hyperinsulinemia/?fetal defects Trials on glyburide

CONTD
OBSTETRIC MANAGEMENT In general, women with gestational diabetes who do not require insulin seldom require early delivery or other interventions. Well controlled diabetes delivery at 40 weeks ACOG 2001 suggested that cesarean delivery should be considered in women with a sonographically estimated fetal weight of 4500 grams or more.

Contd..

Induction of labor with Oxytocin or after priming with prostaglandin Prophylactic antibiotics given Strictly monitor in labor

CONTD..
Women who require insulin therapy for fasting hyperglycemia, however, typically undergo fetal testing and are managed as if they had overt diabetes. POSTPARTUM CONSEQUENCES Women diagnosed with gestational diabetes undergo evaluation with a 75-g oral glucose tolerance test at 6 to 12 weeks after delivery . Women whose 75-g test is normal should be reassessed at a minimum of 3-year intervals

CONTD..
Patients with GDM dont require insulin after delivery.antibiotics given. CONTRACEPTION

Low-dose hormonal contraceptives may be used safely by women with recent gestational diabetes .

OVERT DIABETES
DEFINITION Women known to have diabetes before pregnancy is called pregestational or overt diabetes.

contd
DIAGNOSIS OF OVERT DIABETES DURING PREGNANCY Women with high plasma glucose levels, glucosuria, and ketoacidosis women with a random plasma glucose level greater than 200 mg/dL plus classic signs and symptoms such as polydipsia, polyuria, and unexplained weight loss or Fasting plasma glucose of 126 mg/dL

Effects
Fetal effects Abortion/ PTL / malformation / IUD / hydramnios Neonatal effects respiratory distress / hypoglycemia /hypocalcaemia /hyperbilirbinemia /macrosomia / cardiac hypertrophy /inheritance of diabetes

Contd..
Maternal effects Nephropathy Retinopathy Neuropathy Pre eclampsia Ketoacidosis Infection

MANAGEMENT
PRECONCEPTION

To prevent early pregnancy loss as well as congenital malformations in infants of diabetic mothers
ADA has defined optimal preconceptional glucose control using insulin to include selfmonitored preprandial glucose levels of 70 to 100 mg/dL and postprandial values of less than 120 at 2 hours. Hemoglobin A1 or A1c measurement -- circulating glucose for the past 4 to 8 weeks, is useful to assess early metabolic control. The most significant risk for malformations is with levels exceeding 10%

Contd
Folate,

400 ug/day, is given periconceptionally and during early pregnancy

Contd..
Obstetric management maternal serum alpha feto proteins at 16 20 weeks Target USG at 18 - 20 weeks Fetal echo at 24 26 weeks to r/o cardiac anomaly Regular ANC Hospitalise if poor control of diabetes

Contd..
Ante partum surveillance biophysical profile / NST -start at 32 weeks TIMING OF DELIVERY In overt diabetes pregnancy terminated at 37 38 weeks if he fetus is otherwise normal. In all other situations TOP is based on fetal well-being/POG/ neonatal facilities

Contd..

Cesarean section is performed if baby is large or if there are other obstetrical indications such as fetal distress.

contd
Management in labor Omit morning dose of insulin- do FBS, urine sugar and ketone. During labor the woman should be hydrated adequately -i/v saline/ dextrose with insulin IOL with Oxytocin / PG Constant insulin infusion by calibrated pump is most satisfactory .

Contd..

Capillary or plasma glucose levels should be checked 2 hourly and regular insulin should be administered accordingly. Antibiotics

Strict monitoring/ ARM in active labor

Contd..
PUERPERIUM Dose of insulin required decrease --and so adjusted according to blood sugar levels..

CONTRACEPTION Barrier.