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Umar Zein
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Diabetes in Pregnancy
Epidemiology
Classification
Pathophysiology
Morbidity
Fetal
Maternal
Diagnosis
Treatment and Management
References
Epidemiology
Normal pregnancy is
characterized by:
Mild fasting hypoglycemia
Postprandial hyperglycemia
Hyperinsulinemia
Due to peripheral insulin
resistance which ensures
an adequate supply of
glucose for the baby.
Pathophysiology
Human Placental Lactogen (HPL)
Produced by syncytiotrophoblasts of
placenta.
Acts to promote lipolysis increased FFA
and to decrease maternal glucose uptake
and gluconeogenesis. “Anti-insulin”
Estrogen and Progesterone
Interfere with insulin-glucose relationship.
Insulinase
Placental product that may play a minor
role.
A Vicious Cycle???
Fetal Morbidity
Miscarriages
Frequency directly related to degree of
maternal glycemic control.
Up to 44% with poorly controlled DM
(HbA1C >12).
Preterm Delivery
Increase in both spontaneous and
indicated preterm labor (<35 wks).
Fetal Morbidity
Birth Defects
1-2% risk among the general population.
4-8 fold increased risk among preexisting
diabetics.
Most common defects are CNS and CV,
but also an increase in renal and GI
abnormalities.
Up to a 600 fold increase in caudal
regression syndrome.
Fetal Morbidity
Macrosomia
Defined as birthweight above 90th % or
>4000 grams.
Occurs in 15-45% of diabetic
pregnancies, a 4-fold increase over
normal.
Carries many morbidities including birth
trauma, RDS, neonatal jaundice and
severe hypoglycemia.
Fetal Morbidity
Growth Restriction
Although we typically associate maternal
DM with macrosomia, growth restriction
is fairly common among Type 1 diabetic
mothers.
Best predictor is presence of maternal
vascular disease.
Fetal Morbidity
Fetal Morbidity
Polycythemia
Hyperglycemia stimulates fetal erythropoeitin
production.
Can lead to tissue ischemia and infarction.
Hypoglycemia
Think of as an “overshoot” mechanism.
Baby is used to having lots of maternal glucose so
it makes lots of insulin. When born, maternal
glucose is no longer available but insulin remains
high hypoglycemia.
Can lead to seizures, coma and brain damage.
Fetal Morbidity
Postnatal hyperbilirubinemia
Occurs in appox. 25%, double that of
normal.
Thought to be due in large part to
polycythemia.
Respiratory distress syndrome
5-6 fold increased frequency.
May be due to a delay in lung maturation
or simply due to the increased frequency
of preterm deliveries.
Fetal Morbidity
Polyhydramnios
Amniotic fluid volume >2000 mL.
Occurs in 10% of diabetics.
Increased risk of placental abruption and
preterm labor.
Maternal Morbidity
Diabetic neuropathy
Preeclampsia
2-fold increase
Diagnosis
Obstetrical management
Serial US to trend fetal growth, AFI and fetal
anatomy
Fetal well-being monitored with kick counts,
NSTs, BPPs
Postpartum, 95% of GDM mothers return
to normal glucose tolerance, and require
no further insulin.
Glucose tolerance screen 2-4 mo. postpartum
to detect those that remain diabetic.