Treatment of diabetes in

preg
Aim of management
Principles of management
Preconception care
 Aim of management – to reduce perinatal
and maternal morbidity and mortality.
• Manage complications that can
• Principle of management deteriorate – blood pressure control,
• To achieve glycaemic control before retinopathy, nephropathy, ischaemic heart
conception disease.
• Prevent obst complication by good • Counsel on contraception.
antenatal care.
• Antenatal management
• Early detection and prompt Rx of
• Team management – obstetrican,
medical problems
physician, dietician etc
• Careful timing and appropriate mode • Main objective – mean 24hr glucose
of delivery
profile of 5mmol/l
• Intensive neonatal care
• Antenatal complications
• Preconception care • Infections
• Good control before pregnancy/treat- • Miscarriages
ment • IUGR
• Prevent congenital anomalies – folate • Macrosomia
• Counsel couples – about DM in preg, • Hydramnios
insulin therapy, hypoglycaemia, weight/ • Premature labour
dietry advise. • Preeclampsia

Medical complications
keto-acidosis, hypoglycaemia, visual
deterioration, gaustattory vomiting,
ischaemic heart disease.
• Obstetric management.
• Encourage early booking
• History – UTI, candidiasis
• Clinical examination – BP ,
polyhydramnios
• Investigations – urinalysi, urine-
m/c/s, HVS for candidiasis, FBC,
E,U&C, blood sugar profile twice
weekly
• Early viability scan/dating
• Antenatal monitoring
• See more frequently – 2 weekly until
28 weeks of gestation, thereafter
weekly until delivery
• Morphology scan at 20weeks –
Neural tube defects, cardiac defects
(transposition of great vessels most
common major cardiac anomaly), renal
• Fetal growth assessment –
macrosomia (25-40%) AC > 36cm;
IUGR (PE); fundal height
measurement; USS – 2-4weekly (DM =
from 24weeks GA, while in IGT and
GDM from 28weeks)
• Antenatal fetal monitoring
• High risk of fetal hypoxia and IUFD
• Fetal kick chart
• Auscultation
• Continuous fetal monitoring – ideally
daily
• Biophysical profile – weekly or twice
weekly
• Doppler uss.
IGT – does not require intensive
monitoring unless there are other
problems
Admit patient for stabilization of blood
sugar if necessary.
Dietary management
Aim – to control blood glucose level
Caloric intake
30-35 cal/kg/day
• Distribution • Dose – 2/3 of total daily for
• Carbohydrate – 50% morning and 1/3 for evening
• Fat – 30% • Morning dose – 2/3 intermediate
• Protein – 20% insulin and 1/3 soluble insulin
Avoid concentrated or refined sugars • Evening dose – ½ intermediate
Medical management insulin and ½ soluble insulin
• Stop all oral hypoglycaemic drugs – • Dose adjustment + 4units
less reliable in action and cross placenta barrier.
• Aim – blood glucose of 4-6mmol/l
• Patient should have a glucometer
for home glucose monitoring • Monitoring response to
• Good control – assess 2-3 times therapy
weekly • Clinical – hydramnios,
• Poor control – 6 times daily ( before macrosomia, hypoglycaemia
meals and snacks) • Glycosylated haemoglobin monthly
• Insulin therapy – well controlled = < 8.0% (Normal
• Soluble insulin – 6.0%), poorly controlled = >
• Long acting PZI (lente) 11.0%
Mixture of insulin – soluble and • Side effects of insulin
intermediate acting insulin therapy
Daily insulin requirement – 0.7- • Lipoatrophy
1.0units/kg body weight.
• Hypoglycaemia
 Intrapartum management
• Timing of delivery
• Optimal diabetic control – 39-40weeks
• Poorly controlled – early delivery, if
before 34weeks use steroids
(dexamethasone 12mg 12hourly x 2
doses)
• Mode of delivery
• Spontaneous vag delivery – primary
goal
• Indications for c/s – fetal weight >
4.5kg, previous history of shoulder
dystocia, previous c/s, other
contraindication to vag delivery.
• •
Management in labour
• Set up two IVF line
• Capillary blood glucose hourly
• Aim to maintain blood glucose level
between 4-6mmol/l
• Only soluble insulin should be used
• Insulin administration
• Ideally use insulin pump
By preventing hyperglycemia during labour,
ketoacidosis is prevented and the incidence of
• Set up 10% dextrose water – 100ml/hr
(10g/hr).
• Set up insulin pump at 1.0units/hour =
4-6 mmol/l
• Blood glucose > 6mmol/l – double
insulin (2.0unit/hr)
• Blood glucose < 4mmol/l – ½ insulin
dose (0.5unit/hr)
• ½ insulin infusion rate after delivery
• Where insulin pump is not
available
• Set up 5% dextrose water
Administer insulin as follows on table
below
• Second regimen
• 5% D/W
• S.C insulin 1unit hourly
• Other management in labour
• Monitor labour on partogram
• Adequate analgesia – hyperglycaemia
• Continuous fetal monitoring – fetal
distress and perinatal mortality
 Table for insulin therapy

Capillary blood Soluble insulin in Time (hrs) for Supplementary

glucose (mmol/l) 500ml of infusion infusion (rate in s.c dose insulin
drops per minute) given 6 hourly

< 2.0 Nil 2 hrs (84dpm) 0

2.0-3.9 Nil 6 hrs (28dpm) 0
4.0-7.9 6 units 6 hrs (28) 0
8.0-11.9 6 units 6 hrs (28) 6 units
12.0-15.9 6 units 6 hrs (28) 10 units
> 16.0 Call physician Call physician
• Labour should be managed by
experienced obstetrician. (duration should
be less than 12hrs)
• Availability of neonatal services and
neonatologist to attend delivery.
• Poor progress in labour – do c/s
• Induction of labour
• Morning/breakfast insulin should not be
given in the antenatal ward
• Admit to labour ward at 6.00am
• Capillary glucose hourly from 6.00am –
starting with fasting blood glucose.
• Do ARM and set up oxytocin drip on
one arm
• Set up 5% D/W on the second line
• Give S.C insulin 8units stat dose
• Commence insulin titration as in the
table.
• Patient for caesarean delivery
• First on the operation list
• If blood glucose is > 6mmol/l –
postspone surgery
• Do capillary blood glucose hourly from
• Give insulin as stated above
• Puerperal management
• Readjust insulin dose
• Pre-gestational DM – ½ dose
• GDM – give only if blood glucose
demands control
• Discontinue hourly glucose estimation
• Four point test – fasting, pre-breakfast,
pre-lunch and 21.00hrs
• Encourage breast feeding
• Food supplementation after
breastfeeding
• Do OGTT at 6weeks post partum and
at 3 months after delivery
• Refer to the diabetic clinic if either of
above result is positive
• Contraception – at 6 weeks
 Somogyi effect

• Somogyi effect is a state of rebound reactive

hyperglycemia, that occurs in diabetes on long acting
insulin, following a period of relative unrecognised
nocturnal hypoglycemia, which stimulates the release of
hyperglycemic agents – adrenaline, noradrenaline, cortisol,
glucagon and growth hormone (which produces the
hyperglycemia the next morning). The patient suffers
nightmares and night sweats.
• Documenting hypoglycemia between 1.00-5.00am is
diagnostic of this phenomenon
• Treatment is to decrease the amount of long acting insulin
the patient takes before super or at bedtime.
Dawn phenomenon