Diabetes in Pregnancy high risk case presentation

high risk pregnancy topic GDM

1. Diabetes in PregnancyDiabetes in Pregnancy
QUICO, KRISHAN MIRQUICO, KRISHAN MIR
SINGH, PRIYANKASINGH, PRIYANKA

2. Diabetes in PregnancyDiabetes in Pregnancy

DefinitionDefinition

EpidemiologyEpidemiology

ClassificationClassification

PathophysiologyPathophysiology

MorbidityMorbidity

FetalFetal

MaternalMaternal

DiagnosisDiagnosis

Treatment and ManagementTreatment and Management

ReferencesReferences

3. Gestational DiabetesGestational Diabetes

Induced by pregnancyInduced by pregnancy

Type 2 diabetes unmasked or Type 2 diabetes unmasked or
discovered during pregnancydiscovered during pregnancy

4. EpidemiologyEpidemiology

4-6% of pregnancies in the U.S are 4-6% of pregnancies in the U.S are
complicated by DM, accounting for 50-complicated by DM, accounting for 50-
150 thousand babies per year.150 thousand babies per year.

88% GDM, 8% Type II DM, 4% Type 1 DM88% GDM, 8% Type II DM, 4% Type 1 DM

Prevalence also varies by racePrevalence also varies by race

1.5-2% in Caucasians, 5-8% in Hispanic, 1.5-2% in Caucasians, 5-8% in Hispanic,
Asian and African Americans, and up to Asian and African Americans, and up to
15% in some SW Native American groups.15% in some SW Native American groups.

5. ClassificationClassification

6. PathophysiologyPathophysiology

Normal pregnancy is Normal pregnancy is
characterized by: characterized by:

Mild fasting hypoglycemiaMild fasting hypoglycemia

Postprandial Postprandial
hyperglycemiahyperglycemia

HyperinsulinemiaHyperinsulinemia

Due to peripheral insulin Due to peripheral insulin
resistance which ensures resistance which ensures
an adequate supply of an adequate supply of
glucose for the baby.glucose for the baby.

7. PathophysiologyPathophysiology

Human Placental Lactogen (HPL)Human Placental Lactogen (HPL)

Produced by syncytiotrophoblasts of Produced by syncytiotrophoblasts of
placenta.placenta.

Acts to promote lipolysis Acts to promote lipolysis  increased FFA increased FFA
and to decrease maternal glucose uptake and to decrease maternal glucose uptake
and gluconeogenesis. “Anti-insulin”and gluconeogenesis. “Anti-insulin”

Estrogen and ProgesteroneEstrogen and Progesterone

Interfere with insulin-glucose relationship.Interfere with insulin-glucose relationship.

InsulinaseInsulinase

Placental product that may play a minor Placental product that may play a minor
role.role.

8. A Vicious Cycle???A Vicious Cycle???

9. Screening and DiagnosisScreening and Diagnosis

Routine/Universal vs. Selective?Routine/Universal vs. Selective?

4th International Workshop Conference of GDM 4th International Workshop Conference of GDM
Chicago, Illinois, 1999Chicago, Illinois, 1999
“ “Screening should be limited to women meeting Screening should be limited to women meeting
at least one of the four criteria.”at least one of the four criteria.”
>> 25 years of age 25 years of age
< 25 years of age and obese< 25 years of age and obese
Family history of DM in first degree relativesFamily history of DM in first degree relatives
Member of an ethnic/racial group with a high prevalenceMember of an ethnic/racial group with a high prevalence
-Hispanic-Hispanic -Pacific Islander-Pacific Islander --
AfricanAfrican -Indigenous Australian ancestry-Indigenous Australian ancestry
-Native American-Native American -South or East Asian-South or East Asian

10. Screening and DiagnosisScreening and Diagnosis

When?When?
24th to 28th week - if low risk24th to 28th week - if low risk
Immediate/First visit- if high risk Immediate/First visit- if high risk
for GDMfor GDM

11. Steps in screening for and diagnosing gestational diabetes mellitus (GDM). Steps in screening for and diagnosing gestational diabetes mellitus (GDM).
OGTT = oral glucose tolerance testOGTT = oral glucose tolerance test

12. Maternal and Fetal EffectsMaternal and Fetal Effects

Fasting hypergylcemia > 105 mg/dL = Fasting hypergylcemia > 105 mg/dL =
fetal death @ 4-8 weeks of gestation fetal death @ 4-8 weeks of gestation
(ADA)(ADA)

Hypertension Hypertension

CS deliveryCS delivery

MacrosomiaMacrosomia

13. MacrosomiaMacrosomia

Birth wt > 4500 g (ACOG)Birth wt > 4500 g (ACOG)

Organs are affected ( excpt BRAIN)Organs are affected ( excpt BRAIN)

Excessive fat deposition on the shoulder Excessive fat deposition on the shoulder
and trunk and trunk

14. 
IGF-I and IGF-IIIGF-I and IGF-II
- regulation of fetal growth- regulation of fetal growth
- growth factors- growth factors
- proinsulin-like polypeptides- proinsulin-like polypeptides
- produced by all fetal organs- produced by all fetal organs
- potent stimulators of cell - potent stimulators of cell
differentiation and divisiondifferentiation and division

EGF, leptin, and adiponectinEGF, leptin, and adiponectin

15. ManagementManagement

Insulin therapyInsulin therapy
- recommended if standard dietary - recommended if standard dietary
mgt does not maintain fasting mgt does not maintain fasting
plasma glucose @ <95mg/dL or 2-plasma glucose @ <95mg/dL or 2-
hour postprandial plasma glucose hour postprandial plasma glucose
<120mg/dL<120mg/dL

Maternal capillary glucose kept </= Maternal capillary glucose kept </=
95 mg/dL in fasting state95 mg/dL in fasting state

16. 
DietDiet
-obese women with BMI >30kg/m2 = -obese women with BMI >30kg/m2 =
30% caloric restriction30% caloric restriction
-weekly test for ketonuria-weekly test for ketonuria

ExerciseExercise
-diminished need for insulin therapy -diminished need for insulin therapy
in overwt with GD.in overwt with GD.

Glucose monitoringGlucose monitoring
-daily self blood-glucose monitoring -daily self blood-glucose monitoring
fewer macrosomic infantsfewer macrosomic infants

17. Obstetrical ManagementObstetrical Management

Elective CS: brachial plexus injuryElective CS: brachial plexus injury

CS: sonographically estimated fetal CS: sonographically estimated fetal
wt >/= 4500g( ACOG)wt >/= 4500g( ACOG)
Postpartum EvaluationPostpartum Evaluation

75-g oral glucose tolerance test 6-75-g oral glucose tolerance test 6-
12weeks postpartum12weeks postpartum

18. Steps in managing gestational diabetes mellitus (GDM). Steps in managing gestational diabetes mellitus (GDM).
MNT = medical nutritional therapy, FPG = fasting plasma glucose.MNT = medical nutritional therapy, FPG = fasting plasma glucose.

19. PREGESTATIONAL PREGESTATIONAL
DIABETESDIABETES

aka “overt” diabetesaka “overt” diabetes

Random plasma glucose Random plasma glucose
>200mg/dL>200mg/dL

Polydipsia, polyuria, unexplained Polydipsia, polyuria, unexplained
wt losswt loss

Fasting glucose >125mg/dL (ADA)Fasting glucose >125mg/dL (ADA)

Dx cutoff: FPG >126mg/dLDx cutoff: FPG >126mg/dL

20. Fetal EffectsFetal Effects

MiscarriagesMiscarriages

Frequency directly related to degree Frequency directly related to degree
of maternal glycemic control.of maternal glycemic control.

Up to 44% with poorly controlled DM Up to 44% with poorly controlled DM
(HbA(HbA
11C >12).C >12).

Preterm DeliveryPreterm Delivery

Increase in both spontaneous and Increase in both spontaneous and
indicated preterm labor (<35 wks).indicated preterm labor (<35 wks).

21. Fetal MorbidityFetal Morbidity

Birth DefectsBirth Defects

1-2% risk among the general 1-2% risk among the general
population.population.

4-8 fold increased risk among 4-8 fold increased risk among
preexisting diabetics.preexisting diabetics.

Most common defects are CNS and CV, Most common defects are CNS and CV,
but also an increase in renal and GI but also an increase in renal and GI
abnormalities.abnormalities.

Up to a 600 fold increase in caudal Up to a 600 fold increase in caudal
regression syndrome.regression syndrome.

22. Fetal MorbidityFetal Morbidity

Growth RestrictionGrowth Restriction

Although we typically associate Although we typically associate
maternal DM with macrosomia, maternal DM with macrosomia,
growth restriction is fairly common growth restriction is fairly common
among Type 1 diabetic mothers.among Type 1 diabetic mothers.

Best predictor is presence of maternal Best predictor is presence of maternal
vascular disease.vascular disease.

23. Fetal EffectsFetal Effects

Unexplained Fetal DemiseUnexplained Fetal Demise
- - obvious placental insufficiency, abruption, obvious placental insufficiency, abruption,
fetal-growth restriction, oligohydramniosfetal-growth restriction, oligohydramnios
- LGA and die before labor @ 35weeks - LGA and die before labor @ 35weeks
or lateror later
Hyperglycemia-mediated chronic aberrations in Hyperglycemia-mediated chronic aberrations in
transport of oxygen and fetal metabolitestransport of oxygen and fetal metabolites

24. Fetal MorbidityFetal Morbidity

25. Fetal MorbidityFetal Morbidity

PolycythemiaPolycythemia

Hyperglycemia stimulates fetal erythropoeitin Hyperglycemia stimulates fetal erythropoeitin
production.production.

Can lead to tissue ischemia and infarction.Can lead to tissue ischemia and infarction.

HypoglycemiaHypoglycemia

Think of as an “overshoot” mechanism.Think of as an “overshoot” mechanism.

Baby is used to having lots of maternal glucose Baby is used to having lots of maternal glucose
so it makes lots of insulin. When born, so it makes lots of insulin. When born,
maternal glucose is no longer available but maternal glucose is no longer available but
insulin remains high insulin remains high  hypoglycemia. hypoglycemia.

Can lead to seizures, coma and brain damage.Can lead to seizures, coma and brain damage.

26. Fetal MorbidityFetal Morbidity

Postnatal hyperbilirubinemiaPostnatal hyperbilirubinemia

Occurs in appox. 25%, double that of Occurs in appox. 25%, double that of
normal.normal.

Thought to be due in large part to Thought to be due in large part to
polycythemia.polycythemia.

Respiratory distress syndromeRespiratory distress syndrome

5-6 fold increased frequency.5-6 fold increased frequency.

May be due to a delay in lung maturation May be due to a delay in lung maturation
or simply due to the increased frequency or simply due to the increased frequency
of preterm deliveries.of preterm deliveries.

27. Fetal MorbidityFetal Morbidity

PolyhydramniosPolyhydramnios

Amniotic fluid volume >2000 mL.Amniotic fluid volume >2000 mL.

Occurs in 10% of diabetics.Occurs in 10% of diabetics.

Increased risk of placental abruption Increased risk of placental abruption
and preterm labor.and preterm labor.

28. Fetal MorbidityFetal Morbidity

HypocalcemiaHypocalcemia
- total serum calcium <8mg/dL- total serum calcium <8mg/dL
- aberrations in Mg-Ca economy, - aberrations in Mg-Ca economy,
asphyxia, and preterm birthasphyxia, and preterm birth

CardiomyopathyCardiomyopathy
- hypertrophic cardiomyopathy - hypertrophic cardiomyopathy
progressing to CHFprogressing to CHF
- high NT-proANP- high NT-proANP
- disappears @ 6mos- disappears @ 6mos

29. Fetal MorbidityFetal Morbidity

Inheritance of DiabetesInheritance of Diabetes
- 1-3% risk of developing T1DM- 1-3% risk of developing T1DM
- 6% father only- 6% father only
- 20% both parents- 20% both parents

Long-Term Cognitive Dev’tLong-Term Cognitive Dev’t
- negligible impact - negligible impact

30. Maternal MorbidityMaternal Morbidity

Increased risk of DKA due to Increased risk of DKA due to
increasingly resistant DM.increasingly resistant DM.

Increased incidence of UTI due to Increased incidence of UTI due to
glucose-rich urine and urinary stasis.glucose-rich urine and urinary stasis.

Glucosuria is a normal finding of Glucosuria is a normal finding of
pregnancy but may be much higher in pregnancy but may be much higher in
diabetics.diabetics.

Diabetic retinopathyDiabetic retinopathy

Diabetic nephropathyDiabetic nephropathy

31. Maternal MorbidityMaternal Morbidity

Diabetic nephropathyDiabetic nephropathy

Diabetic neuropathyDiabetic neuropathy

Diabetic retinopathyDiabetic retinopathy

Diabetic ketoacidosisDiabetic ketoacidosis

Infections Infections

PreeclampsiaPreeclampsia

2-fold increase2-fold increase

32. DiagnosisDiagnosis

Glucose Challenge Test (24-28 wks)Glucose Challenge Test (24-28 wks)

50 gram glucose load with blood level 50 gram glucose load with blood level
1 hour later.1 hour later.

Does NOT require fasting state.Does NOT require fasting state.

Normal finding is <140 mg/dl.Normal finding is <140 mg/dl.

If >140, need to do a 3 hour glucose If >140, need to do a 3 hour glucose
tolerance test.tolerance test.

33. DiagnosisDiagnosis

Glucose Tolerance TestGlucose Tolerance Test

Draw a fasting glucose level (normal<95).Draw a fasting glucose level (normal<95).

Give 100 gram glucose load with glucose Give 100 gram glucose load with glucose
levels drawn after 1, 2 and 3 hours.levels drawn after 1, 2 and 3 hours.

Normal levels vary widely depending on Normal levels vary widely depending on
who you ask but should be in the who you ask but should be in the
following ranges:following ranges:

1 hr:<180 2 hr:<155 3 hr:<1401 hr:<180 2 hr:<155 3 hr:<140

2 or more abnormal values = GDM.2 or more abnormal values = GDM.

34. Treatment and Treatment and
ManagementManagement

Obviously the main goal is to Obviously the main goal is to
maintain good glycemic control.maintain good glycemic control.

Typically controlled with insulin but Typically controlled with insulin but
oral hypoglycemic agents like oral hypoglycemic agents like
glyburide are also showing promise.glyburide are also showing promise.

35. Treatment and Treatment and
ManagementManagement

Obstetrical managementObstetrical management

Serial US to trend fetal growth, AFI and fetal Serial US to trend fetal growth, AFI and fetal
anatomyanatomy

Fetal well-being monitored with kick counts, Fetal well-being monitored with kick counts,
NSTs, BPPsNSTs, BPPs

Postpartum, 95% of GDM mothers Postpartum, 95% of GDM mothers
return to normal glucose tolerance, and return to normal glucose tolerance, and
require no further insulin.require no further insulin.

Glucose tolerance screen 2-4 mo. Glucose tolerance screen 2-4 mo.
postpartum to detect those that remain postpartum to detect those that remain
diabetic.diabetic.

36. Preconceptional CarePreconceptional Care

Self monitoring Self monitoring
- preprandial glucose level 70-100mg/dL- preprandial glucose level 70-100mg/dL
- postprandial <140mg/dL @1hr; 120mg/dL - postprandial <140mg/dL @1hr; 120mg/dL
@ 2hrs@ 2hrs

Glycosylated hemoglobinGlycosylated hemoglobin
- ave of circulating glucose in the past 4-- ave of circulating glucose in the past 4-
8weeks8weeks
- early metabolic control- early metabolic control

37. First TrimesterFirst Trimester

Monitoring of glulcose controlMonitoring of glulcose control

HospitalizationHospitalization
Insulin TreatmentInsulin Treatment

Multiple daily insulin injectionsMultiple daily insulin injections
- Subcutaneous insulin infusion - Subcutaneous insulin infusion

Adjustments of dietary intakeAdjustments of dietary intake

38. Diet Diet

Normal: 30-35 kcal/kg, taken in 3meals Normal: 30-35 kcal/kg, taken in 3meals
and 3 snacks dailyand 3 snacks daily

Underwt: 40kcal/kg/dUnderwt: 40kcal/kg/d

>120% ideal wt: 24kcal/kg/d>120% ideal wt: 24kcal/kg/d

Ideal Dietary CompositionIdeal Dietary Composition
-Carbohydrate 55%-Carbohydrate 55%
-Protein 20%-Protein 20%
-Fat 25%-Fat 25%

39. Hypoglycemia Hypoglycemia

Preprandial plasma glucose Preprandial plasma glucose
143mg/dL: pregnant143mg/dL: pregnant

<155mg/dL :nonpregnant woman<155mg/dL :nonpregnant woman
Second TrimesterSecond Trimester

Decreased AFPDecreased AFP

Euglycemia:goal of txEuglycemia:goal of tx

Individualized programs: necessaryIndividualized programs: necessary

Increased insulin @ 24weeksIncreased insulin @ 24weeks

40. Third Trimester and Third Trimester and
DeliveryDelivery

White class B or C: CS deliveryWhite class B or C: CS delivery

Adequate IV hydration, glucose at Adequate IV hydration, glucose at
sufficient amounts to maintain sufficient amounts to maintain
normoglycemianormoglycemia

Plasma glucose check regularlyPlasma glucose check regularly

Regular insulin administration Regular insulin administration

41. ReferencesReferences
www.acog.org

Williams Obstetrics (23Williams Obstetrics (23
rdrd
edition) edition)

42. THANK YOU !!!
