Diabetes in pregnancy-overt diabetes: type I DM, type II DM,Gestational diabetes mellitus(GDM)

Diabetes in pregnancy-overt diabetes: type I DM, type II DM,Gestational diabetes mellitus(GDM).Complications:Maternal, Fetal
Screening test- OGCT (Oral glucose challenge test), Diagnostic test-OGTT(Oral glucose tollerance test.Management- meal plan, excersise, insuline schedule, antenatal management, obstetric management,induction of labour, cesarean, normal delivery,management after delivery, puerparial management, follow up,contraception in women with history of GDM ,councelling

1. DIABETES IN PREGNANCY

2. Types
1. Overt or Pregestational DM

A. Type–1 (IDDM) is characterized by young age onset
(Juvenile) and absolute insulinopenia.
They have genetic predisposition with presence of autoantibodies.
B. Type–2 (NIDDM) is characterized by late age onset, overweight woman and
peripheral tissue(skeletal muscle, liver) insulin resistance
(hyperinsulinemia).Genetic predisposition is there.
2. Gestational DM

3. ●By pregnancy hormones
●To provide glucose and glycogenic precursors for the ‘parasitic’ use of the
fetus.
●Provide alternative fuel substrate for the mother.
Changes that occur in carbohydrate metabolism in
pregnancy:

4. ➔Increase in insulin antagonising hormones
-Human placental lactogen- lipolysis ,increases FFA concentration &
antagonises insulin action in periphery
-Estrogen, Progesterone, Cortisol- diabetogenic
➔Placental insulinase- accelerates degradation of insulin- contributing to
diabetogenic state.

5. As a result of continuous use of glucose from the maternal
circulation by the fetus :
●Low fasting blood glucose level & Higher concentration of plasma-free
fatty acids – Accelerated starvation stage
●Decreased gastric emptying & delayed absorption – slow rise in the blood
glucose level after an oral glucose load.
●Due to the peripheral resistance to insulin, blood sugar does not return to
the fasting level after 2 hours, as in the non-pregnant state

6. Glycosuria in pregnancy
➔Repeat and random urine samples taken on one or more occasions throughout
pregnancy reveal glycosuria in about 5–50% cases.
➔During pregnancy, renal threshold is diminished due to the combined effect of increased
glomerular filtration and impaired tubular reabsorption of glucose.
➔ It is present most commonly in mid pregnancy.
➔
If glucose tolerance test is done, glucose leaks out in the urine even though the blood
sugar level is well below 180 mg/100 mL (normal renal threshold).
➔ No treatment is required and the condition disappears after delivery.

7. Maternal
During pregnancy:
1.Abortion: Recurrent spontaneous abortion may be associated with uncontrolled diabetes.

2. Preterm labor (26%) may be due to infection or polyhydramnios.
3. Infection: Urinary tract infection and vulvovaginitis.
4. Increased incidence of preeclampsia (25%).
5. PIH
Effects of DM on pregnancy

8. Hydramnios
Normal
6. Hydramnios (25–50%) is a common association. large baby, large placenta, fetal
hyperglycemia leading to polyuria, increased glucose concentration of liquor irritating the
amniotic epithelium or increased osmosis, are some of the probabilities.

9. 7.Maternal distress may be due to the combined effects of an oversized fetus and
polyhydramnios.
8. Diabetic retinopathy is characterized by the proliferative retinopathy having
neovascularization and microaneurysms. These vessels may rupture and may cause vitreous
hemorrhage, scarring, retinal detachment and loss of vision.
Severity of retinal pathology depends on (a) age (time) of onset, (b) duration of the disease, (c)
degree of rise in blood HbAIC and (d)association of hypertension.
Laser photocoagulation is the preferred treatment.
9.Diabetic nephropathy is diagnosed when creatinine clearance is reduced or there is
persistent proteinuria (≥300 mg/24 hours) during the first 20 weeks of gestation. Predictive
factors for perinatal outcome (e.g., low birth weight, preterm delivery or preeclampsia) are:
(a) Proteinuria > 3 g/24 hours,
(b) serum creatinine > 1.5 mg/dl .

10. Most women (90%) develop preeclampsia. Control of hypertension is important to prevent
further deterioration of kidney function. Calcium channel blocker is commonly used.
These women have significantly reduced life expectancy.
The disease progression is characterized by hypertension, falling glomerular filtration rate and
creatinine clearance.
The end stage disease needs dialysis or renal transplantation. Renal transplantation improves
survival of women with diabetic nephropathy.
10.Coronary artery disease : These women run the high risk for ischaemic heart disease
especially when the disease is long standing.
11.Ketoacidosis

11. During labour:

There is increased incidence of:
(1) Prolongation of labour due to big baby.
(2) Shoulder dystocia
is due to disproportionate growth with increased shoulder/head ratio.
(3) Perineal injuries.
(4) Postpartum hemorrhage.
(5) Operative interference.
Puerperium:
(1) Puerperal sepsis.
(2) Lactation failure
Operative & Anaesthetic
morbidity and mortality

12. Fetal and neonatal hazards
1.Fetal macrosomia (40–50%)
with birth weight > 4 kg (>90th percentile) probably results from :
(a) Maternal hyperglycemia → hypertrophy and hyperplasia of the fetal islets
➔Uncontrolled DM.
➔
Maternal hyperglycemia.
➔Fetal hyperglycemia
➔
Fetal hyperinsulinemia
➔Stimulation of excessive somatic growth
➔Except for brain,most fetal organs are affected by macrosomia
➔Excessive fat deposition on shoulder and trunk-predesposition for shoulder dystocia

14. ➔
Insulin like growth factors (IGF-I and II) are also involved in fetal growth and adiposity.
➔ With good diabetic control, incidence of macrosomia is markedly reduced.
(b)Elevation of maternal free fatty acid (FFA) in diabetes leads to its increased transfer to the
fetus
→ acceleration of triglyceride synthesis → adiposity.
2.Impaired psychomotor development due to DKA in mother.
3.Congenital malformation (6–10%) is related to the severity of diabetes affecting
organogenesis, in the first trimester (both in type 1 and type 2 diabetes).

(Risks of fetal chromosomal abnormalities are not increased.)

15. 4.Birth injuries (brachial plexus) are associated with prolonged labor and shoulder
dystocia due to macrosomic baby.
5.Growth restriction is less commonly observed and is associated with maternal
vasculopathy.
Placental amino acid transporters are involved in fetal macrosomia or IUGR in women with
diabetes.
6.Fetal death has got multifactorial pathogenesis but the final event being hypoxia and lactic
acidemia
➔
In overt DM- still birth
➔
Fasting hyperglycemia > 105 mg/dl – risk for fetal death during last 4-8 wks.

Fetal hyperglycemia and hyperinsulinemia increase fetal oxygen demand.
Glycosylated hemoglobin carries less oxygen molecule.
It binds O 2 more avidly and releases O 2 less.
Other factors involved are fetal polycythemia, and hyperviscosity

18. Neonatal complications include—
(a) Hypoglycemia (< 35 mg/dl) is due to hyperinsulinemia. It
is common in macrosomic infants.
(b) Respiratory distress syndrome is due to excess level of fetal
insulin that blocks the action of cortisol.
Cortisol activates type II pneumocytes for the synthesis of phospholipids (surfactant).
Risk of RDS is reduced when diabetes is well controlled and delivery is done after 38
weeks of gestation
(c) Hyperbilirubinemia is high (25% to 50%) due to
increased red cell production (polycythemia) and break down of red cells
(d) Polycythemia
(e) Hypocalcemia (≤7 mg/dl)
(f) Hypomagnesemia (<7 mg/dl)
(g) Cardiomyopathy Septal hypertrophy and cardiac hypertrophy are also observed.
(h) RVT
long-term effects—childhood obesity, neuropsychological effects and diabetes.

19. Perinatal mortality:
The overall perinatal mortality is increased 2–3 times.
The neonatal deaths are principally due : to hypoglycemia, respiratory distress syndrome,
polycythemia and jaundice.

20. Birth defects

21. Neural tube defect
Anencephaly
Microcephaly

22. Caudal regression syndrome
Sacral agenesis
Omphalocele

23. Tracheo
esophageal
fistula

24. Potential candidate for GDM
(a) Positive family history of diabetes

(b) Having a previous birth of an
overweight baby of 4 kg or more
(c) Previous stillbirth with pancreatic islet
hyperplasia revealed on autopsy
(d) Unexplained perinatal loss

(e) Presence of polyhydramnios or
recurrent vaginal candidiasis in
present pregnancy
(f ) Persistent glycosuria
(g) Age over 30 years

(h) Obesity

(i) Ethnic
group (East Asian, Pacific island
ancestry).

25. Screening strategy for detection of GDM
(a) Low risk—Absence of any risk factors → blood glucose testing is not
routinely required
(b) Average risk—Some risk factors → perform screening test
(c) High risk—Blood glucose test as soon as feasible.

26. A plasma glucose level of 140 mg% is taken
as cut off point for consideration of a 100 gm (WHO– 75 gm)
glucose tolerance test.
Oral Glucose Challenge Test (OGCT) which was earlier done as a
screening test, is now considered as both screening and diagnostic
test.
Method : 50 gm oral glucose load is taken by the patient without
regard to time of day or last meal,after 1 hr plasma glucose level is
estimated, between 24 weeks and 28 weeks of pregnancy.

Screening test for diabetes
Aim - take care of pregnant women in the community.

27. India- screening is essential in all preg.women,
Incidence of GDM – 16.55%(2004),

Diabetes in Pregnancy-Awarness and
Prevention Project –
Prevalence=17.8% in urban,

13.8% in semi urban

9.9% in rural
27 million
Women
-reproductive age
10%
avg prevalence
3 million
Women
With GDM One in every 5
th
pregnant women is likely to have GDM

28. World Health Organization (WHO) and Diabetes in Pregnancy Study
Group India (DIPSI) do not recommend screening test, they suggest
direct diagnostic test.
While some advocate screening routinely to all pregnant mothers,
others reserve it only for the potential candidates.

29. Diagnosis of diabetes
Diagnostic test Week of pregnancy
I Diagnostic Test
II Diagnostic Test
III Diagnostic Test
Ideally, 12-16 weeks or at the time of 1
st

visit for ANC ckeckup
24-28 weeks
32-34 weeks
When to perform diagnostic test ?

30. Diagnostic test :
OGTT
Glucose 75 gm
+
300 ml of water
Venous blood drawn
2 hr
Plasma glucose tested
using
Autoanalyser/ semi
Auto analyser
Capillary blood testing
Glucometer
or
Irrespective
Of the
Time of her
Last meal

31. Diagnostic test-interpretation:
Those women who tested normal with DT at 12-16 weeks should
undergo repeat DT at 24-28 weeks and if found normal again, DT is to
be repeated between 32 and 34 weeks.
Plasma glucose at
2-hr-post glucose load
Interpretation
<140 mg/dL NORMAL
>140 mg/dL GDM

32. Management
●Medical nutrition plan ( meal plan)
●Antenatal care-Exercise, Insulin schedule
●Obstetric care
Aim: to maintain two-hour post-prandial plasma glucose
(PPPG) level in the range of 110-120 mg/dL.
Principles of management : control of diabetes, obstetric management and timing of
delivery and specialised care for the newborn.

33. Meal plan(Medical nutrition therapy)
➔ All women diagnosed to have GDM should be advised to follow the meal
plan for 2 weeks.
➔Splitting the usual breakfast into two equal halves and consuming the
portions with a 2 hr gap in between.
➔
By this, the undue peak in plasma glucose levels after ingestion of the
total quantity of breakfast at one time is avoided.

34. The principles of the meal plan are to:
1. Avoid sugar, sweets, fruit juices and tubers like potatoes, tapioca, beetroot, sweet
potato, and so on
2. Avoid fasting and feasting
3. Eat to satisfy appetite
4. Eat more green leafy vegetables.
After 15 days of meal plan, two-hour PPPG has to be estimated preferably after
breakfast.
5 If PPPG is <120 mg/dl, she is under control by meal plan.
Continue the meal plan and repeat two-hour PPPG once every four weeks till
delivery, provided the values are normal at each testing

35. Diet for woman with GDM
➔
Normal weight woman - 2,000–2,500 Kcal/day
➔Over weight woman - restriction to 1,200–1,800 Kcal/day

➔
Carbohydrate should be 40–50% of total calories.
➔Complex carbohydrates are preferred because simple carbohydrates produce significant post-
prandial hyperglycemia.

36. Diet should contain :
Carbohydrate 40%–50%, protein 20%, fat 30–40% and saturated fat <10%.
Fat may be curtailed, if the patient is obese.
Fiber containing diet (complex carbohydrates) is increased.

Usually three meal regimen, with :
Breakfast 25% of the total calorie intake, lunch 30%, dinner 30% and several snacks are quite
suitable for most of the patients
30 Kcal/kg for normal weight women,
24 Kcal/kg for overweight women and
12 Kcal/kg for morbidly obese women.

37. Ideal plasma glucose (mg/dl) levels in women with pregestational diabetes should be:
Fasting < 95, premeal < 100; 2 hour P.P. values < 120 and morning (2 am–6 am) value > 60.
If values are exceeded even on diet, insulin therapy is suggested.

38. Antenatal care
Control of blood sugar:

Aim : To maintain 2-hour PPPG level in the range of 110-120 mg/dl.

1. Exercise: Moderate exercise of at least 30 minutes daily is prescribed
2. Insulin schedule:
➔ If blood sugar is not controlled by meal plan, initiate insulin therapy based on two-
hour PPPG after breakfast.
➔A postprandial (2 hours) plasma glucose level of more than 140 mg% even on
diet control is an indication of insulin therapy.

39. In overt diabetes-
➔It is difficult to achieve this goal.
➔Diabetes tends to be unstable in the first trimester due to the nausea and
vomiting associated with pregnancy.
➔
Some need to be hospitalised to achieve good control.
➔An increase in insulin requirement from about week 24 onwards.
➔
Close monitoring of blood sugar is essential-at two-weekly intervals
➔ If has been controlled in oral hypoglycemic agents prior to pregnant it is better to switch to
insulin therapy once pregnancy is confirmed, since oral hypoglycemic agents may cause fetal
defects.
➔
However, hypoglycemics are being used with caution as the period of organogensis with
varying results

40. Type I diabetes-
➔ketone testing- if they become hyperglycemic or unwell
➔Suspected DKA -should get admitted immediately in a critical care unit.

➔Optimum control of blood sugar can be achieved by diet alone or diet along with
insulin injections.

41. Do two hour PPPG
Normal
Repeat two-hour PPPG after two weeks
Plasma glucose within 120 mg/dl,
Plasma glucose level >120 mg/dL
Repeat the test every 15 days, and titrtate the dose to achieve the
two-hour PPPG between 110-120mg/dl
>120 mg/dL
Continue the same dose insulin.
Increase the dose by 2 to 4 units i.e., 6 to
8 units,
Intermediate acting insulin
(eg: Insulatard on premixed insulin 30/70,
four units, 30 minute before breakfast).
Insulin Schedule:

42. It is always better to take the help of a physician when the sugar
level becomes difficult to control, especially in overt diabetics.
If the insulin
dose
exceeds 16
units per
day
➔Split dose of insulin - 12 units in the
morning 8 units in
the night
➔monitor every 15 days, both fasting and
postprandial plasma glucose

43. Obstetric Management
Aim : recognising the complications of pregnancy associated with diabetes.
1. Thyroid function test and HbA
1
C at first booking
-HbA
1
C level of 5-6% is desirable.
-Incidence of major congenital malformations is more if the values rise to 9.5% or
more.
- HbA
1
C though desirable is not mandatory.

2. Nuchal scan
-as early as 11-14 weeks - It uses ultrasound to measure the thickness of the fluid
buildup at the back of the developing baby's neck. If this area is thicker than
normal, it can be an early sign of Down syndrome, trisomy 18, or heart problems..

44. 4. Renal assessment
-at first visit.
-Thromboprophylaxis should be given if proteinuria is >5 gm/dl.
5. Targeted ultrasound
Since there is an increased incidence of congenital malformations,
overt diabetics must be subjected to to detect any major anomalies.
6. Maternal serum alphafetoprotein concentration
-at 16-20 weeks gestation

-to detect neural tube defects in the fetus.

3. Retinal assessment
-at first visit, again at 28 weeks.
-If any diabetic retinopathy is present, an additional assessment at 16-20
weeks

45. 8. Antenatal check-up
-Done once in 2 weeks until 32 weeks, and then, weekly.
-At each visit complications should be looked for such as PIH, hydramnios and
macrosomia.
9. Hospitalisation
-should be advised whenever there is poor control of diabetes, diabetic ketoacidosis or if
any complications develop .
10. Antepartum surveillance
- in the form of non stress test, biophysical profile etc. should be started at around 32
weeks in all cases of overt diabetes, uncontrolled diabetes and in gestational diabetes
with any complications.
7. Fetal echo
- done between 24-26 weeks
-to detect any cardiac anomaly in the fetus.

46. Timing of delivery will depend on fetal well-being-
➔
If the patient has GDM which is well controlled on diet and there is no
macrosomia or hydramnios, pregnancy may be continued till near due date
with fetal surveillance.
➔
In overt diabetics, termination of pregnancy is considered at 37-38 weeks, if
the fetus is not under stress as indicated by fetal surveillance.
➔In all other situations, termination of pregnancy is determined by the tests of
fetal well-being, period of gestation and neonatal facilities.
➔
In any case, the pregnancy should not be allowed to overrun the EDD.

47. ADMISSION:
In uncomplicated cases, the patient is admitted at 34–36 weeks.
Early hospitalization facilities:
(1) Stabilization of diabetes
(2) Minimizes the incidence of preeclampsia, polyhydramnios
and preterm labor
(3) To select out the appropriate time and method of delivery

48. Management in labour
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mn
1
Co l u
mn
2
Co lu
mn
3
Induction of labour:
Indications —

(i) Diabetic women controlled on insulin (GDM or class B diabetes) are
considered for induction of labor after 38 completed weeks
(ii) Women with vascular complications (preeclampsia, IUGR)
often require induction after 37 weeks.

49. 1. Induction of labour is planned, the patient's morning dose of insulin is omitted and
fasting blood sugar, urine sugar and acetone are tested.
2 .An intravenous drip of normal saline or 5% glucose with neutralising dose of insulin is
started (Target level 70-130 mg %).
3. Other types of infusion are decided based on blood sugar levels which are estimated
hourly .Urine examination must be done to detect ketosis.
5. Labour is induced with oxytocics after priming the cervix, if required.
Procedure -

50. 6. The fetus is closely monitored to detect fetal distress early.
As soon as the patient reaches the active stage of labour, artificial rupture of
membranes is done to detect any meconium in the liquor
7. Cesarean section is performed if the baby is large or if there are other
obstetrical indications such as fetal distress.

5. Prophylactic antibiotics are started.
.
➔If the labour fails to start within 6–8 hours or if the labor progresses unsatisfactorily,
cesarean section should be performed.

51. Cesarean section
Indications —
(1) Fetal macrosomia (>4 kg
(2) Fetal dystress
(3) Diabetes with complications or difficult to control
(4) Fetal compromise as observed in antepartum fetal monitoring
(5) Elderly primigravidae
(6) Multigravidae with a bad obstetric history
(7) Obstetric complications like preeclampsia, polyhydramnios, malpresentation.
50% of diabetic mothers are
delivered by cesarean section.

52. Procedure:
➔Cesarean section is scheduled for early morning.
➔
On the day of operation, breakfast and the insulin dose are omitted.
➔
Capillary blood glucose level is checked with a glucose meter.
➔
A normal saline infusion is started.
➔
The administration of dextrose drip and the insulin dose are to be maintained as
mentioned in induction until the patient is able to take fluids by mouth

53. ➔Continuous subcutaneous insulin infusion with insulin
pump is preferred as it is more physiological.
➔
The insulin requirement suddenly falls following
delivery and after the omission of the drip, pre-
pregnant dose of insulin is to be administered or
adjusted from the blood glucose level.
➔
Epidural or spinal anesthesia is better than general
anesthesia as oral feeding could be started soon
following the operation.

54. Conditions in which pregnancy may be continued awaiting
spontaneous onset of labor at term -
(1) Young primigravidae or multiparae with good obstetric history
(2) Diabetes well controlled either by diet or insulin and without any obstetrical
complication.
However, in the absence of gadgets for assessment of fetal well-being, it is risky to
continue the pregnancy in such cases up to the EDD.
➔However, labor should not be allowed for more than an arbitrary 12 hours and should
be augmented by low rupture of the membranes and oxytocin or delivered by cesarean section.
➔Shoulder dystocia may be a problem .
➔The cord should be clamped immediately after delivery to avoid hypervolemia.

55. To control blood glucose:
(1) One litre of 5% dextrose drip is started with 10 units of soluble insulin
(2) A general guideline for insulin infusion rate is, 1 unit per hour for blood
glucose of 100–140 mg/dl, 2 units per hour for blood glucose of 141–180 mg/dl
and 3 units per hour for blood glucose of 181–220 mg/dL is followed.
Use of motorized syringe pump for insulin infusion is convenient
(3) Hourly estimation of blood glucose levels is done with glucose meter and the insulin
dose is adjusted accordingly.
The blood glucose level should be maintained between
80 and 100 mg per 100 ml

56. Care of the baby
➔
A neonatologist should be present at the time of delivery.
➔
The baby should preferably be kept in an intensive neonatal care unit and to remain
vigilant for at least 48 hours
➔Asphyxia is anticipated and be treated effectively
➔
To look for any congenital malformation.
➔All babies should have blood glucose to be checked within 2 hours of birth to avoid
problems of hypoglycemia (blood glucose < 35 mg/dl).
➔All babies should receive 1 mg vitamin K intramuscularly.
➔Early breastfeeding within half to 1 hour is advocated and to be repeated at 3 to 4
hourly intervals thereafter to minimize hypoglycemia and hyperbilirubinemi

57. Management in puerparium
1. Antibiotics are given to prevent any infection at immediate puerperium.
2. After delivery, in patients with overt diabetes, there is a rapid fall in the insulin requirement,
and here again, the dose should be adjusted by blood sugar estimation.
3. Patients with GDM often do not require any insulin after delivery.
4. Women with Type I diabetes should reduce their insulin immediately and monitor their blood
glucose.
5.Type II diabetic patients can resume or continue to take metformin and glibenclamide.
6. All GDM women should be offered an Oral Glucose Tolerance Test (OGTT), with 75 gm
glucose at 6 weeks postpartum.

58. Postpartum testing for mothers with GDM

➔Women diagnosed with GDM in pregnancy should undergo 75 gm OGTT to determine their
glycemic status, ideally between 6-12 weeks postpartum .

➔
If normal, the OGTT has to be repeated at six months and thereafter every year after delivery

59. Investigations Normal
FPG
PPPG
IFG(impaired
fasting glucose)
IGT(impaired
glucose tolerance)
Diabetes
<100 mg/dL
<140 mg/dL
100-199 mg/dL
140-199 mg/dL
>200 mg/dL
➔
Diagnostic criteria is that of non-pregnant
adults:

60. ➔If fasting hyperglycemia develops during pregnancy, diabetes is more likely to
persist postpartum.
➔
For those in whom the 75 g OGTT test is normal, a reassessment should be
done at intervals of three years.
➔More than half of women with gestational diabetes ultimately develop overt
diabetes in 20 years.

61. Contraception
➔
Barrier method of contraceptives is ideal for spacing of births.
➔
Low dose combined oral pills containing third generation progestins, are effective
and have got minimal effect on carbohydrate metabolism.

➔Main worry is their effect on vascular disease (thromboembolism and
myocardial infarction).
➔ Progestin only pill may be an alternative long acting progestins
are not used as a first line method.
➔
The IUCD may be used once diabetes is well controlled.

➔Permanent sterilization is considered when family is completed.

62. Preconceptional counselling
➔
Goal is to achieve tight control of diabetes before the onset of pregnancy.
➔Ideally a diabetic woman should be seen jointly by the diabetologist, obstetrician and
dietician.
➔Patient’s glycemic control and vascular status are assessed.
➔Folic acid supplementation (0.4 mg/day) should be started.
➔HbA
1
C level should be measured to plan pregnancy.
➔Women are taught for self-glucose monitoring.
➔
Appropriate advice about diet and insulin is given.

63. Pregnancy counselling in overt diabetes
➔Baseline glucose control and end organ damage should be
assessed , including renal function and retinopathy.
➔Glycosylated Hb estimation – control of sugar for the past 4-8 wks.
➔Folic acid supplementation