Diabetes Mellitus in Pregnancy

1. DIABETES MELLITUS IN
PREGNANCY
Izyan Mohammad

2. DEFINITIONS
Diabetes Mellitus in Pregnancy falls into 2 categories:
1.Gestational Diabetes Mellitus (GDM) – Any
degree of glucose intolerance with onset or first
recognition during pregnancy. Does not
exclude possibility that unrecognised glucose
intolerance may have been present before
onset of pregnancy.
2.Pre-gestational Diabetes Mellitus – diagnosed
when the woman has diabetes before
pregnancy.

3. GESTATIONAL DIABETES MELLITUS
(GDM)

4. Physiology
Pregnancy  ↑ HPL + cortisol (insulin antagonists)
Mother  relative insulin resistance esp 3
rd
trimester
Maternal pancreas  ↑ insulin to maintain carbohydrate
metabolism  ↓ FPG
Carbohydrate intake  ↑ glucose than non-pregnant lady
Glucose crosses placenta by facilitated diffusion and the
fetal blood glucose level closely follows the maternal level
Therefore, fetal glucose levels therefore is normally
maintained within normal limits, as in mother.

5. Modified Penderson Theory: Impact of
Maternal Hyperglycaemia During Pregnancy
MATERNAL PLACENTA FOETAL
↓ Insulin release
↓ glucose utilisation
Hyperglycaemia Hyperglycaemia
↑ Insulin
(hyperinsulinaemia)
Birth weight ↑
↑ Lipid &
↑ Glycogen
? Altered structure
and/or function

6. GDM IN FIRST TRIMESTER
Women found to have fasting hyperglycaemia or
abnormal glucose intolerance in the first
trimester might have pre-existing diabetes
Should be treated as women with glucose
intolerance before pregnancy
First trimester hyperglycaemia  high risk of
congenital abnormalities in foetus

7. SCREENING FOR GDM
Women with high risk of GDM:
BMI >30kg/m
2
First degree relative with Diabetes
Personal history of GDM
Previous macrosomic baby ≥4.5kg
Family origin with high diabetes prevalance (South
Asian, African-Caribbean, Middle-Eastern)
*Previous poor obstetrics outcomes usually associated
with diabetes

8. PRE-GESTATIONAL DIABETES

9. TYPE 1 AND TYPE 2 DIABETES
Pre-conception care is essential
If untreated in first few weeks gestation,
associated with:
Spontaneous abortions
Birth defects
If untreated during 2
nd
or 3
rd
trimester, associated
with:
Foetal macrosomia and metabolic abnormalities
Birth injury
Maternal hypertension and pre-eclampsia
Future diabetes and/or obesity in child

10. PRE-PREGNANCY COUNSELLING
To assess suitability for pregnancy
To look for complications of diabetes, evaluate
and treat complications prior to onset of
pregnancy
To achieve optimal control prior to and during
very early pregnancy
To provide an opportunity for pre-pregnancy
advice and folate supplements

11. MEDICAL ASSESSMENT IN PRE-
CONCEPTION CARE
Duration and type of diabetes
Medical history and current medical
management plan
Chronic diabetes complications:
Retinopathy
Nephropathy
Neuropathy
Co-morbid conditions (in addition to diabetic
complications)
Hypertension (ideal blood pressure <120/80)
Coronary Artery Disease
Hyper- or Hypothyroidism
Other auto-immune disease

12. PREVENTING RETINOPATHY
PROGRESSION
Rapid normalization
of blood glucose
during pregnancy can
trigger retinopathy
progression
Retinal status should
stabilized prior to
conception
Reassess retinal
status each trimester
(more frequently if
retinopathy is
present)

13. RECOMMENDATIONS
Plan pregnancies
Attain a pre-conception HbA1c of < 7%
If planning pregnancy:
Needs retinal screening prior to conception
Screen for diabetic retinopathy and coronary heart
disease
Discontinue oral hypoglycaemic agents and attain
glycaemic targets using insulin, if possible
Replace ACEI and ARBs to other hypertensives that
are safe to take in pregnancy
Stop statins

14. POSSIBLE CONTRA-INDICATIONS
TO PREGNANCY
Ischaemic Heart Disease
Active, unrelated proliferative retinopathy
Renal insufficiency
Severe Gastroparesis
Inability or unwillingness to use Insulin

15. RISKS TO MOTHER WITH
GESTATIONAL DIABETES
Increased risk of Caesarian Section
Pre-eclampsia (2-4 x esp with co-existing
microalbuminuria/frank nephropathy)
Polyhydramnios
Pre-term labour
Post-Partum Haemorrhage
Temporary worsening of renal function
Progression of retinopathy
↑ incidence of infection, severe hyperglycaemia/hypoglycaemia,
DKA
In future:
Recurrent GDM Pregnancies
Risk of developing T2DM (50% in 5 - 10 years)

16. POTENTIAL COMPLICATIONS IN
INFANTS OF MOTHERS WITH
DIABETES
Intra-uterine demise
Spontaneous abortions
Stillbirth (10-30%)
Congenital
malformations
Neural tube defects
Cardiac defects
Caudal Regression
syndrome (rare)

17. POTENTIAL COMPLICATIONS IN
INFANTS OF MOTHERS WITH
DIABETES
Macrosomia
Visceromegaly
Cardiac enlargement
Hepatic enlargement
Respiratory Distress
Syndrome
Asphyxia
Birth injury
Shoulder Dystocia
Erb’s Palsy
Diaphragmatic
paralysis
Facial paralysis

18. MACROSOMIA

19. POTENTIAL COMPLICATIONS IN INFANTS
OF MOTHERS WITH DIABETES
Metabolic complications
Hypoglycaemia (high insulin production in
immediate neonatal period due to recent foetal
hyperglycaemia)
Mothers encouraged to breastfeed ASAP; monitor baby’s
blood glucose; formula-fed or glucose infusion prn
Hypocalcaemia, magnesium deficiency  apnoeic
episodes and fits
Polycythaemia  hyperbilirubinaemia  jaundice
Partial exchange transfusion

20. Management: Obstetrics
Nuchal Traslucency Scan
Detailed US for foetal anomalies
Foetal echocardiography
Serial growth scan
Monitor foetal well-being (doppler US & CTG)
Aim: vaginal delivery between 38 – 40 weeks
50% Ceasarian section because of macrosomia,
pre-eclampsia and failed induction of labour

21. Management: preterm labour &
polyhydramnios
Difficult
Tocolytics (e.g. ritodrine, salbutamol) are
diabetogenic
I/M steroid for foetal lung maturation 
destabilize diabetic control
I/V insulin / glucose infusion if required to ensure
normoglycaemia

22. Management: Intrapartum
Induced/Spontaneous labour  sliding scale of
insulin to maintain normoglycaemia
Test maternal blood glucose hourly
Continuous foetal monitoring advised
Foetal scalp blood sampling if CTG abnormal

23. Management: Post-delivery
Insulin requirements return to pre-pregnant
levels
If GDM, stop insulin
OGTT 6/52 post-delivery to ensure diabetes has
resolved

24. THANK YOU FOR LISTENING