HYPERGLYCEMIA IN PREGNANCY by Dr Selim

HYPERGLYCEMIA IN PREGNANCY by Dr Shahjada Selim

1. HYPERGLYCEMIA IN
PREGNANCY
Dr Shahjada Selim
Assistant Professor
Department of Endocrinology
Bangabandhu Sheikh Mujib Medical University, Dhaka
Email: [email protected], [email protected]

2. Definition
Hyperglycemia is one of the most common
medical disorders seen in women during pregnancy.
The International Diabetes Federation (IDF)
estimates that one in six live births (16.8%) are to
women with some form of hyperglycemia in
pregnancy.
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International Diabetes Federation. IDF Diabetes Atlas, 8th edn. Brussels, Belgium: International Diabetes Federation, 2017.

3. Types of Hyperglycemia in Pregnancy
WHO 2013
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Fig 1: Hyperglycemia in pregnancy

4. Definition
Of them, 75 - 90% are gestational diabetes
mellitus.
 While 10-25% may be due to diabetes in
pregnancy (either pre- existing diabetes—type 1
or type 2—which antedates pregnancy or is first
identified during testing in the index pregnancy.
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International Diabetes Federation. IDF Diabetes Atlas, 8th edn. Brussels, Belgium: International Diabetes Federation, 2017.

5. DIP may either have been
•pre-existing diabetes (type 1 or type 2)
antedating pregnancy, or
•diabetes first diagnosed during
pregnancy (Figures 1 & 2).
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Diabetes in pregnancy (DIP)

6. 02/17/18Hyperglycemia in Pregnancy by Dr Selim 6

7. Similarly, any undiagnosed diabetes antedating
pregnancy may also have undiagnosed diabetic
complications including retinopathy and
nephropathy, which significantly increases
pregnancy risks.
Moreover, hyperglycemia during the critical
period of organogenesis may lead to a high risk
of congenital anomalies and spontaneous
abortions.
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Diabetes in Pregnancy (DIP)

8. Diabetes in Pregnancy (DIP)
Thus, meticulous blood glucose control
before conception and then throughout
pregnancy is recommended.
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9. Diabetes diagnosed in the second or third
trimester of pregnancy, which is not of overt
diabetes level.
Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes - 2018. Diabetes Care 2018; 41 (Suppl. 1):
S13-S27
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Gestational Diabetes Mellitus
(GDM)

10. *GDM implies a relatively milder form of
hyperglycemia compared with that of DIP,
but is also associated with a increased risk
of poor pregnancy outcome and future risk
of diabetes and cardiovascular disease,
and should be managed judiciously.
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11. Incidence
*GDM prevalence has been reported to vary
between 1%−28% in different region globally.
*International Diabetes Federation (IDF) estimates that
one in six live births (16.8%) are to women with some
form of hyperglycemia in pregnancy;
*10-25% of these may be due to DIP, while the majority
(75-90%) is related to GDM.
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12. The prevalence of high blood glucose (hyperglycaemia) in
pregnancy increases rapidly with age and is highest in women
over the age of 45.
International Diabetes Federation. IDF Diabetes Atlas, 8th edn. Brussels, Belgium: International Diabetes Federation, 2017.
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13. Hyperglycemia in pregnancy in women aged 20-49 years by IDF region,
2017

14. In 2017:
There were an estimated 204 million women (20-
79 years) living with diabetes. This number is
projected to increase to 308 million by 2045.
1 in 3 women with diabetes were of reproductive
age.
21.3 million or 16.2% of live births had some form
of hyperglycemia in pregnancy. An estimated
85.1% were due to gestational diabetes.International Diabetes Federation. IDF Diabetes Atlas, 8th edn. Brussels, Belgium: International Diabetes Federation, 2017.
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15. In 2017:
1 in 7 births was affected by gestational diabetes.
The vast majority of cases of hyperglycemia in
pregnancy were in low- and middle-income
countries, where access to maternal care is often
limited.
International Diabetes Federation. IDF Diabetes Atlas, 8th edn. Brussels, Belgium: International Diabetes Federation, 2017.
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16. Pathophysiology
*Early in pregnancy, maternal estrogen and
progesterone increase and promote pancreatic ß-cell
hyperplasia and increased insulin release
*As pregnancy progresses, increased levels of
human placental lactogen, cortisol, prolactin,
progesterone, and estrogen lead to insulin
resistance in peripheral tissues.
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17. Maternal Glucose Regulation
*Tendency for maternal hypoglycemia between
meals - fetal demand
*Increasing tissue insulin resistance during
pregnancy
­ Diabetogenic placental steroid
­ Estrogen, Progesterone
­hPL
*Increased insulin production (= 30% mean)
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18. Fetal
hyperinsulinemia
Fetus
Fetal pancreas stimulated
Mother
P
la
c
e
n
ta
Insulin
Maternal
hyperglycemia
The Impact of Maternal Hyperglycemia During Pregnancy
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19. Maternal Hyperglycemia
*Causes fetal hyperglycemia
*Leading to fetal hyperinsulinemia
*Fetal hyperinsulinemia - even short periods (1-2
hours) lead to detrimental consequences in:
*fetal growth
*fetal well-being
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20. Fetal Hyperinsulinemia
*Promotes storage of excess nutrients –
*macrosomnia
*Increased catabolism of excess nutrients - energy
usage and low fetal oxygen storage
*Episodic fetal hypoxia
*Increased catecholamines causing:
*hypertension
*cardiac hypertrophy
*Increased Erythropoietin:
*Hyperbilirubinaemia
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21. Pathophysiology …..cont
*Table 1 describes the diabetogenic potency and
time of peak effect of these hormones. The timing of
these hormonal events is important in regard to
scheduling testing for GDM.
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22. Pathophysiology
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23. *GDM results when there is delayed or insufficient insulin secretion in the presence of
increasing peripheral resistance
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24. Increased lipolysis
 Mother uses fat for her caloric needs &
serves glucose for fetal needs
 Changes of gluconeogenesis
 Fetus preferentially utilizes alanine & other
amino acids deprivng the mother of major
neoglucogenic source
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25. Complication of GDM
Maternal effect:
Associated with poor glycemic control
Increased maternal mortality
Preeclampsia
Birth canal trauma
Long term- Metabolic syndrome
Increased CVS risk

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26. Complication of GDM cont.
Fetal Effect:
Fetal Macrosomia
Still birth
Birth injury
Long term- obesity and DM in offspring
Hypoglycemia
Hyperbilirubinemia
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27. The Impact of Fetal Macrosomnia
•Increased hyperbilirubinemia
•Increased hypoglycemia
•Increased acidosis
•Increased birth trauma
•Macrosomic children are more likely to develop
glucose intolerance in adulthood
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28. Perinatal Risks for All Diabetic Pregnancies:
Mortality/Morbidity
Miscarriage
IUGR
Macrosomia
Birth Injury
Stillbirth
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29. Neonatal Risks for All Diabetic Pregnancies:
Morbidity and Mortality
•Polycythemia and hyperviscosity
•Neonatal hypoglycemia
•Neonatal hypocalcemia
•Hyperbilirubinemia
•Hypertrophic and congestive cardiomyopathy
•RDS
•Childhood impaired glucose tolerance
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30. Risk assessment
Low risk status:
 Age <25 years
Weight normal before pregnancy
Member of an ethnic group with low
prevalence of GDM
No first degree relative of DM
No H/O abnormal glucose tolerance

No H/O poor obstetric outcome
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31. Risk assessment
High risk status:

Obesity
Advanced maternal age, >25 yrs
Asian origin irrespective of age
Previous H/O DM or abnormal glucose tolerance
Glycosuria
H/O poor obstetric outcome
``
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32. *Test for undiagnosed T2DM at the 1
st

prenatal visit in those with risk factors. B
*Test for GDM at 24–28 weeks of gestation in
women not previously known to have
diabetes.
*Screen women with GDM for persistent
diabetes at 4–12 weeks postpartum, using
the OGTT.
ADA Recommendations:
Detection and Diagnosis of GDM 2018
American Diabetes Association Standards of Medical Care in Diabetes.
Classification and diagnosis of diabetes. Diabetes Care 2016; 39 (Suppl. 1): S13-S22
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33. *If GDM is not Dx. repeated at 24-28 wks or
at any time a pt. has a symtoms or signs
suggestive of hyperglycemia
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34. *Women with GDM history should have lifelong
screening for development of diabetes or
prediabetes at least every 3 years.
*Women with GDM history found to have
prediabetes should receive lifestyle
interventions or metformin to prevent diabetes.
Detection and Diagnosis of GDM
American Diabetes Association Standards of Medical Care in Diabetes.
Classification and diagnosis of diabetes. Diabetes Care 2016; 39 (Suppl. 1): S13-S22
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35. *At 24-28 weeks gestation in women not
previously dx’d with overt diabetes
*75-g OGTT; Measure plasma glucose at fasting
and at 1 and 2 hours.
*GDM dx’d when plasma glucose exceeds:
*Fasting: 92 mg/dL (5.1 mmol/L)
*1 h: 180 mg/dL (10.0 mmol/L)
*2 h: 153 mg/dL (8.5 mmol/L)
One-Step Strategy
American Diabetes Association Standards of Medical Care in Diabetes.
Classification and diagnosis of diabetes. Diabetes Care 2016; 39 (Suppl. 1): S13-S22
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36. Two-step Strategy
Step 1:
* In women not previously dx’d with overt
diabetes, perform 50-g GLT (nonfasting); Measure
plasma glucose at 1 hour.
* If 1 hour plasma glucose level is ≥140 mg/dL*
(7.8 mmol/L), proceed to step 2.
*ACOG recommends 135 mg/dL in high-risk ethnic minorities with
higher prevalence of GDM.
American Diabetes Association Standards of Medical Care in Diabetes.
Classification and diagnosis of diabetes. Diabetes Care 2016; 39 (Suppl. 1): S13-S22
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37. Step 2: 100-g OGTT is performed while patient is fasting. The
diagnosis of GDM is made if 2 or more of the following plasma
glucose levels are met or exceeded:
Two-step Strategy
American Diabetes Association Standards of Medical Care in Diabetes.
Classification and diagnosis of diabetes. Diabetes Care 2016; 39 (Suppl. 1): S13-S22
Carpenter/Coustan or NDDG
Fasting 95 mg/dL (5.3 mmol/L) 105 mg/dL (5.8 mmol/L)
1h 180 md/dL (10.0 mmol/L) 190 mg/dL (10.6 mmol/L)
2h 155 mg/dL (8.6 mmol/L) 165 mg/dL (9.2 mmol/L)
3h 140 mg/dL (7.8 mmol/L) 145 mg/dL (8.0 mmol/L)
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38. MANAGEMENT ISSUES

*Patient education
*Medical Nutrition therapy
*Pharmacological therapy
*Glycemic monitoring: SMBG and targets
*Fetal monitoring: ultrasound
*Planning on delivery

39. Treatment plan
Multi disciplinary approach
Close monitoring & treatment of
GDM are very important for mother
& baby
Lifestyle modification
Pharmacotherapy
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40. Multi-disciplinary approach
Obstetrician
Endocrinologist
Physician
Dietician
Pediatrician
Diabetic nurse.
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41. Preconception Counseling:
*Starting at puberty, preconception counseling
should be incorporated into routine diabetes
care for all girls of childbearing potential.
*Family planning should be discussed and
effective contraception should be prescribed
and used until a woman is prepared and
ready to become pregnant.
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Management of Diabetes in Pregnancy: Standards of Medical Care in Diabetes - 2018. Diabetes Care 2018; 41 (Suppl. 1): S137-S143
Hyperglycemia in Pregnancy by Dr Selim

42. Preconception Counseling
*Preconception counseling should address the
importance of glycemic control as close to
normal as is safely possible, ideally <6.5%, to
reduce the risk of congenital anomalies.
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Management of Diabetes in Pregnancy: Standards of Medical Care in Diabetes - 2018. Diabetes Care 2018; 41 (Suppl. 1): S137-S143
Hyperglycemia in Pregnancy by Dr Selim

43. *Women with preexisting type 1 or type 2 diabetes
who are planning pregnancy or who have become
pregnant should be counseled on the risk of
development and/or progression of diabetic
retinopathy.
Management of Diabetes in Pregnancy:
Standards of Medical Care in Diabetes - 2018. Diabetes Care 2018; 41 (Suppl. 1): S137-S143
02/17/18Hyperglycemia in Pregnancy by Dr Selim 43
Preconception Testing:
Management of Diabetes in Pregnancy: Standards of Medical Care in Diabetes - 2018. Diabetes Care 2018; 41 (Suppl. 1): S137-S143

44. *Dilated eye examinations should occur before
pregnancy or in the first trimester, and then
patients should be monitored every trimester and
for 1-year postpartum as indicated by the degree
of retinopathy and as recommended by the eye
care provider.
Management of Diabetes in Pregnancy:
Standards of Medical Care in Diabetes - 2018. Diabetes Care 2018; 41 (Suppl. 1): S137-S143
02/17/18Hyperglycemia in Pregnancy by Dr Selim 44
Preconception Testing:
Management of Diabetes in Pregnancy: Standards of Medical Care in Diabetes - 2018. Diabetes Care 2018; 41 (Suppl. 1): S137-S143

45. Glycemic Targets:
*Fasting and postprandial self-monitoring of
blood glucose are recommended in both
GDM and preexisting diabetes in
pregnancy to achieve glycemic control.
Some women with preexisting diabetes
should also test blood glucose
preprandially.
Management of Diabetes in Pregnancy:
Standards of Medical Care in Diabetes - 2018. Diabetes Care 2018; 41 (Suppl. 1): S137-S143
02/17/18Hyperglycemia in Pregnancy by Dr Selim 45
Management of Diabetes in Pregnancy: Standards of Medical Care in Diabetes - 2018. Diabetes Care 2018; 41 (Suppl. 1): S137-S143

46. Glycemic Targets:
*Due to increased red blood cell turnover, A1C is
slightly lower in normal pregnancy than in normal
nonpregnant women.
*The A1C target in pregnancy is 6-6.5%; <6% may
be optimal if this can be achieved without
significant hypoglycemia, but the target may be
relaxed to <7% if necessary to prevent
hypoglycemia.
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Management of Diabetes in Pregnancy: Standards of Medical Care in Diabetes - 2018. Diabetes Care 2018; 41 (Suppl. 1): S137-S143
Hyperglycemia in Pregnancy by Dr Selim

47. Management of GDM:
*Lifestyle change is an essential
component of management of GDM and
may suffice for the treatment of many
women. Medications should be added to
achieve glycemic targets.
Management of Diabetes in Pregnancy:
Standards of Medical Care in Diabetes - 2018. Diabetes Care 2018; 41 (Suppl. 1): S137-S143
02/17/18Hyperglycemia in Pregnancy by Dr Selim 47
Management of Diabetes in Pregnancy: Standards of Medical Care in Diabetes - 2018. Diabetes Care 2018; 41 (Suppl. 1): S137-S143

48. Management of GDM:
*Insulin is the preferred medication for
treating hyperglycemia in GDM as it
does not cross the placenta to a
measurable extent.
Management of Diabetes in Pregnancy:
Standards of Medical Care in Diabetes - 2018. Diabetes Care 2018; 41 (Suppl. 1): S137-S143
02/17/18Hyperglycemia in Pregnancy by Dr Selim 48
Management of Diabetes in Pregnancy: Standards of Medical Care in Diabetes - 2018. Diabetes Care 2018; 41 (Suppl. 1): S137-S143

49. Management of GDM:
*Metformin and glyburide might be
used, but both cross the placenta to
the fetus, with metformin likely crossing
to a greater extent than glyburide.
*All oral agents lack long-term safety
data.
Management of Diabetes in Pregnancy:
Standards of Medical Care in Diabetes - 2018. Diabetes Care 2018; 41 (Suppl. 1): S137-S143
02/17/18Hyperglycemia in Pregnancy by Dr Selim 49
Management of Diabetes in Pregnancy: Standards of Medical Care in Diabetes - 2018. Diabetes Care 2018; 41 (Suppl. 1): S137-S143

50. Management of GDM
*Metformin, when used to treat
polycystic ovary syndrome and
induce ovulation, need not be
continued once pregnancy has
been confirmed.
Management of Diabetes in Pregnancy:
Standards of Medical Care in Diabetes - 2018. Diabetes Care 2018; 41 (Suppl. 1): S137-S143
02/17/18Hyperglycemia in Pregnancy by Dr Selim 50
Management of Diabetes in Pregnancy: Standards of Medical Care in Diabetes - 2018. Diabetes Care 2018; 41 (Suppl. 1): S137-S143

51. *Insulin is the preferred agent for management of
both T1DM and T2DM in pregnancy because it
does not cross the placenta, and because oral
agents are generally insufficient to overcome the
insulin resistance in T2DM and are ineffective in
T1DM.
Management of Diabetes in Pregnancy:
Standards of Medical Care in Diabetes - 2018. Diabetes Care 2018; 41 (Suppl. 1): S137-S143
Management of Diabetes in Pregnancy: Standards of Medical Care in Diabetes - 2018. Diabetes Care 2018; 41 (Suppl. 1): S137-S143
Management of GDM
Hyperglycemia in Pregnancy by Dr Selim
02/17/18

52. *Women with T1DM or T2DM should be
prescribed low-dose aspirin 60-150 mg/day
(usual dose 81 mg/day) from the end of the first
trimester until the baby is born in order to lower
the risk of preeclampsia.
Management of Diabetes in Pregnancy:
Standards of Medical Care in Diabetes - 2018. Diabetes Care 2018; 41 (Suppl. 1): S137-S143
Management of Diabetes in Pregnancy: Standards of Medical Care in Diabetes - 2018. Diabetes Care 2018; 41 (Suppl. 1): S137-S143
Management of GDM
Hyperglycemia in Pregnancy by Dr Selim 02/17/18

53. *In pregnant patients with diabetes and
chronic hypertension, blood pressure
targets of 120-160/80-105 mmHg are
suggested in the interest of optimizing long-
term maternal health and minimizing
impaired fetal growth.
Management of Diabetes in Pregnancy:
Standards of Medical Care in Diabetes - 2018. Diabetes Care 2018; 41 (Suppl. 1): S137-S143
Management of Diabetes in Pregnancy: Standards of Medical Care in Diabetes - 2018. Diabetes Care 2018; 41 (Suppl. 1): S137-S143
Hyperglycemia in Pregnancy by Dr Selim
Management of GDM
02/17/18

54. *Potentially teratogenic medications (i.e.,
ACE inhibitors, ARBs, statins) should be
avoided in sexually active women of
childbearing age who are not using reliable
contraception.
Management of Diabetes in Pregnancy:
Standards of Medical Care in Diabetes - 2018. Diabetes Care 2018; 41 (Suppl. 1): S137-S143
Management of Diabetes in Pregnancy: Standards of Medical Care in Diabetes - 2018. Diabetes Care 2018; 41 (Suppl. 1): S137-S143
Hyperglycemia in Pregnancy by Dr Selim
Management of GDM
02/17/18

55. Future risks - Mother
*At least 4-12 weeks post delivery, standard
75 g OGTT for all GDM

56. Future risks - Mother
*≥ 90% normoglycemic
*Recurrence of GDM – 30-60%
*Older
*Multipara
*Weight gain interpregnancy
*Higher infant BW in index pregnancy
*IGT and T2DM
*20% IGT postpartum
*3.7% @ 6m , 4.9% @ 15m and 18.9% @ 9 y

57. Conclusion
*Gestational diabetes is a common
problem in Bangladesh
*Risk stratification and screening is
essential in all Indian pregnant
women
*Tight glycemic targets are required
for optimal maternal and fetal
outcome

58. Conclusion
*Patient education is essential to
meet these targets
*Long term follow up of the mother
and baby is essential

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Thank
s