Pregestational Diabetes in pregnancy

Presentation at Monthly Seminar of Obstetrics and Gynaecology Eden Hospital< Medical College, Kolkata- July, 2012

2. OVERT DIABETESOVERT DIABETES

3. Classic signs/ symptoms of DM
+
RBS >200 mg/dl
FBS ≥126 mg/dl
2 hr PPBS ≥200 mg/dl

5. PRE-CONCEPTIONAL CARE
PRECONCEPTIONAL COUNSELING
Good glycaemic control before pregnancy can
reduce (but not eliminate) the risk of adverse
pregnancy outcomes
Regular glucose monitoring
Diet, body weight and exercise
 Weight reduction if BMI > 27 kg/m2
The importance of planning of pregnancy and the
role of contraception
Folic acid (5 mg/day) until 12 weeks of gestation to
reduce the risk of NTD

6. PRE-CONCEPTIONAL CARE (CONTD.)
GLYCAEMIC CONTROL
Glucometer for self-monitoring of blood glucose
Pre-conceptional Glucose level (ADA,1999a)
FBS 70-100 mg/dl
PPBS (1 hr) <140 mg/dl
PPBS (2 hr) <120 mg/dl
HbA1c
≤6%
Within 3 SD of normal mean
If ≥10%, strongly advised to avoid pregnancy (NICE, 2008)
Testing of ketone by strips if they become
hyperglycaemic or unwell.

7. PRE-CONCEPTIONAL CARE (CONTD.)
DRUGS (NICE, 2008)
Metformin- can be used in the pre-conception period and
during pregnancy, when the likely benefits from improved
glycaemic control outweigh the potential for harm
All other OHAs- should be discontinued before pregnancy
except Glyburide
Aspart & Lispro insulin- no adverse effects in pregnancy
NPH insulin- the first choice for long-acting insulin in
pregnancy
ACE inhibitors and ARBs- discontinued before conception
or as soon as pregnancy is confirmed
Statins- discontinued before pregnancy or as soon as
pregnancy is confirmed

8. PRE-CONCEPTIONAL CARE (CONTD.)
RETINAL ASSESSMENT (NICE, 2008)
Done at the first appointment
Thereafter annually, if no diabetic retinopathy is found
By digital imaging with mydriasis using tropicamide
Women should defer rapid optimisation of glycaemic
control until after retinal assessment and treatment have
been completed

9. PRE-CONCEPTIONAL CARE (CONTD.)
RENAL ASSESSMENT (NICE, 2008)
Includes measurement of microalbuminuria before
pregnancy
Referral to a nephrologist should be considered
before discontinuing contraception if
Serum creatinine ≥120 µmol/L
Estimated GFR <45 ml/min/1.73 m
2

10. MANAGEMENT IN FIRST TRIMESTER
DIETARY MANAGEMENT
3 meals and 3 snacks per day
Consistent timing with food intake
To facilitate insulin dosage & avoid
hypoglycaemia
Specially for NPH + Regular insulin
Not so rigorous for Glargine + Aspart/ Lispro

11. MANAGEMENT IN FIRST TRIMESTER
(CONTD.)
INSULIN THERAPY
Mainstay of management in type I DM
To cover
Basal needs (Basal Insulin)-
Intermediate/ Long acting Insulin-
To suppress hepatic neoglucogenesis
between meals & during fasting
PP rise of sugar (Prandial Insulin)-
Short acting Insulin

12. PHARMACOKINETICS OF INSULIN
PREPARATIONS
ONSET PEAK
(Hrs)
DURATION
(Hrs)
SHORT ACTING
LISPRO <15 min 0.5-1.53-4
ASPART <15 min 0.5-1.53-4
REGULAR 30-60 min2-3 4-6
INTERMEDIATE ACTING
ISOPHANE INSULIN (NPH) 1-3 hr 5-7 13-18
INSULIN ZINC SUSPENSION
(LENTE)
1-3 hr 4-8 13-20
LONG ACTING
EXTENDED INSULIN ZINC
SUSPENSION (ULTRALENTE)
2-4 hr 8-14 18-30
INSULIN GLARGINE 1-4 hr Peakless24

13. INSULIN THERAPY (CONTD.)
I.Multiple daily SC injections
Total daily requirement
0.6 U/kg current weight- 1
st
trimester
0.7 U/kg current weight- 2
nd
trimester
0.9 U/kg current weight- 3
rd
trimester
Regular + NPH – commonly used
4/6 at breakfast (2/3 NPH, 1/3 Regular)
1/6 before dinner- Regular
1/6 at bed time- NPH
To be administered >30 min before meal
Mid-morning & mid-afternoon snacks necessary to
avoid hypoglycaemia
Glargine + Lispro/ Aspart-
Mimics physiological system
Less rigorous timing of meals
But Inj Lispro necessary before each meals

14. INSULIN THERAPY (CONTD.)
II.Subcutaneous insulin infusion pump
Only for those women who are
highly motivated,
where multiple daily injections are ineffective &
no disabling hypoglycaemia
Needs strict asepsis
Needs less Insulin (0.3-0.5 U/kg)
II. Inhaled Insulin
Not well studied in pregnancy
Needs PFT monitoring

15. INSULIN THERAPY (CONTD.)
Insulin: Carbohydrate ratio:
One method to calculate prandinal Insulin
How many grams of CHO is covered by 1 U
Regular Insulin
Insulin : CHO = 500/ total daily requirement
Typically in the range of 10-15
Insulin Sensitivity Factor
Estimated drop in blood glucose per unit of Regular
Insulin
Equal to 1500/ total daily requirement
Amount of supplemental Insulin needed =
difference between actual and desired blood
glucose/ sensitivity factor
Useful to make sliding scale

16. MANAGEMENT IN FIRST TRIMESTER
(CONTD.)
BLOOD SUGAR MONITORING
Self-monitoring of capillary blood glucose (CBG)
 Finger-prick method using a Glucometer
Noninvasive- by Iontophoresis
Goals of glucose control (ACOG, 2005)
Fasting ≤ 95 mg/dl
Premeal ≤ 100 mg/dl
1 Hr PP ≤ 140 mg/dl
2 Hr PP ≤ 120 mg/dl
02.00- 06.00 AM ≥ 60 mg/dl
Mean (Average) 100 mg/dl
HbA1c ≤ 6 %

17. BLOOD SUGAR MONITORING (CONTD.)
Blood Sugar should be measured in fasting, 1 hr
before meals and at bed time (NICE, 2008)
Rotine use of HbA1C in 2
nd
and 3
rd
trimester is not
recommended (NICE, 2008)
Ketone should be measured if women feel unwell or
hyperglycaemic

18. MANAGEMENT IN SECOND TRIMESTER
Congenital anomaly detection
Vaginal probe USG at 10-14 weeks to detect NTD &
Nuchal tranlucency
MSAFP (values lower in DM) at 16-20 weeks to
detect NTD
Detailed sonographic examination at 18-20 weeks
Fetal echocardiography for the four-chamber view
of the fetal heart and outflow tracts at 20-22 weeks
Individualized glycaemic control
Insulin requirement increases after 24 weeks
Dietary management continues
Regular antenatal visits

19. MANAGEMENT IN THIRD TRIMESTER
Insulin and dietary control continues
Fetal monitoring
Ultrasound monitoring
Fetal growth and amniotic fluid volume
Every 4 weeks from 28 to 36 weeks
Routine monitoring of fetal well-being
Not recommended before 38 weeks
Indications of monitoring of fetal well-being
From 28 weeks
Women at risk of IUGR (macrovascular disease and/or
nephropathy)
Unstable DM
 Women requiring >100 U insulin/day

20. MANAGEMENT IN LABOUR
Decision for delivery
To be taken at 36 weeks- Induction vs CS
Discussion with patient, keeping respect to her
decision
CS often for macrosomia in White class B and C
DM is not a contraindication to VBAC
Timing of delivery
Stable DM- at 38 weeks
Unstable DM- as soon as fetal lung maturity is
attained

21. MANAGEMENT IN LABOUR (CONTD.)
Preterm labour
β-mimetics are to be avoided
Nifedipine is preferred drug
<32 weeks, intrauterine infections to be
excluded
Steroids for lung maturity are not contraindicated
 Needs additional insulin
 Close monitoring
Labour management
IVF & insulin for glycaemic control
Careful monitoring

22. MANAGEMENT IN PUERPERIUM
CBG should be regularly monitored
Often patient needs no insulin in 1
st
24 hr
Start with ½ to 2/3 of pre-delivery doses of insulin
Breastfeeding should be encouraged
Risk of hypoglycaemia during breast feeding
Infections promptly detected and treated
Contraceptive advices
IUCD does not increase infection rate
Hormonal contraceptives are avoided in vascular disease
Puerperal sterilisation, if suitable
Counseling regarding future pregnancy

24. INSULIN RESISTANCE
Impaired metabolic response to endogenous or
exogenous insulin (ADA)
Peak insulin levels in 3 hr GTT (µU/ml)
<100- normal
100-150- mild resistance
150-300- moderate resistance
>300- severe resistance
FBS (mg/dl) : fasting insulin (µU/ml) <4.5
C-peptide assay
Glucose-clamp technique

25. METABOLIC SYNDROME
Also called syndrome X, Insulin Resistance syndrome
or Deadly Quartet
NCEPATP III definition-
At least three of the following
FBS ≥110 mg/dl
Abdominal obesity (waist circumference >35 inch. In
women, >40 inch in men)
Triglycerides >150 mg/dl;
HDL <50 mg/dl in women,
<40 mg/dl in men
BP ≥ 130/85 mm Hg

26. MANAGEMENT IN PREGNANCY
DIETARY MANAGEMENT
Like GDM
To maintain a calorie intake adequate for
pregnancy but with minimum weight gain
Ideal weight gain
Normal weight 25-35 lb
Overweight 15-25 lb
Obese 11-20 lb
Underweight 28-40 lb

27. MANAGEMENT IN PREGNANCY
(CONTD.)
GLYBURIDE
Normal weight/ moderately obese
Good β-cell functions
Duration of DM <5 years

28. MANAGEMENT IN PREGNANCY (CONTD.)
INSULIN THERAPY
Glyburide
+
NPH insulin at bed time
(to suppress hepatic neoglucogenesis to lower FBS)
Or
Glargine in the morning (less hypoglycaemia)
Starting dose is 20 U SC usually
If CBG values are still elevated, the dose may be ↑
by 5 U every 5 days until adequate control is
obtained

29. MANAGEMENT IN PREGNANCY
(CONTD.)
BLOOD SUGAR MONITORING
Self-monitoring of CBG
HbA1C
Fructosamine <2.6 µmol/L

30. MANAGEMENT OF LABOUR AND
PUERPERIUM
Similar to GDM

32. DIABETIC NEPHROPATHY
Especially in type I
Hypertension & proteinuria
Risk of Preeclampsia and preterm labour, IUGR
Renal assessment to be done in the first ANC visit
Referral to a nephrologist - if
Serum creatinine ≥120 µmol/L
Total protein excretion >2 g/day
Estimated GFR should not be used in pregnancy
 Thromboprophylaxis should be considered-
If proteinuria >5 g/day (macroalbuminuria)

33. DIABETIC RETINOPATHY (DR)
Both in type I & type II DM
Pregnancy worsens retinopathy
Acute rigorous metabolic control worsens
retinopathy
Slows down progression of retinopathy in long term
Insulin Lispro may worsen retinopathy (?)
Retinopathy is associated with reduced fetal growth

34. RETINAL CHANGES IN DIABETES
Beningn/ Background / Nonproliferative
retinopathy- (White class D)
Microaneurysm
(first and commonest finding)
Blot haemorrhage
Serous leak → hard exudates
Pre-proliferative retinopathy-
Retinal ischaemia/ infarction
→ Cotton wool exudates
Proliferative retinopathy-
(White class R)
Neovascularisation on retinal surface & vitreous

35. MANAGEMENT OF RETINOPATHY

36. DIABETIC NEUROPATHY
Peripheral sensory-motor neuropathy- uncommon in
pregnancy
DIABETIC GASTROPATHY-
More troublesome in pregnancy
Nausea, vomiting, nutritional problems
Difficult glucose control
Needs Metoclopramide, H2 receptor blockers,
Erythromycin or Intermittent gastric intubation

37. INFECTIONS
Urinary tract infections
Associated with preterm labour
May cause pyelonephritis
Screening and treatment of asymptomatic
bacteruria to be done
Respiratory tract infections
Vulvovaginal infections
Puerperal pelvic infections
Wound infections after Caesarean Section
Needs prompt diagnosis and treatment with
antibiotics

38. DIABETIC KETOACIDOSIS (DKA)
Most serious complication
Affects 1% of diabetic pregnancies
Fetal loss 20%
Unique to type I DM
Precipitating factors
Hyperemesis gravidarum
Noncompliance to insulin therapy
Tocolytics, corticosteroids
Pregnant women usually develop DKA at
lower level of glucose than nonpregnant
individuals

39. DIAGNOSIS OF DKA
Blood glucose >250 mg/dl usually
Ketone bodies in urine & plasma
Arterial pH <7.3
Serum bicarbonate <15 mEq/L

40. MANAGEMENT OF DKA
(ACOG 2005)
Laboratory assessment
ABG, glucose, ketones, eletrolytes every 1-2 hr
Insulin
IV loading 0.2-0.4 U/Kg
IV maintenance 2-10 U/hr
Fluids
Isotonic NaCl
1 L in 1
st
hr
500-1000 ml/hr for next 2-4 hr
250 ml/hr until 80% replaced
Total replacement in 1
st
12 hrs of 4-6 L

41. MANAGEMENT OF DKA (CONTD.)
Glucose
When CBG <250 mg/dl, 5%DNS infusion
Potassium
If initially normal/ low- 15-20 mEq/ hr
If elevated, wait, until it becomes normal, then
20-30 mEq/ L IV solution
Bicarbonate
 If pH < 7.1, add 1 amp (44 mEq) to 1 Lit of
0.45% NS

42. HYPEROSMOLAR NONKETOTIC COMA
Peculiar to type II DM
Severe hyperglycaemia (>600 mg/dl)
Serum hyperosmolarity (>320 mOsm/L)
No ketonaemia
Management-
Aggressive fluid therapy to combat severe
dehydration
Insulin
Potassium
Rarely seen in pregnancy

43. HYPOGLYCAEMIA
Especially occurs in 1
st
trimester with type I DM
Peak incidence at 10-15 weeks
Significant hypoglycaemia occurs when CBG
values are less than 35 mg/dl
Woman should know symptoms of hypoglycaemia
Management
Oral glucose
If unconscious- 20 ml of 50% dextrose, followed
by 10% dextrose drip
If severe, injection Glucagon 1 mg IM/ SC

44. FASTING HYPERGLYCAEMIA
SOMOGYI’S PHENOMENON
High fasting blood sugar & C/O nightmares/ nocturnal
sweating
Nocturnal hypoglycaemia (01.00- 05.00 AM) →
exaggerated counter-regulatory response
Treatment is to DECREASE the night dose of
intermediate/ long acting insulin
DAWN PHENOMENON
High fasting blood sugar in absence of nocturnal
hypoglycaemia
Cause not known exactly
Treatment is to INCREASE the night dose of
intermediate/ long acting insulin

45. THANK YOUTHANK YOU