Pregestational Diabetes- Modern + Ayurveda aspect

Pregestational diabetes a major obstetrical problem now a days. These PPT contains modern as well as Ayurveda aspect for preventing a pregnant women & her baby from developing complications.

1. Pregnancy complicated with
Diabetes mellitus


Presented by:
Dr. Priyanka Hajare
PTSR Dept.
National Institute of Ayurveda,
Jaipur

2. Diabetes mellitus (DM)
Diabetes mellitus is a clinical syndrome
characterized by deficiency of or
insensitivity to insulin.
Most common metabolic disorder
complicating pregnancy.

3. Prevalence rate
•Diabetes mellitus is a common medical condition
complicating pregnancy and its prevalence is rising
continuously.
•The world prevalence was around 6.4% in 2010 and
has been estimated to increase upto 7.7% by 2030.

4. Classification during pregnancy
•Pregestational/ Overt
diabetes
•(Affects approx. 1-3
pregnancies per 1000 births)
Diabetes before
pregnancy
•Gestational diabetes
•(Complicates approx. 4% of
pregnancies)
Diabetes
diagnosed during
pregnancy

5. Pregnancy is itself a
Diabetogenic condition
The diabetogenic state of pregnancy is attributed to following causes:
 Insulin resistance: It is due to following factors-
oPlacental production of human placental lactogen, placental growth
hormone, and placental insulinase all of which have anti-insulin
action.
oIncreased production of cortisol, estriol, progesterone and prolactin.
oIncreased insulin destruction by the kidney and placenta.
oResistin, a placental hormone, plays a part in insulin sensitivity
imposed by other hormones during pregnancy and thus is a potential
important mediator of insulin resistance.

6. Diabetogenic state
Lypolysis
FFA
Glucose
Insulin to
maintain
glucose
homeostatsis
(leads to
hunger)
Placental
hormones:
HPL,
Estrogen,
Progesterone
Block insulin
receptor 
 Insulin
resistance

7. Cntd..
Increased body weight and
calorie intake during
pregnancy also aggravate
the insulin resistance.
Increased food consumption
and static life style are other
factors responsible for
hyperglycemic state in
pregnancy.

8. Mechanism of Ketoacidosis
Lack of Insulin
Glucose LypolysisFFA
Diuresisdehydration
and electrolyte loss
 Ketone
bodies

9. Classification of Diabetes complicating
pregnancy (White’s classification)

White’s classification provides simple and useful
information on pregnancy risks and prognosis.
Diabetes that begins during pregnancy:






Plasma Glucose level
Class Onset Fasting 2-Hour
Postprandial
Therapy
A1 Gestational < 105 mg/dl < 120 mg/dl Diet
A2 Gestational > 105 mg/dl > 120 mg/dl Insulin

10. Diabetes with onset before the pregnancy
Class Age of
onset (Year)
Duration
(Year)
Vascular
disease
Therapy
B Over 20 < 10 None Insulin
C 10-19 10-19 None Insulin
D Before 10 > 20 Benign
retinopathy
Insulin
F Any Any Nephropathy Insulin
R Any Any Proliferative
retinopathy
Insulin
H Any Any Heart Insulin

11. DIAGNOSIS
Women with-
Random plasma glucose level > 200 mg/dl plus classic
sign and symptoms such as:
Polydipsia
Polyuria
Unexplained weight loss
Fasting glucose level > 125 mg/dl, considered to have
Overt diabetes first detected in pregnancy.
American
Diabetes
Assocation
(ADA, 2017 a)
And
WHO (2013)

12. RISK FACTORS
•Risk factors for impaired carbohydrate
metabolism in pregnant women include:
A strong familial history of diabetes
Prior delivery of a large newborn
Persistent glycosuria
Unexplained fetal losses

13. QUESTION



•What are the Complications of
Diabetes Mellitus in Pregnancy ?

14. COMPLICATIONS OF
DIABETES MELLITUS IN PREGNANCY
•During Pregnancy:

Spontaneous
abortion
Urinary Tract
Infection (UTIs)
Candidal
vaginitis
Pre-
eclampsia
Polyhydraminos

15. Complications
During Delivery
Preterm
labour
•Infection,
Polyhydramnios
may be the cause
Shoulder
dystocia
Prolonged
labour

16. Complications
During Delivery
Increase incidence
of Operative or
Instrumental
deliveries
Trauma to
maternal
genital tract
& fetus

Post partum
Hemorrhage
•Due to instrumental
delivery, Extension
of episiotomy,
Uterine over
distension (Atonic)

17. Complications-
Post Delivery

18. QUESTION


•Which Congenital Anomalies
occur in fetus ?

19. Fetal and Neonatal Complications
Congenital Anomalies: Incidence of major malformations
is increased four-fold in the offspring of women with overt diabetes.
Common fetal malformations include: Central nervous system-
Meningomyelocoele
Hydrocephalus,
Microcephaly
Spina bifida Anencephaly
Holoprosencephaly
Encephalocoele

20. Complications- Cardiac
Transposition
of great vessels
Aortic
coarctation
Atrial septal
defect
Patent ductus
arteriosus
Ventricular
septal defect
Cardiomegaly

21. Complications- Renal
RENAL
Renal
atresia/agenesis
Ureteral
duplication
Hydronephrosis
Cystic
kidneys

22. Complications- GIT
D
u
o
d
e
n
a
l

a
t
r
e
s
i
a

Anal
atresia
Duodenal
atresia
Small left
colon
syndrome
Single
umbilical
artery
Tracheo-
esophageal
fistula

23. Complications- Skeletal & spine
 Caudal regression syndrome:
(Sacral agenesis) is the most
common defect and a unique
anomaly.

24. QUESTION



•What is Fetal macrosomia ?

25. Fetal macrosomia
The American College of Obstetricians and Gynecologists (ACOG) defined
macrosomia as birth-weight over 4,000 g irrespective of gestational age or
greater than the 90
th
percentile of the expected weight.
Except for the brain, most fetal organs are affected by macrosomia.
Macrosomic infants are anthropometrically different from large for age
infants with-
Increased subcutaneous skin fold thickness
Increased muscle mass
Visceromegaly (e.g. Liver)

26. Pathogenesis
(Pederson hypothesis)
MOTHER
Maternal
hyperglycemia
FETUS
Fetal hyperglycemia

Fetal hyperinsulinaemia
FETAL MACROSOMIA
Excessive
growth and
lipid
distribution

27. QUESTION



•What is DIPSI ?

28. SCREENING
Early pregnancy glucose screening is advisable for the
women with PCOS who becomes pregnant.
Prolactin level are increased 5 to 10 folds during pregnancy
and may have an impact on carbohydrate metabolism. Thus
patient with hyperprolactinaemia also deserve early screening.
One step approach in 1
st
ANC visit:
75 grams 2 hour oral GTT
Recommended by WHO,
FOGSI and DIPSI (Diabetes in
pregnancy study group of
India)

29. DIPSI Guidelines for screening
Irrespective of the time of last
meal.
Women is given 75 gm of
glucose in 300 ml of water to
drink.
Plasma glucose measured after 2
hours.
If women vomits with in 30
minutes, repeat test next day.

30. DIPSI GUIDELINES
PLASMA GLUCOSE IN PREGNANCY
< 120 gm/dl Normal
120-139 gm/dl Gestational glucose
intolerance
140-199 gm/dl Gestational diabetes mellitus
> 200 gm/dl Overt diabetes

31. QUESTION


•Normal value for Glycosylated Haemoglobin
HbA1C ?

32. Glycosylated Haemoglobin
HbA1C
It represents a retrospective integration of
the average glucose levels during the
previous 6-8 weeks (the average RBC
lifespan).
When elevated above 10%, it is indicative
of poor glycemic control in the previous 6
weeks.

33. Glycosylated Haemoglobin
HbA1C
Hemoglobin combines with glucose at its β-terminal valine
residue to form the glycosylated Hb when exposed to glucose
for a long time.

34. Management of Diabetes
in Pregnancy
PRECONCEPTION CARE -
The couple is explained the need to plan pregnancy with good
glycemic control so as to minimize the risk of congenital anomalies.
HbA1C level should be in the normal range, i.e. 4-6.5%.
Life style modification in the of weight management, daily exercise,
cessation of smoking and reduced alcohol intake.
Folic acid supplementation 5 g daily is prescribed for 3 months prior
to conception.

35. QUESTION


•What are the 4 pillars of treatment for
DM management in pregnancy ?

36. 4 Pillars of
Diabetes management
Medical
Nutritive
Therapy
Physical
activity
(30 min/day)
Oral
Hypoglycemic
agent
1
2
3
4
Insulin

37. INSULIN
THERAPY
When to start ?
When blood glucose targets cannot be reached by medical nutritive therapy
(MNT) and Oral hypoglycemic agents (OHA).
Insulin requirements increases throughout the pregnancy:
0.7 units/kg/day 6-18 weeks
0.8 units/kg/day Between 18-26 weeks
0.9 units/kg/day Between 26-36 weeks
1.0 units/kg/day From 36 weeks to delivery

38. Action profiles of commonly
used Insulins

INSULIN TYPE ONSET PEAK (Hour) DURATION (Hour)
SHORT ACTING (Subcutaneous)
Lispro < 15 min 0.5-1.5 hour 3-4 hour
Glulisine < 15 min 0.5-1.5 hour 3-4 hour
Aspart < 15 min 0.5-1.5 hour 3-4 hour
Regular 30-60 min 2-3 hour 4-6 hour
LONG ACTING (Subcutaneous)
Detemir 1-4 hour Minimal Up to 24
Glargine 1-4 hour Minimal Up to 24
Neutral Protamine
Hagedorn (NPH)
1-4 hour 6-10 10-16

40. METABOLIC DISORDER
Metabolism: Process uses to make energy from
the food.
Metabolic disorders occurs when abnormal
chemical reaction in body disrupts this process
(Jatharagni & Dhatvagni vikriti).
It is disease of Medo dhatu dushti with additional
derangement of mamsa, kleda, rasa, rakta,
majja, shukra.

41. Cntd..
•Ayurveda line of treatment starts from correction in Medo
dhatu which is responsible for further pathophysiology of
Prameha.

42. Reference
ओजोमेह – गर्भवती
र्ैषज्य रत्नावली ९० - ओजोमेह चिचित्सा
ओजोमेह चिदाि
“क्षारेण चिवाां िटु िा िषायेि वचजभते गर्भवती जिस्य
ओजस्करेवाभ मधुरः सदैव अन्नपाि जाते अचतमात्रे र्चक्षते”(र्ै.र. ९०/३)
It is mentioned in texts that excessive use of Atimadhura, atiguru,
paryushita ahara & atibhojan can lead to ojomeha in Garbhini.

43. Garbhini
Madhumeha
 गर्ोपघातिर र्ाव (ि.शा.८/२१)
If the pregnant mother follows dietetics mode of life Kapha aggravating,
like nitya madhura aahara and vihaara like excessive sleep, the fetus or
child will suffers from Prameha, Atisthula, Mukam, Tandralu, Agyani,
Murkha and Alpaagni.
आहार विहार गर्भ पर प्रर्ाि
मधुरचित्या प्रमेचहणां मूिमचतस्थूलां वा
स्वप्नचित्या तन्द्रालुमबुधमल्याचि

44. Garbha vriddhi and
Fetal macrosomia
Acharya Sushruta has mentioned Garbha vriddhi which can be
correlated with Macrosomia. In Garbha vriddhi there is
excessive increase in size of abdomen and perspiration.
“गर्ो जठराचर्वृद्धां स्वेदां ि” (सु.सू.१५/१६)
Acharya Bhavapraksha adds further that labour is much
difficult.
“उदराचदप्रवृद्धस्तु वृधे गर्ेऽचर्जायते ।
स्वेदश्च गर्भवत्याः स्यात्प्रसवे व्यसिां महत् ।। ७३।।”(र्ा० प्र० पूवभ०७)

45. PREVENTION
Preconception care
Garbhadhana sanskara: Acting
through epigenetic.
Early screening of risk factors
Early intervention
Low glycemic diet

46. QUESTION


•What female should taken in
preconception care according to
Acharya Charaka ?

47. PRE-CONCEPTION
CARE
“अथाप्येतौ स्त्रीपुांसौ स्नेहस्वेदाभ्यामुपपाद्य, िमनविरेचनाभ्याां संशोध्य, क्रमेण प्रिृ
चतमापादयेत्|
सांशुधौ िास्थापनानुिासनाभ्यामुपािरेत्; उपािरेच्च मधुरौषधसांस्कृ ताभ्याां घृतक्षीरा
भ्याां पुरुषां, स्त्रियं तु तैलमाषाभ्याम्||४|| (ि.शा.४)

‘ वृष्यः परां वातहरः चिग्धोष्णमधुरो गुरुः ।
वक्ष्यो बहुमलः पुांस्वां माषः शीघ्रां ददाचत ि ॥'(ि. सू. २७)
 जीविीय (रा.चि)

48. Pharmacological activities of
Vigna mungo (Masha):

PART EXTRACT PHARMACOLOGICAL
ACTIVITY


Pulses
Tris-HCL Enterokinase
inhibition
Methanol Antimicrobial
Cooked pulse Antidiabetic

49. Monthly dietary regimen
in pregnancy complicated
with Diabetes

First Month: Non medicated milk, liquid diet.
Second Month: Milk medicated with madhura tikta rasa drugs.
Third Month: Milk with honey and ghrita, Krushra.
Fourth Month: Milk with butter, Shashti rice with curd, jangala
mansa, food mixed with milk and navneeta.
Fifth Month: Ghrita ,Shashti rice with curd, food mixed with
milk.

50. Monthly dietary regimen
in pregnancy complicated
with Diabetes
Sixth Month: Ghrita prepared from milk medicated with madhura-
tikta drugs, Ghrita or rice gruel medicated with gokshura.
Seventh Month: Ghrita medicated with prithakparnyadi group of
drugs.
Eighth Month: Kshira yavagu mixed with ghrita, Asthapana basti
(bala, atibala, shatushpa, honey and ghrita)
Ninth month: Anuvasana basti with oil prepared with madhura tikta
drugs, vaginal tampoon of this oil, different varieties of cereals.

51. Diet intervention in Pregnancy
complicatedwith Diabetes
(AIIA SOP)
6:00 am - 2-3 almonds/1 walnut/1 date in rotation, Tea without sugar
8:00 am - Multigrain roti, Egg, veg parantha, phulka with chutney
10:30 am - Cow's milk without sugar ,soups
1:00 pm - Dal, roti, sabji , steamed salad, buttermilk, rice
3:30 pm - One fruit (Orange, apple, sweet lime, pear, pomegranate)
5:30 pm - Cow milk without sugar (200 ml), soups, One khakra / Laaja
8:30 pm - Daal roti, sabji, steamed salad, rice
10:00 pm - Cow milk without sugar

52. Diet intervention in Pregnancy
(NIA)

53. Diet intervention in Pregnancy
(NIA)

54. MANAGEMENT
Nisha amalaki – 1gm. BD
Guduchi satwa - 500mg to 1gm with
honey (BR)
Shatavari swarasa - 25 ml mixed with
boiled cow's milk twice a day
Triphala churna - 3 gm with 10 gm honey
Haritaki churna - 3-10 gm with honey
(BP)
Udakpaan saarodak (Vijaysaar) –
throughout day for drinking.

55. According to
Symptoms
UTI: Chandra prabha Vati 500mg BD
Ajirna & Agnimandya: Phaltrikadi kashaya 20 ml BD
Vaginal Infection:Panchavalkala/Triphala kashaya Bahya
Yoni prakshalan

Gastro-intestinal Symptoms:Praval Panchamrit Rasa
Switch over to Insulin if Parameters Worsen (B.S-PP
>200mg/dl)

56. Cntd..
If patient is on Insulin- for tapering
the dose of insulin, Ayurveda
medicines can be added under close
observation.

57. Herbs in Ayurveda for
Pregnancy complicating with Diabetes
Pterocarpus marsupium (Vijaysaar):
It has been shown to cause pancreatic beta cell regranulation.
The heartwood of the tree is used to make tumblers/
goblets/beakers which are filled with water and allowed to
stand overnight to give “Beeja wood water” the positive
activity of which against diabetes has been confirmed.
Epicatechin, its active principle, has been found to be
insulinogenic, enhancing insulin release and conversion of
proinsulin to insulin in vitro.

58. Cntd..
Trigonella foenum graecum (Fenugreek):
 It is found all over India and the fenugreek seeds are
usually used as one of the major constituents of
Indian spices.
4-hydroxyleucine, a novel amino acid from fenugreek
seeds increased glucose stimulated insulin release by
isolated islet cells in both rats and humans.

59. Cntd..
Tinospora cordifolia (Guduchi):
Oral administration of the extract of Tinospora
cordifolia (T. cordifolia) roots for 6 weeks resulted in
a significant reduction in blood and urine glucose and
in lipids in serum and tissues in alloxan diabetic rats.
The extract also prevented a decrease in body weight.

60. Cntd..
Phyllanthus amarus (Bhuiawala):
Traditionally it is used in diabetes therapeutics.
Methanolic extract of Phyllanthus amarus was found to
have potent antioxidant activity.
This extract also reduced the blood sugar in alloxanized
diabetic rats.
The plant also shows anti-inflammatory, antimutagenic,
anticarcinogenic.

61. Cntd..
Ocimum sanctum (Holy basil):
The aqueous extract of leaves of Ocimum sanctum
showed the significant reduction in blood sugar level
in both normal and alloxan induced diabetic rats.

62. Cntd..
Momordica charantia (Bitter gourd):
It is commonly used as an antidiabetic and antihyperglycemic
agent in India as well as other Asian countries.
Extracts of fruit pulp, seed, leaves and whole plant was shown
to have hypoglycemic effect in various animal models.
The phytochemical momordicin, charantin and a few
compounds such as galactose-binding lectin and insulin-like
protein isolated from various parts of this plant have been
shown to have insulin mimetic activity.

63. Cntd..
Eugenia jambolana (Jamun):
Oral administration of pulp extract of the fruit of
Syzygium cumini to normoglycemic and STZ
induced diabetic rats showed hypoglycemic activity
in 30 min possibly mediated by insulin secretion and
inhibited insulinase activity.

64. Cntd..
Emblica officinalis (Amalaki):
It decreases lipid peroxidation, antioxidant,
hypoglycemic.

65. Cntd..
Azadirachta indica (Neem):
Hydroalcoholic extracts of this plant showed anti-
hyperglycemic activity in streptozotocin treated rats and
this effect is because of increase in glucose uptake and
glycogen deposition in isolated rat hemidiaphragm.
Apart from having anti-diabetic activity, this plant also
has antibacterial, antimalarial, antifertility,
hepatoprotective and antioxidant effects.

66. Cntd..
Aegle marmelos (Bel or Bilva):
Administration of aqueous extract of leaves improves
digestion and reduces blood sugar and urea, serum
cholesterol in alloxanized rats as compared to control.
Along with exhibiting hypoglycemic activity, this
extract also prevented peak rise in blood sugar at 1h
in oral glucose tolerance test.

67. Cntd..
Gymnema sylvestre(Gurmar):
Gymnema’s antidiabetic activity appears to be due to
a combination of mechanisms.
It increases the activity of enzymes responsible for
glucose uptake and utilization, and inhibits peripheral
utilization of glucose by somatotrophin and
corticotrophin.

68. Asana preferred in
I Trimester

LOWER LIMB RELAXATION:
• Padanguli naman (toe bending)
• Goolf naman (ankle bending)
• Goolf chakra (ankle rotation)
• Goolf choornan (ankle crank)
UPPER LIMB RELAXATION:
• Mushtika Bandhana (hand clenching)
• Manibandha Naman (wrist bending)
• Kehuni Naman (elbow bending)
• Skandha Chakra (Shoulder socket rotation)

69. Asana
HEAD AND NECK MOVEMENTS:
•Greeva Sanchalna (Neck movements)
SUPINE POSTURES: Shavasana (Corpse pose)
BREATHING EXERCISES:
• Anuloma-Viloma
• Bhramari Pranayam
• Asana designed for II Trimester:
Asana mainly increasing pelvic blood flow.
Warm-Up Exercises

70. Asana for
III trimester
Those asana which causing relaxation of pelvic musculature:
SITTING POSTURES:
1.Poorna Titali Asana (full butterfly)
2.Vajrasana (thunderbolt pose)
3.Siddhasana (Accomplished Pose)
SUPINE POSTURE:
1. Matsya Kridasana (flapping fish pose)

71. APATHYA FOR
DIABETES

73. Cntd..

74. Pathya