Diabetes in Pregnancy

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Diabetes in Pregnancy

• S Chandra

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Epidemiology

• Most common medical complication of Pregnancy
• affects 2-3 of pregnancies
• Gestational DM 90
• Preexisting DM 10

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CHO Metabolism
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CHO Metabolism

• Effects of Pregnancy
• mild fasting hypoglycemia postprandial
  hyperglycemia
• due to inc plasma volume in early gestation and
  inc fetal glucose utilization as pregnancy
  advances
• progressive increase in tissue resistance to
  insulin
• increase insulin secretion to maintain
  euglycemia
• suppressed glucagon response
• inc prolactin, cortisol
• HPL has GH like effects

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Glucose Metabolism

• Normal pregnancy Diabetogenic state
• increase in pc BG
• insulin resistance
• Early Pregnancy
• Anabolic state
• increase in maternal fat stores
• decreased FFA concentration
• decrease in insulin requirements

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Type I Diabetes

• Abrupt onset
• usually young age
• occasionally occurs in 30s or 40s
• lifelong requiremnent for insulin replacement
• may have genetic predisposition for islet cell ab
• concordance in MZ twins for dev of DM is 33
• suggests other factors also imp (environmental)

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Type 2 DM

• Abnormalities of insulin sensitive tissues
• decreased skeletal muscle and hepatic sensitivity
  to insulin
• abnormal B cell response
• inadequate response for a given degree of
  glycemia
• usually older
• increased BMI
• insidious onset
• strong genetic component
• MZ twin data lifetime risk 58-100

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Diagnosis of DiabetesNon Pregnant

• Fasting plasma BG gt7.0mmol/l
• Casual plasma BG gt11.1mmol/lImpaired Fasting
  Glucose
• FPG 6.1-7.0 mmol/l Impaired Glucose Tolerance
• normal FPG
• 2 h 75gOGTT test with BG 7.8-11.1 mmol/l
• Canadian
  Diabetes Association 1998

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Classification and Risk Assessment

• Class DM onset Duration Vascular Dis
  Insulin Need
• Gestational Dm
• A1 Any Any - -
• A2 Any Any -
• Pregestational DM
• B gt20 lt10 -
• C 10-19 10-19 -
• D lt10 gt20
• F Any Any
• R Any Any
• T Any Any
• H Any Any

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Gestational Diabetes

• Definition
• CHO intolerance of variable severity first
  diagnosed in Pregnancy
• Prevalence 2-4
• Risk Factors
• maternal age gt25
• Family history
• glucosuria
• prior macrosomia
• previous unexplained stillbirth
• ethnic group Hispanic, Black, First Nations

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Gestational Diabetes

• Screening
• PC 50/Trutol
• 1 hr after 50g load of glucose
• gt7.8mmol/l abnormal
• 15 of patients screen positive value gt10.3
  diagnostic of GDM (no OGTT needed)

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Gestational Diabetes

• Screening
• 24-28 weeks routine
• no need to fast
• screen at 1st prenatal visit if hx of previous
  GDM
• screen earlier (12-24 weeks ) if risk factors

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Gestational Diabetes

• Diagnosis OGTT
• 2 or more values greater than or equal to above
  cutoffs diagnostic of GDM
• single abnormal value indicates CHO intolerance

2H
Fasting 5.3 1h 10.6 2h
8.9
3 H
Fasting 5.3 1h 10.6 2h 9.2 3h
8.1
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Gestational Diabetes

• Maternal Risks
• birth trauma
• operative delivery
• 50 lifetime risk in developing Type II DM
• recurrence risk of GDM is 30-50

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Gestational Diabetes
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Gestational Diabetes

• Fetal Risks
• no increase in congenital anomalies
• increased risk of stillbirth if fasting pc
  hyperglycemia
• macrosomia
• birth trauma-shoulder dystocia and related
  complications

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Gestational Diabetes

• Management
• goal is to optimize BG levels to minimize risk of
  adverse perinatal outcomes
• diet
• exercise
• insulin therapy

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Gestational Diabetes

• Management Diet
• patients without fasting hyperglycemia
• average 8000-9000 kj/day.
• BMIgt27 -- 25 kcal/kg/ideal body weight/d
• BMI 20-26 -- 30
• BMIlt20 -- 38

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Gestational Diabetes

• Diet general principles
• 55 CHO 25 Protein 20 fat
• Normal weight gain 10-12 kg
• avoid ketosis
• liberal exercise program to optimize BG control

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Gestational Diabetes

• If persistent hyperglycemia after one week of
  diet control proceed to insulin
• 6-14 weeks 0.5u/kg/day
• 14-26 weeks 0.7u/kg/day
• 26-36 weeks 0.9u/kg/day
• 36-40weeks 1 u /kg/day

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Gestational Diabetes

• If fasting hyperglycemia start with NPH hs
• initial dose 6-8 U
• if only pc hyperglycemia use humalog 2-4u ac the
  specific meal
• adjust 2u/time 1 formula /time
• BG target ac lt5.3 2 h pc lt6.7

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Gestational Diabetes

• Intrapartum management
• check bg hourly
• maintain BG 4-6mmol/L

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Gestational Diabetes

• Postpartum
• often will not require insulin
• if fasting hyperglycemia - more likely to develop
  persistent Diabetes
• 6 weeks post partum 75g OGTT
• yearly fasting BG
• emphasize importance of maintaining N weight,
  exercise

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Gestational Diabetes

• Neonatal Risks
• hypoglycemia 50 in macrosomic
  5-15 if N BG control in Pgy
• Hyperbilirubinemia
• polycythemia
• hypocalcemia
• hypomagnesiumia

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Preexisting Diabetes

• Preconception Counselling
• risk of NTD 1-2
• Folic Acid 1-4 mg /day
• BG 3.5-5.3 prior to meals
• switch to MDI regimen (insulin ac meals and HS)
• keep track of cycles

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Preexisting Diabetes

• Normoglycemia prior to conception
• ideally HBA1C 6 or less
• Team approach
• glucose monitoring qid
• ACE contraindicated should be D/C at conception
  or use Diltiazem instead
• baseline HBA1C, 24h urine for protein Cr Cl ,
  opthalmology review
• switch from OHA to insulin

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• Assess for end organ disease
• assess for nephropathy - inc risk of PIH
• Assess and treat retinopathy - may progress
• assess for neuropathy
• generally remains stable during pregnancy
• assess and treat vasculopathy
• CAD is a relative C/I for pregnancy

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Preexisting Diabetes

• Maternal Risks
• PIH /PET
• polyhydramnios
• preterm labour
• operative delivery 50
• birth trauma
• infection
• increase in insulin requirements
• DKA

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Prexisting Diabetes
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Preexisting Diabetes

• Fetal Risks
• congenital anomalies 3X inc risk
• unexplained stillbirth
• shoulder dystocia
• macrosomia
• IUGR

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Preexisting Diabetes

• Neonatal Risks
• hypoglycemia
• hypocalcemia
• hyperbilirubinemia/polycythemia
• idiopathic RDS
• delayed lung maturity
• prematurity
• predisposition to diabetes

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Preexisting Diabetes

• Congenital anomalies
• 3x the general population risk
• approaches the gen pop risk (2-3) if optimal
  control in periconception period
• related to glycemic control during embryogenesis

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Congenital anomalies

• CVS
• ASD/VSD,coarctation,transposition,
• cardiomegaly
• CNS
• anencephaly, NTD, microcephaly

• GI
• duodenal atresia, anorectal atresia, situs
  inversus
• GU
• renal agenesis
• Polycystic kidneys
• MSK
• caudal regression
• siren

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Preexisting Diabetes

• Maternal Surveillance
• Blood pressure
• renal function
• urine culture
• thyroid function
• BG control HB A1C
  
• q trimester
  
• monthly

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Preexisting Diabetes

• Fetal Surveillance
• U/S for dating/viability 8 weeks
• Fetal anomaly detection
• nuchal translucency 11-14w
• maternal serum screen
• anatomy survey 18-20 w
• Fetal echo 22 w

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• Multidose Insulin
• breakfast 25 H
• lunch 15 H
• supper 25 H
• hs 35 NPH
• indicates insulin as a of total daily dose

Gabbe Obstet Gynecol 2003
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Insulin Therapy

• onset (h) peak
  duration
• insulin analogs .25 0.5-1.5 6-8
• rapid acting 0.5 2-4 8-12
• intermediate 1-1.5 4-8 12-18

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Insulin Therapy

• Insulin Pump
• Allows insulin release close to physiologic
• Use short acting insulin
• 50-60 of total dose is basal rate
• 40-50 given as boluses
• Potential complications
• Pump failure
• Infection
• Increased risk of DKA if above happens

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Peripartum Management

• Withhold subcutaneous insulin from onset of
  labour or induction
• IV D10 _at_50cc/h
• IV short acting insulin in NS usually starting at
  0.5-1u/h 10cc insulin
  in 100 cc NS(1U10cc)

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Peripartum Management

• insulin rate usually based on BG and pre-delivery
  insulin requirement
• eg. For each 75-100 total units /24h of
  pre-delivery insulin, 1 unit per hour needed
• measure capillary BG hourly VPG q2-3h
• target 4-6mmol/L

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Peripartum Management

• Following delivery
• stop insulin infusion
• begin sub Q insulin
• resume previous MDI schedule at 1/2 -2/3 the pre
  pregnancy dose
• maintain IV D5W _at_50cc/h until oral feeds tolerated

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Oral Hypoglycemic agents

• Traditionally not recommended in pregnancy
• Recent RCT of oral glyburide vs insulin for GDM
• 440 patients
• BG measured 7x daily
• Treatment started after 11 weeks gestation

Langer NEJM 2000
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Oral Hypoglycemic agents

• Glyburide Insulin
• Achieved N BG 82 88
• LGA infants 12 13
• Macrosomia 7 4
• C Section 23 24
• Hypoglycemia 9 6
• Preeclampsia 6 6
• Anomalies 2 2

Langer NEJM 2000
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Fetal Surveillance

• Goals
• Minimize/eliminate the risk of fetal death
• Early detection of fetal compromise
• Prevent unnecessary premature delivery
• Main benefit is the NPV of these tests
• Provides reassurance that fetus with a N test
  unlikely to die in utero
• Allow prolongation of pregnancy fetal maturation

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Fetal Surveillance

• Gestational Diabetic Diet controlled
• Can start fetal surveillance at term (40 weeks)
• GDM on insulin/Type II DM/ Type I DM
• Start weekly BPP from 32 weeks
• Consider earlier testing if
• suboptimal control
• Hypertension
• vasculopathy

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Timing of Delivery

• GDM Diet controlled
• Same as non diabetic
• Offer induction at 41 weeks if undelivered
• GDM on Insulin/Type II/Type I
• If suboptimal control deliver following
  confirmation of lung maturity if lt39 weeks
• Otherwise deliver by 40 weeks
• Generally do not allow to go postterm

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Mode of Delivery

• Macrosomic infants of diabetic mothers have
  higher rates of shoulder dystocia than non
  diabetic mothers
• Ultrasound estimates of fetal weight become
  significantly inaccurate after 4000g
• Reasonable to recommend C/S delivery if EFW is
  gt4500g

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Diabetic Ketoacidosis

• 5-10 of pregnant Type 1 pts
• Risk factors
• New onset DM
• Infection
• Insulin pump failue
• Steroids
• B mimetics
• Fetal mortality 10

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Diabetic Ketoacidosis

• Management
• ABCs and ABG
• Assess BG, ketones electrolytes
• Insulin
• .2-.4U/Kg loading and 2-10U/h maintenance
• Begin 5 dextrose when BG is 14 mmol/l
• When potassium is N range begin 20mEq/h
• Rehydration isotonic NaCl
• 1L in 1st hour
• .5-1l/h over 2-4h
• 250cc/h until 80 replaced
• Replace Bicarb and phosphate as needed

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Diabetic Ketoacidosis

• Rehydration isotonic NaCl
• 1L in 1st hour
• .5-1l/h over 2-4h
• 250cc/h until 80 replaced
• Replace Bicarb and phosphate as needed

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Any questions?