Diabetes in Pregnancy

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Diabetes in Pregnancy
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Classification

• Pregestational diabetes
• Type 1 DM
• Type 2 DM
• Secondary DM
• Gestational diabetes

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Definition

• Gestational diabetes (GDM) is defined as
  glucose intolerance of variable degree with onset
  or first recognition during the present
  pregnancy.

Pregestational diabetes precedes the diagnosis
of pregnancy.
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Magnitude of problem GDM

• GDM varies worldwide and among different racial
  and ethnic groups within a country
• Variability is partly because of the different
  criteria and screening regimens

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Whom to screen ?

• Risk stratification based on certain
  variables
• Low risk no screening
• Average risk at 24-28 weeks
• High risk as soon as possible

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Low risk for GDM

• To satisfy all these criteria
• Age lt25 years
• Weight normal before pregnancy
• Member of an ethnic group with a low prevalence
  of GDM
• No known diabetes in first-degree relatives
• No history of abnormal glucose tolerance
• No history of poor obstetric outcome

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High risk
Intermediate risk
At least one of the criteria in the list

• Marked obesity
• Prior GDM
• Glycosuria
• Strong family history

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Screening and Diagnosis of GDM in the U.S.

• Use the 50 g oral glucose challenge with BS taken
  1 hour later
• Screen all pregnant women _at_ 24-28 weeks
• Test earlier in selected patients
• Threshold of 130 mg/dL or greater

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How to screen?

• Oral glucose tolerance
• test ( OGTT) with 100 gm glucose

Fasting 95 mg/dl
1-h 180 mg/dl
2-h 155 mg/dl
3-h 140 mg/dl

• Overnight fast of at least 8 hours
• At least 3 days of unrestricted diet
• and unlimited physical activity
• gt 2 values must be abnormal

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• Urine glucose monitoring is not useful in
  gestational diabetes mellitus
• Urine ketone monitoring may be useful in
  detecting insufficient caloric or carbohydrate
  intake in women treated with calorie restriction

Urine monitoring
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Problems of GDM fetal

• Increases the risk of fetal macrosomia
• Neonatal hypoglycemia
• Jaundice
• Polycythemia
• Hypocalcemia, hypomagnesemia
• Birth trauma
• Prematurity

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Problems fetal

• Cardiac( including great vessel anomalies) most
  common
• Central nervous system 7.2
• Skeletal cleft lip/palate, caudal regression
  syndrome
• Genitourinary tract ureteric duplication
• Gastrointestinal anorectal atresia

Poor glycemic control at time of conception risk
factor
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Caudal regression syndrome
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Caudal regression syndrome
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Problems of GDM maternal

• Weight gain
• Maternal hypertensive disorders
• Miscarriages
• Third trimester fetal deaths
• Cesarean delivery (due fetal growth disorders)
  
• Long term risk of type 2 diabetes mellitus

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Pregnancy in diabetic mother risks

• Progression of retinopathy esp. severe
  proliferative retinopathy
• Progression of nephropathy especially if renal
  failure
• Coronary artery disease Post MI patients high
  risk of maternal death

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Management
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Preconception counselling

• Diabetic mother glycemic control with
  insulin/SMBG
• Target HbA1c lt 7
• Folic acid supplementation 5 mg/day
• Ensure no transmissible diseases HBsAg, HIV,
  rubella
• Try and achieve normal body weight diet/exercise
• Stop drugs oral hypoglycemic drugs, ACE
  inhibitors, beta blockers

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Clinical parameters checked at each visit

• medications
• pre-pregnancy weight
• weight gain
• edema
• pallor
• blood pressure
• Fundal height

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Patient educationCornerstone in GDM management

• Maternal complication
• Fetal complication
• Medical Nutrition therapy
• Glycemic monitoring SMBG and targets
• Fetal monitoring ultrasound
• Planning on delivery
• Long term risks

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Glycemic targets

• Fasting venous plasma lt 95 mg/dl
• 2 hour postprandial lt120 mg/dl
• 1 hour postprandial lt130 mg/dl (140)
• Pre-meal and bedtime 60 to 95 mg/dl

If diet therapy fails to maintain these targets gt
2 times/week, start insulin
These are venous plasma targets, not glucometer
targets
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Why these tight glycemic targets?

• Prospective study in type1 patients with
  pregnancy

FBS Macrosomia
gt105 mg/dl 28.6
95-105 10
lt95 mg/dl 3
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GDM
Medical nutrition therapy
Failure to maintain glycemic targets
INSULIN THERAPY
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Medical nutrition therapy

• Promote nutrition necessary for maternal and
  fetal health
• Adequate energy levels for appropriate
  gestational weight gain,
• Achievement and maintenance of normoglycemia
• Absence of ketones
• Regular aerobic exercises

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Medical nutrition therapy

• Approximately 30 kcal/kg of ideal body weight
• gt 40-45 should be carbohydrates
• 6-7 meals daily( 3 meals , 3-4 snacks). Bed time
  snack to prevent ketosis
• Calories guided by fetal well being/maternal
  weight gain/blood sugars/ ketones
• Energy requirements during the first 6 months of
  lactation require an additional 200 calories
  above the pregnancy meal plan.

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Self monitored blood glucose

• 4 times/day minimum, fasting and 1 to 2 hours
  after start of meals
• Maintain log book
• Use a memory meter
• Calibrate the glucometer frequently

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Fetal monitoring

• Baseline ultrasound fetal size
• At 18-22 weeks major malformations
• fetal
  echocardiogram
• 26 weeks onwards growth and liquor volume
• III trimester frequent USG for accelerated
  growth
• ( abdominal head circumference)

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Timing of delivery

• Small risk of late IUD even with good control
• Delivery at 38 weeks
• Beyond 38 weeks, increased risk of IUD without an
  increase in RDS
• Vaginal delivery preferred
• Caesarian section only for routine obstetric
  indication
• just GDM is not an indication !
• Unfavorable condition of the cervix is a problem
• 4500 grams, cesarean delivery may reduce the
  likelihood of brachial plexus injury in the
  infant (ACOG)

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Management of labor and delivery

• Maternal hyperglycemia in labor fetal
  hyperinsulinemia,
• worsen fetal acidosis
• Maintain sugars 80-120 mg/dl (capillary
  70-110mg/dl )
• Feed patient the routine GDM diet
• Maintain basal glucose requirements
• Monitor sugars 1-4 hrly intervals during labour
• Give insulin only if sugars more than 120 mg/dl

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Glycemic management during labour

• Later stages of labour start dextrose to
  maintain basal nutritional requirements 150-200
  ml/hr of 5 dextrose
• Elective LSCS check FBS, if in target no
  insulin, start dextrose drip
• Continue hourly SMBG
• Post delivery keep patients on dextrose-normal
  saline till fed
• No insulin unless sugars more than normal ( not
  GDM targets ! )

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Post partum follow up

• Check blood sugars before discharge
• Breast feeding helps in weight loss
• Lifestyle modification exercise, weight
  reduction
• OGTT at 6-12 weeks postpartum classify patients
  into normal/impaired glucose tolerance and
  diabetes
• Preconception counseling for next pregnancy

Increased risk of cardiovascular disease, future
diabetes and dyslipidemia
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Immediate management of neonate

• Hypoglycemia 50 of macrosomic infants
• 515 optimally
  controlled GDM
• Starts when the cord is clamped
• Exaggerated insulin release secondary to
  pancreatic ß-cell hyperplasia
• Increased risk blood glucose during labor and
  delivery exceeds 90 mg/dl

Anticipate and treat hypoglycemia in the infant
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Management of neonate

• Hypoglycemia lt40 mg/dl
• Encourage early breast feeding
• If symptomatic give a bolus of 2- 4 cc/kg, IV,
  10 dextrose
• Check after 30 minutes, start feeds
• IV dextrose 6-8 mg/kg/min infusion
• Check for calcium, if seizure/irritability/RDS
• Examine infant for other congenital abnormalities

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Long term risk offspring

• Increased risk of obesity and abnormal
• glucose tolerance
• Due to changes in fetal islet cell function
• Encourage breast feeding less chance of obesity
  in later life
• Lifestyle modification

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Conclusion

• Gestational diabetes is a common problem
• Risk stratification and screening is essential in
  all pregnant women
• Tight glycemic targets are required for optimal
  maternal and fetal outcome
• Patient education is essential to meet these
  targets
• Long term follow up of the mother and baby is
  essential

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Courtesy MSNBC News Services Jan. 24, 2005
17 pound baby born to Brazilian diabetic mother
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• thank you