Diabetes in pregnancy

Pelvic inflammatory disease, (PID)

DIABETES INPREGNANCY

Dr. Jograjiya

Post Graduate Student, Department of Gynaecology and

Obstetrics

PGIMSR, ESIC, Basaidarapur, New Delhi-110015

Proposed Classification System for Diabetes in Pregnancy

Definitions

Gestational

diabetes

Pre-gestational

diabetes

(Overt)

Definitions

Any degree of glucose

intolerance with onset or first

recognition during pregnancy

Gestational Diabetes

Metzger BE, Coustan DR (Eds.): Proceedings of the Fourth International Workshop-Conference on Gestational Diabetes Mellitus. Diabetes Care 21 (Suppl. 2):B1– B167, 1998

Definitions

Pre-gestational Diabetes

Diabetes diagnosed before

pregnancy

Etiological Classification of Diabetes Mellitus

White Classification in Diabetes Complicating Pregnancy

Screening and diagnosis

Rationale for treatment

Monitoringof blood glucose

Diet and exercise

Insulininitiation and follow-up

Maternal and fetal surveillance

Labor and delivery

Postpartum follow-up

Gestational Diabetes

Gestational

diabetes

Screening

Risk factors for GDM

Increasing maternal age and weight

Previous GDM

Previous macrosomic infant

Family history of diabetes among

first-degree relatives

Ethnic background with a high

prevalence of diabetes

International Diabetes Federation (2009)

Global Guideline on Pregnancy and Diabetes

Gestational

diabetes

Screening

Universal Screening

recommend for High risk

pregnant women



Gestational

diabetes

Screening

Allwomen should undergo

screening at first prenatal visit

and after 26 to 28 weeks if

negative on previous testing.

AFES Study Group on Diabetes in Pregnancy (ASGODIP), 1996

Gestational

diabetes

Screening


50-g glucose

challenge test

(GCT)


>140 mg/dL

Gestational

diabetes

Diagnosis>140 mg/dL

50-g glucose

challenge test

(GCT)

Oral glucosetolerance test (OGTT)

75-g or 100 g?

Thresholds

for

diagnosis

ADA ASGODIP

75-g

WHO

75-g100-g 75-g

FBS 95 95 - -

1 h 180 180 - -

2 h 155 155 140 140

3 h 140 - - -

100-g OGTT

Carbohydrate intake of at least 150 g/day 3days

prior

Fast for 8 to 10 hours but not more than 14 hours

75 grams of anhydrous dextrose powder as chilled 25%

solution (400 cc) flavored

Drink within 5 minutes (first swallow is time zero)

Terminate test should nausea and vomiting occur

Collect samples at 0, 1 , 2 and 3 hours

100-g OGTT

Abstain from tobacco, coffee, tea, food and

alcohol during test

Sit upright and quietly during the test

Slow walking is permitted but avoid vigorous

exercise

Gestational

diabetes

Rationale for treatmentIncreased risk for

macrosomic or LGA infants

25

0

50

100

75

MMC VMMC PoGH CSMC PGH

%

GDM Normal


Isip-Tan unpublished data

Gestational

diabetes

Rationale for treatmentIncreased risk for

Cesarean sections

20

40

60

80

100

MMC VMMC PoGH PGH

%

GDM Normal


Isip-Tan unpublished data

Gestational

diabetes

Monitoring blood glucose

Self-monitor blood glucose levels

both fasting and postprandial,

preferably 1 h after a meal.




Fifth International Workshop-Conference on Gestational Diabetes Mellitus (2007)

National Institute for Health & Clinical Excellence (2008)

Canadian Diabetes Association (2008)

5th Int’l Workshop NICE CDA

Fasting 90-99 mg/dL

(5.0-5.5 mmol/L)

63-106 mg/dL

(3.5-5.9 mmol/L)

68-94 mg/dL

(3.8-5.2 mmol/L)

1 h after

meal

<140 mg/dL

(<7.8 mmol/L)

<140 mg/dL

(<7.8 mmol/L)

99-139 mg/dL

(5.5-7.7 mmol/L)

2 h after

meal

<120-127 mg/dL

(<6.7-7.1 mmol/L)

90-119 mg/dL

(5.0-6.6 mmol/L)

Dietary Management

Determine if patient is overweight

Expected pregnant weight =

ideal body weight (for height) +

expected weight gain/trimester

IOM recommendations for

weight gain by pre-

pregnancy BMI

* Assume a 0.5-2.0 kg (1.1-4.4 lbs) weight gain in the first trimester

2009Prepregnancy BMI Total weight

gain (lbs)

Rates of weight gain*

2nd and 3rd trimester

(lbs/week)

Underweight

BMI <18.5

<28-40 1

(1-1.3)

Normal weight

BMI 18.5-24.9

25-35 1

(0.8-1)

Overweight

BMI 25.0-29.9

15-25 0.6

(0.5-0.7)

Obese

BMI >30.0

11-20 0.5

(0.4-0.6)

Dietary Management

Jovanovic L (Ed). Medical Management of Pregnancy Complicated by Diabetes (2009)

Recommended Daily Caloric Intake

Pregravid BMI Category kcal/kg/day

Low (BMI <18.5 kg/m2) 36-40

Normal (BMI 18.5-24.9 kg/m2) 30

High (BMI 25-29.9 kg/m2) 24

Obese (BMI >29.9 kg/m2) 12

Dietary Management



For considerably overweight

women with GDM, reduce energy

intake by no more than 30% of

habitual intake

Total cal/day = 1,800-2,000

Not less than 2,000 cal/day if multiple pregnancy

3 meals and 3 snacks

40% complex high fiber carbohydrate

20% protein

40% fats (ACOG 2013)

Dietary Management

Avoid concentrated sweets

No cookies, cakes, pies, soft

drinks, chocolate, table sugar,

fruit juice, juice drinks, Kool-Aid,

Hi-C, nectars, jams or jellies

Avoid convenience foods

No instant noodles, canned

soups, instant potatoes, frozen

meals or packaged stuffing

Dietary Management


Eat small frequent meals

Eat about every 3 hours

Include a good source of protein

at every meal and snack (i.e. low-

fat meat, chicken, fi ish, low-fat

cheese, nuts, peanut butter,

cottage cheese, eggs and turkey)

Dietary Management


Dietary Management

Eat a very small breakfast

No more than 1 starch

exchange (<15g carbohydrate

so limit cereal, bread, pancakes,

toast, bagels, muffins and

Danishes and no fruit juice


Dietary Management

Choose high-fiber foods

Fresh and frozen vegetables

Beans and legumesFresh fruits (except at breakfast)


Dietary Management

Free foods - eat as desired


cabbage mushrooms celery

radish cucumber zucchini

lettuce green beans spinach

onion green onion garlic

broccoli asparagus nopales

spinach lemon/lime butter

olives sour cream avocado

olive oil

Monitor urine ketones before

breakfast to detect starvation

ketonuria

Individualize!

Monitor blood glucose levels, urine

ketones, appetite and weight gain

Dietary Management

Exercise


ACOG (2013)

Walking for 20 minutes two time

daily that exercise improved

cardiorespiratory fitness without

improving pregnancy outcome.

Exercise is a useful adjunct to treatment

Avoid excessive abdominal muscle contraction


Insulin Initiation

ADA Protocol

Fasting whole BG >95 mg/dL

1-h postprandial whole BG >140 mg/dL

2-h postprandial whole BG >120 mg/dL

Insulin Initiation

Diet therapy alone for one

postprandial glucose

abnormal before starting

insulin

If fasting glucose (on OGTT) >95 mg/dL

or Two postprandial glucose abnormal

start insulin with dietary therapy at

diagnosis

Insulin Regimens

Human insulin

Insulin analogues

Insulin lispro and aspart safe and effective

and have a more rapid onset of action than

regular insulin

Limited experience with insulin glargine and detemir

Insulin Regimens

ASGODIP Protocol

Intermediate-acting insulin 30 min prebreakfast

Intermediate-acting insulin 30 min presupper + rapid-

acting insulin

Three injections of rapid-acting insulin given 30 minutes

before each meal + intermediate-acting OR long-acting

insulin at bedtime

Initiating dose is typically 0.7–1.0 units/kg/day given in

divided doses (ACOG, 2013).

Subsequent visits

ASGODIP Protocol

Every 2 weeks to check

glycemic control

W/F obstetric complications(i.e. macrosomia, IUGR,

preeclampsia and hydramnios)

Date

time CBG Comments

11/20

after 160 pancakes

breakfast

after 148 spaghetti

lunch

after 118

dinner

Maternal surveillance

Increased frequency of preterm

birth in untreated GDM

Use of corticosteroids not

contraindicated but intensify

glucose monitoring and adjust

insulin

Risk of hypertensivedisorders

increased


Fetal surveillance

ASGODIP Protocol

Ultrasound at 11-13 weeks

first visit to determine age of

pregnancy

At 18-20 weeks to detect

malformations

Once at 36-37 weeks to monitor

growth

HbA1c values >7.0% or fasting plasma

glucose >120 mg/dL (6.7 mmol/L)Jovanovic L (Ed). Medical Management of Pregnancy Complicated by Diabetes (2009)

Glycemic control during labor and delivery

Usual dose of intermediate-acting insulin is given at bedtime.

Morning dose of insulin is withheld.

Intravenous infusion of normal saline is begun.

Once active labor begins or glucose levels decrease to < 70

mg/dL, the infusion is changed from saline to 5-percent dextrose

and delivered at a rate of 100–150 mL/hr (2.5 mg/kg/min) to

achieve a glucose level of approximately 100 mg/dL.

Glucose levels are checked hourly using a bedside meter

allowing for adjustment in the insulin or glucose infusion rate.

Regular (short-acting) insulin is administered by intravenous

infusion at a rate of 1.25 U/hr if glucose levels exceed 100

mg/dL.

Glycemic control during labor and delivery

ASGODIP Protocol

After delivery, resume diet

Generally do not require insulin

GDM with high insulin requirements during pregnancy

should have CBG monitoring

Give insulin only if CBGs persistently high (>200 mg/dL)

Postpartumfollow-up

Schedule 100-g OGTT after 6 weeks

60-70% chance of developing GDM in

subsequent pregnancies

40-60% chance of developing type 2

diabetes in the future


Postpartumfollow-up

Annual follow-up

Measure FBS

Assess weight reduction

Review pregnancy plans


Pre-gestational diabetes

Diagnosis

Impact on Pregnancy

Effects on Fetus

Maternal Effects

Preconception care

Monitoring of blood glucose

Hypoglycemia

Special considerations

Diagnosis

Impact on Pregnancy

Effects on Fetus

• Spontaneous Abortion

• Altered growth

• Preterm Delivery

• Unexplained Fetal Demise

• Hydramnios

• Respiratory Distress Syndrome

• Hypoglycemia.

• Hypocalcemia.

• Hyperbilirubinemia and Polycythemia.

• Cardiomyopathy

• Long-Term Cognitive Development

• Inheritance of Diabetes.

Maternal Effects

•Preeclampsia•Diabetic Nephropathy•Diabetic Retinopathy •Diabetic Neuropathy•Diabetic Ketoacidosis •Infection

Management Diabetic Ketoacidosis

Preconception Care

Contraceptive advice

Risks of pregnancy (maternal and

fetal/neonatal)

Importance of maintaining blood

glucose levels

Genetic counseling

Personal commitment by women

and her family

Preconception Care

Prepregnancy Assessment

History and PE

Gynecologic evaluation

Lab evaluation

HbA1c, urinalysis and culture, 24-h

urine for creatinine CL and protein

Thyroid panel: FT4 1.0-1.6 and TSH

<2.5 uU/L

ECG or treadmill

Neuropathy testing if indicated

Preconception Care

Potential Contraindications to Pregnancy

Ischemic heart diease

Active proliferative retinopathy, untreated

Renal insufficiency

Creatinine CL <50 ml/min or serum creatinine >2

mg/dL or heavy proteinuria (>2 g/24 h) or

hypertension (BP

>130/80 mm Hg despite treatment)

Severe gastroenteropathy

Nausea/vomiting, diarrhea

Preconception Care

Shift Type 2 diabetics on OHA to insulin

Maternal HbA1c to assess risk of malformations

Goal < 6 % if possible Monitor every 1 to 2

months

400 μg/day orally is given periconceptionally and

during early pregnancy

Discontinue contraception

Stable glycemic control

Maternal diabetic complications and coexisting medical

problems acceptableDiabetes Care 26:S91-93, 2003


Fifth International Workshop-Conference on Gestational Diabetes Mellitus (2007)

National Institute for Health & Clinical Excellence (2008)

Canadian Diabetes Association (2008)

5th Int’l Workshop NICE CDA

Fasting 90-99 mg/dL

(5.0-5.5 mmol/L)

63-106 mg/dL

(3.5-5.9 mmol/L)

68-94 mg/dL

(3.8-5.2 mmol/L)

1 h after

meal

<140 mg/dL

(<7.8 mmol/L)

<140 mg/dL

(<7.8 mmol/L)

99-139 mg/dL

(5.5-7.7 mmol/L)

2 h after

meal

<120-127 mg/dL

(<6.7-7.1 mmol/L)

90-119 mg/dL

(5.0-6.6 mmol/L)

Hypoglycemia

Attempts to achieve normoglycemia in type

1 DMincrease risk of

hypoglycemia (DCCT)

No evidence that

hypoglycemia is an independent risk

to the developing embryo Clear risk

to the mother

Diabetes Care 26:S91-93, 2003

Diabetic Retinopathy

May accelerate during pregnancy

Gradual attainment of good metabolic

control before conception

Preconception laser photocoagulation

with standard indications

Baseline dilated comprehensive eye

examination

Follow up eye exam during pregnancy


Diabetic Retinopathy

Risk factors for progression

Duration of diabetes

Retinal status

Elevated HbA1c

Hypertension

Valsalva maneuver (increases risk of retinal

hemorrhage)


Hypertension

Type 1 diabetics frequently develop

hypertension in association with

diabetic nephropathy

Type 2 diabetics commonly have

coexisting hypertension

Pregnancy-induced hypertension

proteinuria in excess of 190 mg/day

before conception or in early pregnancy


Hypertension

Aggressive monitoring and control to

reduce risk of worsening

nephropathy, development of

retinopathy or clinical atherosclerosis

Avoid ACE-inhibitors, ARBs, beta-

blockers and diuretics in women

contemplating pregnancy

SBP <130 mm Hg

DBP <80 mm Hg


Diabetic Nephropathy

• Baseline assessmentof renal

function before conception and

followed at regular intervals

•urine albumin-to-creatinine

ratio 24 h albumin excretion



Permanent worsening of renal function

in >40% of women with incipient renal

failure (serum crea > 3 mg/dL or crea

clearance < 50 mL/min)

Permanent worsening of renal function

does not occur more often in women

with less severe nephropathy



Proteinuria >190 mg/24 h before or

during early pregnancy triples risk of

hypertensive disorders in second half

of pregnancy

Risk of IUGR during later pregnancy if

protein excretion > 400 mg/24 h

Discontinue ACE inhibitors in women

attempting pregnancy who have

microalbuminuria


Neuropathy

Autonomic neuropathy may complicate

managementgastroparesis

urinary retention

hypoglycemic unawareness

orthostatic hypotension

Peripheral neuropathy especially compartment

syndromes i.e. carpal tunnel syndrome may be

exacerbated


Cardiovascular disease

Untreated CAD is associated with a

high mortality rate

Successful pregnancies after coronary

revascularization in women with diabetes

Normal exercise tolerance to

maximize probability that patient will

tolerate increased cardiovascular

demands of gestation


Gestational

diabetes

Screen all pregnant Indian

women

Be aware of the limitations of

self-monitored blood glucose

Do not wait too long to shift to

insulin if diet therapy fails

Ensure postpartum OGTT

Key Points

Counsel diabetic women of

child-bearing potential on

contraception and risks of

unplanned pregnancy with poor

metabolic control

Shift to insulin

Aim for A1c <6%

Key Points

Pre-gestational

diabetes

Advise regarding possible

worsening of diabetic

complications during pregnancy

Discontinue ACE-inhibitors in

albuminuric women attempting

pregnancyPre-gestational

diabetes

Key Points

ThankYou

Diabetes in pregnancy

Healthcare

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