Diabetes in Pregnancy
L.Sekhavat MD
Diabetes in PregnancyGestational Diabetes
Pre-gestational diabetes (overt)Insulin dependent (type1)Non-insulin dependent (type 2)
Definition
Gestational diabetes mellitus (GDM) is defined as any degree of glucose intolerance with onset or first recognition during pregnancy
Diabetes in pregnancy
Pre-existing diabetes Gestational diabetes
Pre-existing diabetesIDDM (Type1)
NIDDM(Type2) True GDM
Gestational diabetes typically is 3rd trimester disorder
Overt diabetes is 1st trimester
Some general character istic of type1 and type 2 diabetes
Characteristic type1 type2 genetic ch 6 unknownAge at onset <40 >40Habitus normal to wasted obesePlasma insullin low to absent normal to highInsullin therapy responsive R/resistant
Classification of diabetesClass onset FBS 2hpp therapyA1 gestational <90 <120 dietA2 gestational >90 >120 insullinClass age of onset duration V diseasesB >20 10-19 noneC 10-19 10-19 noneD <10 >20 B retionopathyF any any nephropathyR any any P retionopathyH any any heart D
Normal Maternal Glucose Regulation
Tendency for maternal hypoglycemia between meals - fetal demandIncreasing tissue insulin resistance during pregnancy
↑ Diabetogenic placental steroid↑ Estrogen, Progesterone↑HPL
Increased insulin production (= 30% mean)
Fetalhyperinsulinemia
Fetus
Fetal pancreas stimulated
MotherPl
acen
ta
Insulin
Maternal hyperglycemia
The Impact of Maternal Hyperglycemia Dur ing Pregnancy
Maternal HyperglycemiaCauses fetal hyperglycemiaLeading to fetal hyperinsulinemiaFetal hyperinsulinemia - even short periods (1-2 hours) lead to detrimental consequences in:
fetal growthfetal well-being
Fetal Hyper insulinemiaPromotes storage of excess nutrients -macrosomniaIncreased catabolism of excess nutrients -energy usage and low fetal oxygen storageEpisodic fetal hypoxiaIncreased catecholamines causing:
hypertensioncardiac hypertrophy
Increased Erythropoietin:Hyperbilirubinaemia
Diagnosis:
Glucosuria is common in pregnancy (Renal glycosuria)
so not diagnostic.
Fasting and 2 hours postprandialvenous plasma sugar dur ing pregnancy.
Diabetic>120 mg/ dl.>95 mg/dl
Not diabetic< 120mg/ dl.<95 mg/dl
Result2h postprandialFasting
Risk Factors:> 25 years oldPrevious macrosomnic infantUnexplained fetal demisePrevious GDMFamily hx - GDM/NIDDMObesity > 90KgSmoking
50-g oral glucose challengeThe screening test for GDM, a 50-g oral
glucose challenge, may be performed in the fasting or fed state. Sensitivity is improved if the test is performed in the fasting state .
A plasma value above 130-140 mg/dl one hour after is commonly used as a threshold for performing a 3-hour OGTT. If initial screening is negative, repeat
testing is per formed at 24 to 28 weeks.
3 hour Oral glucose tolerance test
Prerequisites:Normal diet for 3 days before the test.No diuretics 10 days before.At least 10 hours fast.Test is done in the morning at rest.
Giving 100 gm (75 gm by other authors) glucose in 250 ml water orally
Criter ia for glucose tolerance testThe maximum blood glucose values during
pregnancy:fasting 95 mg/ dl, one hour 180 mg/dl,2 hours 155 mg/dl, 3 hours 140 mg/dl.
If any 2 or more of these values are elevated, the patient is considered to have an impaired glucose tolerance test.
Pregnancy Complication
HydramniosSpontaneous abortionsCongenital malformationsMacrosomiaDiabetic ketoacidosisNeonatal metabolic complications
Macrosomia -Pathogenesis
Macrosomnia(Greater than 90 precentile, 4200 grammes)
Increased birth traumaMacrosomnia as a child and glucose intolerance in adulthood
Congenital AnomaliesCardiac defects 8.5%CNS defects 5.3%
AnencephaSpina Bifida
All Anomalies 18.4%Specially over t diabetes The most r isk is HgA1c >10
Maternal ComplicationsPre-eclampsiaDiabetic ketoacidosisMaternal hypoglycemiaMaternal traumaHigher C/S rateRetinal disease/renal disease not affected significantly by pregnancy
Per inatal Mor tality/Morbidity
MiscarriageIUGRMacrosomiaBirth Injury
Neonatal Morbidity and Mor tality
Neonatal hypoglycemiaPolycythemiaHyperbillirubinemiaHypertrophic and congestive cardiomyopathyARDSDevelopment of obesity and diabetes in childhood
Treatment of Gestational DiabetesDiet and exerciseGlucose monitoringInsulin if necessary (Hypoglycemic agents?)2-weekly visits to Diabetic service/antenatal service & Growth Monitoring (scan)Delivery based on obstetric issues
Diet Therapy
Goals of an Effective diet: NormoglycemiaAdequate weight gainGood fetal health
Medical nutrition therapy should include the provision of adequate calories and nutrients to meet the needs of pregnancy
( Diet: 50% carb, 20% prot, 30% fat)
Exercise Therapyexercise diminishes peripheral resistance to insulin cardiovascular conditioning increase affinity and receptor bindingReduction in both fasting and postprandial glucose
may decrease need for other therapies in Gestational Diabetes
insulin therapy is recommended when medical nutrition therapy fails to maintain self-monitored glucose at the following levels:
Fasting blood glucose <95 mg/dLor1-hour postprandial blood glucose <140
mg/dL or2-hour postprandial blood glucose <120
mg/dL
Insulin therapy
The total first dose of insulin is calculated according to the patient’s weight as follow:
In the first trimester .......... weight x 0.7In the second trimester........ weight x 0.8In the third trimester........... weight x 0.9
Insulin therapy
Insulin Therapy (dosage)Divide the injections:
60% Regular insulin30% before breakfast15% before lunch15% before dinner
40% NPH30% before breakfast10% before bed
One study demonstrated that the 4 injection a day as compared to 2 injections a day improved glycemic control and perinatal outcome
ManagementTest AFP at 16-20 weeksAntenatal visits – 2 weekly after 24 weeksNST weekly (starting at 28-30 wks)Anomaly scan at 16- 20-weeks andGrowth scans from 26-28 weeksDelivery
Around term if insulin dependent unless complicationsDiet only control as normal antenatal patients
When antepartum testing suggests
fetal compromise, delivery must be
considered.
Intrapar tum managementIV fluids (5% dextrose) + insulinHourly glucose monitoringManage labor as normal
The need of insulin typically decreased after delivery so:Avoid of NPH and used Regular insulin
Management - Postpar tumUse pre pregnancy insulin levels when on diet and monitor. Breast feeding?GDM - long term risk of NIDDMContraception
After delivery nearly all postpartum women will become normoglycemic 1/3 to 2/3 will have recurrent GDM in subsequent pregnancies
Over than 50% of gestational diabeteslead to overt diabetes
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