Diabetes Mellitus
It is a syndrome characterized by
disturbance of carbohydrates, fats, proteins,
minerals and water caused by absolute or
relative deficiency or decreased sensitivity
of insulin either congenital or acquired.
Incidence
 Second commonest medical disorder in
pregnancy.
 Generally the incidence is reported to be 1%.
Classification of Diabetes Complicating
Pregnancy (A.C.O.G May 1986)
Class Age of Duration Vascular
Onset
Disease
Therapy
A
B
Any
> 20
Any
< 10
None
None
Diet Only
Insulin
C
10 – 19
10 – 19
None
Insulin
D
< 19
> 20
Benign
Insulin
Retinopathy
Insulin
F
Any
Any
Nephropathy
Insulin
R
Any
Any
Profiferaive
Insulin
Retinopathy
Insulin
Heart Disease
Insulin
H
Any
Any
Gestational Diabetes
WHO:
Diabetes in pregnancy when fasting
glucose >7.9mmol or > 11 mmol/L
2hours after a 75 gm glucose load.
Gestational Diabetes:
Meets the WHO criteria for diabetes
during pregnancy but reverting to
normal after puerperium
Potential Diabetes
Risk of developing diabetes at some
age in woman’s life.
 Strong family H/O diabetes
 A child with birth weight of 4kg or more
 A stillborn child with pancreatic islet cell
hyperplasia or other congenital anomalies
 Maternal weight > 90 kg.
 Previous unexplained IUD or early neonatal
death or recurrent abortion.
Pregnancy & Carbohydrate
Metabolism
 Pregnancy is diabetogenic.
 Pregnancy alters carbohydrates metabolism
but adaptation occurs and there is no effect
on mother and fetus, as insulin secretion
also increases.
 When there is abnormal maternal response,
there is increased fetal risk.
 Decreased sensitivity to insulin with
increasing gestation due to cortisole,
estrogen, progesterone, hPL and
degradation of insulin by placenta.
Pregnancy & Carbohydrate
Metabolism (Contd.)
 Early pregnancy: fasting serum insulin and
Peak after glucose intake are equal to nonpregnant state.
 Late pregnancy levels are higher at 28 weeks.
 There is tendency to post parendial
hypoglycaemia.
 For normal glucose homeostasis more insulin
is to be secreted adequate reserve of  cell.
 Pregnancy can reveal a tendency to
carbohydrate in tolerance
30%
 Maternal age parity and genetics also has its
effects.
Effects of Pregnancy on Diabetes
 Lowered renal threshold for glucose.
 Increase in Progesterone, H.P.L, cortisole,
placental insulinase and insulin antibodies.
 Insulin requirement increases steadily.
 Control is difficult.
 Increased tendency of acidosis ketosis
 Increased risk of complications such as
nephropathy and retinopathy
Effect of Diabetes on Pregnancy
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Infertility
Spontaneous abortions
Infection
Candidiasis
Pre-eclampsia
Polyhydramnios
Pre-term labour
Macrosomia
Sudden intrauterine death
Perinatal death
Post-partum hemorrhage
Congenital malformations
Management
Aims
 To maintain euglycaemia and prevent
complications.
 To deliver at appropriate time.
 Intensive neonatal care.
Diet Control
 30 – 30k cal/kg body weight for the nonobese patients
 25k cal/kg body weight for obese patients
CHO
Proteins
Fat
50 – 55%
15 – 20%
20 – 30%
Antenatal Management
 Early booking.
 Ultrasound in early pregnancy and at 20 weeks
for anomaly scan.
 Fortnight visits to estimate maternal
complications and assess fetal well-being
 After 24 weeks monthly ultrasound for fetal
growth.
 In last trimaster fetal kick count, CTG and
biophysical profile.
 Late pregnancy admission to hospital to plan
delivery.
Medical Management
 Insulin therapy (maintain glucose between 4 – 6
mmol/L).
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Insulin requirement increases steadily.
Never use oral hypoglycaemics.
Self monitoring with glucometer.
Patients education regarding insulin
injections, symptoms of hypoglycaemia,
urine testing, dietary advice and to report
immediately if any complication occurs.
Admissions To The Hospital If:
 Inadequate control of Diabetes.
 Condition is newly diagnosed.
 An intercurrent Infection.
 Any medical or obstetric complication.
Obstetric Management
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Plan normal delivery if every thing is OK
Induction and augmentation.
Omit morning insulin.
IV insulin therapy.
Monitor uterine contractions and fetal heart
rate and CTG
Adequate analgesia.
Maintain partogram.
Second stage shortened by ventous or forceps.
Supervised by the senior.
Watch for diabetic ketoacidosis.
Neonatal Management
 Nursery care.
 Blood glucose estimation.
 Treatment of hypoglycaemia,
hypocalcaemia and jaundice.
Neonatal Complications
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Hypoglycaemia
Hypocalcaemia
Hypomagnecaemia
Hyperbilirubinaemia
Polycythemia
Respiratory distress syndrome
Cardimyopathy
 Late inherent diabetes mellitus
Maternal hyperglycaemia & hyperacidaemia
Fetal hyperglycaemia & hyperacidaemia
Fetal pancreatic hyperplasia
Fetal hyperinsulinaemia
Macrosomia
Organomegaly
Neonatal hypoglycaemia
Increased erythropoisis
Decreased surfactant
Post-Natal Management
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Blood glucose level after delivery.
Insulin requirement decreases.
Prevention of wound infection.
Breast feeding.
Post-natal checkup after 6 weeks.
Contraceptive advice.
Thank You