Diabetes in pregnancy
Dr. Lubna Maghur MRCOG
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Diabetes is a common medical disorder
effecting 2-5% of pregnancies.
It is associated with maternal morbidity and
mortality.
Good antenatal care and blood sugar control is
associated with major reduction in its
complications.
Objectives
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To understand the changes of glucose
metabolism in pregnancy.
Te be able to list the different methods used to
diagnose diabetes in pregnancy.
To be able to define gestational diabetes.
To list the effect of diabetes on pregnancy.
To list the effect of pregnancy on diabetes.
To understand the management of diabetes in
pregnant women.
Physiological changes
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In normal pregnancy fasting blood sugar is
slightly reduced.
In normal pregnancy renal threshold for glucose
increases leading to glucoseurea.
Pregnancy is a state of insulin resistance and
glucose intolerance.
This is due to increase in anti-insulin hormones.
The insulin resistance increases with increased
gestation.
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This does not effect normal pregnancy as
insulin levels will increase.
Patients with relative glucose intolerance will
develop gestational diabetes.
Patients who are established diabetics may
require increase dosage of their medication.
Definition
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Complex disease characterized by
Carbohydrate intolerance of variable degree of
severity.
Types of diabetes in pregnancy
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Type I( IDDM): There is absolute insulin
deficiency , usually effects children and young
adults.
Type II diabetes(NIDDM): There is increase
insulin resistance, usually effects adults.
Gestational diabetes: Diabetes occurring for
the first time during pregnancy.
Screening for diabetes in
pregnancy
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History and examination : risk factors.
Glucose urea.
Random blood sugar.
Fasting blood sugar.
Oral GGT
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When to screen?
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Risk factors for gestational
diabetes
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Previous history of diabetes.
Positive family history.
Age and parity.
History of IUFD.
History of recurrent abortion.
History of Large size babies (>4Kg).
Polyhydramnious.
Obesity.
Diagnosing gestational diabetes
Should be performed in all high risk patients or
if screening is positive.
 FBS > 100mg/dl
 Glycosylated haemoglobin?????
 GTT.
How to perform GTT
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Normal diet for 3 days.
Over night fasting 8 – 12 hours.
Obtain fasting blood sample.
Drink 75 g glucose solution within 5 min.
Obtain blood sample 2 hour later.
Blood sugar results
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Fasting blood sugar should be < 100mg/dl.
Blood sugar at 2 hours should be <140mg/dl.
Impaired glucose if 2 hours level 140200mg/dl.
Diabetic if fasting >100 and 2 hours level
>200mg/dl
Effect of pregnancy on diabetes
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Insulin requirement increases 2 folds
especially between 28-32 weeks.
Hyperemesis and infection increase the risk of
diabetic ketoacidosis.
Nephropathy, retinopathy and neuropathy may
deteriorate in pregnancy.
Effects of diabetes on pregnancy
Maternal;
 Increase risk of pre-eclampsia.
 Increase risk of infection; UTI, candidiasis,
and postpartum.
 Increase cesarean section rate.
Fetal complications
Early pregnancy:
Miscarriage, congenital abnormalities,
 Late pregnancy:
Macrosomia, polyhydramnious, unexplained
intrauterine fetal death, IUGR, increase
perinatal mortality, shoulder dystocia.
 Neonatal:
Hypoglycemia, hypomagnisemia, hypokalemia,
hyperbilirobinemia, RDS, polycythemia.
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Congenital anomaly and diabetes
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Hyperglycemia is teratogenic.
Chromosomal abnormalities are not increased.
The commonest abnormality is congenital
heart disease and neural tube defects.
Other abnormalities may occur.
Sacral agenesis is characteristic but rare
Fetal macrosomia
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Fetus >90 centile.
Occurs due to maternal hyperglycemia.
May lead to prolonged labour, increase risk of
instrumental delivery, increase risk of C/S, and
shoulder dystocia.
Large babies are more likely to suffer from
hypoglycemia.
Management of diabetes in
pregnancy
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Pre-pregnancy counseling.
Antenatal care.
Controlling blood sugar.
Management of diabetes in labour.
Postpartum management.
Pre-pregnancy counseling
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Most important in the management of diabetes.
Good diabetic control is essential before
pregnancy to prevent early complications.
Diabetic control is measured by glycosylated
Hb.
Folic acid to reduce NTD 3 months before.
If uncontrolled use contraception.
If on oral hypoglycemic change to insulin.
Advice healthy diet and life style.
May advice against pregnancy in some cases.
Antenatal care.
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Should be managed in a joint clinic.
Early booking.
Anomaly scan at 18-22 weeks.
Frequent antenatal follow up with U/S to
monitor fetal growth.
Check blood pressure and urine albumen at
every visit.
Avoid delivery before 38 weeks unless other
complications.
Pregnancy should not go beyond 40 weeks.
Controlling blood sugar.
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Good control of blood sugar improves
maternal and fetal complications.
Good diet control but avoid starvation (3 meals
and 3 snacks).
Patients with newly diagnosed with gestational
diabetes is can be first treated with diet
control.
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The aim is to keep blood sugar near
normoglycemia (<100mg/dl fasting and
140mg/dl post-brandial).
Usually blood sugar is controlled with 2 doses
of mixed inslulin.
Better control is achieved with 4 doses.
Self control is ideal.
The patient may need to be admitted to
hospital for blood sugar control at some stage.
Management of diabetes in
labour.
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C/S is for obstetric indications.
Patient is kept NPO.
Dextrose infusion is set up.
Insulin infusion at rate of 2-6 units per hour.
If patient is having a cesarean section morning
dose of insulin is omitted.
Continous electronic fetal monitoring.
Postpartum management.
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Reduce the insulin to pre-pregnancy dose or
half the pregnancy dose.
Breast feeding mothers have lower insulin
requirements.
If delivered by C/S continue insulin infusion
until the patient is eating then retern to
subcutanous insulin.
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Patients with gestational diabetis may improve
after delivery but the have increase risk of
developing GD in next pregnancies and
NIDDM later in life (40-60%).
Summary
The ultimate goal of our
management is …..
Healthy mother and healthy baby