Diabetes and Pregnancy

Diabetes and PregnancyDr. Mohammadeid Mohtaseb

Diabetes in pregnancyPre-existing diabetesGestational diabetesPrediabetesIDDM (Type1)NIDDM(Type2)True GDM

Preexisting DM and pregnancyGestational diabetesDiabetes and Pregnancy

Preexisting diabetes in pregnancyType 1 DM ( IDDM)Type 2 DM (NIDDM)

Preexisting DM in pregnancyEffect of pregnancy on pre-existing DMIncrease requirement for insulin dosesNephropathy , autonomic neuropathy may deteriorateProgress in diabetic retinopathy (2X)HypoglycemiaDiabetic ketoacidosis

Preexisting DM In PregnancyEffect of preexisting DM on pregnancyMaternal 1. increase risk of miscarriage 2. increase risk of preclampsia 3. increase risk of infection eg vaginal candidiasis, UTI, endometrial or wound infection 4. increase LSCS rate

Preexisting DM in Pregnancy(2) FETAL 1. increase risk of congenital abnormalities sacral agenesis, congenital heart disease, neural tube defects Hba1c level Risk normal not increased 10% 25 %

Preexisting DM in Pregnancy2. Perinatal mortality (excluding congenital abnormality ) 2 fold increased3. Increase risk of sudden unexplained intrauterine fetal death.

Complications of pregnancy in pre-existing DMMaternal:Increase insulin requirmentHypoglycemiaInfectionKetoacidosisDeterioration in retinopathyIncreased proteinuria+edemaMiscarriagePolyhydramnioShoulder dystociaPreeclampsiaIncreased caesarean rate

Fetal: Congenital abnormalitiesIncreased neonatal and perinatal mortalityMacrosomiaLate stillbirthNeonatal hypoglycemiaPolycythemiajaundice

Maternal hyperglycemia|Fetal hyperglycemia|Fetal pancreatic beta-cell hyperplasia|Fetal hyperinsulinaemia|Macrosomia,organomegaly, polycythaemia, hypoglycemia, RDS

Management Aim

Achieve maternal near normoglycemic level to prevent adverse perinatal outcomes

DietLow-carbohydrate diet , high fibre with caloric restrictionFrequent small snacks may be needed between mealsAvoid starvation

Insulin3 pre-meal short acting insulin (actrapid) +/- intermediate-acting insulin (protophane) as it allows maximum flexibility Target blood glucose: fasting < 5mmol/L 2 hr 250 mmol/L)

Gestational diabetesDefinition Carbohydate intolerance of variable severity first recognised during the present pregnancy. This includes women with preexisting but previously unrecognised diabetes

Gestational diabetesShould all pregnant women be screened or only those with risk factors?Is it safe to screen all?Which screening test and which diagnostic test are the most reliable?Which cut-off values should we use?What are the risk for mothers and babies and can treatment improve outcome?What are the connection between gestational diabetes and type 2 DM?

Gestational diabetes Screening and diagnosis In general, the test is performed btn 24-28 wk because at this point in gestation the diabetogenic effect of pregnancy is manifest and there is sufficient time remaining in pregnancy for therapy to exert its effect

PREGNANCY IS A DIABETOGENIC STATE FOR THE FOLLOWING REASONS:human placental lactogen has anti-insulin and lipolytic effects. It increases the glucose levels in maternal plasma and thus makes more glucose available to the fetussteroid hormones have an anti-insulin effect (especially corticosteroids and progesterone)some insulin may be destroyed by the placenta

Gestational diabetes

Gestational diabetesScreening and diagnosis In general, risk factor includes: 1. age>25y 2. BMI > 25 3. previous GDM 4. Family hx of DM in 1st degree relative 5. previous macrosomic baby (>4 kg) 6. polyhydramnios 7. large for date baby in current pregnancy 8. previous unexplained stillbirth

Gestational diabetesScreening and diagnosis

9.metabolic abnormalities HDL 250mg/dl 10. PCO11.HbA1c >5.7 12.Evidance of insulin resistance (acanthosis nigricans or sever obesity )

Criteria for the Diagnosis of DiabetesA1C 6.5%ORFasting plasma glucose (FPG)126 mg/dL (7.0 mmol/L)OR2-h plasma glucose 200 mg/dL(11.1 mmol/L) during an OGTTORA random plasma glucose 200 mg/dL (11.1 mmol/L)

ADA. I. Classification and Diagnosis. Diabetes Care 2014;37(suppl 1):S15; Table 2

Gestational diabetesIncidence 2-9% more common in Asian and Indian women In developed countries, increasing trend because of epidemic of obesity

Gestational diabetesClinical significance of GDMHigh incidence of macrosomia, and adverse pregnancy outcomes, A significant proportion(30%) identified as GDM in fact have DM before pregnancy

Gestational diabetesWomen with glucose intolerance just above normal range are at low risk for pregnancy complications, those with more severe glucose intolerance approaching the criteria of diabetes are at risk of neonatal complications

Fetal complicationsMacrosomia (>4 kg) risk is 16-29% as compared to 10% in controlIncrease in caesarean delivery, intrumental deliveries ( forceps/vacuum), birth trauma, such as brachial plexus injuries , clavicular fracturesIncrease in neonatal hypoglycemia (24% ), hyperbilirubinemia, hypocalcemia, polycythemiaChildren are at risk of type 2 DM and obesity in life

Maternal complicationsIncrease risk of hypertensive disordersIncrease risk of caesarean and Increased Risk (40-60%) of developing type 2 DM within10-15 yr.

Gestational diabetesDoes treatment improves outcomesConflicting results 1. Cochrane datebase systemic review 2005 (3 studies only) no difference in outcomes except neonatal hypoglycemia

2. Australian Carbohydrate Intolerance Study in Pregnant Women (ACHOIS study) 2005 ( 490/510 subjects) treatment of diabetes reduces serious perinatal morbility and may improve the womans health-related quality of life

Gestational diabetesManagementManagement similar as preexisting DMNeed for glucose monitoringStart with Diet controlCommence insulin for poor controlDelivery plan individualised

Gestational diabetesIn view of risk of developing type 2 DM the woman should be screened annually for DM on yearly basis.

Diabetes and PregnancyConclusionPreexisting DM in pregnancyGood glucose control is important for decreasing morbiditiesInsulin is still the gold standard of tx in pregnancyIncreasing evidence for clincial effectiveness for treatment with oral hypoglycemic agents

Diabetes and pregnancyconclusion(2) Gestational diabetes no consensusThe morbidities increases as glucose level approaching the diagnosis as DMPossible that treatment improves outcomesOverlap with preexisting DM, esp type2Long term implication for health of the mother and baby

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