Diabetes Mellitus In Pregnancy

DIABETES MELLITUS IN PREGNANCY SOLEDAD CHU-CRISOSTOMO, MD, FPOGS Department of Obstetrics and Gynecology

OUTLINE Classification during pregnancy  Pathophysiologic alterations in pregnancy  Diagnosis  Maternal and fetal effects  Management  Postpartum follow up 

CLASSIFICATION DIABETES DURING PREGNANCY 

PREGESTATIONAL  Diabetes



antedates pregnancy

GESTATIONAL DIABETES  Onset

of first recognition during pregnancy

CLASSIFICATION



Based on underlying pathogenesis (National Diabetes Data Group) Nomenclature

Old Name

Clinical Features

Type I Insulin-dependent DM (IDDM)

Juvenile-onset DM

Ketosis prone, insulin-deficient

Type II Non-insulindependent DM (NIDDM)

Adult-onset DM

Ketosis-resistant, insulin-resistant; obesity, family history& age are common risk factors

Type III Gestational diabetes (GDM)

Gestational diabetes

Occurs only during pregnancy; established by glucose tolerance test; obesity and age are common risk factors

CLASSIFICATION  Based on degree of glycemia, on the onset and duration of the

disease and presence of secondary vascular and other end organ complications (White Classification) Class A1 A2

Class B C D F R H

Onset Gestational Gestational

Age of onset Over 20 10-19 Before 10 Any Any Any

Fasting Plasma Glucose <105 mg/dl >105 mg/dl

Duration (yr) <10 10-19 >20 Any Any any

2-hour postprandial glucose <120 mg/dl >120 mg/dl

Vascular disease None None Benign retinopathy Nephropathy Proliferative retinopathy Heart

Therapy Diet Insulin

Therapy Insulin Insulin Insulin Insulin Insulin Insulin

PATHOPHYSIOLOGY 

Type 1- insulin dependent diabetes  Develops

in genetically susceptible person  Immune mediated 

Predisposition triggered by viral infection → inflammatory insulitis with lymphocytic infiltration of islets → immune stimulation of antibodies against the B-cell → cellular destruction → insulin deficiency → hyperglycemia → Diabetes

PATHOPHYSIOLOGY 

Type 1- insulin dependent diabetes  When fasting blood glucose

levels are low →they are

more prone to ketonemia  Glucose reserved for the fetus, while maternal metabolic needs are served by the breakdown of fats into fatty acids and ketones  → ketones easily transported across the placenta causing neuropsychiatric defects in the offspring  → high maternal ketone level causes metabolic acidosis  → if uncorrected, the dehydration and electrolyte imbalance lead to cardiac dysrhythmias, hemodynamic collapse and death

PATHOPHYSIOLOGY 

Type 1- insulin dependent diabetes  Clinical

onset typically abrupt and severe  Associated with weight loss, fatigue, polyuria, polydipsia, blurring of vision and dehydration  Individuals are insulinopenic and dependent on exogenous insulin for life

PATHOPHYSIOLOGY



Type 2- non-insulin dependent diabetes 



With 3 defects noted: 1. Impaired insulin secretion 2. Increase hepatic glucose output 3. Inefficient peripheral tissue glucose utilization Reduction in insulin with increase glucagon draining into the liver → increases hepatic glucose production but there is absence of insulin response to intravenous or oral glucose

PATHOPHYSIOLOGY



Gestational diabetes 



Carbohydrate intolerance with onset of recognition during pregnancy regardless of whether or not insulin is used in the treatment Hyperglycemia due to: 1. Increase hepatic glucose production 2. Peripheral tissue insulin resistance

DIAGNOSIS: OVERT DIABETES  Fasting

plasma glucose of 126 mg/dl or higher  Glucosuria  Ketoacidosis  Random plasma glucose level greater than 200mg/dl  Presence of the classic signs and symptomspolydipsia, polyuria and unexplained weight loss  High index of suspicion if with the following- strong family history of diabetes, having delivered large baby, unexplained fetal losses, persistent glycosuria

DIAGNOSIS: GESTATIONAL DIABETES 

WHY SCREEN?  GDM

is one of the most common medical problems in pregnancy  GDM is an in-utero risk factor for spontaneous abortion, prematurity, fetal malformation, and metabolic derangement  Risk for fetal macrosomia which leads to an increased risk for operative delivery by CS, vacuum or forceps and birth trauma (shoulder dystocia, clavicle fracture, peripheral nerve injury)

DIAGNOSIS: GESTATIONAL DIABETES



WHY SCREEN?  Neonatal

risk factor for hypoglycemia, hypocalcemia, hyperbilirubinemia, respiratory distress syndrome, and congenital malformation  Women with GDM are at increased risk for developing the following complications later in life: metabolic complications, coronary heart disease, CVA, polyneuropathy, blindness, non traumatic amputations and end stage renal disease

DIAGNOSIS: GESTATIONAL DIABETES



WHOM TO SCREEN: UNIVERSAL OR SELECTIVE SCREENING? Risk Factors for Gestational Diabetes Mellitus    

>25 years of age <25 years of age and obese (>20% over desired BW or BMI >27 kg/m2 Family history of diabetes in first degree relatives Members of ethnic/racial group with high prevalence of diabetes ( Hispanic-American, Native Americans, AsianAmerican, African-American, or Pacific Islander)

LOW RISK if Pregnant women meeting none of the criteria

DIAGNOSIS: GESTATIONAL DIABETES 

HIGH RISK  Historical risk factors 

Past pregnancy –



Present pregnancy –

Abnormal glucose tolerance Macrosomia (BW>8lbs Congenital malformation Recurrent abortions Unexplained intrauterine deaths Family history (first degree relative) Maternal obesity ( >180 lbs or BMI > 2 kg/m2) Drugs affecting carbohydrate metabolism (steroids, betamimetic, etc.) Age ≥ 30 years Racial predilection (Indian)

DIAGNOSIS: GESTATIONAL DIABETES



HIGH RISK  Obstetric

risk factors  Polyhydraminos  Macrosomis babies  Fetal abnormality  Recurrent genital tract infection

DIAGNOSIS: GESTATIONAL DIABETES



WHEN TO SCREEN ?  LOW

RISK – 24th to 28th weeks of gestation  HIGH RISK – immediately at first prenatal visit  If initial test are normal- repeat test at 24-28 weeks and again later at 32-34 weeks due to increasing glucose sensitivity as pregnancy progresses

DIAGNOSIS: GESTATIONAL DIABETES



HOW TO SCREEN ? 

TWO-STEP TESTING 1. Screening test – OGCT  50 grams oral anhydrous glucose load followed by plasma glucose determination 1 hour later  No fasting needed  Value > 140 mg/dl (7.8 mmol/l) or >130 mg/dl ( 7.5 mmol/l) need confirmatory test

DIAGNOSIS: GESTATIONAL DIABETES



HOW TO SCREEN ? 

TWO-STEP TESTING

1. Confirmatory test – OGTT  100 grams 3 hour oral glucose tolerance test  Fast for 10-16 hours, not less or more  + GDM if obtain any 2 abnormal values of the 4 plasma glucose values

DIAGNOSIS: GESTATIONAL DIABETES

Carpenter & Coustan

O’Sullivan & Mahan / NDDG

OGCT

130 mg/dl

140 mg/dl

OGTT Fasting 1 hour 2 hour 3 hour

95 mg/dl 180 mg/dl 155 mg/dl 140 mg/dl

105 mg/dl 190 mg/dl 165 mg/dl 145 mg/dl

DIAGNOSIS: GESTATIONAL DIABETES



HOW TO SCREEN ?  ONE-STEP TESTING 

WHO,ASEAN  



75 grams anhydrous glucose load followed by I blood sugar value measured after 2 hours Value >140 mg% considered abnormal and treatment is began

Fourth International Workshop-Conference on GDM 

75 grams glucose load followed by OGTT using the criteria of Carpenter and Coustan

DIAGNOSIS: GESTATIONAL DIABETES



HOW TO SCREEN ?



REMINDERS: (OGTT) 







Do not do on patients who have an acute or chronic illness that can affect the test. Discontinue all drug therapy hat can affect the test for at least 3 days prior to the test ( see table). Have a patient eat a carbohydrate intake of at least 150 grams/day for 3 days prior to the test Fast for 10 to 16 hours, not less or more

DIAGNOSIS: GESTATIONAL DIABETES



HOW TO SCREEN ?  REMINDERS (OGTT) 





Have patient drink the glucose solution within 15 minutes. The first swallow is time zero. Discontinue the test if patient develop nausea and vomiting. Collect samples at 0, 1 and 2 hours. Have patient abstain from tobacco, coffee, tea, food and alcohol during the test. Slow walking is permitted but vigorous exercise should be avoided.

DIAGNOSIS: GESTATIONAL DIABETES

Drugs That May Impair Glucose Tolerance 

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Diuretics & Antihypertensives – chlorthalidone, furosemide, thiazides, diazoxide, metazolone, propanolol, bumetamide, ethacrynic acid, clonidine, calcium channel blockers Hormones – corticosteroids, adrenocorticotropic hormone, glucagon, oral contraceptives thyroid hormones Psychoactive agents – haloperidol, lithium, tricyclic antidepressants Cathecholamines and their neurologically active agent – Phenytoin, epinephrine, isoproterenol, levedopa, norepinephrine Antineoplastic agents – Alloxas, streptozotocin, Lasparginase Miscellaneous – caffeine, indomethacin, isonizid, nicotinic acid, acetaminophen, morhine, cimetidine

MATERNAL & FETAL EFFECTS OF DIABETES 

FETAL EFFECTS OF GESTATIONAL DIABETES  Fetal

anomalies are not increased  Unexplained stillbirth is observed with elevated fasting glucose (Class A2)  Increased risk of fetal death during the last 4 to 8 weeks of gestation if with fasting hyperglycemia (> 105mg/dl)

MATERNAL & FETAL EFFECTS OF DIABETES



ADVERSE MATERNAL EFFECTS OF GESTATIONAL DIABETES  Increased

frequency of hypertension and the need for cesarean delivery

MATERNAL & FETAL EFFECTS OF DIABETES



FETAL EFFECTS OF OVERT DIABETES  2-4

% perinatal losses with improved fetal surveillance, neonatal intensive care and maternal metabolic control  Abortion in patients with poor glycemic control during first trimester especially among type 1 diabetes with initial glycohemoglobin A1 concentration above 12% or persistent preprandial glucose concentration above 120 mg/dl  Preterm delivery at 34 weeks or less in 9% of women with pregestational diabetes

MATERNAL & FETAL EFFECTS OF DIABETES



FETAL EFFECTS OF OVERT DIABETES  Increased

incidence of fetal anomalies among type 1 diabetes although diabetes is not associated with increased risk for fetal chromosomal abnormalities  Unexplained fetal death  Increased frequency of placental insufficiency in association with severe preeclampsia  Hydraminos possibly due to fetal polyuria caused by fetal hyperglycemia

MATERNAL & FETAL EFFECTS OF DIABETES



NEONATAL EFFECTS OF OVERT DIABETES      

Respiratory distress due to prematurity Hypoglycemia due to hyperplasia of the fetal B-islet cells induced by chronic maternal hyperglycemia Hypocalcemia Hyperbilirubinemia Cardiac hypertrophy due to hyperinsulinemia Altered fetal growth/macrosomia

Long term cognitive development and inheritance of diabetes – not greatly affected by maternal diabetes

MATERNAL & FETAL EFFECTS OF DIABETES



MATERNAL EFFECTS OF OVERT DIABETES       

10-fold increase in maternal mortality due to ketoacidosis, underlying hypertension, preeclampsia and pyelonephritis Diabetic nephropathy Diabetic retinopathy Diabetic neuropathy Preeclampsia causing preterm delivery Ketoacidosis Infections like candida vulvovaginitis, UTI, puerperal pelvic infections, respiratory tract infections causing preterm delivery

MANAGEMENT 

PRENATAL CHECK UP  Gestational

Diabetes

Frequency of visits – every 2 weeks for glycemic control and asses obstetric complications (macrosomia, intrauterine growth retardation, preeclampsia, hydraminos)  Ultrasound – at first visit to determine AOG at 20-22 weeks to detect malformations at 32-34 weeks to monitor growth 

MANAGEMENT



PRENATAL CHECK UP

 Pregestational

Diabetes

Frequency of visits – every 2 weeks or more often to asses glycemic control and obstetric complications  Ultrasound – as in GDM  At 36th week – creatinine, uric acid and electrolytes 

MANAGEMENT



DIET  Total

calories/day – 1800 to 2000 calories  Frequency of meals – 3 main meals, 3 snacks  Distribution of calories: 

 

Carbohydrate – 50-60% of total calories, no simple sugars but complex, high fiber type Proteins – 18-20% of total calories Fats – equal to or less than 30% of total calories

MANAGEMENT



EXERCISE  Improves

glycemic control when compared with diet

alone  Do exercises that use upper body muscles with less mechanical stress on the trunk region during exercise  Effects on glucose levels only become apparent after 4 weeks of exercise

MANAGEMENT



INSULIN  Gestational

Diabetes should be placed on insulin

when:  

1-2 weeks of diet fails to control blood glucose Pre-breakfast blood glucose is 100mg% or more and when 2 hours blood glucose is 140mg% or more

 Pregestational

diabetics should discontinue their oral hypoglycemic agents and be shifted to insulin  Type of insulin – highly purified human insulin

MANAGEMENT



ANTENATAL FETAL MONITORING  In

general, GDM’s who are well controlled on diet alone, normotensive and have normal fetal growth do not require additional tests of fetal well being before 30 completed weeks of gestation

MANAGEMENT



ANTENATAL FETAL MONITORING  Additional

tests of fetal well being indicated in the

following:  GDM’s on insulin, well controlled  GDM’s on insulin, poorly controlled  Presence of maternal hypertension  Fetal macrosomia +/- polyhydraminos  Fetal IUGR

MANAGEMENT



ANTENATAL FETAL MONITORING  Limitation

of tests in predicting sudden intrauterine

death  Antenatal tests of fetal well being:  



Fetal movements charted from 34 weeks Antenatal cardiotocographs (CTG) done bi-weekly from 36 weeks for pregestational diabetics and GDM’s on insulin therapy Biophysical Profile Scoring in all GDM’s on insulin therapy and pregestational diabetics from 36 weeks

MANAGEMENT



DELIVERY  Should

be accomplished at 38 weeks when gestational age is certained. 



If uncertained, lecithin-sphingomyelin ratio is measured and if 2.0 or greater, delivery is done. If severe hypertension develops, delivery is carried out even if the ratio is less than 2.0

 Early

delivery if diabetic control is poor or in the presence of other complications where continuation of pregnancy may be detrimental to the mother or fetus

MANAGEMENT



DELIVERY  Caution

on the use of B-sympathomimetic drugs as tocolysis in preterm labor and glucocosteroid as these can worsen maternal glucose control and cause ketoacidosis  In the absence of other obstetric complications, vaginal delivery is the aim.

MANAGEMENT



DELIVERY  Labor

induction may be tried provided the fetus is not very large and the cervix is favorable for induction  Active management of labor is practiced - with labor augmentation when necessary, glucose monitored, adequate hydration  Diabetes is not an indication for cesarean section but is commonly used in the overtly diabetic women within class B or C White classification to avoid traumatic delivery of large infant at or near term

MANAGEMENT



INFANTS OF DIABETIC MOTHERS  Admitted

to ward nursery for neonatal pediatric care  Blood sugar obtained half to one hour after birth to check for hypoglycemia and feed baby as early as possible  Repeat blood glucose monitoring just before the second feed and third feed and more frequently if indicated

MANAGEMENT



INFANTS OF DIABETIC MOTHERS  Infants

of pregestational diabetics should be screened for congenital malformations associated with diabetes  Look for other associated morbidity – polycythemia, hyperbilirubinemia, hypocalcemia, and respiratory problems

POSTPARTUM FOLLOW UP 

POSTNATAL ASSESSMENT  75

grams oral glucose tolerance test at 6-12 weeks after delivery for women with gestational diabetes

POSTPARTUM FOLLOW UP



CONTRACEPTION  Estrogen

in OCP can increase risk of thromboembolism, myocardial infarction and stroke in diabetic women already at risk for vascular disease  Low dose OCP which do not increase cardiovascular risk maybe used but only by women without vasculopathy or additional risk factors such as history of ischemic heart disease

POSTPARTUM FOLLOW UP



CONTRACEPTION  Progestin-only

contraceptives can be used because of minimal effect on carbohydrate metabolism  Intrauterine devices are not recommended because of possible increased risk of pelvic infections

POSTPARTUM FOLLOW UP



PRE-PREGNANCY COUNSELLING  Should

be impressed on all young diabetic female so that they may be educated on good control of diabetes before contemplating pregnancy  Patients who may be well controlled on oral hypoglycemics should be advised to change to insulin therapy for fine control and maintain normoglycemia at time of conception and during early gestation

GET READY FOR THE QUIZ BEE

CASE A 30 year old woman presents 8 weeks pregnant. She is not obese and does not have a history of any medical problem. Her father has type 2 diabetes mellitus requiring insulin. Vital signs and physical examination are normal. There is no protein or glucose in her urine.

Questions 1. The most appropriate screening test for gestational diabetes in this patient is a. Fasting blood sugar as soon as possible b. 1 hour post 50 grams glucose as soon as possible c. 1 hour post 50 grams glucose with the first appearance of glycosuria d. 1 hour post 50 grams glucose at 24-28 weeks of gestation e. 3 hour glucose tolerance test at 24-28 weeks of gestation

Questions 1. The screening test revealed a value of 129 mg/dl. The next step is to a. Treat the patient with insulin b. Do a 100 grams OGTT as soon as possible c. Do a 100 grams OGTT at 24-28 weeks AOG d. Repeat the OGCT at 24-28 weeks AOG e. Do nothing since patient is not diabetic

Questions 1. At 22 weeks AOG the patient complained of puritus vulva and curd like vaginal discharge. She has glycosuria on urinalysis. The next step is to a. b. c. d. e.

Treat the patient with insulin Do a OGCT immediately Do a OGCT at 24-28 weeks AOG Do a 100 grams OGTT at 24-28 weeks AOG Do nothing since patient is not diabetic

Questions 1. The patient has been found to have gestational diabetes mellitus. You start her on a diabetic diet and plan to begin insulin therapy if a. b. c. d.

Her fetus becomes macrosomic She gains more than 3 lbs per week Glucose is detected in her urine Her 2 hour post prandial glucose consistently rises above 120 mg/dl e. As soon as diagnosed

Questions 1. The patient asked about her perinatal and neonatal risks after being diagnosed to have gestational diabetes. You will tell her that she has an increased risk of the following except a. b. c. d. e.

Macrosomia Structural anomalies Operative delivery Fetal hypocalcemia Fetal hyperbilirubinemia

Questions 1.

The patient is now 38 weeks AOG and has maintained good control of her blood sugar with diet alone. She asked regarding the mode of delivery. It is appropriate to tell her that  In the absence of other obstetric complications, vaginal delivery is aimed.  She will be delivered by cesarean section once she goes into labor  She can choose any date for her scheduled cesarean section  Labor should be induced now that she reached 38 weeks.