OBSTERTRICS DIABETES IN PREGNANCY Carbohydrate Metabolism in Early Pregnancy Hormonal alteration: Increased estrogen & progesterone Beta cell

ll hyperplasia Increased insulin secretion Effects Tissue glycogen storage Hepatic glucose production Peripheral glucose utilization Fasting plasma glucose Carbohydrate Metabolism in Late Pregnancy Hormonal change Human placental lactogen (HPL) Prolactin Cortisol Placental growth hormone Tumor necrosis factor Leptin Effects Insulin resistance Diabetogenic Glucose tolerance Hepatic glycogen stores Hepatic glucose production Metabolic change: Facilitated anabolism during feeding, accelerated starvation during fasting to ensure glucose & amino acids to fetus Normal Maternal Glucose Regulation Maternal tendency to develop hypoglycemia between meals & at night while fasting Levels of diabetogenic placental steroid & peptide hormones rise linearly throughout the 2nd & 3rd trimesters: Tissue resistance to maternal insulin Progressive maternal insulin resistance requires augmentation in pancreatic insulin production to maintain euglycemia Failure to augment pancreatic insulin production results in maternal & fetal hyperglycemia Classification of Diabetes during Pregnancy (NDDG) Pregestational Diabetes Type I ( Insulin deficient): Autoimmune disease Destruction of pancreatic cell No insulin production Ketoacidosis Insulin deficient Type II (Insulin Resistant) Resistance to insulin Hyperglycemia Hyperlipidemia Gestational Diabetes: Type III Pregestational Diabetes type I & II Characteristics Type I Ketoacidosis Frequent Age at onset < 40 years old Body habitus Lean HLA type DR3, DR4 Immune markers ICA, IAA Type II Rare > 40 years old Obese None None

Intermediate stage between normal glucose homeostasis & diabetes IFG: Fasting plasma glucose 110mg/dl to 126mg/dl IGT: 2 hour plasma glucose 140mg/dl to 199mg/dl Overt Diabetes Classic signs & symptoms: Polydipsia, polyuria & unexplained weight loss plus Random plasma glucose >200mg/dl or Fasting plasma glucose >/= 126 mg/dl or 2 hour plasma glucose >200mg/dl during a 75gm OGTT Gestational Diabetes Mellitus Glucose tolerance that begins or is first recognized during pregnancy Arises from significant maternal insulin resistance Preclinical Type II diabetes, unmasked by the hormonal stress of pregnancy Screening Low Risk 24-28 weeks 50gm Glucose challenge test Threshold value: 130 mg/dl High Risk 1st trimester screening (Any time it is discovered, request tests immediately) 100gm OGTT or 75gm OGTT if normal repeat at 24-28 weeks 100 gram oral glucose tolerance test (OGTT) mg/dL mmol/L Fasting 95 5.3 1 hour 180 10.0 2 hour 155 8.6 3 hour 140 7.8 Any 2 values elevated = GDM High risk Maternal age >35yrs Previous macrosomic infant Previous unexplained fetal demise Previous pregnancy with GDM Family history of DM Obesity Glucosuria Fetal effects Abortion Congenital anomalies: Cardiac & neural tube defects (Spina bifida) IUGR: Because of vasculopathy Fetal obesity Birth injury: Associated with macrosomia Preterm delivery Unexplained fetal death Maternal effects Diabetic Nephropathy Diabetic Retinopathy Diabetic Neuropathy Preeclampsia Ketoacidosis Infections Neonatal effects

Impaired Glucose Tolerance & Impaired Fasting Glucose CHRABI Page 1 of 2

 Respiratory Distress Syndrome: Delays pulmonary maturity Hypoglycemia immediately after birth: High glucose in maternal blood High glucose in fetal circulation High insulin With the withdrawal of continued support of glucose source once delivered Hypoglycemia Hypocalcemia Hyperbilirubinemia Cardiac Hypertrophy Childhood Obesity Childhood Impaired Glucose Tolerance Management of Diabetes during Pregnancy Preconceptional care Metabolic control prior to pregnancy Monitoring of capillary blood glucose (CBG) levels Pre meals: 70 - 100 mg/dl 1 hr post-prandial: < 140 mg/dl 2 hr Post prandial: < 120 mg/dl Hemoglobin A1c: Represents 1-2 months level of blood glucose Smooth glucose control using insulin Folate, 400 ug/day: 1 month prior to conception & all throughout 1st trimester Diabetes in Pregnancy Diet Normal body weight: 30-35 kcal/kg/day Obese: 24 kcal/kg/d Caloric composition: Complex carbohydrates: 40 - 50% Proteins: 20% Unsaturated fats: 30 - 40% Given as 3 meals & 3 snacks daily Insulin therapy Insulin does not pass the placenta Maintain CBG levels as close to normal 1st trimester: 0.7 - 0.8 u/kg/d 2nd trimester - 0.8 -1.0 u/kg/d 3rd trimester - 0.9 - 1.2 u/kg/d Oral hypoglycemics: Not recommended because it can pass the placenta & cause fetal hypoglycemia & teratogenic effects Monitoring of glucose control Capillary glucose monitoring Fasting: </= 95 mg/dl Premeals: </=100 mg/dl 1 hour PP: < 140 mg/dl 2 hour PP: < 120 mg/dl Mean Capillary glucose levels: 100 mg/dl Hgb A1c - 6% Fetal Surveillance Accurate dating Congenital Anomaly Scanning Monitoring of fetal growth Antepartum Fetal Monitoring: Fetal movement counting (FMC), biophysical score (BPS), non-stress test (NST), contraction stress test CST) & uterine artery Doppler velocimetry Timing of Delivery CHRABI Page 2 of 2

Early delivery Vasulopathy, nephropathy, prior stillbirth & poor glucose control Amniocentesis for lung maturity Expectant management Good glucose control Not recommended beyond the estimated due date Insulin Management during Labor & Delivery Usual dose of intermediate-acting insulin is given at bedtime. Morning dose of insulin is withheld. Intravenous infusion of normal saline is begun. Once active labor begins or glucose levels decrease to <70 mg/dl, the infusion is changed to 5% dextrose & delivered at a rate of 100-150 cc/hr to achieve a glucose level of 100 mg/dl Glucose levels are checked hourly. Regular (short acting) insulin is administered by intravenous infusion at a rate of 1.25 U/h if glucose levels exceed 100 mg/dl. Breast feed Yes!!! DUHAWEE HAPPY BIRTHDAY BEEEEMWAH!!!