DIABETES IN PREGNANCY

DR. SALWA NEYAZI CONSULTANT OBSTETRICIAN GYNECOLOGIST PEDIATRIC & ADOLESCENT GYNECOLOGIST

PHYSIOLOGICAL CHANGES OF GLUCOSE METABOLISM IN PREGNANCY Pregnancy is a state of insulin resistance & relative glucose intolerance This is due to placental production of antiinsulin hormones : hPL, cotisol, and glucagon FBS  Postprandial glucose Insulin production 2 folds in N women Insulin requirements in diabetic women  renal threshold for glucose glycosuria

DIAGNOSIS OF GESTATIONAL DIABETES MELLITUS

Women in whom the criteria of DM are met in pregnancy include a gp of diabetics who were undiagnosed before pregnancy FBS > 7 mmol/L on 2 occasions Or RBS > 11.1 mmol/L on 2 occasions Borderline cases GTT DM is Dx if FBS > 7 mmol/L or 2 hrs > 11.1 mmol/L Impaired glucose tolerance 2hrs G 8-11 mmol/L with a N FBS

EFFECT OF PREGNANCY ON DM

Insulin requirement in pregnancy reaching a max at term & being at least 2 X the prepregnancy requirement Pt with diabetic nephropathy deterioration in renal function with  in creatinine clearance & proteinuria h this deterioration in renal function is usually reversed after delivery

EFFECT OF PREGNANCY ON DM
2X in retinopathy h rapid improvement in glycemic control worsening retinopathy due to retinal blood flow icidence of hypoglycemia Ketoacidosis is rare unless associated with hyperemesis, infections, tocolytic & corticosteroid Rx

EFFECTS OF DM ON PREGNANCY
incidence of congenital abnormalities The risk is related to the degree of glycemic control 5% with Hb A1c > 8% 25% with Hb A1c > 10% with risk of abortions Sacral agenesis, congenital heart defects, skeletal abnormalities & neural tube defects Perinatal & neonatal mortality 2-4 X Unexplained IUFD at term / more in macrosomic babies

EFFECTS OF DM ON PREGNANCY
Macrosomia the incidence is with poor diabetic control not eliminated by tight control associated with risk of operative delivery, birth trauma, & shoulder dystocia Hyperglycemia fetal polyuria polyhydramnios PROM, preterm delivery Prematurity pose an added problem as pulmonary surfactant production is slightly delayed in babies of diabetic mothers

EFFECTS OF DM ON PREGNANCY
Postnatally, babies are at risk of hypoglycemia & jaundice risk of PET especially in pt with pre-existing hypertension & nephropathy where it reaches almost 30%

MANAGEMENT
Multidisciplinary team including obstetricians, endocrinologists, dieticians, & midwives optimize outcome Preconception councelling To achieve normoglycemia as far as possible hFBS < 5 mmol/L hPP < 7.5 mmol/L Dietary advice on a low sugar, low fat, high fiber diet Regular capillary glucose series (7 point profile) Combined short acting & intermediate acting insulin

MANAGEMENT
Regular assessment of Hb A1c Ophthalmologic examination & Rx of retinopathy Regular monitoring of renal function in Pt with diabetic nephropathy Detailed U/S screening for congenital malformations in the 2nd trimester (20wk) to exclude NTD, sacral agenesis, & cardiac defects Frequency of antenatal visits needs to be individualized

ANTENATAL FETAL SURVELANCE

incidence of IUFD justify close monitoring in the 3rd trimester Serial U/S biometry to detect macrosomia, hydramnios, IUGR Umbilical artery doppler in Pt with IUGR CTG BPP

LABOR & DELIVERY

With well controlled DM with appropriately grown fetus pregnancy is allowed to proceed till term When there is concern about fetal well being or macrosomia the risk of IUFD must be weighed against the risk of RDS of the babies are >90th centile CS rate of 50-60% Intrapartum care should focus on meticulous diabetic control & continuous electronic fetal monitoring . Blood glucose should be 4-7 mmol/L achieved by 5% Dextrose infusion & insulin infusion

LABOR & DELIVERY

After delivery mternal insulin requirement rapidly returns to the pre-pregnancy level If abnormal glucose tolerance was 1st Dx in pregnancy GTT should be done 6 wk postpartum

Gestational diabetes
Carbohydrate intolerance of variable severity 1st Dx in pregnancy will include women with undiagnosed DM There is no consensus on the optimal screening for GDM hUniversal screening hScreening pt > 25 Y hClinical risk factors: previous GDM, family Hx , previous macrosomic baby, previous unexplained IUFD, obesity, glycosuria, polyhdramnios, LGA in current pregnancy h The timing of screening also contraversal

Implications of GDM
perinatal mortality & morbidity but to a lesser extent than DM No risk of congenital malformations Macrosomia is the main risk factor for adverse outcome risk of operative deliveries incidence of PET Women with GDM have a significantly risk of DM later in life (50% over 10-15 Y)

Management
Combined diabetic obstetric approach Initial approach by dietery modification including caloric reduction in obese Pt The need for insulin is manifested by persistent PP hyperglycemia (7.5-8 mmol/l) or persistant fasting hyperglycemia (>5.5-6 mmol/L) Regular U/S scans to assess fetal growth & well being Early delivery is not advised unless there is a complicating factor

Management
Intrapartum management hDepends on whether the pt is on diet control alone or on insulin h Pt on insulin need to be on sliding scale hFollowing delivery insulin must be discontinued GTT should be done 6 wks postpartum

MACROSOMIA
Fetal Wt >4000-4500 gm regardless of gestational age Risks of macrosomia include shoulder dystocia, erbs palsy,  5 min APGAR score, admission to NICU & obesity later in life Risk factors for the development of macrosomia: h prior HX of macrosomia h maternal pre-pregnancy Wt hexcessive Wt gain in pregnancy hmultiparity

MACROSOMIA (risk factors)

hmale fetus hgestational age >40wks hrace hmaternal birth Wt hmaternal Ht hmaternal age h+ve GCT with-ve GTT hGD, DM

MACROSOMIA
How macrosomic infants of diabetic mothers differ from those without diabetes? How is macrosomia predicted? How does it affect the management of labor & delivery? When is CS recommended for macrosomia? What is the role of induction of labor?