Obstetric Management of

pregnancy Complicated by
Diabetes Mellitus

BY

DR. BENNET ARIWERYOKUMA

DEPT. OF OBSTETRICS & GYNAECOLOGY
UPTH PORT HARCOURT.
 INTRODUCTION

The discovery of insulin in

1921 is the most significant advancement
in the treatment of pregnancy complicated
by diabetes mellitus.
Prior to that time, pregnancy in the
diabetic woman was uncommon and was
accompanied by high maternal and fetal
morbidity and mortality.
With improved understanding of the patho
physiology of the disease, coupled with
improved fetal surveillance and timing of
the delivery, perinatal mortality has
dropped from 65% to less than 5%.
There is the rule of 15:
-15% of the obstetric population has
abnormal glucose metabolism
-15% of that population has abnormal OGTT
-15% of those who have abnormal OGTT
will require insulin
-15% of all patients with GDM have fetal
birth weight >4kg
 Types of Diabetes mellitus in Pregnancy
90% are GDM
10% are type I and II diabetes mellitus.

IMPORTANCE OF OBSTETRIC MANAGEMENT

-- Hyperglycaemia is teratogenic
FETAL:
CNS –microcephaly, meningocoele, cuadal regresion
syndrome, sacral agenesis, retinopathy.

CHEST-respiratory distress syndrome.

CVS –ventricular & atrial septal defects, cardiomegaly , transposition

of the great vessels.
-Renal- congenital abnormality of the kidney;
hydronephrosis, renal agenesis, double ureters.
-GIT- duodenal and anal atresia, gastrochisis,
small left colon syndrome, single umbilical
artery.
-SKELETAL – polydactyly, sacral agenesis,
excessive fat and muscles.
Mother:
-abortion, premature Iabour, UTI,
-pyelonephritis, candidiasis.
-nephropathy
-worsening retinopathy
-vasculopathy of the uterine and
placental vessels.
 AIMS OF MANAGEMENT OF
PREGNANCY COMPLICATED BY
DIABETIS MELLITUS
- good glycaemic control of 4-6mmol/L
- glycosylated haemoglolin of <8% before
and during pregnancy.
- early detection of pregnancy and fetal
abnormalities.
- fetal surveillance
- detection and treatment of obstetric and
medical complications.
- timing and mode of delivering.
- good management of the puerperium;
lactation and contraception.
MANAGEMENT IS BY A
MULTIDICIPLINARY TEAM MADE UP
OF:-
- Obstetrician
- Diabetic physician: control of blood sugar
and its complications .
- Diabetic neonatologist: to resuscititate the
baby at birth and further management.
 hypomagnesaemia, hypocalcaemia
polycythemia, hyperbilirubinaemia.
- Dietician: plans the diet for the obese, normal
weight and the underweight.
- Diabetic nurse : counsel, teach hygiene, insulin
injection and storage.
- An anaesthetist: for labour analgesia &
operative deliveries
- The patient herself: motivation & co-operation
PRECONCEPTION CARE
- particularly for pregestational diabetics.
- counsel patient on the need to control
diabetis before pregnancy.
- treat complications like retinopathy and
nephropathy that may deteriorate in
pregnancy.
- diet
- ANC and the use of insulin.
- Lactation and Contraception .

ANTENATAL CARE
-Ideally patient should graduate from the
preconception clinic to the antenatal clinic
with a controlled blood sugar. This
ensures early booking.
History – age, educational level, occupation
parity, LMP, EDD, gestation at booking,

symptoms, URTI, UTI, Candidiasis.

- Past obstetric history;
previous hx. of GDM
stillbirth, macrosomia, IND
duration of diabetic disease
- Medications;
oral hypoglycaemic agents
insulin
- Family history of diabetes.
Clinical examination should look for weight,
fever, pallor, hypertension, fundal height,
polyhydramnous, retinoscopy and vaginal
candidiasis .
INVESTGATIONS: General tests: pcv,
urinalysis for sugar, protein and ketones.
E/U/Cr, blood group and genotype.
Specific Tests:-
- Fasting blood sugar.
- glucose challenge test of 50gm
followed by 2 hours post prandial
blood sugar
gn
- OGTT - FBS >7.8mmol/l
2hrs > 11mmol/l
Indications for OGTT – maternal weight>90kg, birth
wt>4kg, Diabetic 1st degree relative,
Glycosuria x1<20wks, or x 2>20wks, previous IUFD,
polyhydramnous, IND.
FREQUENCY OF ANC:-
2wkly until - 28wks
wkly from 28wks until delivery .
Ultrasound
1st scan – at 7 weeks to confirm fetal life
and number of fetuses .
2nd scan - 16-20 weeks for structural
abnormalities.
3rd scan – 22-24 weeks specifically for
fetal echocardiogram.
-Estimation of fetal growth pattern
using HC, BPD, AC, FL to
calculate the fetal weight . However, birth
weight USS assessment is not very
accurate. With fetal weight above 3kg,
scan assessment of the weight is a little
better than clinical assessment.
 4th scan :- monthly fetal growth and
amniotic fluid volume monitor.
FETAL SURVELLANCE :-
- weekly from 32 weeks.
- twice weekly from 36 weeks.
1. Biochemical tests (oestriol and HPL) &
contraction stress tests have been
abandoned.
.Cardiff kick count for 12 hours
>10 kicks in 12 hours is normal
- this is cheap and useful but does not prevent
unexplained stillbirth.
-reliable for 24 hrs.
4.Non stress test (CTG) :-
A cardiotocograph is used to monitor the fetal
heat rate for 20-30 minutes.
The result can be reactive or non reactive.
Reactive – baseline heart rate- 120 -160 bpm
-2 accelerations within 20mins of
15bpm above the baseline each lasting 15sec.
- Baseline variation of 5-15 bpm
-No declerations
-However, the predictive value of CTG
is in doubt.

Biophysical profiles:-To evaluate the fetus with a

Non reactive NST.Test is done for 40mins.
 Score 2 0
NST Reactive Non reactive
HR >2 accelerations <2 accelerations
FBM 1 nil
TFBM >3 <2
F-tone >1 absent/slow
MVP 2-7cm <2cm
or AFI 10-25cm <5 >25cm
Maximum score- 10
Minimum score- 0
8 -10 Normal

4 – 6 equivocal,
therefore repeat test.
0 – 2 poor,
terminate pregnancy
-Doppler umbilical artery velocimetry to
study the systolic and diastolic wave
forms.The presence of reverse diastolic
wave calls for immediate delivery.

-Lecitin / sphyngomylin ratio of 2:1 indicates

fetal lung maturity.
Admission
All patients with poor diabetic control
should be admitted for stabilization
anytime in pregnancy.
Dietary Management
-30-35 cal/kg/day
1800-2400cal/day
Obese patient =1600cal-1800cal/day
Normal patient = 2000 cal/day
Under weight patient >2000 cal/day
Carbohydrate 40-50%
Fat 30%
Protein 20-30%
Patient should avoid simple sugars.
Snacks are taken to prevent
Hypoglycaemia.
Medical management
-stop all hypoglycaemic agents because
they are teratogenic and cause fetal
hyperinsulinaemia.
-patients should have glucometer to
measure the blood glucose for good
control.
Humulin, -regular, intermediate, long
acting, or mixture of soluble and
intermediate insulin are used.
Daily insulin requirement is 0.7- 1 unit /kg
body weight
Insulin therapy is bd or tds
A dose of 2/3 of the total daily dose in the
morning and 1/3 in the evening.
And the morning dose should be 2/3
intermediate and 1/3 soluble .
Evening dose should be ½ intermediate
and ½ soluble.
Timing of Delivery:-
-Knowledge of delayed lung maturity, stillbirth, macrosomia
is important
-For well controlled patient delivery at 39-40wks is
recommended.
- Delivery at 40 weeks may be complicated by placenta
failure & sudden fetal death
-For poorly controlled diabetic delivery should be at 37-
38weeks.
Route of delivery
- vaginal delivery is the main objective.
- C/S for fetal macrosomia & other obstetric
indications.
- The rate of C/S in diabetic patients is 50%
Labour
- Inform anaesthetist, neonatologist and the
physician.
 FBS on admission, then hourly until delivery.
- IVF of 5% dextrose at 125ml/hr to provide energy
and prevent ketosis.
- 1 unit of insulin subcut hourly to maintain blood
sugar between 4-6 mmol/l
- monitor labour with parthogram.
- Epidural analgesia for pain relief as it reduces
stress.
- continuous CTG monitoring.
Blood sugar Insulin in Drops/min More insulin
mmol/l 500ml of
5% dextrose
<2 nil 84 nil

2-3.9 nil 28 nil

4-7.9 6 units 28 nil

8-11.9 6 units 28 6 units

12-15.9 6 units 28 10 units

>16 Call
physician
Induction of labour
-Start at 6 am
-skip morning insulin dose
- Do FBS
-ARM & oxytocin in normal saline
-iv 5% dextrose at 125ml /hr
-add to infusion10 units of insulin to run at 1U/hr.
Caesarean Section;
-1st patient on the list
-If blood glucose >6mmol/l postpone surgery.
-check blood sugar hourly
PUERPERIUM
-reduce insulin to1/2 in the pregestational diabetic
-For GDM, give insulin if blood sugar is high.
Lactation:
-patient should lactate and take snacks.
-Do 4 point blood sugar tests-
Lactation is encouraged and the patient should
take snacks.
OGTT at 6wks postpartum and at 3months.
Contraception
BTL
Barrier methods
COC - with caution for fear of cardiovascular
complications
POP causes irregular bleeding
PRETERM LABOUR;-
-Magnesium sulphate
-beta adrenergic agents and steroids are
diabetogenic
Recurence of GDM is 60-70%
10% of GDM patients develop frank diabetes
after 10-20 years