Transcript DIABETES IN PREGNANCY - Kannur Medical College

DIABETES IN
PREGNANCY
Dr Chippy Tess Mathew
CLASSIFICATION
OVERT DIABETES
Seen in women known to be diabetic
before the onset of pregnancy.
 IDDM mostly

GESTATIONAL DIABETES
EFFECT OF PREGNANCY ON
DIABETES
Diabetogenic state
 Insulin requirement increases
 Ketosis can occur
 Lowered renal threshold
 Retinal changes are aggravated
EFFECT OF DIABETES ON
PREGNANCY
Abortion
 Fetal malformations*
 Preterm delivery*
 PIH
 Fetal macrosomia-birth trauma
 Hydramnios
 Maternal infections
 Unexplained fetal deaths*

GESTATIONAL DIABETES
INCIDENCE
1%
DEFINITION
Carbohydrate intolerance of variable
severity with onset or first detected during
the present pregnancy
RISK FACTORS FOR
SCREENING FOR GDM

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Family history of diabetes -1st degree relative
Having a previous baby of wt >4kg
Previous stillbirth
Unexplained perinatal loss
Polyhydramnios
Persistent glycosuria
Age> 30
obesity
SCREENING TEST
OGCT
 24-28 weeks
 Cut off – 140mg%
 Procedure
DEFINITIVE TEST
OGTT
OGTT

GTT
TIME
Fasting
WHOLE
BLOOD
90
PLASMA
mg%
105
1 hr
165
190
2 hr
145
165
3h
125
145
White’s classification
Class
Onset
Therapy
A1
A2
Gest
Gest
Fbs<105
>105
Duration
Ppbs>120
>120
Complication
Diet
insulin
B
C
D
>20yrs
10-19
<10
<10
10-19
>20
None
None
Retinopathy
insulin
Insulin
Insulin
F
R
Any
Any
Any
Any
Nephropathy
Prolif retinopathy
Insulin
insulin
H
any
any
heart
insulin
MANAGEMENT
AIMS
 To control diabetes
 Timing of delivery
 Management in labor
 Care of the newborn
MANAGEMENT CONTD
ANTENATAL CARE
Maintain blood sugar at FBS <95 / PPBS< 120
mg%
Regular blood checkups at 3 weeks interval (post
prandial better than pre-prandial)
Management options Diet
 exercise
 Diet + insulin

Contd..
Diet in pregnant diabetics
 Total calories- 30 -35 kcal/kg of ideal body
weight
 Given in split meals of 3 meals and 3
snacks
 Ideal diet – 55% carbohydrates
20% proteins
25% fat- < 10% saturated fat
contd
INSULIN
If PPBSL >150 mg% in spite of dietary regulations
start on insulin/ FBS > 105 mg% plasma
Plain insulin in 3 divided doses pre meals
Optimize the insulin dose
Sometimes combination of lente and regular
OHA usually not used –more chance of fetal
hyperinsulinemia/?fetal defects
Trials on glyburide
CONTD
OBSTETRIC MANAGEMENT
 In general, women with gestational diabetes who
do not require insulin seldom require early
delivery or other interventions.
 Well controlled diabetes delivery at 40 weeks
 ACOG 2001 suggested that cesarean delivery
should be considered in women with a
sonographically estimated fetal weight of 4500
grams or more.
Contd..

Induction of labor with Oxytocin or after
priming with prostaglandin

Prophylactic antibiotics given

Strictly monitor in labor
CONTD..
Women who require insulin therapy for fasting
hyperglycemia, however, typically
undergo fetal testing and are managed as if they
had overt diabetes.
 POSTPARTUM CONSEQUENCES
Women diagnosed with gestational diabetes
undergo evaluation with a 75-g oral glucose
tolerance test at 6 to 12 weeks after delivery .
Women whose 75-g test is normal should be
reassessed at a minimum of 3-year intervals

CONTD..
Patients with GDM don’t require insulin after
delivery.antibiotics given.
CONTRACEPTION

Low-dose hormonal contraceptives may
be used safely by women with recent
gestational diabetes .
OVERT DIABETES
DEFINITION
 Women known to have diabetes before
pregnancy is called pregestational or overt
diabetes.
contd
DIAGNOSIS OF OVERT DIABETES
DURING PREGNANCY
 Women with high plasma glucose levels,
glucosuria, and ketoacidosis
 women with a random plasma glucose
level greater than 200 mg/dL plus classic
signs and symptoms such as polydipsia,
polyuria, and unexplained weight loss or
 Fasting plasma glucose of 126 mg/dL
Effects
Fetal effects
Abortion/ PTL / malformation / IUD /
hydramnios
 Neonatal effects
respiratory distress / hypoglycemia
/hypocalcaemia /hyperbilirbinemia
/macrosomia / cardiac hypertrophy
/inheritance of diabetes

Contd..
Maternal effects
 Nephropathy
 Retinopathy
 Neuropathy
 Pre eclampsia
 Ketoacidosis
 Infection
MANAGEMENT
PRECONCEPTION

To prevent early pregnancy loss as well as congenital
malformations in infants of diabetic mothers

ADA has defined optimal preconceptional glucose
control using insulin to include selfmonitored preprandial
glucose levels of 70 to 100 mg/dL and postprandial
values of less than 120 at 2 hours.

Hemoglobin A1 or A1c measurement -- circulating
glucose for the past 4 to 8 weeks, is useful to assess
early metabolic control. The most significant risk for
malformations is with levels exceeding 10%
Contd…
 Folate,
400 ug/day, is given
periconceptionally and during
early pregnancy
Contd..
Obstetric management
 maternal serum alpha feto proteins at 16
– 20 weeks
 Target USG at 18 - 20 weeks
 Fetal echo at 24 – 26 weeks to r/o cardiac
anomaly
 Regular ANC Hospitalise if poor control of diabetes
Contd..
Ante partum surveillance –biophysical
profile / NST -start at 32 weeks
TIMING OF DELIVERY
In overt diabetes pregnancy terminated at
37 – 38 weeks if he fetus is otherwise
normal.
In all other situations TOP is based on fetal
well-being/POG/ neonatal facilities

Contd..

Cesarean section is performed if baby is
large or if there are other obstetrical
indications such as fetal distress.
contd…
Management in labor
 Omit morning dose of insulin- do FBS,
urine sugar and ketone.
 During labor the woman should be
hydrated adequately -i/v saline/ dextrose
with insulin
 IOL with Oxytocin / PG
 Constant insulin infusion by calibrated
pump is most satisfactory .
Contd..

Capillary or plasma glucose levels should
be checked 2 hourly and regular insulin
should be administered accordingly.

Antibiotics

Strict monitoring/ ARM in active labor
Contd..
PUERPERIUM
Dose of insulin required decrease --and so
adjusted according to blood sugar levels..

CONTRACEPTION
Barrier.