Diabetes And Pregnancy

Etiological Classification

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Type 1 A

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Immune-mediated β-cell destruction

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Type 1 B

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Idiopathic β-cell destruction

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Type 2

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Range from insulin resistance to insulin secretory defect with insulin resistance

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Genetic mutations in β-cell function Genetic defects in insulin action Genetic Syndromes-Down, Kleinfelter, Turner Diseases of exocrine pancreas-e.g., pancreatitis, … Endocrinopathies-e.g., Cushing Syndrome, … Drug or chemical induced-e.g., thiazides, … Infections-e.g., congenital rubellla, CMV

Gestational Diabetes

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Classification of Diabetes Complicating Pregnancy Class A1 A2 Onset Gestational Gestational FBS < 105 mg/dl > 105 mg/dl 2-hr PP < 120 mg/dl >120 mg/dl Therapy Diet Insulin F R H Class B and C D Vascular disease None Benign Retinopathy Nephropathy Proliferative Retinopathy Heart Therapy Insulin Insulin Insulin Insulin Insulin

Screening Strategies

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Low-risk

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Blood glucose testing not routinely required, if all of the following characteristics are present:

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Member of an ethnic group with a low prevalence of

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gestational diabetes No known diabetes in 1 st degree relatives Age < 25 yr Weight: normal before pregnancy No history of abnormal glucose metabolism No history of poor obstetrical outcome

Screening Strategies

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Average-risk

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Perform blood glucose testing at 24-28 weeks using one of the following:

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Average-risk: women of hispanic african, native

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american, south or east asian origins High-risk: women with marked obesity, strong family history of type 2 diabetes, prior gestational diabetes, or glucosuria

Screening Strategies

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High-risk

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Perform blood glucose testing as soon as feasible if gestational diabetes is not diagnosed, blood glucose testing should be repeated at 24-28 weeks or at any time a patient has symptoms or signs suggestive of hyperglycemia:

ACOG Criteria

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ACOG 2001 Criteria for Diagnosis of Gestational Diabetes Using 100-g GTT Status Fasting 1 hr 2 hr 3 hr

Plasma/Serum Carpenter et al.

mg/dl 95 180 155 140

National Diabetes Plasma Data Group

mg/dl 105 190 165 145

Postpartum Evaluation

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Postpartum evaluation for Glucose Intolerance in Women with Gestational Diabetes Normal Fasting < 110 mg/dl 2-hr < 140 mg/dl* Impaired fasting Glucose or Impaired Glucose Tolerance 110-125 mg/dl 2-hr ≥ 140-199 mg/dl* Diabetes Mellitus ≥ 126 mg/dl 2-hr ≥ 200 mg/dl* * Requires a 75-gr glucose load

Pregnancy Outcomes

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Preeclampsia

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Preterm birth

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Macrosomia

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Growth restriction

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Still Births

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Perinatal mortality

Pregnancy Outcomes

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Preeclampsia Frequency (%)

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B: 12

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C: 22 D: 23 F: 54 Total: 21

Pregnancy Outcomes

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Congenital Malformations (in type 1 DM)

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Caudal regression

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Situs inversus Spina bifida, hydrocephaly, or other CNS defects Aencephaly Heart Anomalies (Transposition of great vessels, VSD, and ASD)

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Anal-Rectal Atresia Renal Anomalies (agenesis, cystic kidney, duplex ureter)

Management

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Diet:

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30-35 Cal/kg of ideal body weight

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3 meal and 3 snakes daily 55% carbohydrate, 20% protein, 25% fat, and less than 10% saturated fat

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Lower caloric intake in Obese women as long as weight loss and ketonuria are avoided

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Insulin:

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Insulin is usually recommended when standard dietary management does not consistently maintained the FBS < 95 mg/dl, or 2-hr PP < 120 mg/dl (ACOG 2001)

Management

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Intrapartum Insulin Infusion: Blood Glucose (mg/dl) < 100 100-140 141-180 181-220 > 220 Insulin Dosage (Unit/hour) 0 1 1.5

2 2.5

a Intravenous Fluids (125 ml/hr) D5 Lactated Ringer D5 Lactated Ringer Normal Saline Normal Saline Normal Saline a Dilution is 25 unit of Regular insulin in 250 ml of normal saline with 25 ml flushed through line administrated intravenously. A finger-stick glucose test is performed every 1-2 hr. The insulin pump and intravenous solution are adjusted accordingly.

Adverse Effects

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Fetal Effects

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Abortion

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Preterm Delivery Malformations Unexplained fetal death Hydramniosis

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Neonatal Effects

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Neonatal Distress

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Hypoglycemia Hypocalcemia Hyperbilirubinemia Cardiac Hypertrophy Long-term Cognitive Development Inheritance of Diabetes Altered Fetal Growth

Adverse Effects

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Maternal Effects

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Diabetic Nephropathy

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Diabetic Retinopathy Diabetic Neuropathy Preeclampsia Ketoacidosis Infections