Diabetes in Pregnancy

Hasanuddin, MD

Diabetes in Pregnancy
Epidemiology Classification Pathophysiology Morbidity

Fetal Maternal

Diagnosis Treatment and Management References

Epidemiology

4-6% of pregnancies in the U.S are complicated by DM, accounting for 50150 thousand babies per year.

88% GDM, 8% Type II DM, 4% Type 1 DM 1.5-2% in Caucasians, 5-8% in Hispanic, Asian and African Americans, and up to 15% in some SW Native American groups.

Prevalence also varies by race

Classification

Pathophysiology

Human Placental Lactogen (HPL)

Produced by syncytiotrophoblasts of placenta. Acts to promote lipolysis increased FFA and to decrease maternal glucose uptake and gluconeogenesis. Anti-insulin

Estrogen and Progesterone

Interfere with insulin-glucose relationship. Placental product that may play a minor role.

Insulinase

A Vicious Cycle???

Fetal Morbidity

Miscarriages
Frequency directly related to degree of maternal glycemic control. Up to 44% with poorly controlled DM (HbA1C >12).

Preterm Delivery

Increase in both spontaneous and indicated preterm labor (<35 wks).

Fetal Morbidity

Birth Defects
1-2% risk among the general population. 4-8 fold increased risk among preexisting diabetics. Most common defects are CNS and CV, but also an increase in renal and GI abnormalities. Up to a 600 fold increase in caudal regression syndrome.

Fetal Morbidity

Macrosomia
Defined as birthweight above 90th % or >4000 grams. Occurs in 15-45% of diabetic pregnancies, a 4-fold increase over normal. Carries many morbidities including birth trauma, RDS, neonatal jaundice and severe hypoglycemia.

Fetal Morbidity

Growth Restriction
Although we typically associate maternal DM with macrosomia, growth restriction is fairly common among Type 1 diabetic mothers. Best predictor is presence of maternal vascular disease.

Fetal Morbidity

Fetal Morbidity

Polycythemia

Hyperglycemia stimulates fetal erythropoeitin production. Can lead to tissue ischemia and infarction. Think of as an overshoot mechanism. Baby is used to having lots of maternal glucose so it makes lots of insulin. When born, maternal glucose is no longer available but insulin remains high hypoglycemia. Can lead to seizures, coma and brain damage.

Hypoglycemia

Fetal Morbidity

Postnatal hyperbilirubinemia
Occurs in appox. 25%, double that of normal. Thought to be due in large part to polycythemia.

Respiratory distress syndrome

5-6 fold increased frequency. May be due to a delay in lung maturation or simply due to the increased frequency of preterm deliveries.

Fetal Morbidity

Polyhydramnios
Amniotic fluid volume >2000 mL. Occurs in 10% of diabetics. Increased risk of placental abruption and preterm labor.

Maternal Morbidity
Increased risk of DKA due to increasingly resistant DM. Increased incidence of UTI due to glucose-rich urine and urinary stasis.

Glucosuria is a normal finding of pregnancy but may be much higher in diabetics.

Diabetic retinopathy Diabetic nephropathy

Maternal Morbidity
Diabetic neuropathy Preeclampsia

2-fold increase

Diagnosis

Glucose Challenge Test (24-28 wks)

50 gram glucose load with blood level 1 hour later. Does NOT require fasting state. Normal finding is <140 mg/dl. If >140, need to do a 3 hour glucose tolerance test.

Diagnosis

Glucose Tolerance Test

Draw a fasting glucose level (normal<95). Give 100 gram glucose load with glucose levels drawn after 1, 2 and 3 hours. Normal levels vary widely depending on who you ask but should be in the following ranges:

hr:<180 2 hr:<155 3 hr:<140

2 or more abnormal values = GDM.

Treatment and Management

Obviously the main goal is to maintain good glycemic control.

Typically controlled with insulin but oral hypoglycemic agents like glyburide are also showing promise.

Treatment and Management

Obstetrical management

Serial US to trend fetal growth, AFI and fetal anatomy

Postpartum, 95% of GDM mothers return to normal glucose tolerance, and require no further insulin.

Glucose tolerance screen 2-4 mo. postpartum to detect those that remain diabetic.

References
www.acog.org Current Obstetric & Gynecologic Diagnosis & Treatment (2003) Williams Obstetrics (2005)