Pregnancy with Diabetes Mellitus

Wang yanming

1
 Introduction

insulin deficiency
Diabetes
mellitus peripheral tissue resistance (decreased
sensitivity) to the action of insulin

hyperglycemia insulin sensitivity

insulin resistance
 Classification
two situations:
Diabetes mellitus complicating
pregnancy Pregestational /overt diabetes
mellitus
Diabetes mellitus is diagnosed before this pregnancy.10%

Gestational diabetes mellitus (GDM)

Diabetes mellitus is first manifests during this
pregnancy. 90%
1.May have its onset or be first recognized during
pregnancy.(true)
2.Diabetes may have previously existed but not diagnosed.
Definition

Gestational diabetes mellitus (GDM)

It is an impairment in carbohydrate metabolism
that first manifests during pregnancy.

These patients may have borderline carbohydrate

metabolism impairment at baseline or be
entirely normal in the nonpregnant state.

The entity usually presents late in the second or

during the third trimester.
 Epidemiology
The incidence of GDM ranges from 1% to 12% of pregnant
women depending on the population.
In China: 1% - 5%.
Majority of these women (>50%) with GDM ultimately
develop overt diabetes by next 15 to 20 years.These
cases are basically preexisting type 2 diabetes. part of
GDM suffering from impaired -cell function but
remained undetected
 The characteristic of carbohydrate
metabolism during pregnancy
1st stage: FPG is lower than non-
pregenant state.FPG:10%
The fetus gets more glucose from the mater
The kidney blood floor and GFR ,
absorption of glucose can not increase, more
glucose leaks out in the urine due to renal,
glycosuria .
Estrogen and progesterone increase the
utilization of glucose.
2nd,3rd trimestry: FPG

estrogen, progesterone,
cortisol, HPL, etc

antagonize the effects of insulin

insulin sensitivity decreased by 40%

in the 3rd trimester. hyperglycemia

insulin secretion

physiological changes

GDM
 Effects of pregnancy on diabetes

Pregestational diabetes aggravation

The insulin sensitivity is lowered.We should
adjust the dosage of insulin according to the
gestational week and placenta status.
--early stage: the dosage of insulin
--late stage: the dosage of insulin
--in labor: the dosage of insulin
--postpartum: the dosage of insulin

It is difficult to stabilize the blood glucose

Effects of diabetes on pregnancy

Depending on the development of diabetes and blood

glucose levels.
Maternal Fetal Neonatal
Maternal:
During pregnancy
1 Abortion:15-30%.Usually occure in prepregnant
diabetes.Recurrent spontaneous abortion may be
associated with uncontrolled diabetes.
2 Increased incidence of preeclampsia(25%)
3 Infection: Urinary tract infection and vulvovaginitis
 4 Polyhydramnios (2550%) is a common
complication.large baby, large placenta, fetal
hyperglycemia leading to polyuria, increased
glucose concentration of liquor irritating the
amniotic epithelium or increased osmosis, are
some of the probabilities.
5.Maternal distress may be due to the
combined effects of an oversized fetus and
polyhydramnios
6 Ketoacidosis
7 the recurrence rate is high
8 Preterm labor:(26%) may be due to infection
or polyhydramnios.
 Fetal
Fetal macrosomia :(2542%)with birth weight > 4 kg
Maternal hyperglycemia hypertrophy and
hyperplasia of the fetal islets of langerhans
increased secretion of fetal insulin stimulates
carbohydrate utilization and accumulation of fat.
Congenital malformation 7-fold it is related
to the severity of diabetes affecting organogenesis in
the first trimester pregestational
daibetes .mainly cardiovascular system and nervous
system.
Fetal growth restriction:(21%) is less commonly
observed and is associated with maternal
vasculopathy.
 Neonatal
Hypoglycemia: is due to hyperinsulinemia. It is common in
macrosomic infants.
Respiratory distress syndrome : is due to excess level of
fetal insulin that blocks the action of cortisol. Cortisol
activates type II pneumocytes for the synthesis of
phospholipids (surfactant). Risk of RDS is reduced when
diabetes is well controlled and delivery is done after 38
weeks of gestation.
Polycythemia; Hypocalcemia; Hypomagnesemia;
Hyperbilirubinemia
long-term effectschildhood obesity, neuropsychological
effects and diabetes
 Diagnosis

history high risk factors

clinical manifestation
laboratory examination:
FPG(fasting plasma glucose)
GHbA1c (glycosylated hemoglobin A)
random plasma glucose
75g OGTT
The diagnosis of PGDM

The patient is diagnosed DM before this pregnancy.

The patient with high risk factors and did not do any
examination of DM before present pregnancy ,should
examine at the first antenatal visit.
---FPG 7.0mmol/l 126 mg/dl
---HbA1C 6.5%
---typical symptom + random plasma glucose11.1mmol/l
The diagnosis of GDM
---Screening strategy(1)
The screening method employed is by using 75 g oral
glucose tolerance test between 24 weeks and 28 weeks
of pregnancy.
In our country, every pregnant woman is advised to do
75 g OGTT at about 24-28 weeks of gestation.
If the GDM symptoms are present after 28 weeks, the
OGTT should be done again.
method: 1 FPG
2 75g glucose+200-300ml water, oral in
5minutes
3 1-hour plasma glucose after oral glucose
4 2-hour plasma glucose after oral glucose
 The diagnosis criteria
The diagnosis of GDM
---Screening strategy(2)

between 24 weeks and 28 weeks of pregnancy.

FPG
FPG 5.1 mmol/l GDM
4.4 mmol/l FPG 5.1 mmol/l OGTT
FPG <4.4 mmol/l

The patient with high risk factors, OGTT is normal

at the first antenatal visit check one more time
at the late trimester
 Classification

m mol/l = mg% 0.0555

A1: FPG < 5.3mmol/l, 2h-postprandial < 6.7mmol/l
A2: FPG 5.3mmol/l, 2h-postprandial 6.7mmol/l
 Management
Antepartum Management
-- Preconception counseling of PGDM
-- Principles in the management
-- The satisfied plasma glucose level
-- Glycemic control during pregnancy
-- prenatal care
Intrapartum Management
-- The optimum time and method of delivery when? how?
-- Management in labour
Postpartum Management
Care of the baby
 Management

overt diabetes,class D or F
or R. ()
well controlled DM .()

can
canwe
wepregnant
pregnantor
ornot
not CHALLENGE!!!
Preconception counseling of PGDM Management

Goal is to achieve tight control of diabetes before the

onset of pregnancy.
Diabetologist, obstetrician and dietician--appropriate
advice about diet and insulin is given.
Folic acid supplementation (0.4mg/day)
Women are taught for self-glucose monitoring.(7 times
daily)
 Management

Principles in the management are:

Careful antenatal supervision and glycemic control, so as to
maintain the glucose level as near to physiological level as possible
To find out the optimum time and method of delivery
Arrangement for the care of the newborn.

The satisfied plasma glucose level

FPG: 3.3~5.3 mmol/l
30 minute preprandial plasm glucose: 3.3~5.3 mmol/l
2 hour postprandial plasm glucose: 4.4~6.7 mmol/l
The plasm glucose at night:4.4~6.7 mmol/l
 Management
Glycemic control during pregnancy

Diet :
Diet control is the main method of treatment of GDM
Meal plans: individualized.
Calories: 30 to 35 cal/kg (ideal body weight, IBW) per day.
carbohydrates 50%-60%, protein 20%-25%, fat 25%-30%
Avoid ketoacidosis
exercise:
Glycemic control during pregnancy Management

medicine:When diabetes is first detected during

pregnancy and cannot be controlled by diet alone, it
should be treated with insulin.Oral hypoglycemic agents
(glibenclamide, metformin) are also being used to
maintain glycemic control.
1. Early pregnancy: insulin
2. Late pregnancy: insulin , peaking at 32 to 36 weeks
3. Postpartum: insulin1/3-1/2
4. Diabetic ketoacidosis: insulin, ivgtt

Insulin is macromolecular protein,

can not through the placenta,
it is the best choice of the
medicine control GDM.
 During labor
(1) Prolongation of labor due to big baby
(2) Shoulder dystocia: is due to disproportionate growth
with increased shoulder/head ratio.
(3) Perineal injuries.
(4) Postpartum hemorrhage.
(5) Operative interference.
Antenatal care Management

the early trimester PGDM

-should closely monitor the plasm glucose, adjust the dose of
insulin timely, avoid hypoglycemia
-Check once a week until 10 weeks of gestation
the middle trimester
- Check twice a week
- the dose of insulin should increased G20w
G 32 w
- Check once a week
- Pay attention to BP edema urine protein
- Pay attention to the fetal development fetal
maturation fetus- placenta function NST
- hospitalization when necessary
 Management
The indications of termination

1 GDM glycemic control () , insulin () EDC

2 GDM glycemic control () , insulin () 39w
3 PGDM, glycemic control () , insulin () 39w

4 GDM PGDM glycemic control () insulin () maternal

and fetal complications( vascular complications: preeclampsia,
IUGR, infection fetal distress) () terminate the pregnancy
timely.
 Management
Methods of terminate

Diabetes is not the indication of cesarean section.

Induction of labor:
Cesarean section: The indications are
Fetal macrosomia (>4 kg)
Diabetes with complications or difficult to control
Fetal compromise as observed in antepartum fetal monitoring
Elderly primigravidae
Multigravidae with a bad obstetric history
Obstetric complications like preeclampsia, polyhydramnios,
malpresentation.
As such 50% of diabetic mothers are delivered by cesarean section.
general treatment

Have a rest and calm down

Appropriate diet
Pay attention to the changes of blood glucose,
urine glucose and ketone.
Adjust the dose of insulin in time
Strengthen the fetal supervision

31
vaginal delivery

Still the diabetes diet in labor

stop using subcutaneous insulin in labor,
insulin intravenous infusion
should finish delivery within 12 h, produce
long will increase ketoacidosis, fetal
hypoxia and the risk of infection

32
 Cesarean section
On the day of operation, breakfast and the insulin dose are
omitted. A normal saline infusion is started.
Plasm glucose 6.67~10.0mmol/L in c-section.
The administration of dextrose drip and the insulin dose are
to be maintained until the patient is able to take fluids by
mouth (ACOG-2005). Continuous subcutaneous insulin
infusion with insulin pump is preferred as it is more
physiological.
The insulin requirement suddenly falls following delivery and
after the omission of the drip, pre-pregnant dose of insulin is
to be administered or adjusted from the blood glucose level.
 Management
Postpartum Management
Puerperium: reducing the dose of insulin,
preventing infection

OGTT at 6-12w Postpartum, if positive may be

pre-existing or detected for the first time during
present pregnancy.

Follow-up: Nearly 50% of women with GDM would

develop overt diabetes over a follow-up period of
520 years.
 Care of the baby Management

Improvement in the care of diabetes in pregnancy has reduced

perinatal mortality significantly.
A neonatologist should be present at the time of delivery.
The baby should preferably be kept in an intensive neonatal care unit
and to remain vigilant for at least 48 hours, to detect and to treat
effectively any complication likely to arise.
Asphyxia is anticipated and be treated effectively
To look for any congenital malformation.
All babies should have blood glucose to be checked within 2 hours
of birth to avoid problems of hypoglycemia (blood glucose < 35 mg/dl).
All babies should receive 1 mg vitamin K intramuscularly.
Early breastfeeding within half to 1 hour is advocated and to be
repeated at three to four hourly intervals thereafter to minimize
hypoglycemia and hyperbilirubinemia.
 Management of Gestational
Diabetes
At home:
1. Self-monitoring (BG) 2. Controlled diet 3. insulin and/or
Metformin (7 times daily)

In clinic: Challenge
Blood glucose review Treatment is difficult
(every 2-4 weeks) to predict
Dietary advice and Demanding for
medication patient
adjustments and for the doctor
KEY POINTS
Gestational Diabetes Mellitus (GDM) is defined as carbohydrate
intolerance of variable severity with onset or first recognition
during the present pregnancy.
Potential risk factors for GDM
Complications of GDM
Pregnancy is a diabetogenic state due to several contra-insulin
factors causing decreased sensitivity of the peripheraltissues to
insulin (insulin resistance).
Metabolic events for a woman with diabetes in pregnancy is
maternal hyperglycemia Fetal hyperglycemia Fetal pancreatic
islet cells hyperplasia and hypertrophy Increased fetal insulin
secretion Excessive fetal growth Fetal macrosomia
Increased birth injury.
Fetal congenital malformations are high in diabetic woman
(pregestational diabetes); commonest is cardiovascular
 Complications of diabetes in pregnancy are increased both for the
mother, fetus and the neonates
Screening for GDM is done between 24 and 28 weeks of pregnancy
Treatment of women with diabetes in pregnancy: Dietary therapy.
Insulin is given when glycemic control is not achieved with dietary
therapy. Oral hypoglycemic agents (glibenclamide, metformin) are
also being used to maintain glycemic control.
Close antenatal fetal assessment for women with both GDM and
pregestational diabetes is maintained. It depends on degree of
glycemic control, presence of vascular disease (nephropathy,
retinopathy) or hypertension.
 A 32-year-old G0 woman with type 1 diabetes mellitus (T1DM)
presents for a preconception visit. She was diagnosed with T1DM
at age 4 and other than some challenges with glucose control
during her teenage years, she generally has good control per her
report. She uses a subcutaneous insulin pump. She has no history
of retinopathy, renal disease, heart disease, proteinuria,
peripheral neuropathy, or any other medical conditions. Her BP is
128/76 mm Hg.
During your counseling, which of the following do you NOT mention
that she or her fetus is at increased risk for during pregnancy?
a. Preeclampsia
b. Congenital abnormalities
c. Breech presentation
d. Cesarean delivery
e. Fetal macrosomia
 A 29-year-old G2P1 woman with obesity, a history of GDM in the
prior pregnancy, and a strong family history for type 2 diabetes
mellitus (T2DM) presents at 7 weeks gestation by LMP. In her
previous pregnancy, she required insulin therapy. She delivered at
39 weeks and her baby boy weighed 4,300 g (or approximately 9
lb).

In addition to the routine prenatal laboratory tests, what other

testing do you also obtain at this point?
a. A glucose challenge test with fasting blood glucose
b. An ultrasound to estimate fetal weight
c. Anti-insulin antibodies
d. No testing at this point; we would get a glucose challenge test
at 24 weeks gestation
e. No other testing needed; we assume she has GDM