Diabetes Mellitus in

Pregnancy
 Diabetes is increasing at an alarming rate in Asian
countries including the Philippines.
Both the prevalence and incidence of type 2 diabetes
(T2D) continue to increase with a commensurate upward
trend in the prevalence of prediabetes
Rapid urbanization with increasing dependence on
electronic gadgets and sedentary lifestyle contribute
significantly to this epidemic.
 Diabetes care in the Philippines is disadvantaged and
challenged with respect to resources, government support, and
economics.
The national insurance system does not cover comprehensive
diabetes care in a preventive model and private insurance
companies only offer limited diabetes coverage.
Thus, most patients rely on out-of-pocket expenses, namely,
laboratory procedures and daily medications.
Consequently, poor pharmacotherapy adherence impairs
prevention of complications. Moreover, behavioral modifications
are difficult due to cultural preferences for a traditional diet of
refined sugar, including white rice and bread
Diabetes mellitus
Diabetes is a chronic and progressive disorder.
The term diabetes mellitus (DM) describes a metabolic
disorder that affects the normal metabolism of
carbohydrates, fats and protein.
It is characterized by hyperglycemia and glycosuria
resulting from defects in insulin secretion, or insulin action
or both.
Diabetes is the most complication of pregnancy. common
medical
White Classification in Pregnancy
Beginning several years ago, the American College of Obstetricians and Gynecologists (2012,
2013) no longer recommended the White classification.

Instead, the current focus is whether diabetes antedates pregnancy or is first diagnosed during
pregnancy. Many now recommend adoption of the classification proposed by the American
Diabetes Association
(ADA),
TYPES OF DIABETES
In nonpregnant individuals, the type of diabetes is based on its
presumed etiopathogenesis and its pathophysiological
manifestations.
Absolute insulin deficiency characterizes type 1 diabetes.
In contrast, defective insulin secretion, insulin resistance, or
increased glucose production characterizes type 2 diabetes.
Both types are generally preceded by a period of abnormal glucose
homeostasis.
The terms insulin-dependent diabetes mellitus (IDDM) and
noninsulin-dependent diabetes mellitus (NIDDM) are now obsolete.
Pancreatic -cell destruction can begin at any age, but type 1
diabetes is clinically apparent most often before age 30.
Type 2 diabetes usually develops with advancing age
Classification During Pregnancy
Diabetes is the most common medical complication of
pregnancy.

Women can be separated into those who were known to

have diabetes before pregnancypregestational or
overt,

And those diagnosed during pregnancygestational

diabetes.
PREGESTATIONAL DIABETES
The increasing prevalence of type 2 diabetes in general,
and in younger people in particular, has led to an
increasing number of affected pregnancies.

Many women found to have gestational diabetes are likely

to have type 2 diabetes that has previously gone
undiagnosed.
Diagnosis
Women with high plasma glucose levels, glucosuria, and
ketoacidosis present no problem in diagnosis.
Similarly, women with a random plasma glucose level >200
mg/dL plus classic signs and symptoms such as polydipsia,
polyuria, and unexplained weight loss or those with a
fasting glucose level exceeding 125 mg/dL are considered
by the ADA (2012) to have overt diabetes.
Women with only minimal metabolic derangement may be
more difficult to identify.
Risk factors for impaired
carbohydrate
metabolism in pregnant
women include a strong
familial history of
diabetes, prior delivery
of a large newborn,
persistent
glucosuria, or
unexplained fetal losses.
Impact on Pregnancy
With pregestationalor overtdiabetes, the embryo, fetus, and
mother frequently experience serious complications directly
attributable to diabetes.
Fetal Effects Neonatal Effects.
Spontaneous Abortion. Respiratory Distress Syndrome
Preterm Delivery. Hypoglycemia., Hypocalcemia.
Malformations. Hyperbilirubinemia and
Polycythemia
Altered Fetal Growth. Cardiomyopathy
Unexplained Fetal Demise.
Hydramnios.
Maternal Effects
Preeclampsia.
Diabetic Nephropathy.
Diabetic Retinopathy.
Diabetic Neuropathy.
Diabetic Ketoacidosis.
Infections.
GESTATIONAL DIABETES
Gestational diabetes develops during pregnancy
(gestation).
Like other types of diabetes, gestational diabetes affects
how your cells use sugar (glucose).
Gestational diabetes causes high blood sugar that can
affect your pregnancy and your baby's health
In gestational diabetes, blood sugar usually returns to
normal soon after delivery. But if you've had gestational
diabetes, you're at risk for type 2 diabetes
 During early pregnancy, increases in estrogens,
progestins, and other pregnancy-related hormones lead to
lower glucose levels, promotion of fat deposition, delayed
gastric emptying, and increased appetite.
As gestation progresses, however, postprandial glucose
levels steadily increase as insulin sensitivity steadily
decreases.
For glucose control to be maintained in pregnancy, it is
necessary for maternal insulin secretion to increase
sufficiently to counteract the fall in insulin sensitivity.
GDM occurs when there is insufficient insulin secretion to
counteract the pregnancy-related decrease in insulin
sensitivity.
 The Transfer of the nutrients through the placenta from the
mother to the fetus is very important.

In fact glucose crosses the placenta by a simple diffusion,

aminoacids need an active transport and free fatty acids
with a gradient dependent.

In addition, ketone bodies cross easily by diffusion

whereas insulin does not cross through.
 In diabetic pregnancy, because of an absolute or relative
insulin deficiency, there is a reduced uptake and/or a
hyper-production of nutrients by the diabetic mother, and
therefore a condition of hyper-alimentation for the embryo
or the foetus, with relative consequences according to time
of pregnancy.
This condition in early pregnancy may induce congenital
anomalies, whereas a precocious over-stimulation of fetal
-cells lead to hyper-insulinemia that is the main cause of
foetal morbidity in diabetic pregnancy.
Same condition may be involved in later complications in
the offspring of diabetic mother
 It should be noted that fetus is surrounded by the amniotic
fluid, that he produces and swallows continuously.
The amniotic fluid is rich of nutrients such as glucose which
decrease progressively in normal pregnancy,but not in
diabetic pregnancy,especially when there is poor metabolic
control.
Therefore the fetus receives from the diabetes mother
more nutrients through placental blood and by ingestion of
amniotic fluid.in addition, Insulin and other protein
hormones do not cross the placenta
 So the assay of these hormones in the amniotic fluid may
have a diagnostic and prognostic use.
Differential Diagnosis
Pre-gestational diabetes

Gestational diabetes

Diabetic Ketoacidosis

Diabetic Nephropathy

Acute/Chronic Renal Failure

Screening and Diagnosis
Clinical presentation (History and PE)
Strong familial history of diabetes
Have given birth to large infants (4 kg or more)
Demonstrate persistent glucosuria,
Have unexplained fetal losses
Presence of polyhydramnios candidiasis in present pregnancy.
Over the age of 30
Obesity
Sedentary Lifestyle
Ethnic group (East Asian, pacific island ancestry) or recurrent
vaginal Infection.
Baseline assessment of the pregestational
diabetic mother
Organ system Testing

Serum creatinine, 24-hour urine

Renal
protein, and creatinine clearance

Blood pressure, EKG (for long-

Vascular
standing disease)

Ophthalmology Retinal evaluation

Infectious Urine culture

Endocrine Thyroid stimulating hormone

Management
Women with gestational diabetes can be divided into two
functional classes using fasting glucose levels.
Pharmacological methods are usually recommended if diet
modification does not consistently maintain the fasting
plasma glucose levels < 95 mg/dL or the 2-hour
postprandial plasma glucose < 120 mg/dL (American
College of Obstetricians and Gynecologists, 2013).
 Diabetic Diet
On average, this includes a daily caloric intake of 30 to 35
kcal/kg.
the ADA (2003) has suggested that obese women with a
BMI > 30 kg/m2 may benefit from a 30-percent caloric
restriction, which approximates 25 kcal/kg/d.
Exercise
The results suggest that exercise improved
cardiorespiratory fitness
Obstetrical Management
Insulin Therapy
Recommended when standard dietary management does
not consistently maintain fasting plasma glucose at <95
mg/dL or the 2hour postprandial plasma glucose < 120
mg/dL (ACOG, 2001).
Alternatively, weight-based split-dose insulin is
administered twice daily.
Total dose of 20 to 30 units OD, before breakfast, is
commonly used to initiate therapy which is divided into two-
thirds intermediate-acting insulin and a third short-acting
insulin
SUMMARY