DIABETES IN PREGNANCY

Introduction
2 types of diabetes during pregnancy
GDM Established DM

Gestational Diabetes (GDM)

A carbohydrate intolerance of varying degrees and severity with onset or first recognition during pregnancy with a probable resolution after the end of pregnancy due to insulin resistant Diabetes, glucose intolerance or insulin resistance may have existed before the pregnancy. GDM is not the same as Type 1 or Type 2 Diabetes

Pat Sonnenstuhl,ARNP, CNM

Pathophysiology
At 12-16 weeks, placenta become more active and produces many hormones such as :
HPL, glucagon, cortisol, thyroxine, and growth

hormone Due to increase of above hormones, it disturbs the function of insulin and metabolism of CHO

Pregnancy Pathophysiology
During the third trimester of pregnancy, insulin resistance increases by 50%.
Maternal pancreatic beta cells increase

insulin secretion almost threefold to compensate for increased insulin resistance.

Pat Sonnenstuhl,ARNP, CNM

Pregnancy Pathophysiology
The subsequent increase in insulin secretion causes the maternal glucose levels to increase 80% of the blood levels of non-pregnant women If the mothers pancreas is unable to produce sufficient insulin to overcome insulin resistance, maternal glucose levels increase and GDM occurs

Pat Sonnenstuhl,ARNP, CNM

Pregnancy Pathophysiology
GDM complicates pregnancy by further increasing insulin resistance GDM disappears after pregnancy because the

hormonal changes that caused insulin resistance are no longer present

Pat Sonnenstuhl,ARNP, CNM

Screening

h/o previous big baby>3.6kg Age >35 yr old Strong FH of DM Previous h/o GDM Glycosuria(urine sugar) for more than 2 occasions Obesity>80kg h/o of unexplained IUD. Eg: FSB or MSB Polyhydramnios h/o congenital abnormality h/o recurrent abortion >2times Recurrent fungal infection of the skin, vag candidiasis and UTI

Diagnosis
By MOGTT
Preferably done between 16 to 20 weeks, and

needed to repeat at 28 and 34 weeks. Fasting >7 mmol/l 2HPP> 7.8mmol/l

Establish DM
A diabetic before pregnancy
2 types:
TYPE 1 INDEPENDENT ON INSULIN

Seen in young mothers

Type 2 non independent on insulin

Very difficult to control and very high risk to

get fetal complication

Obstretic problem
1.Polyhydramnios - PROM leaking liquor pada 34 minggu
2.Cord prolapsed,

3. Abruptio placenta
4. Pre Eclampsia 5. Premature labour 6. Risk of Caesarean Section big baby 7. Obstructed labour/prolonged labor

Fetal complication
- Sudden death
- Spina bifida - Macrocephalus - Sacral agenesis - Shoulder dystocia - Abortion (2 kali ganda) - Polyhydramnios

- Neural tube defect - Down syndromme - Heart defect - Macrosomia baby

Maternal complication
1. Uncontrolled Diabetes bagi IDDM
2. Hyperglycaemia glycosuria dan

3.
4. 5. 6. 7.

ketoacidosis Recurrent infection UTI, Candidiasis Diabetic Retinopathy IDDM Diabetes ketoacidosis (DKA) PPH Trauma - genetalia

Neonatal complication
hypoglycaemia

investigation
Screening- MOGTT
Investigation after diagnosis
BSP

Refer to dietician
Renal profile UFEME

 For monitoring
HbA1c- to check glucose control for the past 3

months
Immediately after diagnosis Especially for establish DM and GDM on insulin
BSP For diet control, monitoring every 2 weeks For those on insulin, monitoring every 1 week 4 -6 mmol/l

Management
Antenatal
Identify high risk mothers Refer to doctor Refer to hospital (OnG )
For establish DM, needed to refer at 20 to 24 weeks for detailed scan If BSP is uncontrolled, refer to tertiary care for glucose stabilization

 Advice on
Hygiene Diet

Insulin
Exercise Complication of high glucose towards fetal,

mother and obstretic problem and hypoglycemia

Symptoms of hypoglycemia

 What to do if hypoglycemia?
d/s > 3.5 Ask pt to drink a cup of milo or eat multiple

candies After 30 min symptoms go away, to eat snack

 All diabetic or GDM cases must refer at 38 weeks(HKM)

All diabetic and GDM on insulin refer at 38

weeks and on diet control at 40 weeks(HTAA)

Post partum
Rpt MOGTT after 6 weeks delivery