Diabetes & PregnancyDec.23.2013

•Gestational diabetes mellitus is defined as glucose intolerance of variable degree with onset or first recognition during pregnancy

•Abnormal maternal glucose regulation occurs in 3-10% of pregnancies.

•Gestational diabetes mellitus accounts for 90% of cases of diabetes mellitus in pregnancy, while preexisting type 2 diabetes accounts for 8% of such cases.

Maternal-Fetal Metabolism in Normal Pregnancy

• Each meal sets in motion a complex series of hormonal actions, including a rise in blood glucose and the secondary secretion of pancreatic insulin, glucagon, somatomedins, and adrenal catecholamines. These adjustments ensure that an ample, but not excessive, supply of glucose is available to the mother and fetus.

• pregnant women tend to develop hypoglycemia (plasma glucose mean = 65-75 mg/dL) between meals and during sleep.

• Levels of placental steroid and peptide hormones (eg, estrogens, progesterone, and chorionic somatomammotropin) rise linearly throughout the second and third trimesters.

• By the third trimester, 24-hour mean insulin levels are 50% higher than in the nonpregnant state.

Maternal-Fetal Metabolism in Diabetes

•the maternal pancreatic insulin response is inadequate, maternal and, then, fetal hyperglycemia results.

•The energy expenditure associated with the conversion of excess glucose into fat causes depletion in fetal oxygen levels.

Maternal Complications• Chronic hypertension

• Pre-eclampsia

• Diabetic ketoacidosis

• Maternal hypoglycemia

• Maternal trauma

• Higher C Section rate

• Retinal disease/renal disease not affected significantly by pregnancy

• 50% lifetime risk in developing Type II DM• Recurrence risk of GDM is 30-50%

• Hypertensive disorders are a major complication of women with diabetes who become pregnant.

• Approximately 10% to 20% of women with diabetes will experience hypertensive disease related to pregnancy.

• This percentage is increased in women with preexisting renal dysfunction; as 40% of women with mild preexisting nephropathy and nearly 50% with significant disease.

• women with diabetic retinopathy and chronic hypertension experience rates of preeclampsia as high as 60%.

• Often times it is hypertension and not diabetes which leads to morbidity and subsequent iatrogenic preterm delivery.

Fetal effects• higher rates of fetal wastage which appears to be

related to the degree of glycemic control, . This includes higher rates of first-trimester losses as well as increased rates of stillbirth in later trimesters.

• Fetal overgrowth or macrosomia is commonly associated with poor maternal glycemic control.

• . Women with underlying vascular and/or renal disease experience increased rates of fetal growth restriction.

•Episodic fetal hypoxia leads to increased catecholamines causing: –Fetal hypertension–Cardiac remodelling and hypertrophy–Increased erythropoietin, RBC’s, hematocrit –Poor fetal circulation and hyperbilirubinemia–Stillbirth

Fetal macrosomia is associated with increased rates of maternal and neonatal birth trauma and higher rates of neonatal ICU admissions.

Babies born to mothers with suboptimal glycemic control experience increased ratesof congenital anomalies.

CVS :ASD/VSD,

CoA :Transposition, :Cardiomegaly

CNS:Anencephaly,:NTD,:Microcephaly

GI :duodenal atresia, anorectal atresia, situs inversus

GU :renal agenesis :Polycystic kidneys

MSK :caudal regression

Congenital anomalies

Preexisting Diabetes

Neonatal Effects for All Diabetic Pregnancies:

•Polycythemia and hyperviscosity

•Neonatal hypoglycaemia

•Neonatal hypocalcaemia, hypomagnesaemia

•Hyperbilirubinemia

•Hypertrophic and congestive cardiomyopathy

•RDS

•Childhood impaired glucose tolerance

Keep in mind that just because your patient have GDM it does not mean that these problems will occur.

•Infants of mothers with preexisting diabetes mellitus experience double the risk of serious injury at birth, triple the likelihood of cesarean delivery, and quadruple the incidence of newborn intensive care unit (NICU) admission.

PRINCIPLE DANGERS

GESTATIONAL DIABETES:Fetal hyperinsulinemia

PREGESTATIONAL DIABETES:Fetal Anomalies

Risk Factors For Gestational Diabetes

• maternal age >30• BMI >25• Family history• Glucosuria• PCOS• Prior GDM• prior macrosomia• previous unexplained stillbirth• ethnic group: Hispanic, Black, Asians Low risk woman must not have any positive risk factor.

Gestational Diabetes Screening

• Its performed between 24-28 weeks of gestation.

• no need to fast.• screen at 1st prenatal visit if hx of previous GDM.• screen earlier (12-24 weeks ) in high risk groups.

Gestational Diabetes Screening

Universal screening is advisable.

• 1 hour 50 gm glucose load (GCT)• Venous plasma glucose cut-offs

• 140 mg/dl• 130 mg/dl

Diagnosis of Gestational Diabetes

Three Hour 100 gm glucose tolerance test (GTT)

Two abnormal values required for the diagnosis of gestational diabetes

NDDG Carpentar and Coustan

FBS 105 FBS 95

1 hour 190 1 hour 180

2 hour 165 2 hour 155

3 hour 145 3 hour 140

Treatment Plan for GDM

• Knowing your blood sugar (glucose) level and keeping it under control

• Eating a healthy diet, as outlined by your health care provider• Getting regular, moderate physical activity• Maintaining a healthy weight gain• Keeping daily records of your diet, physical activity, and glucose

levels

•Avoidance of large meals with high percentage of simple carbohydrates

•Three small meals with three snacks are preferred

• Low glycemic index foods release calories from the gut slowly and improve metabolic control

• Caloric content:– 35 calories/Kg Ideal body– No less than 1800 calories and no more than 2800

calories– “Eyeball Technique”

- Small patient 1800 calories- Medium patient 2200 calories- Large patient 2400 calorie

28 PBRC 2006

Role of physical activity

• Women with gestational diabetes often need regular, moderate physical activity to help control their blood sugar levels by allowing insulin to work better.

• Examples include:• Walking• Prenatal aerobics classes• Swimming

• However, a consultation and approval by a health care provider is needed before beginning any physical activity during pregnancy.

Caution

Keep in mind that it may take 2 to 4

weeks before physical

activity has an effect on blood sugar levels.

Know your blood sugar level & keep it under control

•Use insulin in patients with gestational diabetes to achieve optimal glycemic control.

• Adjust insulin doses to achieve fasting whole-blood glucose levels of 70 to 100 mg/dL and 2-hour postprandial levels of <140 mg/dL.

If persistent hyperglycemiaafter one week of dietcontrol proceed to insulin• 6-14 weeks 0.5u/kg/d• 14-26 weeks 0.7u/kg/d• 26-36 weeks 0.9u/kg/d• 36-40weeks 1 u /kg/d

Gestational DiabetesINSULIN

Know your blood sugar level & keep it under control

• You may have to test four times a day:

1. In the morning before eating breakfast, referred to as the Fasting glucose level2. 1 or 2 hours after breakfast3. 1 or 2 hours after lunch4. 1 or 2 hours after dinner

• You may also have to test your glucose level before you go to bed at night. This is referred to as your nighttime or nocturnal glucose test.

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Maintain a healthy weight

• Healthy weight gain can refer to your overall weight gain or your weekly rate of weight gain.

• Some health care providers focus only on overall gain or only on weekly gain, but some keep track of both types of weight gain.

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Maintain a healthy weightWeekly Rate Of Weight Gain

Time Frame Expected Weight Gain

In the first trimester of pregnancy

(the first 3 months)

Three to six pounds for the entire three

months

During the second and third trimester

(the last 6 months)

Between ½ and 1 pound each week

If you gained too much weight early in the

pregnancy

Limit weight gain to ¾ of a pound each week (3 pounds

each month) to help get your blood sugar level

under control

A weight gain of two pounds or more each week is

considered high.

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Maintain a healthy weightThings to Keep in Mind

1. A weekly rate of weight gain may go up and down throughout the pregnancy.

2. A physician can assess whether weight gain is appropriate or not.

3. A weight loss can be dangerous during any part of the pregnancy, therefore any weight loss needs to be reported to a health care provider right away.

4. If weight gain slows or stop, and does not increase again after one-to-two weeks, it should be reported to a health care provider immediately. Adjustments in your treatment plan may be necessary.

Know the symptoms of hypoglycemiaIf your blood sugar level drops below 60 at any time, you have hypoglycemia. This can be very dangerous. Hypoglycemia is already common in all women with gestational diabetes, but for women taking insulin for this condition, they are at greater risk.

Why does low blood sugar occur?

• Too much exercise• Skipping meals or snacks• Delaying meals or snacks• Not eating enough• Too much insulin

Symptoms of Hypoglycemia

• Very hungry• Very tired• Shaky or trembling• Sweating or clamminess• Nervous• Confused• Like you’re going to pass out or faint• Blurred vision

* Report any abnormal blood sugar level to your health care provider right away, in case a change in your treatment plan is needed.

Hypoglycemia Prevention Strategies

Consistent Monitoring

Before All Meals & Snacks

Pre/Post Exercise

Bedtime

3 a.m. (occasionally)

Fetal Surveillance and Delivery

• Women requiring pharmacologic therapy for GDM and those with additional comorbid conditions who do not require medical therapy should undergo increased surveillance to improve neonatal outcome.

• Early ultrasound evaluations are useful to provide accurate dating, and anatomy surveys performed between 18 and 20 weeks gestation are important to evaluate for congenital anomalies.

• Antenatal testing should begin no later than 32 weeks’ gestation in women requiring insulin or oral hypoglycemic therapy.

• Women treated with diet therapy alone may wait for testing to begin later.

• Antenatal surveillance should be carried out at least weekly with fetal non-stress tests or biophysical profile evaluations

Timing of Delivery GDM Diet controlled• Same as non diabetic • Offer induction at 41 weeks if undelivered GDM on Insulin/Type II/Type I• If suboptimal control, deliver followingconfirmation of lung maturity if <39Weeks.• Otherwise deliver by 40 weeks• Generally do not allow to go postterm

Intrapartum management

•ABSOLUTE REQUIREMENTS:– Maintain plasma glucose 80 – 110 mg/dl with iv

dextrose and insulin infusion

• Hourly glucose monitoring

•Continuous fetal heart rate monitoring

•Continuous tocodynametry

•Manage labor as normal

HYPOGLYCEMIA DURING AN INSULIN DRIP

For Glucose <60• Turn off Insulin drip for 30 minutes • Continue D5W (or D5LR) at 100 – 125

cc/hr• Recheck Glucose after 30 minutes• If blood glucose on recheck is still <60

• Give 25 ml of D50 IV (or 10-12 grams glucose)

• Recheck Blood Glucose every 30 minutes • Restart insulin when glucose >101 mg/dl

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What should I do after delivery?• Six weeks after your

baby is born, you should have a blood test to find out whether your blood sugar level is back to normal.

• Based on the results you will fall into one of the three categories:

If your category is… You should…

Normal

Get checked for diabetes every 3 years

Impaired Glucose Tolerance

Get checked for diabetes every year and talk with your health care provider to learn about ways to lower your risk for developing diabetes.

Diabetic

Work with your health care provider in setting up a treatment plan for your diabetes.

Pre-Pregnancy Management

• Preconceptional care– Tight glucose control (HbA1c)– Assessment and treatment of associated medical problems

- Hypertension, - Renal disease, - Retinal disease- Heart disease

– Folic acid

• Stop all oral diabetic medication 3 months before conception.

• Switch all women with pregestational diabetes on oral diabetic treatments to insulin before conception.

• Use insulin in all pregnancies requiring medication for glucose control.

• Stop ACE inhibitor therapy and review the patient's other medications before conception.

Thank You