‫شمس الهدى‬ ‫ُ‬ ‫الحبيب فأشرقت‬ ‫ُ‬ ‫ُول َد‬

‫ماء لـنـا وجـــ َّل عــطـــــا ُء‬ ‫س ِ‬ ‫ِهـبـةُ ال َّ‬

‫بـدر أضـا َء الـمشرقـيـن بـنـوره‬ ‫ٌ‬
‫وتعطــرت لـقــدومـه األجــوا ُء‬ ‫َّ‬
‫بارئُــه فكان لــنـا هـ ًدى‬ ‫ربّــاهُ ِ‬
‫ضـا ُء‬ ‫جــوم جبـيـنـهُ الــو ّ‬
‫َ‬ ‫بهر النُّ‬‫َ‬
‫رسول هللا جئتك دمع عينى‬ ‫هو أُسوةٌ في ك ِّل ما قد قـالـه‬
‫يسيل وفي يدي ذبلت وردى‬
‫بــه يـقتدي وبـفـعــله النُّجبـا ُء‬
‫صلّـوا عليه كـمـا يصلّي ربُّـنــا‬
‫صالةَ على الحبيب دوا ُء‬ ‫إن ال َّ‬
‫ث اإللــهُ لخلـقه‬ ‫خير َم ْن ب َع َ‬
‫يا َ‬
‫خير جاؤوا‬ ‫من مرسلين بك ِّل ٍ‬
‫قلت مـا‬ ‫ْ‬
‫ولكن َ‬ ‫كنت أ ِّمـيـا ً‬
‫قـد َ‬
‫ُ‬
‫يعجز البُلغـا ُء‬ ‫عن مث ِل قـولــ ِه‬
Endocrinal disorder in pregnancy
‫بسم هللا الرحمن الرحيم‬
‫‪Diabetes mellitus‬‬
Diabetes Mullets
• is a collection of metabolic disorders with hyperglycaemia as
the common feature.
• Diabetes is a disorder of carbohydrate metabolism that
requires immediate changes in lifestyle.
• In its chronic forms, diabetes is associated with long-term
vascular complications, including retinopathy, nephropathy,
neuropathy and vascular disease.
• The most common endocrine disorder
• Incidence. 2-5% of the total pregnancies may be affected by
diabetes. .
• 87.5% of pregnancies complicated by diabetes are estimated
to be due to gestational diabetes (which may or may not
resolve after pregnancy),
• with 7.5% being due to type 1 diabetes and the remaining
5% being due to type 2 diabetes.
• about 65% cases involve gestational diabetes,
whereas 35% cases are associated with pre-
existing diabetes, of which 25% of cases may
be associated with pre-existing type 1
diabetes and 10% may involve pre-existing
type 2 diabetes(The American Diabetes
Association (ADA) and National Diabetes Data
Group (NDDG)
Classification
• pre-existing D M.
• pre-existing insulin-dependent diabetes mellitus
(IDDM)
• pre-existing non-insulin-dependent diabetes
mellitus (NIDDM).
• Gestational.diabetes during the course of
pregnancy
• The prevalence of type 1 diabetes, and especially
type 2 diabetes, has increased in recent years. The
incidence of gestational diabetes is also increasing
as a result of higher rates of obesity in the general
population and more pregnancies in older women.
PHYSIOLOGICAL CHANGES IN PREGNANCY
• Pregnant women have considerably altered
carbohydrat metabolism. There is hyperplasia of the
pancreatic islet cells which leads to a doubling in
insulin production between the first and the third
trimesters.
• increase in insulin sensitivity during the first
trimester,
• the release of insulin-resistant hormones(human
placental lactogen, glucagons, progesterone and
corticotrophin-releasing hormone) from the
placenta results in progressive glucose intolerance
(insulin resistance) with advancing gestation
• In addition to the increased glucose uptake of the
fetus, there is increased peripheral uptake,
• increased glycogenesis and reduced hepatic
gluconeogenesis.
• The renal tubular threshold for glucose falls, such
that glycosuria is common.
• Overall, fasting glucose levels fall by 10–20% and
postprandial levels are higher.
 Type 1 diabetes (5%)
• Type 1 diabetes mellitus (juvenile onset ) is an
autoimmune disease that usually presents in
childhood or young adulthood(typically under age
of 20y ). Autoimmune destruction of the
pancreatic Beta cells results in insulin deficiency
and causes symptoms of thirst, polyuria, blurred
vision, weight loss and, if untreated, progression to
life-threatening diabetic ketoacidosis.
• Diabetes in pregnancy is associated with risks to
the woman and to the developing fetus.
• Not associated with obesity 10%have first degree
relative
 Type 2 diabetes (90%)
• Type 2 disease (maturity onset) is a disease of peripheral
insulin resistance rather than deficiency. Although it more
commonly occurs over the age of 40 years, it often occurs at a
younger age (20-25 years and upwards)
• The prevalence of type 2 diabetes is expected to rise with
increasing maternal obesity, age and social deprivation.
• 50% first degree relative .
• The risks of affected offspring are higher than in type 1
diabetes.
• Women with type 1 or type 2 diabetes are at risk of vascular
• complications (both macro- and microvascular), resulting in a
• reduced life expectancy.
• all women with pre-existing diabetes (type 1 and type 2) have
• uniformly poorer outcomes than women without diabetes
Pre-conception care
• avoiding unplanned pregnancy.
• good glycaemic control before conception.
• . information about how diabetes affects pregnancy
and how pregnancy affects diabetes.
• the role of diet, body weight and exercise
• the risks of hypoglycaemia and hypoglycaemia
unawareness during pregnancy
• how nausea and vomiting in pregnancy can affect
glycaemic control
• the increased risk of having a baby who is large for
gestational age, which increases the likelihood of
birth trauma, induction of labour and caesarean
section.
• the need for assessment of diabetic retinopathy
before and during pregnancy
• the need for assessment of diabetic nephropathy
before pregnancy
• the importance of maternal glycaemic control
during labour and birth and early
• feeding of the baby in order to reduce the risk of
neonatal hypoglycaemia
• the possibility of transient morbidity in the baby
during the neonatal period, which may require
admission to the neonatal unit
• the risk of the baby developing obesity and/or
diabetes in later life.
• Women with diabetes who are planning to
become pregnant should be offered monthly
measurement of HbA1c
• should be offered self-monitoring of blood
glucose.
• take high dose (5 mg) folic acid pre-conception
and for the first 12 weeks.
• Targets for therapy pre-pregnancy should be
to maintain HbA1c at per cent 6.5% (les than
48mmol/mol) and pre-meal glucose levels of
4–7 mmol/L.
• Strongly advise women with diabetes whose
HbA1c level is above 86 mmol/mol (10%) not
to get pregnant until their HbA1c level is
lower.
 Effects of diabetes on pregnancy

• Increased risk of miscarriage

• Risk of congenital malformation 2-4 fold than
normoglycemic
• Risk of macrosomia
• Increased risk of pre-eclampsia
• Increased risk of stillbirth
• Increased risk of infection
• Increased operative delivery rate.
• polyhydramnios
• RDS(lung maturity)
• Preterm labour
Effects of pregnancy on diabetes

• • Change in eating pattern

• • Increase in insulin dose requirements
• • Greater importance of tight glucose control
• • Increased risk of severe hypoglycaemia
• • Risk of deterioration of pre-existing retinopathy
• • Risk of deterioration of established nephropathy.
• Cardiac ,IHD
• PIH&P E increased to 10-20 %
• Risk of neuropathy .
• Recurrent Vulvo–vaginal infection.
 Factors associated with poor
pregnancy outcome in diabetes
• • Maternal social deprivation
• • No folic acid intake pre-pregnancy
• • Suboptimal approach of the woman to managing
her diabetes
• • Suboptimal pre-conception care
• • Suboptimal glycaemic control at any stage
• • Suboptimal maternity care during pregnancy
• • Suboptimal fetal surveillance of big babies
 Gestational diabetes mellitus (GDM)
• (GDM) is defined as impaired carbohydrate tolerance
resulting in hyperglycaemia, which first develops or
becomes diagnosed during pregnancy.
• Some of these women have previously undiagnosed
diabetes, usually type 2or rarely type 1.
• Diagnosed in most cases in T2 or earlyT3 .
• Incidence 2-5% of pregnancy.
• GDM can be associated with several complications
such as increased risk of stillbirths and macrosomia.
Diagnosis and management of GDM is important
because it can help reduce the rate of complications.
• recommend that screening for GDM should be considered in
all pregnant women. There are only a few exceptions for
whom an oral glucose tolerance test (OGTT) is not indicated.
These are very low risk patients, including
• A.nulliparous women < 25 years of age and BMI < 25 kg/m2,
B. multiparous women < 40 years of age and BMI < 25
kg/m2 and who have had no previous macrosomic children.
To avoid missing cases.
Screening
• Selective screening for those with the highest risk factors
has been recommended. Risk factors for GDM include:
• 1-Glucosuria
• 2-Age over 30 years
• 3-Obesity.( BMI < 30 kg/m2)
• 4-Family history of diabetes.
• 5-Past history of GDM or glucose intolerance
• 6-Previous macrosomic child
• 7-Previous unexplained IUFD
• 8-Two or more miscarege.
• 9-Polycystic ovarian syndrome.
• 10-smoking.
Diagnostic criteria
 Management of diabetes in pregnancy
• Pregnant women with diabetes should be managed in
a joint clinic with an obstetrician and physician.
Input from a dietician is also important and often a
nurse or midwife specialist will act as an adviser to
adjust the dose of insulin.
Women with pre-existing diabetes
• should be referred directly to this clinic at booking,
• and those in whom a diagnosis of gestational diabetes
is made at a later stage should also be referred.
A plan for the pregnancy should be set out and should
• include targets for glycaemic control, renal and retinal
• screening, fetal surveillance and plan for delivery
• Diagnose gestational diabetes if the woman
has either:
• • a fasting plasma glucose level of 5.6
mmol/litre or above or
• • a 2-hour plasma glucose level of 7.8
mmol/litre or above
Antenatal care
• care specifically for women with diabetes, in addition to
the care provided routinely for healthy pregnant women
• Monitoring blood glucose and ketones during pregnancy.
• Women with diabetes should be advised to test fasting
blood glucose levels and blood glucose levels 1 hour after
every meal during pregnancy.
• Women with insulin-treated diabetes should be advised to
test blood glucose levels before going to bed at night during
pregnancy.
• Women with type 1 diabetes who are pregnant should be
offered ketone testing strips and advised to test for
ketonuria or ketonaemia if they become hyperglycaemic or
unwell.
Medical
• Hypoglycaemic therapy should be considered
for women with gestational diabetes if diet
and exercise fail to maintain blood glucose
targets during a period of 1–2 weeks.
• Hypoglycaemic therapy should be considered
for women with gestational diabetes if
ultrasound investigation suggests fetal
macrosomia
• (abdominal circumference above the 70th
percentile) at diagnosis.
• Hypoglycaemic therapy for women with
gestational diabetes (which may include regular
insulin, rapid-acting insulin analogues [aspart and
lispro] and/or
• oral hypoglycaemic agents [metformin and
glibenclamide).
• The aim of glucose control is to keep fasting levels
between 3.5 and 5.3 mmol/L
• and postprandial levels les than 7.8 mmol/L,
• with insulin treatment usually indicated outside
these ranges.
Types of insulin
• Insulin pump therapy, otherwise known as continuous
subcutaneous insulin infusion (CSII) use in type1.
• They use an external pump that is able to
• deliver insulin from a refillable reservoir, through plastic
tubing, under the skin via subcutaneously placed
cannula.
• Recently, tubeless patch pumps have been introduced.
• closed-loop systems measure G in the interstitial fluid
with no need for human intervention.
• rapid acting insulin only used.
• During labour and delivery, glucose control can be
maintained using CSII
Insulin pumps allow for rapid,
flexible and precise dosing,
• The pump enables extensive programming to aide
calculations of amounts of insulin needed for a
meal, or to correct a high glucose level, as well as
different patterns of basal rates to fit changing
lifestyles and different needs during a 24-hour
period. At present most pregnant women use
simple pumps that just deliver insulin,
• but next generation sensor-augmented pumps
with inbuilt continuous glucose monitoring will
gradually become more widespread,.
 Thyroid disease
Hyperthyroidism:
1/500. usually dx before pregnancy.
90%Autoimmune (Graves dis)
Toxic adenoma.
Women with well treated dis rarely have maternal Complication of pregnancy
the drug may be stop or reduced in T3.
poor control disease associated with.
Maternal thyrotoxic crises., miscarriage . ,hypertension, IUGR ,PE
Symptoms include tremor, sweating,
insomnia, hyperactivity and anxiety.
Signs include goitre, Graves’
ophthalmopathy, tachycardia,
hypertension with a wide pulse pressure,
weight loss and pretibial myxoedema.
Treatment during pregnancy should be
drug therapy, aiming to maintain
maternal fT3 and fT4 levels inthe
high/normalrange
Medical Rx
(carbimazol, or propylthiouracil(ptu) in low dose(cross the placenta and
cause fetal hypothyroidism) both drugs cause neutropenia and

agranulocytosis. So be aware of the symptom of infection .
And T F T should be carried out and check regularly .ptu associated with
acute liver failure 1/1000 in adult and 1/2000 in children so not used as a
first line of treatment .only in T1 due to possible association between used
of carbimazol and aplasia cutis.
Both drugs are cross the placenta fetal hypothyroidism rarely seen . TSH
receptor –stimulating antibodies also cross the placenta and can effect the
thyroid status. Drugs not discouraged from breast feeding
B –blocker can be used before ant thyroid drugs
Hypothyroidism
1% of pregnant women . common cause
Autoimmum (Hashimotos) thyroiditis
Iodine deficiency 
Rx thyroxin replacement therapy(Euthyroid). With replacment therapy the
pregnancy out come well ,but poor control associated with variety of adverse
outcomes. Including
1-congenital abnormalities.
2-hypertions
3-fetal growth restriction
4-premature delivery
5-postpartum haemorrhge
6-miscarge
7-infertility
8- placental abruption
9-reduced intelligence and motor development of offspring .
Thyroxin taken on empty stomach and 4 hours apart from iron or any
supplement (calcium)
 Thyroid storm
A life threating event that arises in those with underlying thyroid
disease and can be fetal in20-50%of untreated cases.it is usually
the result of .
1-under treatment

2-infection
3-labour
Diagnosed by clinical (hyperthyroid )sweating , pyrexia,
tachycardia , atrial fibrillation,hypertension
,hyperglycaemia.vomiting agitation and cardiac failure
Rx
Ptu (Propylthiouracil)
Corticosteroids
B-blocker (block the peripheral effect of thyroxin)
rehydration
Parathyroid disorders of pregnancy .
Diseases of the parathyroid gland are uncommon in

women of childbearing age. However, total serum
calcium is low in normal pregnancy, but ionized serum
calcium remains within normal limits. Serum
parathyroid H levels are slightly decreased in the second
half of pregnancy. Primary hyperparathyroidism, if
unrecognized, may increase maternal and fetal
morbidity, which is related to the level of serum calcium.
The most common cause is, a single parathyroid
adenoma, accounting for about 80% of cases. Maternal
complications include acute pancreatitis, hypercalcemia
crisis, and toxemia.
An increased incidence of prematurity and
neonatal hypocalcemia has been reported when
maternal hypercalcemia is significantly elevated.

Other causes of hypercalcemia are rare in
pregnancy.
Hypoparathyroidism is seldom seen in
pregnancy; the most common cause is after
surgical thyroidectomy. The doses of vitamin D
and calcium do not change during pregnancy;
however, hypercalcemia may develop in the
postpartum period.
Osteoporosis sub sequent of use of heparin
 Adrenal disease in pregnancy
Cushing’s Syndrome rare can be Rx by
surgery 
Maternal complications of Cushing's
syndrome include hypertension,
preeclampsia, diabetes, myopathy,
opportunistic infections, and fracture.
Postoperative wound infection and
dehiscence may occur following cesarean
delivery. Premature labor occurs
in more than 50% of cases.
 Adrenal
Insufficiency(Addisons dis)
Is associated with
laboratory findings
of hyponatremia, hyperkalemia,
hypoglycemia, eosinophilia, and
lymphocytosis. Hyperkalemia may be
absent, because of the pregnancy
increase in the renin angiotensin system
Congenital Adrenal Hyperplasia
Pheochromocytoma in Pregnancy
 Pregnancy and pituitary disorders.
The pituitary gland is one of the most affected organs with
altered anatomy and physiology. The pituitary gland is enlarged

as a result of lactotroph hyperplasia. Due to physiological changes
in the pituitary and target hormone levels, binding globulins, and
placental hormones, hormonal evaluation becomes more complex
in pregnant women.

Pituitary adenomas may cause problems by their hormone

secretion that affects the
mother and the fetus beside
causing an increased risk
of tumor growth.