1. Diabetes Mellitus in
pregnancy
Dr Rashed Al-Amr
Dr Rashed Al-Amr
Dermatology resident
Dermatology resident
Trust Academy
Trust Academy
2. TYPES OF DIABETES
American Diabetes Association (ADA) classified
American Diabetes Association (ADA) classified
the disease in four categories
the disease in four categories
Type 1 diabetes
Type 1 diabetes:
: autoimmune destruction of the
autoimmune destruction of the
pancreatic β cells, resulting in an inability to produce and
pancreatic β cells, resulting in an inability to produce and
secrets insulin.
secrets insulin.
Type 2 diabetes
Type 2 diabetes:
: insulin resistance, a relative insulin
insulin resistance, a relative insulin
deficiency as well, or it may be both.
deficiency as well, or it may be both.
Third category:
Third category: gestational diabetes mellitus (GDM) is
gestational diabetes mellitus (GDM) is
defined as the onset or first recognition of diabetes during
defined as the onset or first recognition of diabetes during
pregnancy.
pregnancy.
Fourth category:
Fourth category: is associated with genetic disorders,
is associated with genetic disorders,
pancreatic diseases, drug and chemical use, and infections
pancreatic diseases, drug and chemical use, and infections
4. Classification of DM in pregnancy
Pregnant diabetes are divided in to:
Pregnant diabetes are divided in to:
1.
1. The disease exists prior to pregnancy
The disease exists prior to pregnancy
( Pre-gestational diabetes).
( Pre-gestational diabetes).
2.
2. The disease diagnosed or develops for
The disease diagnosed or develops for
the first time during the pregnancy
the first time during the pregnancy
( Gestational diabetes).
( Gestational diabetes).
Gestational diabetes occurs in 1-3% of
Gestational diabetes occurs in 1-3% of
white pregnant women.
white pregnant women.
5. Metabolic changes during
pregnancy:
In normal pregnancy:
In normal pregnancy:
In early pregnancy:
In early pregnancy:
1- Increased estrogen and progesterone
1- Increased estrogen and progesterone
(insulin antagonists).
(insulin antagonists).
2- Increased insulin secretion.
2- Increased insulin secretion.
3- Lower plasma glucose level.
3- Lower plasma glucose level.
4- Elevated post-prandial values (insulin
4- Elevated post-prandial values (insulin
resistant).
resistant).
6. Metabolic changes during
pregnancy:
In the second half of pregnancy:
In the second half of pregnancy:
1.
1. Raised levels of
Raised levels of human chorionic
human chorionic
somatotropin, prolactin, cortisol
somatotropin, prolactin, cortisol
and glucagons(insulin antagonists).
and glucagons(insulin antagonists).
2.
2. Decreased glucose tolerance.
Decreased glucose tolerance.
3.
3. Increased insulin resistance.
Increased insulin resistance.
7. Metabolic changes in
gestational diabetes:
1.
1. Impairment of insulin secretion by
Impairment of insulin secretion by
the beta cells of the pancreas.
the beta cells of the pancreas.
2.
2. Increased insulin resistance.
Increased insulin resistance.
3.
3. Elevated fasting plasma
Elevated fasting plasma
glucose.and elevated post-prandial
glucose.and elevated post-prandial
glucose levels.
glucose levels.
8. Current recommendations for
screening for GDM
Do risk assessment at first visit, with no screening
Do risk assessment at first visit, with no screening
for low risk
for low risk
Low-risk ethnicity (Caucasian, European)
Low-risk ethnicity (Caucasian, European)
Age < 25
Age < 25
BMI
BMI <
< 25
25
No known diabetes in first degree relative
No known diabetes in first degree relative
No h/o glucose intolerance
No h/o glucose intolerance
No h/o obstetric complications usually
No h/o obstetric complications usually
associated with GDM
associated with GDM
9. Current recommendations for
screening for GDM
High risk patients should be screened as early as
High risk patients should be screened as early as
possible and repeated at 24-28 weeks if
possible and repeated at 24-28 weeks if
screening negative
screening negative
Strong family history of diabetes
Strong family history of diabetes
Prior history of GDM
Prior history of GDM
Morbid obesity (BMI >30)
Morbid obesity (BMI >30)
Previous unexplained still birth.
Previous delivery of macrosomic infant.
Previous congenital abnormality.
10. Screening tests:
50-g oral glucose challenge
The screening test for GDM, a 50-g oral glucose
The screening test for GDM, a 50-g oral glucose
challenge, may be performed in the fasting or fed
challenge, may be performed in the fasting or fed
state. Sensitivity is improved if the test is
state. Sensitivity is improved if the test is
performed in the fasting state .
performed in the fasting state .
A plasma value above
A plasma value above 130 – 140 mg/dl
130 – 140 mg/dl one hour
one hour
after is commonly used as a threshold for
after is commonly used as a threshold for
performing a 3-hour OGTT.
performing a 3-hour OGTT.
If initial screening is negative, repeat testing is
If initial screening is negative, repeat testing is
performed at 24 to 28 weeks.
performed at 24 to 28 weeks.
11. Screening tests:
3 hour Oral glucose tolerance test
Prerequisites:
Normal diet for 3 days before the test.
No diuretics 10 days before.
At least 10 hours fast.
Test is done in the morning at rest.
Giving 75 gm (100 gm by other authors)
glucose in 250 ml water orally
12. 3 hour Oral glucose tolerance test
Criteria for glucose tolerance test:
The maximum blood glucose values during
pregnancy:
fasting 90 mg/ dl,
one hour 165 mg/dl,
2 hours 145 mg/dl,
3 hours 125 mg/dl.
If any 2 or more of these values are elevated,
the patient is considered to have an impaired
glucose tolerance test.
13. Screening for diabetes in pregnancy
The best method for screening for gestational
The best method for screening for gestational
diabetes continues to be controversial.
diabetes continues to be controversial.
The 2-step system is currently recommended in the
The 2-step system is currently recommended in the
United States. A 50-g, 1-hour glucose challenge test
United States. A 50-g, 1-hour glucose challenge test
(GCT) is followed by a 100-g, 3-hour OGTT for
(GCT) is followed by a 100-g, 3-hour OGTT for
those with an abnormal screening result.
those with an abnormal screening result.
For high-risk women, or in areas in which the
For high-risk women, or in areas in which the
prevalence of insulin resistance is 5% or higher a 1-
prevalence of insulin resistance is 5% or higher a 1-
step approach can be used by proceeding directly
step approach can be used by proceeding directly
to the 100-g, 3-hour OGTT.
to the 100-g, 3-hour OGTT.
17. Control of diabetes:
Diet control:
Diet control:
Control of maternal weight gain (350-400gm per week =
Control of maternal weight gain (350-400gm per week =
30-35 kcal/kg/day).
30-35 kcal/kg/day).
For obese women (BMI >30 kg/m2), a 30–33% calorie
For obese women (BMI >30 kg/m2), a 30–33% calorie
restriction (to 25 kcal/kg actual weight per day or less) has
restriction (to 25 kcal/kg actual weight per day or less) has
been shown to reduce hyperglycemia
been shown to reduce hyperglycemia
Caloric restrictions (carbohydrates 50 %, proteins 25 %,
Caloric restrictions (carbohydrates 50 %, proteins 25 %,
fats 25 %).
fats 25 %).
Multiple meals are recommended (three meals and three
Multiple meals are recommended (three meals and three
snacks) to prevent hypoglycemia.
snacks) to prevent hypoglycemia.
18. Control of diabetes:
Therapy is recommended when medical nutrition therapy
Therapy is recommended when medical nutrition therapy
fails to maintain self-monitored glucose at the following
fails to maintain self-monitored glucose at the following
levels:
levels:
Fasting
Fasting
whole blood glucose
whole blood glucose <
<95 mg/dL
95 mg/dL
1-hour postprandial
1-hour postprandial
whole blood glucose
whole blood glucose <
<140 mg/dL
140 mg/dL
2-hour postprandial
2-hour postprandial
whole blood glucose
whole blood glucose <
<120 mg/dL
120 mg/dL
20. Control of diabetes:
Insulin therapy:
Insulin therapy:
Multiple daily injections is required.
Multiple daily injections is required.
A mixture of short acting and intermediate
A mixture of short acting and intermediate
acting should be used. Two-third in the
acting should be used. Two-third in the
morning and one-third in the evening.
morning and one-third in the evening.
The dose is adjusted with muliple glucose levels
The dose is adjusted with muliple glucose levels
( one fasting are 3 two hours after meal).
( one fasting are 3 two hours after meal).
Higher dose usually needed with the progress
Higher dose usually needed with the progress
of pregnancy.
of pregnancy.
The post-prandial level should be <120mg.
The post-prandial level should be <120mg.
21. Insulin therapy:
The total first dose of insulin is calculated
The total first dose of insulin is calculated
according to the patient’s weight as follow:
according to the patient’s weight as follow:
In the first trimester .......... weight x 0.6
In the first trimester .......... weight x 0.6
In the second trimester........ weight x 0.7
In the second trimester........ weight x 0.7
In the third trimester........... weight x 0.8
In the third trimester........... weight x 0.8
22. Antenatal Obstetric Management:
Serial ultrasound fetal assessment to:
Serial ultrasound fetal assessment to:
1- exclude anomalies.
1- exclude anomalies.
2- fetal growth and size.
2- fetal growth and size.
3-fetal well-being (biophysical profile).
3-fetal well-being (biophysical profile).
4- exclude polyhydramnios.
4- exclude polyhydramnios.
Attempt to achieve a vaginal delivery around
Attempt to achieve a vaginal delivery around
38 weeks of gestation (mostly by induction of
38 weeks of gestation (mostly by induction of
labor).
labor).
Caesarean section still needed in 50% of cases
Caesarean section still needed in 50% of cases
due to macrosomia, Pre-eclampsia, and failed
due to macrosomia, Pre-eclampsia, and failed
inductions.
inductions.
23. Management in labour:
Blood glucose should be monitored every 2
Blood glucose should be monitored every 2
hours.
hours.
Short acting insulin is used for control by
Short acting insulin is used for control by
sliding scale.
sliding scale.
Continuous CTG and fetal blood sampling if
Continuous CTG and fetal blood sampling if
needed.
needed.
After delivery, women with GD may need no
After delivery, women with GD may need no
insulin, and those with established diabetes
insulin, and those with established diabetes
return to pre-pregnancy level.
return to pre-pregnancy level.
