DIABETES MELITUS IN

PREGNANCY
 Types
Risk factors for GDM
Screening
Diagnostic criteria
Complications
Management
 TYPES
GESTATIONAL DIABETES MELLITUS (GDM)
Carbohydrate intolerance of variable severity with onset or first recognition
during the present pregnancy (National Diabetes Data Group,1985) It includes
women with pre-existing but previously unrecognized diabetes
PRE-EXISTING DIABETES MELLITUS (TYPE 1)

Insulin-dependent diabetes mellitus juvenile onset

PRE-EXISTING DIABETES MELLITUS (TYPE 2)

Non-insulin-dependent diabetes mellitus- maturity onset

RISK FACTORS FOR SCREENING GDM

BMI above 30 kg/m2

Previous baby weighing 4.5 kg or above
Previous gestational diabetes
First degree relative with diabetes
Family origin from high prevalence area (South Asian, black Caribbean and
middle eastern)
SCREENING FOR GDM

Assessment of risk factors at

booking

Previous history of GDM Risk factors (+)

Self monitoring of OGTT at 16-18 weeks 2 hr 75 g oral glucose

blood glucose If normal, repeat tolerance test (OGTT)
monitoring at home at 24-28 weeks at 24-28 weeks
MODIFIED ORAL GLUCOSE TOLERANCE
TEST (MALAYSIA)

Fasting from 12 am till the next morning

Take blood for fasting blood sugar
Give patient to drink 75 g glucose + 250 ml water, drink in 10-15 min
After 2 hours, take blood again for 2 hr postprandial blood sugar
DIAGNOSTIC CRITERIA

There is no international consensus on diagnostic criteria for GDM.

WHO criteria Diabetes outside of GDM

pregnancy

Fasting >=7.0 mmol/L >=7.0 mmol/L (>5.6 mmol/L in

malaysia)

2 hour >=11.1 mmol/L >=7.8 mmol/L

In Malaysia GDM Fasting >5.6 mmol/L, 2 hr >7.8 mmol/L

MATERNAL COMPLICATIONS
PRE-EXISTING DIABETES GDM
Increased insulin requirements Pre-eclampsia
Hypoglycaemia Hypoglycaemia
Infection Polyhydramnios
Ketoacidosis Recurrent infections
Deterioration in retinopathy Induction of labour
Increased proteinuria and oedema Increased caesarean section rate
(nephropathy)
Miscarriage Shoulder dystocia
Polyhydramnios Birth trauma
Shoulder dystocia
Pre-eclampsia
Increased caesarean section rate
Birth trauma
FETAL COMPLICATIONS
PRE-EXISTING DIABETES GDM
Congenital abnormalities no increase in congenital abnormality (exception in
unrecognized DM pre-dating pregnancy and
hyperglycaemia in 1st trimester)
macrosomia macrosomia
Late stillbirth Late stillbirth
Neonatal hypoglycaemia Neonatal hypoglycaemia
Polycythaemia Polycythaemia
Respiratory distress syndrome Respiratory distress syndrome
Neonatal jaundice Neonatal jaundice
Birth trauma Birth trauma
Perinatal death Perinatal death
Preterm delivery
Obesity and/or diabetes developing later in babys Obesity and/or diabetes developing later in babys
life life
PATHOPHYSIOLOGY OF FETAL EFFECTS (MODIFIED
PEDERSON)

Maternal hyperglycaemia

Fetal hyperglycaemia

Fetal pancreatic beta cell

hyperplasia
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
MANAGEMENT OF GDM

Medical manangement
Obstetric management
Antenatal management
Intrapartum management
Postnatal management
MEDICAL MANAGEMENT OF GDM

Collaboration between obstetrician and physician

Multidisciplinary diabetes pregnancy clinic
Diet control , refer to dietician
Regular exercise
Monitoring home based glucose monitoring (HBGM) / Blood sugar profile (BSP) (4 times/ day)
Aim of glucose control BSP 4-6 mmol/ L, HBGM fasting -3.5-5.5 mmol/ L, 1 hr post prandial
-<7.1 mmol/L
If not control with diet and lifestyle changes for 2 weeks Insulin / Metformin
Insulin- 4 times daily basal bolus insulin regime (rapid acting insulin)
in more severe case, rapid acting insulin 3 times+ intermediate acting at night
OBSTETRIC MANAGEMENT

Regular check of BP, urinalysis to assess PE

Regular monitoring for complications ( infection,
polyhydramnios)
Reular USG assessment of fetal growth, amniotic fluid
Any concern for fetal well being- Cardiotocography, Doppler
ultrasound
Antenatal Elective birth after 38 weeks by induction of labour (on diet
control -40 wk, control with insulin- 38 wk) as there is risk
of unexplained still birth in late pregnancy
EL caesarean section if indications are present
OBSTETRIC MANAGEMENT
Women on larger doses of insulin IV dextrose and insulin sliding scale
Target blood glucose level- 4-7 mmol/ L
Following delivery insulin infusion should be discontinued. All oral
Intrapartum hypoglycaemic drugs should be stopped.

Check blood glucose level prior to transfer to community care

FBS at 6 weeks and annually to screen diabetes
Postnatal
MANAGEMENT OF PRE-EXISTING DIABETES
MELLITUS
Pre-pregnancy management
Medical management and management of complications
Obstetric management
Antenatal management
Intrapartum management
Postnatal management
PRE-PREGNANCY MANAGEMENT

Counselling
Folic acid high dose (5 mg) before conception to prevent neural
tube defect
Diabetes therapy should be intensified and adequate
contraception used until glucose control is good.
Targets HbA1c at 6.5%, pre- meal glucose level -4-7 mmol/L
Retinal assessment (refer to opthamologist)
Renal assessment
MEDICAL MANAGEMENT

Collaboration between obstetrician and physician

Multidisciplinary diabetes pregnancy clinic
Diet control , refer to dietician
Type 1 -Insulin- 4 times daily basal bolus insulin regime (rapid acting insulin) achieve better
glycaemic control compared with regimes using mixed insulins
Type 2- most women require treatment with insulin
Monitoring self monitoring
Target HbA1c <6%,
pre-meal glucose 3.5-5.5 mmol/L
2 hr postprandial -4-6.5 mmol/L
MANAGEMENT OF COMPLICATIONS

Retinal assessment
Refer to opthamologist
Renal assessment
Refer to nephrologist
Strict control of hypertension
OBSTETRIC MANAGEMENT

Early dating and viability scan

Detailed anomaly scan of fetus at 18-20 wks, including
four chambered assessment of fetal heart
Regular check of BP, urinalysis to assess PE
Regular USG assessment of fetal growth, amniotic fluid
Any concern for fetal well being- Cardiotocography,
Doppler ultrasound
Antenatal Elective birth after 38 weeks by induction of labour (on
diet control -40 wk, control with insulin- 38 wk) as there
is risk of unexplained still birth in late pregnancy
EL caesarean section if indications are present
OBSTETRIC MANAGEMENT
Women on larger doses of insulin IV dextrose and insulin sliding scale
Target blood glucose level- 4-7 mmol/ L
Following delivery rate of infusion is halved in type 1
Type 1 -once normal eating start, subcutaneous insulin with pre pregnancy dose
Intrapartum Type 2- can resume metformin or glibenclamide

Check blood glucose level prior to transfer to community care

FBS at 6 weeks and annually to screen diabetes
back to routine diabetes care.
Postnatal
INVESTIGATIONS USED IN DM

Screening for GDM OGTT

Monitoring HBGM/ BSP
HBA1C- to assess glycaemic control
THANK YOU