SlideShare a Scribd company logo
1 of 62
Download to read offline
DIABETES IN PREGNANCY 
Dr. Nidhi Singh
INTRODUCTION 
• Abnormalities of carbohydrate metabolism occur frequently 
during pregnancy 
• 3-5% of all pregnant patient show glucose intolerance 
• 90% of these have gestational diabetes 
• Approximately 50% of women with GDM will develop type II 
diabetes later in life.
Diabetogenic effects of pregnancy 
1. Insulin resistance 
• Production of human placental lactogen 
• Production of cortisol, estriol and progesterone 
• Destruction by kidney and placenta 
2. Increased lipolysis 
3. Changes in gluconeogenesis
Effects of diabetes on mother 
• Preeclampsia 
Affects 10-25% of all pregnant diabetics 
• Infections 
Chorioamnionitis and postpartum endometritis 
• Postpartum bleeding 
• Cesarean section
Effects of diabetes on fetus 
• Congenital abnormalities 
• Hypoglycemia 
• Hyperviscosity syndrome 
• Hyaline membrane disease 
• Macrosomia 
• Hypocalcemia 
• Apnea and bradycardia 
• Traumatic delivery
Effects of pregnancy on diabetes 
• More insulin required to achieve homoeostasis 
• Progression of diabetic retinopathy 
• Worsening of diabetic retinopathy 
• Increased risk of death in diabetic cardiomyopathy
Etiological classification of diabetes 
• Type I: β cell destruction 
– Immune mediated 
– Idiopathic 
• Type II DM 
• Others 
– Genetic defects of beta-cell function 
– Genetic defects in insulin action 
– Genetic syndrome 
– Endocrinopathies 
– Drugs 
– Infections 
• Gestational DM
White’s classification during pregnancy 
Gestational diabetes Discovered during pregnancy, glycemia may or may not be 
maintained by diet alone; insulin may be required 
Class A Discovered before preg, controlled with diet alone, any duration 
or age of onset 
Class B Onset age 20 yr or older, duration less than 10yrs 
Class C Onset age 10-19yrs, duration 10-19yrs 
Class D Onset age under 10yrs, duration >20yrs, background 
retinopathy 
Class R Proliferative retinopathy, or vitreous hemorrhage 
Class F Nephropathy with proteinuria over 500mg/day 
Class RF Criteria for both classes R and F coexist 
Class H Arteriosclerotic heart disease clinically evident 
Class T Prior renal transplantation
Classification scheme used from 1986 through 
1994 for Diabetes complicating pregnancy 
Class Onset Fasting 2 hour PP Therapy 
A1 Gestational <105 mg/dl <120 mg/dl Diet 
A2 Gestational >105 mg/dl >120 mg/dl Insulin 
Class Age of onset (yr) Duration (yr) Vascular disease Therapy 
B >20 <10 yr None Insulin 
C 10-19 yr 10 to 19 None Insulin 
D <10 yr >20 Benign 
retinopathy 
Insulin 
E Any Any Nephropathy Insulin 
R Any Any Proliferative 
retinopathy 
Insulin 
H Any Any Heart Insulin
Gestational diabetes 
• Onset in pregnancy 
• Affects 1-2% of all pregnancies 
• More than half of Gestational diabetes 
develop overt diabetes in 20yrs 
• Obesity and diabetes in offspring
High risk for GDM 
• History of still birth 
• History of neonatal death 
• History of fetal macrosomia 
• Concomitant obesity and hypertension 
• Development of oligohydramnios, 
polyhydramnios, preeclampsia and fetal 
macrosomia 
• Inadequate metabolic control with diet alone
Screening strategy for detecting GDM 
• Low risk: 
* Blood glucose testing not routinely required in: 
– Member of an ethnic group with low prevalence 
– No known diabetes in 1st degree relatives 
– Age < 25yrs 
– Weight normal before pregnancy 
– Weight normal at birth 
– No history of abnormal glucose metabolism 
– No history of poor obstetrical outcome
Screening strategy for detecting GDM 
• Average risk 
* Blood glucose testing at 24-28 wks (1 step/2step) 
– Member of an ethnic group with high prevalence 
– Diabetes in a first degree relative 
– Age ≥ 25yrs 
– Overweight before pregnancy 
– Weight high at birth
Screening strategy for detecting GDM 
• High risk 
* Blood glucose testing as soon as feasible 
– Severe obesity 
– Strong family history of type 2 diabetes 
– Previous history of GDM 
– Impaired glucose metabolism 
– Glucosuria
Screening (OGTT) 
• Plasma glucose level measured 1 hr after 50g glucose load 
• Without regarding to time of day/ time of last meal 
• Plasma glucose level > 130mg/dl; sensitivity 90% 
• Plasma glucose level > 140mg/dl; sensitivity is 80%
Diagnosis of GDM by OGTT 
Time 100 g Glucose 
(American diabetes 
association criteria) 
75 g glucose 
(WHO criteria) 
Fasting 95 mg/dl 5.3 mmol/L 95 mg/dl 5.3mmol/L 
1-h 180mg/dl 10mmol/L 180mg/dl 10mmol/L 
2-h 155mg/dl 8.6mmol/L 155mg/dl 8.6mmol/L 
3-h 140mg/dl 7.8mmol/L - -
Maternal risks 
• Birth trauma 
• Operative delivery 
• Polyhydraminos 
• 50% lifetime risk in developing Type II DM 
• Recurrence risk of GDM is 30-50%
Fetal risks 
• No increase in congenital anomalies 
• Increased risk of stillbirth if fasting+ PP hyperglycemia 
• Macrosomia, BW >4000gm occurs in 17-29% of 
pregnancies 
• Birth trauma-shoulder dystocia and related complications 
• Neonatal hypoglycemia
Fetal macrosomia 
• Defined as fetal weight > 4000gm 
• Brain not effected, shoulder dystocia 3% 
Maternal hyperglycemia 
Fetal hyperinsulinemia 
Excessive somatic growth 
• Diagnosis and management is important 
• USG should begin at 20wks; to be done at every 4 wks 
• Also due to IGF-1 and IGF-2 
• Maternal obesity is important confounding factor
diabetes in pregnancy
Management of GDM 
Class Onset Fasting 2 hour PP Therapy 
A1 Gestational <105 mg/dl <120 mg/dl Diet 
A2 Gestational >105 mg/dl >120 mg/dl Insulin 
Nutritional therapy-total calorie intake: 
average 2000-2500 kcal/day. 
BMI >40 -- 12 kcal/kg/ideal body weight/d 
BMI>27 -- 25 kcal/kg/ideal body weight/d 
BMI 20-26 -- 30 “ 
BMI<20 -- 38 “
Management of GDM 
• Diet : general principles 
• 55% CHO 25% Protein 20% fat 
• Normal weight gain 10-12 kg 
• Avoid ketosis 
• Liberal exercise program to optimize BG control 
• Daily self BG monitoring 
• Breakfast should provide 25%, Lunch 30% and dinner 
30%. Obese women may be managed with lower 
caloric intake.
Management of GDM 
• If persistent hyperglycemia after one week of 
diet control proceed to insulin 
• 6-14 weeks 0.5u/kg/day 
• 14-26 weeks 0.7u/kg/day 
• 26-36 weeks 0.9u/kg/day 
• 36-40weeks 1 u /kg/day
Oral hypoglycaemic agents 
• Traditionally not recommended in pregnancy 
because of teratogenic effects 
• Glyburide and Metformin
Glyburide 
• Sulfonylureas 
• MOA- release of insulin 
• Hypoglycemia and weight gain are the main 
side effects 
• Non-teratogenic, classified as category B drug
Glyburide treatment regimen 
who fail Diet therapy 
1. Glucometer BG measurment fasting and 1 or 2 hrs 
following breakfast, lunch and dinner 
2. Glucose level goals (mg/dl): fasting < 100, 1-h < 155 
and 2hrs < 130 
3. Glyburide starting dose 2.5mg orally with morning 
meals 
4. Increased daily glyburide dose by 2.5mg/wk, 
increment until 10mg/day, then switch to twice 
daily dosing until max of 20mg/day, then switch to 
insulin if 20mg/day does not achieve glucose goal.
Obstetrical management 
• Cesarean delivery should be considered in women 
with sonographical estimated weight > 4500gm 
• Elective cesarean delivery has no significant effect on 
incidence of brachial plexus injury 
• Fetal monitoring
Postpartum evaluation 
• Women diagnosed with GDM to be evaluated with 75gm 
OGTT at 6-12wks postpartum 
• Metabolic assessment recommended after preg with GDM 
Time Test purpose 
Postdelivery (1-3 d) Fasting or random plasma 
glucose 
Detect persistent, overt 
diabetes 
Early postpartum (6-12wk) 75g 2h OGTT PP classification of Glu met 
1yr Postpartum 75g 2h OGTT Assess Glu metabolism 
Annually Fasting plasma glucose Assess Glu metabolism 
Tri- annually 75g 2h OGTT Assess Glu metabolism 
Prepregnancy 75g 2h OGTT Classify glu metabolism 
• Contraception: low dose hormonal contraceptives
Pregestational diabetes/ overt diabetes 
• Patients with symptoms of DM and plasma Glucose 
concentration 200mg/dl or more 
• The condition may be preexisting or detected during 
present pregnancy
Criteria for diagnosis of impaired Glucose 
tolerance and diabetes with 75g oral 
glucose 
Time Normal 
tolerance 
Impaired glucose 
tolerance 
diabetes 
Fasting < 110 mg/dl ≥ 110 and <126 ≥ 126 mg/dl 
2 hr Post glucose <140 mg/dl ≥ 140 and <200 ≥ 200 mg/dl
Maternal effects 
• During pregnancy 
– Abortions 
– Preterm labor 20% 
– Infections (UTI) 
– Preeclampsia 25% 
– Polyhydraminos 25-50% 
– Maternal distress 
– Diabetic retinopathy 
– Diabetic nephropathy 
– Ketoacidosis
Maternal effects 
• During labor: 
– Prolongation of labour due to big baby 
– Shoulder dystocia 
– Perineal injury 
– Postpartum hemorrhage 
– Operative interventions 
• During Puerperium: 
– Puerperal sepsis 
– Lactation failure
Fetal hazards 
• Congenital anomalies 3 times increased risk 
– Caudal regression- 1.3/1000 
– Situs invertus 
– Spina bifida, hydrocephaly, other CNS defects 
– Anencephaly 
– Cardiac anomalies: VSD, TGA, ASD, COA 
– Anorectal atresia 
– Renal anomalies: agenesis, cystic kidney, duplex 
ureter
Fetal hazards 
• Unexplained stillbirth 
• Hypoglycemia, hypocalcemia, hyperbilirubinemia, 
polycythemia 
• Cardiomyopathies 
• Inheritance of diabetes 
• Shoulder dystocia 
• Macrosomia 
• IUGR 
• RDS
Preconceptional counselling 
• Preconception Counselling 
• Risk of NTD ~1-2% 
• Folic Acid 400μg/day 
• Preconceptional glucose control using insulin. 
• Fasting < 70-100 mg/dl, and PP <140mg/dl at the 
end of 1 hr and <120mg/dl at the end of 2hr.
Preconceptional counselling 
• Normoglycemia prior to conception 
• Ideally HBA1C 6% or less 
• Team approach 
• Glucose monitoring qid 
• ACE inhibitors contraindicated 
• Baseline HbA1C, 24h urine for protein Cr Cl , 
ophthalmology review 
• Switch from OHA to insulin
Pregestational /Overt Diabetes 
• Assess for end organ disease 
– assess for nephropathy - inc risk of PIH 
– Assess and treat retinopathy - may progress 
– assess for neuropathy 
• generally remains stable during pregnancy 
– assess and treat vasculopathy 
• CAD is a relative C/I for pregnancy
Maternal Surveillance 
- Blood pressure monitoring 
– renal function every trimester 
– urine culture monthly 
– thyroid function 
– BG control HB A1C every trimester
Fetal Surveillance 
– USG for dating/viability ~ 8 weeks 
– Transvaginal USG examination at 10-14 weeks 
– Fetal anomaly detection 
• nuchal translucency 11-14weeks 
• maternal serum screen- free β HCG and PAPA-A 
• MSAFP at 16w to screen for open Neural tube 
defect 
• anatomy survey 18-20 weeks 
• Fetal echo 22weeks 
–Weekly biophysical profile, NST
Trimestric approach 
• 1st Trimester: 
– Careful monitoring of glucose control is essential 
– OHA to Insulin therapy 
• 2nd trimester: 
– Maternal serum alpha fetoprotein at 16-20wks 
– Targeted sonographic examination at 18-20wks 
– Euglycemia with self monitoring is the goal 
– Increased insulin requirement after 24wks 
• 3rd Trimester: 
– Cesarean delivery to avoid traumatic birth
Admissions 
– At 34-36 weeks in uncomplicated cases 
– It facilitates 
i. Stabilisation of diabetes 
ii. Less incidence of Preeclampsia, Polyhydramnios 
and Preterm labour 
iii. Selecting time and mode of termination
Insulin therapy 
• OHA not currently recommended for overt diabetes 
• Maternal glycemic control with multiple daily insulin 
inj and adjustment of dietary intake 
• S/C insulin infusion by calibrated pumps 
• Self monitoring using glucometer recommended
Self monitored capillary BG goals 
Specimen Level (mg/dl) 
Fasting ≤ 95 
Premeal ≤ 100 
1 hr- postprandial ≤140 
2 hr- postprandial ≤ 120 
2-6hr ≥ 60 
Mean (average) 100 
Hb A1c ≤ 6
Management of diabetes in pregnancy 
insulin therapy 
• Insulin Pump 
– Allows insulin release close to physiologic levels 
– Use short acting insulin 
– 50-60% of total dose is basal rate 
– 40-50% given as boluses 
– Potential complications 
• Pump failure 
• Infection 
• Increased risk of DKA
Management of diabetes in pregnancy 
insulin therapy 
Short acting Onset Peak Duration 
Regular 
0.5 – 1 hr 
2 – 4 hrs 
4-6 hrs 
Lispro 
20 mints 
0.5 – 1½ hr 
3 – 4 hrs 
Aspart 
25 mints 
30 – 1½ hr 
3 – 4 hrs 
Intermediate acting 
NPH/ Isophane 
lente 
(Insulin zinc suspension 
1 – 3 
1 - 3 
5 - 7 
4 - 8 
13 - 18 
13 – 20 
Long Acting 
Ultra lente / Protamine 
Glargine 
4 – 6 
1 – 4 
14 – 18 
Minimal peak 
activity 
24 – 36 g 
24hrs
Insulin therapy 
• Regular and NPH are the most commonly used 
preparations 
• Regular insulin/NPH combination- 
– Slow absorption, administered 30min before 
meals 
– Midmorning & midafternoon snacks necessary 
– Rapidly acting insulin like Lispro prevent 
hypoglycemia
Insulin therapy 
• Lispro and aspartate– 
– should be taken immediately before meals 
– Lispro and aspartate used for prandial insulin and 
insulin pump therapy
Insulin therapy 
• Glargine- 
– Longest acting 
– Less episodes of nocturnal hypoglycemia 
– Given in morning hours 
• Detemir
Timing of Delivery 
• Diet controlled 
– Same as non diabetic 
– Offer induction at 41 weeks if undelivered 
• On Insulin/Type II/Type I 
– If suboptimal control deliver following confirmation of lung 
maturity if <39 weeks 
– Otherwise deliver by 40 weeks 
– Generally do not allow to go post term 
• DOC for initial tocolysis: Nifedipine
Mode of Delivery 
• Macrosomic infants of diabetic mothers have 
higher rates of shoulder dystocia 
• Cord is to be clamped immediately 
• Reasonable to recommend C/S delivery if EFW 
is >4500g
Insulin requirement in labor 
Insulin requirements 
During induction of labor During elective caesarean section 
•Usual insulin dose and meal on evening before surgery 
•Overnight fast from 12 midnight 
Day before IOL 
•Normal diet 
•Normal insulin dose 
evening before IOL 
•No overnight fast 
Day of IOL 
•give half the morning dose of insulin before 
light breakfast 
•Insert prostaglandin gel as early as possible 
•Continuous CTG 
•Start IV insulin infusion once labor establishes
Insulin therapy intrapartum 
CG Level Management 
• 60-90 mg/dl 5%-10% DNS at 100 ml/hr 
• 90-120mg/dl 0.9% NS or RL at 100ml/hr 
• 120-140 mg/dl 5Uin 500ml 5% dex at 100ml/hr 
• If >140 mg% then plain insulin sc by sliding scale: 
• 140-180 mg/dl 4U 
• 180 -250 mg/dl 8U 
• 250-400 mg/dl 12U 
• >400 mg% 16U 
• CG and urinary ketone level should be measured every 
2 hourly.
Contraception in DM 
• Barrier methods are safe, inexpensive with fewer side effects 
• OCPs cause insulin resistance due to progesterone component 
and there is high risk of thromboembolism, MI and CVA. 
• IUCDs cause infection, glucose precipitates with Copper and 
thus reduction of efficacy. 
• Permanent method are used in couples with complete family
Diabetic Ketoacidosis 
• 5-10% of pregnant Type 1 patients 
• Serious medical emergency 
• Risk factors 
– New onset DM 
– Infection 
– Insulin pump failure 
– Steroids 
• Fetal mortality 10%
Diabetic Ketoacidosis 
• Diagnosis: 
– BG conc > 250mg/dl 
– Ketone bodies in urine and plasma 
– Arterial pH <7.3 
– Serum bicarbonate < 15meq/L
Diabetic Ketoacidosis 
• Management 
– ABC’s and ABG 
• Assess BG, ketones electrolytes 
– Insulin 
• 0.2-0.4U/Kg loading and 2-10U/h maintenance 
– Begin 5% dextrose when BG is 250 mg% 
– When potassium is N range begin 20mEq/h 
– Rehydration isotonic NaCl 
• 1L in 1st hour 
• 0.5-1L/h over 2-4h 
• 6-8 L over 1st 24 hours. 
• 250cc/h until 80% replaced 
• Replace Bicarb and phosphate as needed
Metabolic syndrome 
• Definition (WHO) 
– Diabetes, impaired glucose tolerance, impaired 
fasting glucose, insulin resistance+ atleast 2 of foll: 
• Abdominal obesity 
• Trigycerides > 150 mg/dl 
• HDL < 40 mg/dl 
• BP≥ 140/90 mm Hg 
• Microalbuminuria > 20μg/min
Metabolic syndrome 
• Definition (NCEPATP III) 
– At least 3 of the following: 
• Fasting plasma glucose > 110mg/dl 
• Abdominal obesity (waist circumference> 35 in.) 
• Triglycerides >150 mg/dl; HDL < 50mg/dl 
• BP ≥ 130/85 mmHg
Indian experience 
• Incidence of GDM is 3-5% 
• Numbers are increasing 
• 90% diagnosed cases are of GDM 
• Fetal macrosomia 32% 
• PIH 48% 
• Hydramnios 4% 
• IUD 12% 
• Fetal malpresentation 16% 
• Cesarean section 44% 
• Maternal mortality 10 times
Medicolegal Pitfalls 
• Congenital anomalies in infant- 
– Explained to the mother 
– Preventability by good glycemic control should be 
mentioned and recorded 
• Birth injuries and Perinatal asphyxia 
– USG should be done 2-3wks prior to delivery 
– Offer cesarean section if EFW >4500gm
Take Home Message 
• Preventing congenital anomalies is a challenge 
• Maintaining euglycemia is the key 
• Educating community is the cornerstone
diabetes in pregnancy

More Related Content

What's hot

Diabetes Mellitus in Pregnancy
Diabetes Mellitus in PregnancyDiabetes Mellitus in Pregnancy
Diabetes Mellitus in Pregnancymeducationdotnet
 
Diabetes mellitus in pregnancy
Diabetes mellitus in pregnancyDiabetes mellitus in pregnancy
Diabetes mellitus in pregnancykusumaneela
 
GESTATIONAL DIABETES MELLITUS
GESTATIONAL DIABETES MELLITUSGESTATIONAL DIABETES MELLITUS
GESTATIONAL DIABETES MELLITUSNishanth Ps
 
Diabetes and Pregnancy
Diabetes and PregnancyDiabetes and Pregnancy
Diabetes and PregnancyPk Doctors
 
Thyroid diseases in pregnancy
Thyroid diseases in pregnancyThyroid diseases in pregnancy
Thyroid diseases in pregnancyikramdr01
 
An update on gdm management
An update on gdm managementAn update on gdm management
An update on gdm managementnamkha dorji
 
GESTATIONAL DIABETES MELLITUS SCREENING
GESTATIONAL DIABETES MELLITUS SCREENING GESTATIONAL DIABETES MELLITUS SCREENING
GESTATIONAL DIABETES MELLITUS SCREENING ROHAN THOMAS ROY
 
Management of diabetes in pregnancy
Management of diabetes in pregnancyManagement of diabetes in pregnancy
Management of diabetes in pregnancySharon Treesa Antony
 
Gestational diabetes mellitus
Gestational diabetes mellitusGestational diabetes mellitus
Gestational diabetes mellitusNishitha Ashok
 
Diabetes In Pregnancy
Diabetes In PregnancyDiabetes In Pregnancy
Diabetes In Pregnancydoctorshazly
 
Gestational diabetes mellitus
Gestational  diabetes mellitus Gestational  diabetes mellitus
Gestational diabetes mellitus Aboubakr Elnashar
 
Hypertension in pregnancy
Hypertension in pregnancyHypertension in pregnancy
Hypertension in pregnancyAadil Sayyed
 
Pre eclampsia; eclampsia
Pre eclampsia; eclampsiaPre eclampsia; eclampsia
Pre eclampsia; eclampsiaEddo Adams
 
All about Gestational Diabetes Mellitus,
All about Gestational Diabetes Mellitus,All about Gestational Diabetes Mellitus,
All about Gestational Diabetes Mellitus,ozhin araz
 
Diabetes in pregnancy
Diabetes in pregnancy Diabetes in pregnancy
Diabetes in pregnancy obgymgmcri
 
MANAGEMENT OF PREECLAMPSIA BY DR SHASHWAT JANI
MANAGEMENT OF PREECLAMPSIA BY DR SHASHWAT JANIMANAGEMENT OF PREECLAMPSIA BY DR SHASHWAT JANI
MANAGEMENT OF PREECLAMPSIA BY DR SHASHWAT JANIDR SHASHWAT JANI
 
Management of Sickle Cell Disease in Pregnancy
Management of Sickle Cell Disease in PregnancyManagement of Sickle Cell Disease in Pregnancy
Management of Sickle Cell Disease in PregnancyApollo Hospitals
 

What's hot (20)

Diabetes Mellitus in Pregnancy
Diabetes Mellitus in PregnancyDiabetes Mellitus in Pregnancy
Diabetes Mellitus in Pregnancy
 
Diabetes mellitus in pregnancy
Diabetes mellitus in pregnancyDiabetes mellitus in pregnancy
Diabetes mellitus in pregnancy
 
GESTATIONAL DIABETES MELLITUS
GESTATIONAL DIABETES MELLITUSGESTATIONAL DIABETES MELLITUS
GESTATIONAL DIABETES MELLITUS
 
Diabetes and Pregnancy
Diabetes and PregnancyDiabetes and Pregnancy
Diabetes and Pregnancy
 
Thyroid diseases in pregnancy
Thyroid diseases in pregnancyThyroid diseases in pregnancy
Thyroid diseases in pregnancy
 
An update on gdm management
An update on gdm managementAn update on gdm management
An update on gdm management
 
Diabetes in Pregnancy
Diabetes in PregnancyDiabetes in Pregnancy
Diabetes in Pregnancy
 
GESTATIONAL DIABETES MELLITUS SCREENING
GESTATIONAL DIABETES MELLITUS SCREENING GESTATIONAL DIABETES MELLITUS SCREENING
GESTATIONAL DIABETES MELLITUS SCREENING
 
Management of diabetes in pregnancy
Management of diabetes in pregnancyManagement of diabetes in pregnancy
Management of diabetes in pregnancy
 
Gestational diabetes mellitus
Gestational diabetes mellitusGestational diabetes mellitus
Gestational diabetes mellitus
 
Diabetes In Pregnancy
Diabetes In PregnancyDiabetes In Pregnancy
Diabetes In Pregnancy
 
Gestational diabetes mellitus
Gestational  diabetes mellitus Gestational  diabetes mellitus
Gestational diabetes mellitus
 
Hypertension in pregnancy
Hypertension in pregnancyHypertension in pregnancy
Hypertension in pregnancy
 
Diabetes In Pregnancy
Diabetes In PregnancyDiabetes In Pregnancy
Diabetes In Pregnancy
 
Pre eclampsia; eclampsia
Pre eclampsia; eclampsiaPre eclampsia; eclampsia
Pre eclampsia; eclampsia
 
Gestational Diabetes by Dr Shahjada Selim
Gestational Diabetes by Dr Shahjada SelimGestational Diabetes by Dr Shahjada Selim
Gestational Diabetes by Dr Shahjada Selim
 
All about Gestational Diabetes Mellitus,
All about Gestational Diabetes Mellitus,All about Gestational Diabetes Mellitus,
All about Gestational Diabetes Mellitus,
 
Diabetes in pregnancy
Diabetes in pregnancy Diabetes in pregnancy
Diabetes in pregnancy
 
MANAGEMENT OF PREECLAMPSIA BY DR SHASHWAT JANI
MANAGEMENT OF PREECLAMPSIA BY DR SHASHWAT JANIMANAGEMENT OF PREECLAMPSIA BY DR SHASHWAT JANI
MANAGEMENT OF PREECLAMPSIA BY DR SHASHWAT JANI
 
Management of Sickle Cell Disease in Pregnancy
Management of Sickle Cell Disease in PregnancyManagement of Sickle Cell Disease in Pregnancy
Management of Sickle Cell Disease in Pregnancy
 

Viewers also liked

Carbohydrate metabolism in pregnancy
Carbohydrate metabolism in pregnancyCarbohydrate metabolism in pregnancy
Carbohydrate metabolism in pregnancysaisucheethra
 
Diabetes Mellitus in pregnancy " Gestational diabetes mellitus''
Diabetes Mellitus in pregnancy " Gestational diabetes mellitus''Diabetes Mellitus in pregnancy " Gestational diabetes mellitus''
Diabetes Mellitus in pregnancy " Gestational diabetes mellitus''Nassr ALBarhi
 
Physiological changes during pregnancy
Physiological changes during pregnancyPhysiological changes during pregnancy
Physiological changes during pregnancyNaila Memon
 
Physiological Changes In Pregnancy
Physiological Changes In Pregnancy	Physiological Changes In Pregnancy
Physiological Changes In Pregnancy Khalid
 
Pregnancy Induced Hypertension, Preeclampsia, Eclampsia
Pregnancy Induced Hypertension, Preeclampsia, EclampsiaPregnancy Induced Hypertension, Preeclampsia, Eclampsia
Pregnancy Induced Hypertension, Preeclampsia, EclampsiaDr. Seyed Morteza Mahmoudi
 
Stemming The Rising Tide Of Iron Deficiency Anemia In India
Stemming The Rising Tide Of Iron Deficiency Anemia In IndiaStemming The Rising Tide Of Iron Deficiency Anemia In India
Stemming The Rising Tide Of Iron Deficiency Anemia In IndiaRavishankar Vishwanath
 
Care of late preterm infant sandip
Care of late preterm  infant sandipCare of late preterm  infant sandip
Care of late preterm infant sandipSandip Gupta
 
Gestational diabetes mellitus dr. sandesh, dr anupama, dr sundar
Gestational diabetes mellitus  dr. sandesh, dr   anupama, dr sundarGestational diabetes mellitus  dr. sandesh, dr   anupama, dr sundar
Gestational diabetes mellitus dr. sandesh, dr anupama, dr sundarDr. Sundar Karki
 
Management of late preterm babies
Management of late preterm babiesManagement of late preterm babies
Management of late preterm babiesAndrea Josephine
 
2015-08-06 PSEDM 16th Diabetes and General Endocrinology Course in Bacolod - ...
2015-08-06 PSEDM 16th Diabetes and General Endocrinology Course in Bacolod - ...2015-08-06 PSEDM 16th Diabetes and General Endocrinology Course in Bacolod - ...
2015-08-06 PSEDM 16th Diabetes and General Endocrinology Course in Bacolod - ...Jeremy F. Robles MD, FPCP, FPSEM
 

Viewers also liked (20)

GESTATIONAL DIABETES
GESTATIONAL DIABETESGESTATIONAL DIABETES
GESTATIONAL DIABETES
 
Carbohydrate metabolism in pregnancy
Carbohydrate metabolism in pregnancyCarbohydrate metabolism in pregnancy
Carbohydrate metabolism in pregnancy
 
Gestational Diabetes.
Gestational Diabetes.Gestational Diabetes.
Gestational Diabetes.
 
Diabetes Mellitus in pregnancy " Gestational diabetes mellitus''
Diabetes Mellitus in pregnancy " Gestational diabetes mellitus''Diabetes Mellitus in pregnancy " Gestational diabetes mellitus''
Diabetes Mellitus in pregnancy " Gestational diabetes mellitus''
 
Diabetes in pregnancy
Diabetes in pregnancyDiabetes in pregnancy
Diabetes in pregnancy
 
Physiological changes during pregnancy
Physiological changes during pregnancyPhysiological changes during pregnancy
Physiological changes during pregnancy
 
Physiological Changes In Pregnancy
Physiological Changes In Pregnancy	Physiological Changes In Pregnancy
Physiological Changes In Pregnancy
 
Diabetes in Pregnancy
Diabetes in PregnancyDiabetes in Pregnancy
Diabetes in Pregnancy
 
Diabetes in pregnancy
Diabetes in pregnancyDiabetes in pregnancy
Diabetes in pregnancy
 
Pregnancy Induced Hypertension, Preeclampsia, Eclampsia
Pregnancy Induced Hypertension, Preeclampsia, EclampsiaPregnancy Induced Hypertension, Preeclampsia, Eclampsia
Pregnancy Induced Hypertension, Preeclampsia, Eclampsia
 
Gestational Diabetes Mellitus
Gestational Diabetes MellitusGestational Diabetes Mellitus
Gestational Diabetes Mellitus
 
Anemia with pregnancy
Anemia with pregnancyAnemia with pregnancy
Anemia with pregnancy
 
Stemming The Rising Tide Of Iron Deficiency Anemia In India
Stemming The Rising Tide Of Iron Deficiency Anemia In IndiaStemming The Rising Tide Of Iron Deficiency Anemia In India
Stemming The Rising Tide Of Iron Deficiency Anemia In India
 
Care of late preterm infant sandip
Care of late preterm  infant sandipCare of late preterm  infant sandip
Care of late preterm infant sandip
 
Iron Sucrose
Iron SucroseIron Sucrose
Iron Sucrose
 
Gestational diabetes mellitus dr. sandesh, dr anupama, dr sundar
Gestational diabetes mellitus  dr. sandesh, dr   anupama, dr sundarGestational diabetes mellitus  dr. sandesh, dr   anupama, dr sundar
Gestational diabetes mellitus dr. sandesh, dr anupama, dr sundar
 
Management of late preterm babies
Management of late preterm babiesManagement of late preterm babies
Management of late preterm babies
 
abnormal labour
abnormal labourabnormal labour
abnormal labour
 
2015-08-06 PSEDM 16th Diabetes and General Endocrinology Course in Bacolod - ...
2015-08-06 PSEDM 16th Diabetes and General Endocrinology Course in Bacolod - ...2015-08-06 PSEDM 16th Diabetes and General Endocrinology Course in Bacolod - ...
2015-08-06 PSEDM 16th Diabetes and General Endocrinology Course in Bacolod - ...
 
GDM
GDMGDM
GDM
 

Similar to diabetes in pregnancy

Similar to diabetes in pregnancy (20)

Gestational Diabetes Mellitus
Gestational Diabetes MellitusGestational Diabetes Mellitus
Gestational Diabetes Mellitus
 
Diabetes in Pregnancy
Diabetes in PregnancyDiabetes in Pregnancy
Diabetes in Pregnancy
 
diabetis in pregnancy.pptx
diabetis in pregnancy.pptxdiabetis in pregnancy.pptx
diabetis in pregnancy.pptx
 
Diabetes in pregnancy
Diabetes in pregnancyDiabetes in pregnancy
Diabetes in pregnancy
 
Diabetes managemen
Diabetes managemenDiabetes managemen
Diabetes managemen
 
Diabetes in pregnancy
Diabetes in pregnancyDiabetes in pregnancy
Diabetes in pregnancy
 
Diabetes Asia
Diabetes AsiaDiabetes Asia
Diabetes Asia
 
GDM .pptx
GDM .pptxGDM .pptx
GDM .pptx
 
Endocrine Disorders in Pregnancy
Endocrine Disorders in PregnancyEndocrine Disorders in Pregnancy
Endocrine Disorders in Pregnancy
 
Gestational Diabetes Mellitus (GDM)
Gestational Diabetes Mellitus (GDM)Gestational Diabetes Mellitus (GDM)
Gestational Diabetes Mellitus (GDM)
 
Diabetes&pregnancy
Diabetes&pregnancyDiabetes&pregnancy
Diabetes&pregnancy
 
gdm (1).pptx
gdm (1).pptxgdm (1).pptx
gdm (1).pptx
 
Gestational Diabetes Mellitus
Gestational Diabetes MellitusGestational Diabetes Mellitus
Gestational Diabetes Mellitus
 
GDM: An Update
GDM: An UpdateGDM: An Update
GDM: An Update
 
Gestational diabetes mellitus
Gestational diabetes mellitusGestational diabetes mellitus
Gestational diabetes mellitus
 
GDM_ Dr Selim
GDM_ Dr SelimGDM_ Dr Selim
GDM_ Dr Selim
 
gdm (1).pptx
gdm (1).pptxgdm (1).pptx
gdm (1).pptx
 
&lt;마더리스크라운드>Type 2 diabetes in pregnancy
&lt;마더리스크라운드>Type 2 diabetes in pregnancy&lt;마더리스크라운드>Type 2 diabetes in pregnancy
&lt;마더리스크라운드>Type 2 diabetes in pregnancy
 
Gestational Diabetes Mellitus.pptx
Gestational Diabetes Mellitus.pptxGestational Diabetes Mellitus.pptx
Gestational Diabetes Mellitus.pptx
 
gestationaldiabetesmellitus-140529092010-phpapp02 (1).pptx
gestationaldiabetesmellitus-140529092010-phpapp02 (1).pptxgestationaldiabetesmellitus-140529092010-phpapp02 (1).pptx
gestationaldiabetesmellitus-140529092010-phpapp02 (1).pptx
 

Recently uploaded

CPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing studentCPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing studentsaileshpanda05
 
Bulimia nervosa ( Eating Disorders) Mental Health Nursing.
Bulimia nervosa ( Eating Disorders) Mental Health Nursing.Bulimia nervosa ( Eating Disorders) Mental Health Nursing.
Bulimia nervosa ( Eating Disorders) Mental Health Nursing.aarjukhadka22
 
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdfCONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdfDolisha Warbi
 
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdfSGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdfHongBiThi1
 
Using Data Visualization in Public Health Communications
Using Data Visualization in Public Health CommunicationsUsing Data Visualization in Public Health Communications
Using Data Visualization in Public Health Communicationskatiequigley33
 
AORTIC DISSECTION and management of aortic dissection
AORTIC DISSECTION and management of aortic dissectionAORTIC DISSECTION and management of aortic dissection
AORTIC DISSECTION and management of aortic dissectiondrhanifmohdali
 
AUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functionsAUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functionsMedicoseAcademics
 
Unit I herbs as raw materials, biodynamic agriculture.ppt
Unit I herbs as raw materials, biodynamic agriculture.pptUnit I herbs as raw materials, biodynamic agriculture.ppt
Unit I herbs as raw materials, biodynamic agriculture.pptPradnya Wadekar
 
blood bank management system project report
blood bank management system project reportblood bank management system project report
blood bank management system project reportNARMADAPETROLEUMGAS
 
EXERCISE PERFORMANCE.pptx, Lung function
EXERCISE PERFORMANCE.pptx, Lung functionEXERCISE PERFORMANCE.pptx, Lung function
EXERCISE PERFORMANCE.pptx, Lung functionkrishnareddy157915
 
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfSGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfHongBiThi1
 
Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.Vaikunthan Rajaratnam
 
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdfSGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdfHongBiThi1
 
Physiology of Smooth Muscles -Mechanics of contraction and relaxation
Physiology of Smooth Muscles -Mechanics of contraction and relaxationPhysiology of Smooth Muscles -Mechanics of contraction and relaxation
Physiology of Smooth Muscles -Mechanics of contraction and relaxationMedicoseAcademics
 
Trustworthiness of AI based predictions Aachen 2024
Trustworthiness of AI based predictions Aachen 2024Trustworthiness of AI based predictions Aachen 2024
Trustworthiness of AI based predictions Aachen 2024EwoutSteyerberg1
 
power point presentation of Clinical evaluation of strabismus
power point presentation of Clinical evaluation  of strabismuspower point presentation of Clinical evaluation  of strabismus
power point presentation of Clinical evaluation of strabismusChandrasekar Reddy
 
BENIGN BREAST DISEASE
BENIGN BREAST DISEASE BENIGN BREAST DISEASE
BENIGN BREAST DISEASE Mamatha Lakka
 
Male Infertility Panel Discussion by Dr Sujoy Dasgupta
Male Infertility Panel Discussion by Dr Sujoy DasguptaMale Infertility Panel Discussion by Dr Sujoy Dasgupta
Male Infertility Panel Discussion by Dr Sujoy DasguptaSujoy Dasgupta
 
ayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologypptayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologypptPradnya Wadekar
 
Basic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptxBasic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptxkomalt2001
 

Recently uploaded (20)

CPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing studentCPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing student
 
Bulimia nervosa ( Eating Disorders) Mental Health Nursing.
Bulimia nervosa ( Eating Disorders) Mental Health Nursing.Bulimia nervosa ( Eating Disorders) Mental Health Nursing.
Bulimia nervosa ( Eating Disorders) Mental Health Nursing.
 
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdfCONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
 
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdfSGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdf
 
Using Data Visualization in Public Health Communications
Using Data Visualization in Public Health CommunicationsUsing Data Visualization in Public Health Communications
Using Data Visualization in Public Health Communications
 
AORTIC DISSECTION and management of aortic dissection
AORTIC DISSECTION and management of aortic dissectionAORTIC DISSECTION and management of aortic dissection
AORTIC DISSECTION and management of aortic dissection
 
AUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functionsAUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functions
 
Unit I herbs as raw materials, biodynamic agriculture.ppt
Unit I herbs as raw materials, biodynamic agriculture.pptUnit I herbs as raw materials, biodynamic agriculture.ppt
Unit I herbs as raw materials, biodynamic agriculture.ppt
 
blood bank management system project report
blood bank management system project reportblood bank management system project report
blood bank management system project report
 
EXERCISE PERFORMANCE.pptx, Lung function
EXERCISE PERFORMANCE.pptx, Lung functionEXERCISE PERFORMANCE.pptx, Lung function
EXERCISE PERFORMANCE.pptx, Lung function
 
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfSGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
 
Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.
 
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdfSGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
 
Physiology of Smooth Muscles -Mechanics of contraction and relaxation
Physiology of Smooth Muscles -Mechanics of contraction and relaxationPhysiology of Smooth Muscles -Mechanics of contraction and relaxation
Physiology of Smooth Muscles -Mechanics of contraction and relaxation
 
Trustworthiness of AI based predictions Aachen 2024
Trustworthiness of AI based predictions Aachen 2024Trustworthiness of AI based predictions Aachen 2024
Trustworthiness of AI based predictions Aachen 2024
 
power point presentation of Clinical evaluation of strabismus
power point presentation of Clinical evaluation  of strabismuspower point presentation of Clinical evaluation  of strabismus
power point presentation of Clinical evaluation of strabismus
 
BENIGN BREAST DISEASE
BENIGN BREAST DISEASE BENIGN BREAST DISEASE
BENIGN BREAST DISEASE
 
Male Infertility Panel Discussion by Dr Sujoy Dasgupta
Male Infertility Panel Discussion by Dr Sujoy DasguptaMale Infertility Panel Discussion by Dr Sujoy Dasgupta
Male Infertility Panel Discussion by Dr Sujoy Dasgupta
 
ayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologypptayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologyppt
 
Basic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptxBasic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptx
 

diabetes in pregnancy

  • 1. DIABETES IN PREGNANCY Dr. Nidhi Singh
  • 2. INTRODUCTION • Abnormalities of carbohydrate metabolism occur frequently during pregnancy • 3-5% of all pregnant patient show glucose intolerance • 90% of these have gestational diabetes • Approximately 50% of women with GDM will develop type II diabetes later in life.
  • 3. Diabetogenic effects of pregnancy 1. Insulin resistance • Production of human placental lactogen • Production of cortisol, estriol and progesterone • Destruction by kidney and placenta 2. Increased lipolysis 3. Changes in gluconeogenesis
  • 4. Effects of diabetes on mother • Preeclampsia Affects 10-25% of all pregnant diabetics • Infections Chorioamnionitis and postpartum endometritis • Postpartum bleeding • Cesarean section
  • 5. Effects of diabetes on fetus • Congenital abnormalities • Hypoglycemia • Hyperviscosity syndrome • Hyaline membrane disease • Macrosomia • Hypocalcemia • Apnea and bradycardia • Traumatic delivery
  • 6. Effects of pregnancy on diabetes • More insulin required to achieve homoeostasis • Progression of diabetic retinopathy • Worsening of diabetic retinopathy • Increased risk of death in diabetic cardiomyopathy
  • 7. Etiological classification of diabetes • Type I: β cell destruction – Immune mediated – Idiopathic • Type II DM • Others – Genetic defects of beta-cell function – Genetic defects in insulin action – Genetic syndrome – Endocrinopathies – Drugs – Infections • Gestational DM
  • 8. White’s classification during pregnancy Gestational diabetes Discovered during pregnancy, glycemia may or may not be maintained by diet alone; insulin may be required Class A Discovered before preg, controlled with diet alone, any duration or age of onset Class B Onset age 20 yr or older, duration less than 10yrs Class C Onset age 10-19yrs, duration 10-19yrs Class D Onset age under 10yrs, duration >20yrs, background retinopathy Class R Proliferative retinopathy, or vitreous hemorrhage Class F Nephropathy with proteinuria over 500mg/day Class RF Criteria for both classes R and F coexist Class H Arteriosclerotic heart disease clinically evident Class T Prior renal transplantation
  • 9. Classification scheme used from 1986 through 1994 for Diabetes complicating pregnancy Class Onset Fasting 2 hour PP Therapy A1 Gestational <105 mg/dl <120 mg/dl Diet A2 Gestational >105 mg/dl >120 mg/dl Insulin Class Age of onset (yr) Duration (yr) Vascular disease Therapy B >20 <10 yr None Insulin C 10-19 yr 10 to 19 None Insulin D <10 yr >20 Benign retinopathy Insulin E Any Any Nephropathy Insulin R Any Any Proliferative retinopathy Insulin H Any Any Heart Insulin
  • 10. Gestational diabetes • Onset in pregnancy • Affects 1-2% of all pregnancies • More than half of Gestational diabetes develop overt diabetes in 20yrs • Obesity and diabetes in offspring
  • 11. High risk for GDM • History of still birth • History of neonatal death • History of fetal macrosomia • Concomitant obesity and hypertension • Development of oligohydramnios, polyhydramnios, preeclampsia and fetal macrosomia • Inadequate metabolic control with diet alone
  • 12. Screening strategy for detecting GDM • Low risk: * Blood glucose testing not routinely required in: – Member of an ethnic group with low prevalence – No known diabetes in 1st degree relatives – Age < 25yrs – Weight normal before pregnancy – Weight normal at birth – No history of abnormal glucose metabolism – No history of poor obstetrical outcome
  • 13. Screening strategy for detecting GDM • Average risk * Blood glucose testing at 24-28 wks (1 step/2step) – Member of an ethnic group with high prevalence – Diabetes in a first degree relative – Age ≥ 25yrs – Overweight before pregnancy – Weight high at birth
  • 14. Screening strategy for detecting GDM • High risk * Blood glucose testing as soon as feasible – Severe obesity – Strong family history of type 2 diabetes – Previous history of GDM – Impaired glucose metabolism – Glucosuria
  • 15. Screening (OGTT) • Plasma glucose level measured 1 hr after 50g glucose load • Without regarding to time of day/ time of last meal • Plasma glucose level > 130mg/dl; sensitivity 90% • Plasma glucose level > 140mg/dl; sensitivity is 80%
  • 16. Diagnosis of GDM by OGTT Time 100 g Glucose (American diabetes association criteria) 75 g glucose (WHO criteria) Fasting 95 mg/dl 5.3 mmol/L 95 mg/dl 5.3mmol/L 1-h 180mg/dl 10mmol/L 180mg/dl 10mmol/L 2-h 155mg/dl 8.6mmol/L 155mg/dl 8.6mmol/L 3-h 140mg/dl 7.8mmol/L - -
  • 17. Maternal risks • Birth trauma • Operative delivery • Polyhydraminos • 50% lifetime risk in developing Type II DM • Recurrence risk of GDM is 30-50%
  • 18. Fetal risks • No increase in congenital anomalies • Increased risk of stillbirth if fasting+ PP hyperglycemia • Macrosomia, BW >4000gm occurs in 17-29% of pregnancies • Birth trauma-shoulder dystocia and related complications • Neonatal hypoglycemia
  • 19. Fetal macrosomia • Defined as fetal weight > 4000gm • Brain not effected, shoulder dystocia 3% Maternal hyperglycemia Fetal hyperinsulinemia Excessive somatic growth • Diagnosis and management is important • USG should begin at 20wks; to be done at every 4 wks • Also due to IGF-1 and IGF-2 • Maternal obesity is important confounding factor
  • 21. Management of GDM Class Onset Fasting 2 hour PP Therapy A1 Gestational <105 mg/dl <120 mg/dl Diet A2 Gestational >105 mg/dl >120 mg/dl Insulin Nutritional therapy-total calorie intake: average 2000-2500 kcal/day. BMI >40 -- 12 kcal/kg/ideal body weight/d BMI>27 -- 25 kcal/kg/ideal body weight/d BMI 20-26 -- 30 “ BMI<20 -- 38 “
  • 22. Management of GDM • Diet : general principles • 55% CHO 25% Protein 20% fat • Normal weight gain 10-12 kg • Avoid ketosis • Liberal exercise program to optimize BG control • Daily self BG monitoring • Breakfast should provide 25%, Lunch 30% and dinner 30%. Obese women may be managed with lower caloric intake.
  • 23. Management of GDM • If persistent hyperglycemia after one week of diet control proceed to insulin • 6-14 weeks 0.5u/kg/day • 14-26 weeks 0.7u/kg/day • 26-36 weeks 0.9u/kg/day • 36-40weeks 1 u /kg/day
  • 24. Oral hypoglycaemic agents • Traditionally not recommended in pregnancy because of teratogenic effects • Glyburide and Metformin
  • 25. Glyburide • Sulfonylureas • MOA- release of insulin • Hypoglycemia and weight gain are the main side effects • Non-teratogenic, classified as category B drug
  • 26. Glyburide treatment regimen who fail Diet therapy 1. Glucometer BG measurment fasting and 1 or 2 hrs following breakfast, lunch and dinner 2. Glucose level goals (mg/dl): fasting < 100, 1-h < 155 and 2hrs < 130 3. Glyburide starting dose 2.5mg orally with morning meals 4. Increased daily glyburide dose by 2.5mg/wk, increment until 10mg/day, then switch to twice daily dosing until max of 20mg/day, then switch to insulin if 20mg/day does not achieve glucose goal.
  • 27. Obstetrical management • Cesarean delivery should be considered in women with sonographical estimated weight > 4500gm • Elective cesarean delivery has no significant effect on incidence of brachial plexus injury • Fetal monitoring
  • 28. Postpartum evaluation • Women diagnosed with GDM to be evaluated with 75gm OGTT at 6-12wks postpartum • Metabolic assessment recommended after preg with GDM Time Test purpose Postdelivery (1-3 d) Fasting or random plasma glucose Detect persistent, overt diabetes Early postpartum (6-12wk) 75g 2h OGTT PP classification of Glu met 1yr Postpartum 75g 2h OGTT Assess Glu metabolism Annually Fasting plasma glucose Assess Glu metabolism Tri- annually 75g 2h OGTT Assess Glu metabolism Prepregnancy 75g 2h OGTT Classify glu metabolism • Contraception: low dose hormonal contraceptives
  • 29. Pregestational diabetes/ overt diabetes • Patients with symptoms of DM and plasma Glucose concentration 200mg/dl or more • The condition may be preexisting or detected during present pregnancy
  • 30. Criteria for diagnosis of impaired Glucose tolerance and diabetes with 75g oral glucose Time Normal tolerance Impaired glucose tolerance diabetes Fasting < 110 mg/dl ≥ 110 and <126 ≥ 126 mg/dl 2 hr Post glucose <140 mg/dl ≥ 140 and <200 ≥ 200 mg/dl
  • 31. Maternal effects • During pregnancy – Abortions – Preterm labor 20% – Infections (UTI) – Preeclampsia 25% – Polyhydraminos 25-50% – Maternal distress – Diabetic retinopathy – Diabetic nephropathy – Ketoacidosis
  • 32. Maternal effects • During labor: – Prolongation of labour due to big baby – Shoulder dystocia – Perineal injury – Postpartum hemorrhage – Operative interventions • During Puerperium: – Puerperal sepsis – Lactation failure
  • 33. Fetal hazards • Congenital anomalies 3 times increased risk – Caudal regression- 1.3/1000 – Situs invertus – Spina bifida, hydrocephaly, other CNS defects – Anencephaly – Cardiac anomalies: VSD, TGA, ASD, COA – Anorectal atresia – Renal anomalies: agenesis, cystic kidney, duplex ureter
  • 34. Fetal hazards • Unexplained stillbirth • Hypoglycemia, hypocalcemia, hyperbilirubinemia, polycythemia • Cardiomyopathies • Inheritance of diabetes • Shoulder dystocia • Macrosomia • IUGR • RDS
  • 35. Preconceptional counselling • Preconception Counselling • Risk of NTD ~1-2% • Folic Acid 400μg/day • Preconceptional glucose control using insulin. • Fasting < 70-100 mg/dl, and PP <140mg/dl at the end of 1 hr and <120mg/dl at the end of 2hr.
  • 36. Preconceptional counselling • Normoglycemia prior to conception • Ideally HBA1C 6% or less • Team approach • Glucose monitoring qid • ACE inhibitors contraindicated • Baseline HbA1C, 24h urine for protein Cr Cl , ophthalmology review • Switch from OHA to insulin
  • 37. Pregestational /Overt Diabetes • Assess for end organ disease – assess for nephropathy - inc risk of PIH – Assess and treat retinopathy - may progress – assess for neuropathy • generally remains stable during pregnancy – assess and treat vasculopathy • CAD is a relative C/I for pregnancy
  • 38. Maternal Surveillance - Blood pressure monitoring – renal function every trimester – urine culture monthly – thyroid function – BG control HB A1C every trimester
  • 39. Fetal Surveillance – USG for dating/viability ~ 8 weeks – Transvaginal USG examination at 10-14 weeks – Fetal anomaly detection • nuchal translucency 11-14weeks • maternal serum screen- free β HCG and PAPA-A • MSAFP at 16w to screen for open Neural tube defect • anatomy survey 18-20 weeks • Fetal echo 22weeks –Weekly biophysical profile, NST
  • 40. Trimestric approach • 1st Trimester: – Careful monitoring of glucose control is essential – OHA to Insulin therapy • 2nd trimester: – Maternal serum alpha fetoprotein at 16-20wks – Targeted sonographic examination at 18-20wks – Euglycemia with self monitoring is the goal – Increased insulin requirement after 24wks • 3rd Trimester: – Cesarean delivery to avoid traumatic birth
  • 41. Admissions – At 34-36 weeks in uncomplicated cases – It facilitates i. Stabilisation of diabetes ii. Less incidence of Preeclampsia, Polyhydramnios and Preterm labour iii. Selecting time and mode of termination
  • 42. Insulin therapy • OHA not currently recommended for overt diabetes • Maternal glycemic control with multiple daily insulin inj and adjustment of dietary intake • S/C insulin infusion by calibrated pumps • Self monitoring using glucometer recommended
  • 43. Self monitored capillary BG goals Specimen Level (mg/dl) Fasting ≤ 95 Premeal ≤ 100 1 hr- postprandial ≤140 2 hr- postprandial ≤ 120 2-6hr ≥ 60 Mean (average) 100 Hb A1c ≤ 6
  • 44. Management of diabetes in pregnancy insulin therapy • Insulin Pump – Allows insulin release close to physiologic levels – Use short acting insulin – 50-60% of total dose is basal rate – 40-50% given as boluses – Potential complications • Pump failure • Infection • Increased risk of DKA
  • 45. Management of diabetes in pregnancy insulin therapy Short acting Onset Peak Duration Regular 0.5 – 1 hr 2 – 4 hrs 4-6 hrs Lispro 20 mints 0.5 – 1½ hr 3 – 4 hrs Aspart 25 mints 30 – 1½ hr 3 – 4 hrs Intermediate acting NPH/ Isophane lente (Insulin zinc suspension 1 – 3 1 - 3 5 - 7 4 - 8 13 - 18 13 – 20 Long Acting Ultra lente / Protamine Glargine 4 – 6 1 – 4 14 – 18 Minimal peak activity 24 – 36 g 24hrs
  • 46. Insulin therapy • Regular and NPH are the most commonly used preparations • Regular insulin/NPH combination- – Slow absorption, administered 30min before meals – Midmorning & midafternoon snacks necessary – Rapidly acting insulin like Lispro prevent hypoglycemia
  • 47. Insulin therapy • Lispro and aspartate– – should be taken immediately before meals – Lispro and aspartate used for prandial insulin and insulin pump therapy
  • 48. Insulin therapy • Glargine- – Longest acting – Less episodes of nocturnal hypoglycemia – Given in morning hours • Detemir
  • 49. Timing of Delivery • Diet controlled – Same as non diabetic – Offer induction at 41 weeks if undelivered • On Insulin/Type II/Type I – If suboptimal control deliver following confirmation of lung maturity if <39 weeks – Otherwise deliver by 40 weeks – Generally do not allow to go post term • DOC for initial tocolysis: Nifedipine
  • 50. Mode of Delivery • Macrosomic infants of diabetic mothers have higher rates of shoulder dystocia • Cord is to be clamped immediately • Reasonable to recommend C/S delivery if EFW is >4500g
  • 51. Insulin requirement in labor Insulin requirements During induction of labor During elective caesarean section •Usual insulin dose and meal on evening before surgery •Overnight fast from 12 midnight Day before IOL •Normal diet •Normal insulin dose evening before IOL •No overnight fast Day of IOL •give half the morning dose of insulin before light breakfast •Insert prostaglandin gel as early as possible •Continuous CTG •Start IV insulin infusion once labor establishes
  • 52. Insulin therapy intrapartum CG Level Management • 60-90 mg/dl 5%-10% DNS at 100 ml/hr • 90-120mg/dl 0.9% NS or RL at 100ml/hr • 120-140 mg/dl 5Uin 500ml 5% dex at 100ml/hr • If >140 mg% then plain insulin sc by sliding scale: • 140-180 mg/dl 4U • 180 -250 mg/dl 8U • 250-400 mg/dl 12U • >400 mg% 16U • CG and urinary ketone level should be measured every 2 hourly.
  • 53. Contraception in DM • Barrier methods are safe, inexpensive with fewer side effects • OCPs cause insulin resistance due to progesterone component and there is high risk of thromboembolism, MI and CVA. • IUCDs cause infection, glucose precipitates with Copper and thus reduction of efficacy. • Permanent method are used in couples with complete family
  • 54. Diabetic Ketoacidosis • 5-10% of pregnant Type 1 patients • Serious medical emergency • Risk factors – New onset DM – Infection – Insulin pump failure – Steroids • Fetal mortality 10%
  • 55. Diabetic Ketoacidosis • Diagnosis: – BG conc > 250mg/dl – Ketone bodies in urine and plasma – Arterial pH <7.3 – Serum bicarbonate < 15meq/L
  • 56. Diabetic Ketoacidosis • Management – ABC’s and ABG • Assess BG, ketones electrolytes – Insulin • 0.2-0.4U/Kg loading and 2-10U/h maintenance – Begin 5% dextrose when BG is 250 mg% – When potassium is N range begin 20mEq/h – Rehydration isotonic NaCl • 1L in 1st hour • 0.5-1L/h over 2-4h • 6-8 L over 1st 24 hours. • 250cc/h until 80% replaced • Replace Bicarb and phosphate as needed
  • 57. Metabolic syndrome • Definition (WHO) – Diabetes, impaired glucose tolerance, impaired fasting glucose, insulin resistance+ atleast 2 of foll: • Abdominal obesity • Trigycerides > 150 mg/dl • HDL < 40 mg/dl • BP≥ 140/90 mm Hg • Microalbuminuria > 20μg/min
  • 58. Metabolic syndrome • Definition (NCEPATP III) – At least 3 of the following: • Fasting plasma glucose > 110mg/dl • Abdominal obesity (waist circumference> 35 in.) • Triglycerides >150 mg/dl; HDL < 50mg/dl • BP ≥ 130/85 mmHg
  • 59. Indian experience • Incidence of GDM is 3-5% • Numbers are increasing • 90% diagnosed cases are of GDM • Fetal macrosomia 32% • PIH 48% • Hydramnios 4% • IUD 12% • Fetal malpresentation 16% • Cesarean section 44% • Maternal mortality 10 times
  • 60. Medicolegal Pitfalls • Congenital anomalies in infant- – Explained to the mother – Preventability by good glycemic control should be mentioned and recorded • Birth injuries and Perinatal asphyxia – USG should be done 2-3wks prior to delivery – Offer cesarean section if EFW >4500gm
  • 61. Take Home Message • Preventing congenital anomalies is a challenge • Maintaining euglycemia is the key • Educating community is the cornerstone