DIABETES MELLITUS AND

PREGNANCY

Mrs. Shwetha Rani C.M.

Associate Professor & H.O.D.
Department of Obstetric & Gynecological Nursing
SCPM College Of Nursing & Paramedical Sciences,
Gonda. U.P.
Diabetes Mellitus
• Diabetes mellitus is a chronic metabolic disorder due to either insulin
deficiency (relative or absolute) or due to peripheral tissue resistance
(decrease sensitivity) to the action of insulin.
• The pathophysiology involved are:
➢Insulin resistance and
➢Inadequate secretion of insulin(B cell dysfunction)
Classification
Diabetes in
pregnancy

Pre-existing Gestational
diabetes diabetes

IDDM NIDDM Pre-existing True GDM

(Type1) (Type2) diabetes
Types
• Type 1 (IDDM)
➢Young onset(juvenile) and absolute insulinopenia.
➢Genetic predisposition with presence of autoantibodies.
• Type 2 (NIDDM)
➢Late age onset
➢Overweight women
➢Peripheral tissue insulin resistance (hyperinsulinaemia)
GESTATIONAL DIABETES MELLITUS

• Gestational Diabetes Mellitus is carbohydrates intolerance of variable

severity with onset or first recognition during the present pregnancy.

• The entity usually presents in the second or during the third

trimester.
OVERT DIABETES

• A patient with symptoms of Diabetes Mellitus (polyuria, Polydipsia,

weight loss) and random plasma glucose concentration of 200 mg/dl
or more is overt diabetes.

• It may be detected for the first time in pregnancy.

• According to ADA, FBS >126mg/dl and PP(75gm)> 200 mg/dl.

EFFECT OF PREGNANCY ON DIABETES

• During pregnancy, due to altered carbohydrate metabolism and an

impaired insulin action, it is difficult to stabilise the blood glucose.

• The insulin antagonism is due to the combined effect of HPL,

estrogen, progesterone, free cortisol and degradation of the insulin
by the placenta.
• The insulin requirement during pregnancy increases as pregnancy
advances.

• During pregnancy, renal threshold is diminished, due to the combined

effect of increased glomerular filtration and impaired tubular
reabsorption of glucose. Glucose leaks out in the urine even though the
blood sugar level is well below 180mg/100 ml.

• Hence, repeated blood glucose test becomes mandatory.

• With the accelerated starvation, there is rapid activation of lypolysis with
short period of fasting.

• Ketoacidosis can be precipitated during hyperemesis in early pregnancy,

infections and fasting of labor.

• It can be iatrogenically induced by certain drugs like corticosteroids used in

management of pre term labor.

• Insulin requirements fall significantly in puerperium.

• Vascular changes, especially retinopathy, nephropathy, CAD and neuropathy

may be worsened during pregnancy.
Effect of diabetes on pregnancy
• To the Mother
• During pregnancy:
• Abortion: recurrent spontaneous abortion may be associated with
uncontrolled DM.
• Preterm labor(20%)- infection or polyhydramnious
• Infection- UTI and vulvo vaginitis
• Increased incidence of pre-eclampsia
• Polyhydramnios (25-50%)
• Maternal distress
• Diabetic retinopathy

• Diabetic nephropathy

• ketoacidosis
During Labor
Increase incidence of:
• Prolong labor due to big baby
• Shoulder dystocia
• Perineal injuries
• Postpartum haemorrhage
• Operative interferences
Puerperium
• Puerperial sepsis
• Lactation failure
• PPH
Fetal and Neonatal Hazards
• FETAL MACROSOMIA:(30-40%)

• Elevation of
maternal free
fatty acids

• Maternal
hyperglycemia
• Congenital malformation(6-10%)
• Neonatal hypoglycaemia(<37mg/dl)
• Respiratory distress syndrome
• Hyperbillirubinaemia
• Polycythemia
• Hypocalcemia(<7mg/dl)
• cardiomyopathy
Long term effects:
• Childhood obesity
• Neuropsychological effects and diabetes
• Stillbirth
• Perinatal mortality(2-3 times)
GDM
WHO ARE THE POTENTIAL CANDIDATES ?
• Positive family history of diabetes (parents or siblings).

• Previous birth of an overweight baby of 4 kg or more

• Previous stillbirth with pancreatic disease..

• Unexplained perinatal loss.

• Presence of polyhydramnios or recurrent vaginal candidiasis in present pregnancy.

• Persistent glycosuria

• Age over 30 years

• Obesity

• Ethnic group (East Asian, Pacific Island Ancestry)

Whom should you plan for screening for GDM?

• Low risk- absence of any risk factors mentioned above.

• Average risk- some risk factors

• High risk- blood glucose test as soon as feasible.

• (50gm oral glucose challenge test without regard to time of day or

last meal, between 24-28 weeks of pregnancy.)
Hazards of GDM

• Increased perinatal loss associated with fasting hyperglycaemia .

• Increased incidence of macrosomia

• Polyhydramnios

• Birth trauma

• Reoccurrence of GDM in subsequent pregnancy is about 50 %.

Management
• Aim
Achieve maternal near normoglycemic level to prevent adverse perinatal
outcomes
Diagnostic Tests Used to Assess and Manage Diabetes.
• Blood glucose-Random, Fasting, Postprandial, Capillary Blood Glucose.
• Glucose Tolerance test.
• HbgA1C or A1C.
• Glycosylated Albumin
• Ketonuria
• Proteinuria : Albuminuria, Microalbuminuria
• BUN, Creatinine, GFR.
Diagnosis of Diabetes

• Fasting Plasma Glucose > 126 mg/dl

• Symptoms of DM and a random blood glucose level of > 200 mg/dl.

• Oral glucose tolerance test – 2 hr after 75 gm glucose load > 200 mg/dl.
 Management
• Close antenatal supervision.
• Periodic FBS/PP . FBS < than 90mg/dl.
• Maintenance of mean plasma blood glucose between 105 and 110 mg/dl.
• Diet, exercise with or without insulin.
• Human Insulin should be started if FBS exceeds 90mg/dl and 2 hours
postprandial value is greater than 120 mg/dl(repetitive) even on diet
control.
• Diet- normal woman (2000-2500kcal/day) and restriction to 1200-1800
kcal/day for over weight woman is recommended.
• Exercise (aerobic, brisk walking) programmes are safe in pregnancy.
Obstetric management
• Spontaneous labor for good glycaemic control.

• Elective delivery for uncontrolled GDM, requiring insulin or with

complications (macrosomia) at around 38 weeks.