Diabetes in Pregnancy

Umar Zein
FK UNPRI
MEDAN
 Diabetes in Pregnancy

 Epidemiology
 Classification
 Pathophysiology
 Morbidity
 Fetal
 Maternal
 Diagnosis
 Treatment and Management
 References
 Epidemiology

 4-6% of pregnancies are complicated by

DM, accounting for 50-150 thousand
babies per year.
 88% GDM, 8% Type II DM, 4% Type 1 DM
 Prevalence also varies by race
 1.5-2% in Caucasians, 5-8% in Hispanic,
Asian and African Americans, and up to
15% in some SW Native American groups.
Classification
 Pathophysiology

 Normal pregnancy is
characterized by:
 Mild fasting hypoglycemia
 Postprandial hyperglycemia
 Hyperinsulinemia
 Due to peripheral insulin
resistance which ensures
an adequate supply of
glucose for the baby.
 Pathophysiology
 Human Placental Lactogen (HPL)
 Produced by syncytiotrophoblasts of
placenta.
 Acts to promote lipolysis  increased FFA
and to decrease maternal glucose uptake
and gluconeogenesis. “Anti-insulin”
 Estrogen and Progesterone
 Interfere with insulin-glucose relationship.
 Insulinase
 Placental product that may play a minor
role.
A Vicious Cycle???
 Fetal Morbidity

 Miscarriages
 Frequency directly related to degree of
maternal glycemic control.
 Up to 44% with poorly controlled DM
(HbA1C >12).
 Preterm Delivery
 Increase in both spontaneous and
indicated preterm labor (<35 wks).
 Fetal Morbidity

 Birth Defects
 1-2% risk among the general population.
 4-8 fold increased risk among preexisting
diabetics.
 Most common defects are CNS and CV,
but also an increase in renal and GI
abnormalities.
 Up to a 600 fold increase in caudal
regression syndrome.
 Fetal Morbidity

 Macrosomia
 Defined as birthweight above 90th % or
>4000 grams.
 Occurs in 15-45% of diabetic
pregnancies, a 4-fold increase over
normal.
 Carries many morbidities including birth
trauma, RDS, neonatal jaundice and
severe hypoglycemia.
 Fetal Morbidity

 Growth Restriction
 Although we typically associate maternal
DM with macrosomia, growth restriction
is fairly common among Type 1 diabetic
mothers.
 Best predictor is presence of maternal
vascular disease.
Fetal Morbidity
 Fetal Morbidity

 Polycythemia
 Hyperglycemia stimulates fetal erythropoeitin
production.
 Can lead to tissue ischemia and infarction.
 Hypoglycemia
 Think of as an “overshoot” mechanism.
 Baby is used to having lots of maternal glucose so
it makes lots of insulin. When born, maternal
glucose is no longer available but insulin remains
high  hypoglycemia.
 Can lead to seizures, coma and brain damage.
 Fetal Morbidity

 Postnatal hyperbilirubinemia
 Occurs in appox. 25%, double that of
normal.
 Thought to be due in large part to
polycythemia.
 Respiratory distress syndrome
 5-6 fold increased frequency.
 May be due to a delay in lung maturation
or simply due to the increased frequency
of preterm deliveries.
 Fetal Morbidity

 Polyhydramnios
 Amniotic fluid volume >2000 mL.
 Occurs in 10% of diabetics.
 Increased risk of placental abruption and
preterm labor.
 Maternal Morbidity

 Increased risk of DKA due to

increasingly resistant DM.
 Increased incidence of UTI due to
glucose-rich urine and urinary stasis.
 Glucosuria is a normal finding of
pregnancy but may be much higher in
diabetics.
 Diabetic retinopathy
 Diabetic nephropathy
 Maternal Morbidity

 Diabetic neuropathy
 Preeclampsia
 2-fold increase
 Diagnosis

 Glucose Challenge Test (24-28 wks)

 50 gram glucose load with blood level 1
hour later.
 Does NOT require fasting state.
 Normal finding is <140 mg/dl.
 If >140, need to do a 3 hour glucose
tolerance test.
 Diagnosis

 Glucose Tolerance Test

 Draw a fasting glucose level (normal<95).
 Give 100 gram glucose load with glucose
levels drawn after 1, 2 and 3 hours.
 Normal levels vary widely depending on
who you ask but should be in the
following ranges:
1 hr:<180 2 hr:<155 3 hr:<140
 2 or more abnormal values = GDM.
Treatment and Management

 Obviously the main goal is to

maintain good glycemic control.
 Typically controlled with insulin but oral
hypoglycemic agents like glyburide are
also showing promise.
Treatment and Management

 Obstetrical management
 Serial US to trend fetal growth, AFI and fetal
anatomy
 Fetal well-being monitored with kick counts,
NSTs, BPPs
 Postpartum, 95% of GDM mothers return
to normal glucose tolerance, and require
no further insulin.
 Glucose tolerance screen 2-4 mo. postpartum
to detect those that remain diabetic.