DIABETES MELITUS IN

PREGNANCY.

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DR S.A. OKOGBENIN
CONSULTANT : IRRUA SPECIALIST
TEACHING HOSP.
LECTURER :AMBROSE ALLI UNIVERSITY

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 Introduction
• Definition: metabolic disorder
– Abnormality in carbohydrate metabolism
– Relative or absolute insulin lack.
• 20th century witness remarkable outcome.
• Before this life expectancy was short
• Survivors had infertility.
• Those who got pregnant had disastrous
outcome. MM=30-60%, PM=60%.
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 Introduction cont.
• In 1921 banting and best discovered insulin.
• Fertility was restored
• MM improved remarkably.
• PM remained high
– Fetal macrosoma, and IUFD were the causes.
– Early delivery & C/S were the antidote.
– Late IUFD was still a problem.
• 1930 White classification.
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 Introduction cont.
• 1930 White classification, fetal risk was
proportional to severity of mat diabetes,this
permitted individualized timing of delivery
and perinatal survival =85%.
• TODAY, refinement in management has
reduced PM to near that of normal
pregnancy, except for cong. abnormality.

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 Classifications
• Type 1: Insulin dependent
– Immune mediated in genetically susceptible
persons.
– Predisposition is permissive rather than causal.
– Abnormality in Chromosome 6
– Monozygotic twins =50%
– Low vertical transmission.

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 Classifications
• Type 2, non insulin dependent.
– FAMILIAL
– Monozygotic twins=100%
– Older, obese and less severe.

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 Classification in pregnancy
• Overt D.M .Gestational
Chronic ,10% 90%
Type 1 or type2

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 Classification in pregnancy
• Overt DM, • Gest. DM. 90%.
chronic,10% .Type 1or • Carbohydrate intolerance
type 2 of varying severity with
onset or first recognition
in preg.
• Change in glucose
metabolism
• Type 2 unmasked in preg.
• In 20yrs 50% will develop
diabetes
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 White classification
Class Onset FBS 2HPP THER
A1 GEST <105 >120
A2 GEST >105 >120
B >20Yr <10yr -
C 10-19 10-19 -
D <10 >20 B. Reti
F any any Neph
R any any P.reti
H any any heart
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 Pregnancy&cho metabolism
• Reduced insulin sensitivity.
• Increased fasting insulin
• Increased diabetogenic hormones
• Increased insulinase
• In diabetics, insulin requirement increases
in preg.

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 Pregnancy effects on DM
• More difficult to control
• Proliferative retinopathy may worsen but
the course of background retinopathy and
nephropathy does not change,instead it is
nephropathy assoc with HT and proteinuria
that worsen pregnancy outcome.
• No other long term effect of preg on DM.

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 Effect of DM on Pregnancy
• Spont.abortion
• Cong. Abnormality
• Fetal death
• Macrosoma
• Perinatal mortality
• Preterm delivery
• polyhydramnios
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 Effect of DM on preg.
• Infections
• PIH.

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 DIAGNOSIS
• SYMPTOMS & SIGNS
• SCREENING
– No consensus
– FBS,2HPP. RBS
– 50% glucose oral challenge, 1hr glucose
140mg/dl. 130mg/dl
– Universal or selective.
– Timing of screening.

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 Diagnosis cont.
• 75g glucose OGTT (WHO)
• 100g OGTT (ACOG) 3hr monitoring

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 Management
• Prepregnancy clinic
• Combined management
• Early booking and dating
• More frequent visits
• Admit for stabilization
• Dietary contol
• Mild exercise
• Use insulin not oral hypoglyceamics
• Various insulin regime(Post prandial survillance
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 Management cont
• Alpha fetoprotein
• USS at 20 weeks
• Value of antenatal testing.
• Timing& mode of delivery
• Insulin management in labour.
• Avoid prolong labour
• 1-2hourly glucose measurement.
• Intraprtum monitoring.
• SHOULDER DYSTOCIA
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 Post partum
• Titrate insulin
• OGTT 6-12 WEEKS LATER
• OGTT 3YEARLY.
• 60-70% reccurrence.of GDM
• CONTRACEPTION

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 NEONATE
• MACROSOMIA
• RDS
• Hypoglycaemia
• Hypocalaemia
• Hyperbilirubin
• Polycytaemia
• Perinatal mortality=2-4%( cong abn,unexp IUFD)
• cardiac hypertrophy.
• 1-3% inheritance.
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