Medical Complications in Pregnancy:

DIABETES MELLITUS
MUHAMMAD ZULHILMI BIN ABU BAKAR
DEFINITION
 A metabolic disorder of multiple aetiology
that affects the normal metabolism of
carbohydrates, fats and protein
characterized by chronic hyperglycemia as a
result of defective in insulin secretion,
insulin action or both
diagnosis
 Fasting plasma concentration: >7.8 mmol/L
 2 hour plasma concentration(OGTT): >11.1
mmol/L
 If two hours level are between 7.8 and
11.1,most likely pt. have impaired glucose
tolerance test.(pre diabetes)
CLASSIFICATION
1. Type 1(IDDM)
2. Type 2(NIDDM)
3. Gestational diabetes
4. Others -genetic defects in insulin processing or action
-endocrinopathies
-drugs
-exocrine pancreatic defects
-genetic syndromes associated with dm
DIABETES IN PREGNANCY

Gestational
90%
Diabetes in
pregnancy
Pregestational
10%
 Gestational diabetes mellitus(GDM)
Gestational diabetes mellitus(GDM)

 Defined as glucose intolerance of variable

severity with onset or first identified during
the present pregnancy.
 Constitutes 90 percent of diabetes in
pregnancy
 Generally occurs in the latter half of
pregnancy.
 Therefore it has no effect on organogenesis
and does not cause congenital defects
 Disappear after delivery
 Pregestational diabetes
Pregestational diabetes

 Either type 1(iddm) or type 2(niddm)

 Type 1 occurs in younger age group and end
organ complications is likely to be
more.Hence they to have increased maternal
and obs risks
 Type 2 usually occurs in obese patients and
have less maternal and obs compared to type
1
 PREGNANCY AS A
DIABETOGENIC STATE
 Pregnancy alters carbohydrate in such away more glucose is
made available to the fetus

What cause the diabetogenic state?

 Elevated placental hormones such as
estrogens,progesterone,prolactin,human placental lactogen.
 Plasma cortisol also rises during pregnancy.
 Cause ‘contrainsulin’ effect and state of insulin resistance
 Further aggravated by increase body weight and increase caloric
intake during pregnancy
 Gestational diabetes develops when the pancreas ,despite the
production of insulin cannot overcome the effect of these
counter regulatory hormones
 In contrast pregestational diabetes becomes worse during
pregnancy
 RISK FACTORS
1. Historical factors
 Age>30 years
 Previous gdm
 Family history of dm
 Bad obs history
 History of macrosomia
 Prev. fetal anomalies
 History of recurrent abortions or unexplained stillbirth
 Drug history-steroids,tocolytic drug
2. Clinical factor in the present pregnancy
 Congenital fetal anomalies
 Pre-eclampsia
 Obesity>90 kg
 Recurrent uti,vaginal candidiasis
 Presence of glycosuria on more than 2 occasions
SCREENING FOR DIABETES
 Gdm is asymptomatic ,hence we need screening test to detect
gdm
1. Universal screening(all pregnant women)
2. Selective screening(presence of risk factors for gdm)

 for universal screening –do the glucose challenge test

No special preparation is needed for this test
50 grams of oral glucose is given between 24 to 28 weeks pog

Blood glucose is determined 1 hours later.

A plasma glucose level of > 7.8 is considered significant to perform

comfirmation diagnostic test.

 Selective screening-oral glucose tolerance test

75 grams of oral glucose is given

Only 2 reading are taken-fasting glucose level and 2 hour post glucose

The diagnosis of dm is made when fasting glucose level are ≥7.8 and or 2
hour level of >11.1

If the 2 hours levels are between 7.8 and 11.1,the patient is said to have
impaired glucose tolerance test and should be treated as gdm.
MATERNAL COMPLICATIONS
1. Pre-eclampsia
2. Recurrent infection-vaginal candidiasis,uti
3. Retinopathy
4. Nephropathy
5. Neuropathy
6. Micro/macroangiopathy
7. Polyhydramnios—pprom, cord prolapse,
8. ketoacidosis
9. Increased instrumental and CS rates
10. Study shows that after gdm,40-60% of
women develop type 2 dm within 10 years
FETAL COMPLICATIONS
1. Miscarriage
2. Congenital anomalies(4 fold)-sacral
agenesis,ntd,cardiac and renal anomalies
3. Macrosomia
4. Respiratory distress syndrome
5. Hypoglycemia-result of hyperplasia of beta
cell
6. SIUD
7. Prematurity
8. Malpresentation
9. Shoulder dystocia.
10. polycythemic -jaundice
INVESTIGATION
1. Blood sugar level-weekly assessment is
required.useful in deciding wether to start
insulin or adjusting insulin dosage
2. Urine microscopy and culture-to exclude
uti(bacteriuria)
3. HbA1c-done in first trimester.it gives
retrospective assessment 12 weeks
ago.high HbA1c at the end of first
trimester indicates sugar control was poor
during organogenesis period.
4. Maternal serum AFP-done between 16 to
20 weeks pog
5. Diagnostic imaging-gestational age, fetal
abnormalies, fetal growth, liquor volume .
6. Doppler of umbilical artery-done in cases of
diabetic vasculopathy
MANAGEMENT-
THE KEY TO SUCCESSFUL MANAGEMENT IN DIABETIC PREGNENCY IS EARLY
DIAGNOSIS WHICH ALLOWS TREATMENT TO BE STARTRED EARLY.

Antenatal management
 Plasma glucose level should be maitained between 4-6
mmol/L
 Early dating and scan to exclude fetal abnormalities
 Diet control should be attempted first.if fail,insulin
should be started.
 Admission-poor blood sugar
control,PIH,polyhydramnios.bsp should be monitored
 Timing for delivery-if on insulin,38 weeks,if on diet
control,can prolonged to term
 Mode of delivery-lscs if macrosomia
baby,malpresentation,evidence of fetal compromise
 Check BP
 Fetal growth chart
 Monitor closely with continuos ctg
TREATMENT
 Oral hypoglycemic drug are generally not
recommended as it can cause teratogenic effect
towards fetus and can cross placenta causing
hypoglycemia

 Diet therapy
 Total calories advised is 24-30 kcal/kg of the
present body weight.In obese diabetic pt.
24kcal/kg is adviced
 The calories should be distributed between 3
meals and 3 snacks
 Dietery control decrease postprandial glucose
level and it also improve insulin action.
 Blood glucose level and weight gain can be used
to formulate a meal plan
 Exercise
 Light exercise help by lowering fatty acid
 Contracting muscle help stimulate glucose
transport hence decrease blood sugar
 Better done after meals
 Exercise involving the muscle of upper part of
the body is sufficient to lower down glucose
level.
 Insulin regimes
 15% required insulin therapy
 Insulin is indicated in all pregestational diabetes
and poorly controlled gdm
 The popular regimes use a mixture of short
acting and medium acting insulin
Pre-pregnancy counselling
 This play an important roles for
pregestational diabetes in order to prevent
early pregnancy loss and congenital
anomalies.
 Complete assessment of diabetic status
should be done to find out wether she fit to
go through pregnancy.HbA1c can be done to
evaluate blood glucose control 12 weeks ago.
 Those with oral hypoglycemic should be
switched to insulin theraphy.
THE RULE OF 15 FOR GDM
 15% of pt. with positive gct will have gdm
 15% percent of GDM will required insulin
 15% of GDM will have macrosomia
 15% of GDM will have impaired gtt after
delivery