Diabetes Mellitus

in Pregnancy
BAYA PRECIOUS MAR HAN
CORDENILLO REMEJAY
DIAO JOSHUA
DIABETES MELLITUS IN PREGNANCY

01 TAKE OFF CASE

02 DIABETES MELLITUS DEFINED

DIAGNOSIS
03

TREATMENT AND MANAGEMENT

04
TAKE OFF CASE
General Data
A case of P.L.
31 y.o.
G2P1
 C.S (1001)
Married
Filipino
Catholic
Cebu City
Past medical Hx
 2017-1st Pregnancy diagnosed
with Gestational Diabetes Mellitus
 C.SControlled
-Diet
 Non hypertensive, Non Asthmatic
 No Previous Hospitalizations
 No Previous Surgeries
 Heredofamilial Disease: Diabetes
Mellitus on paternal side
 Food and Drug allergies: None
Personal and Social History
 Non smoker
 Non alcoholic beverage drinker
 No history
C.S of illicit drug use
Menstrual History
 M- 12 y.o.
 I- regular
 C.S
 D- 5-7 days
 A- 2 pads/day fully soaked
 S- no dysmenorrhea
Sexual History
 C- 29 y.o.
 P- 1 partner
 C-none
C.S
 P- 2017 (unremarkable)
 S- (-)Sexually transmitted disease
 Obstetric History
OB score: G2P1 (1001)
Year Type Duration of Gender Weight Remarks
 C.S Pregnancy
G1 2017 NSD FT M 3KG (+)GDM-
Diet
VCMC Controlled
Present Preg
G2 nancy
LMP-11/20/19
Obstetric History
G2- Present Pregnancy
 LMP: 11/20/18
 PMP:
 C.S 10/2018
 AOG: 37 1/7 weeks
Prenatal History
 Noted missed menses for 2 months
 Pregnancy test done (+)
 1stPNC
C.S at 12 weeks AOG under PD ser
vice, regular visits thereafter
 Transvaginal ultrasound done, showed
Intrauterine Pregnancy 12 2/7 weeks
AOG by Crown Rump Lenght, no subcho
rionic Hemorrhage
Prenatal History
 Meds given: Folid Acid 1 tab OD, Calcium
Tab BID
 Initial labs requested, all unremarkable
 C.S
except for 75grams OGTT: showing Fastin
g Blood Sugar- 76 mg/dl, 2HR- 179 mg/dl
 Patient diagnosed with Gestational Diabet
es Mellitus and advised for Capillary Bloo
d Glucose monitoring
Prenatal History
 CBG monitoring (Pre meals= 72-95 mg/dl
2H Post Prandial 79-118mg/dl)
 C.S
 Pelvic UTZ done at 26 2/7 weeks AOG, s
howed Intrauterine Pregnancy 26 3/7 wee
ks AOG by Fetal Biometry, cephalic, place
nta anterior, high lying grade I, adequate A
mniotic Fluid Volume, Estimated Fetal Wei
ght 987 grams, Appropriate for gestational
Age
Prenatal History
 Biophysical Profile done at 331/7 weeks
AOG and showed Intrauterine 34 1/7
weeks,
 C.Scephalic, BPP score 8/8

 HBAIc of 5.4%

 No history of maternal illness

 No history of BP elevation
Chief complaint
 watery vaginal discharge

HPI  C.S

 1 hour Prior to admission, noted sudden g

ush of watery vaginal discharge, associate
d with irregular uterine contractions with g
ood fetal movement. Persistence of sympt
oms prompted admission
Physical Exam
GS-Awake conscious coherent, Not in
respiratory distress

V/S of: BP- 110/70 mmHg, PR-80 bpm, R

R-20cpm, T- 36.3, W- 127 lbs, H- 158cm,
BMI- 22.8

Skin: warm, good turgor and mobility

HEENT: Anicteric sclerae, Pink palpebral
conjunctiva
C/L: Equal chest expansion, clear breath
sounds
CVS: Distinct heart sounds, (-) murmur
Physical Exam
ABD: Gravid, fundic height- 29cm, EFW- 2,48
0g, FHT 140bpm

L1-Breech L2-FB left L3-unengaged L4-Ceph

alic
GUT: Speculum exam: + pooling of clear amn
iotic fluid
Ruptured BOW, clear, Cephalic
IE- 5cm dilated cervix, 60% effaced, medium i
n consistency, midposition, station minus 3,
Bishop’s score of 7
Ext: SPP, CRT < 2 sec
 G2P1 (1001), Pregnancy Uterine, 37 1/7
weeks AOG, Cephalic in labor , Premat
ure Rupture of Membranes, Gestational
Diabetes Mellitus- Diet Controlled

Impression
DIABETES MELLITUS DEFINED
 Diabetes Mellitus in Pregnancy
group of common metabolic disorders that share the phenotype of hyperglycemia
WHO 1998: “ any degree of glucose intolerance with onset or 1st recognition
during pregnancy”

1) delineate between those with probable pre existing diabetes that is 1st
identified during pregnancy from those women whose condition is mere
transient manifestation of pregnancy induced insulin resistance
2) reflect greater morbidities associated with pre existing diabetes mellitus
compared with gestational diabetes
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 Carbohydrate Metabolism in Pregnancy

mild fasting hypoglycemia, postprandial hyperglycemia, and hyperinsulinemia

gravidas demonstrate prolonged hyperglycemia and hyperinsulinemia

pregnancy induced state of peripheral resistance w/c ensures sustained post

prandial supply of glucose to the fetus

Mechanism: endocrine and inflammatory factors

Prevalence

<1-28% World wide

ASGODIP

14% Philippines
 Types of Diabetes

TYPE 1: B cell destruction, usually absolute insulin deficiency

Immune mediated
Idiopathic

TYPE 2: Ranges from predominantly insulin resistance to predominantly an

insulin secretory defect with insulin resistance

Other types: Genetic defects, genetic syndromes, Endocrinopathies, Drug

induced, Infection

Gestational Diabetes
 Classification During Pregnancy

OVERT DIABETES MELLITUS

first recognized during pregnancy but levels meet standard nonpregnant
criteria for diabetes as set by ADA
may reflect undiagnosed pre existing type 2 DM

GESTATIONAL DIABETES MELLITUS

milder form of hyperglycemia
induced by pregnnacy related insulin resistance
 Risk Factors Associated with Hyperglycemia in
Pregnancy
 BMI > 25 kg/m2
 Previous macrosomic baby
 Family
 history
C.S of diabetes
 Ethnic origin with high prevalence of diabetes
(Asian, Aboriginal, Pacific Islander)
 HbA1c >/= 5.7%, IGT, IFG on Previous Testing
 History of Cardiovascular Disease
 Hypertension (>/= 140/90 mmHg or on therapy for
hypertension)
 Risk Factors Associated with Hyperglycemia in
Pregnancy
 HDL cholesterol level, 35 mg/dL and/or a
triglyceride level >/= 250 mg/dL
 Women  C.S
with Polycystic Ovary Syndrome
 Physical Inactivity
 Other clinical Conditions associated with insulin
resistance (e.g severe obesity)
 Previously elevated blood glucose level
 Age >/= 40 years
 Medications: Corticosteroids, Antipsychotics
 Impact on Pregnancy
PREGESTATIONAL DIABETES
FETAL EFFECTS
Spontaneous abortion, preterm delivery, malformations, altered fetal growth,
unexplained fetal death, fetal effects, hydramnios
NEONATAL EFFECTS
Respiratory distress syndrome, hypoglycemia, hypocalcemia, hyperbilirubinemia
and polycythemia, cardiomyopathy, long term cognitive development, inheritance
of diabetes
MATERNAL EFFECTS
Preeclampsia, Diabetic Nephropathy, Diabetic Retinopathy, Diabetic Neuropathy,
Infection
 Impact on Pregnancy

GESTATIONAL DIABETES
MATERNAL AND FETAL EFFECTS
Unexplained stillbirth, malformation, higher frequency of hypertension and
cesarean delivery, fetal macrosomia, neonatal hypoglycemia, maternal obesity
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Maternal
complications
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Maternal
complications
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Fetal
complications
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Fetal
complications
DIAGNOSIS
 Screening

 GDM is one of the most common medical problems in

pregnancy (3-5%)
 Significant risks
 Adverse outcomes increases as FBS & OGTT value increases
 Whom to screen?

 Risk factors:
 >25 Y.O.
 <25 Y.O. + BMI >27 kg/m2
 Pre-pregnant weight >110% of ideal body weight
 BMI >30 kg/m2
 First degree relatives with DM
 Previous baby >4.1kg
 Whom to screen?

 Personal history of abnormal glucose tolerance

 Filipino (pacific islander ethnicity)
 Previous unexplained perinatal loss or malformed
child
 Glycosuria at first PNC
 Polycystic Ovarian Syndrome
 Current use of corticosteroids
 hypertension
3 forms of intolerance (ADA)
Insert the title of your subtitle Here

Type 1 DM Type 2 DM Gestational DM

01 Often diagnose 02 03
in childhood  More overweigh  Glucose
Immunologic t intolerance i
destruction of  Can often be co dentified d
b-cells in the ntrolled through uring p
pancreas diet modification
regnancy
DKA is more  Insulin
 May resolve
common resistance
postpartum
 Diagnosis in the nonpregnant state

Normal values Impaired glucos DM

e tolerance
Fasting plasma gl <100 mg/dL 110-125 mg/dL >126mg/dL
ucose
75g OGTT (2h) <140 mg/dL 140-199 mg/dL >200 mg/dL
Symptoms of DM
and plasma gluco
se (without regar
d to time of last m
eal) >200mg/dL
 Diagnostic criteria of GDM
75g OGTT (WHO 75g OGTT (IADP 100g OGTT (Car
) SG) penter & Cousta
n)
Fasting plasma gl 95 mg/dL 95 mg/dL 95 mg/dL
ucose
1hr 180 mg/dL 180 mg/dL 180 mg/dL
2h 155 mg/dL 153 mg/dL 155 mg/dL
3h 140 mg/dL
 POGS-CPG consensus

WHO IADPSG/ADA co POGS-CPG cons

nsensus ensus
FBS > 125 mg/dL >92 mg/dL >92 mg/dL
1h > 180 mg/dL
2h > 140 mg/dL > 153 mg/dL > 140 mg/dL
 POGS-CPG consensus

Fasting plasma glucose >126 mg/dL

HbA1C >6.5%
Random plasma glucose >200 mg/dL
MANAGEMENT
 Recommendations for Filipino women
based on POGS CPG consensus

POGS
CPG
 Preconception evaluation & prevention

 HbA1c levels should be as close to normal as possible (<7%) be

fore conception is attempted (Level II-2, Grade B)
 Starting at puberty, preconception counseling should be i
ncorporated in the routine DM clinic visit for all women of
childbearing potential (Level III, Grade C)
 Women who are diabetic and contemplating pregnancy should b
e evaluated, and If indicated, should be treated for retinopathy,
nephropathy and CVD (Level III, Grade C)
 Preconception evaluation & prevention

 Medications should be evaluated prior to conception

 ACE inhibitors
 ARBs
 Most insulin therapies
 Consider potential risks and benefits of meds which are contraindicated
in pregnancy in all women of childbearing potential, and counsel women
using medications accordingly (Level III, Grade C)
 Preconception evaluation & prevention
 Management of preexisting DM related complications:
 HPN
 Nephropathy
 Retinopathy
 Antepartum management

 Medical nutrition therapy should be an integral part of GDM manageme

nt.
 Assessment of food intake
 Physical activity
 Medication history and intake
 Weight status (before, during, after pregnancy
 Antepartum management
 MNT:
 May be administered as a sole management approach
 If sufficient to maintain normal glycemic control
 May be combined with pharmacologic tx/other ancillary measures to ach
ieve normal glycemia
 (Level I, grade A)
 Antepartum management

 MNT
 Nutrition requirements are the same for pregnant women with or without
GDM
 Weight management and energy intake need to be monitored throughou
t pregnancy
 Consumption of carbohydrates with low glycemic index is recommended
(Level I, Grade A)
 Antepartum management

 MNT
 Offering advice regarding alcohol consumption and smoking cessation i
s recommended (Level III, Grade C)
 Physical activity/exercise to improve glycemic control
 Reduce CVD risk
 Contribute to weight management goals
 Overall well being
 (Level I, Grade B)
 Antepartum management

Antepartum blood glucose management

1. Outpatient glucose targets
a) For GDM: (Level III, Grade C)
Preprandial glucose concentrations <95 mg/dL
1h postmeal glucose <140 mg/dL
2h postmeal glucose <120 mg/dL
 Antepartum management

2. Treatment of hyperglycemia in pregnancy

If unable to maintain normoglycemia with a carbohydrate restricted diet is i
nsulin
 Antepartum management

3. Monitoring
If on diet treatment alone, patient may monitor CBG QID
Fasting blood glucose once a day
Postprandial blood glucose 3x a day
If with pharmacological therapy, patient may monitor 4-6x/day
Include preprandial values
 Antepartum management

 Antepartum fetal surveillance

 Screening for congenital anomalies
 Monitoring for fetal well being
 Ultrasound assessment for EFW
Antepartum management

Fetal monitoring techniques

1. Perceived fetal movements
2. Ultrasound evaluation
3. Non Stress Test
4. Contraction Stress Test
 Intrapartum management

Intrapartum blood glucose control

1. During labor:
Targets for control during labor:
Capillary glucose 70-110 mg/dL
Last insulin dose is given SQ night before or morning
Monitor plasma glucose every 1-4h
Give short-acting insulin via IV infusion @ 0.5-1 unit/hr for plasma
glucose above 120 mg/dL
Discontinue IV insulin immediately prior to delivery
 Intrapartum management

Intrapartum blood glucose control

2. For elective Cesarean Section patients:
Last insulin dose SQ night before
Random plasma glucose immediately prior to CS
Short acting insulin 0.5-1 unit/hour for plasma glucose about 120 mg/d
L
Discontinue IV insulin immediately prior to delivery
Check plasma glucose q2h post CS for up to 24h
 Intrapartum management

Intrapartum blood glucose control

3. Immediate postpartum period

 Plasma glucose q4-6h for 24h

 SQ insulin when indicated
 Intrapartum management

Intrapartum fetal surveillance and delivery

 Postpartum management

 Status of glucose metabolism

 Postpuerperal reclassification
 Longterm prevention/delay of type 2 DM
 THANK YOUREFERENCES
GUYTON AND HALL PHYSIOLOGY 11TH EDITION
HARRISON’S 20TH EDITION
WILLIAM’S OBSTETRICS 25TH EDITION
CPG ON DIABETES MELLITUS IN PREGNANCY
2019 ANNUAL POST GRADUATE COURSE ELISES MOLON: GDM