Management of Diabetes during

pregnancy

Prof . Aboubakr Elnashar

Benha university, Egypt

Aboubakr Elnashar

Diabetes during pregnancy:

1. Gestational diabetes mellitus (GDM).

2. Pregestational diabetes:

type 1 diabetes mellitus (T1DM)

type 2 diabetes mellitus (T2DM).

Aboubakr Elnashar

Preconception care 1. Educate

2. Encorage

3. Review

4. Assess

Antenatal care •Screening & Diagnosis

•M: G control

Assess

•F: Wt

Wellbeing

Cong mal

Delivery

Intrapartum care Monitor Blood glucose

Postpartum care Aboubakr Elnashar

A. Pre-Conception Care

I. Health education: 1. Risks of DM can be reduced but not eliminated.

2. Avoidance of unplanned pregnancy:

HbA1C 10%: Don't allow

HbA1C 6.1%: allow

3. Hypoglycaemia awareness.

4. Pregnancy-related nausea/vomiting & their effect

on glycaemic control.

5. Frequent appointments during ANC.

Aboubakr Elnashar

Risks

Miscarriage

Cong malformation

Stillbirth

Macrosomia (>4 kg or birth

wt centile >90)

Sh dystocia: B trauma

Res distress

Neonatal hypoglycemia

and poor feeding

Hypoglycemia

D Ketoacidosis

Induction of labour

or CS

PET

Worsening of Retinal

and renal dis

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II. Encourage patient to: 1. Dietary restrictions

2. Exercises

3. Reduce wt if BMI 27

4. Self-monitoring by glucometer

monthly HbA1C

ketone strips.

Aboubakr Elnashar

III. Review, replace& offer mediations: 1. Discontinue:

a. Hypoglycaemic agents except: Metformin

Glibenclamide (Daonil). b. Anti-hypertensive agents e.g. angiotensin-converting enzyme inhibitors (ACE) (Captopril)* angiotensin-II receptor antagonists )angiotensin ii receptor blocker) (ARB) (Candesartan, eprosartan, irbesartan,

losartan, olmesartan, telmisartan, and valsartan ( Diovan c. Anti- cholesterol e.g Statin (Levacor, Zocor, Pravachol, Lipitor,

Crestor( 2. Give: Folic Acid (5 mg OD)

*Captopril (Category D): oligohydramnios, pulmonary hypoplasia, IUGR

Aboubakr Elnashar

Safety of medications before and during

pregnancy Metformin:

safe

Rapid-acting insulin analogues(aspart, lispro):

safe

long-acting insulin analogues (ultrlent, glargine) :

Evidence is limited.

Isophane (NPH) insulin:

first-choice long-acting insulin during pregnancy.

Aboubakr Elnashar

IV. Assess: 1. Retina

2. Renal function: refer to Nephrologist if

(i) Microalbuminuria 2 gm /d

(ii) Creatinine 120 M mol/L=1.25 mg

1mg=88.4 M mol/L

3. Thyroid status:

D.M. Type I

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B. Antenatal care

I. Screening

•Who?

All pregnant women.

•When:

At booking

At 24-28 w

•How?

FBS: 90 > mg/dl

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•FBG:

High sensitivity (81%)

Good specificity (76%) with a cut off of 86 mg/dl (4.8

mmol/l) (Perucchini et al, 1999)

Easier

Cheaper

More acceptable

Can be applied to all pregnant women

More than once during pregnancy.

Suitable for screening

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II. Diagnosis The 75 g WHO OGTT Fasting venous & capillary blood glucose are similar.

After a meal or a glucose challenge, capillary are higher than

venous levels.

It is not necessary for both values to be abnormal

No need for GTT

FBS 125 mg/dl or

Random venous plasma glucose 200 mg/dl if

confirmed on a subsequent day

Plasma glucose Mg/dl

Fasting 100

2-h 145

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Recommendations of International Association of

Diabetes and Pregnancy Study Groups (IADPSG)

2010

1-step 75-g OGTT

screening at-risk individuals during 1st ANV.

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1. Diabetic Centre

2. ANC clinic: /1-2 w

Objective:

Medical TT: M: Glycemic control

Retinal and renal assessment

Obstetric TT: F: wellbeing

Wt

Cong malformation

Delivery

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Medical treatment Goals

achieving normoglycemia

preventing postprandial glucose excursions

optimizing compliance

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I. Glycemic control

Objective:

These targets are the same for type 1, type 2 and

gestational diabetes).

{1. Outcomes (birth-weight and neonatal hypoglycaemia)

correlate better with postprandial than with preprandial

glucose levels.

2. Postprandial targets: better improvements in maternal

HbA1Clevels}.

Capillary blood

glucose

Mg/dl(mmol/L)

Fasting <105(5.9)

1 Hour <140 (7.8) 2 Hours <125 (7.0)

Aboubakr Elnashar

Fasting and premeal blood glucose: 90 mg/dL

(5.0 mmol/L) and

Postprandial glucose: 120 mg/dL (6.7 mmol/L).

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Monitoring

1. SMBG: self-monitored blood glucose

Fasting levels and 1 h after every meal. 1H is

recommended (NICE, 2008)

Women taking insulin should also test before

bedtime

Experts recommend that finger-stick blood

glucose measurement be performed 6–8

times/d, specifically, first thing in the morning

(fasting), premeal, 1 h after the start of each

meal (postprandial glucose), and at bedtime.

In pregnancy, postprandial serum glucose peaks

at approximately 1 h after a meal.

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2. Hb A1c

weekly.

extremely useful, in conjunction with patient

diaries, to assist patients to achieve excellent

glycemic control and prevent the complications of

diabetes in pregnancy.

Do not use HbA1c routinely in 2nd and 3rd

trimesters

{1. falls in response to physiological changes in

pregnancy

2. Time scale is not appropriate in pregnancy

Reflects BG levels in the preceding 4-12 w and

not subtle changes in BG}.

Aboubakr Elnashar

3. Women with type 1 diabetes should be offered

ketone testing strips for use if they become

hyperglycaemic or feel unwell

4. More evidence is being published that supports

a minimal weight gain for pregnant women who

are obese, which is a large portion of the GDM

and T2DM population.

5. Medical review on a regular basis (1-2 weekly)

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How?

1. Diet

•The first line therapy for 1-2 w

• > 30 w or FBS >105 mg/dl:

Insulin started simultaneously with the diet

•3 meals & 4 snacks with last snack at bed time

•Caloric needs acc to BMI (The American Diabetes Association, 2003)

< 30 kg/m2: 30 Kcal/kg

>30 kg/m2: 25 Kcal/kg

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Carbohydrates 40%

Protein 30%,

Fat 30% (Garner, 1995).

Concentrated sweets & added sugars: eliminated.

Complex CHO with high fiber contents: preferable

{slower glucose rise after ingestion}

The classic food pyramid model:

Recommends that carbohydrates such as bread,

cereal, rice, and pasta comprise the majority of the

meal, is now antiquated.

It has been replaced with a new meal planning target

that emphasizes more vegetables and whole grains

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2. Exercise •Reduce insulin requirement by as much as 50%.

•Effect appears after 4 w.

•1h after mealtimes.

•For 20-30 min

•Upper extremity or lower extremity ms excerises while

recumbent do not increase uterine contractions (Durak et

al, 1990 ;de Veciana and Mason, 2000).

Gentle aerobic exercise

Walking (Homko et al, 1998).

Aboubakr Elnashar

3. Insulin

•Types

NICE:

glulisine, glargine and detemir. are avoided during

pregnancy.

Lispro and Aspart benefits:

1. fewer hypoglycaemic episodes

2. better control Aboubakr Elnashar

Aboubakr Elnashar

Regular insulin: inappropriate for use during

pregnancy.

{cannot control the postprandial spike in blood

glucose adequately unless it is administered 60–90

min before the onset of the meal}

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Calculation of insulin dose:

1. Initial insulin dose: TDD

2. Adjustments acc to

a. meal and blood glucose diaries

b. results of point-of-care Hb A1c measurements.

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4. Oral hypoglycaemic agents:

Sulphonylureas, chlorpropamide, tolbutamide:

Not recommended for use in pregnancy.

1. crossed the placenta & stimulated fetal insulin

secretion: fetal macrosomia & hyperinsulinaemic

hypoglycaemia and seizures in neonates.

2. Major congenital malformations in animals

(Greene, 2000)

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Metformin and Glibenclamide= glyburide(Daonil)

Safe (NICE, 2008).

Metformin

PCOS: Decrease 1st T abortion & G DM

Cross placenta, but no increase in cong malformation

an alternative to insulin therapy in pregnant women

with type 2 diabetes

Glibenclamide

Cross placenta in small amounts New oral hypoglycemic: Nateglinide (Starlix)

Very few data

Aboubakr Elnashar

Hypoglycaemia

blood glucose of <3.5 mmol/L(63 mg/dl)

Common with:

1. Tighter glycaemic control

2. Type 1 diabetes: much more likely to suffer

recurrent hypoglycaemia (61%) than those with

type 2 (21%).

Educate family about the symptoms and tt of

hypogly-caemia.

Aboubakr Elnashar

Treatment:

1. Conscious:

a. consuming 10-15 g of glucose (4 teaspoons of

sugar, 1/2 a can of juice or 3 glucose tablets)

b. slower releasing carbohydrate (bread or a

sand-wich).

2. unconscious:

Glucagon (0.5-1 mg) IM: rapid onset and lasts 90

minutes.

Aboubakr Elnashar

3. In hospital:

150 mL of 10% dextrose IV

Once a patient is conscious, they should be given

oral therapy as above.

4. If after 10 m the blood glucose remains less

than 5 mmol/L(90 mg/dl), the treatment should be

repeated.

5. Insulin doses with the next meal should not be

withheld but may require modification.

Aboubakr Elnashar

Diabetic ketoacidosis (DKA)

occurs when there is insufficient insulin to

metabolize blood glucose.

1. failure to appreciate the increasing insulin

requirements in pregnancy

2. missed insulin doses

3. concurrent illness such as infection, steroid

therapy and stress.

plasma glucose: ≥12 mmol/L(216 mg/dl),

arterial pH: ≤7.3

ketonuria or ketonaemia

poor maternal and fetal outcome

CTG abnormalities are typical in 3rd T and resolve

with treatment of the hyperglycaemia. Aboubakr Elnashar

Treatment

should involve the diabetic teams,

treatment of the precipitating cause

intravenous insulin via a sliding scale.

continuous CTG may be necessary, but should be

given careful consid-eration. CTG abnormalities

are to be expected in a woman with DKA, and it

would be unsafe to perform an emergency

caesarean until the woman is stable from metabolic

and haemodynamic perspectives.

Severe hyperglycaemia requiring intensive

treatment is defined as persistent pre-meal blood

glucose values of greater than 12 mmol/L on two

consecutive occasions, or a random level of more

than 15 mmol/L(270 mg/dl). Involvement of

diabetologists is recommended as it is important to

Aboubakr Elnashar

II. Retinal and renal assessment

1.At booking if not done in the pre-ceeding 12 m

2.At 28 w if booking is normal

3.The presence of hypertension also worsens

progression of retinopathy, thus it has been

suggested that, in women with these

complications, blood pressure should be kept at

120-130/70-80 mmHg.

Betablockers should be avoided as

antihypertensives due to their possible adverse

effects of glucose metabolism.

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Obstetric

I. Screening for F malformation

1.Screening for Down Syndrome

2.Anomaly scan including detailed four-chambered

assessment of the fetal heart.

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II. Fetal wellbeing:

Indications:

Insulin is required

Poorly controlled diabetics

Hypertension

History of IUFD

Tests: no reliable test. A combination of tests must be employed.

Kick chart, NST, AFI, Doppler

Aboubakr Elnashar

III. Screening for macrosomia

•Clinical & US: inaccurate (±10-20%).

•US: The best single measurement:

Serial measurements of AC

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IV. Delivery

• Time: Induction at 38w in insulin requiring GDM: lower rate

of:

macrosomia (10% Vs 23%),

CS (25% Vs 30%) and

Shoulder dystocia (0% Vs 3%) (Kjos et al, 1993). Delivery before 38W:

Poor glucose control

Poor compliance

Co morbidities e.g. hypertension

Corticosteroids:

<36 w

Induction of labour at 40 w in Diet controlled GDM

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Care for

Preterm Labour

1. Steroids

2. Re-adjustment

of hypoglycaemic

agents

3. Tocolysis: can

be given (not

betamimmetic)

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•Mode:

Elective CS: > 4000 & 4250g (Inzucchi, 1999).

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C. Intra-partum care

•The target glucose level: 75-125 mg/d

•Blood glucose/h

-> 125 mg/dl: 2-4 u IV regular insulin and assess the

coming hour.

-< 75mg/dl: 10% dextrose infusion and assess after 15

min.

Women with GDM controlled with insulin should be

instructed to stop insulin use once labor starts, and then

reevaluate their glycemic control with frequent SMBG

testing in the postpartum period.

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•IV dextrose and insulin: -Indication:

Type 1 diabetes

BG not maintained between 75& 125 mg/d.

-Strength of solution:

(1 u/ ml) (50 u insulin in 50 ml 5% dextrose)

-Rate:

if blood glucose

0-70 mg/dl= 0.5 u/h

71-140 mg/dl= 1 u/h

141-215 mg/dl= 2 u/h

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D. Postpartum care I. Breast feeding:

Encouraged

{Reduces the insulin requirement by 25%

Breast- feed babies have a much lower risk of

developing DM}

Glyburide and metformin are secreted into breast milk

and should not be used during lactation in women with

T2DM.

Breastfeeding can cause life-threatening hypoglycemia

for lactating women on insulin, especially those with

T1DM. Women who are both breastfeeding and on a

form of basal insulin must either decrease their basal

rate during lactation or eat a carbohydrate-containing

snack before breastfeeding.

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II. Glycemic control

Insulin-treated pre-existing diabetes:

•Reduce insulin (30-50%)

•Self-monitor blood glucose to establish correct dose

•{Risk of hypoglycaemia, especially while breastfeeding}

To have food available before or during breastfeeding.

Once women with type 1 diabetes are eating normally,

s.c. insulin should be recommenced at either the pre-

pregnancy dose or at a 25% lower dose if the women

intends to breast-feed,

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Type 2 diabetes:

•Resume or continue taking metformin and

glibenclamide

•Not to take any other oral hypoglycaemic agents while

breastfeeding.

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Gestational diabetes:

•Stop hypoglycaemic medication

•Advise: weight control, diet and exercise

•FBS at 6-w postnatal, then annually.

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III. Contraception

•Copper IUCD, Mirena:

not associated with PID

(Kimmerle et al, 1993 ; Kjos et al,1994)

•DMPA: Deterioration of CHO tolerance

increase risk of diabetes

•NORPLANT:

No deterioration (Fahmy et al, 1991 ; Konje et al,1992; Singh et al,1992)

Aboubakr Elnashar

GDM: not a contraindication for COC

Diabetes with retinopathy/nephropathy/neuropathy or

with other vascular disease or disease duration >20

yr: contraindicated or relatively contraindicated

depending upon severity

Low-dose COCs

•didn't influence development of Diabetes (Kjos et al,1998)

•Non smoker, <35 years, healthy: no hypertension,

nephropathy, retinopathy, or other vascular disease.

Progestin-only Pill

with breast feeding: 3 fold risk of diabetes (Kjos et al,1998)

Should be prescribed with caution, if at all.

Aboubakr Elnashar

Aboubakr Elnashar

Summary

Diabetes during pregnancy is the most common

complication of pregnancy. Pregestational planning

is imperative for all women with preexisting

diabetes.

Pregnant women who have no known diabetes but

who have any risk factors for GDM should be

screened with the 75-g OGTT at the initial prenatal

visit, and all women should be screened by 28

weeks gestation.

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Clinicians should be prepared for an increase in the

number of women identified with diabetes during

pregnancy and develop a thorough and efficient

model for outpatient management. Patient

education is the foundation for successful

management of diabetes during pregnancy.

The goal of therapy will continue to be

normoglycemia before, during, and after all

pregnancies complicated by diabetes.

The world of diabetes is rapidly evolving, with

many new tools on the horizon for diagnosis,

monitoring, and treatment. These tools will make

the management of diabetes in pregnancy easier

and possibly safer. Aboubakr Elnashar

Some promising developments for diabetes in

pregnancy include weekly point-of-care Hb A1c

testing, the routine use of CGMs in T1DM, and the

implementation of universal screening guidelines.

With these potentially cost-effective advances in

diabetes during pregnancy comes the hope of

preventing macrosomia and decreasing the

prevalence of childhood obesity and T2DM in the

offspring of diabetic mothers.

Aboubakr Elnashar

Benha University Hospital

E-mail:elnashar53@hotmail.com

Aboubakr Elnashar