By

Dr. Lamiaa Gamal

Diabetes during

pregnancy

Type 1 diabetes

7.5%

Type 2 diabetes

5%

Gestational diabetes

87.5%

Prediabetes

Rare diagnosis during pregnancy

Presented by Unexpected coma

Early pregnancy screening test for women admitted to blood sugar control

TYPE 2 DIABETES

Q: Is it type 2 Diabetes or gestational diabetes?

A: the International Association of Diabetes and

Pregnancy Study Groups now recommend that

high-risk women who are found to have diabetes at

their initial prenatal visit, according to standard

diagnostic criteria, receive a diagnosis of overt

diabetes rather than gestational diabetes

Type 2 Diabetes is better prognosis than

type 1 Diabetes

better glycemic control

fewer large for gestational age infants

fewer preterm deliveries

fewer neonatal care admissions

PREDIABETES

People who are at increased risk of

developing diabetes

Impaired fasting glucose (IFG)

Impaired glucose tolerance (IGT)

IMPAIRED FASTING GLUCOSE (IFG)

A condition in which the fasting blood

sugar level is elevated (100-125 mg/dL)

after an overnight fast but is not high

enough to be classified as diabetes

IMPAIRED GLUCOSE TOLERANCE (IGT)

A condition in which the blood sugar

level is elevated (140-199 mg/dL after a

2-h OGTT) but is not high enough to be

classified as diabetes

GESTATIONAL DIABETES

is defined as any degree of glucose intolerance

with onset or first recognition during the present

pregnancy and can in some cases inadvertently

include women with pre-existing, undiagnosed DM.

PREVALENCE

1.5

89

0

10

20

30

40

50

60

70

80

90

100

deaths DALYs

Frequency of deaths and DALYS due to Diabetes in 2012

million

http://www.who.int/nmh/publications/ncd-status-report-2014/en/

The global prevalence of diabetes was

estimated to be 9% in 2014.

The prevalence of diabetes was highest in the

WHO Region of the Eastern Mediterranean

Region (14% for both sexes) and lowest in the

European and Western Pacific Regions (8% and

9% for both sexes, respectively).

Gestational diabetes is known to occur in at

least 1-5% of all pregnancies

IDF estimates that 21.4 million or 16.8% of

live births to women in 2013 had some form

of hyperglycaemia in pregnancy.

An estimated 16% of those cases were due

to diabetes in pregnancy and would require

careful monitoring during the pregnancy

and follow-up post-partum.

http://www.idf.org/diabetesatlas

REGIONAL DIFFERENCES IN THE PREVALENCE (%) OF

HYPERGLYCAEMIA IN PREGNANCY

North America

and

Caribbean Region

10.4%

(lowest)

South-east Asia Region 25%

(highest)

A staggering 91.6% of cases of

hyperglycaemia in pregnancy were in

low- and middle-income countries, where

access to maternal care is often limited.

The prevalence of hyperglycaemia in pregnancy increases rapidly with age and is highest in women over the age of 45 (47.7%), although there are fewer pregnancies in that age group.

This explains why just 23% of global cases of hyperglycaemia in pregnancy occurred in women over the age of 35, even though the risk of developing the condition is higher in these women

2

8

15

0

2

4

6

8

10

12

14

16

white women Hispanic, black, andAsian populations

Native Americans fromthe southwestern United

States

Gestational diabetes and race

%

High recurrence risk with future pregnancies has

been reported to be as high as 68%.

One-third will develop overt diabetes mellitus

within 5 years of delivery, with higher-risk

ethnicities having risks nearing 50%.

Black women have been shown to have lower

rates of macrosomia, despite similar levels of

glycemic control

Hispanic women have higher rates of macrosomia

and birth injury than women of other ethnicities,

even with aggressive management

RISK FACTORS FOR GESTATIONAL DIABETES

• Body mass index more than 30 kg/m²

• Previous macrosomic baby weighing 4.5 kg or more

• Previous gestational diabetes

• Family history of diabetes (first-degree relative with diabetes)

• Certain ethnic groups

• age > 25 years

• essential or pregnancy related hypertension

• unexplained stillbirth/miscarriages and glycosuria

• Polycystic ovarian syndrome

PATHOGENESIS

(NORMAL PREGNANCY)

Meal

Rise of blood glucose

insulin, glucagon, somatomedins, and adrenal catecholamines

Glucose supply to mother and fetus

DURING NORMAL PREGNANCY

Interprandial hypoglycemia (plasma glucose mean = 65-75 mg/dL).

Levels of placental steroid and peptide hormones (e.g, estrogens, progesterone, and chorionic somatomammotropin) rise linearly throughout the second and third trimesters.

By the third trimester, 24-hour mean insulin levels are 50% higher than in the nonpregnant state.

Diabetogenic

potency

Peak

elevation

(weeks)

Hormone

Weak 10 Prolactin

Very weak 26 Estradiol

Moderate 26 Human chorionic

sommatomamotropin (hcs)

Very strong 26 Cortisol

Strong 32 Progesterone Adapted from jovanovic –peterson L, Peterson C: Review of gestational diabetes mellitus and low calorie diet

and physical exercise as therapy. Diabetes Metab Rev 12:287-308, 1996

DURING DIABETES

Inadequate maternal insulin secretion

Fetal hyperinsulinemia

recurrent postprandial hyperglycemic episodes

energy expenditure due to the

conversion of excess glucose into fat

depletion in fetal oxygen levels

Fetal hypoxia

surges in adrenal catecholamines

Hypertension, Cardiac remodeling and hypertrophy, Stimulation of

erythropoietin, red cell hyperplasia, and Increased hematocrit

excess nutrient storage

Macrosomia

MATERNAL MORBIDITY

• Half the patients with preexisting

retinopathy experienced deterioration during pregnancy

• All the patients had partial regression following delivery and returned to their prepregnant state by 6 months postpartum

Diabetic retinopathy

• pregnancy does not measurably alter the time course of diabetic renal disease, nor does it increase the likelihood of progression to end-stage renal disease

Renal disease

• Chronic hypertension 1 in 10 diabetic pregnancies

• Preeclampsia is more frequent among women with diabetes (approximately 12%) versus the non-diabetic population (8%)

• The rate of preeclampsia has been found to correlate with the level of glycemic control

Elevated blood

pressure

• Increased risk of developing type 2 diabetes

• 5 percent of women who have gestational diabetes develop type 2 diabetes within 6 months of delivery, about 60 percent will develop type 2 diabetes within 10 years

Diabetes

OTHER ASSOCIATED MORBIDITIES

Preterm labour

Premature rupture of membranes

Increased ceserean section

Obstructed labour and birth traumas

Cumulative incidence of type 2 diabetes in

women with a history of gestational diabetes

MATERNAL MORTALITY

World Health Organization 2014

FETAL MORBIDITY

Miscarriage

• Patients with long-standing (>10 y) and poorly controlled diabetes (HbA1C exceeding 11%) have been shown to have a miscarriage rate of up to 44%

Birth defects

• General population 1-2%

• With overt diabetes, the likelihood of a structural anomaly is increased 4- to 8-fold

Growth restriction

• underlying maternal vascular disease( diabetes-associated retinal or renal vasculopathies and/or chronic hypertension(

Obesity

• Approximately 30% of fetuses of women with diabetes mellitus in pregnancy are large for gestational age (LGA). In preexisting diabetes mellitus, this incidence appears to be slightly higher (38%).

Macrosomia

• a birth weight above the 90th percentile for gestational age or greater than 4000 g.

• Macrosomia occurs in 15-45% of babies born to diabetic women, a 3-fold increase from normoglycemic controls

Metabolic syndrome

• By age 10-16 years, offspring of diabetic pregnancy have a 19.3% rate of impaired glucose intolerance

• The childhood metabolic syndrome includes childhood obesity, hypertension, dyslipidemia, and glucose intolerance

Cardiovascular risk factors

• higher levels of biomarkers for endothelial damage and inflammation, as well as higher leptin levels, BMI, waist circumference, and systolic blood pressure and decreased adiponectin levels

Neurocognitive development

• both GDM and low socioeconomic status were at even greater risk for ADHD and also at increased risk for compromised neurobehavioral functioning

PERINATAL MORTALITY CAUSES:

Congenital malformations

Respiratory distress syndrome (RDS)

Extreme prematurity

PERINATAL MORBIDITY IN DIABETIC PREGNANCY

Morbidity Gestational Diabetes Type 1 Diabetes Type 2 Diabetes

Hyperbilirubinemia 29% 55% 44%

Hypoglycemia 9% 29% 24%

Respiratory distress 3% 8% 4%

Transient tachypnea 2% 3% 4%

Hypocalcemia 1% 4% 1%

Cardiomyopathy 1% 2% 1%

Polycythemia 1% 3% 3%

SCREENING OF GDM

High risk group

• During the 1st trimester ( 1st prenatal visit)

Routine • Between 24-28 weeks of

gestation

Screen women with GDM for

persistent diabetes 6-12 weeks

postpartum using

oral glucose tolerance test

(OGTT) and

nonpregnancy diagnostic

criteria

Continue to screen women with

history of GDM for diabetes or

pre diabetes

at least every 3 years

Women with GDM history and pre

diabetes should receive

lifestyle interventions or

metformin

for diabetes prevention

There is no uniform approach for GDM

diagnosis. Two options:

“One-step”: 2-h 75-g OGTT

(International Association of Diabetes and

Pregnancy Study [IADPSG] consensus)

OR

“Two-step”: 1-h 50-g (non fasting) screen

followed by 3-h 100-g OGTT for those who

screen positive

(National Institutes of Health [NIH] consensus)

ONE STEP

Perform OGTT in the morning after an overnight

fast of at least 8 h

GDM diagnosis: when any of the following plasma

glucose values are exceeded Fasting: ≥92 mg/dL (5.1 mmol/L)

1 h: ≥180 mg/dL (10.0 mmol/L)

2 h: ≥153 mg/dL (8.5 mmol/L)

TWO STEP

Perform a 50-g GLT (non fasting), with plasma

glucose measurement at 1 h (Step 1), at 24–28

weeks of gestation in women not previously

diagnosed with overt diabetes

If the plasma glucose level measured 1 h after

the load is ≥140 mg/dL* (7.8 mmol/L), proceed

to 100-g OGTT (Step 2); the 100-g OGTT should

be performed when the patient is fasting

The diagnosis of GDM is made when the plasma

glucose level measured 3 h after the test is ≥140

mg/dL (7.8 mmol/L).

DIAGNOSTIC CRITERIA OF DIABETES MELLITUS

According to the American Diabetes Association’s "Standards of Medical Care in Diabetes—2010:

Hemoglobin A1C (HbA1C) >= 6.5%

Fasting plasma glucose = >126 mg/dL

A 2-hour plasma glucose level >= 200 mg/dL during a 75-g OGTT

A random plasma glucose level >= 200 mg/dL in a patient with classic symptoms of hyperglycemia or hyperglycemic crisis

POST DIAGNOSTIC TESTING

1st TRIMESTER

• HbA1C

• Blood urea nitrogen (BUN)

• Serum creatinine

• Thyroid-stimulating hormone , Free thyroxine levels

• Spot urine protein-to-creatinine ratio

• Capillary blood sugar levels

• Ultrasonographic assessment for pregnancy dating and viability

2nd TRIMESTER

• Spot urine protein-to-creatinine study in women with elevated value in first trimester

• Repeat HbA1C - Capillary blood sugar levels

• Detailed anatomic ultrasonogram at 18-20 weeks and a fetal echocardiogram if the maternal glycohemoglobin value was elevated in the first trimester

3rd TRIMESTER

•blood glucose, blood pressure follow up

• Growth ultrasonogram to assess fetal size every 4-6 weeks from 26-36 weeks in women with overt preexisting diabetes; perform a growth ultrasonogram for fetal size at least once at 36-37 weeks for women with gestational diabetes mellitus

FETAL BIOPHYSICAL TESTS

Various fetal biophysical tests can ensure that the

fetus is well oxygenated, including:

Fetal heart rate testing

Fetal movement assessment

Ultrasonographic biophysical scoring

Fetal umbilical Doppler Ultrasonographic

studies.

MANAGEMENT

• avoid single large meals and foods with a large percentage of simple carbohydrates

• Supplemental calcium and vitamin D at 24 to 28 weeks gestation may improve metabolic profile of women with GDM

Diet

• Aim for at least 30 minutes

most days of the week

Physical activity

• to achieve glucose profiles similar to those of non diabetic pregnant women

Insulin

• these 2 drugs to be effective, and no evidence of harm to the fetus has been found, although the potential for long-term adverse effects remains a concern

Glyburide and

metformin

• For natal complications and associated shoulder dystocia

Obstetric care

• Treatment of hypoglycemia

• Early breast feeding Management of neonate

BREAST FEEDING

breast-fed infants have a much lower risk of

developing diabetes than those exposed to cow's

milk proteins.

Studies of breastfeeding women with diabetes

indicate that lactation, even for a short duration,

also has a beneficial effect on overall maternal

glucose and lipid metabolism.

BREAST FEEDING

For postpartum women who had gestational diabetes mellitus during their pregnancies, breastfeeding may offer a practical low-cost intervention that helps reduce or delay the risk of subsequent diabetes.

A study by Gunderson et al found that a higher intensity of lactation among exclusively or mostly breastfeeding (< 6 oz formula per 24 h) -mothers improved insulin sensitivity and glucose metabolism.

A 2013 systematic review and meta-analysis of

randomized trials for the US Preventive Services

Task Force found that appropriate management

of GDM(nutritional therapy, self blood glucose

monitoring, administration of insulin if target

blood glucose concentrations are not met with

diet alone) resulted in reductions in:

●Preeclampsia (three trials)

●Birth weight >4000 grams (five trials)

●Shoulder dystocia (three trials)

http://www.uptodate.com/contents/gestational-diabetes-mellitus-glycemic-control-and-maternal-prognosis

PREVENTION

patients who lose weight before pregnancy

and follow an appropriate diet may lower

their risk of gestational diabetes mellitus.

marked weight loss and attention to diet are

not likely to be successful.

12-week standard exercise program during

the second half of pregnancy had no benefit

in preventing gestational diabetes in healthy

women with normal BMI.

breastfeeding should be recommended.