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Diabetes in Pregnancy

Diabetes in Pregnancy. Ryan Agema MS III. Diabetes in Pregnancy. Epidemiology Classification Pathophysiology Morbidity Fetal Maternal Diagnosis Treatment and Management References. Epidemiology.

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Diabetes in Pregnancy

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  1. Diabetes in Pregnancy Ryan Agema MS III

  2. Diabetes in Pregnancy • Epidemiology • Classification • Pathophysiology • Morbidity • Fetal • Maternal • Diagnosis • Treatment and Management • References

  3. Epidemiology • 4-6% of pregnancies in the U.S are complicated by DM, accounting for 50-150 thousand babies per year. • 88% GDM, 8% Type II DM, 4% Type 1 DM • Prevalence also varies by race • 1.5-2% in Caucasians, 5-8% in Hispanic, Asian and African Americans, and up to 15% in some SW Native American groups.

  4. Classification

  5. Pathophysiology • Normal pregnancy is characterized by: • Mild fasting hypoglycemia • Postprandial hyperglycemia • Hyperinsulinemia • Due to peripheral insulin resistance which ensures an adequate supply of glucose for the baby.

  6. Pathophysiology • Human Placental Lactogen (HPL) • Produced by syncytiotrophoblasts of placenta. • Acts to promote lipolysis  increased FFA and to decrease maternal glucose uptake and gluconeogenesis. “Anti-insulin” • Estrogen and Progesterone • Interfere with insulin-glucose relationship. • Insulinase • Placental product that may play a minor role.

  7. A Vicious Cycle???

  8. Fetal Morbidity • Miscarriages • Frequency directly related to degree of maternal glycemic control. • Up to 44% with poorly controlled DM (HbA1C >12). • Preterm Delivery • Increase in both spontaneous and indicated preterm labor (<35 wks).

  9. Fetal Morbidity • Birth Defects • 1-2% risk among the general population. • 4-8 fold increased risk among preexisting diabetics. • Most common defects are CNS and CV, but also an increase in renal and GI abnormalities. • Up to a 600 fold increase in caudal regression syndrome.

  10. Fetal Morbidity • Macrosomia • Defined as birthweight above 90th % or >4000 grams. • Occurs in 15-45% of diabetic pregnancies, a 4-fold increase over normal. • Carries many morbidities including birth trauma, RDS, neonatal jaundice and severe hypoglycemia.

  11. Fetal Morbidity • Growth Restriction • Although we typically associate maternal DM with macrosomia, growth restriction is fairly common among Type 1 diabetic mothers. • Best predictor is presence of maternal vascular disease.

  12. Fetal Morbidity

  13. Fetal Morbidity • Polycythemia • Hyperglycemia stimulates fetal erythropoeitin production. • Can lead to tissue ischemia and infarction. • Hypoglycemia • Think of as an “overshoot” mechanism. • Baby is used to having lots of maternal glucose so it makes lots of insulin. When born, maternal glucose is no longer available but insulin remains high  hypoglycemia. • Can lead to seizures, coma and brain damage.

  14. Fetal Morbidity • Postnatal hyperbilirubinemia • Occurs in appox. 25%, double that of normal. • Thought to be due in large part to polycythemia. • Respiratory distress syndrome • 5-6 fold increased frequency. • May be due to a delay in lung maturation or simply due to the increased frequency of preterm deliveries.

  15. Fetal Morbidity • Polyhydramnios • Amniotic fluid volume >2000 mL. • Occurs in 10% of diabetics. • Increased risk of placental abruption and preterm labor.

  16. Maternal Morbidity • Increased risk of DKA due to increasingly resistant DM. • Increased incidence of UTI due to glucose-rich urine and urinary stasis. • Glucosuria is a normal finding of pregnancy but may be much higher in diabetics. • Diabetic retinopathy • Diabetic nephropathy

  17. Maternal Morbidity • Diabetic neuropathy • Preeclampsia • 2-fold increase

  18. Diagnosis • Glucose Challenge Test (24-28 wks) • 50 gram glucose load with blood level 1 hour later. • Does NOT require fasting state. • Normal finding is <140 mg/dl. • If >140, need to do a 3 hour glucose tolerance test.

  19. Diagnosis • Glucose Tolerance Test • Draw a fasting glucose level (normal<95). • Give 100 gram glucose load with glucose levels drawn after 1, 2 and 3 hours. • Normal levels vary widely depending on who you ask but should be in the following ranges: • 1 hr:<180 2 hr:<155 3 hr:<140 • 2 or more abnormal values = GDM.

  20. Treatment and Management • Obviously the main goal is to maintain good glycemic control. • Typically controlled with insulin but oral hypoglycemic agents like glyburide are also showing promise.

  21. Treatment and Management • Obstetrical management • Serial US to trend fetal growth, AFI and fetal anatomy • Fetal well-being monitored with kick counts, NSTs, BPPs • Postpartum, 95% of GDM mothers return to normal glucose tolerance, and require no further insulin. • Glucose tolerance screen 2-4 mo. postpartum to detect those that remain diabetic.

  22. References • www.acog.org • Current Obstetric & Gynecologic Diagnosis & Treatment (2003) • Williams Obstetrics (2005)

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