Update on management of diabetes in pregnancy

1. Update on management of diabetes in pregnancy Prepared by Dr.Intisar Al-Alem October 2009

2. Classification of Diabetes &pregnancy Gestational-diabetes develops during pregnancy (due to the diabetogenic effect of pregnancy) Pre gestational-diabetes is present prior to pregnancy (Type1, or Type2)

3. Definition: Gestational diabetes mellitus (GDM): Is carbohydrate intolerance resulting in hyperglycemia of variable severity with onset or first recognition during pregnancy The definition applies irrespective of whether or not insulin is used for treatment or the condition persists after pregnancy, it does not exclude the possibility that glucose intolerance may antedate pregnancy but has been previously Unrecognized

4. Prevalence & Incidence: Approximately 3-6 % of all pregnancies are complicated by GDM, Prevalence is range from 1-14% of all pregnancies Incidence 0.5% of GDM in women younger than 20 years of age and 4% in women aged 35-39 years (in United State) Usually it resolves after delivery, women with GDM have a 17-63 % risk of developing non gestational diabetes within 5-16 years after GDM-affected pregnancy

5. Women at high risk for developing GDM: • Overweight /obesity • Aged >35 • Personal history of GDM • Glycosuria • Family history of diabetes • Poor obstetric history (previous unexplained stillbirth, foetal malformation or large baby (>4kg) • More than 3 previous children

6. Screening and Diagnostic Criteria for GDM:

7. Contraindications to pregnancy: • Sever nephropathy with decreased renal function • Advanced ischemic heart disease • Unresponsive proliferative retinopathy • Older women • Teenage girls • Very poor glcated haemoglobin GHbA1c >10% , ketoacidosis in early pregnancy

8. Whit's classification of diabetes during pregnancy : Gestational diabetes: Abnormal glucose tolerance test but euglycemia maintained by diet alone or diet alone insufficient, insulin required. Class ADiet alone sufficient, any duration or age at onset Class BAge at onset >=20 yr and duration <10 yr Class CAge at onset 10-19 yr or duration 10-19 yr

9. Whit's classification of diabetes during pregnancy : Class D Age at onset <10 yr or duration >=20yr or background retinopathy or hypertension Class R Proliferative retinopathy or vitreous hemorrhage Class F Nephropathy Class RF Criteria for both classes R and F Class H Arteriosclerotic heart disease Class T Prior renal transplantation

10. Management of diabetic pregnancy : Pre-pregnancy management: • Optimize metabolic control • Educate about diabetic pregnancy • Normalize blood pressure • Treat sight-threatening retinopathy

11. Management of diabetic pregnancy : Management during pregnancy: Seen every two weeks until 30 weeks, then weekly • Optimize glycaemic control: ADA recommendations (fasting < 95mg/dl,1-hourpostprandial <140 mg/dl, and/or 2-hours postprandial <120 mg/dl ), education, optimize insulin therapy, check glycated hemoglobin • Folic acid supplements • Discourage smoking • Fetal monitoring: Ultrasound (congenital anomalies) • Obstetric assessment : Screen for complications: Nephropathy, retinopathy, vascular disease Pre-eclampsia, polyhydramnios, urinary tract infection

12. Insulin Therapy: • The use of rapid acting analogs lispro & aspart insulins in pregnancy is approved and offers a valuable treatment option • The use of long acting analogs insulins glargine & detemir in pregnancy is not approved until now • Multiple insulin injection regimen or insulin pump • The basal insulin is supplied by the administration of neutral protamine Hagedorn [NPH]) at bedtime or both before breakfast and at bedtime. The meal-related insulin includes the use of insulin lispro or aspart before meals (0-15 min) or regular insulin before meals (30-45 min).

13. Insulin Therapy: • A starting dose for insulin, depends on maternal weight (in kg) and pregnancy trimester. a 24-hour total insulin dose is calculated using 0.7 units (U)/kg in first trimester, 0.8 U/kg in second trimester, and 0.9 U/kg in third trimester. • Two-thirds of the total dose is given in the morning before breakfast and one-third at night (half of that before supper and half prior to bedtime

14. Post-partum care of mother: • Reduce insulin infusion rate by 50% as soon as delivery has occurred • Maternal insulin requirement drops immediately to pre-pregnancy level or may even be 10 – 15% below that • Women with gestational diabetes do not need any insulin once the placenta is delivered • Mother may need less insulin or more calories if breast feeding (500kcal per day)

15. Complications of GDM: • Complications to mother • Complications to baby

16. Maternal problems associated with diabetes: • Weight gain • Hypoglycaemia and loss of hypoglycaemia awareness • Risk of worsening of retinopathy • Pregnancy-induced hypertension • Worsening of renal disease/proteinuria • Myocardial infarction

17. Maternal problems associated with diabetes: • Rapid tightening of glycaemic control may lead to rapid worsening of retinopathy • Women with microalbuminuria or proteinuria are more at risk of PIH or worsening proteinuria/worsening renal function as pregnancy progresses • More likely to have a caesarean section (50%) • Increased risk of developing type2 diabetes

18. Problems affecting the foetus in utero &during labour: • Congenital malformation • IUGR (in mothers with nephropathy or vascular disease) • IUD • Macrosomia & shoulder dystocia • Dysmaturity – RDS • Polycythaemia

19. Problems affecting the neonate: • Neonatal hypoglycaemia • Neonatal hypocalcaemia • Neonatal jaundice • Increased rate of foetal loss (perinatal mortality 48/1000 for babies of diabetic mothers, compared to 8.9/1000 for background population • Increase incidence of diabetes in the offspring's

20. Optimum care for pregnant diabetic woman before & during pregnancy, provided by multidisciplinary team, can reduce maternal and fetal complications. The team should consist of a diabetologist, internist or family practice physician, obstetrician, diabetes educators, nurse, dietitian, and social worker.

21. Thank You