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Diabetes in Pregnancy

Diabetes in Pregnancy. S Chandra. Epidemiology. Most common medical complication of Pregnancy affects 2-14% of pregnancies Gestational DM 90% Preexisting DM 10%. CHO Metabolism. Effects of Pregnancy mild fasting hypoglycemia; postprandial hyperglycemia

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Diabetes in Pregnancy

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  1. Diabetes in Pregnancy S Chandra

  2. Epidemiology • Most common medical complication of Pregnancy • affects 2-14% of pregnancies • Gestational DM 90% • Preexisting DM 10%

  3. CHO Metabolism • Effects of Pregnancy • mild fasting hypoglycemia; postprandial hyperglycemia • due to inc plasma volume in early gestation and inc fetal glucose utilization as pregnancy advances • progressive increase in tissue resistance to insulin • increase insulin secretion to maintain euglycemia • suppressed glucagon response • inc prolactin, cortisol • HPL has GH like effects

  4. Glucose Metabolism • Normal pregnancy : Diabetogenic state • increase in BG • insulin resistance • Early Pregnancy • Anabolic state • increase in maternal fat stores • decreased FFA concentration • decrease in insulin requirements

  5. Type I Diabetes • Abrupt onset • usually young age • occasionally occurs in 30’s or 40’s • lifelong requiremnent for insulin replacement • may have genetic predisposition for islet cell ab • concordance in MZ twins for dev of DM is 33% • suggests other factors also imp (environmental)

  6. Type 2 DM • Abnormalities of insulin sensitive tissues • decreased skeletal muscle and hepatic sensitivity to insulin • abnormal B cell response • inadequate response for a given degree of glycemia • usually older • increased BMI • insidious onset • strong genetic component • MZ twin data lifetime risk 58-100%

  7. Diagnosis of DiabetesNon Pregnant • Fasting plasma BG >99mg/dl • Casual plasma BG >200mg/dlImpaired Fasting Glucose • FPG 100-125 mg/dlImpaired Glucose Tolerance • normal FPG • 2 h 75gOGTT test with 140-199 mg/dl

  8. Classification and Risk Assessment Class DM onset Duration Vascular Dis Insulin Need Gestational Dm A1 Any Any - - A2 Any Any - + Pregestational DM B >20 <10 - + C 10-19 10-19 - + D <10 >20 + + F Any Any + + R Any Any + + T Any Any + + H Any Any + +

  9. Gestational Diabetes • Definition • CHO intolerance of variable severity first diagnosed in Pregnancy • Prevalence 2-4% • Risk Factors • maternal age >30 • Family history • glucosuria • prior macrosomia • previous unexplained stillbirth • ethnic group: Hispanic, Black, First Nations

  10. Gestational Diabetes • Screening • PC 50/Trutol • 1 hr after 50g load of glucose • >7.8mmol/l abnormal*140mg % • 15% of patients screen positive* value >10.3 190mg/dl diagnostic of GDM (no OGTT needed)

  11. Gestational Diabetes • Screening • 24-28 weeks routine • no need to fast • screen at 1st prenatal visit if hx of previous GDM • screen earlier (12-24 weeks ) if risk factors

  12. Gestational Diabetes • Diagnosis OGTT • 2 or more values greater than or equal to above cutoffs diagnostic of GDM • single abnormal value indicates CHO intolerance 2H 3 H Fasting 5.3 1h 10.6 2h 8.9 Fasting 5.3 1h 10.6/ 180 2h 9.2 /155 3h 8.1/140

  13. Gestational Diabetes Maternal Risks • birth trauma • Macrosomia, Polyhydromnios • operative delivery • 50% lifetime risk in developing Type II DM • recurrence risk of GDM is 30-50%

  14. Gestational Diabetes

  15. Gestational Diabetes Fetal Risks • no increase in congenital anomalies • increased risk of stillbirth if fasting+ pc hyperglycemia • macrosomia • birth trauma-shoulder dystocia and related complications

  16. Gestational Diabetes • Management • goal is to optimize BG levels to minimize risk of adverse perinatal outcomes • diet • exercise • insulin therapy

  17. Gestational Diabetes • Management : Diet • patients without fasting hyperglycemia • average 8000-9000 kj/day. • BMI>27 -- 25 kcal/kg/ideal body weight/d • BMI 20-26 -- 30 “ • BMI<20 -- 38 “

  18. Gestational Diabetes • Diet : general principles • 55% CHO 25% Protein 20% fat • Normal weight gain 10-12 kg • avoid ketosis • liberal exercise program to optimize BG control

  19. Gestational Diabetes • If persistent hyperglycemia after one week of diet control proceed to insulin • 6-14 weeks 0.5u/kg/day • 14-26 weeks 0.7u/kg/day • 26-36 weeks 0.9u/kg/day • 36-40weeks 1 u /kg/day

  20. Gestational Diabetes • If fasting hyperglycemia start with NPH hs • initial dose 6-8 U • if only pc hyperglycemia use humalog 2-4u ac the specific meal • adjust 2u/time 1 formula /time • BG target ac <5.3 2 h pc <6.7

  21. Gestational Diabetes • Intrapartum management • check bg hourly • maintain BG 4-6mmol/L

  22. Gestational Diabetes • Postpartum • often will not require insulin • if fasting hyperglycemia - more likely to develop persistent Diabetes • 6 weeks post partum 75g OGTT • yearly fasting BG • emphasize importance of maintaining N weight, exercise

  23. Gestational Diabetes Neonatal Risks • hypoglycemia 50% in macrosomic5-15% if N BG control in Pgy • Hyperbilirubinemia • polycythemia • hypocalcemia • hypomagnesiumia

  24. Preexisting Diabetes • Preconception Counselling • risk of NTD ~1-2% • Folic Acid 1-4 mg /day • BG 3.5-5.3 prior to meals • switch to MDI regimen (insulin ac meals and HS) • keep track of cycles

  25. Preexisting Diabetes • Normoglycemia prior to conception • ideally HBA1C 6% or less • Team approach • glucose monitoring qid • ACE contraindicated : should be D/C at conception or use Diltiazem instead • baseline HBA1C, 24h urine for protein Cr Cl , opthalmology review • switch from OHA to insulin

  26. Assess for end organ disease • assess for nephropathy - inc risk of PIH • Assess and treat retinopathy - may progress • assess for neuropathy • generally remains stable during pregnancy • assess and treat vasculopathy • CAD is a relative C/I for pregnancy

  27. Preexisting Diabetes • Maternal Risks • PIH /PET • polyhydramnios • preterm labour • operative delivery ~50% • birth trauma • infection • increase in insulin requirements • DKA

  28. Prexisting Diabetes

  29. Preexisting Diabetes • Fetal Risks • congenital anomalies 3X inc risk • unexplained stillbirth • shoulder dystocia • macrosomia • IUGR

  30. Preexisting Diabetes • Neonatal Risks • hypoglycemia • hypocalcemia • hyperbilirubinemia/polycythemia • idiopathic RDS • delayed lung maturity • prematurity • predisposition to diabetes

  31. Preexisting Diabetes • Congenital anomalies • 3x the general population risk • approaches the gen pop risk (2-3%) if optimal control in periconception period • related to glycemic control during embryogenesis

  32. CVS ASD/VSD,coarctation,transposition, cardiomegaly CNS anencephaly, NTD, microcephaly GI duodenal atresia, anorectal atresia, situs inversus GU renal agenesis Polycystic kidneys MSK caudal regression siren Congenital anomalies

  33. Preexisting Diabetes • Maternal Surveillance • Blood pressure • renal function * • urine culture ** • thyroid function • BG control HB A1C* • * q trimester • ** monthly

  34. Preexisting Diabetes • Fetal Surveillance • U/S for dating/viability ~ 8 weeks • Fetal anomaly detection • nuchal translucency 11-14w • maternal serum screen • anatomy survey 18-20 w • Fetal echo 22 w

  35. Multidose Insulin • breakfast 25% H • lunch 15% H • supper 25% H • hs 35% NPH • indicates insulin as a % of total daily dose Gabbe Obstet Gynecol 2003

  36. Insulin Therapy onset (h) peak duration • insulin analogs .25 0.5-1.5 6-8 • rapid acting 0.5 2-4 8-12 • intermediate 1-1.5 4-8 12-18

  37. Insulin Therapy • Insulin Pump • Allows insulin release close to physiologic • Use short acting insulin • 50-60% of total dose is basal rate • 40-50% given as boluses • Potential complications • Pump failure • Infection • Increased risk of DKA if above happens

  38. Peripartum Management • Withhold subcutaneous insulin from onset of labour or induction • IV D10 @50cc/h • IV short acting insulin in NS usually starting at 0.5-1u/h**10cc insulin in 100 cc NS(1U=10cc)

  39. Peripartum Management • insulin rate usually based on BG and pre-delivery insulin requirement • eg. For each 75-100 total units /24h of pre-delivery insulin, 1 unit per hour needed • measure capillary BG hourly VPG q2-3h • target: 4-6mmol/L

  40. Peripartum Management • Following delivery • stop insulin infusion • begin sub Q insulin • resume previous MDI schedule at 1/2 -2/3 the pre pregnancy dose • maintain IV D5W @50cc/h until oral feeds tolerated

  41. Oral Hypoglycemic agents • Traditionally not recommended in pregnancy • Recent RCT of oral glyburide vs insulin for GDM • 440 patients • BG measured 7x daily • Treatment started after 11 weeks gestation Langer NEJM 2000

  42. Oral Hypoglycemic agents Glyburide Insulin Achieved N BG 82% 88% LGA infants 12% 13% Macrosomia 7 4 C Section 23 24 Hypoglycemia 9 6 Preeclampsia 6 6 Anomalies 2 2 Langer NEJM 2000

  43. Fetal Surveillance • Goals • Minimize/eliminate the risk of fetal death • Early detection of fetal compromise • Prevent unnecessary premature delivery • Main benefit is the NPV of these tests • Provides reassurance that fetus with a N test unlikely to die in utero • Allow prolongation of pregnancy – fetal maturation

  44. Fetal Surveillance • Gestational Diabetic Diet controlled • Can start fetal surveillance at term (40 weeks) • GDM on insulin/Type II DM/ Type I DM • Start weekly BPP from 32 weeks • Consider earlier testing if • suboptimal control • Hypertension • vasculopathy

  45. Timing of Delivery GDM Diet controlled • Same as non diabetic • Offer induction at 41 weeks if undelivered GDM on Insulin/Type II/Type I • If suboptimal control deliver following confirmation of lung maturity if <39 weeks • Otherwise deliver by 40 weeks • Generally do not allow to go postterm

  46. Mode of Delivery • Macrosomic infants of diabetic mothers have higher rates of shoulder dystocia than non diabetic mothers • Ultrasound estimates of fetal weight become significantly inaccurate after 4000g • Reasonable to recommend C/S delivery if EFW is >4500g

  47. Diabetic Ketoacidosis • 5-10% of pregnant Type 1 pts • Risk factors • New onset DM • Infection • Insulin pump failue • Steroids • B mimetics • Fetal mortality 10%

  48. Diabetic Ketoacidosis • Management • ABC’s and ABG • Assess BG, ketones electrolytes • Insulin • .2-.4U/Kg loading and 2-10U/h maintenance • Begin 5% dextrose when BG is 14 mmol/l • When potassium is N range begin 20mEq/h • Rehydration isotonic NaCl • 1L in 1st hour • .5-1l/h over 2-4h • 250cc/h until 80% replaced • Replace Bicarb and phosphate as needed

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