Diabetes in pregnancy

1. Diabetes in pregnancy Dr Than Than Yin

2. Physiological changes • Pregnancy is a state of physiological insulin resistance and relative glucose intolerance • Glucose handling is altered • Glucose tolerance decreases progressively with increasing with pregnancy • Renal tubular threshold for glucose fall in pregnancy

3. Diabetes in pregnancy Gestational diabetes Pre-existing diabetes -0.4% Pre-existing GDM True GDM Type 1 0.5% Type2 3-4%

4. Maternal Increased insulin requirements Hypoglycemia Infection Ketoacidosis Deterioration in retinopathy Increased proteinuria and oedema Miscarriage Polyhydramnios Shoulder dystocia Pre-eclampsia (threefold to fourfold increased) Increased caesarean section rate Fetal Congenital abnormalities -4%-neural tube defects, congenital heart disease Increased neonatal morbidity Increased perinatal mortality-3% Macrosomia Preterm delivery Neonatal hyperglycemia Polycythemia Jaundice Respiratory distress syndrome Complications of pregnancy in pre-existing diabetes

5. Diagnosis of diabetes mellitus • Random blood glucose >11.1 mmol/Lit • Fasting blood glucose >7 mmol/Lit • 2 hour plasma glucose concentration >11.1 mmol/Lit after 75mg anhydrous glucose in an oral glucose tolerance test

6. Management • Women with diabetes planning pregnancy require pre-pregnancy counseling • Pregnant women with diabetes- seen in joint clinic with obstetricians and physicians • Multidisciplinary clinics with dieticians and nurse prationers

7. Impaired GTT • After fasting -<7.0 • After 2hrs - >7.8

8. MedicalManagement • To achieve normoglycemia • Increase the frequency of home blood glucose monitoring • Target fasting -3.5-5.4 mmol/Lit 7.8 mmol/Lit after postprandial

9. Management Women with type I diabetes • require higher doses of insulin Type 2 diabetes • Oral hypogylcemic agents- traditionally discontinued in pregnancy • NICE guideline states that Metformin can be used