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Diabetes in Pregnancy

Diabetes in Pregnancy. Max Brinsmead PhD FRANZCOG February 2013. Types and Incidence. KNOWN DIABETIC (Before pregnancy) Insulin dependent – Type 1 or Juvenile Onset Diabetes NIDM – Type 2 or Maturity Onset Diabetic Together account for <1% of pregnancies GESTATIONAL DIABETES

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Diabetes in Pregnancy

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  1. Diabetes in Pregnancy Max Brinsmead PhD FRANZCOG February 2013

  2. Types and Incidence • KNOWN DIABETIC (Before pregnancy) • Insulin dependent – Type 1 or Juvenile Onset Diabetes • NIDM – Type 2 or Maturity Onset Diabetic • Together account for <1% of pregnancies • GESTATIONAL DIABETES • Diagnosed during a pregnancy • May or may not resolve after pregnancy • Comprise 2 – 9% of pregnancies depending on the population

  3. Glucose Metabolism in Pregnancy • Pregnancy is a diabetogenic stress • Results from antagonism of insulin by placental hormones • HPL, Sex steroids and corticosteroids • The diabetogenic stress increases as pregnancy advances • But reverses quickly after placenta delivers • BUT… • Facilitated transfer of glucose to the parasitic fetus  fasting hypoglycaemia

  4. The Effect of Diabetes on Pregnancy •  Maternal blood sugar will •  Fetal blood sugar and… •  Fetal insulin • This causes… •  Fetal growth which  • Dystocia  Caesarean or shoulder difficulties  • Brachial plexus palsy • BUT • Fetal brain growth is reduced • Lung maturation is delayed • And the neonate is at risk of hypoglycaemia & hypocalcaemia

  5. Effect of Diabetes on Pregnancy (2) •  Fetal blood sugar will cause •  Fetal glycosuria • Polyhydramnios • There is risk of intrauterine death • ?due to hypoxia • ?due to ketoacidosis • There is Rate of maternal Pre eclampsia • ?due to placental bed vasculopathy • There are Risks of Prematurity • Some of which is due to intervention on behalf of the mother

  6. Extra Risks for Type 1 Diabetics • First trimester hyperglycaemia causes… • Rates of congenital malformation (CNS & Heart) • If there is diabetic vasculopathy then the inevitable kidney damages causes… • Rates of pre eclampsia • Risk of fetal growth retardation

  7. The Effect of Pregnancy on Diabetes • Insulin antagonism  Insulin requirements • Pregnancy is a state of lipidolysis so IDDM patients are at risk of ketoacidosis • Especially during labour • Will be complicated by nausea, vomiting & slow gastric emptying • And altering energy expenditure • A desire for tight glucose control and a parasitic fetus puts the mother at risk of serious hypoglycaemia • Retinopathy and nephropathy may deteriorate rapidly • Insulin requirements change rapidly after delivery

  8. Principles of Management • Family Planning • Preconception care • Stringent blood glucose control before pregnancy • Monitor HBA1c • Meticulous blood glucose control throughout pregnancy • Multidisciplinary care from Physician, Dietition, Nurse Educator and Obstetrician • Watch for known complications • Timely delivery • Appropriate mode of delivery • Family Planning

  9. Controversies in Gestational Diabetes • Selective or universal testing • At least 50% missed unless all screened • Glucose challenge or GTT • 75G one hour test is best for screening • International Group Physicians recommends universal 1-step testing with 75g 2 hr test • Criteria for diagnosis • Criteria for the use of insulin

  10. Criteria for Selective Testing • First degree affected relative • Age >35 years • Ethnic origin • Obesity BMI >30 • Poor obstetric history esp. “unexplained stillbirth” • Previous fetal macrosomia (>4.5Kg) • Clinical suspicion • Polyhydramnios • Macrosomia • Previous Gestational Diabetes

  11. Criteria for the Diagnosis • May begin with Fasting and 2 hr Postprandial GLUC • If Fasting >7.8 or • 2 hr PP >11.0 then… • This patient requires insulin ASAP • Best test is the WHO 75G 2 hr GTT • Diabetes is Fasting GLUC >5.4 or… • 2 hr PP >7.8

  12. Management of Gestational Diabetes • Diet • Abstinence from all simple sugars • Reduce fats and oils • Regular meals with complex CHO (low glycaemic index) • Exercise • Self-tested blood glucose 4x  once daily • Aim for Fasting GLUC <5.0 • And 2 hr PP <6.5 • Metformin or Insulin if targets not met • Cease any insulin at delivery • Repeat 75g GTT after 8 – 12 weeks

  13. Role for Oral Hypoglycaemics • Use Metformin or Glibenclamide • Achieves the same outcomes as insulin if target GLUC are met • Better than insulin at controlling maternal weight • 7 – 46% will go on to require insulin

  14. Management of Insulin Dependent Diabetes • Before Pregnancy • Normalise HBa1c • Folic acid 5 mg daily • Check kidney and retina • Multidisciplinay care • Self-tested blood glucose 4x daily • Aim for Fasting GLUC <5.0 • And 2 hr PP 5.9 – 6.4 • Prenatal diagnosis • 1st trimester screening by serum biochemistry + ultrasound • Routine morphology at 18w • Cardiac ultrasound at 22w • Scan for growth and umbilical Dopplers • 28 & 36w

  15. Delivery of the Pregnant Diabetic • Timing for Type 1 diabetics is often a juggle between difficult sugar control and fetal maturity • Low threshold for Caesarean especially if fetal macrosomia is suspect • Most gestational diabetics induced at term i.e. >37 completed weeks • Monitor GLUC in labour • May require dextrose and insulin by infusion for those who are insulin-dependant • Monitor the fetus in labour

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