1. Diabetes in PregnancyDiabetes in Pregnancy
Ryan Agema MS IIIRyan Agema MS III

2. Diabetes in PregnancyDiabetes in Pregnancy
 EpidemiologyEpidemiology
 ClassificationClassification
 PathophysiologyPathophysiology
 MorbidityMorbidity
 FetalFetal
 MaternalMaternal
 DiagnosisDiagnosis
 Treatment and ManagementTreatment and Management
 ReferencesReferences

3. EpidemiologyEpidemiology
 4-6% of pregnancies in the U.S are4-6% of pregnancies in the U.S are
complicated by DM, accounting for 50-complicated by DM, accounting for 50-
150 thousand babies per year.150 thousand babies per year.
 88% GDM, 8% Type II DM, 4% Type 1 DM88% GDM, 8% Type II DM, 4% Type 1 DM
 Prevalence also varies by racePrevalence also varies by race
 1.5-2% in Caucasians, 5-8% in Hispanic,1.5-2% in Caucasians, 5-8% in Hispanic,
Asian and African Americans, and up toAsian and African Americans, and up to
15% in some SW Native American groups.15% in some SW Native American groups.

4. ClassificationClassification

5. PathophysiologyPathophysiology
 Normal pregnancy isNormal pregnancy is
characterized by:characterized by:
 Mild fasting hypoglycemiaMild fasting hypoglycemia
 PostprandialPostprandial
hyperglycemiahyperglycemia
 HyperinsulinemiaHyperinsulinemia
 Due to peripheral insulinDue to peripheral insulin
resistance which ensuresresistance which ensures
an adequate supply ofan adequate supply of
glucose for the baby.glucose for the baby.

6. PathophysiologyPathophysiology
 Human Placental Lactogen (HPL)Human Placental Lactogen (HPL)
 Produced by syncytiotrophoblasts ofProduced by syncytiotrophoblasts of
placenta.placenta.
 Acts to promote lipolysisActs to promote lipolysis  increasedincreased
FFA and to decrease maternal glucoseFFA and to decrease maternal glucose
uptake and gluconeogenesis. “Anti-uptake and gluconeogenesis. “Anti-
insulin”insulin”
 Estrogen and ProgesteroneEstrogen and Progesterone
 Interfere with insulin-glucose relationship.Interfere with insulin-glucose relationship.
 InsulinaseInsulinase
 Placental product that may play a minorPlacental product that may play a minor
role.role.

7. A Vicious Cycle???A Vicious Cycle???

8. Fetal MorbidityFetal Morbidity
 MiscarriagesMiscarriages
 Frequency directly related to degree ofFrequency directly related to degree of
maternal glycemic control.maternal glycemic control.
 Up to 44% with poorly controlled DMUp to 44% with poorly controlled DM
(HbA(HbA11C >12).C >12).
 Preterm DeliveryPreterm Delivery
 Increase in both spontaneous andIncrease in both spontaneous and
indicated preterm labor (<35 wks).indicated preterm labor (<35 wks).

9. Fetal MorbidityFetal Morbidity
 Birth DefectsBirth Defects
 1-2% risk among the general population.1-2% risk among the general population.
 4-8 fold increased risk among preexisting4-8 fold increased risk among preexisting
diabetics.diabetics.
 Most common defects are CNS and CV,Most common defects are CNS and CV,
but also an increase in renal and GIbut also an increase in renal and GI
abnormalities.abnormalities.
 Up to a 600 fold increase in caudalUp to a 600 fold increase in caudal
regression syndrome.regression syndrome.

10. Fetal MorbidityFetal Morbidity
 MacrosomiaMacrosomia
 Defined as birthweight above 90Defined as birthweight above 90thth
% or% or
>4000 grams.>4000 grams.
 Occurs in 15-45% of diabeticOccurs in 15-45% of diabetic
pregnancies, a 4-fold increase overpregnancies, a 4-fold increase over
normal.normal.
 Carries many morbidities including birthCarries many morbidities including birth
trauma, RDS, neonatal jaundice andtrauma, RDS, neonatal jaundice and
severe hypoglycemia.severe hypoglycemia.

11. Fetal MorbidityFetal Morbidity
 Growth RestrictionGrowth Restriction
 Although we typically associate maternalAlthough we typically associate maternal
DM with macrosomia, growth restrictionDM with macrosomia, growth restriction
is fairly common among Type 1 diabeticis fairly common among Type 1 diabetic
mothers.mothers.
 Best predictor is presence of maternalBest predictor is presence of maternal
vascular disease.vascular disease.

12. Fetal MorbidityFetal Morbidity

13. Fetal MorbidityFetal Morbidity
 PolycythemiaPolycythemia
 Hyperglycemia stimulates fetal erythropoeitinHyperglycemia stimulates fetal erythropoeitin
production.production.
 Can lead to tissue ischemia and infarction.Can lead to tissue ischemia and infarction.
 HypoglycemiaHypoglycemia
 Think of as an “overshoot” mechanism.Think of as an “overshoot” mechanism.
 Baby is used to having lots of maternal glucoseBaby is used to having lots of maternal glucose
so it makes lots of insulin. When born, maternalso it makes lots of insulin. When born, maternal
glucose is no longer available but insulin remainsglucose is no longer available but insulin remains
highhigh  hypoglycemia.hypoglycemia.
 Can lead to seizures, coma and brain damage.Can lead to seizures, coma and brain damage.

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

15. Fetal MorbidityFetal Morbidity
 PolyhydramniosPolyhydramnios
 Amniotic fluid volume >2000 mL.Amniotic fluid volume >2000 mL.
 Occurs in 10% of diabetics.Occurs in 10% of diabetics.
 Increased risk of placental abruption andIncreased risk of placental abruption and
preterm labor.preterm labor.

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

17. Maternal MorbidityMaternal Morbidity
 Diabetic neuropathyDiabetic neuropathy
 PreeclampsiaPreeclampsia
 2-fold increase2-fold increase

18. DiagnosisDiagnosis
 Glucose Challenge Test (24-28 wks)Glucose Challenge Test (24-28 wks)
 50 gram glucose load with blood level 150 gram glucose load with blood level 1
hour later.hour later.
 Does NOT require fasting state.Does NOT require fasting state.
 Normal finding is <140 mg/dl.Normal finding is <140 mg/dl.
 If >140, need to do a 3 hour glucoseIf >140, need to do a 3 hour glucose
tolerance test.tolerance test.

19. DiagnosisDiagnosis
 Glucose Tolerance TestGlucose Tolerance Test
 Draw a fasting glucose level (normal<95).Draw a fasting glucose level (normal<95).
 Give 100 gram glucose load with glucoseGive 100 gram glucose load with glucose
levels drawn after 1, 2 and 3 hours.levels drawn after 1, 2 and 3 hours.
 Normal levels vary widely depending onNormal levels vary widely depending on
who you ask but should be in the followingwho you ask but should be in the following
ranges:ranges:
 1 hr:<180 2 hr:<155 3 hr:<1401 hr:<180 2 hr:<155 3 hr:<140
 2 or more abnormal values = GDM.2 or more abnormal values = GDM.

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

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

22. ReferencesReferences
 www.acog.orgwww.acog.org
 Current Obstetric & GynecologicCurrent Obstetric & Gynecologic
Diagnosis & Treatment (2003)Diagnosis & Treatment (2003)
 Williams Obstetrics (2005)Williams Obstetrics (2005)