Diabetes & Pregnancy
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This document provides an overview of diabetes in pregnancy. It defines diabetes mellitus and describes the main types: type 1, type 2, and gestational diabetes. Risk factors, screening, and diagnostic criteria for gestational diabetes are covered. The document also discusses complications of diabetes in pregnancy for both mother and baby, as well as management through medical nutrition therapy, exercise, medication and insulin. Postpartum care is also summarized.
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Diabetes & Pregnancy
- 3. A metabolic condition characterized by chronic hyperglycaemia as a result of defective insulin secretion, insulin action or both What is DM?
- 4. Type 1(IDDM) Type 2(NIDDM) Gestational diabetes Others Genetic defects in insulin processing or action Endocrinopathies Drugs Exocrine pancreatic defects Genetic syndromes associated with DM Types
- 5. Placental Diabetogenic hormones Increased Plasma Cortisol levels State of insulin resistance Increased body weight and caloric intake Pregestational diabetes becomes worse during Pregnancy & GDM develops when the pancreas cannot overcome the effect of these hormones Is Pregnancy Diabetogenic ?
- 6. Diabetes & Pregnancy Diabetes in Pregnancy GDM 90% Chronic DM 10% Incidence rising
- 7. Maternal Fetal Miscarriages FGR Preeclampsia Preterm labour Birth trauma IUD / Still births IOL Macrosomia Increased maternal morbidity Congenital malformations Future risk for Type 2 DM Postnatal hypoglycemia Worsening of Retinopathy / Shoulder dystocia Nephropathy RDS LSCS / Operative vaginal delivery Polycythemia & Jaundice Sepsis Complications
- 8. Obesity Diabetes mellitus Reproductive problems Metabolic syndrome The child - later on….
- 9. History
- 10. Greek physician in 80 to 138 C.E. Described diabetes mellitus “melting of flesh and limbs into urine” “ One cannot stop them from making or drinking water” Aretaeus of Cappadocia
- 11. Started the first Diabetic pregnancy Clinic in 1924 Achieved from 50% to 90% survival rate among babies born Her studies showed about strict diet control and early delivery improved outcome Priscilla White, MD
- 12. Screening
- 13. Screening
- 14. Importance 1. Intervention in pregnancy will improve out come 2. Greater risk in developing Type 2 DM in later life Diabetes in pregnancy , NICE guideline 3, 2015 ACHOIS – Australian Carbohydrate intolerance study in preg women 2005 Screening
- 15. Screening Screening 1st Trimester 2nd Trimester
- 16. On selected population with 75 g 2 hour OGTT Fasting Plasma Glucose can be used as a screening test in high risk population 50 g GCT has inconclusive data to support as a screening test Evidence does not support HbA1c as a screening test Diabetes in pregnancy , NICE guideline 3, , 2015 Screening
- 17. Gold standard to diagnose GDM is 75 g 2 Hour OGTT Between 24 to 28 weeks Can be performed or repeated up to 32 weeks Diagnosis
- 18. Previous pregnancy - GDM Early self monitoring of blood glucose 75 g OGTT at booking visit Repeat OGTT between 24 to 28 weeks if booking OGTT normal OGTT at 24 / 52 for other risk factors for GDM Diabetes in pregnancy , NICE guideline 3,, 2015 Diagnosis of GDM
- 19. Obesity ( BMI > 30 Kg / m2 ) Ethnicity ( South Asians, Chinese ) Previous GDM Family History of DM Previous Macrosomia ( > 4.5 kg ) PCOS Advanced maternal age Previous unexplained perinatal death Polyhydramnios Smoking Diabetes in pregnancy , NICE guideline 3, Wednesday February 25th, 2015 Risk Factors for GDM
- 20. Developed prior to HAPO 75 g 2 hour OGTT FPG 126 mg / dL 2nd Hour Plasma Glucose 140 mg / dL Limitation HAPO detect more Macrosomic babies than from WHO criteria HAPO study. NEJM 2008 WHO Criteria
- 21. Overt Diabetes
- 22. Strong Continuous associations between glycaemic levels below those diagnostic of diabetes and adverse pregnancy outcome ( increase in birthweight and increased cord blood C- Peptide levels ) Hyperglycaemia α Adverse Pregnancy Outcomes HAPO study. NEJM 2008 HAPO
- 23. 25,505 pregnant women, 15 centres, 9 countries Primary Outcomes BW > 90th % Cord blood serum C-peptide >90 % Primary CS Neonatal hypoglycaemia Secondary Outcomes Premature delivery Shoulder Dytocia Intensive neonatal care Hyperbilirubinaemia Pre eclampsia HAPO NEJM 2008; 358:1991-2002 HAPO
- 24. HAPO Need to reconsider current diagnostic criteria ……
- 25. Adopted from HAPO and other studies From 24 to 28 weeks FBS 92 mg/dL 1h 180 mg/dL 2h 153 mg/dL Diagnosis requires only one threshold value exceeded International Ass of Diabetes and Pregnancy Study Groups . Diabetes Care 2010 IADPSG Criteria – 2008
- 27. Preconception
- 28. Diabetes carries increased risk for NTD High dose Folic acid ( 5 mg / day ) From pre-conception to 12 / 52 of gestation significantly reduces the incidence of NTD Diabetes in pregnancy , NICE guideline 3, 2015 Folic Acid
- 29. Pregestational DM associated with Adverse Pregnancy Outcomes ( APO ) Presence of complications of DM increase risk for APO Sub optimal glycaemic control is associated with APO Diabetes in pregnancy , NICE guideline 3, 2015 Glycaemic Control
- 30. BMI > 30 Kg / m2 associated with Increased incidence for IGT, HT, PPH, Caesarean sections, Macrosomia, Congenital malformations, Preterm births, Perinatal morbidity & mortality Diabetes in pregnancy , NICE guideline 3,, 2015 Obesity
- 31. ACE Inhibitors / Angiotensin 2 Receptor Antagonist Associated APO Pre term births FGR Major Congenital malformations Statins Associated APO Major Congenital malformations Thus all the drugs should be discontinued prior to conception or as soon as pregnancy is confirmed Diabetes in pregnancy , NICE guideline 3,, 2015 Drugs
- 32. Degree of glycaemic control at conception is associated with congenital malformations and miscarriages Good pregnancy out come is associated with HbA1c < 6.5 % Advise against pregnancy if HbA1c > 10 % Diabetes in pregnancy , NICE guideline 3, Wednesday February 25th, 2015 HbA1c
- 33. Measure in all pregestational DM at booking visit Measure in T2 / T3 to asses level of risk in pre gestational diabetes No use as a indicator for blood sugar control in T2 /T3 Diabetes in pregnancy , NICE guideline 3,, 2015 HbA1c
- 35. GDM DM + Pregnancy Early pregnancy BS normal Elevated BS since before Usually no effect on organogenesis pregnancy Less likely to have congenital defects Effect during Diabetes disappears after delivery organogenesis More macrosomia More congenital fetal defects X 8 FGR common Difference between GDM & DM
- 41. Normalisation of blood glucose Limited weight gain Monitoring for anomalies and complications Avoiding macrosomia Planned delivery Strategy
- 42. Significant improvement of major APO Macrosomia Shoulder Dystocia Primary Caesarean sections Still birth Diabetes in pregnancy , NICE guideline 3,, 2015 Medical Nutritional Therapy
- 43. Some evidence on Post Prandial Exercise to improve Post Prandial Blood Glucose Diabetes in pregnancy , NICE guideline 3, Wednesday February 25th, 2015 Exercise
- 44. OHG Offer if blood sugar targets not met with MNT & Exercise within 1 to 2 weeks No significant difference in rates of major malformations between OHG group with non OHG group 10 RCT , OR 1.06, 95% CI 0.65 – 1.7 Diabetes in pregnancy , NICE guideline 3,, 2015 Pharmacology
- 45. Safe in pregnancy Offer if blood sugar targets not met with MNT & Exercise within 1 to 2 weeks Metformin
- 46. In GDM, Metformin (alone or with supplemental insulin) is not associated with increased perinatal complications as compared with insulin. The women preferred metformin to insulin treatment. Is a reasonable therapeutic option to Insulin* Australian New Zealand Clinical Trials Registry number, 12605000311651 *Diabetes in pregnancy , NICE guideline 3, Wednesday February 25th, 2015 MiG Trial
- 47. Metformin in Gestational Diabetes: The Offspring Follow-Up (MiG TOFU) 2 year follow up of MiG Trial Children exposed to metformin had larger measures of subcutaneous fat, but overall body fat was the same as in children whose mothers were treated with insulin alone. Diabetes Care 34:2279–2284, 2011 MiG TOFU
- 48. The first OHG agent to have proven efficacy and safety in pregnancy Minimal placental transfer No significant difference in major adverse out comes when compared with Insulin But High treatment failure and Maternal hypoglycaemia Diabetes in pregnancy , NICE guideline 3, Wednesday February 25th, 2015 Langer et al. N Eng J Med 2000 Glibenclamide
- 49. Can offer Glibenclamide to Those on Metformin but refuses Insulin Those not tolerating Metformin Start at 2.5mg/day up to 20 mg /day Diabetes in pregnancy , NICE guideline 3, 2015 Glibenclamide
- 50. No significant difference in major out come But Metformin is better tolerated Diabetes in pregnancy , NICE guideline 3, 2015 Glibenclamide Vs. Metformin
- 51. Is the drug of choice Offer Insulin if blood sugar targets not met with MNT, Exercise, Metformin Offer Insulin +/- Metformin if FPG > 7.0 mmol /l at diagnosis ( 126 mg/dl ) Offer Insulin +/- Metformin if FPG > 6.0 to 6.9 mmol /l (108 mg/dl to 124 mg/dl if there are complications ( Macrosomia, Polyhydramnios ) Diabetes in pregnancy , NICE guideline 3, 2015 Insulin
- 52. Rapid acting ( Lispro, Aspart, Glulisine ) No difference in HbA1c reduction More hypoglycaemia No difference in APO Long acting ( Ditemir, Glargine ) Some evidence on HbA1c reduction No difference in APO Diabetes in pregnancy , NICE guideline 3, Wednesday February 25th, 2015 Insulin
- 53. Isophane Insulin ( Crystalline Zinc insulin with Protamine ) Good baseline control 1st line choice as the long acting Insulin Diabetes in pregnancy , NICE guideline 3, Wednesday February 25th, 2015 Neutral Protamine Hagedorn
- 54. Type 1 DM FBS, Pre meal, 1 hour post meal & bed time glucose daily throughout pregnancy Type 2 DM / GDM on Insulin FBS, Pre meal, 1 hour post meal & bed time glucose daily through out pregnancy Diabetes in pregnancy , NICE guideline 3, Wednesday February 25th, 2015 Antenatal Blood Sugar Monitoring
- 55. Maintain FBS 95 mg / dL 1 hr PPBS 140 mg / dL 2 hr PPBS 115 mg / dL Maintain CBS > 4 mmol / L on Insulin or Glibenclamide Diabetes in pregnancy , NICE guideline 3, 2015 Antenatal Blood Sugar Monitoring
- 56. Daily monitoring Vs. Weekly monitoring Daily monitoring is not cost effective & practical Pre prandial Vs. Post prandial Post prandial group received more Insulin & had smaller babies Diabetes in pregnancy , NICE guideline 3,, 2015 Antenatal Blood Sugar Monitoring
- 57. One hour PPBS Vs. Two hour PPBS Peak blood sugar levels at 60 to 90 minutes More acceptable & tolerable One hour PPBS preferable but no Significant difference in out come Diabetes in pregnancy , NICE guideline 3, Wednesday February 25th, 2015 Antenatal Blood Sugar Monitoring
- 58. Ketone Bodies Test In Type 1 DM if unwell or in hyperglycaemia In Type 2 DM in hyperglycaemia Diabetes in pregnancy , NICE guideline 3, Wednesday February 25th, 2015 Antenatal Monitoring
- 59. Delivery
- 60. Type 1 or type 2 diabetes with no other complications to have an elective birth between 37+0 / 52 and 38+6 / 52 of pregnancy Consider elective birth before 37+0 / 52 for type 1 or type 2 diabetes if there are metabolic or any other maternal or fetal complications Advise women with gestational diabetes to give birth no later than 40+6 / 52 Consider elective birth before 40+6 / 52 for women with gestational diabetes if there are maternal or fetal complications Diabetes in pregnancy , NICE guideline 3, Wednesday February 25th, 2015 Delivery
- 62. Insulin-treated pre-existing diabetes should reduce their insulin immediately after birth and monitor their blood glucose levels GDM should discontinue blood glucose-lowering therapy immediately after birth In GDM Offer a FBS 6–13 weeks after the birth If a FBS not done by 13 weeks, offer FBS or HbA1c Do not routinely offer a 75 g 2-hour OGTT Offer an annual HbA1c for GDM who have a negative postnatal test for diabetes Diabetes in pregnancy , NICE guideline 3, Wednesday February 25th, 2015 Post Partum Care
- 63. Continuous glucose monitoring (CGM) Continuous subcutaneous insulin infusion (CSII) CGM carried in conjunction with CSII Have good Glycaemic control & minimal complications Diabetes in pregnancy , NICE guideline 3, Wednesday February 25th, 2015 Future
- 64. References Diabetes in pregnancy , NICE guideline 3, Wednesday February 25th, 2015 HAPO study. NEJM 2008 IADPSG. Diabetes Care 2010 Dewhurst's Text book of Obstetrics and Gynecology, 7th Edition WHO, Diabetes in pregnancy, 2013
- 65. Questions ?
- 66. Thank You ! Thank You !!