1. Pregnancy and Diabetes
Prof. M.C.Bansal
MBBS,MS,MICOG,FICOG
Professor OBGY
Ex-Principal & Controller
Jhalawar Medical College & Hospital
Mahatma Gandhi Medical College, Jaipur.

2. ‘My sugars are high and I must worry
Since, within my womb a child I carry
Must reduce the sugars before its too late
Or baby will end up being high birth weight’

3. Epidemiology
 Prevalence is 3.8 to 21.1% in different parts of
country
 Incidence of diabetes among Asian
women is rising & it is more frequently
being diagnosed at younger ages
 Several women & their yet unborn
offsprings are at potential risk of an
adverse outcome
 More in urban areas than rural areas

4. What are the metabolic changes in
normal pregnancy?
Pregnancy is associated with 2 important changes
1. Insulin resistance (permit foetus to draw on available
fuel stores preferentially )
2. Hormonal changes –Progesterone,
HCG,HPL,cortisol, estradiol,prolactin-
disturb glucose metabolism & result in Pregnancy: Insulin
•
 Decreased FPG & Increased PPG resistant state
 Increased insulin levels •If β cells fail to
 β-cell hypertrophy & hyperplasia overcome this-
results in GDM
 Decreased insulin sensitivity (IR)
 Enhanced lipolysis

6. WHO & NDDG Classification
Pregestational Gestational diabetes
diabetes  impaired glucose
 Type 1 tolerance of
 Type 2 pregnancy
 Undiagnosed pre-
existing diabetes
 Undiagnosed pre-
existing IGT

7. When can Diabetes & Pregnancy
coexist?
DM & pregnancy coexist under 2
circumstances
1. Known diabetic (type 1 or type 2) may
become pregnant –Pregestational diabetes
Known
Diabetic
2. Diabetes-first makes its appearance in a
woman when she is pregnant-Gestational
diabetes (GDM)
Develops
Non diabetes for
Diabetic 1st time

8. What is GDM?
 GDM= Gestational Diabetes Mellitus
 The Third International Gestational Diabetes
Workshop defined GDM as -Carbohydrate
intolerance of variable severity with onset
or first recognition during pregnancy
 If diabetic state regresses after delivery: diagnosis
is confirmed
 If diabetic state does not regress : reclassified as
type 1 or type 2

9. Risk Factors for GDM
 Strong family history
 Women who have given birth to large baby
>4 Kg
 History of recurrent pregnancy loss
 Persistent glycosuria
 Age > 25 Yrs
 Past history of GDM
 Obese or overweight or show excessive
weight gain during pregnancy

10. Risk Factors for GDM
 History of pre-eclampsia
 History of polyhydramnios
 Chronic hypertension
 History of still birth, congenital malformations
 Recurrent or severe moniliasis or UTI

12. Why all Indian women
should be screened for
glucose intolerance
during pregnancy ?

13. Screening is essential in all pregnant women
as the Indian women have 11 fold increased
risk of developing glucose intolerance during
pregnancy compared to Caucasian women
Dornhost A, Paterson CM, Nicholls JS, Wadsworth J, Chiu DC, Elkeles
RS, Johnston DG, Beard RW: High prevalence of GDM in women
from ethnic minority groups. Diabetic Med 1992: 9 (9): 820-2.

14. When to screen
 Optimally performed at 24- 28 wks of
gestation
 In high risk patients it is wiser to screen in
first antenatal visit
 Early detection causes better fetal
outcome
 In pregnant woman with normal GCT in
first trimester but if there is rapid maternal
wt gain or fetal macrosomia suspected,
then repeat test at 24-28 wks

15. Screening procedures
 American Diabetes Association (ADA )
 World Health Organization (WHO )
 AmericanCollege of Obstetrician and
Gynecology ( ACOG )

16. • ADA recommends two step procedures for screening and
diagnosis of diabetes in selective population.
• An initial screening by measuring plasma glucose one hour after
50g oral glucose load (glucose challenge test [GCT]).
• A glucose threshold value equal to or > 140mg/dl identifies GDM
• Those found positive at the screening test are given 100g OGTT

18. ADA CRITERIA FOR
DIAGNOSIS OF GDM
100 g OGTT
Fasting 95 mg/dl (5.3mmol/L)
1 – hr 180mg/dl (10mmol/L)
2 – hr 155mg/dl (8.6mmol/L)
3 – hr 140mg/dl (7.8mmol/L)
Two or more of the venous plasma concentrations must be met or
exceeded for a positive diagnosis.
Ref :O’Sullivan & Mahan → Carpenter & Couston;
ADA Position Statement on GDM 2006)

19. Drawback Of ADA criteria
 Cut off values do not correlate with fetal
outcome
 No of samples are drawn many ( Four )
 Venous samples are needed
 Two visits are necessary so patient may
not report back

20. WHO CRITERIA FOR
DIAGNOSIS OF GDM
2 hr pp after 75 Outside
In pregnancy
gm glucose pregnancy
>200 mg/dl DM DM
>140- 199 mg /dl GDM IGT
>120-139mg/dl GGI -
<120mg/dl Normal Normal

21. WHO CRITERIA FOR
DIAGNOSIS OF GDM
 Drawback –
 Criteria
not based on maternal and fetal
outcome but easy adoptability
 Advantages –
 Need not to be fasting
 Both screening and diagnostic procedure
 Least disturbance in woman’s routine

22. Glycosylated Haemoglobin
(A1c)
 Normal A1c level in pregnancy is
5.3 – 6
 Not reliable as they reflect too long
a time period.
 May serve as a prognostic value

23. Glycosylated Haemoglobin
(A1c)
May be useful to find out whether
the woman is a pre GDM or GDM
Useful in monitoring the control
during pregnancy but not for day to
day management

24. Measuring other parameters
 BP monitoring – if >130/80 alpha
methyldopa should be started
 Retinal examination
 Microalbuminuria to be looked for
 Thyroid functions

25. Clinical parameters to be monitored
 Pre-pregnancy weight
 Weight gain during ANC
 Edema
 Pallor
 Thyroid enlargement
 Uterine height more than period of gestation

26. MATERNAL COMPLICATIONS
 Effects
of diabetes on mother
Risk of recurrent abortions –in first
trimester
Infections
Postpartum bleeding
High Caesarean section rate
Risk of pre-eclampsia

27. GDM
~ 35% DEVELOP DIABETES
By 10 YEARS
GDM AFTER
PARTURITION

28. Effects of pregnancy on diabetes
 Moreinsulin is necessary to achieve
metabolic control
 Progression of diabetic neuropathy
 Worsening of diabetic nephropathy
 Increase cardiomyopathy and myocardial
infarctions

29. Effect of Maternal Fuels on Fetal & Offspring’s
Development
Mother Fetus Neonate Child
Hypoglycemia
& other
complications
P
Insulin l macrosomia Obesity
a
c IGT
e
n
Plasma t Insulin
Glucose a
Amino acids
“Mixed Diabetes
lipids
Nutrients”

30. Fetal Complications
 Congenital malformations –
 Mainlyin type I –due to metabolic
derangements present at the time of
conception, during blastogenesis and
organogenesis
 Hyperglycemia – macrosomia
 Hypocalcemia
 Intermittent
hypoglycemia- risk of IUGR
 Hyperviscosity syndrome

31. Fetal Complications
 Hyaline membrane disease
 Apnea and bradycardia
 Unexplainedfetal demise – during last 4-
8 weeks of gestation

32. Common congenital malformations
 Cardiovascular System – TGV,
VSD,Coarctation of aorta, PDA, ASD,
Single ventricle
 Central Nervous System – spina bifida,
anencephaly, holoprosencephaly, neural
tube defects
 Skeletal – cleft lip and palate, caudal
regression syndrome

33. Common congenital malformations
 Genitourinary
Tract – ureteric duplication,
hydronephrosis, renal agenesis,
 Gastrointestinal
– anorectal atresia,
imperforate anus, duodenal atresia

34. Neonatal complications
 Respiratory distress
 Hypoglycemia
 Hypocalcemia
 Hyperbilirubinemia
 Hyperviscosity Syndrome
 Cardiac hypertrophy
 Perinatal Deaths
 Long term effects on cognitive
developments

36. Management of pregnancy in a
woman with diabetes
 Women with DM (pregestational DM)
 planned in advance
 good control-established before conception- avoid
risks of hyperglycaemia / glucotoxicityand
ketoacidosis during embryogenesis / organogenesis
 If it occurs accidentally or unaware of DM
 risks are explained
Pregestational
•planned pregnancy
•tight control at conception

37. Management of GDM
 Patienteducation
 Medical nutrition therapy (MNT)
 Physical activity
 Self monitoring blood glucose
 Self administration of Insulin

38. Medical Nutrition Therapy
 Adequate calories/nutrition to meet the
need of pregnancy
 Wt gain expected in pregnancy – 300-400
gm/wk total 10-12 kg
 Avoid excess wt gain and post prandial
hypoglycemia

39. Calorie allotment and wt gain
Current wt
Recommended daily Recommended
( %of ideal calorie intake Kcal/kg total wt gain in kg
body wt )
< 80-90 36-40 12.5-18
100-120 30 11.5-16
120-150 24 7-11.5
>150 12-18 At least 6

40. Calorie counting
 Breakfast – split in two equal halves and
eat at 2 hr interval – to avoid undue peak
in plasma glucose level
 Dawn phenomenon – peaking of plasma
glucose is high with breakfast than with
lunch or dinner, in GDM mother first phase
of insulin is deficient so it is divided in two
halves

41. FETAL MONITORING
Risk based on glycemic
Procedure control, vascular disease
Low risk high risk
Dating ultrasound 8 - 12 weeks 8 - 12 weeks
Prenatal genetic diagnosis As needed As needed
Targeted perinatal ultrasound:
18 - 22 weeks 18 - 22 weeks
fetal echocardiography
Fetal kick counts 28 weeks 28 weeks
28 and 37
Ultrasound for fetal growth Monthly
weeks1
Antepartum FHR monitoring, 36 weeks,
27 weeks, 1 - 3/week
modified BPP weekly
Amniocentesis for lung maturity - 35 - 38 weeks
Induction of labor 40 weeks2 35 - 38 weeks

42. Fetal Ultrasound
Indirectly indicates glycemic control
 Ultrasound scan for fetal growth and
liquor volume every two weeks from 26th
week
 Fetal abdominal circumference provides a
baseline for further serial measurements
which can indicate growth acceleration
or restriction.

43. Target Blood Glucose Level
 Mean plasma glucose
 105-110 mg/dl for good fetal outcome
 Fasting Plasma Glucose
 90 mg/dl ( 80 -90 mg/dl )
2 hrs Plasma Glucose 120 mg /dl

44. Insulin Therapy
 MNT for 2 weeks, if even then fasting
Plasma glucose >90 mg/dl and post meal
glucose >120 mg/dl – Begin Insulin
 Premix Insulin 30/70 of any brand
 4 units BBF- increase every 4 th day by 2
units till 10 units
 If FPG >90 mg/dl give 6 units BBF and 4
units BD

45. Insulin Therapy
 If post breakfast glucose is high begin with
premix 50/50
 If 2 hr Plasma glucose >200 mg/dl at
diagnosis start 8 units of premixed insulin
BBF and titrate it on follow up.

46. Insulin Therapy
 If GDM only has post prandial hyperglycemia
with normal FBG then start with rapid and
regular insulin 2- 3 times a day with each meal.
 Human insulin does not cross placenta.
Usually women with GDM do not require
>20 units of insulin/day in comparison to
type I or II who may require higher doses

47. Oral Hypoglycemic Agents
 Trialand work reveals beneficial role of
glibenclamide and metformin
 No consensus evolved
 ACOG do not recommend use of OHA in
pregnancy

48. Significance of control of
maternal glucose levels
 Increase maternal carbohydrate intolerance –
increase adverse fetal and maternal outcome
 If maternal Blood Glucose level is
 120- 139 mg/dl - Risk of Type II DM is 19% in
offspring
 140-199 mg/dl – risk increases to 30%

50. Management guidelines
 Obstetricmanagement
 Glycemic control : Pre Induction
 Monitoring Insulin : Low dose sliding scale
High dose sliding scale
Insulin
infusion
 Management of Hypoglycemia
 Elective caesarean section
 Postpartum
 Neonatal Management

51. Preterm labour
 Choice – Nifedipine
 Rule out infection ( seen in 40% of
cases)

Beta Adrenergics : X
Increase glycogenolysis and lipolysis
tendency to metabolic acidosis

52. Insulin Type / Regimen
Aim:
To mimic Natural pattern of insulin
secretion
To Avoid:
•Post prandial Hyperglycemia
•Pre meal Hypoglycemia
•Nocturnal Hypoglycemia

53. Obstetric management
 The standard management of labour for a
'high risk' pregnancy
 Continuous electronic fetal monitoring
 Ensure adequate analgesia with a lower
threshold for epidural in labour.
 Labour should not be prolonged
 Prepare for the possibility of shoulder
dystocia.
 Active management of third stage.

54. Monitoring labor in Type 1 & Type 2
Diabetes Mellitus
 Stable  Unstable
 Deliver at 38 wks  Delivered
as soon
 CBG during induction as lung maturity is
normal range : 0.9% saline attained
>120mg/dl : continous insulin
infusion
<70 mg/dl : DNS
 Active phase : DNS

55. GDM : When to deliver ?
High risk Low risk
 Induce at 38 wks  Delivery planned at 40
wks gestation
 Spontaneous onset of
labour is awaited
 Avoid prolonged
pregnancy
 At 40 wks
<4500 gms : induce
>4500 gms : elective
CS
ACOG

56. Elective caesarean section
 Usual insulin the night before Caesarean
section
 Morning of Caesarean section - withhold
usual insulin
 Measure blood glucose level in theatre prior
to anesthesia
 Avoid IV Dextrose unless hypoglycemic. If
indicated, insulin and glucose infusions are
given to keep the blood glucose under 140
mg/dl.
 Postoperatively use low-dose sliding scale
 then, fasting and before each meal.

57. Insulin during labour in GDM ?
 Most do not require it
 Capillaryblood glucose measured 2-4
hrly : upward deviation corrected with
small doses of regular insulin / low dose
IV insulin infusion
 Very low blood glucose : 50-100 ml bolus
of 5-10%DS

58. Intravenous insulin infusion
For patients requiring intensive therapy and/or poor
control on a sliding scale,e.g. severe preeclampsia.
Via syringe pump
50 units regular insulin in 50 mLs of Normal saline
Aim : blood glucose level 72 – 126 mg/dl(4-7mmol/L)

59. Plasma Glucose and Insulin flow at
the time of onset of labor
<70 mg/dl 5% GNS – 100 ml/hr
90-120 mg/dl NS – 100 ml /hr
120 -140 mg/dl NS 100 ml/ hr + 4 units
of regular insulin (in
500ccNS)
140 -180 mg/dl NS 100 ml/hr +6 units of
regular insulin
>180 mg/dl NS 100 ml/ hr +8 units of
regular insulin

60. Blood glucose monitoring
 Type 1 and Type 2 and GDM on insulin 2-hourly
 GDM not on insulin 4-hourly
 Intravenous therapy
Not routinely required for diabetes management
Normal Saline should be used if requires IV therapy,
no need for routine IV Dextrose
Caution with fluid overload in severe pre-eclampsia

62. 1.Pelvic floor trauma
vaginal deliveries in diabetics:
20 % suffer 2nd,3rd & 4th degree perineal tears
Predisposing factors : macrosomia
nulliparity
episiotomy
instrumental delivery
2.Shoulder dystocia : non diabetics : 0.5%
diabetic : 3.2%
Am J Obstet & Gynecol 1991;165: 831-837

63. Management of GDM – Post
partum
 Blood glucose monitoring B.D. for 48 hours
 Insulin is ceased post delivery : >95%
cases do not require it any more
 If blood glucose levels > 126mg/dl ,
continue to monitor until discharge -
fasting and 2 hours after meals
 If blood glucose levels are persistently
elevated after 72 hours, contact Diabetes
Consultant

64. Management of Type 1 & 2 –
Post partum
 Type 2 will usually not require insulin in the
postnatal period unless blood glucose levels
are consistently elevated. Start at ½ or 2/3
of pre delivery dose
 Oralhypoglycemic agents (sulfonylureas,
glitazones) are usually not recommended
while breastfeeding

65. Neonatal Management
 Commence feeding within one hour of birth and
feed 3 - 4 hourly.
 Measure Blood Sugar Level (BSL) : at four hours
of age or before the second feed (whichever
comes first)
 immediately - if clinical signs of hypoglycemia
present
 before each subsequent feed until 3 consecutive
readings ≥ 2.6 mmol/L
 Recommence glucose monitoring if change in
feeding or clinical condition.

66. Follow Up of GDM
 OGTT with 75 gm Glucose using WHO
criteria at 6-8 wks postpartum. If normal
repeat at 6 months and every yr
 Toavoid neural tube defects in unplanned
pregnancy daily folic acid is recommended

67. Counseling
 Ifwoman plans pregnancy she should
have very good control of DM – FPG <90
mg/dl at the time of conception to avoid
fetal malformations
 contraceptives – low dose hormones may
be given

68. Preventive measures start from
intrauterine life and continues
through out life from early
childhood.

69. A short term
intensive care gives
a long term pay off
in the primary
prevention of
obesity, IGT and
diabetes, as
‘Preventive medicine
starts before birth’