Hello friends I am sharing a ppt on Diabetes in pregnancy

1. Pelvic inflammatory disease, (PID)
DIABETES IN
PREGNANCY
Dr. Jograjiya
Post Graduate Student,
Department of Gynaecology and
Obstetrics
PGIMSR, ESIC, Basaidarapur,
New Delhi-110015

2. Proposed Classification System for
Diabetes in Pregnancy

3. Definitions
Gestational
diabetes
Pre-gestational
diabetes
(Overt)

4. Definitions
Any degree of glucose
intolerance with onset or first
recognition during pregnancy
Gestational Diabetes
Metzger BE, Coustan DR (Eds.): Proceedings of the Fourth International Workshop-
Conference on Gestational Diabetes Mellitus. Diabetes Care 21 (Suppl. 2):B1– B167, 1998

5. Definitions
Pre-gestational Diabetes
Diabetes diagnosed before
pregnancy

6. Etiological Classification of
Diabetes Mellitus

7. White Classification in Diabetes Complicating Pregnancy

8. Screening and diagnosis
Rationale for treatment
Monitoringof blood glucose
Diet and exercise
Insulininitiation and follow-up
Maternal and fetal surveillance
Labor and delivery
Postpartum follow-up
Gestational Diabetes

9. Gestational
diabetes
Screening
Risk factors for GDM
Increasing maternal age and weight
Previous GDM
Previous macrosomic infant
Family history of diabetes among
first-degree relatives
Ethnic background with a high
prevalence of diabetes
International Diabetes Federation (2009)
Global Guideline on Pregnancy and Diabetes

10. Gestational
diabetes
Screening
Universal Screening
recommend for High risk
pregnant women
International Diabetes Federation (2009)
Global Guideline on Pregnancy and Diabetes

11. Gestational
diabetes
Screening
Allwomen should undergo
screening at first prenatal visit
and after 26 to 28 weeks if
negative on previous testing.
AFES Study Group on Diabetes in Pregnancy (ASGODIP), 1996

12. Gestational
diabetes
Screening
International Diabetes Federation (2009)
50-g glucose
challenge test
(GCT)
Global Guideline on Pregnancy and Diabetes
>140 mg/dL

13. Gestational
diabetes
Diagnosis
>140 mg/dL
50-g glucose
challenge test
(GCT)
Oral glucose
tolerance test (OGTT)
75-g or 100 g?
Thresholds
for
diagnosis
ADA ASGODIP
75-g
WHO
75-g100-g 75-g
FBS 95 95 - -
1 h 180 180 - -
2 h 155 155 140 140
3 h 140 - - -

14. 100-g OGTT
 Carbohydrate intake of at least 150 g/day 3days
prior
 Fast for 8 to 10 hours but not more than 14 hours
 75 grams of anhydrous dextrose powder as chilled 25%
solution (400 cc) flavored
 Drink within 5 minutes (first swallow is time zero)
 Terminate test should nausea and vomiting occur
 Collect samples at 0, 1 , 2 and 3 hours

15. 100-g OGTT
Abstain from tobacco, coffee, tea, food and
alcohol during test
Sit upright and quietly during the test
Slow walking is permitted but avoid vigorous
exercise

16. Gestational
diabetes
Rationale for treatment
Increased risk for
macrosomic or LGA infants
25
0
50
100
75
MMC VMMC PoGH CSMC PGH
%
GDM Normal
AFES Study Group on Diabetes in Pregnancy (ASGODIP), 1996
Isip-Tan unpublished data

17. Gestational
diabetes
Rationale for treatment
Increased risk for
Cesarean sections
20
40
60
80
100
MMC VMMC PoGH PGH
%
GDM Normal
AFES Study Group on Diabetes in Pregnancy (ASGODIP), 1996
Isip-Tan unpublished data

18. Gestational
diabetes
Monitoring blood glucose
Self-monitor blood glucose levels
both fasting and postprandial,
preferably 1 h after a meal.
International Diabetes Federation (2009)
Global Guideline on Pregnancy and Diabetes

19. Monitoring blood glucose
Fifth International Workshop-Conference on Gestational Diabetes Mellitus (2007)
National Institute for Health & Clinical Excellence (2008)
Canadian Diabetes Association (2008)
5th Int’l Workshop NICE CDA
Fasting 90-99 mg/dL
(5.0-5.5 mmol/L)
63-106 mg/dL
(3.5-5.9 mmol/L)
68-94 mg/dL
(3.8-5.2 mmol/L)
1 h after
meal
<140 mg/dL
(<7.8 mmol/L)
<140 mg/dL
(<7.8 mmol/L)
99-139 mg/dL
(5.5-7.7 mmol/L)
2 h after
meal
<120-127 mg/dL
(<6.7-7.1 mmol/L)
90-119 mg/dL
(5.0-6.6 mmol/L)

20. Dietary Management
Determine if patient is overweight
Expected pregnant weight =
ideal body weight (for height) +
expected weight gain/trimester

21. IOM recommendations for
weight gain by pre-
pregnancy BMI
* Assume a 0.5-2.0 kg (1.1-4.4 lbs) weight gain in the first trimester
2009
Prepregnancy BMI Total weight
gain (lbs)
Rates of weight gain*
2nd and 3rd trimester
(lbs/week)
Underweight
BMI <18.5
<28-40 1
(1-1.3)
Normal weight
BMI 18.5-24.9
25-35 1
(0.8-1)
Overweight
BMI 25.0-29.9
15-25 0.6
(0.5-0.7)
Obese
BMI >30.0
11-20 0.5
(0.4-0.6)

22. Dietary Management
Jovanovic L (Ed). Medical Management of Pregnancy Complicated by Diabetes (2009)
Recommended Daily Caloric Intake
Pregravid BMI Category kcal/kg/day
Low (BMI <18.5 kg/m2) 36-40
Normal (BMI 18.5-24.9 kg/m2) 30
High (BMI 25-29.9 kg/m2) 24
Obese (BMI >29.9 kg/m2) 12

23. Dietary Management
International Diabetes Federation (2009)
Global Guideline on Pregnancy and Diabetes
For considerably overweight
women with GDM, reduce energy
intake by no more than 30% of
habitual intake
Total cal/day = 1,800-2,000
Not less than 2,000 cal/day if multiple pregnancy

24. 3 meals and 3 snacks
40% complex high fiber carbohydrate
20% protein
40% fats (ACOG 2013)
Dietary Management

25. Avoid concentrated sweets
No cookies, cakes, pies, soft
drinks, chocolate, table sugar,
fruit juice, juice drinks, Kool-Aid,
Hi-C, nectars, jams or jellies
Avoid convenience foods
No instant noodles, canned
soups, instant potatoes, frozen
meals or packaged stuffing
Dietary Management
Jovanovic L (Ed). Medical Management of Pregnancy Complicated by Diabetes (2009)

26. Eat small frequent meals
Eat about every 3 hours
Include a good source of protein
at every meal and snack (i.e. low-
fat meat, chicken, fiish, low-fat
cheese, nuts, peanut butter,
cottage cheese, eggs and turkey)
Dietary Management
Jovanovic L (Ed). Medical Management of Pregnancy Complicated by Diabetes (2009)

27. Dietary Management
Eat a very small breakfast
No more than 1 starch
exchange (<15g carbohydrate
so limit cereal, bread, pancakes,
toast, bagels, muffins and
Danishes and no fruit juice
Jovanovic L (Ed). Medical Management of Pregnancy Complicated by Diabetes (2009)

28. Dietary Management
Choose high-fiber foods
Fresh and frozen vegetables
Beans and legumes
Fresh fruits (except at breakfast)
Jovanovic L (Ed). Medical Management of Pregnancy Complicated by Diabetes (2009)

29. Dietary Management
Free foods - eat as desired
Jovanovic L (Ed). Medical Management of Pregnancy Complicated by Diabetes (2009)
cabbage mushrooms celery
radish cucumber zucchini
lettuce green beans spinach
onion green onion garlic
broccoli asparagus nopales
spinach lemon/lime butter
olives sour cream avocado
olive oil

30. Monitor urine ketones before
breakfast to detect starvation
ketonuria
Individualize!
Monitor blood glucose levels, urine
ketones, appetite and weight gain
Dietary Management

31. Exercise
International Diabetes Federation (2009)
ACOG (2013)
Walking for 20 minutes two time
daily that exercise improved
cardiorespiratory fitness without
improving pregnancy outcome.
Exercise is a useful adjunct to treatment
Avoid excessive abdominal muscle contraction
Global Guideline on Pregnancy and Diabetes

32. Insulin Initiation
ADA Protocol
Fasting whole BG >95 mg/dL
1-h postprandial whole BG >140 mg/dL
2-h postprandial whole BG >120 mg/dL

33. Insulin Initiation
Diet therapy alone for one
postprandial glucose
abnormal before starting
insulin
If fasting glucose (on OGTT) >95 mg/dL
or Two postprandial glucose abnormal
start insulin with dietary therapy at
diagnosis

34. Insulin Regimens
Human insulin
Insulin analogues
Insulin lispro and aspart safe and effective
and have a more rapid onset of action than
regular insulin
Limited experience with insulin glargine and detemir

36. Insulin Regimens
ASGODIP Protocol
Intermediate-acting insulin 30 min prebreakfast
Intermediate-acting insulin 30 min presupper + rapid-
acting insulin
Three injections of rapid-acting insulin given 30 minutes
before each meal + intermediate-acting OR long-acting
insulin at bedtime
Initiating dose is typically 0.7–1.0 units/kg/day given in
divided doses (ACOG, 2013).

37. Subsequent visits
ASGODIP Protocol
Every 2 weeks to check
glycemic control
W/F obstetric complications
(i.e. macrosomia, IUGR,
preeclampsia and hydramnios)
Date
time CBG Comments
11/20
after 160 pancakes
breakfast
after 148 spaghetti
lunch
after 118
dinner

38. Maternal
surveillance
Increased frequency of preterm
birth in untreated GDM
Use of corticosteroids not
contraindicated but intensify
glucose monitoring and adjust
insulin
Risk of hypertensivedisorders
increased
Jovanovic L (Ed). Medical Management of Pregnancy Complicated by Diabetes (2009)

39. Fetal surveillance
ASGODIP Protocol
Ultrasound at 11-13 weeks
first visit to determine age of
pregnancy
At 18-20 weeks to detect
malformations
Once at 36-37 weeks to monitor
growth
HbA1c values >7.0% or fasting plasma
glucose >120 mg/dL (6.7 mmol/L)
Jovanovic L (Ed). Medical Management of Pregnancy Complicated by Diabetes (2009)

40. Glycemic control during
labor and delivery
 Usual dose of intermediate-acting insulin is given at bedtime.
 Morning dose of insulin is withheld.
 Intravenous infusion of normal saline is begun.
 Once active labor begins or glucose levels decrease to < 70
mg/dL, the infusion is changed from saline to 5-percent dextrose
and delivered at a rate of 100–150 mL/hr (2.5 mg/kg/min) to
achieve a glucose level of approximately 100 mg/dL.
 Glucose levels are checked hourly using a bedside meter
allowing for adjustment in the insulin or glucose infusion rate.
 Regular (short-acting) insulin is administered by intravenous
infusion at a rate of 1.25 U/hr if glucose levels exceed 100
mg/dL.

41. Glycemic control during
labor and delivery
ASGODIP Protocol
After delivery, resume diet
Generally do not require insulin
GDM with high insulin requirements during pregnancy
should have CBG monitoring
Give insulin only if CBGs persistently high (>200 mg/dL)

42. Postpartum
follow-up
Schedule 100-g OGTT after 6 weeks
60-70% chance of developing GDM in
subsequent pregnancies
40-60% chance of developing type 2
diabetes in the future
Jovanovic L (Ed). Medical Management of Pregnancy Complicated by Diabetes (2009)

43. Postpartum
follow-up
Annual follow-up
Measure FBS
Assess weight reduction
Review pregnancy plans
Jovanovic L (Ed). Medical Management of Pregnancy Complicated by Diabetes (2009)

44. Pre-gestational diabetes
Diagnosis
Impact on Pregnancy
Effects on Fetus
Maternal Effects
Preconception care
Monitoring of blood glucose
Hypoglycemia
Special considerations

45. Diagnosis

46. Impact on Pregnancy

47. Effects on Fetus
• Spontaneous Abortion
• Altered growth
• Preterm Delivery
• Unexplained Fetal Demise
• Hydramnios
• Respiratory Distress Syndrome
• Hypoglycemia.
• Hypocalcemia.
• Hyperbilirubinemia and Polycythemia.
• Cardiomyopathy
• Long-Term Cognitive Development
• Inheritance of Diabetes.

49. Maternal Effects
•Preeclampsia
•Diabetic Nephropathy
•Diabetic Retinopathy
•Diabetic Neuropathy
•Diabetic Ketoacidosis
•Infection

50. Management Diabetic Ketoacidosis

51. Preconception Care
Contraceptive advice
Risks of pregnancy (maternal and
fetal/neonatal)
Importance of maintaining blood
glucose levels
Genetic counseling
Personal commitment by women
and her family

52. Preconception Care
Prepregnancy Assessment
History and PE
Gynecologic evaluation
Lab evaluation
HbA1c, urinalysis and culture, 24-h
urine for creatinine CL and protein
Thyroid panel: FT4 1.0-1.6 and TSH
<2.5 uU/L
ECG or treadmill
Neuropathy testing if indicated

53. Preconception Care
Potential Contraindications to Pregnancy
Ischemic heart diease
Active proliferative retinopathy, untreated
Renal insufficiency
Creatinine CL <50 ml/min or serum creatinine >2
mg/dL or heavy proteinuria (>2 g/24 h) or
hypertension (BP
>130/80 mm Hg despite treatment)
Severe gastroenteropathy
Nausea/vomiting, diarrhea

54. Preconception Care
Shift Type 2 diabetics on OHA to insulin
Maternal HbA1c to assess risk of malformations
Goal < 6 % if possible Monitor every 1 to 2
months
400 μg/day orally is given periconceptionally and
during early pregnancy
Discontinue contraception
Stable glycemic control
Maternal diabetic complications and coexisting medical
problems acceptable
Diabetes Care 26:S91-93, 2003

55. Monitoring blood glucose
Fifth International Workshop-Conference on Gestational Diabetes Mellitus (2007)
National Institute for Health & Clinical Excellence (2008)
Canadian Diabetes Association (2008)
5th Int’l Workshop NICE CDA
Fasting 90-99 mg/dL
(5.0-5.5 mmol/L)
63-106 mg/dL
(3.5-5.9 mmol/L)
68-94 mg/dL
(3.8-5.2 mmol/L)
1 h after
meal
<140 mg/dL
(<7.8 mmol/L)
<140 mg/dL
(<7.8 mmol/L)
99-139 mg/dL
(5.5-7.7 mmol/L)
2 h after
meal
<120-127 mg/dL
(<6.7-7.1 mmol/L)
90-119 mg/dL
(5.0-6.6 mmol/L)

56. Hypoglycemia
Attempts to achieve normoglycemia in type
1 DMincrease risk of
hypoglycemia (DCCT)
No evidence that
hypoglycemia is an independent risk
to the developing embryo Clear risk
to the mother
Diabetes Care 26:S91-93, 2003

57. Diabetic Retinopathy
May accelerate during pregnancy
Gradual attainment of good metabolic
control before conception
Preconception laser photocoagulation
with standard indications
Baseline dilated comprehensive eye
examination
Follow up eye exam during pregnancy
Diabetes Care 26:S91-93, 2003

58. Diabetic Retinopathy
Risk factors for progression
Duration of diabetes
Retinal status
Elevated HbA1c
Hypertension
Valsalva maneuver (increases risk of retinal
hemorrhage)
Jovanovic L (Ed). Medical Management of Pregnancy Complicated by Diabetes (2009)

59. Hypertension
Type 1 diabetics frequently develop
hypertension in association with
diabetic nephropathy
Type 2 diabetics commonly have
coexisting hypertension
Pregnancy-induced hypertension
proteinuria in excess of 190 mg/day
before conception or in early pregnancy
Diabetes Care 26:S91-93, 2003

60. Hypertension
Aggressive monitoring and control to
reduce risk of worsening
nephropathy, development of
retinopathy or clinical atherosclerosis
Avoid ACE-inhibitors, ARBs, beta-
blockers and diuretics in women
contemplating pregnancy
SBP <130 mm Hg
DBP <80 mm Hg
Diabetes Care 26:S91-93, 2003

61. Diabetic Nephropathy
•Baseline assessmentof renal
function before conception and
followed at regular intervals
•urine albumin-to-creatinine
ratio 24 h albumin excretion
Diabetes Care 26:S91-93, 2003

62. Diabetic Nephropathy
Permanent worsening of renal function
in >40% of women with incipient renal
failure (serum crea > 3 mg/dL or crea
clearance < 50 mL/min)
Permanent worsening of renal function
does not occur more often in women
with less severe nephropathy
Diabetes Care 26:S91-93, 2003

63. Diabetic Nephropathy
Proteinuria >190 mg/24 h before or
during early pregnancy triples risk of
hypertensive disorders in second half
of pregnancy
Risk of IUGR during later pregnancy if
protein excretion > 400 mg/24 h
Discontinue ACE inhibitors in women
attempting pregnancy who have
microalbuminuria
Diabetes Care 26:S91-93, 2003

64. Neuropathy
Autonomic neuropathy may complicate
management
gastroparesis
urinary retention
hypoglycemic unawareness
orthostatic hypotension
Peripheral neuropathy especially compartment
syndromes i.e. carpal tunnel syndrome may be
exacerbated
Diabetes Care 26:S91-93, 2003

65. Cardiovascular disease
Untreated CAD is associated with a
high mortality rate
Successful pregnancies after coronary
revascularization in women with diabetes
Normal exercise tolerance to
maximize probability that patient will
tolerate increased cardiovascular
demands of gestation
Diabetes Care 26:S91-93, 2003

66. Gestational
diabetes
Screen all pregnant Indian
women
Be aware of the limitations of
self-monitored blood glucose
Do not wait too long to shift to
insulin if diet therapy fails
Ensure postpartum OGTT
Key Points

67. Counsel diabetic women of
child-bearing potential on
contraception and risks of
unplanned pregnancy with poor
metabolic control
Shift to insulin
Aim for A1c <6%
Key Points
Pre-gestational
diabetes

68. Advise regarding possible
worsening of diabetic
complications during pregnancy
Discontinue ACE-inhibitors in
albuminuric women attempting
pregnancy
Pre-gestational
diabetes
Key Points

69. ThankYou