An alternative way at looking at pregnancy complicated by diabetes. A guide for the student in understanding this problem and the important points to be included in a clinical assessment.

1. DIABETES MELLITUS IN PREGNANCY
5 POINTS FOR THE UNDERGRAD TO CONSIDER
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2. Associate Professor Dr
Hanifullah Khan
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3. FACTS ABOUT DM

4. Prevalence & Consensus
Diabetes mellitus (DM) and other forms of glucose
intolerance are widely prevalent worldwide#
The incidence of GDM remains obscure mainly due to the
lack of consensus on investigative and diagnostic criteria#
GDM develops as soon as pancreatic β-cell secretion
becomes insufficient to compensate for the physiological
insulin resistance#
usually manifests during the second half of pregnancy.

5. Important fact
To understand the effects of hyperglycaemia on the
fetus, it should be remembered that glucose crosses the
placenta freely but maternal insulin does not. #
Thus, maternal hyperglycaemia leads to fetal
hyperglycaemia with a consequent rise in fetal insulin
secretion

6. What does excess fetal
insulin do?
Cause increased weight gain#
fetuses > 4000g are termed macrosomic#
Obstructed labour & caesarean section#
Due to disproportion between fetal size and birth canal #
Increased risk of injury and complications - those that do pass through#
may inflict maternal and fetal birth trauma#
shoulder dystocia #
Sudden fetal demise in utero at term - for reasons still unknown

7. Beyond delivery
Respiratory distress syndrome#
Hypoglycaemia#
Adulthood and associated obesity, diabetes and the
metabolic syndrome

8. Maternal problems
Increased risk of developing DM#
Past history of GDM increases the risk of recurrence in
subsequent pregnancies#
Increased risk of later occurrence of DM

9. 5 Points
1. It is important to differentiate between gestational
& pregestational DM
2. Patients with DM are frequently asymptomatic
3. Certain factors will provide a clue of possible DM
4. Monitoring of DM involves history, examination
& investigation, in that order
5. DM may present late with complications of
pregnancy
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10. 1. It is important to differentiate
between gestational &
pregestational DM

11. What is DM?
A metabolic condition
characterized by chronic
hyperglycemia as a result
of defective insulin
secretion, insulin action
or both
i. Type 1(IDDM)
ii. Type 2(NIDDM)
iii. Gestational diabetes
iv. Others -genetic defects in insulin processing or
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action
-endocrinopathies
-drugs
-exocrine pancreatic defects
-genetic syndromes associated with DM

12. Either type 1 or type 2#
Type 1 #
younger age group #
increased maternal and obs risks#
Type 2 #
usually occurs in obese patients

13. • Glucose intolerance
of variable severity
with onset or first
identification during
the pregnancy
– Constitutes 90 percent of diabetes in
pregnancy
– Generally occurs in the latter half of
pregnancy
– Usually no effect on organogenesis (no
congenital defects)
– Disappears after delivery

14. Pregnancy predisposes to persistent
hyperglycaemia
• glucose is made available to the fetus
– ↑ placental hormones
– ↑ plasma cortisol
– A state of insulin resistance
– Further aggravated by ↑ body
weight and ↑ caloric intake
during pregnancy
!
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• Pregestational diabetes
becomes worse during
pregnancy
• GDM develops when the pancreas cannot overcome the
effect of these hormones

15. 5 Points
1. It is important to differentiate between gestational
& pregestational DM
2. Patients with DM are frequently asymptomatic
3. Certain factors will provide a clue of possible DM
4. Monitoring of DM involves history, examination
& investigation, in that order
5. DM may present late with complications of
pregnancy

16. 2. Patients with DM are
frequently asymptomatic
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17. In Asymptomatic Patients
Screening test needed
– OGTT
Either
– Universal screening
– Selective screening (based on risk factors)

18. OGTT
75 grams of oral glucose is given
3 readings -fasting glucose level, 1 hr and 2 hr post glucose
The diagnosis of DM is made when fasting glucose level are
≥7.8 and or 2 hour level of >11.1
If the 2 hours levels are between 7.8 and 11.1,the patient is
said to have impaired glucose tolerance test and should be
treated as GDM

19. Screening Algorithm

20. 5 Points
1. It is important to differentiate between gestational
& pregestational DM
2. Patients with DM are frequently asymptomatic
3. Certain factors will provide a clue of possible DM
4. Monitoring of DM involves history, examination
& investigation, in that order
5. DM may present late with complications of
pregnancy

21. 3. Certain factors will
provide a clue of possible
DM
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22. Factors for
screening
★Risk Factors
• Age>30 years
• Previous GDM
• Family history of DM
• Bad Obs history
• History of macrosomia
• Prev. fetal anomalies
• History of unexplained
stillbirth
Associated Clinical Factors
• Congenital fetal
anomalies
• Pre-eclampsia
• Obesity > 90 kg
• Recurrent UTI, vaginal
candidiasis
• Presence of glycosuria
on more than 2
occasions

23. 5 Points
1. It is important to differentiate between gestational
& pregestational DM
2. Patients with DM are frequently asymptomatic
3. Certain factors will provide a clue of possible DM
4. Monitoring of DM involves history, examination
& investigation, in that order
5. DM may present late with complications of
pregnancy

24. 4. Monitoring of DM
involves history,
examination
& investigation,
in that order
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25. Assessment of the
pregnancy
Take precise history - maternal well-being, FM#
Examine for complications - remember; maternal, fetal
& placental#
Investigations - in order of priority#
ultrasound scan, urine, blood tests, CTG

26. 5 Points
1. It is important to differentiate between gestational
& pregestational DM
2. Patients with DM are frequently asymptomatic
3. Certain factors will provide a clue of possible DM
4. Monitoring of DM involves history, examination
& investigation, in that order
5. DM may present late with complications of
pregnancy

27. 5. DM may
present late
with complications
of pregnancy
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28. Maternal Complications -
Obstetric
1. Pre-eclampsia
2. Recurrent infection-vaginal candidiasis,uti
3. Polyhydramnios—pprom, cord prolapse,
4. Increased instrumental and CS rates
5. Anomalies & abortions
6. Sudden IUD
7. Post-delivery, 40-60% of women develop type 2 DM
within 10 years

29. Maternal Complications -
Medical
1. Retinopathy
2. Nephropathy
3. Neuropathy
4. Micro/macroangiopathy

30. Fetal
complications
1. Congenital anomalies (4
fold) - sacral agenesis,
NTD, cardiac and renal
anomalies
2. Macrosomia
3. Respiratory distress
syndrom
4. Hypoglycemia-result of
hyperplasia of beta cell
5. Prematurity
6. Malpresentation
7. Shoulder dystocia
8. Polycythemic -jaundice
Text

31. Mechanism of macrosomia

32. Shoulder
Dystocia

33. 5 Points
1. It is important to differentiate between gestational
& pregestational DM
2. Patients with DM are frequently asymptomatic
3. Certain factors will provide a clue of possible DM
4. Monitoring of DM involves history, examination
& investigation, in that order
5. DM may present late with complications of
pregnancy

34. This is your group!