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Title: DIABETES IN PREGNANCY


1
DIABETES IN PREGNANCY
  • Josephine Carlos-Raboca, MD
  • Chief, Section of Endocrinology,Diabetes and
    Metabolism
  • Makati Medical Center

2
M.E 39 year old female
  • She is a G3P1 (1011) who was referred to
    Endocrinology service on her 28th week of
    gestation due to findings of elevated blood
    sugar values in her 75g OGTT. (fasting 107 mg/dL,
    1hr 191 mg/dL 2-h 158 mg/dL)

3
Past Medical History
  • Non diabetic, non hypertensive, non asthmatic
  • FMHx
  • () Diabetes and Hypertension Mother
  • PSHx
  • Non smoker, non alcoholic beverage drinker
  • No regular form of exercise

4
Physical Examination
  • BP 120/70 mmHg, HR 76 bpm, RR 16
  • Wt 85 kg, Ht 53 BMI 33.2
  • Anicteric, pink palpebral conjunctivae, (-)
    cervical adenopathy, (-) carotid bruits, Thyroid
    not enlarged, no pharyngeal congestion
  • Equal chest expansion with clear breath sounds
    both lungs, (-) crackles
  • Adynamic precordium, Normal rate, regular rhythm
    with distinct S1, S2, (-) murmur

5
Physical Examination
  • Gravid abdomen, normal bowel sounds, () fetal
    heart tones
  • Full and equal pulses, pink nail beds with good
    turgor, (-) edema, (-) cyanosis, (-)
    hyperpigmentation

6
  • She was initially started on a diet plan and
    4x/day blood sugar monitoring for 1 week

Fasting 1-h post BF 1-h post Lunch 1-h post dinner
mg/dL 96 148 129 157
7
  • She was started on 2x/day insulin with a dose of
    aspartame insulin 6 units (novorapid) pre
    breakfast and pre dinner

Fasting 1-h post BF 1-h post lunch 1-h post diner
mg/dL 88 117 112 124
8
  • repeat LSCS 2, breech presentation cord coil
  • Live baby boy BW 2,863 gm AS 8/9

9
Outline
  • Gestational Diabetes
  • Definition/Prevalence
  • Pathogenesis
  • Complications
  • Screening and Diagnosis
  • Management
  • Pregestational Diabetes

10
Gestational Diabetes Mellitus (GDM)
  • Any degree of glucose in tolerance with onset or
    first recognition during pregnancy.
  • 4th International Workshop-Conference on GDM,
    1998.

11
Prevalence of GDM
  • 1 14
  • USA--- 3-5
  • MMC (Asian Population) Raboca et al 13.4

12
Pathogenesis
13
Pregnancy is a diabetogenic state characterized
by insulin resistance and hyperinsulinemia
14
Metabolic Adaptations during Pregnancy
  • placental hormones affect both glucose and
    lipid metabolism to ensure ample fetal fuel
    supply and nutrients always.
  • There is a switch from carbohydrate to fat
    utilization that is facilitated by both insulin
    resistance and increased plasma concentration of
    lipolytic hormones
  • Butte, NF. Carbohydrate and lipid metabolism in
    pregnancy normal compared with gestational
    diabetes mellitus. Am J Clin Nutr 2000 711256S.

15
Maternal metabolic adaptation
  • Accelerated starvation during fasting to provide
    fuel and nutrients to fetus at all times
  • Fasting plasma glucose 63-75 mg/dl
  • Fasting capillary blood glucose 55-65 mg/dl
  • rise in ketones and fatty acids

16
Metabolic Adaptations during Pregnancy
  • The fasted state is one of accelerated
    starvation. Alternative fuels are made available
    for the mother and glucose is reserved for the
    fetus
  • Maternal Fuels Free fatty acids, ketones,
    glycerol
  • There is hyperplasia of Beta cells, increased
    insulin secretion and early increase in insulin
    sensitivity followed by progressive insulin
    resistance.
  • Butte, NF. Carbohydrate and lipid metabolism in
    pregnancy normal compared with gestational
    diabetes mellitus. Am J Clin Nutr 2000 711256S.

17
  • Maternal insulin resistance results from
    increased release of diabetogenic hormones such
    as
  • Corticotropin Releasing Hormone
  • Chorionic Somatomammotropin
  • Progesterone
  • Tumor necrosis factor-a
  • A post receptor defect in the skeletal muscle
    B-subunit and at Insulin receptor substrate-1 may
    also contribute to the decline in insulin action.
  • Yamashita, H, Shao, J, Friedman, JE. Physiologic
    and molecular alterations in carbohydrate
    metabolism during pregnancy and gestational
    diabetes mellitus. Clin Obstet Gynecol 2000
    4387.

18
diabetogenic hormones during pregnancy
  • Growth hormone
  • Corticotropin releasing hormone
  • Placental lactogen
  • Progesterone

19
Pathogenesis
  • Autoimmune beta cell destruction
  • Highly penetrant genetic abnormality that leads
    to impaired insulin secretion
  • Beta cell dysfunction with chronic insulin
    resistance

20
Metabolic Adaptations during Pregnancy
  • Insulin levels are higher in both the fasting and
    the postprandial states during pregnancy
  • The fasting glucose is 10-20 lower in pregnancy
    due to
  • Increased storage of tissue glycogen
  • Increased peripheral glucose utilization
  • Decreased hepatic glucose production
  • Glucose consumption by the fetus

21
Metabolic Adaptations during Pregnancy
  • The placenta readily transfers glucose, amino
    acids, and ketone bodies to the fetus but is
    impermeable to large lipids.
  • Serum triglyceride and cholesterol levels
    increase during pregnancy by approximately 300
    and 50 respectively.
  • The large rise in TG is largely due to
  • Increased hepatic lipase activity
  • Reduced lipoprotein lipase activity
  • Herrera, E. Metabolic adaptations in pregnancy
    and their implications for the availability of
    substrates to the fetus. Eur J Clin Nutr 2000
    54 Suppl 1S47.

22
Why Screen for GDM?
23
Pregnancy outcome GDM
Outcome Relative risk 95 percent confidence level
Macrosomia Macrosomia Macrosomia
ADA 1.3 0.7 to 2.2
WHO 1.4 1.1 to 2.0
Preeclampsia Preeclampsia Preeclampsia
ADA 2.3 1.2 to 4.2
WHO 1.9 1.2 to 3.0
Perinatal death Perinatal death Perinatal death
ADA 3.1 1.4 to 6.5
WHO 1.6 0.9 to 2.9
Adapted from data in Schmidt, MI, Duncan, BB,
Reichelt, AJ, et al. Diabetes Care 2001 241151
24
Perinatal Complications
  • Macrosomia
  • Hypoglycemia
  • Respiratory Distress Syndrome (RDS)
  • Hypocalcemia
  • Hyperbilirubinemia
  • Polycythemia

25
Congenital Malformations
  • Skeletal
  • Cardiac (septal and outflow tract lesions)
  • CNS and neural tube defects
  • Gastrointestinal Defects
  • Genitourinary Tract lesions

26
Other complications
  • Pre-ecclampsia
  • Operative delivery
  • Obesity and diabetes later in life

27
Who do we screen?
  • Pregnant women with any of the following
  • A family history of diabetes, especially in first
    degree relatives
  • Prepregnancy weight 110 percent of ideal body
    weight or significant weight gain in early
    adulthood
  • Age greater than 25 years
  • Previous delivery of a baby greater than 9 pounds
    4.1 kg
  • Personal history of abnormal glucose tolerance
  • Member of an ethnic group with higher than the
    background rate of type 2 diabetes (in most
    populations, the background rate is approximately
    2 percent)

28
Who do we screen?
  • Previous unexplained perinatal loss or birth of a
    malformed child
  • Maternal birth weight greater than 9 pounds 4.1
    kg or less than 6 pounds 2.7 kg
  • Glycosuria at the first prenatal visit
  • Polycystic ovary syndrome
  • Current use of glucocorticoids
  • Essential hypertension or pregnancy-related
    hypertension
  • Solomon, CG, Willett, WC, Carey, VJ, et al. A
    prospective study of pregravid determinants of
    gestational diabetes mellitus. JAMA 1997
    2781078.

29
When to screen?
  • Screening is optimally performed at 24-28 weeks
    of gestation.
  • Jovanovic, L, Peterson, CM. Screening for
    gestational diabetes. Optimum timing and criteria
    for retesting. Diabetes 1985 34 Suppl 221.
  • It should be done during the first prenatal visit
    if there is high degree of suspicion that the
    patient has undiagnosed type 2 diabetes
  • Gestational diabetes mellitus. Diabetes Care
    2004 27 Suppl 1S88.
  • Women with a history of GDM have a 33-50 risk of
    recurrence, and some of these recurrences may
    represent type 2 DM
  • ACOG Practice Bulletin. Clinical management
    guidelines for obstetrician-gynecologists.
    Number 30, September 2001 (replaces Technical
    Bulletin Number 200, December 1994). Gestational
    diabetes. Obstet Gynecol 2001 98525.

30
How to screen for GDM
  • A fasting plasma glucose level of gt126 mg/dL (7.0
    mmol/l) or a casual plasma glucose gt200mg/dL
    (11.1 mmol/l) meets the threshold for the
    diagnosis of diabetes, if confirmed on a
    subsequent day
  • Precludes the need for any glucose challenge
  • Diabetes care vol 26, jan 2003

31
Screening and Recommendations5th International
Workshop Conference on GDM
  • Diabetes Care Vol 30 Sup 2 July 2007
  • GDM should be ascertained at first prenatal visit

32
Low Risk screening is not routine if all
conditions are met
  • Belongs to an ethnic group with low prevalence of
    GDM
  • Negative history of diabetes mellitus type 2 in
    first degree relative
  • Less than 25 years old
  • Normal weight before pregnancy
  • Normal weight at birth
  • No history of abnormal glucose metabolism
  • No history of poor obstetric outcome

33
Average risk screen at 24-28 weeks of gestation
  • Two step method
  • 50gm GCT if positive go to diagnostic test
  • One step method
  • proceed to diagnostic test

34
High Risk
  • Severe obesity
  • Strong family history of diabetes mellitus type 2
  • Previous history of GDM, impaired glucose
    metabolism or glucosuria.
  • If initially negative for GDM, repeat at 24-28
    weeks of gestation or anytime with signs and
    symptoms suggestive of hyperglycemia

35
Screening
  • Glucose Challenge Test
  • Give 50 g oral glucose load without regard to
    time of day.
  • Measure plasma or serum glucose after 1 hour.
  • A glucose level gt130 mg/dL (7.8 mmol/l) is
    abnormal.
  • Proceed with Oral Glucose Tolerance Test (OGTT)

36
Screening test
  • Glucose Challenge Test
  • 50 gm oral glucose load
  • Plasma glucose 1 hour after
  • gt 130 mg/dl (90 sensitive)
  • gt 140 mg/dl (80 sensitive)

37
Diagnosis
Plasma or serum glucose level Carpenter/Coustan Plasma or serum glucose level Carpenter/Coustan Plasma level National Diabetes Data Group Plasma level National Diabetes Data Group
mg/dL mmol/L mg/dL mmol/L
Fasting 95 5.3 105 5.8
One hour 180 10.0 190 10.6
Two hours 155 8.6 165 9.2
Three hours 140 7.8 145 8.0
100 gram oral glucose load is given to patient
who is fasting. Data from Expert Committee on
the Diagnosis and Classification of Diabetes
Mellitus. Report of the Expert Committee on the
Diagnosis and Classification of Diabetes
Mellitus. Diab Care 2000 23(suppl 1)S4.
38
Diagnosis of GDM
  • 100 gm OGTT 75 gm OGTT
  • mg/dl mml/L mg/dl
    mml/L
  • F 95 5.3 95
    5.3
  • 1H 180 10.0 180
    10.0
  • 2H 155 8.6 155
    8.6
  • 3H 140 7.8
  • gt 2 values met GDM
  • ASGODIP, WHO
  • European Diabetes
  • Policy Group 1992-1998 75 gm OGTT, 2H gt140

39
Diagnosis
American Diabetes Association American Diabetes Association
At least two values that meet or exceed the following glucose concentrations At least two values that meet or exceed the following glucose concentrations
Fasting gt95 mg/dL (5.3 mmol/L)
One hour gt180 mg/dL (10.0 mmol/L)
Two hour gt155 mg/dL (8.6 mmol/L)
World Health Organization World Health Organization
Fasting gt125 mg/dL (7.0 mmol/L)
OR OR
Two hour gt140 mg/dL (7.8 mmol/L)
Criteria for a positive 2 hour 75 g OGTT for the
diagnosis of GDM
40
Management of GDM
  • Diet/Medical Nutrition therapy
  • Blood Glucose Monitoring
  • Exercise
  • Medication

41
GOALS
  • Normal outcome of index pregnancy.
  • Decrease risk for abnormal glucose and
    insulin homeostasis.
  • Mother (before, during, after pregnancy).
  • Infant subsequent generations.

42
Medical Nutrition Therapy
  • Goals
  • Achieve normoglycemia
  • Prevent ketosis
  • Provide adequate weight gain
  • Contribute to fetal well-being

43
Medical Nutrition Therapy
  • Caloric allotment
  • Nutritional management of obese gestational
    diabetic woman. J Am Coll Nutr 199211246

BMI kcal/kg
lt22 40 kcal
22 25 30 kcal
26 - 29 24 kcal
30 12 15 cal
44
Medical Nutrition Therapy
Carbohydrate 33 40
Proteins 20
Fats 40
Timing Total Calories
Breakfast 10
Lunch 30
Dinner 30
Snacks 30
  • Gestational Diabetes mellitus 2004

45
ADA 2004
  • Medical Nutrition Therapy
  • provide adequate calories to sustain
    maternal and fetal requirements and
  • to achieve glycemic control
  • adequate weight gain
  • Avoid starvation ketosis
  • Protein 0 .75 g/kg/d 10 g
  • Carbohydrate portion 35-40
  • Folic acid 400 ug/day

46
Weight Gain in Pregnancy
  • BMI weight gain 1st trim 2nd-3rd trim
  • lt20 28-40 lbs 5lb 1.07lb/wk
  • 21-26 25-35 3.5 .97
  • 26-29 15-25 2.0 .67
  • gt29 15
  • Krause Food Nutrition and Diet 11th ed L.
    Kathleen, Mahan and Strump 2004

47
Diet for GDM patient
  • For normal weight 30 kcal/kg of Present BW
  • For overweight 24 kcal/kg of Present BW
  • For morbidly obese 12 kcal/kg Present BW
  • 3 meals, 3 snacks, 40 of total calories CHO
  • Medical Management of Pregnancy Complicated
    by Diabetes

48
Self Blood Glucose Monitoring
  • Monitor Blood Glucose concentration at least 4
    times daily.
  • Timing Fasting and 1 hour after the first bite
    of each meal
  • Gestational Diabetes Mellitus. Diabetes care
    2004

49
Blood glucose monitoring
  • Frequency has not been established
  • 4-6x a day depending on severity
  • PPPG more correlated with macrosomia
  • (RCT PPPG vs Preprandial
  • lower A1c -3 vs -.6 plt.001
  • lower BW 7lbs10oz vs 8lbs7oz plt0.01
  • Less CS 12 vs 42 p,0.04

50
Self Blood Glucose Monitoring
  • One hour postprandial monitoring was associated
    with the following benefits as compared to
    preprandial monitoring
  • Better glycemic control (HbA1c 6.5 vs 8.1
    percent)
  • Lower incidence of large for gestational age
    infants (12 vs 42 percent)
  • A lower rate of cesarian delivery for
    cephalopelvic disproportion (12 vs 36 percent).
  • Postprandial vs preprandial blood glucose
    monitoring in women with GDM requiring insulin
    therapy. N Engl J med 1995 3331237

51
Insulin
  • When to use?
  • maternal blood glucose levels
  • fetal abdominal circumference at 29-33 weeks
  • amniotic fluid insulin at 28 weeks

52
Abdominal circumference
  • Study by Buchanan 1994
  • gt75th percentile abdominal circumference
    used to initiate insulin
  • lesser LGA 13 vs 45 in diet treated

53
ADA 2001
  • Insulin Required if diet fails to maintain
    glucose
  • at following levels.
  • Fasting whole blood glucose lt 95 mg/dl (5.3
    mml/L)
  • Fasting Plasma Glucose lt 105 mg/dl (5.8 mml/L)
  • OR
  • 1H Postprandial whole blood glucose lt 140 mg/dl
    (7.8 mml/L)
  • 1H Postprandial Plasma Glucose lt 155 mg/dl (8.6
    mml/L)
  • OR
  • 2H Postprandial whole blood glucose lt 120 mg/dl
    (6.7 mml/L)
  • 2H Postprandial Plasma Glucose lt 130mg/dl (7.2
    mml/L)

54
Blood glucose levels
  • FPG gt 95mg/dl (90)
  • 1 hour PPBG gt 140 mg/dl (120)
  • 2 hppg gt 120 mg/dl
  • ( ) Jovanovic

55
Insulin in pregnancy
  • Human insulin should be used if prescribed
  • SBMG should guide the doses and timing of insulin
    regimen
  • The rapid Insulin analogs lispro and aspart have
    been found to be clinically effective with
    minimal transfer across placenta and no evidence
    of teratogenesis. Level B
  • Long acting analogs no study in pregnancy

56
Insulin Therapy
  • 15 of women with GDM are placed on insulin
    therapy
  • The dose of insulin varies in different
    populations because of varied rates of obesity,
    ethnic characteristics, and other demographic
    criteria
  • Generally 0.5 to 1.4 U/kg (present weight) is
    required to maintain target glucose levels.
  • A mixed/split insulin regimen is generally used

57
Insulin Therapy
  • 50 as NPH Insulin given in three equal doses
    before breakfast, before dinner and before
    bedtime
  • 50 as three preprandial rapid-acting insulin
    injections
  • Four times a day insulin regimen is more superior
    to twice a day regimen in improving glycemic
    control and perinatal outcome.
  • Nachum, Z. twice daily vs four times daily
    insulin dose injection for diabetes in
    pregnancy. RCT BMJ 1999

58
Insulin Regimen
  • If High FBS HS intermediate insulin at 0.15
    u/kg
  • High PPBS regular insulin premeals
  • High preprandial and postprandial
  • multiple injections
  • 0.7 u/kg 6-18weeks
  • 0.8 u/kg 9-26 weeks
  • 0.9 u/kg 27-36 weeks
  • 1.0 u/kg 37 weeks to term

59
Oral Anti-hyperglycemic Agents
  • Currenlty the ADA and ACOG do not endorse the use
    of oral hyperglygemic agents during pregnancy
  • Gestational diabetes mellitus care 2004
  • Tolbutamide or chlorpropamide
  • Cross the placenta and can cause fetal
    hyperinsulinemia which can lead to macrosomnia
    and prolonged neonatal hypoglycemia.
  • Maternal-fetal transport of hyperglycemic
    drugs. Clin pharmacokinet 2003

60
Oral diabetic drugs
  • Langer NEJM 343(16)1134-38,2000
  • use of glyburide after 8 weeks of
    gestation in 201 women on glyburide vs 203
    insulin
  • Conclusion No difference in neonatal outcomes
    such as LGA, hypoglycemia anomaly or stillbirth

61
Glyburide vs Insulin
  • A study of 404 women with singleton pregnancy and
    GDM that required treatment. (San Antonio,Texas)
  • FBS of at least 95mg/dl and less than 140mg/dl
  • Between 11th and 33rd week of pregnancy
  • 201 patients assigned to receive glyburide
  • 83 Hispanics, mostly Mexican-American, 12 non
    Hispanic white, 5 Black
  • 8 women in the glyburide group switched to
    insulin
  • Glyburide not detected in cord serum of any
    infant.

62
Metformin in PregnancyGlueck,Fertility and
Sterility Vol 77 Issue 3 March 2002 520-25
  • Metformin 1.5 - 2.55 g/d throughout pregnancy
    in women with PCOS
  • Number 19 with live births
  • Outcome reduction of GDM
  • no bad maternal effects and
    no birth defects

63
Metformin
  • Crosses placenta
  • Should be discontinued in first trimester
  • Higher perinatal mortality and preecclampsia
  • Off label use PCOS pregnancy with recurrent
    fetal loss

64
Treatment with metformin compared with insulin
(the Metformin in Gestational Diabetes MiG
Trial)
65
Metformin in Gestational Diabetes (MIG) Trial
  • Prospective Randomized controlled trial in women
    with GDM 20-33 weeks gestation
  • Randomized to insulin or metformin
  • Primary outcome composite of neonatal morbidity
  • Key trial in assessing potential role of
    metformin during pregnancy

66
Metformin versus Insulin for the treatment of
Gestational Diabetes
  • 751 women with GDM enrolled at 20-33 weeks
    gestation
  • 373 (metformin) 378(insulin)
  • Primary Outcomes
  • neonatal hypoglyvemia(2.6mmol/l)
  • Respiratory distress
  • need for phototherapy
  • birth trauma
  • 5 min APGAR lt7
  • prematurity lt37 weeks)

67
  • Secondary outcomes
  • Maternal hypertensive complications
  • Neonatal anthropometric measurements
  • Maternal glycemic control
  • Postpartum glucose tolerance
  • Acceptability of treatment

68
Results
  • rate of primary outcome
  • 32 (Met) vs 32.2 (insulin)
  • Acceptability
  • 76.6 vs 27.2
  • No difference in secondary outcomes

69
Conclusions
  • Metformin is an effective and safe treatment
    option in gestational diabetes requiring insulin
  • Metformin is more acceptable to women than
    insulin
  • Long term study needed to establish long term
    safety

70
Acarbose
  • Eficacia de la acarbose para controlar el
    deterioro de la tolerancia a la glucose durante
    la gestacion. Zarate A, Ochoa R, Hernandez M,
    Basurto L Ginecol Obstet Mex 68 4245, 2000
  • A case series of six GDM patients treated with
    50mg acarbose TID with meals.
  • Glucose levels were normalized in all 6 patients
  • All six babies born were apparently normal
  • Side effect GI discomfort

71
Acarbose
  • A comparison of oral acarbose and insulin in
    women with gestational diabetes mellitus.
    deVeciana M, Trail PA, Lau TK, Dulaney KObstet
    Gynecol 99 (Suppl.)5S, 2002
  • Randomized trial in 91 GDM patients failing diet
    therapy
  • Glucose control and glycohemoglobin were similar
  • 6 of acarbose treated patientd required insulin

72
Other Agents
  • The use of thiazolidinediones, glitinides, and
    GLP-1 is considered experimental
  • No controlled data available in pregnancy
  • Chan, LY, Yeung, JH, Lau, TK. Placental transfer
    of rosiglitazone in the first trimester of human
    pregnancy. Fertil Steril 2005 83955.

73
Exercise
  • Safe exercise
  • 1. does not cause fetal distress, decrease in
    birth weight, uterine contractions or
  • maternal hypertension
  • 2. Not supine
  • 3. Upper body exercise arm ergometry
  • 4. walking

74
Exercise contraindicated
  • Hypertension
  • Preterm rupture of membranes
  • Preterm labor
  • Incompetent cervix
  • Persistent 2nd and 3rd trimester bleeding
  • IUGR

75
Peripartum Management
  • Maternal hyperglycemia should be avoided during
    labor to prevent fetal hyper-insulinemia and
    subsequent neonatal hypoglycemia.
  • Maternal blood glucose concentration should be
    maintained between 70 and 90 mg/dL
  • Blood glucose should be monitored on the day
    after delivery to ensure that the mother no
    longer has hyperglycemia.

76
Post partum care/concerns
  • 50-60 risk for DM 2 in 10-15 years
  • DM 1 in GAD
  • 75 gm OGTT 6 weeks after for prognostication
    (earlier DM2 in 5 years in IGT )

77
  • 75 gm OGTT gt 6-12 wks postpartum
  • if normal, repeat after one year and every
    3 years
  • if IFG, test every year and lifestyle
  • modification
  • Follow up offspring for development of
    obesity and glucose intolerance

78
50 in 20 years timePredictors of DM
  • maternal obesity
  • fasting hyperglycemia
  • duration of time from index pregnancy

79
Follow-Up
  • At least six weeks after delivery, or shortly
    after cessation of breast feeding, all women with
    previous GDM should undergo an oral glucose
    tolerance test using a two-hour 75 gram oral
    glucose tolerance test.
  • In women who did not undergo screening for GDM,
    but diabetes is suspected postpartum because of
    infant outcome, postpartum screening for diabetes
    may be considered.

80
Pregestational Diabetes
81
  • Counseling about risk of malformation with
    poor control
  • Use of low dose estrogen progestogen
  • contraceptive till good metabolic control is
  • achieved.
  • Goals
  • HBA is 1 above normal
  • Preprandial CBG 70-110 mg/dl (3.9-5.6mml/L)
    CPG 80-110 mg/dl (4.4-6.1
    mml/L)
  • 2H Postprandial CBG lt 140 mg/dl (7.8mml/L)
    CPG lt 155 mg/dl
    (8.6mml/L)

82
What medical problems should you
consider in a diabetic pregnant?
83
  • Acceleration of retinopathy
  • Pregnancy induced hypertension
  • Progression of Nephropathy

84
retinopathy
  • Stabilize prior to pregnancy
  • Photocoagulation if necessary
  • Monitor for progression
  • high risk for biggest drop in a1c
  • due to hypercoagulable state

85
Coronary artery disease
  • Pregnancy increases oxygen consumption
  • Avoid pregnancy if possible
  • Statins not used
  • If necessary, fibrates and niacin may be used

86
BP meds in pregnancy
  • Methyldopa
  • Hydralazine
  • Calcium antagonist
  • Clonidine
  • labetalol

87
DM Nephropathy
  • Renal function may deteriorate in more sever
    disease
  • Prone to pre-eclampsia
  • BP target lt130/80
  • Stop ACE inhibitors and ARBs
  • may cause fetal anuria, pulmonary
    hypoplasia, oligohydramnios

88
  • Preparing for delivery
  • Target glucose 120 mg/dl
  • D5 0.45 NSS at 100-125 ml/hour
  • CBG every 1-4 hours
  • Insulin infusion to start at 1unit/hour of
    regular insulin if CBG gt 120 mg/dl

89
Conclusions
  • Pregnancy is a diabetogenic state
  • Hyperglycemia causes adverse effects in pregnancy
    for mother and fetus.
  • Detection, diagnosis and proper treatment are
    necessary for good pregnancy outcome.
  • Diabetic patients must be prepared and assessed
    for complications prior to pregnancy.
  • Special problems for pregnant diabetics need to
    be addressed.

90
THANK YOU.
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