Associate Professore, Perinatologist

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• Associate Professore, Perinatologist
• Urmia University of Medical Sciences
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Type of diabet in pregnancy

• Pre pregnancy diabet
• type 1
• type 2 diabetes
• maturity onset diabetes of the young (MODY)
  autosomal dominant
• Gestational diabet
• Class A1
• Class A2

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• (Gestational)

A1 (85) A2 (15)
90
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• women with gestational diabetes mellitus receive
  treatment (Grade 1A)
• medical nutritional therapy
• exercise
• self-monitoring of blood glucose levels
• insulin therapy
• improves perinatal outcome
• preeclampsia
• macrosomia
• shoulder dystocia

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Medical nutritional therapy initial approach
Calories are generally divided over three meals
and two to four snacks 40 percent
carbohydrate 20 percent protein 40 percent fat
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Self blood glucose monitoring effectiveness of
medical nutritional therapy
ADA and ACOG glucose targets are ?Fasting blood
glucose concentration 95 mg/dL (5.3
mmol/L) ?One-hour postprandial blood glucose
concentration 140 mg/dL (7.8 mmol/L) ?Two-hour
postprandial glucose concentration 120 mg/dL
(6.7 mmol/L)
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moderate exercise as part of the treatment plan
no medical or obstetrical contraindications
to this level of physical activity (Grade 1B)
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• Absolute contraindications

• Relative contraindications

• Significant cardiac disease
• Restrictive lung disease
• Cervical insufficiency
• Multiple gestation
• Placental abruption
• Placenta previa
• Premature labor
• Ruptured fetal membranes
• Preeclampsia
• gestational hypertension

• Severe anemia
• Unevaluated arrhythmia
• Bronchitis
• Poorly controlled diabetes, primary hypertension,
  seizure disorder, or thyroid disease
• Extreme obesity, malnutrition, or eating disorder
• Sedentary lifestyle
• Fetal growth restriction
• Heavy smoking

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insulin therapy

• with nutritional therapy
• exercise alone
• do not achieve
• adequate glycemic control

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• Self-Monitored Capillary Blood Glucose Goals
  Specimen Level (mg/dL)
• Fasting 95
• Premeal 100
• 1-hr postprandial 140
• 2-hr postprandial 120
• 02000600 60
• Mean (average) 100
• Hemoglobin A1c 6

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• A1 - Euglycemia achieved with diet and exercise
• A2 - Require medication to achieve euglycemia

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management Gestational Diabetes

• A1 (Diet controlled)
• Targeted scan at 16-18 wks (no fetal echo)
• Fasting 2 hr PPG weekly
• Growth scan

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Gestational Diabetes

• A2 (not controlled with diet alone)
• Targeted scan at 16-18 wks (no fetal echo)
• Fasting 2 hr PPG
• Growth scan every 4 wks after insulin or oral
  medication started (but no earlier than 26 wks)
• Twice wkly antenatal testing at 28 - 32 wks

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Timing of delivery

• Preterm delivery
• only for the usual
• Obstetric indications
• preeclampsia
• fetal growth restriction
• abruption
• premature labor with or without premature rupture
  of membranes
• non-reassuring fetal testing
• Maternal
• worsening
• Maternal renal function
• active proliferative retinopathy

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Time of delivery

• Class A1 term gestation
• Class A2
• 39 weeks

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ACOG recommends

• cesarean delivery in diabetic
• estimated fetal weight exceeds 4,500 g
• protracted labor
• failure of descent

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Ultrasoundin pregestational diabet

• Dating scan at 8 12 wks
• Nuchal translucency 11-14 wks
• Targeted scan including fetal echo at 18-20 wks
• Growth scan at 26 wks and every 4 wks thereafter
• NST AFI twice wkly starting at 32 wks 28 -wks
  if poorly controlled or class D- T.

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Serum insulin in labor
dose of insulin u/hr
Serum 125cc/hour

• lt70
• 100lt
• 100-140
• 141-180
• 220-181
• gt220

Serum BS
dextrose 5 Ringer lactate D5 Ringer lactate
D5 Normal salin Normal salin Normal salin

• -
• -
• 1
• 1,5
• 2
• 2.5

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Postpatrum

• gestational diabetes are at increased risk of
  developing diabetes after pregnancy

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Management post delivery

• 1-3 day post delivery
• Postpartum

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• Postdelivery (13 d)
• Fasting
• random plasma glucose
• Detect persistent, overt diabetes

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Classification of the American Diabetes
Association (2013)

• Early postpartum (612 wk)
• 75-g, 2-hr OGTT Postpartum classification of
  glucose metabolism
• 1-yr postpartum
• 75-g, 2-hr OGTT Assess glucose metabolism
• Annually
• Fasting plasma glucose Assess glucose metabolism
• Triannually
• 75-g, 2-hr OGTT Assess glucose metabolism
• Prepregnancy
• 75-g, 2-hr OGTT Classify glucose metabolism

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????????? 110lt 140lt
?????? ???? ??? ????? 125-110 199-140 ?
??????? 126? 200?
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• ?????????? u/hr
• -
• -
• 1
• 5/1
• 2
• 5/2

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• 70lt
• 100lt
• 140-100
• 180-141
• 220-181
• 220gt

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PATHOGENIC EVENTS
Maternal Hyperglycemia
Fetal Hyperglycemia
Fetal Hyperinsulinemia
?Fetal substrate uptake
?Oxygen uptake
Lung Surfactant?
?BMR
Lipids / Amino acid ?
Hypoxemia
? SB
?Erythropoietin
Respiratory Distress Syndorme
Polycythemia
Marosomia
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PEDERSEN THEORY

• Maternal Diabetes

Glucose crosses placenta
Carbohydrate surplus of fetus
Increased secretion of insulin
Stimulation of protein, lipid glycogen
synthesis
Free amino acid
Stimulatory effect on development of B cells
MACROSOMIA
Release Insulin like growth factor
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Type of Diabetes
Period of exposure
Teratogen
Complications
Aberrant fuel mixture
P G D M
Spontaneous abortions Early growth
delay Congenital anomalies
1st trimester
Foetus
Hyper insulinaemia
G D M
2nd trimester
Macrosomia Selective Organomegaly CNS development
delay Chronic hypoxia Stillbirth
3rd trimester
Birth injury
delivery
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Thank your attention