DIABETES MELLITUS IN PREGNANCY5 POINTS FOR THE UNDERGRAD TO CONSIDER

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Associate Professor Dr Hanifullah Khan

FACTS ABOUT DM

Prevalence & ConsensusDiabetes 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.

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

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

Beyond delivery

Respiratory distress syndrome#

Hypoglycaemia#

Adulthood and associated obesity, diabetes and the metabolic syndrome

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

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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5 Points

1. It is important to differentiate between gestational &

pregestational DM

What is DM?

A metabolic condition characterized by chronic hyperglycemia as a result

of defective insulin secretion, insulin action

or both

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i. Type 1(IDDM) ii. Type 2(NIDDM) iii. Gestational diabetes iv. Others -genetic defects in insulin processing or

action -endocrinopathies -drugs -exocrine pancreatic defects -genetic syndromes associated with DM

Either type 1 or type 2#Type 1 #

younger age group #increased maternal and obs risks#

Type 2 #usually occurs in obese patients

• 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

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

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

5 Points

2. Patients with DM are frequently asymptomatic

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In Asymptomatic Patients

Screening test needed – OGTT Either – Universal screening – Selective screening (based on risk factors)

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

Screening Algorithm

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

5 Points

3. Certain factors will provide a clue of possible

DM

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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

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

5 Points

4. Monitoring of DM involves history,

examination & investigation,

in that order

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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

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

5 Points

5. DM may present late

with complications of pregnancy

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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

Maternal Complications - Medical

1. Retinopathy 2. Nephropathy 3. Neuropathy 4. Micro/macroangiopathy

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

Mechanism of macrosomia

Shoulder Dystocia

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

5 Points

This is your group!