Management of diabetes during pregnancy

1. Management of Diabetes during
pregnancy
Prof . Aboubakr Elnashar
Benha university, Egypt
Aboubakr Elnashar

2. Diabetes during pregnancy:
1. Gestational diabetes mellitus (GDM).
2. Pregestational diabetes:
type 1 diabetes mellitus (T1DM)
type 2 diabetes mellitus (T2DM).
Aboubakr Elnashar

3. Preconception care
1. Educate
2. Encorage
3. Review
4. Assess
Antenatal care
•Screening & Diagnosis
•M: G control
Assess
•F: Wt
Wellbeing
Cong mal
Delivery
Intrapartum care
Monitor Blood glucose
Postpartum care
Aboubakr Elnashar

4. A. Pre-Conception Care
I. Health education:
1. Risks of DM can be reduced but not eliminated.
2. Avoidance of unplanned pregnancy:
HbA1C  10%: Don't allow
HbA1C  6.1%: allow
3. Hypoglycaemia awareness.
4. Pregnancy-related nausea/vomiting & their effect
on glycaemic control.
5. Frequent appointments during ANC.
Aboubakr Elnashar

5. Risks
 Miscarriage
Cong malformation
Stillbirth
Macrosomia (>4 kg or birth
wt centile >90)
Sh dystocia: B trauma
Res distress
Neonatal hypoglycemia
and poor feeding
Hypoglycemia
D Ketoacidosis
 Induction of labour
or CS
PET
Worsening of Retinal
and renal dis
Aboubakr Elnashar

6. II. Encourage patient to:
1. Dietary restrictions
2. Exercises
3. Reduce wt if BMI  27
4. Self-monitoring by glucometer
monthly HbA1C
ketone strips.
Aboubakr Elnashar

7. III. Review, replace& offer mediations:
1. Discontinue:
a. Hypoglycaemic agents except:
Metformin
Glibenclamide (Daonil).
b. Anti-hypertensive agents e.g.
angiotensin-converting enzyme inhibitors (ACE) (Captopril)*
angiotensin-II receptor antagonists
)angiotensin ii receptor blocker) (ARB) (Candesartan, eprosartan, irbesartan,
losartan, olmesartan, telmisartan, and valsartan ( Diovan
c. Anti- cholesterol e.g Statin (Levacor, Zocor, Pravachol, Lipitor,
Crestor(
2. Give: Folic Acid (5 mg OD)
*Captopril (Category D): oligohydramnios, pulmonary hypoplasia, IUGR
Aboubakr Elnashar

8. Safety of medications before and during
pregnancy
Metformin:
safe
Rapid-acting insulin analogues(aspart, lispro):
safe
long-acting insulin analogues (ultrlent, glargine) :
Evidence is limited.
Isophane (NPH) insulin:
first-choice long-acting insulin during pregnancy.
Aboubakr Elnashar

9. IV. Assess:
1. Retina
2. Renal function: refer to Nephrologist if
(i) Microalbuminuria  2 gm /d
(ii) Creatinine  120 M mol/L=1.25 mg
1mg=88.4 M mol/L
3. Thyroid status:
D.M. Type I
Aboubakr Elnashar

10. B. Antenatal care
I. Screening
•Who?
All pregnant women.
•When:
At booking
At 24-28 w
•How?
FBS: 90 > mg/dl
Aboubakr Elnashar

11. •FBG:
High sensitivity (81%)
Good specificity (76%) with a cut off of 86 mg/dl (4.8
mmol/l) (Perucchini et al, 1999)
Easier
Cheaper
More acceptable
Can be applied to all pregnant women
More than once during pregnancy.
Suitable for screening
Aboubakr Elnashar

12. II. Diagnosis
The 75 g WHO OGTT
Fasting venous & capillary blood glucose are similar.
After a meal or a glucose challenge, capillary are higher than
venous levels.
It is not necessary for both values to be abnormal
No need for GTT
FBS 125 mg/dl or
Random venous plasma glucose 200 mg/dl if
confirmed on a subsequent day
Plasma glucose Mg/dl
Fasting 100
2-h 145
Aboubakr Elnashar

13. Recommendations of International Association of
Diabetes and Pregnancy Study Groups (IADPSG)
2010
1-step 75-g OGTT
screening at-risk individuals during 1st ANV.
Aboubakr Elnashar

14. 1. Diabetic Centre
2. ANC clinic: /1-2 w
 Objective:
Medical TT: M: Glycemic control
Retinal and renal assessment
Obstetric TT: F: wellbeing
Wt
Cong malformation
Delivery
Aboubakr Elnashar

15. Medical treatment
Goals
achieving normoglycemia
preventing postprandial glucose excursions
optimizing compliance
Aboubakr Elnashar

16. I. Glycemic control
Objective:
These targets are the same for type 1, type 2 and
gestational diabetes).
{1. Outcomes (birth-weight and neonatal hypoglycaemia)
correlate better with postprandial than with preprandial
glucose levels.
2. Postprandial targets: better improvements in maternal
HbA1Clevels}.
Capillary blood
glucose
Mg/dl(mmol/L)
Fasting <105(5.9)
1 Hour <140 (7.8)
2 Hours <125 (7.0)
Aboubakr Elnashar

17. Fasting and premeal blood glucose: 90 mg/dL
(5.0 mmol/L) and
 Postprandial glucose: 120 mg/dL (6.7 mmol/L).
Aboubakr Elnashar

18. Monitoring
1. SMBG: self-monitored blood glucose
Fasting levels and 1 h after every meal. 1H is
recommended (NICE, 2008)
Women taking insulin should also test before
bedtime
Experts recommend that finger-stick blood
glucose measurement be performed 6–8
times/d, specifically, first thing in the morning
(fasting), premeal, 1 h after the start of each
meal (postprandial glucose), and at bedtime.
In pregnancy, postprandial serum glucose peaks
at approximately 1 h after a meal.
Aboubakr Elnashar

19. 2. Hb A1c
 weekly.
extremely useful, in conjunction with patient
diaries, to assist patients to achieve excellent
glycemic control and prevent the complications of
diabetes in pregnancy.
Do not use HbA1c routinely in 2nd and 3rd
trimesters
{1. falls in response to physiological changes in
pregnancy
2. Time scale is not appropriate in pregnancy
Reflects BG levels in the preceding 4-12 w and
not subtle changes in BG}.
Aboubakr Elnashar

20. 3. Women with type 1 diabetes should be offered
ketone testing strips for use if they become
hyperglycaemic or feel unwell
4. More evidence is being published that supports
a minimal weight gain for pregnant women who
are obese, which is a large portion of the GDM
and T2DM population.
5. Medical review on a regular basis (1-2 weekly)
Aboubakr Elnashar

21. How?
1. Diet
•The first line therapy for 1-2 w
• > 30 w or FBS >105 mg/dl:
Insulin started simultaneously with the diet
•3 meals & 4 snacks with last snack at bed time
•Caloric needs acc to BMI
(The American Diabetes Association, 2003)
< 30 kg/m2: 30 Kcal/kg
>30 kg/m2: 25 Kcal/kg
Aboubakr Elnashar

22. Carbohydrates 40%
Protein 30%,
Fat 30% (Garner, 1995).
Concentrated sweets & added sugars: eliminated.
Complex CHO with high fiber contents: preferable
{slower glucose rise after ingestion}
The classic food pyramid model:
Recommends that carbohydrates such as bread,
cereal, rice, and pasta comprise the majority of the
meal, is now antiquated.
It has been replaced with a new meal planning target
that emphasizes more vegetables and whole grains
Aboubakr Elnashar

23. 2. Exercise
•Reduce insulin requirement by as much as 50%.
•Effect appears after 4 w.
•1h after mealtimes.
•For 20-30 min
•Upper extremity or lower extremity ms excerises while
recumbent do not increase uterine contractions (Durak et
al, 1990 ;de Veciana and Mason, 2000).
Gentle aerobic exercise
Walking (Homko et al, 1998).
Aboubakr Elnashar

24. 3. Insulin
•Types
NICE:
glulisine, glargine and detemir. are avoided during
pregnancy.
Lispro and Aspart benefits:
1. fewer hypoglycaemic episodes
2. better control Aboubakr Elnashar

25. Aboubakr Elnashar

26. Regular insulin: inappropriate for use during
pregnancy.
{cannot control the postprandial spike in blood
glucose adequately unless it is administered 60–90
min before the onset of the meal}
Aboubakr Elnashar

27. Calculation of insulin dose:
1. Initial insulin dose: TDD
2. Adjustments acc to
a. meal and blood glucose diaries
b. results of point-of-care Hb A1c measurements.
Aboubakr Elnashar

28. 4. Oral hypoglycaemic agents:
Sulphonylureas, chlorpropamide, tolbutamide:
Not recommended for use in pregnancy.
1. crossed the placenta & stimulated fetal insulin
secretion: fetal macrosomia & hyperinsulinaemic
hypoglycaemia and seizures in neonates.
2. Major congenital malformations in animals
(Greene, 2000)
Aboubakr Elnashar

29. Metformin and Glibenclamide= glyburide(Daonil)
Safe
(NICE, 2008).
Metformin
PCOS: Decrease 1st T abortion & G DM
Cross placenta, but no increase in cong malformation
an alternative to insulin therapy in pregnant women
with type 2 diabetes
Glibenclamide
Cross placenta in small amounts
New oral hypoglycemic: Nateglinide (Starlix)
Very few data
Aboubakr Elnashar

30. Hypoglycaemia
blood glucose of <3.5 mmol/L(63 mg/dl)
Common with:
1. Tighter glycaemic control
2. Type 1 diabetes: much more likely to suffer
recurrent hypoglycaemia (61%) than those with
type 2 (21%).
Educate family about the symptoms and tt of
hypogly-caemia.
Aboubakr Elnashar

31. Treatment:
1. Conscious:
a. consuming 10-15 g of glucose (4 teaspoons of
sugar, 1/2 a can of juice or 3 glucose tablets)
b. slower releasing carbohydrate (bread or a
sand-wich).
2. unconscious:
Glucagon (0.5-1 mg) IM: rapid onset and lasts 90
minutes.
Aboubakr Elnashar

32. 3. In hospital:
150 mL of 10% dextrose IV
Once a patient is conscious, they should be given
oral therapy as above.
4. If after 10 m the blood glucose remains less
than 5 mmol/L(90 mg/dl), the treatment should be
repeated.
5. Insulin doses with the next meal should not be
withheld but may require modification.
Aboubakr Elnashar

33. Diabetic ketoacidosis (DKA)
 occurs when there is insufficient insulin to
metabolize blood glucose.
1. failure to appreciate the increasing insulin
requirements in pregnancy
2. missed insulin doses
3. concurrent illness such as infection, steroid
therapy and stress.
plasma glucose: ≥12 mmol/L(216 mg/dl),
arterial pH: ≤7.3
ketonuria or ketonaemia
poor maternal and fetal outcome
CTG abnormalities are typical in 3rd T and resolve
with treatment of the hyperglycaemia.
Aboubakr Elnashar

34. Treatment
should involve the diabetic teams,
treatment of the precipitating cause
intravenous insulin via a sliding scale.
continuous CTG may be necessary, but should be
given careful consid-eration. CTG abnormalities
are to be expected in a woman with DKA, and it
would be unsafe to perform an emergency
caesarean until the woman is stable from metabolic
and haemodynamic perspectives.
Severe hyperglycaemia requiring intensive
treatment is defined as persistent pre-meal blood
glucose values of greater than 12 mmol/L on two
consecutive occasions, or a random level of more
than 15 mmol/L(270 mg/dl). Involvement ofAboubakr Elnashar

35. II. Retinal and renal assessment
1.At booking if not done in the pre-ceeding 12 m
2.At 28 w if booking is normal
3.The presence of hypertension also worsens
progression of retinopathy, thus it has been
suggested that, in women with these
complications, blood pressure should be kept at
120-130/70-80 mmHg.
Betablockers should be avoided as
antihypertensives due to their possible adverse
effects of glucose metabolism.
Aboubakr Elnashar

36. Obstetric
I. Screening for F malformation
1.Screening for Down Syndrome
2.Anomaly scan including detailed four-chambered
assessment of the fetal heart.
Aboubakr Elnashar

37. II. Fetal wellbeing:
Indications:
Insulin is required
Poorly controlled diabetics
Hypertension
History of IUFD
Tests: no reliable test. A combination of tests must be employed.
Kick chart, NST, AFI, Doppler
Aboubakr Elnashar

38. III. Screening for macrosomia
•Clinical & US: inaccurate (±10-20%).
•US: The best single measurement:
Serial measurements of AC
Aboubakr Elnashar

39. IV. Delivery
• Time:
 Induction at 38w in insulin requiring GDM: lower rate
of:
macrosomia (10% Vs 23%),
CS (25% Vs 30%) and
Shoulder dystocia (0% Vs 3%) (Kjos et al, 1993).
 Delivery before 38W:
Poor glucose control
Poor compliance
Co morbidities e.g. hypertension
Corticosteroids:
<36 w
 Induction of labour at 40 w in Diet controlled GDM
Aboubakr Elnashar

40. Care for
Preterm Labour
1. Steroids 2. Re-adjustment
of hypoglycaemic
agents
3. Tocolysis: can
be given (not
betamimmetic)
Aboubakr Elnashar

41. •Mode:
Elective CS:
> 4000 & 4250g (Inzucchi, 1999).
Aboubakr Elnashar

42. C. Intra-partum care
•The target glucose level: 75-125 mg/d
•Blood glucose/h
-> 125 mg/dl: 2-4 u IV regular insulin and assess the
coming hour.
-< 75mg/dl: 10% dextrose infusion and assess after 15
min.
Women with GDM controlled with insulin should be
instructed to stop insulin use once labor starts, and then
reevaluate their glycemic control with frequent SMBG
testing in the postpartum period.
Aboubakr Elnashar

43. •IV dextrose and insulin:
-Indication:
Type 1 diabetes
BG not maintained between 75& 125 mg/d.
-Strength of solution:
(1 u/ ml) (50 u insulin in 50 ml 5% dextrose)
-Rate:
if blood glucose
0-70 mg/dl= 0.5 u/h
71-140 mg/dl= 1 u/h
141-215 mg/dl= 2 u/h
Aboubakr Elnashar

44. D. Postpartum care
I. Breast feeding:
Encouraged
{Reduces the insulin requirement by 25%
Breast- feed babies have a much lower risk of
developing DM}
Glyburide and metformin are secreted into breast milk
and should not be used during lactation in women with
T2DM.
Breastfeeding can cause life-threatening hypoglycemia
for lactating women on insulin, especially those with
T1DM. Women who are both breastfeeding and on a
form of basal insulin must either decrease their basal
rate during lactation or eat a carbohydrate-containingAboubakr Elnashar

45. II. Glycemic control
Insulin-treated pre-existing diabetes:
•Reduce insulin (30-50%)
•Self-monitor blood glucose to establish correct dose
•{Risk of hypoglycaemia, especially while breastfeeding}
To have food available before or during breastfeeding.
Once women with type 1 diabetes are eating normally,
s.c. insulin should be recommenced at either the pre-
pregnancy dose or at a 25% lower dose if the women
intends to breast-feed,
Aboubakr Elnashar

46. Type 2 diabetes:
•Resume or continue taking metformin and
glibenclamide
•Not to take any other oral hypoglycaemic agents while
breastfeeding.
Aboubakr Elnashar

47. Gestational diabetes:
•Stop hypoglycaemic medication
•Advise: weight control, diet and exercise
•FBS at 6-w postnatal, then annually.
Aboubakr Elnashar

48. III. Contraception
•Copper IUCD, Mirena:
not associated with PID
(Kimmerle et al, 1993 ; Kjos et al,1994)
•DMPA:
Deterioration of CHO tolerance
increase risk of diabetes
•NORPLANT:
No deterioration
(Fahmy et al, 1991 ; Konje et al,1992; Singh et al,1992)
Aboubakr Elnashar

49. GDM: not a contraindication for COC
Diabetes with retinopathy/nephropathy/neuropathy or
with other vascular disease or disease duration >20
yr: contraindicated or relatively contraindicated
depending upon severity
Low-dose COCs
•didn't influence development of Diabetes
(Kjos et al,1998)
•Non smoker, <35 years, healthy: no hypertension,
nephropathy, retinopathy, or other vascular disease.
Progestin-only Pill
with breast feeding: 3 fold risk of diabetes
(Kjos et al,1998)
Should be prescribed with caution, if at all.
Aboubakr Elnashar

50. Aboubakr Elnashar

51. Summary
Diabetes during pregnancy is the most common
complication of pregnancy. Pregestational planning
is imperative for all women with preexisting
diabetes.
Pregnant women who have no known diabetes but
who have any risk factors for GDM should be
screened with the 75-g OGTT at the initial prenatal
visit, and all women should be screened by 28
weeks gestation.
Aboubakr Elnashar

52. Clinicians should be prepared for an increase in the
number of women identified with diabetes during
pregnancy and develop a thorough and efficient
model for outpatient management. Patient
education is the foundation for successful
management of diabetes during pregnancy.
The goal of therapy will continue to be
normoglycemia before, during, and after all
pregnancies complicated by diabetes.
The world of diabetes is rapidly evolving, with
many new tools on the horizon for diagnosis,
monitoring, and treatment. These tools will make
the management of diabetes in pregnancy easier
and possibly safer.
Aboubakr Elnashar

53. Some promising developments for diabetes in
pregnancy include weekly point-of-care Hb A1c
testing, the routine use of CGMs in T1DM, and the
implementation of universal screening guidelines.
With these potentially cost-effective advances in
diabetes during pregnancy comes the hope of
preventing macrosomia and decreasing the
prevalence of childhood obesity and T2DM in the
offspring of diabetic mothers.
Aboubakr Elnashar

54. Benha University Hospital
E-mail:elnashar53@hotmail.com
Aboubakr Elnashar