screening and different treatments for DM during pregnancy

1. Diabetes in
pregnancy : medical
management
BY
L/RADWA RASHEEDY
Lecturer of obstetrics and gynecology
Ain shams university

2. TERMINOLOGY
• The terminology for describing diabetes first diagnosed during
pregnancy varies among national organizations.
• Historically, the term "gestational diabetes" has been defined
as onset or first recognition of abnormal glucose tolerance
during pregnancy .
• The American College of Obstetricians and Gynecologists
(ACOG) continues to use this terminology
• In recent years, the International Association of Diabetes and
Pregnancy Study Groups (IADPSG), the American Diabetes
Association (ADA), the World Health Organization (WHO), the
International Federation of Gynecology and Obstetrics (FIGO),
and others have attempted to distinguish women with
probable preexisting diabetes that is first recognized during
pregnancy from those whose disease is a transient
manifestation of pregnancy related insulin resistance

3. • These organizations typically use the term "gestational
diabetes" to describe diabetes diagnosed during the second
half of pregnancy, and terms such as "overt diabetes" or
"diabetes mellitus in pregnancy" to describe diabetes
diagnosed by standard non pregnant criteria early in
pregnancy,

4. • The gestational age at which a diagnosis of overt versus
gestational diabetes is unclear.
• Stated in another way, if a patient in early pregnancy
(before significant insulin resistance) meets criteria for
diabetes, she is assumed to have had diabetes prior to
the pregnancy, but there is no way to determine at what
gestational age this would no longer be true.

5. IDENTIFICATION OF OVERT
DIABETES IN EARLY PREGNANCY
• The International Association of Diabetes and Pregnancy
Study Groups (IADPSG) concluded that the decision to test for
undiagnosed preexisting diabetes at the first prenatal visit
should be based upon the background frequency of abnormal
glucose metabolism in the population and on local
circumstances
• Both the (ADA) and the (ACOG) suggest early pregnancy
testing for undiagnosed type 2 diabetes in women with risk
factors

6. • The ADA defines women at increased risk of overt diabetes
based on body mass index (BMI) ≥25 kg/m2 (≥23 kg/m2 in
Asian Americans) plus one or more of the following:
• GDM in a previous pregnancy
• HB A1C ≥5.7 percent ,impaired glucose tolerance, or impaired
fasting glucose on previous testing
• First degree relative with diabetes
• High risk race/ethnicity)
• History of cardiovascular disease
• Hypertension (≥140/90 mmHg or on therapy for hypertension)
• HDL cholesterol level <35 mg/dL and/or a triglyceride level
>250 mg/dL
• Polycystic ovary syndrome
• Physical inactivity
• Other clinical condition associated with insulin resistance (eg,
severe obesity, acanthosis nigricans)

7. • ADA criteria for diagnosis of diabetes in non pregnant adults
may be used to diagnose overt diabetes in early pregnancy
HBA1C ≥ 6. 5 percent
OR
FBS≥126 mg/dL(no caloric intake at least 8 hr)
OR
2hr plasma glucose ≥ 200 mg/dl(during OGTT with 75 gm glucose
OR
Patient with classic symptom s of hyperglycemia or hyperglycemic crisis with RBS
≥200 mg/dl

8. • Confirming the Diagnosis Unless there is a clear clinical
diagnosis (e.g., patient in a hyperglycemic crisis or with classic
symptoms of hyperglycemia and a random plasma
glucose≥200 mg/dL ,a second test is required for
confirmation.
• It is recommended that the same test be repeated without
delay using a new blood sample for confirmation because
there will be a greater likelihood of concurrence.

9. • FPG, 2-h PG after 75-g OGTT, and A1C are equally
appropriate for diagnostic testing. It should be noted that
the tests do not necessarily detect diabetes in the same
individuals.
• In conditions associated with increased red blood cell
turnover, such as pregnancy (second and third
trimesters), hemodialysis, recent blood loss or
transfusion, or erythropoietin therapy, only blood
glucose criteria should be used to diagnose diabetes.

10. • HBA1C is not a suitable test to detect mildly impaired glucose
tolerance.
• To identify pregnant women with mildly impaired glucose
tolerance it is better to perform a 75-gram, two-hour oral GTT
when A1C is 5.7 to 6.4 percent at the first prenatal visit

11. • In patients with high risk of having overt diabetes and
screening at booking was negative routine screening at
24 =28 weeks
• And if this screening negative some recommend
rescreening at 32 weeks

12. Gestational DM
• Screening is usually performed as a two step process
where step one identifies individuals at increased risk for
the disease so that step two, diagnostic testing, which is
definitive but usually more complicated or costly than
the screening test, can be limited to these individuals
and avoided in low-risk individuals.
• Alternatively, a diagnostic test can be administered to all
individuals, which is a one step process.
• Candidates for screening: universal screening???
• Timing of screening: 24=28 weeks

13. Candidates for screening
According to NICE 2015
• Assess risk of gestational diabetes using risk factors in a
healthy population.:
• BMI above 30 kg/m2
• previous macrosomic baby weighing 4.5 kg or above
• previous gestational diabetes
• family history of diabetes (first-degree relative with diabetes)
• minority ethnic family origin with a high prevalence of
diabetes(specifically women whose country of family origin is
India, Pakistan or Bangladesh), black Caribbean, Middle
Eastern .Saudi Arabia, United Arab Emirates, Iraq, Jordan,
Syria, Oman, Qatar, Kuwait, Lebanon or Egypt
• Offer women with any one of these risk factors testing for
gestational diabetes

14. • According to ACOG , consistent data that screening all
pregnant women for GDM are lacking
• The use of traditional risk factors to identify GDM will
miss approximately one half of women with GDM.
• It was recognized at the Fifth International Workshop
Conference on Gestational Diabetes Mellitus that certain
features place women at low risk of GDM, and it may not
be cost-effective to screen this group of women.
• However, such low-risk women represent only 10% of
the population and selecting these individuals who
should not be screened may add unnecessary complexity
to the screening process

15. • While the ADA recommended that all pregnant women
not known to have prior diabetes undergo a 75-g OGTT
at 24–28 weeks of gestation

16. two-step approach One-step approach
50-gram one-hour glucose screen
The following thresholds have been
proposed to define a positive screen:
≥130 mg/dL, ≥135 mg/dL, or ≥140
mg/dL
In the absence of clear evidence
supporting a cutoff for the 1-h
glucose, it is suggested that health
care providers select one of these as
a single consistent cutoff for
their practice, with factors such as
community prevalence
rates of GDM considered in that
decision.
Followed by 100 gm OGTT
A positive test is defined by elevated
glucose concentrations at two or
more time points
omits the screening test and
simplifies diagnostic testing
by performing only a 75-gram, two-
hour oral GTT.
A diagnosis of "gestational diabetes"
is made when one or more of the
glucose thresholds are met.

17. One step 75
gram, load
NICE ≥5.6 mmol/
L(100mg/dl)
≥7.8 mmol/l
(140mg/dl)

18. Patients unable to tolerate
oral hyperosmolar glucose
• Serial glucose monitoring – Periodic random fasting and two-
hour postprandial blood glucose testing is a monitoring option
for women at high risk for gestational diabetes who are unable
to tolerate an oral glucose load. This approach is also useful
for women who have dumping syndrome after a roux-en-Y
gastric bypass procedure
• Monitoring glucose values will only identify those cases of
GDM that might require intervention for hyperglycemia and
not all cases of GDM
• Fasting plasma glucose –a fasting plasma glucose level less
than 85 mg/dL (4.7 mmol/L) by 24 weeks of gestation
performed well for identifying women who did not have
gestational diabetes

19. • Test alternatives to the glucose challenge test and GTT
• Serving the hyperosmolar glucose drink on ice may reduce
nausea and vomiting,
• Alternatives to the oral screening and GTTs have been
proposed but have not been validated in large studies. These
approaches typically use candy, a predefined meal, or
commercial soft drinks instead of a standard glucose
monomer or polymer solution
• Intravenous GTT –This approach is rarely used and has not
been well validated against oral GTT results or against
pregnancy outcome

20. GENERAL APPROACH TO
Management

21. Glycemic control target
• Asses glycemic control during pregnancy by frequent daily self
monitoring of blood glucose and periodic measurement of
hemoglobin A1C
Timing/frequency target
fasting ≤95 mg/dL
Pre meal ≤100 mg/dL
1hr or 2hr postmeal(after 1st bite of meal ≤140 mg/dL/≤120 mg/dL
During the night(bed time ≥60 mg/dL
glycosylated hemoglobin test less than or equal to 6%.

22. Selected patients:
Between 2 AM
and 4 AM
If nocturnal hypoglycemia is suspected, (Damp sheets or
bedclothes due to perspiration ,Nightmares, Tiredness, irritability
or confusion ,and headache upon waking
Between 3= 5AM for evaluating pre breakfast hyperglycemia of unclear etiology.
Hyperglycemia at 3 AM to 5 AM suggests hyperglycemia is the
result of inadequate insulin management or carbohydrate snack
consumption at bedtime
A normoglycemic nadir at 3 AM to 5 AM followed by pre breakfast
hyperglycemia suggests the "dawn phenomenon," which
has been attributed to the normal overnight release of counter
regulatory hormones such as growth hormone
Hypoglycemia at 3 AM to 5 AM suggests that the bedtime/evening
insulin dose is too high or the bedtime snack has inadequate
calories. Prebreakfast hyperglycemia is a rebound phenomenon
due to release of stress hormones in response to low blood
glucose levels, which has been termed the "Somogyi effect."

23. • women with type 2 diabetes or gestational diabetes to
test their fasting and 1-hour post-meal blood glucose
levels daily during pregnancy if they are:
• on diet and exercise therapy or
• taking oral therapy
• or single-dose intermediate-acting or long-acting insulin.

24. • These values represent optimal control if they can be
achieved safely. In practice, it may be challenging for
women with type 1 diabetes to achieve these targets
without hypoglycemia, particularly women with a history
of recurrent hypoglycemia.
• In general, women with diabetes should test their urine
for ketones if the blood glucose concentration is above
180 mg/dL ,during periods of illness or stress, or if there
are symptoms compatible with ketoacidosis such as
nausea, vomiting, and abdominal pain.

25. • use of the 1-h postprandial measurement for management of
GDM was associated with better glycemic control, lower
incidence of LGA infants, and lower rates of cesarean delivery
due to cephalopelvic disproportion

26. Non-Pharmacological
Strategies
• Initial treatment of GDM and important part of
preexisting diabetes treatment consist of
• nutritional guidance The goal of nutrition therapy is
to achieve normoglycemia, prevent ketosis, provide
adequate weight gain, and contribute to fetal well-being.
• The nutritional prescription constitutes the calculation of
caloric intake and mounting the daily menu, in addition
to providing basic concepts about nutrition, healthy
eating, the food pyramid and food fractionation to the
patient in order to arouse attention to the importance
• of nutrition in pregnancy.

27. • The recommended caloric intake to provide total gestational
weight gain in the range recommended by the Institute of
Medicine
• These recommendations are based on pre pregnancy (BMI)
• Underweight: 30 kcal/kg in the first trimester, 36 to 40 kcal/kg
in the second and third trimesters
• Normal weight: 30 kcal/kg in the first trimester, 36 kcal/kg in
the second trimester, and 36 to 38 kcal/kg
• in the third trimester
• Overweight and obese: 24 kcal/kg throughout pregnancy

28. • The diet should be planned throughout the day, being split
into three large meals and three snacks (ADA, 2004), being the
carbohydrate intake distributed between them, aiming to
prevent postprandial hyperglycemia.
• Caloric composition
• Complex, high-fiber carbohydrates – 40 to 50 percent of total
calories
• Protein – 20 percent of total calories
• Fats, primarily unsaturated – 30 to 40 percent of total calories
• Carbohydrates and protein contain 4 cal/g; fat contains 9
cal/g.

29. • Calorie distribution:
• Macronutrient distribution should be individualized, but the
following distribution
• Breakfast – 10 to 20 percent of total calories. Because insulin
resistance is greatest in the morning,
• Lunch – 20 to 30 percent of total calories.
• Dinner – 30 to 40 percent of total calories.
• Snacks – Up to 30 percent of total calories.
• Snacking is based on caloric needs and support for
hypoglycemia as well as consideration of pre pregnancy BMI,
as overweight and obese women may not need to snack.
• Bedtime snacks are often needed to minimize nocturnal
hypoglycemia

30. • Physical activity as a strategy for prevention and adjuvant
treatment
• The recommended exercise prescription is low-impact physical
activity, ideally being practiced daily for at least 30 minutes,
which can be divided into three sessions of ten minutes each
Initially .
• Start by 15 minutes daily with gradual increase up to a
maximum of 30 minutes / day),
• Some precautions should be observed such as starting the
physical activity sessions preferably after meals, avoiding
beginning if the blood glucose is below 60 mg / dL or above
250 mg / dL (

31. Pharmacological
Strategies

32. Insulin requirements
• Total daily insulin requirements vary by gestational age as
gestation progresses.
• early first-trimester rise in insulin requirements (between
• gestational weeks 3 and 7
• there is often a significant decline in the late first/early second
trimester (between gestational weeks 7 and 15
• followed by a rise during the remainder of pregnancy
(especially between gestational weeks 28 and 32

33. Insulin types

34. Classification of Insulin Regimes and
Preparations

35. Problem with Regular Insulin
• Slow onset of activity
• Inconvenient for patient (administered 30-60minutes prior to
meal)
• Long duration of activity
• Potential for late postprandial (4-6hours) hypoglycemia
• Lasts up to 12hours
• the ultra-short-acting analogs,are more effective for early
postprandial glucose control, reducing the risk of later
postprandial hypoglycemia.
• Therefore, studies in pregnancy to lispro and aspart, both
demonstrating clinical effectiveness, no evidence of
teratogenesis, low antigenicity, and placental transport of
autoantibodies similar to human regular insulin.
• Lispro and aspart are assigned in the pregnancy category
‘‘B’’ rating,

36. Insulin Lispro ((Humalog)
• Rapidly lowering postprandial glucose levels with fewer
hypoglycemic episodes, and without increasing anti-insulin
antibody levels
• Similar neonatal outcomes versus regular insulin
• Improved patient satisfaction
• Especially helpful in women with hyperemesis or gastroparesis
because they can be dosed after meals
• Insulin lispro is not likely to cross the placenta at a single
standard dose (until 130 units). Insulin lispro is unlikely to
reach or harm the unborn baby.
• studies on experimental animals and in pregnant females
have not shown any embryotoxic or teratogenetic effects of
insulin lispro
• has no adverse impact on progression of retinopathy in
pregnant women

37. Insulin Aspart(NovoRapid)
INSULIN NOVOMIX
• The overall safety and effectiveness of insulin aspart is
comparable to regular human
• Insulin aspart was more effective than regular insulin in
providing postprandial glycemic control.
• Patients showed greater treatment satisfaction with Aspart.
• Studies on experimental animals did not show any
embryotoxic or teratogenetic effects of insulin aspart.
• No studies about the possible placental transfer of insulin
aspart are available in the literature.

38. Insulin Glargine (lantus)
• Glycemic control, birth weight, and prevalence of macrosomia
and neonatal morbidity were similar to human insulin
• Rate of congenital malformations comparable to NPH insulin
• At present the use of insulin glargine in pregnancy is not
approved: well-planned investigations and controlled trials are
needed to achieve a final risk assessment in order to use it in
pregnancy.; up to now, glargine has been assigned a
pregnancy category ‘‘C’’.

39. Insulin Detemir( INSULIN
LEVEMIR)
• in 2012, insulin detemir received US Food and Drug
Administration approval for reclassification to pregnancy
category B from pregnancy category C based on data assessing
maternal efficacy judged by A1C and safety judged by
hypoglycemic episodes in a randomized trial that compared
insulin detemir with NPH insulin
• The pharmaceutical package insert notes that no differences
in pregnancy outcomes or the health of the fetuses and
newborns were seen with insulin detemir compared with
NPH, but study data were incomplete.

40. Type 1 diabetes
• Insulin requirements during the first trimester are similar to
those prior to pregnancy (mostly 0.7 units/kg)
• 0.8 units/kg for weeks 13 to 28,
• 0.9 units/kg for weeks 29 to 34, and
• 1.0 units/kg for weeks 35 to term;
• Approximately 50 percent of the total insulin dose is
administered as a rapid acting insulin before each meal
• and the other 50 percent is administered as an intermediate
insulin (NPH) twice daily.
• The first NPH dose is given before breakfast and the second
dose is given either before dinner with a rapid-acting insulin

41. Type 2 diabetes
• Insulin requirements during the first trimester are similar to those
prior to pregnancy
• During the second half of pregnancy, insulin requirements increase
disproportionately in women with type 2 compared with type 1
diabetes
• For women with excellent glycemic control on an oral anti-
hyperglycemic drug such as metformin at conception, maintaining
euglycemia during organogenesis is critical and more important than
switching to insulin. The majority of these women are overweight or
obese, often with insulin resistance
• Metformin can be continued safely and effectively as the transition
to insulin is initiated and until the dose of injected insulin is
sufficient to achieve metabolic control
• If they do not achieve and maintain target glucose values, begin
insulin therapy with a combination of lispro or aspart insulin and
(NPH) insulin

42. Gestational diabetes mellitus
• When initially diagnosed with GDM, patients are asked to
measure their blood glucose concentration at least four times
daily (fasting and one or two hours after the first bite of each
meal)
• Multiple daily measurements allow recognition of women
who should begin an anti-hyperglycemic agents
• decrease the frequency of glucose monitoring to every other
day or every third day when good glycemic control is
accomplished with medical nutritional therapy

43. Gestational diabetes mellitus
• When initially diagnosed with GDM, patients are asked to
measure their blood glucose concentration at least four times
daily (fasting and one or two hours after the first bite of each
meal)
• Multiple daily measurements allow recognition of women
who should begin an anti-hyperglycemic agents
• decrease the frequency of glucose monitoring to every other
day or every third day when good glycemic control is
accomplished with medical nutritional therapy

44. • ADA recommended that patients with a fasting plasma
glucose (<95 mg/dL) attempt dietary therapy for at least
2 weeks before starting insulin, whereas insulin should
be started at diagnosis or within a week of failed dietary
therapy in patients with fasting glucose levels > (>95
mg/dL). Such severe elevations imply the need for
aggressive therapy with prompt initiation of insulin.
• According to NICE, If the FPG concentration on the
OGTT is >126 mg/dl, then the patient is advised insulin
therapy
• Also it should be considered if blood glucose targets are
not maintained 1 to 2 weeks after introducing changes to
diet and initiating exercise.
• Pharmacological therapy should also be considered at
the time of diagnosis of GDM if fetal macrosomia is
suspected by ultrasound investigations

45. • initiate insulin (or increase the dose) when one-third of
fasting or postprandial glucose levels exceed the target in
a given week.
• There are two pharmacologic options in pregnant
patients who require medical therapy aimed at
controlling blood glucose: insulin and selected oral anti-
hyperglycemic agents. according to ACOG When
pharmacologic treatment of GDM is indicated, insulin
and oral medications are equivalent in efficacy, and
either can be an appropriate first-line therapy. Insulin has
historically been considered the standard therapy for
GDM management in cases refractory to nutrition
therapy.

46. • According to the ADA Insulin is the first-line agent recommended for
treatment of GDM
• While individual randomized controlled trials support the efficacy
and short-term safety of metformin and glyburide for the treatment
of GDM, both agents cross the placenta. Long-term safety data are
not available for any oral agent
• Concentrations of glyburide in umbilical cord plasma are
approximately 70% of maternal levels. Glyburide may be associated
with a higher rate of neonatal hypoglycemia and macrosomia than
insulin or metformin
• Metformin may be associated with a lower risk of neonatal
hypoglycemia and less maternal weight gain than insulin); however,
metformin may slightly increase the risk of prematurity.
• Furthermore, nearly half of patients with GDM who were initially
treated with metformin need insulin in order to achieve acceptable
glucose control

47. According to NICE 2015
• Offer metformin if blood glucose targets are not met using
changes in diet and exercise within 1–2 weeks.
• Offer insulin instead of if metformin is contraindicated or
unacceptable to the woman
• Offer immediate treatment with insulin, with or without
metformin as well as changes in diet and exercise if fasting
plasma glucose level of 126 mg/ dl or above at diagnosis or
fasting plasma glucose level of between 108 =125 if there are
complications such as macrosomia or hydramnios.
• Consider glibenclamide:
• If blood glucose targets are not achieved with metformin but
patient decline insulin therapy or
• who cannot tolerate metformin

48. Glyburide metformin
sulfonylurea biguanide
mechanism of action is stimulation of
the release of insulin from the storage
granules of pancreatic beta cells.
Secondarily it decreases insulin
resistance
suppress hepatic glucose uptake and
decreases intestinal absorption of
glucose
category B drug category B drug
usual starting dose of glyburide is 2.5
mg once or twice daily.
Usual dose is 500 mg to 1500 mg daily
in divided doses
may be increased up-to 20 mg if
necessary.
duration of action is 10-12
hours

49. • One should start low and go slow while initiating insulin in
GDM.
• A safe method of calculating initial dose would be to begin
0.1-0.2 U/kg body weight.
• Typically, regardless of bodyweight, a patient whose glucose
elevations are mostly postprandial is prescribed a starting
dose of 30 units (20 units of intermediate acting insulin and 10
units of rapid acting insulin) in the morning prior to breakfast.
• If the GDM is diagnosed and therapy instituted prior to the
third trimester, we generally start with half this dose, since
insulin resistance has not reached its maximum level in the
second trimester
• If the post-dinner glucose level remains elevated, then an
additional injection of rapid acting insulin is given just prior to
dinner

50. • If fasting glucose is elevated, intermediate acting insulin can
be given along with the dinner dose of rapid acting insulin, or
can be administered separately at bedtime.
• Sometimes an additional dose of rapid acting insulin Is
necessary to maintain euglycemia after lunch, so that
• a total of four injections per day are needed

51. ADA RECOMMENDATION FOR
STARTING INSULIN IN TYPE
2DM

53. nocturnal hypoglycemia.
• Nocturnal hypoglycemia is less common in individuals using
rapid-acting insulin analogs (lispro, aspart, glulisine) rather
than regular insulin before meals and in individuals using long-
acting insulin analogs (glargine, detemir, degludec) rather than
NPH as the basal insulin
• Pre-dinner administration of NPH insulin, especially if the dose
of NPH is increased in view of the next morning’s elevated
fasting glucose value, has the likelihood of producing
nocturnal hypoglycemia.
• Bedtime snacks are the traditional strategy for preventing
nocturnal hypoglycemia.
• Alternative strategy to address nocturnal hypoglycemia is to
shift the pre dinner NPH insulin to bedtime. By this method,
one can alter the time of peak action towards early morning
and minimize the possibility of overnight hypoglycemia

54. Somogyi effect
• Given that the main cause of the Somogyi effect is an
excessive dose of insulin, the first step to prevent it should be
to modify insulin dosage
• in the case of a patient treated with NPH, replace insulin with
a long-acting peakless analogue, e.g. glargine or detemir
• To prevent the occurrence of this phenomenon, the
proportion of proteins to carbohydrates in the last meal of the
day should be increased
• Have a snack with protein before bedtime, like a piece of toast
with peanut butter, or some cottage cheese, or yogurt, or
some nuts and small piece of cheese.
• and a patient should go to bed with a higher level of plasma
glucose than usual

55. Dawn phenomenon
• may be prevented by increasing evening physical activity,
increasing the protein-to-carbohydrate ratio in the last meal of
the day, and by breakfast consumption even though fasting
hyperglycemia
• Exercise later in the day, which may have more of a glucose-
lowering effect in the night.
• Limit bedtime carbohydrates and try more of a protein/fat
type of snack (nuts, peanut butter, cheese, or meat)
• Although an increase in the bedtime doses of hypoglycaemic
agents with night-time peaks of action may correct early
morning hyperglycaemia, it is sometimes associated with
undesirable nocturnal hypoglycaemia

56. Administration of antenatal
corticosteroid
• The hyperglycemic effect begins approximately 12 hours
after the first steroid dose and lasts for about five days
• Start multiple daily blood glucose monitoring 12 hours
after 1st dose and for five days after last dose
• Administration of antenatal corticosteroid therapy (ACS)
will necessitate a spike in insulin requirement.
• Though this is highly variable, an increase of 30% in dose
for 5 days can be anticipated after ACS.

57. • We monitor capillary blood glucose concentrations
hourly, beginning 12 hours after the first dose
of betamethasone and continuing for 24 hours after the
second dose, and then reduce the frequency to several
times per day thereafter if glucose levels are reasonably
well controlled.
• For values >120 mg/dL treat with subcutaneous insulin
• but, in recognition of the risk of diabetic ketoacidosis in
these patients,
• we begin continuous intravenous insulin infusion on the
labor unit if values continue to rise in spite of such
treatment, or if values are above 180 to 200 mg/dL

58. Implications of a fall in insulin
requirements —
• Insulin requirements sometimes fall after 35 weeks of
gestation. This is observed more often in women with type 1
diabetes
• A fall in insulin dose greater than 5 to 10 percent should
prompt assessment of fetal wellbeing and a search for medical
conditions or other factors that could account for the drop.
• Decreasing insulin requirements are weakly associated with
placental insufficiency as well as decreased maternal intake or
vomiting
• If fetal wellbeing is confirmed, then a fall in insulin
requirement is not associated with adverse fetal outcome and
is not an indication for delivery.
• Decreased insulin requirements of up to 30 percent with good
pregnancy outcome have been reported

59. Intrapartum glycemic control
• Good glycemic control remains important
intrapartum because maternal hyperglycemia
during labor increases the risk of fetal acidemia
and neonatal hypoglycemia.
• Avoidance of hyperglycemia is less critical
postpartum, but concern about maternal
hypoglycemia increases because of large, rapid
changes in maternal hormone concentrations
after delivery of the placenta.

60. Intrapartum glucose and insulin
requirements
Latent phase Active phase
Maternal metabolic demands are
minimal
If oral intake is permitted a reduced
calorie diet (eg, 50 percent of daily
caloric intake) will meet energy
demands/if not An IV glucose will be
needed,
Women with type 2 and gestational
diabetes generally produce sufficient
endogenous insulin without need
exogenous insulin.
Women with type 1 diabetes have no
endogenous insulin production and
therefore require intrapartum insulin
Active labor is an intense exercise with
increased energy requirements. Most
women even non diabetics are given 5
percent glucose intravenously as
demands cannot be met by oral intake
which is usually limited or prohibited
during the active phase
insulin requirements
drop to almost zero in the active
phase. So women with type 2 and
gestational diabetes often do not need
supplemental insulin
Women with type 1 diabetes have
lower insulin requirements in active
labor.

61. Intrapartum glucose
monitoring
type 1 diabetes or type 2 diabetes, and
gestational diabetics who are
likely to have undiagnosed type 2
diabetes during pregnancy
gestational diabetes who have
maintained euglycemia antenatally on
diet, lifestyle, and/or
medical therapy,
glucose levels are measured every two
to four hours during the latent phase.
If the woman is eating during latent
phase, pre- and post-prandial
capillary glucose levels should be
monitored.
Glucose levels are measured every one
to two hours during
the active phase
and every hour if insulin is being
infused.
blood glucose levels can be measured
on admission and then no more
frequently than every four to six hours

62. Guidelines for insulin
management for womenwithtype1,2
Subcutaneous insulin regimen (rapid
acting)
Intravenous insulin infusion regimen
regular insulin(
Euglycemia is maintained by giving
one unit of subcutaneous insulin
for each 20 mg/dL increase in
glucose above 120 mg/dL
This approach has been associated
with low maternal and neonatal
complication rates in women with type
1 diabetes and can be used for
women with type 2 or gestational
diabetes requiring insulin.
Insulin is held as long as the glucose
level is ≤120 mg/dL
Above this level, insulin infusion
(units/hour) is begun and increased or
decreased incrementally with
increasing or decreasing maternal
capillary blood glucose levels, which
are measured hourly during insulin
infusion

63. Subcutaneous insulin
regimen
Plasma glucose
level
Sc rapid acting
insulin units
IV fluid used
at 125 mL/hour
Intravenous
infusion
regimen
others
≤120 mg/dL 0 Glucose 5% 0
120=140 mg/dl 1 Glucose 5% 1
140=160 mg/dl 2 Normal saline 2
160 =180mg/dl 3 Normal saline 3 Check for
ketone s
180 =200mg/dl 4 Normal saline 4 Check for
ketone s
More than 200
mg/dl
4 units +regular
insulin IV push
start with 2
Units
Normal saline 4 units +regular
insulin IV push
start with 2
Units
Check for
ketone s

64. Guidelines for insulin
management for GDM
• Using "rotating fluids“ strategy
Maternal plasma glucose IV insulin infusion
(units/hr)
IV fluids
≤100 mg/dL hold Glucose 5%
100=140mg/dL hold Lactated ringer/or NS
More than 140 mg/dL Regular insulin infusion
titrated to maintain CBG
100 mg/dl
Lactated ringer/or NS

65. Scheduled cesarean delivery
• the procedure should be scheduled early in the morning
• A patient on insulin /OHG therapy should maintain her usual
nighttime dose
• However, long-acting insulin at night the dose is decreased by
50 percent, or switched to NPH insulin and one-third of the
long-acting nightly dose is given.
• The morning dose of insulin or oral anti-diabetic agent is held
• In type 1 or type 2 diabetes, if surgery occurs later in the day,
basal insulin (about one-third of the morning dose of
intermediate- or long-acting insulin) is given with a 5 percent
dextrose infusion in order to avoid ketosis
• Glucose levels should be monitored every 1=3hours, especially
in type 1 diabetes or if glucose levels are not in the target
range; a rapid-acting insulin can be given as needed to control
hyperglycemia during this period

66. Induction of labor
• the procedure should be scheduled early in the morning
• A patient on insulin /OHG therapy should maintain her usual
nighttime dose
• However, long-acting insulin at night the dose is decreased by 50
percent, or switched to NPH insulin and one-third of the long-acting
nightly dose is given.
• The morning of induction, the woman eat a light breakfast (half of
her usual breakfast intake) and reduce her insulin dose (NPH and
short- or rapid-acting insulin) by 50 percent
• Continued oral intake (at 50 percent of daily intake during cervical
ripening/latent phase when this period is anticipated to exceed 8 to
12 hours and there is a low risk of emergency operative delivery
• Capillary blood glucose levels are measured pre- and post-meals and
with administration of a rapid-acting insulin to achieve standard
pregnancy goals for euglycemia pre- and post-meals.

67. Postpartum management
• glycemic targets while hospitalized pre meal glucose
concentrations <140 mg/dL (and random glucose
• concentrations <180 mg/dL

68. POSTPARTUM MANAGEMENT
Type 1DM Type 2 DM GDM
markedly reduced insulin needs
for the first 24 to 48 hours and
need frequent monitoring of
glucose levels to avoid
hypoglycemia
Glucose levels tend to be
normal or modestly
elevated in postpartum
women with
type 2 diabetes.
should have fasting
glucose levels monitored
for 24 to 72 hours after
delivery to check for
overt diabetes
Postoperative patients should
receive a 5 % dextrose until
adequate oral intake is resumed.
Fasting, pre- and post-
prandial BG should be
measured. Hyperglycemia
is treated acc sliding scale
BG should be checked every four
to six hours, hyperglycemia
treated according to sliding scales
After 48 hours standard
diabetes management
with diet and therapy
should be resumed, as
needed.
After 48 hours, standard regimen
resumed with calculated total
daily dose of insulin at 0.6
units/Kg postpartum weight or
about 50 percent of the insulin
dose prior to delivery
Metformin is preferred
1st line agent for and
does not produce
hypoglycemia.
Intermediate-acting
insulin in the
AM and PM may also be
needed

69. BG level(
mg/dl)
All DM female regardless classification
Less than 50 1=Give 25 ml(12. 5 mg) of dextrose 50% IV push
2= recheck BG in 15 minutes if less than50 ====repeat 1&2
if 50=69 as below
50=69 1=no insulin
2= if alert & tolerate oral fluid give 200ml juice
If not Give 25 ml(12. 5 mg) of dextrose 50% IV push
3= recheck BG in 15 minutes manage acc level
4= reevaluate the insulin dose
70=100 1=no insulin if it is bedtime BG & recheck at 3 AM
2 give snack if eating (sandwich /200ml milk0
3if NPO===increase glucose 5% level and recheck BG in 2hr
4=reevaluate the insulin dose

70. BG
(mg/dl)
Low dose
Type1DM
Prepreg
BMI ≤25
Intermedi
ate dose
DM2
Prepreg
BMI25=35
High dose
DM2
Prepreg
BMI≥35
AC(before
meal/NPO
HS(hours
of sleep)
AC/NPO HS AC/NPO HS
100=150 No insulin No insulin No insulin No insulin No insulin No insulin
151-200 1 No insulin 2 No insulin 4 2
201-250 2 No insulin 4 1 8 4
251-300 3 1 6 2 12 6
301-350 4 2 8 4 16 8
351-400 5 3 10 6 20 10

71. • Sliding scale should not continue more than 24 hours unless pt
well controlled on it or there is reasons for not adding
maintenance insulin
• Sliding scale not more frequent than /4 hrs
• sliding scale goals are maintaining relaxed glucose levels,
about 140 to 160 mg/dL

72. Postpartum Follow-up of GDM
• should have fasting glucose levels monitored for
24 to 72 hours after delivery to check for overt
diabetes
• If blood glucose levels returned to normal after
birth:
• Offer lifestyle advice (including weight control, diet
and exercise).
• Explain the risks of gestational diabetes in future
pregnancies and risk for type2 DM

73. NICE ADA
Offer a fasting plasma glucose test 6–13
weeks after the birth to exclude diabetes
Do not routinely offer a 75 g 2-hour OGTT
The OGTT is recommended over A1C at
the time of the 4- to 12-week postpartum
If a FBG test has not been performed by 13
weeks, offer it or an HbA1c test if a fasting
plasma glucose test is not possible,
because A1C may be persistently
impacted (lowered) by the
increased red blood cell turnover related
to pregnancy or blood loss at delivery
FBG level below 108 gm/dl /HbA1c below
5.7%
Have low probability of having diabetes
should continue to follow the lifestyle they
need an annual test to check blood glucose
have a moderate risk of developing type 2
diabetes
women should also be tested every
1–3 years thereafter if the 4- to 12-week
75-g OGTT is normal with frequency of
testing depending on other risk factors
FBG bet 108=125 /HbA1c bet5.7% and
6.4% at high risk of developing type 2
diabetes
Ongoing evaluation may be using
HA1C, FBG or 75-g OGTT
FBG 126 /HbA1c 6.5%) or above mostly
have Type 2 DM and offer them a diagnostic
test

74. THANK YOU