Diabetes in Pregnancy

Gestational Diabetes
Impaired carbohydrate intolerance with onset or first
recognition during pregnancy
Incidence documented 5%
Risks
o Obesity BMI >35
o Advance maternal age >40
o PCOS
o Family hx of type 2 or 1st degree with GDM
o Past hx GDM
o Ethnicity
Aboriginal, TSI, Pacific islander, Middle eastern,
African
o Past obstetrics
Gestation diabetes
Large baby (>4kg)
Perinantal loss
Diagnosis
o Australian screening between 26 and 28 weeks
o Earlier testing in higher risk women or clinical feature
If normal should be repeated at 26-28w
o Glucose challenge test (screening test)
Suitable as initial screening approach to patients
without risk factors at 26-28 wks
50g oral glucose load with 1h serum glucose
testing
Non-fasting test
>7.8mmmol/L one hour should proceed to GTT
(diagnostic)
Sensitivity 80%
Specificity 90%
o Glucose Tolerance test
Diagnostic
Ideally performed after high carbohydrate diet of
at least 150g for 3 days prior
Fasting test
75g oral glucose load with serum glucose
conduced at 0 and 2 hours
Diagnosis
Fasting - > 5.5 mmol/L
2h - >8 mmol/L
1 or more elevated
Foetal complications
o Macrosomia and associated morbidity shoulder
dystopia and CPD

Neonatal hypoglycaemia and electrolyte imbalance

Hyperbilirubinaemia
RDS
Longer term outcomes
Increased risk of obesity and diabetes in lifetime
for foetus
Maternal complications
o Symptoms of hypo and hyperglycaemia
o Increase risk of hypertension, pre-eclampsia and
pregnancy complications
o Strong risk factor for development of diabetes later in
life up to 70% risk later in life
Treatment
o Diet (70% rx with this alone)
Nutritional advice
Exercise
Monitor BSL
Fasting <5
1h <7.4
2h <6.7
o Insulin (30%)
Started if BSL exceed goals three or more
consecutive days
4 day regime
o Obstetric management
Observation for complications
Foetal growth, polyhydramnios, preeclampsia, hypertension, APH and IUGR
Third trimester U/S for growth 32-34 wks
CTG from 36w
Timing of deliver individualised
Usually 39-40 weeks if on insulin
Well diet controlled, pregnancy may be able to
extend to post dates
Delivery
o Beware complications arising from large baby
High risk of cephalopelivic disproportion and
shoulder dystocia
o Monitor BSLs
Insulin/ dextrose infusion if
>30 u per day or BSL >7
o Continuous CTG monitoring
o NICU or paediatric assistance at birth
Neonatal care
o BSL taken before 1h of age <2.5 give frequent small
milk feed, <1.5 IV dextrose required
o
o
o
o

o NIC if
Pre-term <37w
Weights >4500g
Persistent hyperglycaemia
o Observe for RDS and hypo
o Breast feeding is fine
Post-partum
o Cease insulin rx
o Monitor BSL for 24h post partum then cease if normal
o Women should have a repeat GTT performed 6w post
delivery
o Women with GDM are at higher risk of developing DM in
later life and should have counselling regarding the
symptoms of hyperglycaemia

Pre-Existing Diabetes (Type 1 and 2)

Affects 1:250 pregnancies
Type 2 increasingly common
Foetal complications
o Increase risk of miscarriage and still birth (20-30% with
poorly controlled diabetes)
Congenital malformations increase proportionally
with HbA1c to 6-10%
o Disorders of foetal growth
IUGR long standing diabetes with macro vascular
disease
Macrosomia excessive glucose transfer across
placenta and secondary foetal hyperinsulinemia
o Foetal wellbeing
Increase still birth rate at term
Increased perinatal death rates 31.8 per 1000 vs
8.5 per 1000
o Neonatal complications
Same as before
Maternal complications
o Hypoglycaemia
o 2-4x increase in hypertensive disorders of pregnancy
o increased risk of infections during pregnancy
o Pregnancy independent risk factor for progression of
retinopathy
o Nephropathy
Patients with pre-existing micro albuminuria more
likely to develop pre-eclampsia
Impairment of renal functions
o Micro vascular and macro vascular complications
increase
o Increase caesarean

Management
o Contraception advice from reproductive age
o Team management
o Optimise glycaemic control
Diet and weight control
Treatment
Review of insulin with consideration of a
insulin pump if not adequately controlled
Aim for HbA1c 6%
Check for pre-existing diseases macro vascular
disease, renal function, retinopathy and review
current meds
High dose folic acid
Home glucose monitoring maintaining BSL
between 4-7 mmol/L
o Medications
Gold standard = insulin
Short acting with meals (actrapid) and
medium acting at night (protophane)
Metformin if wont take insulin
o Monitor BSL and change insulin regime accordingly
More insulin needed around 26 weeks
Obstetric management
o 12 week U/S for
Neural fold
Gross defects
o FAS 18-20 wks
o Cardiac scan 24-36 wks
o Beware of falling insulin requirements
Delivery
o Deliver between 38-39 wks
IOL prostin and oxytocin if required
Vaginal delivery unless contraindicated
Post partum
o Type I
Insulin requirement decreases
Avoid hypos with regular meals
o Type II
Return to pre-pregnancy control
o Contraception counselling