Diabetes IN Pregnanc Y: Presenter: DR Leong Yuh Yang (MD Ukm) Supervisor: DR Noraza Azmeera

DIABETES
IN
PREGNANC
Y
PRESENTER : DR LEONG YUH YANG (MD
UKM)
SUPERVISOR : DR NORAZA AZMEERA
CLASSIFICATION
Diabetes in
Pregnancy
Diabetes and
Pregnancy
Hospital Pakar Sultanah Fatimah 2011
Gestational
Diabetes
mellitus
2
DEFINITION OF GDM
GDM is defined as any degree of glucose

intolerance with onset or first recognition during
pregnancy.
The definition applies regardless of whether

insulin or only diet modification is used for
treatment or whether the condition persists after
pregnancy.
It does not exclude the possibility that

unrecognized glucose intolerance may have
American Diabetes
antedated or begunSource:
concomitantly
with the
Association 2009
pregnancy.
GLOBAL SCENARIO OF
GDM
GDM complicates 4% of all pregnancies in the

U.S., resulting in 135,000 cases annually.
The prevalence may range from 1 to 14% of

pregnancies, depending on the population
studied.
GDM represents nearly 90% of all pregnancies

complicated by diabetes.
Deterioration of glucose tolerance occurs

normally during pregnancy, particularly in the 3rd
Source: American Diabetes
trimester.
Association 2009
MALAYSIA SCENARIO OF
GDM
Diabetes prevalence had increased from 8.3%

(1996) to 14.9% (2006) (NHMS III 2006).
Diabetes admission based on type of diabetes

(1994-2004): GDM represent 30% of total
admission (Ministry of Health Malaysia 2007).
Prevalence of GDM:
Year
Author
1993
2001
Chan
Shamsuddin et
al.
Idris et al.
2009
Study
Location
UMMC
UKMMC
Prevalence of
GDM (%)
12.7
24.9
Alor Setar
18.3
ALAYSIA SCENARIO OF GDM (2

Demographic Data of Patients
with GDM
GDM & ETHNICITY
GDM & AGE (YEARS)
10.4 3 1.5
3
50.7
46.3
85.1
Malay
Chinese
Indian
Others
Less than 25
Figures modified from Idris et al.
25-34
35 & above
6
ALAYSIA SCENARIO OF GDM (3

Demographic Data of Patients
with GDM
GDM & PARITY
4.5
19.4
76.1
Nulliparious
Parity 1-4
Parity 5 & above

Figure modified from Idris et al.
PATHOPHYSIOLOGY
levels of placental steroid and peptide

hormones (eg, estrogens, progesterone,
and chorionic somatomammotropin) rise
linearly throughout the second and third
trimesters.
insulin resistance increases and the

demand for increased insulin secretion with
feeding escalates progressively during
pregnancy.
Twenty-fourhour
mean
insulin levels are 8
Hospital Pakar Sultanah
Fatimah 2011
Inadequate maternal pancreatic insulin

response
fetal hyperglycemia results - manifests as
recurrent postprandial hyperglycemic
episodes.
These postprandial episodes are most
significantly accountable for the
accelerated growth exhibited by the fetus.
Reflex hyperinsulinaemia by the fetus
promoting excess nutrient storage
macrosomia
Antenatally
Identify
risk factors
Screening
Diagnosis
Monitoring
Targets
Other screening tests
10
RISK FACTORS OF GDM

BMI
>27kg/m2
Previous macrosomic baby weighing
4kg or above
Previous gestational diabetes
mellitus (GDM)
First-degree relative with diabetes
Bad obstetric history
Glycosuria at the first prenatal visit
11
Current
obstetric problems
(essential hypertension, pregnancy
induced
hypertension, polyhydramnios and
current use of steroids)
Age
above 25
Source : CPG MX of DM 4th edition
12
Screening
2-hour 75 g oral glucose tolerance test
(OGTT)
Malaysia
WHO
At least once at or more than 24

weeks
Screening at an earlier stage of
gestation depends on the degree
of
suspicion and at the
physicians/obstetricians request
Screen high-risk population
groups during the first trimester
of pregnancy in order to detect
previously undiagnosed
diabetes mellitus.
Women
Hospital Pakar Sultanah Fatimah
2011 at high risk who screen
13
Screening
2-hour 75 g oral glucose tolerance
test (OGTT) (Malaysia)
Fasting
6.1 / 5.6 (ADA) mmol/l
2 hours
7.8
mmol/l

14
Screening
ADA/WHO
ACOG
NICE
High risk women should

be screened as soon as
feasible
screen all
pregnant women
(universal
screening)
1618
weeks if prior GDM;
2428
weeks if risk factors
100 g glucose
100 g glucose
75 g glucose
(2 or more elevated)
(2 or more elevated)
1 or more elevated
Fasting
5.3
mmol/l
1-h
10.0
mmol/l
2-h,
8.6
mmol/l
(only 2 h if 75-g
glucose used)
3-h,
7.8
Fasting
5.3
mmol/l
1-h
10.0
mmol/l
2-h,
8.6
mmol/l
(only 2 h if 75-g
glucose used)
3-h,
7.8
Fasting
mmol/l
2-h
mmol/l
If normal, to repeat at
24 28 weeks
7.0
7.8
15
Frequency of Monitoring
Frequency
should be individualized
Ideal to have self blood glucose
monitoring(SBGM)
On
diet control:
pre-breakfast,1 hour PPG levels
(weekly fortnightly)
16
On insulin therapy:
premeal (breakfast, lunch, dinner)
and
pre-bed glucose levels
(weekly fortnightly).
Once premeal glucose levels are

achieved, PPG testing is
recommended for fine-tuning
of
Source : CPG MX of DM 4
insulin dose.
th
edition
17
WHO
MALAYSIA CPG
Hba1c
can be falsely altered

(increased or decreased) in
patients with
haemoglobinopathies/
recent blood loss
4-6 weekly
Fructosamine
Not an adequate substitute Reflect control in the

for HbA1c, but fulfils
past 2-3 weeks
some of the same functions.
It may be used when there
is -- coexisting haemoglobin
abnormalities falsely
affecting the level of HbA1c
(i.e. thalassemia)
- during pregnancy
for early detection of
deteriorations in glycaemic
control
18
Hba1c Vs Fructosamine
Fructosamine
(mol)
HbA1c
%
200
258
288
6.5
317
346
7.5
375
435
494
10
552
11
611
12
19
Targets
Timing
Level (mmol/l)
Pre breakfast
3.5 5.9
Pre prandial
3.5 5.9
Post prandial
< 7.8

20
The Hyperglycemia and Adverse

Pregnancy Outcome (HAPO) Study
21
Other screenings for pregnancy

with diabetes mellitus
Detail
scan at 18 20 weeks of
gestation
Regular US scan to monitor fetal
growth and amniotic fluid index
22
Definition of Diabetes and

Pregnancy
Known
case of diabetes patient if

pregnant is not known as GDM
Diabetes mellitus and pregnancy
23
Pre Conception Care

Counseling
is important
Pregnancy should be planned
Achieve good glycaemic control
before conception, aim for HbA1c
<6.5%
Insulin therapy may be necessary
before conception
24
Measures
significance
Joint clinic (obstetrician and

physician)
Better control of pre morbidities
Good glycaemic control

preconception and throughout
pregnancy
-reduces risk of complications

-Assessed by Hba1c level
( Hba1c < 6.1% reduces risk of
congenital malformation)
Avoid unplanned pregnancies
-risks associated with pregnancies

complicated by diabetes increase
with the duration of diabetes
-glycaemic targets, monitoring,
medications for diabetes and
medications for complications of
diabetes will need to be reviewed
before and during pregnancy
Source: NICE guideline 2008-DM in Pregnancy25
Measures
Significance
Role of diet, exercise, body weight -To refer dietician

-reduce weight if preconception
BMI > 27kg/m2
-medical nutrition therapy
-T.folate 5mg OD for 1st trimester
Assessment for diabetic
nephropathy
-Serum creatinine > 120 umol/l

-Total protein excretion > 2g/ day
-Estimated GFR < 45 ml/min
*to refer nephrologist
**if already pregnant, eGFR is not
used
- Thrombophylaxis needed if
excretion > 5g/day
Significance
Assessment for diabetic
retinopathy
- Preconception and
during pregnancy
-Retinopathy tends to get worsen during

pregnancy
-assessment by digital imaging with
mydriasis following first antenatal clinic
appointment and again at 28 weeks if the
first assessment is normal.
-If any diabetic retinopathy is present, an
additional retinal assessment should be
performed at 1620 weeks.
-pre proliferative diabetic retinopathy
diagnosed during pregnancy should have
ophthalmological follow-up for at least 6
months following the birth
-should not be considered a
contraindication to vaginal birth.
General management
Diet
control and lifestyle

modification for all
-Medical Nutrition Therapy
-moderate amount of exercise
If conservative mx fails to maintain
satisfactory blood sugar profile after
1-2 weeks
Insulin
commencement
-insulin needs variable
28
-average
0.8 units/kg/day first trimester
1.0 unit/kg/day second trimester
1.2 units/kg/day third trimester
s/c Humulin R tds
s/c Humulin N on
Source :http/ /bestpractice.bmj.com
29
30
ROLE OF ORAL ANTIDIABETIC

IN PREGNANCY
The
American College of
Obstetricians and Gynecologists has
not recommended these agents
during pregnancy
Glyburide/ Glibenclamide
Metformin
31
Timing of Delivery
Diet
control
allow up to EDD and then IOL
Insulin therapy
IOL at 38 weeks
If
complications anticipated---ELLSCS
32
Intrapartum
Management
On
diet control
manage as normal labour
On
insulin therapy
insulin infusion sliding scale +
dextrose/potassium maintenance
33
Investigations
4 Houly urine ketone
Hourly GM
baseline BUSE and then
NBM
Maintain
4 Hly
1 pint D5% + 1 g KCl (100
mls/H)
Insulin infusion sliding scale
34
Post Partum (maternal)

Insulin
requirement drops
immediately after delivery by 60
-75%
In breast-feeding, if glycaemic
control is inadequate with diet
therapy alone, insulin
therapy should be continued at a
lower dose.
In non-breast-feeding mothers, OAD
agents can be continued
35
GDM off insulin therapy and

then monitor GM regularly
If pre existing diabetes to continue
pre-pregnancy insulin/OAD
Repeat OGTT 6/ 52 post delivery
- DM/IFG/IGT
If
36
Post Partum (Baby)

Blood
glucose testing should be

carried out routinely in babies of
women with diabetes at 24 hours
after birth.
should
feed as soon as possible after

birth (within 30 minutes) and then at
frequent intervals (every 23 hours)
37
If
blood glucose values are below 2.0

mmol/l on two consecutive readings
despite maximal support for feeding,
if there are abnormal clinical signs or
if the baby will not feed orally
effectively, additional measures such
as tube feeding or intravenous
dextrose should be given.
38
Complications
antenatally
MOTHER
FETUS
Miscarriage
Stillbirths
Pre eclampsia
Pre term
Polyhydramnions
Prone to infections
Deterioration of
diabetic
retinopathy/nephropat
hy
Fetal malformations
Growth accelerations/
restrictions
Macrosomic baby
39
40
Complications
intrapartum
MOTHER
FETUS
Polyhydramnions
Obstructed labour
Increase risk of
operative
interventions
Macrosomic baby
birth injury
Polyhydramnions
unstable lie
abruptio placenta
during ROM
41
Complications post
partum
MOTHER
FETUS
PPH
Risk of future type 2
DM
Birth injury
Respiratory distress
syndrome
Hypoglycaemia
Hypocalcemia
Hypomagnesaemia
Polycythaemia
Hyperbilirubinaemia
Risk of metabolic
syndrome
42
REFERENCES
American Diabetes Association. 2009. Diagnosis and classification of diabetes

mellitus. Diabetes Care 32 (supplement 1):88-90.
Kulenthran, A. 2006. A practical approach to obstetric problems for the
undergraduate. Third edition. Page 87.
Ministry of Health Malaysia. Diabetes Mellitus. The Third National Health and
Morbidity Survey, 2006 (NHMS III): Executive Summary. Kuala Lumpur: Institute of
Public Health (IPH), Malaysia; 2008, p. 55-7.
Ministry of Health Malaysia. Diabetes Admission and Death by Type of Diabetes for
Malaysia. Putrajaya: Ministry of Health Malaysia; 2007, p. 18.
Chan S. Prevalence of GDM in Malaysia. ASGODIP Report: ASEAN, 7th Congress of
ASEAN Federation of Endocrine Society, 1993.
Shamsuddin K, Mahdy ZA, Rafiaah SI, Jamil MA. Risk Factor screening for abnormal
glucose tolerance in pregnancy. International Journal of Gynecology and Obstetric
2001;75:27-32.
Idris N, Che Hatikah CH, Murizah MZ, Rushdan MN. Universal versus selective
screening for detection of gestational diabetes mellitus in a Malaysian population.
Malaysian Family Physician. 2009;4(2&3):83-87.
Siti Rohana, S. 2010. Risk factors of gestational diabetes mellitus in Gombak district,
Selangor- A case-control study. Paper presented in 5 th International Case-mix
Conference Malaysia in Park Royal Hotel, Kuala Lumpur, Malaysia, December 2010.
43
NICE Clinical Guideline. Diabetes in Pregnancy March 2008

Gestational Diabetes Mellitus: NICE for the
U.S.? Diabetes Care 33:3437, 2010
44
thank you
45

Diabetes IN Pregnanc Y: Presenter: DR Leong Yuh Yang (MD Ukm) Supervisor: DR Noraza Azmeera

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DIABETES

Hospital Pakar Sultanah Fatimah 2011

GDM is defined as any degree of glucose

The definition applies regardless of whether

It does not exclude the possibility that

GDM complicates 4% of all pregnancies in the

The prevalence may range from 1 to 14% of

GDM represents nearly 90% of all pregnancies

Deterioration of glucose tolerance occurs

Diabetes prevalence had increased from 8.3%

Diabetes admission based on type of diabetes

Hospital Pakar Sultanah Fatimah 2011

ALAYSIA SCENARIO OF GDM (2

GDM & AGE (YEARS)

Figures modified from Idris et al.

ALAYSIA SCENARIO OF GDM (3

Parity 5 & above

levels of placental steroid and peptide

insulin resistance increases and the

Inadequate maternal pancreatic insulin

Hospital Pakar Sultanah Fatimah 2011

Hospital Pakar Sultanah Fatimah 2011

RISK FACTORS OF GDM

At least once at or more than 24

6.1 / 5.6 (ADA) mmol/l

Source : CPG MX of DM 4th edition

High risk women should

Hospital Pakar Sultanah Fatimah 2011

Once premeal glucose levels are

can be falsely altered

Not an adequate substitute Reflect control in the

Source : CPG MX of DM 4th edition

The Hyperglycemia and Adverse

Hospital Pakar Sultanah Fatimah 2011

Other screenings for pregnancy

Hospital Pakar Sultanah Fatimah 2011

Definition of Diabetes and

case of diabetes patient if

Hospital Pakar Sultanah Fatimah 2011

Pre Conception Care

Hospital Pakar Sultanah Fatimah 2011

Joint clinic (obstetrician and

Better control of pre morbidities

Good glycaemic control

-reduces risk of complications

Avoid unplanned pregnancies

-risks associated with pregnancies

Source: NICE guideline 2008-DM in Pregnancy25

Role of diet, exercise, body weight -To refer dietician

-Serum creatinine > 120 umol/l

Source: NICE guideline 2008-DM in Pregnancy26

-Retinopathy tends to get worsen during

control and lifestyle

Hospital Pakar Sultanah Fatimah 2011

ROLE OF ORAL ANTIDIABETIC

Hospital Pakar Sultanah Fatimah 2011

Hospital Pakar Sultanah Fatimah 2011

Hospital Pakar Sultanah Fatimah 2011

1 pint D5% + 1 g KCl (100

Post Partum (maternal)

GDM off insulin therapy and

Hospital Pakar Sultanah Fatimah 2011

Post Partum (Baby)