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PREGNANCY AND DIABETES

Diabetes in pregnancy falls into two main categories :

a) Pregnancy in a woman with known NIDDM.

b) Gestational diabetes, which is defined as carbohydrate intolerance of variable severity with its onset, or first recognition, during pregnancy.

GENERAL ASPECTS

  • Diabetes in pregnancy has associations with acute, as well as chronic maternal and fetal complications.

  • With OPTIMAL diabetic control PRIOR TO, AND DURING PREGNANCY, complication rates approach those seen in normal pregnancies.

  • Good diabetic control throughout pregnancy as well as improved neonatal management has lead to a reduction in the incidence of, and the morbidity associated with, conditions characteristically associated with pregnancy in a diabetic women, such as macrosomia, neonatal hypoglycemia, hypocalcemia and renal vein thrombosis.

  • But, good control established only after conception does NOT lead to a decrease in the incidence of spontaneous abortions caused by significant congenital anomalies, or babies born with these anomalies.

  • Spontaneous abortions and babies born with congenital anomalies are seen much less often when good diabetic control has been established PRIOR to conception, and maintained during the first 6-8 weeks of pregnancy.

  • Organogenesis in the fetus takes place within 6 weeks after conception (around 8 weeks after the last menstrual period).

  • Thus, optimal control in the first 6-8 weeks after conception is essential to reduce the risk for congenital malformations. Since most women do not come to medical attention before 2-3 months after conception, women known to be diabetic MUST be tightly controlled prior to conception.

PREGNANCY IN A WOMAN WITH KNOWN NIDDM

  • Pregnancy in all women with known NIDDM must be "PLANNED"!

    Pre-Pregnancy Management

  • Diabetic women of child bearing age, and desirous of pregnancy, must be thoroughly conselled.

  • This counselling must include intensive education about the need for a "tight" control prior to, and during, pregnancy; diet management; insulin injection techniques, methods of self monitoring the blood glucose levels, and the need for a close and regular follow-up.

  • Oral agents must be discontinued and the woman managed with diet and insulin, preferably, human insulins.

  • Target blood glucose values should be 60-90mg% in the fasting state and around 100-200mg% in the 2 hour postprandial state; blood glucose values at all times should be within 6-0120mg%.

  • Glycosylated Hemoglobin and serum fructosamine (if available) levels should be well within the "normal" range.

  • If the control is not within this target range, pregnancy should be postponed until these target values are maintained.

  • All NIDDM women planning a pregnancy must be have a thorough evaluation for the presence of retinopathy and nephropathy.

    Management During Pregnancy

  • Maintain diabetic control at target values at all times.

  • The diet should be 35-40 calories per Kg ideal body weight. Basically, this is her routine diabetic diet plus 500 calories; it is a fallacy that pregnancy requires a diet for two! The diet will need to be tailored to suit the individual patient and adjustments will be required for women who cannot take their prescribed diet due to intense nausea and vomiting.

  • If the patient is not controlled with diet alone, she will require insulin therapy. Most women will require intensive insulin regimens.

  • The control should be monitored by SMBG done three to four times daily and insulin doses adjusted to maintain target levels; Glycosylated hemoglobin estimations should be done every 6-8 weeks.

  • Avoid hypoglycemia.

  • Close antenatal surveillance of the mother and fetus allows most pregnancies to proceed to full term.

    Management During Labour

  • The mode of delivery can be natural, and intervention (induction or Caeserean section) may only be needed for obstetric reasons in most instances.

  • Tight control of maternal glycemia is essential throughout labour.

SPECIAL ASPECT

Hypoglycemia In The Newborn

  • All infants of mothers with NIDDM must have check for blood glucose levels within 30-60 minutes of birth and continued at regular intervals until one is sure that there is not risk for hypoglycemia.

  • Neonatal hypoglycemia is defined as blood glucose levels less than 40mg% in full term infants and less than 30% in premature babies.

  • If the Hemostix readings are between 25 and 45mg%, give gastric or oral feedings of 10-15 ml of 10% glucose, repeated if necessary, and start feeds as soon as possible; if hemostix levels are less than 25mg%, i.v. 10% Dextrose at the rate of 6 mg/kg/minute is started. Bolus doses are to be avoided as this may stimulate the already overactive pancreas to secrete more insulin and add to the problem.

    • GESTATIONAL DIABETES

  • Gestational Diabetes Mellitus (GDM) is defined as carbohydrates intolerance of variable severity with onset, or first recognition, during pregnancy. GDM is associated with a significant increase in stillbirths, macrosomia related morbidity and neonatal hypoglycemia.

    • All pregnant women must undergo testing to rule out gdm
    The Diagnosis of GDM

  • The timing of the test for the diagnosis of GDM is usually in the 24-28 week of pregnancy. Many feel that the test should be carried our as soon as pregnancy is diagnosed, and at the beginning of every trimester; this is especially true for women through to be at high risk.

    Women at high risk
    Maternal FeaturesPerinatal Features
    Family history of diabetes; H/O stillbirth;
    Obesity;H/O congenital
    anomalies; Age over 30;
    Macrosomia, present or before;
    Glycosuria; Hydramnios,
    present or before;
    Random BG > 120 mg%;

    • Management of GDM

  • A diabetic diet of 35-40 calories per Kg pre-pregnancy ideal body weight is usually prescribed; strict calory restriction is not advisable during pregnancy; further adjustments in the number of calories should be done in consultation with the obstetrician keeping in mind the target weight gain aimed for during the pregnancy.

  • Frequent monitoring of the blood glucose levels should be carried out; if the patient cannot carry out SMBG, the blood glucose levels should be estimated atleast 2-3 times weekly.

  • The aim should be to keep the average blood glucose levels between 60 and 110mg%; Fasting blood glucose levels should be between 60-90mg% and the 2 hour post prandial blood glucose levels should be between 100-120mg%; Glycosylated hemoglobin and serum fructosamine (if available) levels should be well within normal limits.

  • If the fasting blood glucose levels are more than 90mg%, or 2 hour postprandial blood glucose more than 120mg%, the frequency of monitoring should be increased to 2-3 times daily.

  • If target values are not met, early initiation of insulin therapy is essential; this is especially so in women who are at high risk.

  • The insulin regimens are usually intensive regimens.

  • The further management of diabetes during pregnancy, maternal and fetal surveillance, timing, mode and management during labour is the similar to that described for women with known TypeII diabetes.

    With optimal management prior to, and through-out pregnancy, women with niddm can have a pregnancy in which the complication rates approach those associated with a "normal" pregnancy !


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