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The most critical period for the embryo
organogenesis, which occurs in the first 42 days of pregnancy,
The level of HbA1c in early pregnancy also correlates with the risk of early fetal loss.
HbA1c of >85 mmol/mol [9.9] is associated with a fetal loss during pregnancy of around 30%
Targets for therapy pre-pregnancy are premeal glucose levels of
4-6 mmol/l. 72-106mg/dl
Maternal and fetal complications of types 1 and 2 DM
1. Congenital abnormality
2. structural malformations, fetal macrosomia
4. increased incidence of infection, severe hyperglycaemia or hypoglycaemia, diabetic ketoacidosis
5. The risk of preeclampsia is increased 3X
6. early term delivery -> in NU addmission and dec breast feeding
It is seen 2-4 times more often than in pregnancies without diabetes with a threefold excess of cardiac and neural tube defects.
Congenital abnormality is an important cause of mortality and morbidity in diabetic pregnancies
Accelerated growth patterns are typically seen in the ____________________________ and are attributable to poorly controlled diabetes in the majority of cases.
late second and third trimesters
___________________, particularly in the third trimester, remains too common in pregnancies complicated by maternal diabetes, being five times higher than in the general population.
All women with diabetes should be offered __________________ from ______________ to reduce the risk of preeclampsia.
12 weeks' gestation
Management of types 1 and 2 diabetes in pregnancy(anti-natal plan )
1. Blood glucose monitoring is encouraged 7 times a day (before and 2 hour after meals) with targets of 4-6 mmol/l [72-106mg/dl]and 2-hour postprandial levels of <6-8 mmol/l [106-145]
2. oral hypoglycemic
3. insulin resitance inc --> inc dose during 2nd half of pregnancy.
4. plan for pregnancy: renal and retinal screeing, fatal surveillance, plan for delivery
5. fetal anamoly scan 18-21 w assessement of cardiac outflow tract
6. serial growth scan
7. anetanal corticosteriod + insulin therapy
timing and mode of delivery - DMT1+2 in pregnancy
- pregnancy has gone well --> achieve a vaginal delivery at between 38 and 39 weeks.
- development of macrosomia or maternal complications such as pre-eclampsia, together with the rate of failed induction, is such that the caesarean section rate amongst diabetic women often is as high as 50%.
Effects of pregnancy on diabetes
1. Nausea and vomiting, particularly in early pregnancy.
2. Greater importance of tight glucose control.
3. Increase in insulin dose requirements in the second half of pregnancy.
4. Increased risk of severe hypoglycaemia.
5. Risk of deterioration of pre-existing retinopathy.
6. Risk of deterioration of established nephropathy.
Effects of diabetes on pregnancy
1. Increased risk of miscarriage.
2. Risk of congenital malformation.
3. Risk of macrosomia.
4. Increased risk of pre-eclampsia.
5. Increased risk of stillbirth.
6. Increased risk of infection.
7. Increased operative delivery rate.
"gestational diabetes" has been defined as
onset or first recognition of abnormal glucose tolerance during pregnancy
Pregnancy is accompanied by insulin resistance
Due to placental secretion of diabetogenic hormones including
- growth hormone,
- corticotropin-releasing hormone,
- placental lactogen prolactin (Insulin antagonists).
Pregnancy is an insulin resistance condition, with changes exacerbated in
the 3rd trimester
The WHO guidelines (2013) recommend a diagnosis with a
fasting glucose of ?
a 1 hour (post 75 g glucose load) of ?
2 hour of ?
- 5.1 mmol/l 
- 10.0 mmol/l 
- 10.0 mmol/l 
Women are educated regarding the risks and are encouraged to maintain capillary blood (fingerprick) glucose levels
??? before meals and
postprandial levels ??? 2 hour after meals.
Screening with a fasting glucose / HbA1c should be offered
6-13 weeks after childbirth.
Factors associated with poor pregnancy outcome in diabetes
- Maternal social deprivation.
- No folic acid intake pre-pregnancy.
- Suboptimal approach of the woman to managing her diabetes.
- Suboptimal preconception care.
- Suboptimal glycemic control at any stage.
- Suboptimal maternity care during pregnancy.
- Suboptimal fetal surveillance of big babies.
Several adverse outcomes have been associated with gestational diabetes mellitus
Preeclampsia, gestational hypertension
Macrosomia and large for gestational age infant
Maternal and infant birth trauma
Operative delivery (cesarean, instrumental)
Fetal/neonatal hypertrophic cardiomyopathy
Neonatal respiratory problems and metabolic complications (hypoglycemia, hyperbilirubinemia, hypocalcemia, polycythemia)
Pregnant women with any of the following characteristics appear to be at increased risk of developing gestational diabetes mellitus; the risk increases when multiple risk factors are present
1. personal hx
2. family history
3. hipanic, AA, native american, asian
4. old maternal age
5. previous birth infant >4000, 4500
6. multiple gestation
7. prepreganncy BMI> 30
most widely used approach for identifying pregnant women with GDM
The two-step approach
The two-step approach
The first step is a 50-gram one-hour glucose challenge test (GCT) without regard to time of day/previous meals.
Screen-positive patients go on to the second step, a 100-gram, three-hour oral glucose tolerance test (GTT), which is the diagnostic test for gestational diabetes mellitus
The one-step approach omits the screening test and simplifies diagnostic testing by performing only a
75-gram, two-hour oral GTT but requires an overnight fast.
Timing of screening/testing
While there are no proven benefits to screening/testing for diabetes in early pregnancy, testing can be performed as early as the first prenatal visit if there is a high degree of suspicion that the pregnant woman has undiagnosed type 2 diabetes
History of gestational diabetes mellitus have a 48 % RR.
In the absence of early testing or if early testing is negative, universal screening is performed at 24 to 28 weeks of gestation
In the absence of early testing or if early testing is negative, universal screening is performed at
24 to 28 weeks of gestation
The diagnosis of gestational diabetes mellitus is based on results of an
If a 75-gram two-hour GTT is planned and the fasting glucose level is ≥92 mg/dL (5.6 mmol/L), then the diagnosis of gestational diabetes mellitus is made and the GTT is cancelled
Criteria for a positive two-hour 75-gram oral glucose tolerance test for the diagnosis of gestational diabetes
Two-hour 75-gram oral glucose tolerance test
Fasting ≥92 mg/dL (5.6 mmol/L)
One hour ≥180 mg/dL (10.0 mmol/L)
Two hour ≥153 mg/dL (8.5 mmol/mol)
The diagnosis of gestational diabetes is made at _________________________ when one or more plasma glucose values meets or exceeds the above values.
24 to 28 weeks of gestation
CONSEQUENCES OF GDM -short term
- still birth
CONSEQUENCES OF GDM -longterm
GDM may affect the offspring's risk of developing
impaired glucose tolerance
approach to women on insulin or oral anti-hyperglycemic drugs or with poor glycemic control
twice weekly CTG plus an amniotic fluid index beginning at 32 weeks of gestation in women who need insulin or an oral antihyperglycemic agent to achieve good glycemic control,
in all women with poor glycemic control ,we generally recommends that These women typically undergo periodic antenatal testing, usually initiated at approximately 32 weeks of gestation.
pregnancies of women who remain euglycemic with nutritional therapy and exercise alone these patients
should not be electively delivered prior to 39 weeks of gestation Timing of induction between 39+0 and 41+0 weeks is more controversial.
women with GDM whose glucose levels are medically managed with insulin or oral agents we recommend
induction of labor at 39 weeks of gestation .
with GDM and estimated fetal weight ≥4500 grams.
Scheduled cesarean delivery
1. periodic assessment of maternal glucose levels
2. Insulin requirements usually decrease during labor,
3. check blood glucose measurements every two hours during labor
Women with GDM who were euglycemic without use of insulin or oral antihyperglycemic drugs during pregnancy
do not normally require insulin during labor and delivery, and thus do not need their blood glucose levels checked hourly.
Women with GDM who used insulin or oral antihyperglycemic drugs to maintain euglycemia
occasionally need insulin during labor and delivery to maintain euglycemia. The Endocrine Society suggests target glucose levels of 72 to 126 mg/dL (4.0 to 7.0 mmol/L)
For women undergoing scheduled cesarean delivery:
insulin or antihyperglycemic drugs are withheld the morning of surgery and the woman is not allowed any oral intake after midnight.
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