Diabetes in Pregnancy😊

Diabetes in Pregnancy

Smoking protective for

• PIH

• UC

String Sign:

• TB

• CHPS

• Crohns Disease

Indications of Aspirin:

• APLA

• Past h/o PIH/chronic Hytn

• Multifetal pregnancy

• Overt DM

• CKD

Pregestational Diabetes

• Also known as Priscilla White: Type non-A diabetes

• Blood sugar levels raised from day 1 of pregnancy

• Hyperglycemia is fetotoxic

• Leads to congenital malformation

• Doesn't resolve after delivery

• Diagnosis:
• FBS: ≥126 mg/dL
• RBS: ≥200 mg/dL
• 2-hour PP: ≥200 mg/dL
• HbA1C: ≥6.5%

Gestational Diabetes

• Also known as Priscilla White: Type A diabetes

• Non-diabetic female conceives but becomes diabetic during pregnancy due to insulin resistance
• Insulin resistance is due to Human Placental Lactogen
• increases as pregnancy advances

• Develops between 24 and 28 weeks (Organogenesis is complete)
• Doesn't lead to congenital malformation

• Type A diabetes can be:
• A1: Gestational diabetes controlled by diet
• A2: Gestational diabetes controlled on insulin or OHA

DIPSI guidelines

In India:

• Test:
• 1st antenatal visit
• repeat at 24-28 weeks

• Fasting: Not required

OGTT Procedure:

• Give 75 g of glucose in 300 mL of water irrespective of previous meals

• To be drunk in 5 minutes

• Result:

2-hour OGTT	Interpretation
< 140 mg/dL	Repeat test at 24-28 weeks
≥ 140 mg/dL	Gestational diabetes
≥ 200 mg/dL	Pregestational / Overt diabetes

• Important points:
• Minimum time gap between 2 tests:
• 4 weeks
• If patient comes for first time after 28 weeks:
• Test only once

IADPSG/ADA Criteria for Gestational Diabetes:

• Test done: Between 24-28 weeks of pregnancy.

• Procedure:
• 8 hours of fasting needed.
• Fasting Blood Sugar (FBS) taken.
• 75g of oral glucose in water administered.
• Blood levels checked after 1 hour and 2 hours

• Diagnosis:
• If ≥ 1 value is abnormal, GDM is diagnosed.

Congenital Malformation in Diabetes

 

• m/c system involved: CVS > CNS

• Hairy Pinna

• m/c congenital malformation:
• VSD > neural tube defect (NTD)

• Most specific:
• Sacral agenesis/
• Caudal regression syndrome
• Most severe → Sirenomelia

• m/c CVS anomaly: VSD

• Most specific CVS anomaly (does not resolve after delivery):
• Transposition of Great Arteries (TGA)

• m/c CVS finding or lesion (reversible after delivery):
• Hypertrophic Cardiomyopathy (HCM)

Ix :

• Risk Predictor : HbA1c.
• <6.5% No additional risk.
• ≥6.5% ↑Risk.

• Screening : Level 1 USG.

• IOC to detect gross congenital anomalies : Level 2 USG.

Note : 

• Gestational diabetes → Congenital malformations absent.

Antenatal Care in Diabetics

National Guidelines

1. For congenital malformation in pregestational diabetes:
• Do HbA1c (risk assessment tool):
• If HbA1c <6.5%: No risk
• If HbA1c ≥10%: 15-20% risk
• Screening of congenital malformation: Level 1 USG
• IOC: Level 2 scan/Target/anomaly scan at 18-20 weeks
• Fetal echo: 22-24 weeks (to be done)

2. Target scan also done in GDM patients:
• Fetal echo not done

3. In both GDM + pregestational diabetes:
• Do 2 growth scans:
• 28-30 weeks
• 34-36 weeks
• (To estimate macrosomia and amniotic fluid)

4. Number of antenatal visits:
• Well controlled GDM/no complications:
• Routine antenatal visits
• Not well controlled GDM/complication seen:
• 1st trimester: Every 2 weeks
• 2nd trimester: Every week

5. Urine R/M and urine culture to be done in: 
• each trimester

6. Begin fetal monitoring at 32 weeks in high-risk pregnancy:
• DFMC (Daily fetal movement count)
• NST and BPS (Biophysical score): Weekly
• No need for umbilical artery doppler unless PIH is present
• Growth scan: Every 3 weeks

Obstetric Management

Gestational diabetes:

• Termination of pregnancy
• Well controlled:
• 39 weeks
• On diet
• On insulin
• Pregestational diabetis
• Type A: Not controlled:
• 37 weeks

Metabolic Goals in Diabetes

• FBS: <95 mg/dL

• 1-hour PP: 140 mg/dL

• 2-hour PP: 120 mg/dL

• HbA1c: <6%

• Average capillary glucose: <100

Insulin

• DOC for diabetes in pregnancy

• Route: Subcutaneous

• m/c used: Human premix insulin

• Vial: 40 IU/mL

• Maximum times syringe can be used: 14 times

• Stored at 4°-8°C (in fridge)

• Mnemonic: 4 degree, 40 IU, 14 times

Medical Nutrition Therapy (MNT)

• Advised to all pregestational and GDM patients

• Carbohydrate: 40%

• Fat: 40% (Saturated fat <10%)

• Protein: 20%

• Give medical nutrition therapy (Diet modification) alone for 2 weeks

• After 2 weeks, check 2-hour PP value:

Simplified Clinical Approach

Management of Pregestational Diabetes

• Patient management:
• Initiate insulin.
• Stop Oral Hypoglycemic Agents (OHA).
• Start medical nutrition therapy.
• Administer aspirin to prevent preeclampsia.

• OHA in pregnancy:
• If a patient refuses insulin, metformin/glyburide may be given in GDM
• OHAs are C/I in pregestational diabetes.

Complications of Diabetes

Fetal Hyperglycemia:

• (Fetal pancreas) Secrete Insulin → ↑ Growth (No role of GTT) → Macrosomia → ↑ Shoulder dystocia.

• Increased chances of abortion, Intrauterine Fetal Demise (IUFD), stillbirth.

• If patient has vascular disease or diabetes mellitus + PIH, they may have Oligohydramnios/ Intrauterine Growth Restriction (IUGR).

Maternal

• Increased risk of
• Asymptomatic bacteriuria.
• Candidiasis.

• Polyhydramnios
• d/t Placentomegaly
• in both GDM & DM
• Polyhydramnios can cause:
• Postpartum Hemorrhage (PPH).
• Abruptio placenta.
• Preterm Rupture of Membranes (PROM).
• Preterm Labor (PTL).
• Cord prolapse.
• Malpresentation.

• Risk of developing diabetes in future:
• 30-50%.

Neonatal (Increased insulin in neonates)

• Neonatal hypoglycemia.
• PENDERSON HYPOTHESIS → Overproduction of insulin by fetal pancreas

• Hypocalcemia.

• Hypokalemia.

• Hypomagnesemia.

• Respiratory distress syndrome.

• Necrotizing enterocolitis.

• Hyperviscosity syndrome and polycythemia/hyperbilirubinemia.

• Note: Never seen in babies of diabetic mothers.
• Anemia.
• Mental retardation.

Macrosomia

• Weight of fetus: ≥4 kg

• Risk factors:
• Post-term pregnancy
• Diabetic mother
• Male fetus
• Maternal obesity

• Management:
• Diagnostics: AC ≥35 cm on USG
• Mode of delivery: Vaginal
• Indications of C-section:
• Diabetic female with fetal weight ≥4.5 kg
• Non-diabetic female with fetal weight ≥5 kg
• H/o C-section: Relative C/I for VBAC

Post-term pregnancy

• Wrong dates
• Inaccurate LMP
• Most common cause

• Heredity

• Previous prolonged pregnancy

• Anencephaly

• Placental sulphatase deficiency
• Leads to ↓ estrogen synthesis

• Primipara / elderly multipara

Features

• Skin changes
• Wrinkled
• Patchy
• Peeling
• More on palms and soles

• Body habitus
• Long
• Thin
• Suggests wasting

• Long nails

• Eyes
• Open
• Unusually alert

• Facial appearance
• Looks old
• Worried appearance

Antenatal Fetal Monitoring

• Indications
• All high-risk pregnancies (begin at 32 weeks)
• Pregnant patients with contractions and/or decreased fetal movement

• Methods
• Screening tests:
• Non-Stress Test (NST) > modified BPS (Amniotic Fluid Index + NST)
• Diagnostic test:
• Biophysical Profile (BPS) / Manning Score

• Fetal Movements
• Cardiff count of 10
• While at rest: 10 FMs in 2 hours
• In activity: 10 FMs in 12 hours
• Maximum fetal movements: Seen at 34 weeks
• Quickening:
• Primigravida: 18-20 weeks
• Multigravida: 16-18 weeks

Non Stress Test (NST)

Normal/Reactive NST:

• Fetal heart rate (FHR): 110-160 bpm

• FHR variability: 5-25 bpm

• Accelerations:
• Increase in FHR by 15 bpm x 15 seconds with fetal movement (good sign)
• In 30-32 weeks: FHR increased by 10 bpm x 10 seconds.
• Reactive NST: ≥2 accelerations in a period of 20 mins.

Non Reactive/Positive NST:

• If acceleration <2 (in 20 mins):
• Repeat NST (For 20 more minutes).
• If <2 accelerations (Non reactive NST):
• BPS (Diagnostic)

• NST Interpretation:

Intrapartum Fetal Monitoring
(Cardiotocography (CTG))

Characteristics of Normal/Category I CTG:

• FHR: 110-160 bpm

• Variability: 5-25 bpm

• Acceleration: Presence (+)

• Deceleration: Dip in FHR by 15 bpm for 15 seconds (max: 2 mins)
• Early: +/-
• Late: Should be -
• Variable: Should be -

NOTE

Types of Deceleration (Dips in FHR with uterine contractions):

Mnemonic:

• Early varunnath → Head → Head compression

• Late varunnath → Placenta (UPI)

• Variable fall off → Cord

• Note:
• An increase in FHR and a decrease in uterine contraction is observed for the 'prolonged deceleration' type.

Category 3 CTG Findings

1. Sinusoidal heart wave pattern

2. Absent variability with any of the following:
• Persistent bradycardia.
• Persistent late deceleration.
• Persistent variable deceleration
• (Only indication for amnioinfusion).

• Management: 
• In utero resuscitation + Immediate C-section.

Parameters having worst prognosis:

• Sinusoidal heart wave pattern > late deceleration > variable deceleration.

Sinusoidal heart wave pattern:

• Constant FHR/

• No variability/

• sine wave pattern.

• Bad prognosis.

• Seen in fetal anemia, fetal hypoxia.

• Mnemonic: Sinusoidal → Sign of anemia and hypoxia

Steps for In-utero resuscitation:

• Lie in left lateral position.

• Stop oxytocin -> Start O2, IV fluids.

• If FHR not normalizing -> Give tocolytics.

note

• If no acceleration for over 20 mins → Observe for another 20 mins

BPS (Biophysical Profile)/Manning Score

• Done with help of USG over 30 minutes.

Component	Score of a given when
Fetal Tone	≥1 episode of extension/flexion
Fetal Breathing	≥1 chest wall movement for ≥30 seconds
Gross Body Movement	≥3 body movements
Amniotic Fluid Volume (AFV)	Single deepest pocket ≥2 cm
NST	Reactive

BPS Scoring and Management

• BPS Interpretation:
• Score of 8 or 10: Associated with normal (N) pH of fetus.
• Score of 0, 2, 4: Associated with fetal acidemia.
• Score of 6: Equivocal.

• Scoring and Management Table:

Score	Management
10/10 or 8/10 with AFV: (N)	Fetus: N repeat BPS weekly
6/10 with AFV: (N)	Equivocal
ㅤ	≥37 weeks: Deliver
ㅤ	<37 weeks: Repeat test in 24 hours
Score 4/10	Deliver ≥32 weeks
Score 2/10 or 0/10	Immediate delivery
8/10 or 6/10 with AFV: ↓	Deliver ≥36 weeks (Chronic asphyxia suspected)

• BPS at 30 weeks
• 10/10 → N
• 6/10 → wait 6 weeks (36, 37 weeks)
• 4/10 → wait 2-4 weeks (32 weeks)
• 2 or 0 → Immediate

• Note:
• Acceleration -> Healthy fetus
• Deceleration -> Compromised fetus
• Order of disappearance: Breath → Movement → Tone
• All except Fluid volume indicate acute fetal asphyxia and acidemia

Modified BPP

• AFI + NST

Fetal Breathing Movements

• Definition:
• Chest movements seen on antenatal USG;
• part of Biophysical Profile.

• Importance:
• Aids respiratory system development.
• Helps nervous system maturation.
• Prepares fetus for breathing after birth.

• Not involved in oxygenation