Hyperglycemias of
pregnancy
Awareness prevents catastrophe
Early Intervention prevents complications
Chairperson For
Session
Prof. Maj. Gen. H. R. Harun
Principal
Holy Family Red Crescent Medical College
Scenario-1
PREPARATIONS FOR AN UNPREPARED DIABETIC
CASE FOR
DELIVERY
DEPARTMENT OF ENDOCRINOLOGY
HOLY FAMILY RED CRESCENT MEDICAL COLLEGE HOSPITAL
PRESENTED BY-
DR. Bushra Mustaque
INTERN DOCTOR
HFRCMCH
Particulars of the Patient
• Name- Mrs. Ayesha Begum
• Age – 30 years
• Religion- Islam
• Occupation- Housewife
• Address – Shirajgonj
• Bed no- GW- 2/14
• Date of admission- 7/9/19
• Date of examination- 7/9/19 @10.00 am
Chief Complaints
• Amenorrhoea for 37 weeks.
History of Present Illness
. According to the statement of the patient, she
was regularly menstruating lady 37 weeks
back. Then she developed amenorrhoea. It
was her planned pregnancy. Her pregnancy
was diagnosed by Urine for pregnancy test
and confirmed by early ultrasonogram. She
was irregular in antenatal check up. Her
pregnancy period was uneventful till 37
weeks. Her bowel and bladder habit was
normal. She was normotensive, non diabetic
and non asthamatic.
History of Past Illness:
•Nothing significant.
Family History:
•Nothing significant.
Immunization history:
•The patient was duly immunized.
•Roxadex given
•TT not given
Drug History:
•Calbo-D
•Ipec plus.
Socioeconomic History:
•The patient belongs to middle class family.
Obstetric History:
•Married for: 13 years
•Gravida: 3rd
•Para: 2 C/S ( 1 death after 2 days & 1 alive)
•ALC: 10 years
Menstrual History:
•Age of menarche: 13 years
•Menstrual cycle: Regular
•Menstrual period: 4-5days
•Menstrual flow: Average
•Dysmenorrhoea: +
•LMP: 25.12.2018
•EDD: 02.10.2019
General Examination
• Appearance –Good.
• Built – Average
• Co-operation – Co-operative,
• Decubitus – on choice.
• Anaemia – Mild (+)
• Jaundice
• Cyanosis
• Clubbing Absent
• Koilonychia
• Leuconychia
• Oedema -
• Dehydration -
• Lymph nodes - Not enlarged
• Thyroid -
General Examination
• Respiration – 14 breaths / min.
• Temperature – 98°F
• Pulse - 80 b / min.
• Blood pressure – 120 / 80 mm Hg
Per Abdominal Examination
• Inspection: Abdomen was uniformly enlarged, umbilicus is
centrally placed and everted.
Stria gravidarum and Linea Nigra: Present
Scar mark from previous caesarian section present on lower
abdomen.
• Palpation:
• Local tempearture: Normal
• Tenderness: Absent
• Height of uterus: 37 weeks size.
• SFH: 37 cm
• Abdominal girth: 95cm
Per Abdominal Examination
• Fundal Grip: Broad, soft, irregular structure that seems to
be foetal buttock.
• Left lateral Grip: Smooth, Curved, Structure that seems to
be foetal back.
• Right Lateral Grip: small knob like irregular parts that seem
to be foetal limb.
• 1st pelvic grip: smooth hard globular structure that seems
to be foetal head.
• 2nd pelvic grip: Head is not engaged.
Auscultation: FHS is 140 beats/minute.
Audible in left spino umbilical line.
Per Vaginal Examination: (Not Done)
Other Systems Examinations
• Cardiovascular System
• Gastrointestinal System NAD
• Respiratory System
• Locomotor System
• Nervous System
Salient Feature
Mrs. Ayesha Begum a 30 years old house wife, 3 rd
gravida with P/H/O 2 C/S hailing from Shirajgonj
was admitted to the hospital with the complaints of
amenorrhoea for 37 weeks.
According to the statement of the patient, she was
normally menstruating lady 37 weeks back. Then
she developed amenorrhoea. It was her planed
pregnancy. Her pregnancy was diagnose by urine
for pregnancy test and confirmed by early
ultrasonogram. She was Under irregular antenatal
check up. Her pregnancy period was uneventful till
37 weeks.
With the above complaints she was admitted to
this hospital for further treatment. Her bowel
and bladder habit was normal. She was
normotensive, non diabetic, non asthmatic. Her
past medical history, family history, personal
history, reveals nothing contributory. She comes
from a middle class family.
On general examination she was normal looking
lady with average built and nutrition. She was
mildly anaemic. Her pulse was 80 beats/ minute
which was regular in rhythm and normal in
volume. Her Blood pressure was 120/80 mmHg.
On abdominal examination abdomen was
uniformly enlarged. Umbilicus was centrally
placed and everted.
On palpation abdomen was non-tender,
temperature was normal, SFH 37 cm, abdominal
girth was 95 cm. There was a single foetus, in
longitudinal lie and cephalic presentation. Head
was not engaged. Liquor volume was clinically
adequate. Foetal heart sound was 140
beats/min , audible in left spino umbilical line.
Foetal movement was present.
Others systemic examination reveals normal.
PROVISIONAL DIAGNOSIS
A case of 3rd gravida with 37 weeks of
pregnancy with mild anaemia.
Hematological
report on
28/8/2019
Hb-9.6 g/dL
Biochemical report
on 28/8/2019
RBS- 8 mmol/L
Investigations
• USG of pregnancy profile
• USG of biophysical profile
• FBS
• 2HABF
• 2HAL
• 2HAD
• TSH
• HbA1C
– Patient refused
• Urine R/M/E
USG for
pregnancy
profile and
biophysical
profile On
7/9/2019
Date FBS (mmol/L) 2HABF 2HAL (mmol/L) 2HAD (mmol/L)
(mmol/L)
8/9/19 6.0 5.2 12.4 11.2
9/9/19
6.6 7.9 9.2 7.5
10/9/19 4.8 - 11.0 7.9
11/9/19 4.6 8.3 7.2 6.1
12/9/19 3.7 6.7 9.3 8.3
13/9/19 5.2 8.2 7.2 -
14/9/19 5.2 7.7 7.8 6.7
15/9/19 3.9 7.1 7.9 7.2
16/9/19 4.2 5.9 6.6 -
FINAL DIAGNOSIS
A case of 3 rd
RECURRENT gravida with 37 weeks of
SPONTANEOUS
pregnancy with mild
HYPOGLYCAEMIA DUEanaemia with
TO SECONDARY
GDM.
ADRENO-CORTICAL INSUFFICI
• Treatment
She was on 2200 Cal diet which was according to her BMI and
was sufficient for her Pregnancy.
Inj Maxsulin R 40
4+4+4 (S/C ½
hrA/C)
-Elective LUCS was done
on 17/9/19 and
female baby was
delivered.
-Weight- 2.6 kg
-APGAR 8/9
-Baby was not
hypoglycemic.
• Baby had upper right
cleft lip and cleft palate.
Baby had no cardiac
anomaly and no CNS
defect detected.
• Mother’s blood sugar
became normal after
delivery . So the insulin
was withdrawn.
• 20/9/19-
FBS- 4.1 mmol/L
2HABF- 6.1 mmol/L
2HAL- 6.6 mmol/L
Hyperglycemias of
pregnancy
Awareness prevents catastrophe
Early Intervention prevents complications
Gestational Diabetes Mellitus
• Any degree of glucose intolerance with onset
or detection for the first time during
pregnancy is called GDM.
• Placental hormones are responsible for the
development of GDM
Epidemiology
• The prevalence of GDM in low-risk populations ranges from
1.4% to 2.8%; in high-risk populations, prevalence ranges from
3.3% to 6.1%
• Abnormal maternal glucose regulation occurs in 3-10% of
pregnancy.
• Prevalence is different among different races and population.
– Compared to European women, prevalence of gestational diabetes has
increased eleven fold in women from the Indian subcontinent .
– The prevalence of GDM in urban Bangladeshi population is about 7.5%.
• DOUBLES the risk of serious injury at birth, TRIPLES the
likelihood of caesarean delivery and QUADRUPLES the
incidence of newborn intensive care unit admission
([Link], June 2000 , Vol 3, Number 6)
Risk Factors of GDM
• History of GDM
• History of unexplained foetal loss or malformation;
delivery of baby >9 lbs
• Maternal age ≥25 yrs
• BMI >25 kg/m2
• Excessive weight gain during pregnancy
• Ethnic group ( East Asian, Pacific Island ancestry)
• General risk factors of T2DM also potentiate the risk of
GDM, eg.
– Pre-diabetes,
– over weight/ obesity,
– positive family history of DM,
– Sedentary lifestyle.
Screening for GDM
• In all pregnancies
– Screening at 24 – 28 weeks of pregnancy
• If there is one or more risk factors for diabetes
may necessitate earlier screening
– 1st prenatal visit
– Some prefer to screen all pregnancies in this
period.
Screening Approaches for Hyperglycemia of
Pregnancy
Screening approaches for hyperglycemia of pregnancy
FPG 5.1 – <7.0 mmol/L GDM
≥7.0 mmol/L Overt DM
1 hr PG (75gm OGTT) ≥10.0 mmol/L GDM
No specific value to diagnose overt DM
2 hr PG (75gm OGTT) 8.5 - <11.1 mmol/L GDM
≥ 11.1 mmol/L Overt DM
RPG (with symptoms of ≥ 11.1 mmol/L Overt DM
hyperglycemia)
No specific value to diagnose GDM
HbA1c ≥ 6.5 % Overt DM
No specific value to diagnose GDM
Screening approaches for
hyperglycemia of pregnancy
• Diagnosis can be made if at least one value crosses
the cut-off.
• Many authorities prefer to do FPG / RPG / HbA1c in
1st prenatal visit only in women with risk factors for
diabetes mainly to detect overt Diabetes (Pre-
existing)
• They prefer to do 2hr 3 sample 75 gm OGTT in 24 –
28 weeks of gestation in all women not known to
have overt diabetes of GDM, mainly to detect GDM.
Targets of Diabetes management during pregnancy
Target of Glycemic Levels
Blood Plasma Glucose • Fasting/pre meal : <5.3 mmol/L
• 1hr post meal : <7.8 mmol/L
• 2hr post meal : < 6.7 mmol/L
HbA1c < 6.0% (Once in each trimester)
No hypoglycemia
Target of Blood Pressure
BP goal • Systolic : 110 – 129 mm of Hg
• Diastolic : 65 – 79 mm of Hg
Target of Weight gain
Weight gain 10 – 15 kg (in persons of normal body Wt & single pregnancy)
Target of Diabetic Education
Person Teaching, training & empowerment to take part in treatment
Treatment Of Diabetic
Pregnancy
Treatment Of Diabetic Pregnancy
• Follow Up schedule
– Every 2 weeks upto 30th gestational week
– Once every week thereafter
• Some important Specific Antenatal check up
– Retinal & Renal assessment – 1st visit
– Detailed Ultrasound (Anomaly scan) – 20th week
– Ultrasound monitoring of fetal growth and
amniotic fluid volume – 38th week
– Tests of fetal well being – 38th week
Treatment Of Diabetic Pregnancy
• Maternal Nutrition & physical activity
– Daily total calories intake is to be 30 Kcal/kg of ideal
body weight in first trimester& 38 kcal/kg of ideal body
weight thereafter
– Or, Basal calorie need + 300 kcal/day from 2 nd trimester.
– Carbohydrate 50-60%, Fat 30%, Protein 10-20% (May be
increased in exchange of carbohydrate)
– Adequate supplementation of Iron, Folic acid, calcium
– Meal plan
• Major meals: Breakfast, Lunch, Dinner
• Snacks : Mid-morning, Mid-afternoon, Bedtime (Bedtime snack
is essential to prevent fasting ketonuria)
– Moderate physical activity should be encouraged.
Treatment Of Diabetic Pregnancy
• Drug Therapy
– Insulin is the only drug recommended for use in
pregnancy
– Insulin therapy should be instituted if dietary compliance
fails to maintain glycemic target
– In Pre-pregnancy diabetes Shift from Oral anti diabetic
drug to Insulin, if pregnancy is planned.
– Dose requirement will show increasing trend with
duration of pregnancy, specially in mid pregnancy
• Multiple dose Insulin therapy can better attain target
• Insulin is started at a dose of 0.2 – 0.5 U/kg/day
• Human short & intermediate acting insulin and Insulin analogues
aspert, lispro & detemir are recommended
– Self monitoring of blood glucose is required to maintain
tight glycemic control.
Treatment Of Diabetic Pregnancy
• Timing and mode of delivery
– Term vaginal delivery is feasible with most
diabetic pregnancies by meticulous glycemic
control.
– Delivery may be considered earlier in presence of
unfavorable conditions :
• Uncontrolled diabetes & chronic complications
• Hypertension, pre-eclampsia
• Fetal growth retardation, etc
– Caesarean section is usually required if the foetal
weight is >4.5 kg.
Early Intervention
prevents complication
Early Intervention prevents
complication
• Before pregnancy, Diabetic treatment to bring
HbA1c <6.0 is desired. Otherwise repeated
abortion or congenital malformation occurs 6
times more than the normal population.
• Obesity and GDM both are independent risk
factor for foetal outcome.
• Most of the foetal disasters are through
Hyper-insulinemia / Hypoxia coupling.
Etiology
Etiology
Complications of Diabetic pregnancy : Maternal
During Pregnancy During labour
• Abortion • Prolonged labour
• Preterm labour (due to infection • Shoulder dystocia
or polyhydramnios) • Perineal injuries
• Pre-eclampsia • PPH
• Polyhydramnios • Operative interference Increased
• Maternal distress due to oversized risk of Caesarean delivery
fetus and polydramnios
• Microangiopathy Puerperium
– Nephropathy,
– retinopathy, • Puerperal sepsis
– neuropathy • Lactational failure
• Large vessel disease
– Coronary artery disease
– Thromboembolic disease
• Infection
• Hypo and hyperglycaemia
Complications of Diabetic pregnancy : Foetal
1st trimester 2nd Trimester
• Congenital abnormalities • Macrosomia
– Cardiac :
3rd Trimester
• ASD, VSD • IUD
• Fallot’s tetralogy • IUGR
– Neural Tube Deffect
• Anencephaly Delivery
• Hydranencephaly • Birth asphyxia
• Hydrocephaly • Shoulder dystocia
– Sacral agenesis/ CRS After delivery
– Cleft lip / Cleft palate • RDS
– Polycystic Kidney Disease • Hypoglycaemia
– Renal agenesis • Neonatal Hypocalcemia
– Duodenal atresia • Polycythaemia
– Tracheoesophageal fistula • Neonatal jaundice
Complications of Diabetic pregnancy : Foetal
Caudal regression syndrome
anencephaly
Complications of Diabetic pregnancy : Foetal
shoulder dystocia
Macrosomia
Malformations Diabetes Controls
n = 709 n = 735
HbA1 c % n n
Anencephaly 7.8 1a
Hydranencephaly 6.1 1
Hydrocephaly 5.9 1a
Multiple CNS, visceral and limb anomalies 5.9 1a
Caudal regression syndrome (10.3) 1
Left heart hypoplasia 7.0 1 1
Left heart hypoplasia (8.0) 1
Tetralogy of Fallot 6.3 1 1
VSD 7.3 5 3
VSD and hydrocephaly (6.5) 1
VSD, short limbs, anterior anus, 1
hypertelorism
Coarctation of aorta 8.9 2
PDA (operated) and multicystic
kidney 6.5 1
Pulmonary stenosis 1
Malformations Diabetes Controls
n = 709 n = 735
HbA1 c % n n
Gastroschisis, amnion adhesion
syndrome 7.2 1 a
Anal atresy, vesicourethral reflux 8.7 1
Duodenal atresy 7.7 1
Intestinal malrotation 6.6 1
Hydronephrosis (operated) 6.2 1
Hypospadia 9.6 2 1
Pelvic cyst and vaginal atresy 10.2 1
Craniosynostosis 2
Limb reductions, missing ante-
brachium and foot 7.9 1 a
Hip anomaly (operated) 9.2 1
Metatarsovarus, equinovarus
(operated) 10.0 2
Metatarsovarus (operated) (7.5) 1
Total 7.9 30 10
Take home Message/
Discussion
• Hyperglycemias during pregnancy are mostly due to
GDM. Recent global prevalence of hyperglycemia in
pregnancy( both pre-pregnancy and GDM) is more than
16% of live births; more than 85% of those are due to
GDM.
• Period of organogenesis must be guarded by normal
blood sugar.
• Pre-pregnancy blood sugar regulation and first trimester
blood sugar control is essential for complication
prevention , mostly prevention of abortion and
congenital malformation.
• in whom GDM was diagnosed at <12 weeks of
gestation approximated the pregnancy
outcome seen in pre-existing diabetes.
• Recommendation for consideration and
further Study :
– All who desire conception With risk factors
present, should be screened for glucose
intolerance.
– Any misshape in prior pregnancy must be
guarded by pre-pregnancy test for glucose
intolerance .
• Congenital malformation (2-6 times higher than non-
diabetic pregnancies; these are much higher for some
particular malformations) .Such as- cardiac or renal
anomaly, caudal regression , CNS defects etc.
• Blood sugar value high or high normal both invites
organogenesis defects.
• Oral anti-diabetic agents must be discontinued. The
women are managed with life style modification and
insulin to achieve the tight metabolic control , which is
defined by HbA1C (<6.0%) . At all times they should be
within the target. If the control is not within target range ,
pregnancy should be postponed until this target values are
achieved and maintained . They should be investigated
and if necessary treated for complications of diabetes or
any associated illness prior to pregnancy .
• Exception to discontinuing oral anti-diabetic drug :
– Metformin may be continued during first trimester on
patients with PCOS or type 2 DM with anovulatory
infertility At first visit should begin increasing insulin to
control blood sugar and taper off metformin
