Diabetes
During
Pregnancy
By: Neim Bedewi
1
Introduction
An increasing number of pregnancies are
complicated by diabetes, whether type 1
diabetes (T1DM), type 2 diabetes (T2DM)
or gestational diabetes (GDM)
All of which are associated with an
increased risk of adverse outcomes
2
Introduction….
Pre-existing DM in pregnancy (T1DM
& T2DM)
DM diagnosed before pregnancy
The prevalence of pre-existing DM has
increased due to the increase in T2DM
Higher rates of complications Vs. general
popn …. Perinatal mortality, congenital
malformations (4X), hypertension,
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preterm delivery, large-for-gestational-
Introduction….
Gestational Diabetes Mellitus
DM diagnosed in the 2nd or 3rd trimester of
pregnancy that was not clearly overt diabetes
prior to gestation
Obesity combined with advancing maternal
age, has driven an increase in the
prevalence of GDM
Risk of adverse maternal, fetal, and
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neonatal outcomes…. macrosomia (birth
Risk factors for
GDM
BMI in the obese range (above 30 kg/m2)
Previous macrosomic baby weighing 4.5
kg
Previous gestational diabetes
Family history of diabetes (first-degree
relative with diabetes)
Ethnicity: South Asian, Black Caribbean,
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Middle Eastern
DKA in Pregnancy
A serious condition associated with greatly
increased perinatal morbidity & mortality
Often at lower blood glucose levels
(even below 180 mg/dl or 10 mmol/l),
DKA can happen insidiously & with
higher GFR and lower renal threshold
for glycosuria in pregnancy 6
Insulin Physiology
Early pregnancy…. enhanced insulin
sensitivity & lower glucose levels
Women with T1DM will have lower
insulin requirements & increased risk
for hypoglycemia
Around 16 wks., insulin resistance begins
to increase, & total daily insulin doses
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increase linearly 5% per wk. through week
Physiology….
A rapid reduction in insulin requirements
can indicate the development of placental
insufficiency
In women with normal pancreatic function,
insulin production is sufficient to meet the
challenge of this physiological insulin
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resistance
Diagnosis
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Criteria for the diagnosis of
diabetes
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screening
One-step strategy
Perform a 75-g OGTT, with PG measurement when
pt. is fasting & at 1 & 2 h, at 24–28 wks. of
gestation in women not previously diagnosed with
DM.
OGTT.. in the morning after an overnight fast of at
least 8 h.
GDM if any of the following PG values are met or
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exceeded:
Cont.…
Two-step strategy
Step 1
Perform a 50-g GLT (non-fasting), with
PG measurement at 1 h, at 24–28 wks.
of gestation in women not previously
diagnosed with DM
If the plasma glucose level measured
1 h after the load is 130, 135, or 140
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Cont.…
Two-step strategy….
Step 2: The 100-g OGTT should be performed
when the pt. is fasting
GDM, if at least 2 of the following 4 PG levels
(measured fasting & at 1,2, & 3h during OGTT)
are met or exceeded:
Fasting: 95 mg/dL (5.3 mmol/L)
1 h: 180 mg/dL (10.0 mmol/L)
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2 h: 155 mg/dL (8.6 mmol/L)
Care
Women with preexisting DM who are
planning a pregnancy should ideally be
managed beginning in preconception in a
multidisciplinary clinic
In addition to achieving glycemic targets
Preconception care focus on nutrition,
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diabetes education, & screening for
Cont.…
Counseling on the risk of development
and/or progression of diabetic retinopathy
Dilated eye examinations in the 1st
trimester, and then every trimester &
for 1 year postpartum as indicated by
the degree of retinopathy 15
Glycemic Targets
FPG 70-95 mg/dL
One-hour postprandial glucose 110-140
mg/dL
Two-hour postprandial glucose 100-
120mg/dL
A1C target in pregnancy is < 6% (42
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mmol/mol)
Manageme
nt
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Management
Medical nutrition therapy
Physical activity, and
Weight management (depend on pre-
gestational weight)
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Therapy
For all pregnant women recommends a
minimum of
175 g of carbohydrate,
71 g protein, and
28 g of fiber
While limiting saturated fats and avoiding
trans fats, but unsaturated fats are
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recommended
GDM Management
Insulin is the 1st-line agent recommended
for treatment of GDM
Metformin and glyburide, are not
recommended as 1st-line treatment for
GDM because they are known to cross the
placenta
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Studies shown that both drugs failed to
Therapy
Glyburide…. higher rate of neonatal
hypoglycemia & macrosomia Vs. insulin or
metformin
Metformin Vs. Insulin
The earlier associated with a lower risk
of neonatal hypoglycemia & less
maternal wt. gain
21
But, growth restriction or acidosis in the
GDM….
Both multiple daily insulin injections and
continuous subcutaneous insulin infusion
are reasonable delivery strategies
Neither of them has been shown to
be superior to the other during
pregnancy
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Management
Insulin should be used for management of
T1DM during pregnancy
Also, it is the preferred one for T2DM
management in pregnancy
Either multiple daily injections or insulin
pump technology can be used in
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pregnancy complicated by type 1 diabetes
Type 1 DM
Women with type 1 diabetes have an
increased risk of hypoglycemia in the 1st
trimester
Pregnancy is a ketogenic state, and
women with T1DM, & to a lesser extent
those with T2DM, are at risk for DKA at
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lower BG levels
Type 1 DM
DKA carries a high risk of stillbirth
Women in DKA who are unable to eat
often require 10% dextrose with an
insulin drip
To adequately meet carbohydrate
demands of the placenta & fetus in
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the 3rd trimester in order to resolve
Type 2 DM
Glycemic control is often easier to achieve
in women with T2DM than in those with
T1DM
But can require much higher doses of
insulin
The risk for associated hypertension and
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other comorbidities may be as high or
Use
Low-dose ASA, 100–150 mg/day starting
at 12 to 16 wks. of gestation to lower the
risk of preeclampsia
Cost benefit analysis conclude that
Reduce morbidity, save lives, & lower
health care costs
Needed to assess the long-term effects of
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prenatal ASA exposure on offspring
Postpartum Care
Insulin resistance decreases dramatically
immediately postpartum
Insulin requirements need to be
evaluated and adjusted
A contraceptive plan should be discussed
and implemented with all women with
diabetes of reproductive potential 28
Lactation
Breastfeeding may also confer longer-
term metabolic benefits to both
mother & offspring
However, lactation can increase the
risk of overnight hypoglycemia
29
Insulin dosing may need to be
References
American Diabetes Association. Classification and diagnosis of
diabetes: Standards of Medical Care in Diabetes_2021.
Diabetes Care 2021;44(Suppl. 1):S152S33
American Diabetes Association. Management of diabetes in
pregnancy: Standards of Medical Care in Diabetes_2021.
Diabetes Care 2021;44(Suppl. 1):S200–S210
Farrar D, Tuffnell DJ, West J, West HM. Continuous
subcutaneous insulin infusion versus multiple daily
30
injections of insulin for pregnant women with diabetes.
Langer O, Conway DL, Berkus MD, Xenakis EM-J, Gonzales
O. A comparison of glyburide and insulin in women with
gestational diabetes mellitus. N Engl J Med
2000;343:1134–1138
Padmanabhan S, Lee VW, Mclean M. The association of
falling insulin requirements with maternal biomarkers
and placental dysfunction: a prospective study of women
with preexisting diabetes in pregnancy. Diabetes Care
2017; 40:1323–1330
31
Rowan JA, Hague WM, Gao W, Battin MR, Moore MP; MiG
Werner EF, Hauspurg AK, Rouse DJ. A cost benefit analysis
of low-dose aspirin prophylaxis for the prevention of
preeclampsia in the United States. Obstet Gynecol
2015;126:1242–1250
32
THANK
U….
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