Clinical Practice Guidelines:

Management of
Type 2 Diabetes Mellitus
(4th Edition) 2009

Topic 10:
Diabetes in Pregnancy

Diabetes in Pregnancy
Pregnancy related
Gestational diabetes (GDM)
Pre-existing diabetes
Type 1 DM
Type 2 DM

GDM - Definition
Any degree of glucose intolerance with onset or
first recognition during pregnancy.
Applies whether insulin or only diet modification
is used for treatment and whether or not the
condition persists after pregnancy.
Does not exclude the possibility that
unrecognised glucose intolerance may have
antedated or begun concomitantly with the
pregnancy.
3

Maternal complications in diabetic

pregnancy

Hypoglycemia, ketoacidosis
Pregnancy-induced hypertension
Pyelonephritis,other infections
Polyhydramnios
Preterm labor
Worsening of chronic complications
retinopathy, nephropathy, neuropathy, cardiac
disease
4

Complications for infants of

mothers with DM

Congenital malformations
Macrosomia
Birth injury
Asphyxia
Respiratory Distress Syndrome
Perinatal mortality
Metabolic abnormalities
Hypoglycaemia, hypokalemia, hypocalcemia,
hyperbilirubinemia, erythrosis
5

Screening
c. Pregnant women should be screened if they
have any of the following risk factors:

BMI > 27kg/m2

Previous macrosomic baby weighing 4 kg or above
Previous GDM
First-degree relative with diabetes
Bad obstetric history
Glycosuria at the first prenatal visit

Current obstetric problems (essential hypertension,

pregnancy induced hypertension, polyhydramnios
and current use of steroids)
6
Age above 25 years

Screening (cont.)
Pregnant women should be screened at least
once at > 24 weeks of gestation, using 75 gm
OGTT.
Screening at an earlier stage of gestation
depends on the degree of suspicion and at the
physician's / obstetrician's request.

Pregnancy and Pre-existing T2DM

Women with pre-existing T2DM who are
planning pregnancy should be referred to
physician/diabetologist for further management.
Pregnancy should be planned.
Achieve good glycaemic control before
conception, aim for HbA1c < 6.5%.
Insulin therapy may be necessary before
conception to achieve good glycaemic control.

Pre-conception care
The importance of avoiding unplanned
pregnancy should be an essential component of
diabetes education for women with diabetes in
reproductive age group.
Offer pre-conception care and advice to women
with diabetes who are planning to become
pregnant before discontinuing contraception.

Pre-conception care (cont.)

Establishing good glycaemic control before
conception and continuing this throughout
pregnancy will reduce the risk of miscarriage,
congenital malformation, stillbirth and neonatal
death.
It is important to explain that risks can be
reduced but not eliminated.

10

During Pregnancy
Achieve and maintain ideal glucose levels.
Advise women with insulin-treated diabetes of
the risks of hypoglycaemia and hypoglycaemia
unawareness in pregnancy, particularly in the
first trimester.
HbA1c (4-6 weekly)

11

Glycaemic targets in pregnancy

Timing

Glucose Level (mmol/L)

Pre-breakfast

3.5 5.9

Pre-prandial

3.5 5.9

1 hour post prandial

< 7.8

2 hour post prandial

4.4 6.7

0200 0400 hours

> 3.9

12

During Pregnancy (cont.)

Close SBGM is required (individualise
frequency of monitoring):
On diet therapy: pre-breakfast,1 hour PPG levels
(weekly-fortnightly)
On insulin therapy: pre-meal (breakfast, lunch,
dinner) and pre-bed (weekly-fortnightly). Once
premeal glucose levels are achieved, PPG
testing is recommended for fine-tuning of insulin
dose
13

During Pregnancy (cont.)

Insulin therapy is indicated when diet fails.
Insulin lispro and aspart may be used.
Although published data suggests that
metformin and glibenclamide are safe, OAD
agents are not generally recommended as they
are not registered for use during pregnancy.

14

At Delivery
GIK regimen can be used during delivery or
lower segment Caesarean section (LSCS)
Labour is exercise need to reduce insulin dose
Requires glucose substrate

15

Post-partum Care
Insulin requirement drops immediately after
delivery by 60 -75%.
In breast-feeding, if glycaemic control is
inadequate with diet therapy alone, insulin
therapy should be continued at a lower dose.
In non-breast-feeding mothers, OAD agents can
be continued.

16

Postnatal Care
Offer women who were diagnosed with
GDM:
Lifestyle advice
OGTT

17

Summary
Normoglycemia is the goal.
Prevention of hypoglycemia is paramount
especially during times of increased insulin
sensitivity.
To achieve goals: Increased glucose monitoring
at peak postprandial glucose concentrations and
at peak insulin levels.

18

Thank you

19