Diabetes Mellitus in

Pregnancy
BY
Dr. Nabil Lymon
Definition
Diabetes in pregnancy may be defined as carbohydrate 

intolerance first diagnosed during pregnancy (gestational

diabetes) or pregnancy in a patient with known diabetes before
.pregnancy (type I or type 2)

Diabetes not only affects carbohydrates but also protein and 

.fat metabolism due to relative or solute insulin deficiency

Effect of Pregnancy on Carbohydrate
:Metabolism
.pregnancy is diabetogenic as it converts latent to overt diabetes
:The diabetogenic effect of pregnancy is due to 

Anti-insulin effect of pregnancy hormones, as HPL, .1

.oestrogen and progesterone
.Increased peripheral insulin resistance .2
.Secretion of insulinase enzymes by the placenta .3
So, diabetes mellitus is aggravated during pregnancy and .4
clinical diabetes may appear for the 1st time during
.pregnancy (gestational diabetes)
 :Effect on the fetus 

Fetal glucose level is directly proportional to 

.maternal glucose concentrations

.Insulin does not cross the placenta 

Fetal hyperglycemia stimulates fetal pancreas to 

.secrete more insulin

:The resultant fetal hyperinsulinemia causes 

Stimulatess fetal lipogensis resulting in macrosomia .1

.Organomegally: liver, heart .2
.Erythropoesis: neonatal polycythemia .3
Decreased surfactant production leading to RDS .4
 Classification of Diabetes Complicating Pregnancy
(Modified White's Classification)
Vascular disease Duration (Yr) Age of onset (Yr) Class
- - Gestational *At
- - Gestational **Az
Non years 10 < Over 20 years B
None to 19 years 10 to 19 years 10 C
Benign retinopathy years 20 > Before 10 years D
***Nephropathy Any Any F
Proliferative retiinopathy Any Any R
Heart Any Any H
Renal transplant Any Any T
* A1: FBS (< 105 mg/dL) & PPS (<120 mg/dL)
** A1: FBS (< 105 mg/dL) & PPS (<120 mg/dL)
*** When diagnosed during pregnancy: 500 mg or more proteinurea per 24
hours urine measured before 20 weeks gestation.
N.B: all classes are treated with insulin except A 1 is treated with diet.
 Complications of Diabetes on pregnancy
.Maternal 

.Difficult diabetic control (Ketoacidosis) .1

Repeated infections during pregnancy and .2

.puerperium
.PET and eclampsia: 15-20% .3

Operative and difficult deliveries: increased CS .4

.rate
.Postpartum hemorrhage .5

Increase incidence of diabetic complications: .6

.nephropathy, neuropathy and retinopathy
 :Fetal 

.Macrosomia .1

.IUGR (in cases with vasculopathy) .2

:Intrauterine fetal death due to .3

.Placental insufficiency .a

.Ketoacidosis .b

.Congenital malformations .c

.Prolonged hypoglycemia .d

.Cord problems .e

.Oligohydraminios .f

.Placental abruption .g
Sudden unexplained fetal death which may be .4
attributed to the chronic changes in O2 transport, acid
base balance and fetal metabolites secondary to
.prolonged fetal hyperglycemia
:Congenital malformations .5
.CNS: as aneneephaly and spina bifida .a

Cardiac: especially ventricular septal defects. It is the .b

most common
.GIT anomalies .c

.Genitourinary .d

Skeletal: caudal regression syndrome or sacral .e

.agenesis. It is the most specific for DM
Polyhydramnios: due to osmotic .4

effect of high amniotic glucose

.level
.Abortion .5

.Preterm labor .6
 :Neonatal 

.Birth injuries .1

.Hypoglycemia .2

.Hypocaleemia .3

Polycythemia .4

.Hyperbilirubinentia .5

.Respiratory distress syndrome .6

.Hypertrophic cardiomyopathy .7

Perinatal mortality: 2-5% (50% of which are .8

.due to fetal anomalies)
 :Inheritance of diabetes mellitus 

Mother with overt diabetes: 1-3% of fetuses will 

.develop type I diabetes

Father with overt diabetes: 6% of fetuses will 

.develop type 1 diabetes

Both have type I diabetes: risk of inheritance is 

.20%
:Diagnosis
A. Risk Factors
.Family history of DM .1

.Previous gestational diabetes .2

:Poor obstetric history .3

.Unexplained fetal deaths .a

.Traumatic and operative delivery .b

..Fetal and neonatal macrosomia > 4kgm .c

Neonatal metabolic changes (jaundice, hypoglycemia, .d

.hypocalcemia)
.Maternal obesity, advanced maternal age, multiparity .e
 :B. Laboratory examinations
Complete urine analysis: test urine for sugar in .1

each antenatal visit and if positive proceed to

.blood investigation
One hour glucose challenge test after 50 gm .2

glucose load without regard to the time of last

meal. A value of 140 mg/dl or higher identifies
80% of all women with gestational diabetes. It is
.the best screening test
kdurs glucose tolerance test (oral 3 .3

glucose tolerancet = OGTT)

. .Fasting for at least 8 hours 

gm glucose in 300 ml water after FBS 100 

.sample
Criteria for-diagnosis gestational diabetes using 

.100 gm OGTT
Fasting plasma glucose > 105 mg/dl 
1hr > 190 mg/dl 
2hr > 165 mg/dl 
3hr > 145 mg/dl 
Diabetes is diagnosed when 2 values or more 
.are abnormal
In high-risk pregnancy, a negative test should 
be repeated at 24-28 weeks, border line values
should also be repeated more frequently

NB. The values of 3 hours OGTT using capillary blood

.is 15% lower ban plasma values
 Glycosylated Hb (HbA1C) .4

It reflects an average of circulating glucose for 

.the past 4-8 weeks

.It is important to assess the glycemic control 

Normally it is less than 7% 

It can determine the risk of congenital anomalies 

.(with high levels)

:Management of Diabetic Pregnancy
:I. Precorceptional care
Diabetic control before pregnancy can prevent 

early pregnancy loss and congenital

.malformations
.Health education programs 

.Folic acid supplementation 

.II. No place for oral hypoglycemic drugs

 :III. Medical care
Dietary recommendation .1
Total caloric intake 30 calories/kgm. for normal 
.weight and 24 calories/kgm. for obese patients
Carbohydrates represent 50-55 %, 25 % protein and 
.20 % fat
Divide meals into six portions daily (3 main meals 
.and 3 snacks between meals)
Encourage exercise .2

Routine ophthalmologic examination at the 1M .3

antenatal visit, repeated monthly and when
.needed
 :Insulin therapy .4
.At least twice daily injections 

Mixture of short and medium acting insulin given 20-30 

.minutes before breakfast and dinner

.How to calculate insulin dose 

In the first half of pregnancy: body weight multiplied by 0.6 equals 

.insulin units per day

.In the second half of pregnancy: body weight multiplied by 0.7 

Than, insulin dose is divided as 2/3 of the dose Before breakfast 

.and 1 /3 before dinner

The goal' is to keep fasting blood glucose < 95mg/d prandial less 

.than I,20mg/dl

.NB. Gestational diabetes class A, is controlled' by diet only

 :IV. Obstetric management
:A. During pregnancy (Antenatal care)
:Maternal monitoring .1

An internist and an obstetrician should work together 

.in a special clinic for diabetic pregnancy

Frequency of visits every 2 weeks up to 34 weeks 

.gestation and weekly thereafter

.Monitor maternal weight gain 

.Test urine for glucose, protein and pus cells 

Patients with vascular changes are hospitalized at 32 

weeks due to increased risk of hypertension,

.preeclampsia and IUGR
 :Fetal monitoring .2

.1st trimester: ultrasound to detect fetal viability 

:2nd trimester 

Triple screen (maternal serum alpha fetoprotein, .a

.unconjugated estriol and (3hCG) at 16-18 week

.Ultrasound: to detect congenital anomalies .b

.Fetal echo: to detect cardiac anomalies at 19-22 weeks .c

 :3rd trimester 

:Ultrasound is done .1
.At 28-30 weeks then at 36-38 weeks in non complicated cases 

Monthly starting from 24-26 weeks to diagnose IUGR in cases 

.with evidence of maternal microvascular disorders

:Fetal wellbeing tests .2
.Begin at 32-34 weeks in non complicated cases 

.At 28 week in complicated cases 

.NST twice weekly from 32 week till delivery 

:Umbilical artery Doppler velocimetry 

To measure S/D ratio (normally < 3 a130 weeks) 

.Elevated S/D ratio in IUGR, PET 

 :B. During labor
The daily dose of insulin is replaced by insulin 

infusion monitored by blood glucose estimation to

.keep blood glucose levels between W-1 10 mg/dl

I.V line for saline ands /glucose (one liter /8hours) 

The same measures ate done when delivery is by 

elective CS
Vaginal delivery is allowed except if CS is 

.indicated (CS rate is 47% of cases)

.Macrosomia 
.IUGR 
.Associated hypertension: or polybydramnios 
.Previous IUFD or bad obstetric history 
.Elderly primigravida 
.Placenta previa 
Any other associated complications or uncontrolled 
.diabetes
Pregnancy is not allowed to reach 40 weeks, 

.except in gestational diabetes class A1

Other classes, labor is induced (AROM and 

pitocin drip) or elective CS after completed 37

weeks if diabetes is controlled and pregnancy
.is not complicated
:Earlier delivery (before 37 weeks) if 

.Diabetes not controlled .1

.IUGR .2
.Polyhydrainnios .3
.Preeclampsia .4
.Fetus at risk .5
.Fetal anomalies .6
.IUFD .7
 :C. Postpartum care
.Encourage lactation
.Increase dietary carbohydrates by 50 gm 

Adjust insulin dose (usually reduced by one third). keep on 

.hyperglycemic side
.Neonatal intensive care (ICU for at least 24-48 his) 

:Family planning (contraceptive advice)

.Tubal ligation if completed family size .1

.Barrier methods .2

.IUD .3

.Oral gestagen only pills (for lactating) .4

.Injectable DtMPA .5

.Norplant .6
 D. Management of Complications
:I. Maternal complications
:Diabetic Ketoacidosis (DKA) .1

:Presented by 

e. Rapid and deep respiration Abdominal pain. .a

.f. HyperglycemiaNausea, vomiting. .b

g. Acidosis Polydepsia. .c

.h. Ketonemia and ketonuria Polyuria. .d

Aanaged by vigorous hydration, regular insulin, potassium, sodium 

.bicarbonate
:Hypoglycemia .2

.When blood glucose level tower than 60mg/dl 

Treated by oral complex carbohydrates or an ampoule of 10% 

.dextrose plus IV fluids

 :Retinopathy .3

:Maybe 

Simple retinopathy 

Proliferative diabetic retinopathy: it may pr s to blindness if left 

.untreated
Photocoagulation diabetic retinopathy can be done safely during 

.pregnancy
:Nephrdpathy .4
Diagnosed by persistent protein of more than 3grams/day, serum 

.creatinine > 1.5 mg/dl, hypertension

These patients need intensive maternal and fetal surveillance throughout 

.gestation

Spontaneous abortion: 6-29% in cases with poor diabetic .5

.control during the periconceptional period

 :Polyhydramnios .6
.Occurs in 3-32% of diabetic patients 

:Pathogenesis is not clear but may be due to 

.Increased fetal glycemic load .a
.Decreased fetal swallowing .b
.Fetal polyuria .c

It is associated with higher perinatal mortality. The mortality rates are 

.due to associatedd congenital anomalies and preterm delivery
:Chronic hypertension and PET .7
Its incidence is increased in diabetics especially those with 
.nephropathy
.Affected patients must be monitored. carefully throughout pregnancy 

:Preterm labor .8
.times higher in diabetics 3-4 

.Mg sulfate is the tacolytic of choice 

 II. Fetal and Neonatal Complications
.Congenital malformations .1

Maerosomia .2

.Estimated fetal weights >90th percentile or > 4 kgm .a

.Higher mortality and morbidity rates due to birth trauma .b

Neonatal hypoglycemia: 25-40% of infants of .3

diabetics develop hypoglycemia with blood glucose

.level < 40mg/dl
Neonatal hypocaleemia and hypomagnesemia: .4

.related to the degree of diabetic control

Neonatal polycythemia: Hct value > 65% due to .1

chronic intrauterine hypoxia which result in

.increased erythropoietm production
Neonatal hyperbilirubinemia and neonatal .2

.jaundice: due to a delay in liver maturation

.Neonatal respiratory distress syndrome .3

.Due to delayed lung maturity .a

Fetal hyperinsulinaemia is thought to suppress .b

.secretion of lung surfactant

.Fetal and neonatal cardiomyopathy .4

.Birth trauma and perinatal asphyxia .5

Thank
you