DIABETES IN PREGNANCY

PGI Neill Sebastien Celeste

Aug 2023

Good morning!

DIABETES IN Pregnancy Page 1 of 84

 PRAYER
Direct, O God we beseech thee
All our actions by Thy holy inspiration
And help them on by Thy gracious assistance
So that every prayer and work of ours
May begin with Thee
And by Thee be happily ended

Amen

DIABETES IN Pregnancy Page 2 of 84

 GENERAL DATA

CNB
33
Filipino
Single
Roman Catholic
Pio del Pilar, Makati City

DIABETES IN Pregnancy Page 3 of 84

 DATE OF CONSULT
August 2, 2023

33
G3P2 (2002)

LMP: Sept. 15, 2022 (unsure)

AOG by LMP: 45w6d
AOG by UTZ: 39w1d
(Jan. 4 = 9w1d)

Chief complaint: follow-up

PNCU x 2 PHU
OSMAK x 10

DIABETES IN Pregnancy Page 4 of 84

 FIRST TRIMESTER
PT positive 4 weeks missed menses.

1st PNCU at 3 months AOG c/o Pio

del Pilar Health Center, with regular
visits.

Patient denies exposure to radiation

nor viral exanthems.

No UTI and BP elevation.

Regular intake of Prenatal

Multivitamins and Folic Acid.

DIABETES IN Pregnancy Page 5 of 84

 SECOND TRIMESTER

Quickening noted at 4 months AOG

Regular prenatal check ups at OsMak OB

OPD

No UTI and BP elevation.

Regular intake of MV + FeSO4 OD.

DIABETES IN Pregnancy Page 6 of 84

 THIRD TRIMESTER
Still with regular PNCU at same HC.

Denies UTI and BP elevation

Regular intake of Multivitamins and

Ferrous Sulfate.

DIABETES IN Pregnancy Page 7 of 84

 CURRENTLY, REVIEW OF SYSTEMS
Good fetal movements (-) Fever
(-) Cough and colds
(-) watery vaginal discharge (-) Difficulty of breathing
(-) Headache
(-) vaginal bleeding (-) Blurring of vision
(-) Epigastric pain
(-) Perceived regular contractions (-) Edema of legs and face

At time of consult, patient denied watery or bloody vaginal discharge, no

contractions noted. Patient claimed to have perceived good fetal movement.

DIABETES IN Pregnancy Page 8 of 84

 PAST MEDICAL
HISTORY
(-) Diabetes Mellitus
(-) Hypertension
(-) Cardiac Disease
(-) Asthma
(-) Thyroid Disorder

No previous operations /
hospitalizations
No allergy to food and drugs

COVID Vaccine
Moderna x2
No booster

DIABETES IN Pregnancy Page 9 of 84

 FAMILY HISTORY
(-) Diabetes Mellitus

(-) Hypertension

(-) Asthma

(-) Cancer

(-) Thyroid Disease

The patient's parents are still alive and apparently well. Patient has 2 siblings, all are
apparently healthy.

Patient denies other heredofamilial diseases such as cancer, liver, kidney, lung, or thyroid
diseases.

DIABETES IN Pregnancy Page 10 of 84

 PERSONAL AND
SOCIAL HISTORY
Previous smoker (stopped 3 years ago,
max 3 sticks per day

Non-alcoholic beverage drinker

College undergraduate
Call center agent
Lives with live in partner and 2 children

DIABETES IN Pregnancy Page 11 of 84

 MENSTRUAL HISTORY
M 15 y/o
I 28-30 days
D 3 days
A 2 ppd, moderately soaked
S (-) dysmenorrhea

The patient has had her menarche at 15 yrs old. She has been regularly menstruating since
15 years old, with an interval of 28-30 days, lasting for 3 days, mild to moderate in flow,
with 2 pads consumed per day, and with no associated dysmenorrhea.

DIABETES IN Pregnancy Page 12 of 84

 CONTRACEPTIVE
HISTORY
(-) IUD

(+) OCP x 2 years

(-) Injectables

DIABETES IN Pregnancy Page 13 of 84

 SEXUAL HISTORY
1st coitus: 18 y/o

Sexual partner/s: 3
1) student, monogamous
2) student, monogamous
3) call center agent, monogamous

No dyspareunia
No postcoital bleeding

(+) Pap smear, 2011

Negative for intraepithelial lesion
or malignancy

The patient had her coitarche at 18 yrs old. She has had 3 sexual partners.

She denies any history of dyspareunia, post-coital bleeding, leucorrhea, and exposure to
sexually transmitted diseases.

Pap smear was done last 2011 revealing normal results.

Reason for the Pap smear was __________

Currently, she is in a monogamous, heterosexual relationship.

DIABETES IN Pregnancy Page 14 of 84

 OBSTETRICAL
HISTORY
G1 2010, term live baby girl
OsMak BW 3.6 kg

G2 2012, term live baby boy

OsMak BW 2.9 kg

G3 current pregnancy

INDICATION to follow

The patient is a multigravid, with an OB score of G3P2 (T2-P0-A0-L2).

The first pregnancy was delivered on 2010 to a term baby girl, with a birthweight of 3600
grams, delivered via transverse LSCS, due to ____________ (indications) at OsMak assisted by
an obstetrician. No fetomaternal complications were noted.

The second pregnancy was delivered last 2012 to a term baby boy, with a birthweight of
2900 grams, delivered via transverse LSCS, due to ____________ (indications) at OsMak
assisted by an obstetrician. No fetomaternal complications were noted as well.

The third pregnancy is her current pregnancy.

DIABETES IN Pregnancy Page 15 of 84

 PHYSICAL EXAMINATION
BP 110/80
HR 91 Pre-pregnancy weight:
RR 21 Height:
Temp 36.7 Weight: 64kg
O2 sat 98% at RA

General Survey: Conscious, not in distress

HEENT: Anicteric sclerae, pink palpebral conjunctivae, no cervical lymphadenopathy, no neck
vein engorgement
Chest / Lungs: Symmetric chest expansion, clear breath sounds
CVS: Adynamic precordium, normal rate, regular rhythm, no murmurs
Abdomen: globular; FH: 33cm FHT: 160s

IE: vagina admits 2 fingers with ease, cervix 1 cm dilated, beginning effacement, intact BOW,
cephalic, floating

Extremities: Full equal pulses, no edema

Neuro: GCS 15

DIABETES IN Pregnancy Page 16 of 84

 ANCILLARIES
UA (1/11/23)
TVS Ultrasound (01/04 RG Medical
Light yellow, turbid, pH 7.0, SG 1.020, WBC
Clinic)
6-10/hpf, RBC 0-1/hpf, EC many, Bacteria
few
SLIUP
AOG 9wks 1 day
CBC (1/11/23)
CRL 2.49 cm
Hgb 124, Hct 36.3, RBC 4.4, Plt 223, WBC
YS 4.6 cm
13, Neu 77.5, Lym 20.0, Mono 2.5
FHR 179 bpm
(No subchorionic hemorrhage
ABO Type B Rh (+)

TVS UTZ (01/04)

single live intrauterine pregnancy 9w1d of sonar age by CRL with good cardiac activity
no subchorionic hemorhage
Normal right ovary, left ovary not seen

DIABETES IN Pregnancy Page 17 of 84

 ANCILLARIES
Pelvic Ultrasound (02/08 OsMak)
Other Labs (03/20)
FBS 79 mg/dl
SLIUP
HBA1C 5.8%
Varying lie
TSH 0.9
13w6d AOG by biometry
EFW: 87g
FHT: 150bpm
Pap Smear (03/30)
AFI: normal amount of amniotic fluid
CONSISTENT WITH ACUTE
SDP: 3.54cm
CERVICOVAGINITIS, MILD TO MODERATE
Normohydramnios
0+3+2
Grade 0 fundal placenta

DIABETES IN Pregnancy Page 18 of 84

 ANCILLARIES
Other Labs (04/18) PELVIC UTZ (5/15 OsMak)
75g OGTT
FBS 82 mg/dl SLIUP
1st hr 165.6 mg/dl Cephalic
2nd hr 165.96 mg/dl 28 weeks by biometry
1198 g
UA (04/18) 167 bpm
0.9/0.7/2.2/488.8 Placenta anterior, high-lying, Grade II
AFI 14.46 cm
Normohydramnios

Diagnosed as GDM at her 24th week of pregnancy.

DIABETES IN Pregnancy Page 19 of 84

 ANCILLARIES
BPS UTZ (6/27 OsMak) BPS UTZ (7/11 OsMak)

SLIUP SLIUP
Cephalic presentation Breech presentation
AOG 34 weeks and 4 days AOG 36 weeks and 6 days
EFW 2603 g EFW 3089 g
FHR 145 bpm FHR 148 bpm
Placenta Ant HL, gr I Placenta Ant HL, gr II
AFI 11.79 cm SDP 5.43cm AFI 23.78 cm SDP 8.09 cm
BIOPHYSICAL SCORE: 8/8 BIOPHYSICAL SCORE: 8/8

DIABETES IN Pregnancy Page 20 of 84

 ANCILLARIES
MODIFIED BPS UTZ (7/23 OsMak)

SLIUP
Breech presentation
AOG weeks and days
EFW g
FHR 159 bpm
Placenta Ant HL, gr II
AFI 15.29 cm SDP 5.43 cm
BIOPHYSICAL SCORE: 8/8

MODIFIED BPS UTZ (7/23/23; initial c/o Dr. Capuchino)

Single live intrauterine pregnancy
breech
FHR 159bpm
AFI 15.29cm
SDP 5.43cm
Placenta anterior, high-lying, grade 2
BPS score 8/8

(CONFIRM ACTUAL RESULTS AT HIMS)

DIABETES IN Pregnancy Page 21 of 84

 CBG MONITORING
Apri 24: 96*-123*-128*-122*-80-118-85 May 8: 97-121-125-124-137-110-95
April 25: 93-121*-118*-119-139*-125*-91 May 9: 97-117-134-115-107-113-91
April 26: 85-125*-102*-115-128*-119-92 May 10: 91-119-137-116-126-121-96
April 27: 100*-116-122*-127*-141*-120-86 May 11: 96-115-138-123-136-116-89
April 28: 97*-109-145*-116-143*-121*-90 May 12: 98-113-120-118-100-112-90
April 29: 95-139-87-131-143-117-90 May 13: 88-115-127-119-92-122-92
April 30: 86-122-107-123-99-115-92 May 14: 87-113-135-119-129-116-89
May 1: 87-122-134-118-132-123-93 May 15: 92-114-139-119-135-113-91
May 2: 90-115-122-112-128-121-89 May 16: 85-117-137-118-135-114-89
May 3: 91-123-96-123-101-119-87 May 17: 94-110-133-115-129-114-86
May 4: 96-115-138-120-128-119-92 May 18: 89-117-136-113-134-116-92
May 5: 97-116-139-121-106-113-95 May 19: 96-119-138-116-130-115-90
May 7: 92-114-122-120-85-112-89 May 20: 91-110-137-121-125-103-87

DIABETES IN Pregnancy Page 22 of 84

 CBG MONITORING
May 21: 90-122-132-121-136-119-93 June 3: 92-110-139-117-136-114-91
May 22: 86-114-138-116-129-118-90 June 4: 86-119-139-117-134-112-94
May 23: 86-119-133-115-137-115-92 June 5:85-113-139-112-136-115-92
May 24: 89-116-135-119-133-114-92 June 6: 86-110-133-117-136-118-93
May 25: 94-118-130-116-125-112-90 June 7: 92-112-133-116-130-116-91
May 26: 92-115-131-118-126-120-88 June 8: 91-112-132-118-136-117-93
May 27:91-116-132-119-130-117-90 June 9: 90-119-137-116-134-115-92
May 28: 93-116-125-114-129-120-92 June 10: 90-116-139-120-137-119-91
May 29: 90-112-130-117-131-111-91 June 11: 93-118-137-115-134-116-89
May 30: 89-115-129-119-127-115-87 June 12: 90-115-136-119-138-117-93
May 31: 86-110-129-115-134-113-92 June 13: 90-119-137-116-138-116-90
June 1: 94-117-137-119-139-116-90 June 14: 92-119-137-116-132-115-89
June 2: 86-115-126-118-124-112-85 June 15: 92-116-132-118-134-119-92

DIABETES IN Pregnancy Page 23 of 84

 CBG MONITORING
June 16: 90-115-132-119-136-112-89 June 29: 91-115-x-x-x-x-x
June 17: 91-116-139-118-134-116-93 July 1: 93-116-97-117-99-114-92
June 18: 91-117-133-119-137-113-89
June 19: 90-118-138-116-137-115-93 07/02 92-113-98-117-96-119-90
June 20: 89-116-136-119-133-117-91 07/03 90-115-99-118-97-113-93
June 21: 94-114-137-118-137-115-90 07/04 94-100-97-119-96-114-94
June 22: 92-117-129-120-138-114-93 07/05 92-115-95-113-97-115-90
June 23: 89-116-134-116-133113-92 07/06 92-116-99-115-97-119-92
June 24: 93-119-134-116-135-117-89 07/07 93-113-98-117-96-116-93
June 25: 91-113-132-116-137-112-92 07/08 90-113-97-117-99-116-94
June 26: 93-114-136-114-133-110-88 07/09 92-117-98-118-96-113-91
June 27: 92-116-136-119-137-117-90 07/10 94-119-99-117-97-120-94
June 28: 93-114-132-118-133-115-92 07/11 92-117-97-119-99-120-94
07/12 92-116-at OB ER

DIABETES IN Pregnancy Page 24 of 84

 CBG MONITORING
07/13 93-114-121-110-124-117-91
07/14 90-113-120-117-123-116-92
07/15 90-115-122-114-120-119-91 7/26 90-113-120-110-121-113-92
07/16 92-118-125-119-121-115-91 7/27: 91-117-121-114-120-117-92
07/17 90-116-122-117-124-115-90 7/28: 90-118-122-115-121-117-91
07/18 89-114-121-116-123-114-92 7/29: 91-117-120-114-119-116-90
07/19 90-112-121-113-120-112-91 7/30: 91-114-120-113-120-117-92
7/20: 93-116-121-117-123-113-90 7/31: 90-119-121-118-122-118-92
7/21: 91-115-120-116-121-116-92 8/1: 91-117-123-118-121-117-92
7/22: 91-113-121-113-120-118-90
7/23: 92-115-124-116-120-114-90
7/24: 89-112-121-110-119-113-92
7/25: 90-115-122-113-121-114-91

DIABETES IN Pregnancy Page 25 of 84

 ASSESSMENT

G3P2 (2002) PU 39 1/7 weeks AOG by UTZ breech in beginning labor

Gestational Diabetes Mellitus, diet- controlled

Previous CS x 2 (I - 2010, OSMAK; II - 2012, OSMAK)

Overweight

DIABETES IN Pregnancy Page 26 of 84

 DEFINITIVE PLAN

For Emergency Low Transverse Cesarian Section III +

Bilateral Tubal Ligation

DIABETES IN Pregnancy Page 27 of 84

 DISCUSSION

DIABETES IN PREGNANCY
Good morning!

DIABETES IN Pregnancy Page 28 of 84

 CLASSIFICATION

Diabetes as we all know, is one of the most common problems in pregnancy especially
here in our country.

Women can be separated into those diagnosed with

diabetes before pregnancy—pregestational or overt diabetes, and those diagnosed during
pregnancy—gestational diabetes.

Pregestational DM, we have type 1 and type 2. Typically, this is the same as your as DM in
non-pregnant patient.

Type 1 Diabetes
An absolute insulin deficiency results from beta cell destruction.

Type 2 Diabetes
Due to an inadequate insulin secretion or you have normal amount but there’s insulin
resistance .

Gestational DM
Diabetes diagnosed when the patient is pregnant.

DIABETES IN Pregnancy Page 29 of 84

 EPIDEMIOLOGY

DIABETES IN Pregnancy Page 30 of 84

 STATISTICS
4.6% 390 million of the population
in the Philippines is diabetic

14% Prevalence of GDM in the

Philippines in 1996

7.5% Prevalence of GDM at the

USTH-CD was 7.5%

HERNANDEZ SS, TAN CE, TREMEDAL MA, ROA LJ, LOCAL VERSUS INTERNATIONAL
CRITERIA IN PREDICTING GESTATIONAL DIABETES MELLITUS-RELATED PREGNANCY
OUTCOMES

It is a pandemic that sweeps the globe, rising in parallel to the incidence of obesity.

GDM prevalence is increasing worldwide, particularly in Asian countries. Roughly 4.6% or

390 million of the population in the Philippines is diabetic to begin with. These statistics
do not even
reflect the 5% of the population who remain undiagnosed and 9% who are prediabetics.

Also, very few studies have been done about GDM in the country. The only available data
on the prevalence of GDM in the Philippines is the study done by Litonjua et al in 1996. In
this study, they identifed that the GDM prevalence in the Philippines is 14%.

A more recent study was done but with limited scope of population, that is covering the
University of Santo Tomas Hospital-Clinical Division
(USTH-CD) only. In the study, they identifed that the prevalence of GDM at the USTH-CD
was 7.5%.

DIABETES IN Pregnancy Page 31 of 84

 PREGESTATIONAL DIABETES
DIAGNOSIS

DIABETES IN Pregnancy Page 32 of 84

 PREGESTATIONAL DIABETES
DIAGNOSIS

Considering the previously mentioned high percentage of undiagnosed diabetes, many

women identified with gestational diabetes likely have previously unrecognized type 2
diabetes.

To diagnose overt diabetes in pregnancy, the International Association of Diabetes and

Pregnancy Study Groups (IADPSG) Consensus Panel (2010) recognizes the
threshold values found in this table for fasting or random plasma glucose and HbA1c
levels at prenatal care initiation.

Women with a random

plasma glucose level >200 mg/dL plus classic signs and symptoms such as polydipsia,
polyuria, and unexplained weight loss, those with a fasting glucose level >125 mg/dL, or
those with a first-trimester glycosylated hemoglobin (HbA1c) level of ≥6.5 percent are
considered by the American Diabetes Association (2019) and the World Health
Organization (2019) to have overt
diabetes first detected in pregnancy.

DIABETES IN Pregnancy Page 33 of 84

 The American Diabetes Association (2020)
and the World Health Organization (2019)
now also consider a plasma glucose level
>200 mg/dL measured 2 hours after a
75-g oral glucose load to be diagnostic.

DIABETES IN Pregnancy Page 34 of 84

 FETAL AND NEONATAL
EFFECTS OF OVERT DIABETES

DIABETES IN Pregnancy Page 35 of 84

 FETAL EFFECTS
SPONTANEOUS ABORTION
Only those whose initial glycohemoglobin A1c
concentrations were > 12 percent or whose
preprandial glucose concentrations were
persistently > 120 mg/dL were at increased risk.

PRETERM DELIVERY
Overt diabetes is an undisputed risk factor for
preterm birth.

MALFORMATIONS
In the National Birth Defects Prevention Study,
the risk of an isolated cardiac defect was
fivefold higher in women with pregestational
diabetes, specifically type 1 diabetes.

SPONTANEOUS ABORTION
Up to 25 percent of overtly diabetic mothers have an early miscarriage, and poor glycemic
control is an associated factor.

In one study, those whose HbA1c concentrations were >12 percent or whose preprandial
glucose concentrations persisted
above 120 mg/dL had an elevated miscarriage risk (Galindo, 2006).

PRETERM DELIVERY
Overt diabetes is an undisputed risk factor for preterm birth.

MALFORMATIONS
In the National Birth Defects Prevention Study, the risk of an isolated cardiac defect was
fivefold higher in women with pregestational diabetes, specifically Type 1 diabetes.

Poorly controlled diabetes, both preconceptionally and

early in pregnancy, is thought to underlie this elevated risk
for major malformation.

The etiological mechanisms that explain this link include

excess production of toxic superoxide radicals, altered cell signaling pathways,
upregulation of some genes by hyperglycemia, and activation of programmed cell death.

DIABETES IN Pregnancy Page 36 of 84

 FETAL EFFECTS
ALTERED FETAL GROWTH

Maternal hyperglycemia prompts

fetal hyperinsulinemia, and this in
turn stimulates excessive somatic
growth.

The incidence of macrosomia rises

significantly when mean maternal
blood glucose concentrations
chronically exceed 130 mg/dL.

ALTERED FETAL GROWTH

Diminished fetal growth may result from congenital malformations or from substrate
deprivation due to advanced maternal vascular disease. That said, fetal overgrowth is
more typical of pregestational diabetes.

What happens is that, maternal hyperglycemia prompts fetal

hyperinsulinemia, and this in turn stimulates excessive somatic growth. Except for the
brain, most fetal organs are affected by the macrosomia that characterizes the fetus of
diabetic women.

Newborns are described as anthropometrically different from other large-for-gestational

age (LGA) neonates (Catalano,
2003; Durnwald, 2004). Specifically, those whose mothers are diabetic have excessive fat
deposition on the shoulders and
trunk, which predisposes to shoulder dystocia or fetopelvic disproportion.

The incidence of macrosomia rises significantly when mean

maternal blood glucose concentrations chronically exceed 130 mg/dL.

DIABETES IN Pregnancy Page 37 of 84

 FETAL EFFECTS
UNEXPECTED FETAL DEMISE

Stillbirth without an identifiable cause

is a phenomenon relatively limited to
pregnancies complicated by overt
diabetes.

These unexplained stillbirths are usually

associated with poor glycemic control.

Fetuses of diabetic mothers also often

have elevated lactic acid levels.

UNEXPECTED FETAL DEMISE

Stillbirth without an identifiable cause is a phenomenon relatively
limited to pregnancies complicated by overt diabetes.

These stillbirths are “unexplained” because common factors such as obvious placental
insufficiency, placental abruption, fetal-growth restriction, or oligohydramnios are not
identified. These fetuses are typically LGA and die before labor, usually later in the third
trimester.

Fetus of diabetic mothers also often have elevated lactic acid levels. These findings
support a hypothesis that hyperglycemic-mediated
chronic aberrations in oxygen and fetal metabolite transport
may underlie these unexplained fetal deaths.

Simply saying, the way i understood it is that, most diabetic mothers will have problems of
fetal demise because of fetal hypoxia. The glucose is competing with oxygen that should
be delivered to the baby. Moreover, maternal ketoacidosis were also found to cause fetal
death.

DIABETES IN Pregnancy Page 38 of 84

 FETAL EFFECTS
HYDRAMNIOS

Women with elevated HbA1c values in

the third trimester were more likely to
have hydramnios.

Amnionic fluid index (AFI) >24 cm

Poor maternal glucose control is

associated with macrosomia and
hydramnios.

A likely explanation is that fetal

hyperglycemia cause fetal polyuria.

HYDRAMNIOS
Diabetic pregnancies are often complicated by excess amnionic fluid.

Women with elevated

HbA1c values in the third trimester were more likely to have hydramnios according to
some studies (Idris, 2010).

Hydramnios is defined as an
amnionic fluid index (AFI) >24 cm.

They also found that poor maternal glucose control was associated with macrosomia and
hydramnios (Vink, 2006). A likely—albeit unproven—explanation is that fetal
hyperglycemia causes fetal polyuria.

DIABETES IN Pregnancy Page 39 of 84

 NEONATAL EFFECTS
RESPIRATORY DISTRESS SYNDROME
Newborns of diabetic mothers were thought to be
at increased risk for respiratory distress from
delayed lung maturation.

Gestational age rather than overt diabetes is

likely the most significant factor associated with
respiratory distress syndrome.

HYPOGLYCEMIA
This is attributed to hyperplasia of the fetal β-islet
cells induced by chronic maternal hyperglycemia.

Low glucose concentrations— defined as < 45

mg/dL—are particularly common in newborns of
women with unstable glucose concentrations
during labor

Early feeding is advocated

NEONATAL =. problems at or during delivery

RESPIRATORY DISTRESS SYNDROME

Newborns of diabetic mothers were thought to be at increased risk for respiratory distress
from delayed lung maturation.

But studies suggest otherwise, rather, gestational age rather than overt diabetes is likely
the most significant factor associated with respiratory distress syndrome.

Diabetes does not appear to alter the beneficial effects of antenatal corticosteroids
to hasten lung maturity.

HYPOGLYCEMIA
Newborns of a diabetic mother experience a rapid drop in plasma glucose concentration
after delivery. This is attributed to hyperplasia of the fetal β-islet cells induced by chronic
maternal hyperglycemia.
Low glucose concentrations— defined as < 45 mg/dL—are
particularly common in newborns of women with unstable glucose concentrations during
labor.

Frequent blood glucose

measurements in the newborn and active early feeding practices can mitigate this
complication.

DIABETES IN Pregnancy Page 40 of 84

 NEONATAL EFFECTS
HYPOCALCEMIA

Defined as a total serum calcium concentration

< 8 mg/dL in term newborns.

HYPERBILIRUBINEMIA and POLYCYTHEMIA

Polycythemia is thought to be a fetal response

to relative hypoxia. this hypoxia leads to
increased fetal erythropoietin levels and red cell
production.

DUNN PM. NEONATAL POLYCYTHAEMIA, BLOOD VISCOSITY, MICROCIRCULATORY

HAEMOLYSIS AND JAUNDICE. WEST OF ENGLAND MEDICAL JOURNAL SEPTEMBER 2017

HYPOCALCEMIA
Early-onset hypocalcemia
is one of the potential metabolic derangements in neonates of diabetic mothers. Its cause
is unclear.

HYPERBILIRUBINEMIA AND POLYCYTHEMIA

Polycythemia is thought to be a fetal response to relative hypoxia. this hypoxia leads to
increased fetal erythropoietin levels and red cell production.

According to Hay (2012), the sources of this fetal hypoxia are hyperglycemia-mediated
elevations in maternal affinity for oxygen and fetal oxygen consumption.

DIABETES IN Pregnancy Page 41 of 84

 NEONATAL EFFECTS
CARDIOMYOPATHY
May have hypertrophic cardiomyopathy that
primarily affects the interventricular septum

CAUSE: insulin excess

May lead to obstructive cardiac failure

COGNITIVE DEVELOPMENT
CHARGE study: Autism spectrum disorders (ASD)
or developmental delay were more common in
children of diabetic women

INHERITANCE OF DIABETES
3-5% risk for Type 1 diabetes if either parent is
affected
40% risk for Type 2 diabetes if both parents are
affected

CARDIOMYOPATHY
Newborns of pregestational and gestational diabetic pregnancies frequently have
hypertrophic cardiomyopathy. This remodeling can be associated with cardiac
dysfunction.

In one study, they propose that pathological ventricular hypertrophy in neonates

born to women with diabetes is due to insulin excess. In severe cases, this may eventually
lead to obstructive cardiac failure.

COGNITIVE DEVELOPMENT
Results from the Childhood Autism Risks from Genetics
and the Environment (CHARGE) study indicated that autism spectrum disorders or
developmental delay also were more
common in children of diabetic women.

INHERITANCE
The risk of developing type 1 diabetes if either parent is affected is 3 to 5 percent. type 2
diabetes has a much stronger genetic
component. If both parents have type 2 diabetes, the risk of their offspring developing it
approaches 40 percent.

**picture inset
The picture here is of massive cardiomegaly (cardiac contour is massively widened with a
CTR over 80%) in a term neonate with respiratory distress, but no evidence of overload
(no alveolar or

DIABETES IN Pregnancy Page 42 of 84

interstitial edema, or pleural effusion).

While the vast majority of neonates with this degree of cardiomegaly, will have a structural
cardiac defect, the lack of secondary signs point to a narrower differential that includes
neonatal cardiomy opathy.

DIABETES IN Pregnancy Page 43 of 84

 MATERNAL EFFECTS OF
OVERT DIABETES

DIABETES IN Pregnancy Page 44 of 84

 MATERNAL EFFECTS
01 PREECLAMPSIA
In one study, preeclampsia developed three
to four times more often in women with
overt diabetes.

Diabetics with coexistent chronic

hypertension were almost 12 times more
likely to develop preeclampsia

Low-dose aspirin given preventively

02 DIABETIC NEPHROPATHY
Clinically detectable nephropathy begins
with microalbuminuria 30 to 300 mg/24
hours.

Macroalbuminuria—more than 300 mg/24

hours—develops in patients destined to have
end stage renal disease.

PREECLAMPSIA
Pregnancy-associated hypertension is the complication that most often forces preterm
delivery in diabetic women.

Moreover, those diabetics with coexistent chronic hypertension were almost 12 times
more likely to develop preeclampsia.

Preventively, low-dose aspirin prophylaxis is recommended

in women at high risk of preeclampsia, which includes those with type 1 or type 2
diabetes.

DIABETIC NEPHROPATHY
Clinically detectable
nephropathy begins with microalbuminuria, recognized as 30 to 300 mg of protein in a 24-
hour urine collection specimen. This may manifest as early as 5 years after diabetes onset.

In general, pregnancy does not appear to worsen diabetic

nephropathy, as most of these women had only
mild renal impairment.

DIABETES IN Pregnancy Page 45 of 84

 MATERNAL EFFECTS
03 DIABETIC RETINOPATHY
Retinal vasculopathy is a highly
specific complication of both type 1
and type 2 diabetes.

The first and most common visible

lesions are small microaneurysms
followed by blot hemorrhages that
form when erythrocytes escape from
the aneurysms

Retinal assessment after first prenatal

visit

04 DIABETIC NEUROPATHY
Uncommon in pregnant women

Diabetic gastropathy → causes nausea

and vomiting, nutritional problems, and
difficulty with glucose control.

DIABETIC RETINOPATHY
Retinal vasculopathy is a highly specific complication of both type 1 and type 2 diabetes.

The first and most common visible lesions are small microaneurysms followed by blot
hemorrhages that form when erythrocytes escape from the aneurysms

The American Academy of Ophthalmology (2019) recommends that pregnant women
with overt diabetes should be offered retinal assessment after the first prenatal visit.
Subsequent eye examinations depend on severity of retinopathy
and level of glucose control. Currently, most agree that laser photocoagulation and good
glycemic control during pregnancy minimize the potential for deleterious effects of
pregnancy.

DIABETIC NEUROPATHY
Peripheral symmetrical sensorimotor diabetic neuropathy is uncommon in pregnant
women. But a form of this, known as
diabetic gastropathy
→ causes nausea and vomiting, nutritional problems, and
difficulty with glucose control.

DIABETES IN Pregnancy Page 46 of 84

 MATERNAL EFFECTS
05 DIABETIC KETOACIDOSIS
Most often encountered in women with type
1 diabetes.

May develop with hyperemesis gravidarum,

infection, insulin noncompliance, insulin
pump failures, β-mimetic drugs given for
tocolysis, and corticosteroids.

DKA results from an insulin deficiency

combined with an excess in counter-
regulatory hormones such as glucagon.

06 INFECTIONS
Common infections
vulvovaginitis,
include
bacterial
Candidal
urinary and
respiratory tract infections, and puerperal
pelvic sepsis.

KETOACIDOSIS
This serious complication develops in approximately 1% of diabetic pregnancies and is
most often encountered in women with type 1 diabetes.

Diabetic ketoacidosis (DKA) may develop with hyperemesis gravidarum, infection, insulin
noncompliance, insulin pump failures, β-mimetic drugs given for tocolysis, and
corticosteroids given to induce fetal lung maturation.

DKA results from an insulin deficiency combined with an excess in counter-regulatory

hormones such as glucagon. This leads to gluconeogenesis
and ketone body formation.

An important cornerstone o management is vigorous rehydration with crystalloid

solutions of normal saline
or Ringer lactate.

INFECTIONS
The rates of many infections are higher in diabetic pregnant women. Common ones
include candidal vulvovaginitis, bacterial urinary and respiratory tract infections, and
puerperal pelvic sepsis.

DIABETES IN Pregnancy Page 47 of 84

 MANAGEMENT OF
OVERT DIABETES

DIABETES IN Pregnancy Page 48 of 84

 PRECONCEPTIONAL CARE
HbA1c level <6.5 percent as optimal glycemic control in women with
pregestational diabetes to minimize early pregnancy loss and congenital
malformations

Optimal preconceptional glucose control in those using insulin:

70 to 100 mg/dL - preprandial glucose levels
100 to 120 mg/dL at peak 2 hour postprandial level
<110 mg/dl mean daily glucose concentration

1ST TRIMESTER 2ND TRIMESTER 3RD TRIMESTER

To minimize early pregnancy loss and congenital malformations, the National

Preconception Health and Healthcare Initiative Clinical Workgroup established values for
optimal glycemic
control before conception (Frayne, 2016). This was defined as a HbA1c level <6.5 percent
in women with pregestational diabetes.

The American Diabetes Association (2017b) has also defined optimal preconceptional
glucose control in those using insulin.
Refective values are self-monitored preprandial glucose levels of 70 to 100 mg/dL, peak
2-hour postprandial values of 100 to
120 mg/dL, and mean daily glucose concentrations <110 mg/dL.

DIABETES IN Pregnancy Page 49 of 84

 FIRST TRIMESTER
The gravida with overt diabetes is best treated with insulin

Adjunctive metformin therapy was associated with improved glycemic control,

reduced maternal weight gain, lower cesarean delivery rate, and less neonatal
adiposity

Maternal glycemic control can usually be achieved with multiple daily insulin
injections and adjustment of dietary intake.

1ST TRIMESTER 2ND TRIMESTER 3RD TRIMESTER

FIRST TRIMESTER
The gravida with overt diabetes is best treated with insulin. Although oral hypoglycemic
agents have been used successfully
for gestational diabetes (p. 1083), these agents are not currently recommended or overt
diabetes.

In an international trial, they found that adjunctive

metformin therapy was associated with improved glycemic control, reduced maternal
weight gain, lower cesarean delivery rate, and less neonatal adiposity.

Maternal glycemic control can usually be achieved with multiple daily insulin injections
and adjustment of dietary intake.

DIABETES IN Pregnancy Page 50 of 84

 A MONITORING
Self monitoring
monitoring)
is recommended (CBG

B DIET
Nutritional planning
Minimum of 175 g/d of carbohydrates is
ideal

Allotted carbohydrates are distributed

throughout the day in three small- to
moderate-sized meals and two to four
snacks.

Weight loss is not recommended but modest

caloric restriction may be appropriate for
overweight or obese women

C HYPOGLYCEMIA
Diabetic control can be unstable in the first
half of pregnancy

Blood glucose values <40 mg/dL

MONITORING
Self - monitoring of capillary glucose levels using a glucometer is recommended because
this involves the woman in her own care.

The American Diabetes Association (2017b) recommends fasting and postprandial glucose
monitoring, and this table lists the glucose goals recommended in pregnancy.

DIET
When it comes to diet, this refers to nutritional planning including appropriate weight gain
through carbohydrate and caloric modifications based on height, weight, and degree of
glucose intolerance (American Diabetes Association, 2012)

A minimum of 175 g/d of carbohydrates ideally is provided.

Allotted carbohydrates are distributed throughout the day in three small- to moderate-
sized meals and two to four snacks. Weight
loss is not recommended, but modest caloric restriction may be appropriate for
overweight or obese women.

An ideal dietary
composition is 55 percent carbohydrate, 20 percent protein, and 25 percent fat, of which
<10 percent is saturated fat.

DIABETES IN Pregnancy Page 51 of 84

HYPOGLYCEMIA
Diabetic control can be unstable in the first half of pregnancy and the incidence of
hypoglycemia peaks during the first trimester.

One study found hypoglycemic events—blood glucose values <40 mg/dL—in 37 of 60

women with type 1 diabetes.

DIABETES IN Pregnancy Page 52 of 84

 SECOND TRIMESTER
Alpha-fetoprotein at 16 to 20 weeks' gestation

Fetal echocardiography in order to detect any cardiac anomaly

5x increased risk for cardiac anomalies

Targeted ultrasound / congenital anomaly scan at 18-20 weeks to detect presence

of NTDs

Normoglycemia with self-monitoring continues to be the goal in glucose control

1ST TRIMESTER 2ND TRIMESTER 3RD TRIMESTER

SECOND TRIMESTER
Maternal serum alpha-fetoprotein determination at 16 to 20 weeks’ gestation is used in
association with targeted sonographic
examination to detect neural-tube detects and other anomalies.

**→if elevated, request ultrasound

**overt DM is associated with congenital malformations

Because the incidence of congenital cardiac anomalies shown in Table 60-6 is increased
fivefold in mothers with diabetes, fetal echocardiography is an important part of second
trimester sonographic evaluation.

Regarding second-trimester glucose control, normoglycemia

with self-monitoring continues to be the goal. After the first
trimester's glucose instability, a stable period ensues. This is
then followed by higher insulin requirements. These stem from
the enhanced peripheral resistance to insulin that is related to pregnancy

DIABETES IN Pregnancy Page 53 of 84

 THIRD TRIMESTER CARE AND DELIVERY
ANTENATAL SURVEILLANCE at 32 to 34 weeks' gestation
Fetal movement counting
Periodic FHR monitoring
Doppler studies
Contraction Stress Testing
Nonstress Testing
Biophysical Scoring

With reassuring testing and no other complications, delivery is anticipated between

39 0/7 and 39 6/7 weeks.

1ST TRIMESTER 2ND TRIMESTER 3RD TRIMESTER

As mentioned, one of the complications of overt diabetes is fetal demise, and this
prompted recommendations for
various fetal surveillance programs beginning in the third trimester

The American College of Obstetricians and

Gynecologists (2020c, 2021) suggests initiating such testing at 32 to 34 weeks’ gestation.

With reassuring testing and no other complications, delivery is anticipated between 390/7
and 396/7 weeks.

DIABETES IN Pregnancy Page 54 of 84

 THIRD TRIMESTER CARE AND DELIVERY
Delivery is planned for 39 weeks’ gestation in those with good glycemic control and
reassuring antenatal testing

Earlier delivery is planned for those with poor glycemic control or significant comorbidities

Labor induction may be attempted when the fetus is not excessively large and the cervix is
favorable

Cesarean delivery at or near term has frequently been used to avoid the traumatic birth

1ST TRIMESTER 2ND TRIMESTER 3RD TRIMESTER

Delivery is planned for 39 weeks’ gestation in those

with good glycemic control and reassuring antenatal testing.

Earlier delivery is planned for those with poor glycemic control or significant
comorbidities.

For vaginal delivery, labor induction may be attempted

when the fetus is not excessively large and the cervix is considered favorable (Chap. 26, p.
486).

Cesarean delivery at or near

term has frequently been used to avoid the traumatic birth of a large fetus in a woman
with diabetes.

DIABETES IN Pregnancy Page 55 of 84

 THIRD TRIMESTER CARE AND DELIVERY
Reducing or withholding the dose of long-acting insulin on the day of delivery is
recommended.

Regular insulin should be used to meet most or all of the insulin needs of the mother

The woman should be adequately hydrated intravenously and given glucose in sufficient
amounts to maintain euglycemia.

Capillary or plasma glucose levels are checked hourly during active labor

Reducing or withholding the dose of long-acting insulin on

the day of delivery is recommended.

Regular insulin should be

used to meet most or all o the insulin needs of the mother during this time, because
insulin requirements typically drop markedly after delivery.

During labor, continuous insulin infusion by

calibrated intravenous pump is most satisfactory (Table 60-10).

The woman should be adequately hydrated intravenously and

given glucose in sufficient amounts to maintain euglycemia.

Capillary or plasma glucose levels are checked hourly during active labor, and regular
insulin is administered accordingly

DIABETES IN Pregnancy Page 56 of 84

 GESTATIONAL DIABETES
MELLITUS

DIABETES IN Pregnancy Page 57 of 84

 GESTATIONAL DIABETES MELLITUS
Pregnancy is potentially DIABETOGENIC
Normal pregnancy is characterized by mild fasting hypoglycemia , post prandial
hyperglycemia & hyperinsulinemia.

Pregnancy induced state of peripheral resistance to insulin

Reduced peripheral uptake of glucose due to insulin resistance
Increased insulin response due to elevated glucose

Who are the culprits?

Estrogen, Progesterone, Human Chorionic Somatomammotropin (human placental lactogen)

These are the patients with no history of DM prior to pregnancy.

The word gestational implies that diabetes is induced by

pregnancy— ostensibly because of exaggerated physiological changes in glucose
metabolism

Gestational diabetes
is defined as carbohydrate intolerance of variable severity with its onset or first
recognition during pregnancy (American College of Obstetricians and Gynecologists,
2019a).

Pregnancy is potentially DIABETOGENIC

Normal pregnancy is characterized by mild fasting hypoglycemia , post prandial
hyperglycemia & hyperinsulinemia.
▪ In healthy pregnant women the fasting plasma glucose concentration falls somewhat
possibly due to increased plasma levels of insulin.

DIABETES IN Pregnancy Page 58 of 84

 SCREENING AND DETECTION
All pregnant women should be screened for GDM with a laboratory-based screening test
using blood glucose levels.
Screening for gestational diabetes should be performed between 24 and 28 weeks age of
gestation

Early pregnancy screening for undiagnosed type 2 DM...is suggested in overweight and
obese women with additional diabetic risk factors, including those with a prior history of
GDM.

(3rd bullet)
Early pregnancy screening for undiagnosed type 2 DM, preferably at the initiation of
prenatal care, is suggested in overweight and obese women with additional diabetic risk
factors, including those with a prior history of GDM.

DIABETES IN Pregnancy Page 59 of 84

 SCREENING AND DETECTION

ACOG Committee on Obstetric Practice. Screening and Diagnosis of Gestational Diabetes Mellitus.
Practice Bulletin Number 190, February 2018

DIABETES IN Pregnancy Page 60 of 84

 ACOG Committee on Obstetric Practice. Screening and Diagnosis of Gestational Diabetes Mellitus.
Practice Bulletin Number 190, February 2018

Despite years of research, there is still no agreement on the optimal screening method for
gestational diabetes.

ACOG (2019a) recommends a screening using 50-g screening test is followed by a

diagnostic 100-g, 3-hour oral glucose tolerance test (OGTT) , if screening results meet or
exceed a predetermined plasma glucose concentration.

For the 50-g screening test, the plasma glucose level is measured 1 hour after a 50-g oral
glucose load without regard to the time of day or time of last meal.

Determine plasma sugar after hour – if 130 - 140mg/dl, do 100 grams OGTT after 8- 14
hours fasting**

**institutional screening thresholds for the 1 hr GCT vary from 130-140 mg/dl. At present,
there are no randomized trials that have examined whether one cut off is more effective
that the other.

Different cut-offs for the 3 hr OGTT have also been proposed (CC and NDDG). One cannot
be clearly recommended over the other due to lack of or absence of clear comparative
trials.

DIABETES IN Pregnancy Page 61 of 84

In 2010, the International Association of Diabetes and Pregnancy Study Group (IADPSG)
recommended that a universal 75-g, 2 hour OGTT be performed during pregnancy and that
the diagnosis of GDM be established when any single threshold value was met or
exceeded.

DIABETES IN Pregnancy Page 62 of 84

 SCREENING AND DETECTION

ACOG Committee on Obstetric Practice. Screening and Diagnosis of Gestational Diabetes

Mellitus. Practice Bulletin Number 190, February 2018

As of 2017, the ADA continues to recognize that there is an absence of clear evidence that
supports the IADPSG-recommended approach versus the more traditional two-step
screening approach.

DIABETES IN Pregnancy Page 63 of 84

 SCREENING AND DETECTION
As recommended by the WHO,
Universal screening for GDM is recommended for Filipino gravidas (during the first
prenatal care)
LEVEL III, GRADE B

Worldwide, the prevalence of GDM differs according to race, ethnicity, age, and body
composition and by screening and diagnostic criteria.

As recommended by WHO
▪ Universal screening for GDM is recommended for Filipino gravidas (during the first
prenatal care)
Level III, Grade B

DIABETES IN Pregnancy Page 64 of 84

 ALGORITHM FOR WOMEN LOW RISK FOR DIABETES MELLITUS

In our country, the Philippines, the Diabetes CPG has partially adopted the IADPSG
consensus by using the 75g OGTT for screening and diagnosing GDM.

DIABETES IN Pregnancy Page 65 of 84

 ALGORITHM FOR WOMEN HIGH RISK FOR DIABETES MELLITUS

DIABETES IN Pregnancy Page 66 of 84

 A1GDM - diet controlled GDM
A2GDM - medication requiring GDM
Williams Obstetrics, 26th ed.
ACOG Committee on Obstetric Practice. Screening and Diagnosis of
Gestational Diabetes Mellitus. Practice Bulletin Number 190, February 2018

ACOG
Women with GDM have a higher risk of developing preeclampsia (9.8% in those with a
fasting glucose less than 115 mg/dL and 18% in those with a fasting glucose greater than
or equal to 115 mg/dL) and...

undergoing a cesarean delivery (25% of women with

GDM who require medication and 17% of women with diet-controlled GDM underwent
cesarean delivery versus 9.5% of controls) (4, 5).

Furthermore, women with GDM have an increased risk of developing diabetes

(predominantly type 2 diabetes) later in life. It is estimated that up to 70% of women with
GDM will develop diabetes within 22-28 years after pregnancy (6-8).

The progression to diabetes also is influenced by race, ethnic-ity, and obesity. For
example, 60% of Latin American women with GDM may develop type 2 diabetes within 5
years of their index pregnancy (9).

Lasrly, similar to women

with overt diabetes, adverse maternal effects associated with gestational diabetes include
a higher frequency of hypertension
and cesarean delivery.

The offspring of women with GDM are at increased risk of macrosomia -- and the most
important

DIABETES IN Pregnancy Page 67 of 84

perinatal correlate with GDM is excessive fetal growth, which may result in both maternal
and
fetal birth trauma. That is why the perinatal goal is to avoid difficult delivery from
macrosomia and concomitant birth trauma associated with
shoulder dystocia.

The excessive shoulder

and trunk fat that commonly characterizes the macrosomic
newborn of a diabetic mother predisposes such neonates to
shoulder dystocia or cesarean delivery.

Additionally, maternal body mass index (BMI) is an independent and

more substantial risk factor for fetal macrosomia than is glucose intolerance..., higher BMI
levels were associated with rising birthweight, regardless of glucose levels

Other fetal effects also include neonatal hypoglycemia, as hyperinsulinemia may provoke
severe neonatal hypoglycemia within minutes of birth. Hyperbilirubinemia, shoulder
dystocia, and birth trauma as mentioned.

There also is an increased risk of stillbirth, although how much this is related to glycemic
control is still debated. (WILLIAMS) But in one study, they found that women with
elevated fasting glucose levels have elevated rates of unexplained stillbirths similar to
those of women with overt diabetes.

Other studies have also demonstrated that fetal exposure to maternal diabetes
contributes to childhood and adulthood obesity, and diabetes in the offspring.

Unlike women with overt diabetes, women with gestational diabetes do not appear to have
fetuses with substantially higher
rates of anomalies than the general obstetrical population (American College o
Obstetricians and Gynecologists, 2019a; Sheffeld,
2002).

DIABETES IN Pregnancy Page 68 of 84

 BLOOD GLUCOSE MONITORING

Once a woman with GDM begins nutrition therapy (dietary counseling), surveillance of
blood glucose levels is required to confirm that glycemic control has been established.

Based on the data available, the general recommendation is for daily blood glucose
monitoring FOUR times a day, once after fasting and again 1 and 2 hrs after each meal.

The ADA and ACOG recommend the following fasting and post prandial values.

DIABETES IN Pregnancy Page 69 of 84

 7-PT CBG MONITORING

DIABETES IN Pregnancy Page 70 of 84

 MANAGEMENT ISSUES:
ANTEPARTUM
NUTRITIONAL THERAPY

Nutritional counseling by a registered

dietitian and development of a
personalized nutrition plan based on
the individual's body mass index for
all patients with GDM

If a dietitian is not readily available, a

clinician should be able to provide
recommendations to the patient
based on three major nutritional
components:
caloric allotment,
carbohydrate intake, and
caloric distribution

ACOG Committee on Obstetric Practice. Screening and Diagnosis of Gestational

Diabetes Mellitus. Practice Bulletin Number 190, February 2018

The goal of medical nutrition therapy in women with GDM is to achieve normal blood
glucose levels, prevent ketosis, provide adequate weight gain, and contribute to
appropriate fetal growth and development.

The ADA recommends nutritional counseling by a registered dietitian and development of

a personalized nutrition plan based on the individual's body mass index for all patients
with GDM (19). In some clinical settings in which a dietitian is not readily available, a
clinician should be able to provide recommendations to the patient based on three major
nutritional components:
1) caloric allotment, 2) carbohydrate intake, and 3) caloric distribution.

A diet composed of 50-60% carbohydrates often will result in excessive weight gain and
postprandial hyperglycemia. Therefore, it has been suggested that carbohydrate intake
be limited to 33-40% of calories, with the remaining calories divided between protein
(20%) and fat (40%).

Given the results of other treatment trials, complex carbohydrates are recommended over
simple carbohydrates because they are digested more slowly, are less likely to produce
significant postprandial hyperglycemia, and potentially reduce insulin resistance

In practice, 3 meals + 2-3 snacks are recommended to distribute carbohydrate intake and
to reduce postprandial glucose fluctuations.

According to Williams, this includes a caloric intake of 30 to 35 kcal/kg/d.

DIABETES IN Pregnancy Page 71 of 84

EXERCISE
In adults with diabetes who are not pregnant, exercise- particularly weight training_
increases lean muscle mass and improves tissue sensitivity to insulin. In overweight or
obese women with GDM, exercise also may be able to improve glycemic control.
Therefore, a moderate exercise program is recommended as part of the treatment plan
for women with GDM (19). Such a plan should mirror diabetes care in general, and women
with GDM should aim for 30 minutes of moderate-intensity aerobic exercise at least 5
days a week or a minimum of 150 minutes per week (31). Simple exercise such as walking
for
10-15 minutes after each meal can lead to improved glycemic control and is commonly
recommended.

DIABETES IN Pregnancy Page 72 of 84

 MANAGEMENT ISSUES:
ANTEPARTUM
PHARMACOLOGIC THERAPY

INSULIN has been considered the

standard therapy for DM
management in cases refractory
to nutrition therapy and exercise

For long-acting and intermediate

acting insulin
NPH insulin
Insullin glargine
Insulin detemir

Short-acting insulin
Insulin lispro
Insulin aspart

ACOG Committee on Obstetric Practice. Screening and Diagnosis of

Gestational Diabetes Mellitus. Practice Bulletin Number 190, February 2018

Pharmacological
methods are usually recommended if diet modification does
not consistently maintain the fasting plasma glucose levels <95 mg/dL or the 2-hour
postprandial plasma glucose <120 mg/dL
(American College o Obstetricians and Gynecologists, 2019a).

Insulin historically has been considered the standard therapy for DM management in
cases refractory to nutrition therapy and exercise and this has continued to be reinforced
by the ADA.

Insulin, which does not cross the placenta, can achieve tight metabolic control and
traditionally has been added to nutrition therapy if fasting blood glucose levels
consistently are greater than or equal to 95 mg/dL, if 1-hour levels consistently are
greater than or equal to 140 mg/dL, or if 2-hour levels consistently are greater than or
equal to 120 mg/dL.

If insulin is used throughout the day in women in whom fasting and postprandial
hyperglycemia are present after most meals, a typical starting total dosage is 0.7-1.0
units/kg daily. This dosage should be divided with a regimen of multiple injections using
long-acting or intermediate-acting insulin in combination with short-acting insulin.

However, if there are only isolated abnormal values at a specific time of day, focusing the
insulin regimen to correct the specific hyperglycemia is preferred. For example, in women
with only elevated fasting values, nighttime administration of intermediate-acting insulin,
such as NPH insulin, may be adequate. Similarly, in women with elevated values only for
breakfast

DIABETES IN Pregnancy Page 73 of 84

postprandial, short-acting insulin before breakfast may be the only insulin needed.
Regardless of the starting dosage, subsequent dosage adjustments should be
individualized according to the woman's monitored blood glucose levels at particular
times of the day.

For long-acting and intermediate acting insulin, NPH insulin has been the mainstay, but
more recently insulin glargine and insulin detemir have been prescribed for long acting
use.

For short acting insulin, insulin analogues -- including insulin lispro and insulin aspart --
have been used in pregnancy and they do not cross the placenta.

Insulin lispro and aspart should be used preferentially over regular insulin because both
have a more rapid onset of action, enabling the patient to administer her insulin right at
the time of meal rather than 10-15mins before an anticipated meal. This provides better
glycemic control and helps avoid hypoglycemic episodes from errors in timing.

DIABETES IN Pregnancy Page 74 of 84

 MANAGEMENT ISSUES:
ANTEPARTUM
ORAL ANTIDIABETIC MEDICATIONS

METFORMIN and GLYBURIDE

long term metabolic influence
to offspring is unknown

differences between neonates

delivered to women in
metformin vs insulin were
MINIMAL

lacks superiority when

compared with insulin

long term outcomes have not

been fully studied

ACOG Committee on Obstetric Practice. Screening and Diagnosis of

Gestational Diabetes Mellitus. Practice Bulletin Number 190, February 2018

Oral antidiabetic medications (eg, metformin and glyburide) increasingly are being used
among women with GDM, despite the fact that they have not been approved by the U.S.
Food and Drug Administration for this indication and even though insulin continues to be
the ADA-recommended first-line therapy.

METFORMIN
Metformin is a biguanide that inhibits hepatic gluconeogenesis and glucose absorption
and stimulates glucose uptake in peripheral tissues. Historically, metformin primarily has
been used in women with pre-gestational diabetes or those with polycystic ovary
syndrome and infertility.

ADA continues to recommend that when pharmacologic treatment of GDM is indicated,

INSULIN is still considered the preferred treatment. Although metformin may be a
reasonable alternative in women who decline insulin therapy or for women who cannot
afford insulin.

GLYBURIDE
is a sulfonylurea that binds to pancreatic beta cell ATP potassium channel receptors to
increase insulin secretion and insulin sensitivity of peripheral tissues.

Previous metaanalyses have noted increased risk of macrosomia and hypoglycemia with
Glyburide use as compared with insulin

DIABETES IN Pregnancy Page 75 of 84

 MANAGEMENT ISSUES: ANTEPARTUM

A1GDM - diet controlled GDM ACOG Committee on Obstetric Practice. Screening and Diagnosis of
A2GDM - medication requiring GDM Gestational Diabetes Mellitus. Practice Bulletin Number 190, February 2018

On medication (A2GDM) with poor control and without co-morbidities: 32 weeks

Begin earlier if other co-morbidities are present

Fetal assessment for A2GDM in general is usually recommended based on the

understanding that there may have been poor control at some point during the pregnancy

Well controlled on diet (A1GDM): no consensus due to lack of data demonstrating stillbirth
risk

Fetal assessment may not be necessary but if performed

Usually begun later than A2GDM and can be based on local practice

Include amniotic fluid volume assessment due to risk of polyhydramios

DIABETES IN Pregnancy Page 76 of 84

 TIMING OF DELIVERY

A1GDM - diet controlled GDM ACOG Committee on Obstetric Practice. Screening and Diagnosis of
A2GDM - medication requiring GDM Gestational Diabetes Mellitus. Practice Bulletin Number 190, February 2018

I. TIMING OF DELIVERY
▪ The timing of delivery should be individualized depending on the glucose control and
whether the patient has any concomitant maternal and / or fetal complications (Savona-
Ventura C. CPG, Management
of DM during Pregnancy)

Delivery in the late preterm period from 34 0/7 weeks to 36 6/7 weeks should be reserved
for those women with failed in-hospital attempts to improve glycemic control and those
with abnormal antepartum fetal testing (ACOG 2018)

- Expert opinion have supported earlier delivery for women with poorly controlled GDM,
delivery between 37 0/7 weeks to 38 6/7 weeks may be justified.

▪ Women with GDM that is well-controlled by medications (A2GDM), delivery is

recommended at 39 0/7 to 39 6/7 weeks AOG. (ACOG 2018)

▪ Patients with well-controlled DM on diet and exercise and with no complicating factors
may await spontaneous labor until 40 weeks and induce
thereafter. (ACOG 2018, POGS CPG Guidelines on DM in Pregnancy 2019)

▪ Elective cesarean section in patients with GDM must be

performed at 39 weeks (POGS CPG on Hyperglycemia in Pregnancy 2019)

DIABETES IN Pregnancy Page 77 of 84

Elective cesarean delivery to avoid brachial plexus injuries in overgrown fetuses is also an
important issue. The American
College of Obstetricians and Gynecologists (2013) has
suggested that cesarean delivery should be considered in women with gestational
diabetes whose fetuses have a
sonographically estimated weight ≥ 4500 g.

▪ Deliver a patient with DM before 39 weeks AOG only for

compelling maternal or fetal indications (Morre TR, Smith CV. DM and Pregnancy April
2011)

DIABETES IN Pregnancy Page 78 of 84

 MANAGEMENT OF POST-PARTUM SCREENING RESULTS

Williams Obstetrics, 26th ed.

American Diabetes Association, 2013
ACOG Committee on Obstetric Practice. Screening and Diagnosis of Gestational Diabetes
Mellitus. Practice Bulletin Number 190, February 2018

DIABETES IN Pregnancy Page 79 of 84

IN summary,

DIABETES IN Pregnancy Page 80 of 84

 COURSE IN THE WARDS
Patient delivered via Low Transverse Cesarean Section to a term live
baby girl and tolerated procedure well.

At the wards, patient had no episodes of profuse bleeding or severe

hypogastric pain. Patient is freely voiding and vital signs stable.

Started on oral medications of Cefuroxime, Mefenamic acid and

Ferrous sulfate.

The rest of the hospital stay was unremarkable. Change of dressing

done prior discharge.

Patient deemed fit for discharge.

DIABETES IN Pregnancy Page 81 of 84

 DISCHARGE PLAN
For 75g OGTT 4-12 weeks post-partum

Take home meds:

1. Cefuroxime 500mg/cap 1 capsule every 12 hours to complete for 7 days
2. Mefenamic Acid 500mg/cap 1 capsule every 8 hours as needed for pain
3. Ferrous Sulfate 325mg/cap 1 capsule every other day to complete for 90 days

Encourage exclusive breastfeeding

Daily body and perineal hygiene

To OB ER anytime if with profuse vaginal bleeding, severe hypogastric pain

Follow up at OB OPD face-to-face for removal of end sutures on August 24, 2023,
11am

Well-advised

DIABETES IN Pregnancy Page 82 of 84

 FINAL DIAGNOSIS
G3P3 (3003) Pregnancy Uterine
Delivered term, frank breech, live baby girl
AS 9,9 BW 4.08 kg BL 54 cm MI 40 weeks LGA
Gestational Diabetes Mellitus, diet- controlled
Previous CS x 2 (I - 2010, OSMAK; II - 2012, OSMAK)

By emergency LTCS III followed by bilateral salpingectomy under CSEA

(08/02/2023)

DIABETES IN Pregnancy Page 83 of 84

 THANK YOU!

REFERENCES
1. Williams Obstetrics 26th edition
2. Clinical Practical Guidelines on Diabetes Mellitus in Pregnancy, Third Edition, November 2018, Philippine Obstetrical and Gynecological
Society (Foundation), Inc. (POGS)
3. ACOG Committee on Obstetric Practice. Screening and Diagnosis of Gestational Diabetes Mellitus. Practice Bulletin Number 190,
February 2018

DIABETES IN Pregnancy Page 84 of 84