Diabetes in Pregnancy

Objectives

1) Define Diabetes Mellitus

2) Explain the functions of insulin and its Antagonist.
3) State the incidence
4) Identify the classifications of Diabetes.
5) Review the signs and symptoms of Diabetes in Pregnancy.
6) Identify the diagnosis of Diabetes on pregnancy.
7) Identify the effects of pregnancy on diabetes.
8) Identify the effects of diabetes on pregnancy.
9) Discuss the management of diabetes in pregnancy, labour and
puerperuim.
10)Discuss advice to the mother on future pregnancies.

Define Diabetes Mellitus

An endocrine disorder that involves disruption of normal carbohydrate

metabolism due to an insufficient amount of insulin produced by the islets of
langerhan in the pancreas. This metabolic defect manifests itself as
Hyperglycaemia and glycosuria.

N.B.
Insulin – a poly peptide secreted by the Beta cells of the islets of langerhan which
controls the metabolism of carbohydrates and interacts with the metabolism of
proteins and lipids.

Actions of Insulin – (is to enhance cellular uptake of glucose as a substrate for

cellular metabolism). Restrains the excessive breakdown of glycogen fat and
protein to glucose.

- Insulin secretion is subnormal blood glucose level will rise

- In stress conditions, glucagons output is increased to mobilize
sugar rapidly and at times aggravates the already high blood sugar.

Incidence of Diabetes

 More likely to be seen in patients over 35 years of age. The incidence of

pre-pregnancy diabetes is about 0.4% of the obstetric population.
 Gestational Diabetes occurs in about 4% or 4 in every hundred
pregnancies. for both groups combined the incidence is 0.5 – 1.0 per cent
or (1:200pts)

Identify/Describe the Classification of Diabetes in Pregnancy

Two main types of pre-pregnancy diabetes.
Type 1 – Juvenille onset
Type 11 – Adult onset.
Potential, latent, chemical, gestational diabetes over chemical prediabetes.
Type 1 (Juvenille Onset)

By insulin dependence, the presence of circulatory islet cell antibodies an onset

before 35 years and a tendency to ketacidosis. There is low or absent
endogenous insulin production.

Type II (Maturity Onset) Diabetes

Has non-insulin dependence, an absence of islet cell antibodies, an onset after

35 years and obesity but ketoacidosis is not common. There is a tendency to
high endogenous insulin production and insulin resistance.

1. Potential Diabets: where there is a normal glucose tolerance test (GTT)

but client has risk factors for developing diabetes for e.g.

a) strong family history of diabetes on both sides of the family near

relatives.
b) Previous pregnancies with large baby weighing >4.5kg.
c) Unexplianed stillbirths and neonatal deaths.
d) Chronic marked obesity.
e) Glycosuria to clinistix in a second fasting urine specimen in
pregnancy.

2. Latent Diabetes – Normal GTT (currently at present, but which becomes

abnormal under stress, obesity or when pregnant.

3. chemical Diabetes/Subclinical Diabetes abnormal glucose tolerance test

but without symptoms.

4. Gestational Diabetes can be defined as carbohydrate intolerance of

varying sverity with first onset or recognition during pregnancy. This
definition applies regardless of whether client is Rx ted with insulin or the
condition persists after pregnancy.

5. Over t/Clinical – client has abnormal glucose tolerance test with symptoms
and a raised fasting blood sugar level.

6. Prediabetes a term used only retrospectively to refer to the period before a

known diabetic develops an abnormal glucose T test.

Describe the signs and symptoms

 - Polyuria – (frequent urination)
- Polydipsia – (excessive thirst)
- Polyphagia – ( excessive hunger)
- Orthostatic dizziness (Dizziness on standing)
- Blurred Vision
- Ult loss – despite adequate food intake
- Pruritis – vulva or all over the body.
- Vaginal discharge with pruritis suggestive of infection with candida.
- Presence of sugar in the urine – glycosuria.
- Presence of acetone in the urine in absence of vomiting.
- Excessive tiredness

Discuss the Diagnosis of Diabetes in Pregnancy

The Diagnosis is based on history clinical manifestations and the results of

biochemical test/investigations.

Where pregnancy diabetes (any type) is present there is no need for further
confirmation during pregnancy.

a. History of diabetes in the family

b. Uloucer has given birth to one or more babies weighing
4.5kg and over macrosomia.
c. History of unexplained stillbirths/ HO repeated abortions.
d. Neonatal deaths.
e. H/O congenital anomalies (15% 1 – 1000 congenital heart
legions).
f. If random Bld sugar is done and Bld sugar level exceed 6.7
mniol/litre biochemical tests are done. And glucose results
shos over 8 minimal per litre diabetes.
g. S + S of polyuria and thirst are diagnostic symptoms.
h. Fasting blood sugar and 2 hours post prandial blood sugar
7.0 mmol/L or move

Normal Blood sugar level 3.8. – 6.1mmol/L

Effects of Diabetes (Childbearing) Pregnancy.

1. Infertility and abortion are more common especially if condition is severe.

2. prenatal mortality and morbidity are significantly higher in diabetic

pregnancies than in normal ones.

3. High incidence of congenital malformations especially oesophageal

atresia.
 4. Polyhydramnios – due to foetal polyuria – foetal hyperglycaemia.

5. Macro somia – large for dates foetus – marcosomia may result in cephato
– pelotic disproportion, prolonged or obstructed labour and impacted
shoulders during delivery.

6. Increase in ult of baby and placenta.

7. Higher incidence of pre eclampsia and eclampsia.

8. Infections especially genitourinary. Tract infection – more common and

over serious infections include bacteruria, chronic pyelonephritis vaginal
moniliasis.

9. If infant macrosomia and polyhdramnios present could lead to difficult

vaginal delivery and post partum haemorrhage.

10. Operative delivery especially C/S is more often necessary.

Effects of Pregnancy on Diabetes

Pregnancy increases the insulin requirements and also lowers the renal
threshold for sugar resulting in Glycosuria. At the end of pregnancy there is a
sharp reduction in insulin requirements. A potential effect is to accelerate the
progress of vascular disease that are secondary to diabetes. Careful
management can prevent or minimize the development of diabetic nephropathy
and retinopathy.

Effects on the Baby

- The baby is often overweight (excess fat and fluid), flabby, sleepy
and difficult to feed (macrosomia).
- There is tendency to hypo glycaemia atelectasis, hyaline
membrane disease which can lead to respiratory distress syndrome
(RDS)
- Small babies < 2.7kg caused by placental dysfunction.
- Congenital malformation
- The baby displays immature behaviour at birth and is usually
treated as premature infant.
- A close watch must kept on the blood sugar level and respiratory
functions.
- It is advisable to pass a N/G tube to rule out oesophageal atresia.
- The infant of the diabetic mother inherits a predisposition to
diabetes.

Management of the Diabetic in Pregnancy

The major objectives of care are:

1. Identification of women at risk for diabetes and the provision of

appropriate antenatal and intranatal perinatal care.

2. Maintainance of blood glucose levels that mimic normal physiological

levels in the pregnant woman. (e.g. fasting blood sugar <45mg/dl).

3. Provision of adequate client education and counseling for safe self-

management of mother and the fetus/newborn.

4. Prevention and early detection of potential complications of diabetes

during the entire childbearing cycle.

5. Promotion of a presitive psychosocial adjustments to childbearing through

understanding and acceptance of pregnancy and diabetes. Evidence
suggest that intensive diabetic substantically reduce perinatal morbidity
and mortality.

Previously as soon as a diagnosis was made the woman was made the
woman was admitted to hospital for stablization. However new
management, for the diabetic woman with no complications, is done at
home during the antenatal period. Regular monitoring of blood sugar
levels is done on an output basis.

One for screening GTTest is fasting blood sugar. Give 100gm of glucose to the
woman. Blood sugar done ½hr. 1hr. 2hrs. 3hrs. Urine tested for Glycosuria or
sullion test – requires no special procedure prior to testing and can be done at
anytime of day 3/7 before patient should have a high carbohydrate (CHO) intake
of 250mgs.

On the morning of the testing, woman is given 50gms of glucose orally then 1hr
later blood glucose is done. If value > 7.0mmol/L then a formal oral GTT should
be done. Usually the woman is admitted about the 16 th – 20th week gestation for
stabilization i.e. finding out the insulin requirements in order to prevent
glycosuria, hypo/hyperglycaemia.
- A series of blood sugar tests are done on alternate days. Fasting
and 2hrs post praudiol [pre prandial 5.5mmol/L].
- Insulin is given according to the blood sugar level. Urine tested
q4hrly <sugar acetone. Woman stated on soluble insulin. 0.7. units
per kg Biot per day.

At 26 weeks 0.8 units/kg Biot.

34 weeks 0.9 units/kg Biot.
Insulin adjusted to ut gain in pregnancy. Once blood sugar is controlled a switch
is made to leute insulin for convenience 2/3 rd of total dose of sol insulin is given in
lente e.g. 60 u/s sol then 40 u/s lente.

Diabenese is not recommended in early pregnancy it is associated with foetal

abnormalities. In late pregnancy the foetus may develop hypoglycaemia which is
difficult to control.

Diet: woman is usually put on at least 2000 calorie diabetic diet. referred to
dietitian who works out energy requirment base on uloomaus prepregnancy
B.M.I. and is discharged on Lente Insulin.

Clinical Visits: Clinic visits 2 weeks up to 32 weeks gestations. Thereafter –

weekly attendance to antenatal clinic (anc) is required. The urine is tested for
sugar and acetone at each visit.

- Fasting Blood Sugar and 2hr Post Prandial tests are also done.
- Assess the woman for signs of anaemia, Pre eclampsia and
infection.

Education Counselling

Advice her to keep her skin clean to prevent infection. The midwife should be
aware that these women are prone to genitourinary infection so particular
attention must be paid to her hygiene. She should educate the woman regarding
the signs and symptoms of infection and that she should seek treatment as soon
as possible if these occur.

For the Known Diabetic

The aim is to control the Diabetic and also avoid hypo glycaemia.
- To maintain a blood glucose level between 4.0 – 5.5 mmol/L, also
to ensure that Post Prandial Peak doesn’t exceed 7.2 mmol/L.
- Blood sample taken for estimation of glycosylated Haemoglobin
(HbA1) during the first trimester is associated with foetal
abnormality.

In the diabetic woman hyperglycaemia causes haemoglobin to become

irreversibly bound to glucose. This glycosylated HbA 1 normally occurs in 4 – 8%
of the woman’s total Hb. (Hollingsworth 1984).

Obstetric Management
Foetal wellbeing monitored closely.
Kick count 10 in 12hrs.
Cardio Tacography
Monitor growth by clinical exam and ultrasonography.
Biophysical profiles and Doppler blood flow studies.

Obstetric Care
Antenatal = 2 weeks to 32 weeks then weekly to term.
Incidence of pre eclampsia up with the diabetic patient. Therefore BP and urine
must be monitored Hospitalization before 38 weeks necessary only if P.E.
Polyhdramnios, foetal growth retardation, infection or inadequate control occur.

At 38 weeks = amniocentesis to estimate Lecthin Sphingomyelin Ration because

incidence of RDS in infant of diabetic woman. Pregnant women with well
controlled diabetes and no obstetric complications are usually delivered vaginally
at 38/40 by induction. Insulin given by sliding scak for poor diabetic control and
obstetric complications. Deliver woman by C/S earlier to avoid risk of intrauterine
death.

Readmission

The diabetic woman’s is normally readmitted between 30 – 32 nd week. However

in current management if well controlled woman is not readmitted. Serial
ultrasound is done to monitor fetal well-being each week and blood sugar, but if
blood sugar poorly controlled or signs of P.E. or infection occur woman is
readmitted.

Further investigation and stablization of blood sugar is done.

- an xray of the foetus is done to rule out abnormalities which will

influence the method of delivery.
- Blood sugar level estimated at least twice per week and soluble
insulin recommend
- Urine tested 4hourly for sugar and acetone.
- MSU to c/sensitivity.Hb also done.
- Vital signs done B/D if abnormalities detected do q4hrly.
- Sonar scanning done to assess gestational age serial Biparietal
cephalometry.
- Urinary Oestriol level done weekly to assess foetal growth. Human
placental lactogen. The patient usually starys in hospital until the
37th week. At this time a decision is made regarding induction of
labour or C/Section. Induction done I primip and multp with a
satisfactory history.

NB

If insulin requirements fall between the 30 – 37 th week this a sign of

impending foetal death.

Factors favouring surgical inductions and vaginal delivery include:

 - Mild Diabetes blood sugar 5.5.mmol/L
- Multiparity with previous normal delivery and normal sized baby.
- Goods obstetric history.

Criteria for c/section include:

- Previous c/section
- Unstable presentation
- Cephalo – Pelvic Disproportion
- Low Oestriol level
- If baby is in the Breech position (in a diabetic)

Management in Labour

In preparation for delivery of patient receives usual dose of insulin done and
eveing snack the day befor delivery. This should produce her normal glucose and
insulin level during morning fasting state. These schedule for elective caesarean
delivery (out labour) should have their operations does early in the morning.

Obstetrician and paediatrician should be present.

- nil by mouth
- glucose infusion given to ensure adequate hydration and calories to
prevent hypoglycaemia = A R M (artificial Rupture of Membranes)
- Oxytocin (drip) I.VI. set up
- ¼ hrly. Observations fo 7.H rate and maternal pulse.
- Soluble insulin dose given according to Dextrostix reading or insulin
glucose infusion is used for vaginal and cesearean electives in
some obstetrics units.
- If woman not delivered within 8 – 12 hrs. inform doctor. An
emergency ceasearean section is done. If c/s decided 2 – 4hrs
prior to the operation and soluble insulin given subcutaneously as
indicate by the result of the blood test. I.V. infusion of glucose is set
up if not already done.

Management of Woman in the Puerperium

Usually in the puerperium the blood sugar levels falls. Fasting and 2 hr post
provided test are done, the insulin requirements of the woman should be
yeasessed.
Avoid infection by careful Hygien and vulval toilet
Encourage the woman to breast feed her baby.

Complications
Acidotic coma is the major cause of maternal mortality in the pregnant diabetic
and foetal perinatal mortality.
Hyperglycaemia Coma
100 u/s Soluble Insulin Sol. Insulin 2 – 3 hrly.
2 bottles Molar lactate to Glucose drink
1 bottle normal saline potassium chloride
Signs Vomiting 29 – q 6H
Thirst when conscious
Drowsiness given per Os
Polyuria
Bounding pulse
Deep Sighing Resp.

Sepsis – must be treated with antibiotics.

Hypoglycaemia/insulin coma
Down BG 50mgs/D/L
Excessive physical activity
1 – 2 after sol. Insulin
4 – 18 hrs. after lente
Sweating, tremor
Headache palpitation
Confusion numbress
Double vision
Drowsiness coma
Treatment 30 – 50mls glucose.
Glucogon 1 – 2mgrs.

I.U. Death Diabetic coma if untreated insulin coma if not closely monitored.

Advice to motheron future pregnancies

- Patient should be advised to avoid over 3 pregnancies.
- Sterilization recommended after 3rd pregnancy.
- Termination if complications arise in the1st trimister
- Encourage medical follow up

 Definition
 Types
- Chemical
- Clinical
- Gestational
- Petential
- Latent

Describe effects of diabetes on Pregnancy.

  Maternal
- Abortion
- Polyhydramnios
- Infection
- Pre-eclampsia

 Foetus
- Infection
- High perinatal mortality rate
- Malformation
- Small for dates
- Risk of intra-uterine
- Prematurity
- Hypogylcaemia
- Birth Trauma (instruments).

Describe effects of Pregnancy on Diabetes

 diabetes Control
 Energy needs
 Insulin needs
 Renal threshold
 Complications

Management needs of Pregnant Client with Diabetes Mellitus

 Physiological Assessment
 Past Obstetrical History
 Inopection
 Investigations
- Urine
- Blood Sugar
- Glucose tolerance test.

Psychological Assessment
- Emotional stake
- Reaction to condition

Socio economic Staties

Management Plan and Implementation

 Medical/Obstetrician referral
 Diet therapy
 Blood sugar prohtes
 Monitoring maternal/foetal
 Weekly weight
 Hospital admission at 32 weeks
 Method of delivery at 36 – 38 weeks
 Psychological needs
- Mother
- Family

 Education Needs
- Future Pregnancies
- Sterilization
- Family Planning
- Tesmination complications