3. DM in Pregnancy
Important History
• Presenting complaint usually will be IOL i/v/o (state the
indication)
• If GDM ask:
• How? MOGTT
• Why?
- Body mass index >27 kg/m2
- Previous history of GDM
- First degree relative with diabetes mellitus
- History of macrosomia (birth weight >4 kg)
- Bad obstetric history
- Glycosuria ≥2+ on two occasions
- Current obstetric problems (essential hypertension, pregnancy-
induced hypertension, polyhydramnios and current use of
corticosteroids)
• When?
- At booking if has risk factor. No RF at 24w then repeat 28
• What’s the reading?
- 0 hr (>5.1) and 2HPP(>7.8)
- If 0 hr>7.0, 2HPP >11.0= overt DM
• Management
- On diet control? Usually assess glucose level for 1 to 2 weeks.
If poorly control start pharmaco
- Metformin? Max dose 1g BD
- Insulin? Usually basal bolus. Ask how many unit each time.
- Compliance to diet/meds? Any complication like hypoglycemia?
• Monitoring
- BSP
• Ask for frequency
o Pre breakfast, pre lunch, pre dinner, pre bed
o Diet control – every 4 weeks
o Insulin – every 2 weeks
• Range of reading (N= 4-6, specific fasting : <5.3,
1HPP<7.8, 2HPP<6.7)
o Controlled – all normal
o Suboptimal – 1 - 2 abnormal
o Poor controlled – 3 – 4 abnormal
• Complication and follow up
Mother Fetal Management
o Increase risk of pre eclampsia
o Recurrent Urinary tract infection
o Vaginal candidiasis
o Skin infection
o Macrosom ia
o Polyhydra mnions
o Congenital anomalies
Serial u/s
11-14w : early scan for dating scan
and major anomalies.
Every 4 weeks from 28w-36w to look
for fetal growth and AFI.
Detailed scan at 18 -20 w to look for
spine and heart problem
Urinalysis: to look for proteinuria,
leukocyte, nitrite for infection.
BP: increase risk for hpt
• History of GDM last pregnancy? Management? Any
complication? MOD?• If underlying DM ask:
- When diagnose?
- What medication?
- Hows sugar control before this?
- Any complication (TOD) develop? Any screening esp
retinopathy and nephropathy done during booking?
- Take folic acid prior to conception?
- Is she given aspirin antenatally?
- Is there any complication to mother and baby during
previous pregnancy like IUD, IUGR, neonatal
hypoglycemia
• Ask about symptoms of labour ( any contraction pain, leaking,
show) and fetal movement
Physical examination
◦ GENERAL :
◦ BMI (obese), BP (risk of getting PE), skin infection
(look at inframammary fold), injection mark of
insulin (look for lipodystrophy), FUNDOSCOPY for
retinopathy
◦ Per abdomen xm:
◦ uterus larger than date, polyhydramnions (positive
fluid thrill)
◦ or uterus smaller than date (IUGR)
◦ Speculum xm:
◦ curdy whitish discharge
Management
Antepartum care
1. Optimize blood sugar level
- Refer dietitian
- Lifestyle modification
- Insulin
2. Anticipate complication
3. Detailed ultrasound
4. Aim for delivery
- Diet control with no complication – allow delivery at term,
not allow postdate (IOL at 40 weeks)
- Diet control with compication – IOL at 38 weeks
- Insulin – IOL / ELSCS at 38 weeks
Intrapartum care
Before labour room
- Good glycemic control – avoid maternal hyper, baby hypo
- Stop s/c insulin
- FBC, GSH, RP
Labour room
- Upon arrival: check dxt
- Maintain dextrose 4-8
IF ON INSULIN
IF > 8
- Sliding scale = DIK regime: dextrose, insulin, kalium
- 500ml 0f D5% + 10 ml of 10% KCL (1 g)
- 2 IV line:
o IV dextrose 5 mixed with KCl, runs at 100 ml/hour
o 50 units of actrapid + 50 ml with NS (via sliding scale)
(1 unit/ml)
- Monitor dxt hourly, and adjust sliding scale- Urine ketone and serum potassium 4 hourly
- Always check hydration status
IF 4 - 8
- dxt hourly
IF < 4
- stop insulin infusion
- give 20 ml IV bolus dextrose 50% and infusion at 150
ml/hour
- recheck dxt after 30 minutes
IF DIET CONTROL – monitor 4 hourly
IF C-SECTION
- normal diet + insulin before
- KNBM by midnight
- Omit morning insulin
- If GA, check dxt every 30 minutes
After labour
MOTHER
- Stop insulin after placenta deliver
- Premeal dxt for at least 1 day
- If ≥ 7 give OHA/insulin
- Counselling – risk of GDM next pregnancy or DM later
- contraception
FETAL
- Breastfeed asap – avoid hypo baby
- Check dxt of baby & do neonatal blood sugar monitoring
(4-6 hourly for 1- 2 days)
- NICU – assess any complication (RDS, congenital
anomalies, hypoglycemia, polycythemia)
**DM – halved insulin until eat normal, then continue s/c
Post-partum
• Repeat MOGTT after 6 weeks :Negative →Screen annually
Discussion
1. Why GDM occur in pregnancy?
- Increase insulin sensitivity in 1st trimester + hyperplasia
of islet cell → Double insulin production
- 2nd trim – placenta – diabetogenic hormones →Insulin
resistance
o Human placental lactogen (hPL) – spare glucose to fetus
o Corticosteroid releasing hormones
o Cortisol
o Growth hormones
o Progesterones, estrogen – gluconeogenesis
o Glucagons
o TNF a
o leptin
- Hyperglycemia→glucose cross placenta, glycosuria
- Normal pregnancy – beta cells able to compensate
- GDM – insufficient beta cell/compensation
2. FPG & 2HPP level to diagnose? Refer above
3. Risk factors GDM/ MOGTT indications? refer above
4. How to do MOGTT
• Procedure
1) Normal diet 3 days prior
2) No smoking, drug, no infection
3) Fasting starts 12 am – plain water allowed4) 8 am take FBS
5) Ingest 75 g glucose + 250 ml water in 10 – 15 minutes
6) Then, rest, no heavy work, no exercise, no smoking
7) Take 1 HPP
8) Take 2 HPP
5. target control FPG, in between meals/pre meal, 1HPP & 2HPP?
Refer above
6. why do at 28 weeks MOGTT?
- Placenta starts to release diabetogenic hormones. Refer
answer no 1
7. frequency of BSP? Refer above
8. timing of delivery for DM complicating pregnancy & GDM
- Diet control with no complication – allow delivery at term,
not allow postdate (IOL at 40 weeks)
- Diet control with compication – IOL at 38 weeks
- Insulin – IOL / ELSCS at 38 weeks\
9. medical nutrition therapy
- CHO controlled meal plan
o Low GI index food
o Control CHO intake
o Control sugar
- Gestational weight gain
10. how to initiate insulin? (Nak pakai basal or bolus) **cpg gdm
pg 47**
- if FPG > 5.3: Start insulatard 0.2 unit/kg at bedtime.
Increase by 2 units every 3 day until reach target
- if 2HPP >6.7 or 1HPP>7.8: Start at 6 unit actrapid, increase
by 2 unit every 3 days until target are reached. If
preprandial actrapid dose >16unit TDS, consider adding 6-
10 units actrapid in morning and titrate accordingly until
targets are reached
11. Complications GDM (maternal & fetus, antenatal,
intrapartum, post partum)
Maternal Fetus
Antenatal • Skin infection
• Vaginal
candidiasis
Recurrent UTI
• Polyhydramnios→
preterm labour
and PPROM
• IUGR
Intrapartum Genital tract trauma
Operative delivery
• Macrosomia → birth
asphyxia & birth
trauma → shoulder
dystocia, clavicular
injury, Erb’s palsy
Postpartum Type 2 DM • Hypoglycemia
• HypoK, hypoMg,
hypoCa
• Polycythemia
• Hyperbilirubinemia12. how to monitor blood glucose intrapartum? Refer above
13. postpartum, continue/ stop insulin? Refer to management
post partum
14. when to repeat MOGTT postpartum?
• 6 weeks post partum
15. How to monitor dextrostix after giving IM Dexa in GDM/ DM
pt
Important History
• Presenting complaint usually will be IOL i/v/o (state the
indication)
• If GDM ask:
• How? MOGTT
• Why?
- Body mass index >27 kg/m2
- Previous history of GDM
- First degree relative with diabetes mellitus
- History of macrosomia (birth weight >4 kg)
- Bad obstetric history
- Glycosuria ≥2+ on two occasions
- Current obstetric problems (essential hypertension, pregnancy-
induced hypertension, polyhydramnios and current use of
corticosteroids)
• When?
- At booking if has risk factor. No RF at 24w then repeat 28
• What’s the reading?
- 0 hr (>5.1) and 2HPP(>7.8)
- If 0 hr>7.0, 2HPP >11.0= overt DM
• Management
- On diet control? Usually assess glucose level for 1 to 2 weeks.
If poorly control start pharmaco
- Metformin? Max dose 1g BD
- Insulin? Usually basal bolus. Ask how many unit each time.
- Compliance to diet/meds? Any complication like hypoglycemia?
• Monitoring
- BSP
• Ask for frequency
o Pre breakfast, pre lunch, pre dinner, pre bed
o Diet control – every 4 weeks
o Insulin – every 2 weeks
• Range of reading (N= 4-6, specific fasting : <5.3,
1HPP<7.8, 2HPP<6.7)
o Controlled – all normal
o Suboptimal – 1 - 2 abnormal
o Poor controlled – 3 – 4 abnormal
• Complication and follow up
Mother Fetal Management
o Increase risk of pre eclampsia
o Recurrent Urinary tract infection
o Vaginal candidiasis
o Skin infection
o Macrosom ia
o Polyhydra mnions
o Congenital anomalies
Serial u/s
11-14w : early scan for dating scan
and major anomalies.
Every 4 weeks from 28w-36w to look
for fetal growth and AFI.
Detailed scan at 18 -20 w to look for
spine and heart problem
Urinalysis: to look for proteinuria,
leukocyte, nitrite for infection.
BP: increase risk for hpt
• History of GDM last pregnancy? Management? Any
complication? MOD?• If underlying DM ask:
- When diagnose?
- What medication?
- Hows sugar control before this?
- Any complication (TOD) develop? Any screening esp
retinopathy and nephropathy done during booking?
- Take folic acid prior to conception?
- Is she given aspirin antenatally?
- Is there any complication to mother and baby during
previous pregnancy like IUD, IUGR, neonatal
hypoglycemia
• Ask about symptoms of labour ( any contraction pain, leaking,
show) and fetal movement
Physical examination
◦ GENERAL :
◦ BMI (obese), BP (risk of getting PE), skin infection
(look at inframammary fold), injection mark of
insulin (look for lipodystrophy), FUNDOSCOPY for
retinopathy
◦ Per abdomen xm:
◦ uterus larger than date, polyhydramnions (positive
fluid thrill)
◦ or uterus smaller than date (IUGR)
◦ Speculum xm:
◦ curdy whitish discharge
Management
Antepartum care
1. Optimize blood sugar level
- Refer dietitian
- Lifestyle modification
- Insulin
2. Anticipate complication
3. Detailed ultrasound
4. Aim for delivery
- Diet control with no complication – allow delivery at term,
not allow postdate (IOL at 40 weeks)
- Diet control with compication – IOL at 38 weeks
- Insulin – IOL / ELSCS at 38 weeks
Intrapartum care
Before labour room
- Good glycemic control – avoid maternal hyper, baby hypo
- Stop s/c insulin
- FBC, GSH, RP
Labour room
- Upon arrival: check dxt
- Maintain dextrose 4-8
IF ON INSULIN
IF > 8
- Sliding scale = DIK regime: dextrose, insulin, kalium
- 500ml 0f D5% + 10 ml of 10% KCL (1 g)
- 2 IV line:
o IV dextrose 5 mixed with KCl, runs at 100 ml/hour
o 50 units of actrapid + 50 ml with NS (via sliding scale)
(1 unit/ml)
- Monitor dxt hourly, and adjust sliding scale- Urine ketone and serum potassium 4 hourly
- Always check hydration status
IF 4 - 8
- dxt hourly
IF < 4
- stop insulin infusion
- give 20 ml IV bolus dextrose 50% and infusion at 150
ml/hour
- recheck dxt after 30 minutes
IF DIET CONTROL – monitor 4 hourly
IF C-SECTION
- normal diet + insulin before
- KNBM by midnight
- Omit morning insulin
- If GA, check dxt every 30 minutes
After labour
MOTHER
- Stop insulin after placenta deliver
- Premeal dxt for at least 1 day
- If ≥ 7 give OHA/insulin
- Counselling – risk of GDM next pregnancy or DM later
- contraception
FETAL
- Breastfeed asap – avoid hypo baby
- Check dxt of baby & do neonatal blood sugar monitoring
(4-6 hourly for 1- 2 days)
- NICU – assess any complication (RDS, congenital
anomalies, hypoglycemia, polycythemia)
**DM – halved insulin until eat normal, then continue s/c
Post-partum
• Repeat MOGTT after 6 weeks :Negative →Screen annually
Discussion
1. Why GDM occur in pregnancy?
- Increase insulin sensitivity in 1st trimester + hyperplasia
of islet cell → Double insulin production
- 2nd trim – placenta – diabetogenic hormones →Insulin
resistance
o Human placental lactogen (hPL) – spare glucose to fetus
o Corticosteroid releasing hormones
o Cortisol
o Growth hormones
o Progesterones, estrogen – gluconeogenesis
o Glucagons
o TNF a
o leptin
- Hyperglycemia→glucose cross placenta, glycosuria
- Normal pregnancy – beta cells able to compensate
- GDM – insufficient beta cell/compensation
2. FPG & 2HPP level to diagnose? Refer above
3. Risk factors GDM/ MOGTT indications? refer above
4. How to do MOGTT
• Procedure
1) Normal diet 3 days prior
2) No smoking, drug, no infection
3) Fasting starts 12 am – plain water allowed4) 8 am take FBS
5) Ingest 75 g glucose + 250 ml water in 10 – 15 minutes
6) Then, rest, no heavy work, no exercise, no smoking
7) Take 1 HPP
8) Take 2 HPP
5. target control FPG, in between meals/pre meal, 1HPP & 2HPP?
Refer above
6. why do at 28 weeks MOGTT?
- Placenta starts to release diabetogenic hormones. Refer
answer no 1
7. frequency of BSP? Refer above
8. timing of delivery for DM complicating pregnancy & GDM
- Diet control with no complication – allow delivery at term,
not allow postdate (IOL at 40 weeks)
- Diet control with compication – IOL at 38 weeks
- Insulin – IOL / ELSCS at 38 weeks\
9. medical nutrition therapy
- CHO controlled meal plan
o Low GI index food
o Control CHO intake
o Control sugar
- Gestational weight gain
10. how to initiate insulin? (Nak pakai basal or bolus) **cpg gdm
pg 47**
- if FPG > 5.3: Start insulatard 0.2 unit/kg at bedtime.
Increase by 2 units every 3 day until reach target
- if 2HPP >6.7 or 1HPP>7.8: Start at 6 unit actrapid, increase
by 2 unit every 3 days until target are reached. If
preprandial actrapid dose >16unit TDS, consider adding 6-
10 units actrapid in morning and titrate accordingly until
targets are reached
11. Complications GDM (maternal & fetus, antenatal,
intrapartum, post partum)
Maternal Fetus
Antenatal • Skin infection
• Vaginal
candidiasis
Recurrent UTI
• Polyhydramnios→
preterm labour
and PPROM
• IUGR
Intrapartum Genital tract trauma
Operative delivery
• Macrosomia → birth
asphyxia & birth
trauma → shoulder
dystocia, clavicular
injury, Erb’s palsy
Postpartum Type 2 DM • Hypoglycemia
• HypoK, hypoMg,
hypoCa
• Polycythemia
• Hyperbilirubinemia12. how to monitor blood glucose intrapartum? Refer above
13. postpartum, continue/ stop insulin? Refer to management
post partum
14. when to repeat MOGTT postpartum?
• 6 weeks post partum
15. How to monitor dextrostix after giving IM Dexa in GDM/ DM
pt
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