Diabetes in pregnancy
From IDWiki
Definition
- Diabetes mellitus diagnosed during pregnancy
Pathophysiology
- Increased insulin resistance during second and third trimester due to human placental lactogen release from the placenta, among other hormones and inflammatory markers
Differential Diagnosis
Epidemiology
- 5.6% in Canada
- 8-18% in Aboriginal people
Risk Factors
- Age >35
- Non-white ethnicity
- History of GDM or IGT
- Obesity
- PCOS
- Macrosomia or twins
- Family history of diabetes
- Current steroid use
Screening
- 50g oral glucose challenge test at 28 weeks
- If ≥11.1, diagnosed with GDM
- If ≥7.8, then needs 75g oral glucose tolerance test (OGTT) to diagnose GDM
- Alternate approach
- No GCT, go straight to OGTT
- Fasting ≥5.1
- 1h ≥10
- 2h ≥8.5
Clinical Manifestations
- History
- Signs & Symptoms
Investigations
- Labs
- Imaging
- Other
Management
- Diabetic diet
- Regular moderate exercise
- Self-monitoring of blood sugars including fasting and post-prandial
- Targets
- Fasting <5.3
- 1h <7.8
- 2h <6.7
- Prefer insulin
- Need to prevent neonatal hypoglycemia
- POCT q1h, target 4-7
- Halve insulin as soon as delivery, and continue to check q1h for four hours
- Breastfeeding decreases risk of diabetes
- Can use metformin, potentially sulfonylurea (but causes macrosomia)
- Probably shouldn't use DPP-4 inhibitors or GLP-1 agonists, or SGLT2 inhibitors
- Avoid ACE inhibitors and statins
- Labour and delivery
Prognosis
- Fetal/Infant
- Macrosomia
- Neonatal hypoglycemia
- Hyperbilirubinemia because lungs and liver are immature
- Respiratory distress syndrome (for same)
- Polycythemia
- Heart defects, sacral agenesis, in preexisting diabetes
- Shoulder dystocia and brachial plexus injury
- Maternal
- Long-term risk of obesity and diabetes
- Operative delivery
- Hypertension and preeclampsia
- Diabetes (5x risk)
