Management of Diabetes in Pregnancy: Naveen Kumar M

Management of Diabetes
in Pregnancy
Naveen Kumar M
Preconceptional counseling
 Goal is to achieve tight control of diabetes before onset of
pregnancy.
 Folic acid (0.4mg/day) should be started.
 HbA1c measured to plan pregnancy.
 Appropriate advice about diet and insulin is given.
Principles in management
1. Careful antenatal supervision and glycemic control.
2. To find out optimum time and method of delivery.
3. Arrangement for care of newborn.
Antenatal care
 Antenatal supervision monthly interval upto 20 weeks and thereafter at 2
weeks intervals.
 Diet:- Normal weight woman ------30kcal /kg.
Overweight women --------24kcal/kg.
Morbidly obese------------12kcal/kg.
 Diet should contain 40-50% carbohydrate.
 Fibre containing diet ( complex carbohydrate) is increased.
 Three meal regimen --------breakfast (25% of total calorie
intake),lunch(30%),dinner(30%) & several snacks.
 Frequent blood sugar estimation.
 HbA1c determined at end of 1st trimester.
 Sonographic evaluation.
 Assessment of fetal well being ,biophysical profile & NST.
 Doppler umbilical artery velocimetry ----------in cases with vasculopathy.
Insulin therapy
 Indication :- A post prandial (2hrs) glucose level >140mg% even on
diet control.
 There is frequent change in insulin need during pregnancy and
changes made in dosage in small increments at time
 During stabilisation process insulin, dose,frequent blood sugar
estimation at night (2am-6am) is necessary using glucose meter.
 As pregnancy advances, “a double mixed regimen “ may be
employed.
 The patient receive 3 to 4 daily injections of regular (human act
rapid) and an intermediate acting insulin (isophane),which is given
before dinner.
 Use of s.c. Insulin infusion by insulin pump is preferred as it is more
physiological.
 Oral hypoglycemic like glibenclamide and metformin also can be
Induction of labor:-
Indications :- 1.Diabetic women controlled on insulin (after 38
weeks).
2.Women with vascular complications (after 37
weeks).
Methods:-
 Prior to induction,usual bed time dose of insulin is given.
 No breakfast &morning dose on day of induction.
 Induction done by low rupture of membranes.
 Simultaneous Oxytocin drip is started, if not contraindicated.
 An i.v. drip of 1 litre of 5% dextrose with 10 units of soluble insulin
is started.
 Blood glucose levels estimated hourly &insulin dose is adjusted.
Cesarean section
Indications:-
 Fetal macrosomia (>4kg).
 Diabetes with complications or difficult to control.
 Fetal compromise as observed in antepartum monitoring.
 Elderly primigravidae.
 Multigravidae with bad obstetric history.
 Preeclampsia, Polyhydramnios, Malpresentation.
Procedure
 C section scheduled for early morning.
 Normal saline infusion is started.
 Administration of dextrose drip &insulin dose as in induction until patient
able to take fluids by mouth.
 Following delivery requirement of insulin falls and pre-pregnancy dose of
insulin is administered or adjusted from the blood glucose level.
 Epidural or spinal anesthesia is better than general.
To control blood sugar.

 1 litre of 5% dextrose drip with 10 units soluble insulin.
 Insulin rate ------------1unit/hr for glucose of 100-140 mg/dl
2units/hr for 141-180 mg/dl
3units/hr for 181-220 mg /dl.
 Hourly estimation of blood glucose is done & dose is adjusted accordingly.
Fetal monitoring :-
 CTG using scalp electrode is maintained.

 Fetal scalp blood pH sampling if indicated.
 The cord is clamped immediately after delivery to avoid
hypervolemia.
Examination of placenta and cord.

 Placenta is larger, cord is thick there is increased
incidence of a single umbilical artery.
 Placentosis can be seen --------- microscopically villi show
edema; numerous cytotrophoblasts, thickened
basement membrane & excessive syncytial knots.
Puerperium:-
 Antibiotics given prophylactically to minimize infection.
 She is to revert to insulin regimen as was prior to pregnancy.
 Breastfeeding is encouraged.
 A fresh blood glucose level after 24hrs help to adjust dose of insulin.
Care of baby :- Preferably baby kept in NICU and to remain vigilant for
atleast 48 hours, to detect & treat complication.
Contraception
 Barrier method is ideal for spacing.
 Low dose combined oral pills (3rd generation progestins) are effective.
 The IUCD may be used once diabetes is well controlled.
 Permanent sterilisation if family is completed.
Long Essay
 Gestational diabetes mellitus-
define,diagnosis,management and complications.
Short Essay
 GDM ---effects,criteria for diagnosis, management.
Short Answers
 Glucose tolerance / challenge test – Indications,
procedure.
 Screening of GDM in antenatal patients.

Management of Diabetes in Pregnancy: Naveen Kumar M

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Management of Diabetes in Pregnancy: Naveen Kumar M

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Management of Diabetes

To control blood sugar.

 CTG using scalp electrode is maintained.

Examination of placenta and cord.

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