• It is the most common medical complication of pregnancy.
Classification
• Today, the Modified White Classification is used less frequently, and instead the classification focusing on whether diabetes is diagnosed before pregnancy or during pregnancy has been put into use.
• According to this, the presence of diabetes before pregnancy is called pregestational diabetes, and glucose intolerance that occurs for the first time during pregnancy or is diagnosed for the first time during pregnancy is called gestational diabetes.
Modified White classification | ||||
Class | Beginning | Fasting Blood Sugar | blood sugar in the 2nd hours after food | Treatment |
A1 | gestational | <105 mg/dL | <120 mg/dL | Diet |
A2 | gestational | > 105 mg/dL | >120 mg/dL | insulin |
Class | starting age | Duration (year) | Vascular disease | Treatment |
B | >20 | <10 | no | insulin |
C | 10---9 | 10---9 | no | insulin |
D | <10 | >20 | Benign retinopathy | insulin |
F | It doesn't matter | It doesn't matter | nephropathy | insulin |
R | It doesn't matter | It doesn't matter | Proliferative retinopathy | insulin |
H | It doesn't matter | It doesn't matter | Heart | insulin |
Screening and Diagnosis
overt DM Screening and Diagnosis
► Overt DM diagnostic criteria:
0 Glucose value > 200 mg/dl in randomized plasma and classical symptoms such as polydipsia, polyuria, unexplained weight loss, or
0 Fasting blood sugar :::: Above 126 mg/dl. The reason for limiting this value is that the risk of retinopathy increases significantly above this value.
0 Hemoglobin Alc > 6.5%
Gestational DM Screening and Diagnosis
► All pregnant women 24-28. gestational diabetes screening is recommended.
► There is some controversy regarding the diagnostic criteria, and two-stage or single-stage screening and diagnostic tests are recommended.
► One-step approach:
0 75 g two-hour OGTT is used as a screening and diagnostic test.
0 Gestational diabetes is diagnosed when at least one of the fasting, first hour and second hour glucose values is above the threshold value.
► Two-stage approach:
0 50 g 1-hour glucose screening test is used as a screening test. If the screening test is positive, a 100-gram OGTT is performed for diagnosis.
0 In the two-stage approach, universal all pregnant women or selective screening can be performed. Therefore, the risk of gestational DM should be determined at the first prenatal visit. Low-risk pregnant women may not be screened. High-risk pregnant women should have a glucose screening test as soon as possible.
0 Low Risk: Routine glucose screening is not required if all of the following are present.
- Ethnicity with a low prevalence of gestational DM (GDM)
- No DM in first degree relatives
- Age< 25
- Normal pre-pregnancy weight
- Normal birth weight
- No history of abnormal glucose metabolism
- No history of poor obstetric outcome
0 Medium Risk: 24-28. Glucose screening test is done between weeks.
0 High Risk: Glucose screening test is performed as soon as possible if one or more of the following is present. If the test is normal, 24-28. It should be repeated every few weeks or whenever there are signs or symptoms indicative of hyperglycemia.
- Severe obesity
- Strong family history for type 2 DM
- Large baby birth history
- History of unexplained fetal loss
- History of GDM, impaired glucose metabolism or glycosuria in previous pregnancies
Recommended Approaches for Gestational DM Complete and Screening
1. One-Stage Approach (75 g Oral Glucose Tolerance Test)
- Fasting glucose -------->= 92
- 1st hour glucose ----->= 180 -------GDM diagnosis is made if the single value is high.
- 2nd hour glucose ------>=153
2. The Two-Stage Approach
a. 50 g Oral Glucose Tolerance Test
- 1st hour glucose --->=135 or 140 -------100 g OGTT should be done.
b. 100 g Oral Glucose Tolerance Test
- Fasting glucose ----->=95
- 1st hour glucose ---->0180------ If two values are higher, the diagnosis of GDM is made.
- 2nd hour glucose 2:: 155
- 3rd hour glucose 2:: 140
Pregestational Diabetes
• The probability of achieving successful pregnancy outcomes in pregestational diabetes depends to some extent on blood sugar control, but more importantly on the degree of underlying cardiovascular or kidney disease. In the White classification, the probability of good pregnancy outcomes decreases as the alphabetical classification progresses.
• Effects of pregestational diabetes on pregnancy outcomes: Macrosomia (45%), gestational hypertension and preeclampsia (28%), preterm birth (28%), fetal growth retardation (5%), perinatal death (1.7%), stillbirth (1%) )
Fetal Complications
► Increased risk of spontaneous abortion: Early pregnancy loss is associated with poor glycemic control, and the risk is markedly increased, especially in women with HbAlc > 12% and persistent postprandial glucose > 120 mg/dl.
► The risk of preterm birth increases. Beta-mimetics should not be preferred as tocolytics in diabetic women because they disrupt glucose regulation.
► The risk of congenital major malformation increases by 2 times: The incidence of major malformation is 11% and it constitutes half of the perinatal mortality. More than half of congenital anomalies are cardiac anomalies. Cardiac defect risk increased 4 times and non-cardiac defect risk increased 2 times.
Most Common Major Congenital Anomalies in Newborns of Diabetic Women (A total of 36, 345 pregnancies were examined) | |||
systems | Type 1 diabetic pregnant women (n=482) | Type 2 diabetic pregnant women (n=4166) | gestational diabetic pregnant women (n=31.700) |
cardiac system | 38 | 272 | 1129 |
Musculoskeletal system | 1 | 31 | 231 |
urinary system | 3 | 28 | 260 |
Central nervous system | 1 | 13 | 64 |
gastro-intestinal system | 1 | 30 | 164 |
Other | 11 | 80 | 355 |
Total | 55 | 454 | 2203 |
The most common congenital system anomaly in patients with pregestational type 1 diabetes is cardiac anomalies.
The anomalies with the highest incidence in those with pregestational diabetes are caudal regression and situs inversus, respectively.
► The risk of severe malformations is associated with poor glycemic control before and during pregnancy. Those with lower glycosylated hemoglobin (HbAlc) levels during conception have a lower risk of anomaly. Due to hyperglycemia, cellular lipid metabolism, production of toxic superoxide radicals and programmed cell death increase, leading to the development of malformations.
Diabetes fetal chromosome! does not increase the risk of anomaly (eg Down syndrome) .
► May cause fetal growth changes:
0 Macrosomia: If the mean maternal glucose level is > 130 mg/dl, the incidence of macrosomia increases significantly and is seen especially in the second half of pregnancy. Since there is more fat accumulation in the shoulders and trunk, it increases the risk of shoulder dystocia and cesarean delivery.
0 IUGG: IUGG can be seen in pregnant women with pregestational diabetes who have vascular complications as a result of a decrease in the substrate passed to the fetus.
► Risk of fetal mortality is increased 3-4 times: Unexplained fetal death rate is increased in women with pregestational diabetes, and stillbirth without an identifiable cause is unique to pregestational DM. unexplained stillbirths
. is associated with poor glycemic control, and lactic acid levels were often found to be high in these fetuses. Villous edema (hydropic) occurs with the induction of maternal hyperglycemia and osmosis. Hence the placenta! transport is broken. They are typically large for gestational age and are usually lost before labor at 35 weeks or later.
0 There is also an increase in the frequency of explainable stillbirth due to placental insufficiency in pregestational DM. It is increased in women with advanced diabetes and vascular complications and is usually associated with preeclampsia. Fetal death may also occur due to ketoacidosis.
amniotic fluid diseases
0 Hydramnios: Pregestational diabetes is often complicated by hydramnios. It occurs with polyuria due to fetal hyperglycemia and is associated with poor maternal glucose control.
0 Oligohydramnios: Oligohydramnios can be seen in pregestational diabetic women with vascular complications.
Neonatal mortality and morbidity
The risk of preterm birth increases.
0 Increased risk of respiratory distress syndrome. Lung maturation is delayed in diabetic pregnant women.
0 Neonatal hypoglycemia, hypocalcemia, hyperbilirubinemia and polycythemia
0 Cardiomyopathy: Hypertrophic cardiomyopathy may be seen and the interventricular septum is usually involved.
0 Inheritance of diabetes: While the risk is 3-5% in children of parents with Type I diabetes; In those with type II diabetes, the risk is 40%.
Maternal Complications
- Maternal mortality increases (0.5%): Factors that increase maternal mortality; ketoacidosis, hypoglycemia, hypertension, preeclampsia, infection.
- Diabetic nephropathy: Pregnancy does not generally worsen diabetic nephropathy. Although progression is not observed in patients with mild renal failure, there may be an acceleration in progression during pregnancy in patients with moderate and severe renal impairment. However, the risk of preeclampsia is significantly increased in pregnant women with nephropathy (class F) (risk 40%).
- Diabetic retinopathy: Progression can be seen in early pregnancy in 25% of women with Type 1 diabetes and 14% of women with Type 2 diabetes. The level of retinopathy before pregnancy is the only independent risk factor that determines the progression. Other risk factors associated with progression are hypertension, elevated IGF-I, and macular edema in early pregnancy. Therefore, routine retinal evaluation should be performed in pregnant women with pregestational diabetes following the first prenatal visit.
Pregnancy does not affect the long-term course of diabetes, except for diabetic retinopathy.
- Diabetic neuropathy: Peripheral symmetrical sensorimotor diabetic neuropathy is rare in pregnant women. However, diabetic gastropathy increases the risk of morbidity and poor perinatal outcome during pregnancy.
- The risk of preeclampsia increases: The risk of preeclampsia is increased 3-4 times in those with pregestational diabetes, and the risk increases 12 times in diabetics with accompanying hypertension. Preeclampsia risk is increased in diabetic women with any vascular complications or pre-existing proteinuria, whether they are hypertensive or not. Hypertension caused or exacerbated by pregnancy is the most important complication leading to preterm delivery in diabetic pregnant women. As the White classification increases, the risk of preeclampsia also increases , and the risk of preeclampsia is associated with glucose control.
- Diabetic ketoacidosis: It is mostly seen in Type 1 diabetes and its incidence is 1%. However, it can also be seen in type II diabetes and gestational diabetes. Ketoacidosis is a predictor of poor prognosis in pregnancy. The fetal loss rate is 20% in ketoacidosis. Predisposing factors; hyperemesis gravidarum, use of beta mimetics for tocolysis, infections, steroid use for lung maturation.
- Infections: Most infections increase in diabetic pregnant women. The most common infections; candida vulvovaginitis, urinary system infection, respiratory system infection, puerperal pelvic infection and wound infection after cesarean section.
Treatment Approach
Pre-Pregnancy Care
► Optimal glycemic control should be provided to prevent early pregnancy losses and congenital malformations. Target glucose levels using pre-pregnancy insulin; FBC: 70 - 100 mg/dl, postprandial 2nd hour peak value; 100-120 mg/dl and daily average glucose value; It is <110 mg/dl.
► In order to evaluate early metabolic control, glycosylated hemoglobin (HbAlc) showing the last 4-8 weeks glucose average should be measured and should be :56.5. The most important risk for malformations is values exceeding 10% (increased 4 times).
► 400 ug/day Folic acid should be given before pregnancy and early pregnancy to reduce the risk of NTD. If indicated, diabetic complications such as retinopathy or nephropathy should be treated.
First Trimester
0 Oral antidiabetics should not be used and insulin therapy should be given.
0 Diet: A diet consisting of a mixture of carbohydrates, proteins and fats but containing a minimum of 175 g/day carbohydrates should be taken.
0 Diabetes tends to be unstable, especially in the first trimester, and maternal hypoglycemia is most common in 10-15 days. monitored for weeks. Glucose control targets during pregnancy;
- AKÅž ►:5 95 mg/dl
- Pp 1st hour ► ::5 140 mg/dl
- Pp 2nd hour ►:5 120 mg/dl
- HbAlc ►:5 % 6%
Second Trimester
0 16-20. Maternal serum AFP level should be measured in terms of anomalies and NTD between gestational weeks and ultrasonography should be performed. Fetal echocardiography should be performed in the second trimester as the risk of cardiac anomaly is increased.
0 Diabetes is more stable in the second trimester and after the 24th week, the need for insulin begins to increase due to the anti-insulinergic effect of pregnancy hormones. The period with the highest insulin requirement is the second half of pregnancy (increases by 3 times).
Third Trimester and Birth
► 32-34. Tests that determine fetal well-being (fetal movement count, fetal heart monitoring, biophysical profile, and CST if necessary) should be started between weeks and weeks.
► Birth should be planned at 38 weeks. If the fetus is not very large and the cervix is suitable, labor induction can be attempted. Estimated birth weight
Cesarean section is preferred for babies weighing �4500 gr. Cesarean section rates are high (80%) in diabetic women to reduce birth trauma due to macrosomic babies.
0 Long-term insulin dose should be reduced or discontinued on the day of delivery. Because the need for insulin decreases markedly after delivery.
puerperium
► There is no need for insulin in the first 24 hours postpartum, and it varies in the following days.
Gestational Diabetes
• It is glucose intolerance of varying degrees that is diagnosed or manifested for the first time during pregnancy. Its incidence is 5-6% and the prevalence varies according to race, age, body composition and screening criteria.
• The probability of fetal death in properly treated gestational diabetes is general.
not different from the population.
• The most important perinatal concern is macrosomia, which causes maternal and fetal birth trauma.
The adverse side effects of gestational diabetes differ from pregestational diabetes and the incidence of fetal anomaly has not increased.
Fetal Complications
The risk of fetal mortality is increased: This risk is lower in diet-regulated gestational diabetes. In addition, unexplained fetal death rate increased in pregnant women with high fasting blood sugar, similar to pregestational diabetes. FAC > 105 mg/dl in the last 4-8 weeks of pregnancy is associated with an increased risk of fetal death.
► Macrosomia: Babies with a birth weight of over 4500 g are macrosomic.
0 Maternal hyperglycemia causes fetal insulinemia, which leads to stimulation of excessive somatic growth, especially in the second half of pregnancy.
0 Factors associated with macrosomia; insulin (C peptide}, IGF I (strong relationship with birth weight), epidermal growth factor, leptin and adiponectin.
0 Maternal obesity is a more important and independent risk factor for fetal macrosomia than glucose intolerance. The risk of gestational diabetes is increased, especially in women with truncal obesity.
Treatment Approach
► The incidence of preeclampsia, shoulder dystocia and macrosomia is significantly lower in treated gestational diabetic pregnant women.
► Pregnant women with gestational diabetes are divided into two functional classes according to whether the blood glucose target can be achieved with diet or not. Target glucose values in gestational diabetes are FPG <95 mg/dl and postprandial 2nd hour <120 mg/dl.
0 Take class if goal can be achieved with diet
0 Class A2 if dietary target cannot be achieved; Treatment is usually switched to insulin.
► Diet: Daily calorie intake should be 30-35 kcal/kg/day; however, it should be restricted to 25 kcaljkg/day in those with BMI>30. 40% of daily calorie needs should be adjusted as carbohydrates, 40% protein and 20% fat.
► Exercise: It reduces the need for insulin in obese patients with gestational DM.
► Glucose monitoring: Postprandial monitoring is more important than preprandial for gestational DM. Glucose monitoring is recommended 4 times a day, with fasting and satiety being measured at the 1st or 2nd hour.
► Insulin: If FAC persists > 95 mg/dl despite diet, insulin is started. Insulin should also be started if the 1st hour of postprandion is > 140 mg/dl or the 2nd hour of the postprandion is > 120 mg/dl.
► Oral hypoglycemic agents; In case of persistent hyperglycemia in gestational diabetes, insulin is the first choice, but there is increasing evidence supporting the safety and efficacy of Glyburide and metformin.
► Prenatal follow-up: Premature birth and other interventions are rarely necessary in gestational diabetics who do not need insulin. Pregnant women using insulin due to fasting hyperglycemia should be followed closely antepartum and managed like pregestational DM.
► Delivery: Induction of labor is not recommended before 39 weeks in gestational diabetic women who do not use insulin. In patients using insulin, delivery at 38 weeks is recommended. In order to avoid brachial plexus injury in macrosomic fetuses, cesarean section should be preferred if the estimated fetal weight is 2= 4500 g.
► Postpartum follow-up: The risk of developing DM in 20 years in women with gestational DM is 0/oSO. For this reason, 75 g OGTT and annual fasting glucose measurement should be performed between 6 and 12 weeks postpartum, postpartum 1 year, every 3 years and before the next pregnancy.
Follow-up Recommendations for Women with Gestational Diabetes After Pregnancy
Time -------------------------------------------Recommended Test
• Postpartum (Day 1-3)-----• Fasting or instant plasma glucose measurement
• Early postpartum (6-12 weeks)----------• 75 g OGTT
• Postpartum 1st year -------• 75 g OGTT
• Annually----• Fasting plasma glucose measurement
• Every three years-------• 75 g OGTT
• Pre-pregnancy----------• 75 g OGT
- Normal ........ ➔ FPS <100, ...... 2hr<140, ..... HbA1c<5.7%
- Impaired glucose tolerance .... ➔ FCA 100-125, .... 2h 140-199, ... HbA1c 5.7-6.4%
- Overt DM .............. ➔ FCA >=126, ........ 2nd hour >=200, ...... HbA1c >= % 6.5
► Since they can be associated with dyslipidemia, hypertension and abdominal obesity (metabolic syndrome), they also carry a risk in terms of cardiovascular complications.
► The risk of recurrence in the next pregnancy is 48%.