Diabetes

Diabetes mellitus is a carbohydrate metabolism illness characterized by hyperglycemia and glycosuria, as well as glucose intolerance that needs insulin therapy. It affects roughly 1% of all pregnancies, making it one of the most frequent metabolic abnormalities that complicate pregnancy. The pancreas cannot create enough insulin in this state, hence glucose cannot be stored. As a result, it accumulates in the blood, resulting in high blood sugar. Some of the extra sugar is eliminated through the urine. Because the tissues are unable to burn glucose, they instead burn fat. As a result, the fat's end product, ketone bodies, is created and shows in the breath and urine.

Risk Factors

The following conditions should raise the possibility of diabetes in the lady.

• Family history of diabetes
• Previous delivery of a large baby
• Previous still birth
• Unexplained perinatal loss
• Presence of polyhydramnios
• Recurrent UTI, vaginal candidiasis, toxemia
• Persistent glycosuria
• Obesity

Carbohydrate Metabolism During Pregnancy

Because the fetus is dependent on the mother for an uninterrupted supply of glucose, profound metabolic adaptation occurs during pregnancy. Maternal hyperinsulinemia and insulin resistance are common throughout pregnancy, especially in the third trimester.

Elevated estrogen and progesterone hormone levels during early pregnancy drive pancreatic beta cell hyperplasia and hyperinsulinemia. Starvation results in increased tissue glycogen decreased hepatic glucose synthesis, enhanced peripheral glucose consumption, and a lower maternal fasting glucose level.

As the pregnancy progresses, the level of human placental lactogen (HPL) rises, which, combined with cortisol, counteracts the effects of insulin, leading to resistance. Following meals, there is a state of facilitated anabolism, with higher triglyceride levels, extended hyperglycemia, and accelerated lipolysis.

Classification of Pregnant Diabetes

Priscilla White's classification was initially used to determine the perinatal outcome of diabetes worsening.

Class A – gestational diabetes

Class B – overt diabetes onset > 20 years, duration < 10 years

Class C – overt diabetes onset <20 years, duration 10-19 years

Class D – overt diabetes, onset < age 10; duration 20 years, Benign retinopathy

Class E – calcified pelvic vessels

Class F – diabetic nephropathy with proteinuria

Class R – malignant diabetes retinopathy

Clinical Features

1. Polyuria
2. Polydipsia

• Polyphagia

1. Glycosuria
2. Weight loss
3. Pruritus vulva

• High blood sugar, more than 120 mg/dl

Effects of Diabetes

Maternal Effects

During pregnancy

• Spontaneous abortion
• Infections
• PIH
• Polyhydramnios
• Preterm labor
• Maternal distress

During labor

• Prolonged labor
• Uterine inertia
• Shoulder dystocia
• Operative deliveries with resultant genital tract injuries

Fetal Effects

• Congenital malformations account for 5-10% of IDDM cases; frequent congenital problems include anencephaly, spina bifida, meningomyelocele, vertebral dysplasia, VSD, and others.
• Infant mortality
• Maternal macrosomia
• Neonatal complications include:
  1. Hypoglycemia due to fetal hyperinsulinemia
  2. Respiratory distress syndrome

• Hyperbilirubinaemia

1. Hypocalcemia
2. Birth injuries due to macrosomia, operative delivery, and shoulder dystocia

• Perinatal mortality is increased 2 to 3 folds
• Fetal intrauterine growth retardation
• Delayed pulmonary maturation

Diagnosis

• Historical suspects
• Genetic history: family positive history
• Obstetric history: previous delivery of large baby, PIH, etc
• Recurrent infection, chronic hypertension
• Maternal age over 30 years.
• Clinical aspects
• Obesity, hypertension
• Repeated urinary and monilial infection
• Polyhydramnios
• Screening tests
• Random blood sugar
• Fasting blood sugar
• Post prandial blood sugar
• GTT

Management

The management may be considered into two parts.

1. Management of diabetes in pregnancy
2. Management of pregnancy in diabetes

Management of diabetes in pregnant women:

• To gain metabolic control.
• Iatrogenic prematurity should be avoided.
• Detecting fetal discomfort before an intrauterine fetal death occurs.
• Attempt to rule out any maternal complications.
• Patient education on:
  • Diet: dietary regulation is the first line of management for gestational diabetes. The calorie consumption should be:
  • 50-60% carbohydrates: avoid simple sugars include complex sugar and dietary fibers.
  • 12-20% protein
  • 10% saturated fat
• Eliminate alcohol and non-sucrose sweeteners
• Exercise: Exercise and insulin may work together to keep blood glucose levels stable.
• Insulin: Insulin is frequently required in gestational diabetes, where a strict blood glucose profile is required.

Management of pregnancy in diabetes:

Principles of the management:

• Diabetes control and careful antenatal supervision
• To determine the best time and method of delivery.
• Make plans for the newborn's care.

Antenatal care:

• Antenatal care should be provided at monthly intervals until 20 weeks, then every 2 weeks until 30 weeks.
• The calorie needed per day is approximately 30-35 kcal per kilogram of body weight.
• Blood and urine sugar levels should be checked on a regular basis.
• The patient should be encouraged to have regular prenatal checkups. Patients with stable IDDM and gestational diabetes are seen every two weeks until 36 weeks when they are seen weekly. Weight gain, uterine growth, fetal status, and pregnancy problems such as PIH and hydramnios should preferably be checked at each antenatal visit.
• Fetal monitoring should include ultrasound, biophysical profiles, and other methods.

Management During Labor

• When the patient is nearing the end of her life, she should be hospitalized. The time of delivery is determined by the danger of intrauterine fetal death, maternal complications, fetal distress, and so on.
• If the predicted fetal weight is 4kg l and the pelvis is adequate and normal clinically, the patient may be delivered vaginally. Fetal monitoring intrapartum, but planned LSCS in situations of elderly primigravidae, fetal malpresentation, macrosomia, and so on.
• To treat diabetes, one liter of 5% dextrose is mixed with 10 units of soluble insulin.
• Blood sugar levels should be estimated every hour, and insulin should be adjusted accordingly. The blood glucose level should be kept between 80 and 100 mg per 100 mL.
• If the potassium level is normal or low, the infusion rate should be kept constant.
• The cardiac tomogram is used to monitor the fetus.
• To minimize hypervolemia, the chord should be clamped shortly after birth.
• The cord should be thoroughly inspected; there is a greater risk of a single umbilical artery.

Postnatal

• Antibiotics should be administered prophylactically to prevent infection.
• Check your blood sugar level. It may fall substantially, reducing the need for insulin immediately after birth.

Care of Baby

• A pediatrician should be in the birthing room.
• The newborn should be kept in a neonatal care facility under close supervision.
• Asphyxia and other respiratory problems may occur, so treat them promptly.
• Two hours after birth, the newborns' glucose levels should be tested.
• Inject it. 1 mg vitamin K IM
• Breastfeeding should be permitted as soon as feasible to reduce the risk of hypoglycemia and hyperbilirubinemia. If the baby is premature, give him or her 10% dextrose orally.