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Diabetes in Pregnancy

Pregnancy in Diabete

Diabetes in pregnancy develops when the pancreas do not produce sufficient insulin in the setting of hyperglycemia induced by this physiological event. Despite its incompletely understood etiology, early recognition is mandatory in order to reduce the risk of many maternal and fetal complications. Repeated measurements of serum glucose levels are needed to make the diagnosis.


Presentation

Under physiological circumstances, placental hormones, increased maternal adiposity, increased pancreatic secretion of insulin, as well as several other factors, together induce a state of insulin resistance in the mother midway through pregnancy [1] [2]. Due to still unknown reasons, some women progress to a state of permanent insulin resistance and develop diabetes in pregnancy.This is described as glucose intolerance that was either unrecognized or absent before pregnancy (the terms pre-gestational diabetes, or overt diabetes are used as well) [1] [2] [3]. Diabetes in pregnancy affects between 2-5% of all pregnant women, and various risk factors have been established: African American, Hispanic and Asian ethnicity (all predispose to a higher rate of diabetes mellitus type 2), preexisting hypertension, history of unexplained miscarriages and stillbirths, a positive family history for diabetes mellitus, obesity, older maternal age, polycystic ovarian syndrome (POS), macrosomia (birth weight of more than 4000 g) of babies born from previous pregnancies, and of course, prior history of diabetes in pregnancy [1] [4]. Although not always, the clinical presentation of increased glucose intolerance is practically absent, as the majority of women are asymptomatic [1]. However, numerous maternal and fetal complications are described in the absence of an early diagnosis and adequate therapy. Women who develop diabetes in pregnancy suffer from recurrent urinary tract infections (UTIs) and may develop hypertension, preeclampsia or eclampsia, a life-threatening disorder [1] [2] [4] [5]. Moreover, the risk of preterm labor is increased as a result of polyhydramnios that frequently develops [2] [4]. On the other hand, excessive fetal growth resulting in macrosomia is virtually always a complication of GDM, which predisposes fetuses to metabolic abnormalities and injuries during delivery (eg. shoulder dystocia and the frequent need for cesarean delivery), while neonatal metabolic changes (hyperbilirubinemia, hypoglycemia, and respiratory distress) are also common [4] [5]. In addition to short-term adverse events, diabetes mellitus can persist even after pregnancy, and a high incidence of cardiovascular diseases in mothers has been reported [1] [2] [4] [5].

Recurrent Urinary Tract Infection
  • Women who develop diabetes in pregnancy suffer from recurrent urinary tract infections (UTIs) and may develop hypertension, preeclampsia or eclampsia, a life-threatening disorder.[symptoma.com]
Increased Appetite
  • appetite Increased thirst Excessive urination Severe cases can cause ketoacidosis Non-insulin dependent diabetes mellitus (NIDDM) Type II diabetes Classically seen in adults who are overweight Insulin is present but insulin receptors unresponsive Gestational[en.wikibooks.org]
  • Pregnancy hormones decrease fasting glucose levels, increase fat deposition, delay gastric emptying and increase appetite. However, over the course of pregnancy, postprandial glucose concentrations increase as insulin resistance increases.[patient.info]
Delayed Gastric Emptying
  • Pregnancy hormones decrease fasting glucose levels, increase fat deposition, delay gastric emptying and increase appetite. However, over the course of pregnancy, postprandial glucose concentrations increase as insulin resistance increases.[patient.info]
Increased Birth Weight
  • There is no agreement on the glycaemic threshold for these adverse outcomes - indeed, large studies have indicated a strong, continuous association of maternal glucose levels (below those diagnostic of diabetes) with increased birth weight, and significant[patient.info]
  • Conclusions Our results indicate strong, continuous associations of maternal glucose levels below those diagnostic of diabetes with increased birth weight and increased cord-blood serum C-peptide levels.[content.nejm.org]
Irritability
Mydriasis
  • Retinal assessment during pregnancy Offer pregnant women with pre-existing diabetes retinal assessment by digital imaging with mydriasis using tropicamide following their first antenatal clinic appointment (unless they have had a retinal assessment in[patient.info]
Behavior Problem
  • There is increasing evidence that a combination of genetics and pregnancy factors leads a child to develop the social, communication, and behavioral problems characteristic of autism.[medicaldaily.com]

Workup

Signs and symptoms of diabetes in pregnancy may not be apparent until delivery or until severe complications occur. For this reason, a thorough patient history is a vital step in assessing risk factors, after which screening methods should be implemented. The debate regarding screening protocols for diabetes in pregnancy is ongoing, with many authors suggesting that apart from low-risk individuals (Caucasian women under 25 years of age, a low body mass index - BMI, and no previous signs of glucose intolerance), serum glucose levels must be evaluated in all pregnant women [1] [2] [3] [4] [6] [7]. Numerous screening guidelines exist for diabetes in pregnancy, including those created by the National Diabetes Data Group (NDDG), American Diabetes Association (ADA), International Association of Diabetes and Pregnancy Study Groups (IADPSG), American College of Obstetricians and Gynecologists and several other [3] [5] [6]. However, the criteria formulated by the World Health Organization (WHO), updated in 2013, are most widely accepted. They recommend screening of all pregnant women by conducting an oral glucose tolerance test (OGTT) with 75g of glucose and subsequent serum measurements [3]. If fasting glucose levels are > 5.1 mmol/L or if levels after 1 hour are > 10 mmol/L, or if levels after 2 hours are > 8.5 mmol/L, a diagnosis of diabetes in pregnancy can be made [3]. Serum evaluation of hemoglobin A1c (HbA1C) is also proposed as a diagnostic tool for confirming diabetes in pregnancy, and the cut-off value of ≥48 mmol/mol (6.5%) was accepted as a supportive criterion for this condition [6].

Hypertriglyceridemia
  • Pregnancy associated hypertriglyceridemia in normal and diabetic women: differences in insulin-dependent, non-insulin dependent and gestational diabetes. Diabetes. 1982;31:1092–7.[degruyter.com]
  • This may help to recognize patients with higher risk of hypertriglyceridemia (those with poorly controlled DM and albuminuria) [ 107 ].[link.springer.com]

Treatment

  • The optimum treatment for HNF1A/HNF4A maturity-onset diabetes of the young and ATP-sensitive potassium (K ATP ) channel neonatal diabetes, outside pregnancy, is sulfonylureas, but there is little evidence regarding the most appropriate treatment during[ncbi.nlm.nih.gov]
  • Management [ 5, 12 ] Treatment of GDM and good glycaemic control reduce serious perinatal morbidity and may also improve the woman's health-related quality of life [ 13, 14 ]. It is often controversial as to when GDM requires treatment.[patient.info]

Prognosis

  • Prognosis The perinatal risks to mother and baby are similar to those with known diabetes, mainly relating to the problems of a large baby. Treatment of GDM is effective in reducing macrosomia, pre-eclampsia and shoulder dystocia [ 19 ].[patient.info]
  • Follow-up and prognosis Gestational diabetes resolves postpartum in more than 90% of women. In general, all insulin and oral hypoglycaemic drugs are ceased immediately postpartum with ongoing blood glucose monitoring until discharge from hospital.[doi.org]
  • Gestational diabetes: problems in classification and implications for long-range prognosis. Adv. Exp. Med. Biol. 1985;189:47-63. . [ Links ] 30. American College of Obstetricians and Gynecologists. Management of diabetes mellitus in pregnancy.[scielo.org.co]

Etiology

  • The genetic etiology of gestational diabetes mellitus has largely been found to overlap that of T2D.[ncbi.nlm.nih.gov]
  • Despite its incompletely understood etiology, early recognition is mandatory in order to reduce the risk of many maternal and fetal complications. Repeated measurements of serum glucose levels are needed to make the diagnosis.[symptoma.com]
  • The clinical role of maternal hyperglycemia below the threshold for the diagnosis of gestational diabetes (GDM) in the etiology of macrosomia remains an area of controversy.[doi.org]
  • Articles in this issue provide insights into some of the clinical associations and etiological mechanisms of the adverse outcomes associated with these conditions.[degruyter.com]

Epidemiology

  • Asthma/metabolism Bronchopulmonary Dysplasia/epidemiology Bronchopulmonary Dysplasia/metabolism Child Diabetes, Gestational/epidemiology* Diabetes, Gestational/metabolism Disease Models, Animal Female Hernias, Diaphragmatic, Congenital/epidemiology Hernias[ncbi.nlm.nih.gov]
Sex distribution
Age distribution

Pathophysiology

  • Barriers were poor socioeconomic status, lack of family, peer and community support, effects of pregnancy, complicated therapeutic regimen, pathophysiology of diabetes, cultural and religious beliefs, and poor health care system.[ncbi.nlm.nih.gov]
  • Having fetal hyperinsulinism is a risk factor for development of both obesity and abnormal glucose metabolism, and might be implicated in pathophysiology.[doi.org]

Prevention

  • An understanding of the physiological changes during pregnancy, management, early detection and prevention of complications and pre-pregnancy care, specific to women with pre-existing diabetes, is important in improving health outcomes in this growing[ncbi.nlm.nih.gov]
  • Offer them advice on preventing type 2 diabetes. See separate Prevention of Type 2 Diabetes article.[patient.info]

References

Article

  1. Gilmartin A “Bird” H, Ural SH, Repke JT. Gestational Diabetes Mellitus. Rev Obstet Gynecol. 2008;1(3):129-134.
  2. Buchanan TA, Xiang AH. Gestational diabetes mellitus. J Clin Invest. 2005;115(3):485-491.
  3. Agarwal MM. Gestational diabetes mellitus: An update on the current international diagnostic criteria. World J Diabetes. 2015;6(6):782-791.
  4. Alfadhli EM. Gestational diabetes mellitus. Saudi Medical Journal. 2015;36(4):399-406.
  5. Rani PR, Begum J. Screening and Diagnosis of Gestational Diabetes Mellitus, Where Do We Stand. J Clin Diagn Res. 2016;10(4):QE01-QE04.
  6. Renz PB, Cavagnolli G, Weinert LS, Silveiro SP, Camargo JL. HbA1c Test as a Tool in the Diagnosis of Gestational Diabetes Mellitus. Wagner B, ed. PLoS ONE. 2015;10(8):e0135989.
  7. Karagiannis T, Bekiari E, Manolopoulos K, Paletas K, Tsapas A. Gestational diabetes mellitus: why screen and how to diagnose. Hippokratia. 2010;14(3):151-154.

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Last updated: 2019-06-28 10:57