MEDICAL DISORDERS IN
PREGNANCY

DIABETES 
.Dr. Khaled B AL BUSTAMI
 MB B CH ; Cairo
 D Obs RCP Ireland
 JBOG
 MRCOG ; London
 FRCOG ; London
1
DEFINITION
D.M. IS A CHRONIC CONDITION OF ALTERED CHO
,FAT, AND PROTEIN METABOLISM .
IT IS AUTO IMMUNE DISEASE 
ABOUT 85% OF PATIENTS HAVE CIRCULATING 
ISLET CELL ANTIBODIES
IT IS DUE TO EITHER 
INSULIN RESISTANCE or 
INSULIN DEFECIENCY 
And leads to 
HYPERGLYCEMIA 

2
TYPES

TYPE I :
JUVENILE TYPE
or INSULIN DEPENDANT
ABOUT 5-15 % OF ALL CASES OF DIABETES ARE TYPE I
MORE COMMON IN MEN THAN IN WOMEN
USUALLY STARTS IN CHILDREN AGED 4 YEARS AND MORE
THERE IS SUDDEN ONSET OF INSULIN DEFECIENCY .
PATIENTS OF TYPE I D.M. ARE PRONE TO KETOACIDOSIS BECAUSE OF
INSULIN DEFECIENCY
DEPENDANCE ON OTHER ENERGY SUBSTRATES
3
TYPE II
ADULT TYPE
THERE IS TISSUE RESISTANCE TO THE ACTIONS OF INSULIN
THEY PRODUCE INSULIN AT AN INADEQUATE LEVEL
THEY ARE NOT PRONE TO KETOACIDOSIS
BUT THEY ARE SUSCEPTIBLE TO NON KETOTIC HYPEROSMOLAR
STATUS THAT CAN OCCUR WHEN SEVERE HYPERGLYCEMIA
RESULTS IN OSMOTIC DIURESIS AND FLUID INTAKE IS
INSUFFECIENT .
4
DURING PREGNANCY CHO METABOLISM IS GREATLY AFFECTED
BY PHYSIOLOGICAL CHANGES TO PRODUCE A STATE OF
INSULIN RESISTANCE


THESE CHANGES ARE AIMED AT SPARING GLUCOSE FOR THE
DEVELOPING FETUS
THEY INCLUDE THE FOLLOWING INSULIN ANTAGONISTS : 
H.P.L. ; WHICH IS INCREASED
PROGESTERONE ; WHICH IS INCREASED .
INCREASED PRODUCTION OF GROWTH HORMONE
INCREASED PRODUCTION OF CORTICOTROPIN
RELEASING HORMONE AND CORTISOL
THESE CHANGES ARE BALANCED IN NORMAL
HEALTHY PREGNANCY BY SECREATION OF
INCREASED AMOUNT OF INSULIN
LEADING TO DECREASED LEVEL OF F.B.S.

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GESTATIONAL DIABETES

THIS IS THE STATE OF CHO INTOLERANCE THAT 
DEVELOPS DURING PREGNANCY 
FIRST RECOGNISED DURING PREGNANCY 
IN G.D. THE B-CELLS OF THE PANCREASE CANN’T PRODUCE
ENOUGH INSULIN AGAINST THE RESISTANCE TO INSULIN
THE PREVALENCE OF GESTATIONAL DIABETES DEFFERS

FROM ONE LOCATION TO THE OTHER ; 0.5-15 %
OF THOSE 10 %


HAVE DIABETES BEFORE PREGNANCY AND 
90 % DEVELOP THIS CONDITION DURING PREGNANCY

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G.D. IS LINKED TO SEVERAL MATERNAL AND FETAL

COMPLICATIONS AND RESULTS IN SUBSTANTIAL
MORBIDITY .
FETAL COMPLICATIONS 
INCREASED INCIDENCE OF ABORTIONS 
INCREASED INCIDENCE OF CONGENITAL ABNORMALITIES
CLEFT PALATE 
NEURAL TUBE DEFECTS 
CONGENITAL HEART DISEASE 
CAUDAL REGRESSION SYNDROME 
FETAL MACROSOMIA LEADING TO TRAUMATIC DELIVERY
AND SHOULDER DYSTOCIA
SUDDEN UNEXPLAINE I.U.F.D. IN LATE PREGNANCY
THIS COMPLICATES 10-30 % OF CASES OF G.D. ; MORE
LIKELY IF POORLY CONTROLLED ; WITH VASCULAR
DISEASE ; MACROSOMIA AND POLYHYDRAMNIOS



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MATERNAL COMPLIONIONS

THESE ARE STRONGLY RELATED TO THE STAGE OF DIABETES
AND RELATED DISEASES BEFORE PREGNANCY : WHITE
CLASSIFICATION
RENAL NEPHROPATHY -------- PRE ECLAMPSIA 
DIABETIC RETINOPATHY ------ GETS WORSE 
INCREASED INCIDENCE OF INFECTIONS 
SEVERE HYPO OR HYPERGLYCEMIC ATTACKS 
INCREASED INCIDENCE OF OPERATIVE DELIVERY 
INCREASED INCIDENCE OF THROMBO EMBOLIC

COMPLICATIONS .

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NEONATAL COMPLICATIONS

THESE ARE CLOSELY RELATED TO GLYCEMIA CONTROL IN
THE ANTENATAL PERIOD
CONGENITAL ABNORMALITIES 
CLEFT PALATE 
CARDIAC ABNORMALITIES 
NEURAL TUBE DEFECTS 
SACRAL AGENESIS 
MACROSOMIA LEADING TO TRAUMATIC BIRTH INJURIES ;
MAINLY BRACHAIL PLEXUS ; AND BIRTH ASPHYXIA 
R.D.S. DUE TO DECREASED SURFACTANT PRODUCTION

2RY TO FETAL HYPERINSULINEMIA .
HYPOGLYCEMIA DUE TO HYPERINSULINEMIA 
HYPOMAGNESEMIA 
HYPOCALCEMIA 
POLYCYTHEMIA 
HYPERBILIRUBINEMIA 
PREMATURITY AND PERINATAL MORTALITY 


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SCREENING FOR DIABETES IN PREGNANCY
SCREEN ALL PREGNANT WOMEN
SCREEN THOSE AT RISK
LOW RISK




AGE < 25 YEARS
B.M.I. < 25.0
NO HISTORY OF GLUCOSE INTOLERANCE
NO KNOWN DIABETES IN FIRST RELATIVES
NO HISTORY OF OBSTETRIC OUTCOME THAT IS
RELATED TO G.D. ( MACROSOMIA – STILL BIRTH –
MALFORMATIONS )
SCREENING IS DONE BY GIVING 50 gm OF

SUGAR REGARDLESS OF TIME OF LAST MEAL ; AND BLOOD
IS TESTED 1 HOUR AFTER THAT :
POSITIVE TEST IF >140 mg/dl 
URINARY TESTING IS UNRELIABLE

WOMEN AT LOW RISK ARE TESTED AT 24-28 WEEKS 
WOMEN AT HIGH RISK ARE TESTED AT FIRST VISIT






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INSULIN RESISTANCE INCREASES DURING PREGNANCY TILL

ABOUT 32 WEEKS .
IF THE SCREENING WAS POSITIVE ; THEN FULL 2 HOURS 75 gm 
ORAL SUGAR LOAD G.T.T. IS PERFORMED 
OLD CRITERIA
NEW CRITERIA 
O’SULLIVAN AND MAHON
CARPENTER AND COUSTAN 
FASTING
105.0 mg/dl
95.0 mg/dl 
1 HOUR
190.0 mg/dl
180.0 mg/dl 
2 HOURS
165.0 mg/dl
155.0 mg/dl 
3 HOURS
145.0 mg/dl
140.0 mg/dl 
POSITIVE TEST IF : 2 OR MORE RESULTS MEET OR EXCEED THE

ABOVE RESULTS
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In 1999 ; The WHO ; adopted :
75 gm Oral Load ; OGTT
And clarified that
GDM
includes impaired Glucose Tolerance ; and Diabetes
Fasting sugar >= 7.0 mmol/l
>= 126.0 mg/dl
2 Hours
>= 7.8 mmol/l
>= 140.0 mg/dl
The international Association of the Diabetes in Pregnancy Study Group
IADPSG
After extensive analysis of the study :
Hyperglycaemia and Adverse Pregnancy Outcome
HAPO
Recommended new criteria based on 75 gm 2 Hours GTT
fating Sugar >= 5.1 mmol/l
92.0 mg/dl
1 hour
>= 10.0 mmol/l
180.0 mg/dl
2 hours
>= 8.5 mmol/l
153.0 mg/dl
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PRE EXISTING DIABETES

OPTIMAL PREGNACY OUTCOME IS MOST LIKELY WHEN THERE HAS
BEEN ADEQUATE PREPARATION BEFORE PREGNANCY AND EARLY
ANTENATAL CARE .
MATERNAL AND FETAL COMPLICATIONS DURING PREGNANCY ARE
DIRECTLY RELATED TO BLOOD GLUCOSE LEVELS .
KNOWN DIABETICS HAVE FIVE-FOLD INCREASE IN INCIDENCE OF
MAJOR FETAL ANOMALIES ; 7.5 % - 10.0 % .
THE EXACT MECHANISM FOR TERATOGENICITY IS NOT WELL 
UNDERSTOOD ; BUT POSSIBLE MECHANISMS INCLUDE :
DEFICIENCIES IN SELECT MEMBRANE LIPIDS 
CHANGES IN PROSTAGLANDINS PATHWAYS 
GENERATION OF OXYGEN RADICALS 
THE RISK FOR MAJOR FETAL ABNORMALITIES AND SPONTANEOUS
ABORTION INCREASE WITH INCREASE IN HbA1c VALUES
IF HbA1c < 9.3 % : 
SPONTANEOUS ABORTION 12.4 % 
MAJOR ABNORMALITIES
3.0 % 
IF HbA1c > 14.4 % : 
SPONTANEOUS ABORTION
37.5 % 
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MAJOR MALFORMATIONS
40.0 % 




IF HbA1c 7.0 % – 7.5 % :
THEN THE RATES ARE EQUAL TO THE GENERAL POPULATION .
THIS LEVEL OF HbA1c CORRESPONDS TO

BLOOD SUGAR LEVEL 150.0 – 160.0 mg/dl
KNOWN DIABETICS SHOULD ALSO HAVE

24 HOUR URINE COLLECTION FOR PROTEIN AND
CREATININE CLEARANCE .
SERUM CREATININE LEVEL 
SERUM ELECTROLYTES
FULL CBC 




E.C.G. 
OPHTHALMOLOGICAL EXAMINATION . 
FT3 FT4 TSH ; ESPECIALLY FOR TYPE I ; DUE TO ITS AUTO
IMMUNE NATURE .

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TEAN
ANTE
NATAL CARE

THIS AIMS AT OPTIMIZING CONTROL TO 
PREVENT OR MINIMISE COMPLICATIONS . 
AVOID KETONES AND POOR NUTRITION . 
THIS IS BEST ACHIEVED IN JOINT MULTI DISIPLINARY CLINICS
INVOLVING : OBSTETRICIANS ; PERINATOLOGISTS ; DIETICIANS ;
DIABETES EDUCATORS ; INTERNISTS ; ENDOCRINOLOGISTS .
PROPER DIET


TOTAL DAILY CALORIE INTAKE IS BASED ON IDEAL BODY WEIGHT :
UNDERWEIGHT
; BMI < 19.8
; 35 kcal/ kg / day 
NORMAL BODY WEIGHT ; BMI 19.8-29.9 ; 30 kcal/kg / day 
OVER WEIGHT
; BMI > 30.0
; 25 kcal/kg/ day 
THE DAILY INTAKE IS USUALLY AIMED AT 1800 – 2600 kcal /day 
THIS DAILY DIET IS DEVIDED BETWEEN

40 % CARBOHYDRATES 
35 % PROTEINS 
25 % FAT



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EXERCISE

SHOULD AVOID SUPINE POSITION 
AVOID BALANCE EXERCISES 
GENTLE EAROBICS AND STRETCHING EXERCISES
PATIENT EDUCATION


THIS SHOULD INCLUDE ALL THE ABOVE POINTS

GLUCOSE SELF MONITORING

THIS RANGES FROM AS MUCH AS 7 TIMES / DAY ; TO ONCE
WEEKLY FASTING AND 2 H P.P.
IF 1 HPP IS < 140.0 mg/dl ; 
GOOD CONTROL NOW AIMS AT

FASTING LEVEL < 95.0 mg/dl 
2 HPP
< 120.0 mg/dl 

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INSULIN THERAPY

ABOUT 15 % OF PATIENTS WITH GDM CANN’T ACHIEVE GOOD
CONTROL WITH DIET AND EXERCISE ALONE .
SO TREATMENT WITH INSULIN OR ORAL HYPOGLYCEMIC AGENTS
SHOULD BE STARTED .
HUMAN INSULIN 
INSULIN IS GIVEN ACCORDING TO BODY WEIGHT 
0.7 – 1.0 UNIT/ kg BODY WEIGHT



2/3 OF THE TOTAL DOSE IS GIVEN IN THE MORNING 
THIS IS DEVIDED INTO 
1/3 OF A SHORT ACTING INSULIN 
2/3 OF AN INTERMEDIATE ACTING INSULIN 
1/3 OF THE TOTAL DOSE IS GIVEN IN THE EVENING 
THIS IS DEVIDED INTO 
½ OF A SHORT ACTING INSULIN 
½ OF AN INTERMEDIATE ACTING INSULIN 
INSULIN REQUIREMENTS INCREASE WITH ADVANCING

GESTATIONAL AGE .
IT CAN BE ADJUSTED AT 3-4 DAYS INTERVALS WITH UP TO 10-20%

17

TYPES OF INSULIN
LISPRO/ASPART/GLULISINE
INHALED INSULIN
HUMAN REGULAR
HUMAN NEUTRAL PROTAMIN
5-15 MIN
10-20 MIN
30-60 MIN
1-2 HOURS
1-2 HOURS
2 HOUR
2-4 HOURS
4-8 HOURS
4-5 HOURS
6 HOURS
8-10 HOURS
10-20 HOURS
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ANTENATAL TESTING

THIS SHOULD START FROM AS EARLY AS FIRST TRIMESTER 
N.T. 10-13 WEEKS

TRIPLE OR QUADS TEST 16-20 WEEKS 

AFP ; B HCG ; U E3 ; INHEBIN A
FETAL ANOMALLY SCAN 22-24 WEEKS

C.T.G. 
BIOPHYSICAL PROFILE AND FETAL DOPPLER 
FETAL WEIGHT ESTIMATION . 
IF PREMATURE LABOUR OCCURS : 
NORMAL ROUTINE MANAGEMENT ; 
TAKING IN CONSIDERATION THAT 
RETODRINE 
SALBUTAMOL 
DEXAMETHASONE 
ARE ALL DIABETOGENIC AGENTS AND INSULIN DOSE SHOULD BE
ADJUSTED ACCORDINGLY

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LABOUR

WHEN HOW WHERE

THE AIM NOW IS DELIVERY BETWEEN 38-40 WEEKS

AFTER TERM THEIR IS INCREASED RISK OF I.U.F.D. AND S.B.

AND INCREASED FETAL WEIGHT
INFANTS OF DIABETIC MOTHERS HAVE DELAYED PULMONARY

MATURITY AND ARE AT INCREASED RISK OF RDS .
THE RISK OF RDS INCREASES WITHH POOR CONTROL . 
THE RISK OF RDS AFTER 38 WEEKS IS ALMOST EQUAL TO NON
DIABETICS .
LUNG MATURITY TESTS ARE REQUIRED IF : 
DELIVERY BEFORE 37 WEEKS 
POOR CONTROL 
UNCERTAIN DATES 
IF SPONTANEOUS LABOUR OCCURS ; ALLOW NVD : 
2 HOURLY BLOOD SUGAR 
CONTINEOUS CTG 
FETAL BLOOD pH AS INDICATED 
LOW THRESHOLD FOR C.S. 

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POST PARTUM
INSULIN REQUIREMENTS DROP RAPIDLY IN THE POST PARTUM
PERIOD .
KNOWN DIABETICS ARE BEST STARTED AT PRE PREGNANCY

DOSE .
ABOUT 1/3 OF CASES DIAGNOSED AS GDM ; HAVE GDM IN A

SUBSEQUENT PREGNANCY .
THESE PATIENTS NEED REPEAT GTT ; AND 
20 – 30 % HAVE ABNORMAL RESULTS

21
CONTRACEPTIVE ADVISE

BARRIER METHODS SEEM MOST APPROPRIATE 
I.U.C.D. IS ASSOCIATED WITH INFECTIONS 
COMBINED O.C.P. INCREASES RISK OF D.V.T. 
PROGESTERONE ONLY PILL IS ASSOCIATED WITH INCREASED
RISK OF IRREGULAR BLEEDING AND HIGHER FAILURE RATES .
CONSIDER STERILISATION WHEN EVER POSSIBLE . 

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THANK YOU
AND 
GOOD LUCK


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