Description

Diabetes in pregnancy can present as pre-existing diabetes (type 1 or type 2) or gestational diabetes mellitus (GDM), which develops during pregnancy. Proper management is crucial to minimize risks to both mother and baby. Types of Diabetes in Pregnancy Pre-Existing Diabetes: Type 1 Diabetes (T1DM): Insulin-dependent diabetes present before pregnancy. Type 2 Diabetes (T2DM): Often associated with obesity, insulin resistance, and may be managed with diet, oral medications, or insulin. Gestational Diabetes Mellitus (GDM): Hyperglycemia diagnosed during pregnancy that was not overt diabetes before conception. Risks Associated with Diabetes in Pregnancy For the Mother: Increased risk of preeclampsia. Cesarean delivery. Polyhydramnios (excess amniotic fluid). Hypoglycemia (in women on insulin). For the Baby: During Pregnancy: Macrosomia (large baby for gestational age, >4 kg). Birth defects (especially in poorly controlled pre-existing diabetes). Miscarriage or stillbirth. After Birth: Neonatal hypoglycemia. Respiratory distress syndrome. Risk of obesity and type 2 diabetes later in life. Screening and Diagnosis Screening for GDM (Typically at 24–28 Weeks Gestation): Glucose Challenge Test (GCT): Non-fasting 50 g oral glucose load with glucose measurement after 1 hour. If ≥140 mg/dL, proceed to an oral glucose tolerance test (OGTT). Oral Glucose Tolerance Test (OGTT): 100 g or 75 g glucose load after overnight fasting. Diagnostic thresholds vary, but glucose levels are measured fasting and at timed intervals. Early Screening: Women with risk factors (e.g., obesity, history of GDM, family history of diabetes) may be screened earlier in pregnancy. Management 1. Preconception Counseling for Pre-Existing Diabetes: Optimize glycemic control before conception (target HbA1c <6.5%). Discontinue teratogenic medications (e.g., ACE inhibitors, statins). Start folic acid supplementation (4–5 mg/day for neural tube defect prevention). 2. Blood Glucose Targets During Pregnancy: Fasting glucose: <95 mg/dL. 1-hour postprandial: <140 mg/dL. 2-hour postprandial: <120 mg/dL. HbA1c: <6–6.5% (may allow slightly higher targets to avoid hypoglycemia). 3. Treatment Approaches: Diet and Lifestyle: Medical nutrition therapy (MNT) with individualized caloric requirements. Moderate exercise (e.g., walking, prenatal yoga). Monitoring: Frequent blood glucose self-monitoring (up to 4–7 times/day). Medications: Insulin: First-line treatment for pre-existing diabetes and GDM not controlled with diet. Oral Medications: Metformin and glyburide may be considered, but insulin is preferred due to better glucose control and safety profile. Continuous Glucose Monitoring (CGM): May be helpful in type 1 diabetes or difficult-to-control cases. 4. Monitoring and Follow-Up: Regular ultrasounds to monitor fetal growth and amniotic fluid levels. Fetal non-stress tests or biophysical profiles in late pregnancy for at-risk pregnancies. Monitor maternal weight gain and signs of complications (e.g., preeclampsia). Delivery Planning Timing of Delivery: Well-controlled diabetes: Deliver at 39–40 weeks. Poorly controlled diabetes or complications: Consider earlier delivery. Mode of Delivery: Vaginal delivery is preferred unless there are obstetric indications for cesarean. Consider cesarean delivery for estimated fetal weight >4.5 kg to avoid shoulder dystocia. Postpartum Management For the Mother: GDM usually resolves postpartum; screen for persistent diabetes at 6–12 weeks with a 75 g OGTT. Lifelong screening every 1–3 years for type 2 diabetes (in women with prior GDM). Pre-existing diabetes: Adjust insulin or medications postpartum. For the Baby: Monitor for neonatal hypoglycemia, jaundice, and other complications. Key Takeaways: Early diagnosis and management are critical for reducing maternal and fetal complications. Multidisciplinary care involving obstetricians, endocrinologists, and dietitians improves outcomes. Postpartum follow-up is essential, especially for women with GDM, due to the risk of developing type 2 diabetes later in life.