When glucosuria is found in a pregnant woman,
it means that
1) she has been diabetic since previously.
2) she has renal glucosuria.
3) she has gestational diabetes mellitus.
1)→continue or strengthen the management of her diabetes
mellitus
2) →in spite of normal glucose tolerance, threshold for
glucose excretion become lower during pregnancy
due to increased glomerular filtration rate and
decreased tubular reabsorption of glucose
3) →definition: woman who altered to be abnormal in
glucose tolerance during pregnancy, and/or woman
found to be abnormal in glucose tolerance for the first
time during pregnancy
Gestational Diabetes Mellitus
(1)

Gestational diabetes mellitus (GDM) may be viewed as,
1) An unidentified preexisting disease, or
2) The unmasking of a compensated metabolic abnormality
by the added stress of pregnancy, or
3) A direct consequence of the altered maternal metabolism
resulting from the changing hormonal milieu rsulting in milder
abnormality in glucose tolerance than diabetic glucose tolerance
pattern.
Those diagnosed with GDM before 24 weeks’ gestation were significantly

older and had a twofold greater incidence of requiring insulin therapy
than did women diagnosed after 24 weeks’ gestation.

A substantial subset of women diagnosed with GDM, particularly those
diagnosed early in pregnancy, may have had preexisting disease that had
gone undiagnosed.
Therefore, it is necessay to assess fasting glucose concentrations at the
beginning of pregnancy in order to diagnose preexisting carbohydrate
intolerance.
Gestational Diabetes Mellitus (2)

Pregnancy creates a metabolic stress that simply pushes a woman with
compensated type 1 DM or type 2 DM into a decompensated state.
Insulin requirements increase substantially (1.5 – 2.5 times) during normal
pregnancy.
If a woman has a limited β cell response secondary to autoimmune β cell
destruction, as seen in type 1 DM, or has β cell secretory reserve
insufficient to meet the demands of pregnancy because of early type 2 DM,
she may decompensate from a normoglycemic state in the nonpregnant
situation to a hyperglycemic state during pregnancy.
It is reported that
a twofold increase in the frequency of HLA DR3 or DR4 in women with
GDM, or
islet cell antibodies (ICA) in as many as 31% of women in whom GDM
developed, however others reported fewer than 10% frequency.
It is far more likely that GDM results from decompensation of prediabetes
or an early stage of type 2 DM.
More than 90% of women in whom DM develops after a history of GDM
have classic type 2 DM.
Pathophysiologic observations of GDM are similar to those of type 2 DM.
Gestational Diabetes Mellitus (3)

Most subjects with GDM revert to normal carbohydrate tolerance

postpartum.
However, depending on the ethnic group, conversion rates postpartum to
nongestational DM may be as high as 9% within the first 6 weeks, with
30%
in the first year.
A 50% prevalence of DM after 28 years of follow-up in those in whom
pregnancy was complicated by GDM.
The prevalence of GDM parallels the prevalence of type 2 DM in high-risk
ethnic and racial groups.
The diagnosis of GDM is necessary to protect the fetus, both in utero and
long term.
All pregnant women should be screened for GDM.
Gestational Diabetes Mellitus (4)

pregnant woman → history taking, urine glucose check, and
plasma glucose check at the time of diagnosis of pregnancy
　　　　　　　　　　　　　　　　　　　　 ↓
　　　 when obese or having diabetes mellitus among first-degree relatives

or past history of giant baby or intrauterine fetal death
or mandatory plasma glucose level 100 mg/dl ( = 5.5 mM )≧
↓
75g oGTT at earlier weeks
↓ ↓
abnormal normal
↓ ↓
manage as DM (GDM) because of postprandial (mandatory) plasma glucose
high possibility diabetes has been level at 24 – 28 weeks of pregnancy
existed before pregnancy ↓ ↓
≧ 5.5 mM ＜ 5.5 mM

↓ ↓
　　　　　　　　　　　　　 75g oGTT 　　 75g oGTT at 32
weeks 　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　
　　　　 of pregnancy
Screening Schedule for Gestational Diabetes

Plasma glucose level : (different from those for non-gestational subjects)
fasting level : 　　　　　　　　　　　 ≧ 100 mg/dl ( = 5.5 mM )
1 hour after 75g glucose load : 180 mg/dl ( = 10 mM )≧
2 hours after 75g glucose load : 150 mg/dl ( = 8.3 mM )≧
diagnose to have gestational diabetes, when one fulfills more than 2
of the above criteria
diagnose to have diabetes mellitus, when one fulfills diagnostic criteria
for diabetes mellitus by Japan Diabetes Society
( fasting level 7.0 mM and/or 2 hours after glucose load 11.1 mM )≧ ≧
should test 75g oGTT after 1 to 3 months post-delivery to see whether
glucose tolerance is normalized or continue to be abnormal
Cases with IGT pattern in postpartum oGTT should be checked
every 3 to 6 months, and those with normal oGTT pattern should
be checked every 1 year because of high frequency of developing DM.

Diagnostic Criteria for Gestational Diabetes

1) Aggravation of diabetic retinopathy
especially, in patients with long standing retinopathy (more than 10
years),
or in patients with pre-proliferative or proliferative retinopathy
Management : photocoagulation should be done before conception
regular examination of fundus
2) Aggravation of diabetic nephropathy

increase in GFR and decrease in protein reabsorption in tubules
may aggravate diabetic nephropathy
toxemia and pyeronephritis also worsen renal function
may lead to increased proteinuria and decrease in Ccr
Management : control glucose and BP extensively,
and treat urinary infection
start dialysis, if Ccr become less than 25 ml/min during pregnancy
3) Increase in insulin requiement
extensive blood glucose control is required during pregnancy
ketoacidosis due to insulin deficiency lead to fetus death
insulin requirement is increased during pregnancy
Management : intensive insulin treatment is necessary

Impact of Pregnancy on Diabetes Mellitus and Its Management

1) Impact on fetus
in the early gestational stage : the initial 7 weeks after conception
(for 9 weeks from the last menstration) is important for organ
formation, which is labile to blood glucose level in mothers
in the middle and late gestational stage : hyperglycemia, ketoacidosis,
hypoglycemic attack, and toxemia lead to intrauterine fetal death
at delivery : perinatal death, giant baby, hypoglycemia, respiratory
failure, hypokalemia, hyperbilirubinemia when mother is hyperglycemic
2) Impact on mother
ketoacidosis or hypoglycemic coma induce abortion
urinary tract infection is common in diabetic pregnant woman
Impact of Diabetes Mellitus on Pregnancy

Planned pregnancy is the principle for diabetic woman.


1) Evaluation of complications
1) patients with nephropathy : permit when Ccr 70 ml/min, without HT≧
do not permit when proteinuria 3 g/day, or ≧
serum creatinine 1.5 mg/dl≧
desirable during normal to microalbuminuric stage of nephropathy
2) patients with retinopathy : permit while simple retinopathy
do not permit when untreated proliferative retinopathy exist
permit when proliferative retinopathy was photocoagulated and stable
extensive regular ophthalmic examination is necessary
2) Management and Guide before Pregnant
Blood glucose control during 1 month before conception and 7 weeks after
conception should be the most rigid. Even a short time of hyperglycemia in
a day might induce malformation in fetus. Meal could be divided into 4 to 6
times in each day. A mild exercise might prevent hyperglycemia.
Management of Pregnancy in Patients with
Diabetes Mellitus

Blood glucose control : fasting plasma glucose 70 - 100 mg/dl ( = 3.9 – 5.5 mM )
2 hours postprandial ＜ 120 mg/dl ( = 6.7 mM )
HbA1c ＜ 5.8 %
SMBG : 6 times a day (before, 2 hours after meal)
Education of insulin therapy
1) CSII (continuous subcutaneous insulin infusion)
2) change to insulin therapy when oral hypoglycemic drugs were administered
Exercise : less than 15 minutes during pregnancy
less than 140 times/min of heart beats
do not exercise when complications exist
Blood pressure control : salt restriction when syst BP 140 or diast BP 90≧ ≧
anti-hypertensive drugs (hydrarazine, αmethyldopa)
when control is insufficient

Target for Diabetic Pregnants (including GDM)
before and during Pregnancy

Management during pre- and post-
conception and during Pregnancy (1)
a. diet therapy
1) energy intake
during first half periods of pregnancy : 30 kcal x IBW + 100 ～ 150 kcal
during second half periods of pregnancy : 30 kcal x IBW + 350 ～ 400 kcal
during nursing after delivery : 30 kcal x IBW + 800 kcal
2) nutrients
Since carbohydrate is necessary at least 50 g everyday for fetal
development, and pregnant woman easily shows ketosis, therefore,
more than 200 g of carbohydrate should be taken everyday during
pregnancy.
Protein to be taken is 1.5 ～ 2.0 g / kg IBW.
3) body weight
Body weight increase should not exceed 8 kg before delivery.

Management during pre- and post-
conception and during Pregnancy (2)
b. insulin treatment
1) When blood glucose control is insufficient with diet therapy alone,
do not postpone starting the insulin therapy to prevent adverse effect
of hyperglycemia to fetus.
2) Intensive insulin treatment should be introduced to maintain good
blood glucose control since pre-conception period.
3) SMBG should be continued (before and 2 hours after each meal,
sometimes 1 hour after each meal). In order to get good control,
sliding scale for insulin doses could be utilized.

4) Doses of insulin required for good control increased in response to
progress in pregnancy, and will reach to 1.5 ～ 2.0 times of
non-pregnant periods.
c. laboratory tests
1) Frequency : During first half of pregnancy, regular checkup once per
month is necessary, however, during second half of pregnancy regular
checkup once per week become necessary for prevent complications.

Management during pre- and post-
conception and during Pregnancy (3)
2) laboratory tests during pregnancy

FPG once per month
HbA1c once per month
urine ketone once per month
BP, BW once per month
urine protein, renal function once per month
fundus finding
retinopathy (-) once per 2 months
retinopathy (+) once per month
fetal echographyic examination once per week ～ once per month
non-stress test 32 ～ 35 weeks once per week
36 weeks ～ twice per week
d. determination to delivery
Determine when to deliver by the fetal development.
When complications do not exist, 38 ～ 40 weeks are appropriate.

Management during pre- and post-
conception and during Pregnancy (4)
e. delivery

1) Vaginal delivery is performed generally.
In case with proliferative retinopathy, or with giant baby having more than
4,500 g, cesarean section is indicated.
2) Since eating is prohibited pre- and post-delivery, start 5% glucose infusion
with 4 units of regular insulin per 500 ml solution at the speed of 100 ml / hr
before delivery.
In case of unstable type 1 diabetes mellitus, insulin administration using sliding
scale should be added to the above infusion.
The target range of plasma glucose concentration is around 100 mg/dl (5.5 mM)
to prevent fetal hypoglycemia.
Check capillary glucose level every 1 ～ 2 hours.
3) Insulin requirement decrease when placenta is delivered.
Therefore, insulin administration should be decreased at just after delivery.
A half of previous insulin dose will be adequate when it is injected subcutaneously.
However, when sliding scale or continuous insulin infusion is adopted using SMBG,
the same dose will be continued.

Problems in Newborn delivered from
Diabetic Mother

The newborn delivered from diabetic mother is strongly influenced by
intrauterine hyperglycemia and resultant hyperinsulinemia, and present
several neonatal complications.
A close cooperation between physician, obstetrician, pediatrician,
ophthalmologist, nutritian, and nurse is required.
Neonatal complications from diabetic mother and its provision
neonatal complication provision
1. neonatal hypoglycemia blood glucose control before delivery
glucose infusion
2. deformity blood glucose control starting pre-conception

3. giant baby intensive blood glucose control
4. neonatal acute respiratory blood glucose control and evaluation of
distress syndrome pulmonary tissue maturation
5. hypocalcemia iv administration of calcium gluconate
6. hyperbilirubinemia photo therapy
7. polycythemia exchange transfusion to get Ht level ＜ 55%