• Preconception counseling is essential for diabetic moms !
• Better glycemic control before pregnancy = better outcomes
• Want HgbA1c to be at 6-7%

• Placental hormones (estrogen, cortisol, and HPL) inhibit insulin
• Macrosomia
• Mom’s blood brings extra glucose to fetus
• Fetus makes more insulin to combat glucose
• Extra glucose is stored as fatà big baby

• Impaired fasting blood glucose (100-125 mg/dl)
• Impaired glucose tolerance test (2 hour value 140-199 mg/dl)
• If fasting >126 or glucose tolerance test >200, consider true diabetes

• Absolute insulin deficiency (pancreas doesn’t make insulin at all)
• Caused by genetic factors
• Due destruction of beta cells in islets of Langerhans
• Prone to ketoacidosis

• Relative insulin deficiency (insulin resistance)
• Hyperglycemia develops gradually
• Risk factors: 
• Aging, sedentary lifestyle, obesity, HTN, hx of gestational diabetes, family hx, ethnicity

• Low risk moms: screened at 24-28 wks
• High risk: screened as early as possible
• Previous hx of GDM, obesity, strong family hx of DM

Screening Test

(see chart slide 6)

• 50 gm “glucola” test; non-fasting test
• Positive if >140 mg/dl
• Do 3 hr GTT test (fast overnight, test with 100 gm glucose load) if positive
• Test at fasting 1, 2, and 3 hrs; positive if 2+ values are elevated
• Do not restrict carbs in 3 days before test; may give false negative (eat at least 150 gm/day)

• PIH, eclampsia
• Genital or urinary tract infections
• PROM and preterm labor
• Hydramnios, PP hemorrhage
• C-section

• Macrosomia (w/ poorly controlled DM or GDM)
• Hypoglycemia (all)
• Hyperbilirubinemia (all)
• Congenital anomalies (w/ pre-existing DM)
• IUGR (w/ pre-existing DM)
• Respiratory distress syndrome (all)

• Acidosis accompanied by the accumulation of ketone bodies (ketosis) in the body tissues and fluids
• Can be caused by hyperglycemia
• Insufficient insulin--> increased ketones in the blood as fatty acids are metabolized
• All pregnant woman at risk, should:
• Test urine ketones daily on 1st morning urine

• Fasting: 60-90 mg/dL
• 2 hour post prandial (after meals): 90-120 mg/dL
• hgbAIc: 6.0% or less 
• Test 4 times a day
• Fasting every morning and 2 hours post prandial

• Tests glycemic control over past 2-3 months; last month weighed most heavily
• Non-diabetic: 5.9% or less
• Good diabetic control: 6.0-7.0%
• Fair control: 7.0-8.0%
• Poor control: >8%

• Test hgbA1C
• Monitor blood glucose levels (home)
• Dietary management--6 small meals/day, carbs controlled, limited concentrated sugar
• Daily urine ketone testing
• Insulin therapy

• NPH and lispro (Humalog)
• Regular insulin (Humulin R)
• Micronase (glyburide): sulfonylurea
• Only oral hypoglycemic approved for use in pregnancy

• First Trimester
• Need is reduced (d/t increased production, sensitivity, and decreased food intake d/t n/v)
• Second Trimester
• Need begins to increase (d/t placental hormones decreasing insulin's effectiveness)
• Third Trimester
• Need doubles or quadruples (levels off by wk 36)

• Monitor glucose levels q2h (maintain at 80-120)
• This range decreases risk of neonatal hypoglycemia
• May need to infuse regular insulin IV to maintain levels

• Day of birth:
• Need decreases drastically, approaching pre-pregnancy levels
• GDM moms may not need supplemental insulin 
• Breastfeeding: maintain lower insulin needs
• Not breastfeeding: return to pre-pregnancy levels 7-10 days PP

• Excessive vomiting during first 10 wks of pregnancy
• Causes loss of at least 5% of prepregnancy weight
• Also experience dehydration, electrolyte imbalances, ketosis, and acetonuria
• More common in:
• Age <20 y.o., hx of migraines, obesity, nonsmokers, multi-gestation, adn molar pregnancies

• Educate mom to assess amount/color of emesis, monitor weight changes, and check urine for ketones
• If hospitalized (not common, can manage at home):
• IV fluids and electrolytes, NPO until n/v stops (24-48 hrs)

• Slowly advance diet as tolerated (once n/v has stopped)
• Small, frequent meals
• Low fat, high protein
• Herbal teas to reduce nausea (chamomille, raspberry)
• Oral hygiene 

• Increased BMR & sympathetic NS activity
• Anxiety, insomnia, weight loss, increased appetite, hair loss, n/v, tachycarida (everything speeds up !)
• Labs:
• Decreased TSH, increased T3 & T4

• PTU (propothiouricil)-- used to suppress mom's thyroid function; will cross placenta, so measure fetus's T4 levels monthy
• Fetus will probably be hypothyroid (d/t PTU exposure)
• Should normalize in a few days PP

Hypothyroidism in Pregnancy

• Rare
• Hypothyroid women have difficulty getting pregnant or carrying fetus in early pregnancy
• Require preconception counseling !