DIABETES and PREGNANCES
Pregnancy in women with diabetes is characterized by an increase in the frequency of congenital malformations, fetal macrosomia, respiratory distress and hypoglycemia at birth. It is now clearly demonstrated that the prognosis for
Pregnancy is dependent on the quality of glycemic control from the periconceptional period to delivery and also on the quality of medical management.
during the entire pregnancy. If the various problems inherent to the diabetic woman becoming pregnant are now well targeted, but not so for diabetes gestational.
1°) The new diagnostic criteria for diabetes
According to the A.D.A. (1997-2004) the thresholds currently used are :
- A fasting blood glucose level greater than or equal to 1.26 gr/l (7 mmol/l) after 8 hours at the
- Casual blood glucose (at any time of day, including post prandial)
greater than or equal to 2 gr/l (11.1 mmol/l).
- A blood glucose level two hours after oral intake of 75 grams of glucose greater than or equal to
2 gr/l (11.1 mmol/l).
A new framework called non-diabetic fasting hyperglycaemia is identified. A blood glucose level of
Fasting between 1.10 gr/l and 1.25 gr/l is abnormal. It is often associated with an excess of
weight, hyperlipidemia, high blood pressure. Half of the subjects will develop more or less
less quickly to type II diabetes.
2°) Pre-gestational diabetesPregnancy in an insulin-dependent diabetic (IDD1) woman is a risk for
potential for both mother and child. Although the last few years have seen
a dramatic decline in fetal mortality and morbidity, it is nonetheless
a high-risk pregnancy. It requires glycemic normalization from the preconception period to delivery and rigorous monitoring by teams accustomed to this type of pregnancy.
pathology. The prognosis is essentially related to glycemic control and whether or not there is
of high blood pressure in the mother.
Type II diabetes (T.D.2) is rarer in women of childbearing age. However, it appears that its frequency increases especially with age.
The fetal risks associated with hyperglycemia are the same as those encountered in type I diabetes.
It is all the more traitor that he is often misunderstood.
In the presence of risk factors it must be systematically sought early in pregnancy. Ignorance can be serious; the treatment is identical to type I diabetes.
Risk factors for diabetes
- Personal history of hyperglycemia
- Family history of diabetes
- Age > 35 years old
- Obesity : BMI > 27 kg / m2
- History of Fetal Macrosomia
- History of H T A or perinatal death
Undiagnosed periconceptional fasting hyperglycemia also appears to be increasing.
the risks of malformations and pregnancy complications. The current critical threshold
withheld for pregnant women appears to be 1.05 grams per liter on an empty stomach. At the slightest doubt a blood glucose level at
Fasting must be requested early in the pregnancy. In the event of an increase, a plan to
Normalizing blood glucose levels and increased monitoring of pregnancy are necessary.
3°) Gestational diabetes
It is defined as a carbohydrate tolerance disorder of variable severity diagnosed as a for the first time during pregnancy. Its frequency is increasing in countries developed. In France the prevalence is estimated at 3 to 6%.
During normal pregnancy there is an increase in insulin resistance.
which is associated with increased insulin secretion. In diabetes
gestational there would be too much insulin resistance not compensated by the increased of insulin secretion, which causes maternal hyperglycemia.
Gestational diabetes without having the severity of pre-gestational diabetes is accompanied by of a number of complications. During pregnancy it is associated with greater frequency of hypertensions and pre-eclampsia. It predisposes to fetal macrosomia and its obstetrical consequences: shoulder dystocia, stretching of the brachial plexus, greater number of C-sections.
In the newborn it increases the risk of hypoglycemia, hypocalcemia, respiratory distress. Finally, in the longer term in the mother the risk of develop type II diabetes is estimated to be 20-60%.
The classic diagnosis is based on oral glucose hyperglycaemia (OGTT).
with 100 grams of glucose. Gestational diabetes is defined by two abnormal values.
H G P O with 100 gr of glucose
on an empty stomach H1 H2 H3
Blood glucose 0.95 1.80 1.55 1.40
Screening was first performed on risk factors or complications pregnant. This directed screening ignores about 1/3 of the cases, so a screening is currently recommended by many associations.
In the absence of risk factors, the best screening period appears to be the end of the second trimester where insulin resistance increases. If there are risk factors, it is better to screening in early pregnancy to detect the most severe diabetes.
Two methods are proposed:
– The classic two-step method: Screening uses the O’ Sullivan test
(blood sugar level one hour after 50 grams of glucose) if this test is positive (blood sugar level above 1.30 grams/l
or 1.40 gr/l?) a 100 gr HGPO with oral glucose load will be performed for confirming the diagnosis.
– The one-step method recommended by WHO: This is a simplified OPGH with fasting blood glucose and blood glucose two hours after 75 grams of glucose.
This method is less evaluated but has the advantage of allowing screening and diagnosis. The results are in accordance with the new A.D.A. definitions.
H G P O Simplified (2 H after 75 gr)
Diabetes…….G to J ≥ 1.26 gr/l or after load ≥ 2 gr/l
Hyperglycemia on an empty stomach …………………………….. G to J ≥ 1.05 and < 1.26 gr /l
Glucose intolerance ………………………………… after a load of > 1.40 and < 2 gr/l
Management is about getting your blood glucose levels back to normal. In 50 to 70% of cases
A simple diet with physical activity is sufficient. If after 15 days the
normalisation of blood sugar levels (< 1.05 gr/l on an empty stomach and 1.30 gr/l post prandial) is not obtained,
insulin treatment will be considered.
Obstetrically if blood glucose levels are normalized with the regimen alone monitoring
identical to that of a normal pregnancy is recommended. If the blood glucose levels are not correct, or
if insulin therapy had to be initiated further monitoring in late pregnancy is
and the course of action is similar to that for pre-gestational diabetes.
The current recommendations are as follows:
1. In pre-gestational diabetes: the importance of eurglycemia in the periconceptional period and during pregnancy.
2. In the absence of known diabetes: in high-risk patients screening for diabetes of
type II and moderate hyperglycemia early in pregnancy and even before the
3. For patients with no specific risk factors: a screening
systematic by load test at the 6th month.