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PGDM-GDM Complications

      1.What are the fetal complications of Gestational Diabetes Mellitus?

Macrosomia:

Macrosomia is defined as a birth weight > 90th percentile for population-specific standards, or a birth weight greater than 4kg. Maternal hyperglycemia increases the amount of glucose transferred to the placenta. In response, fetal insulin secretion increases, resulting in fetal abdominal fat distribution and visceral adiposity, particularly in the liver and heart. Macrosomia raises the risk of birth asphyxia.

Shoulder dystocia and Birth Injuries:

Because of macrosomia, the baby's anterior shoulder is locked behind the pubic bone and cannot be delivered after the head. Macrosomic newborns are up to ten times more likely to have Erb's palsy. 

Still Birth:

Stillbirth is described as fetal loss that occurs after 24 weeks of gestation. The risk of stillbirth is five times greater in diabetic pregnancies than in non-diabetic pregnancies. Congenital abnormalities alone cannot explain such a large proportion, but prenatal hypoxia and acidity may be contributing factors. Fetal hypoxia occurs when hyperinsulinemia causes an increase in substrate availability, which exceeds the placental oxygen supply.

Neonatal hypoglycemia

Prolonged use can result in brain damage and impaired neurodevelopment. Transient hypoglycemia is prevalent, affecting roughly half of diabetic pregnancies. The macrosomic newborn is at risk of hypoglycemia due to hyperinsulinemia caused by secondary beta cell hyperplasia, which inhibits hepatic glucose synthesis. Early feeding minimizes the risk of hypoglycemia, hence all diabetic mothers should be urged to breastfeed within 30 minutes of birth.

Hyperbillirubinemia

The causes of hyperbilirubinemia appear to be multifaceted, including birth trauma, erythrocytosis, hemolysis, and immature hepatic absorption and conjugation of bilirubin.

Respiratory Distress Syndrome

Rather than being a direct result of hyperglycemia, RDS is more likely to occur due to an increased proportion of preterm delivery and a high prevalence of LSCS in diabetic pregnancies. Hesitancy in providing glucocorticoids due to their effect on glycemic control may also contribute to an increased risk of respiratory distress syndrome.

Other complications:

Infants born to diabetic mothers may develop neonatal erythrocytosis, transient hypertrophic cardiomyopathy, hypocalcemia, and hypomagnesemia.

Long term consequences:

GDM adds an intrauterine environmental risk factor to an increased genetic risk of developing obesity, diabetes, and/or metabolic syndrome in childhood. Recent research suggests that GDM may increase the risk of cardio-metabolic morbidities later in life by affecting DNA methylation of genes related to energy metabolism, anti-inflammatory processes, insulin resistance, and β-cell apoptosis. However, the exact mechanism remains unknown.

Hyperglycemia alters the expression of angiogenesis-associated molecules in trophoblasts, as well as pro-inflammatory factors including IL-6 and TNF-α, negatively impacting the intrauterine environment. Not only does maternal glycemia affect offspring obesity, but so does maternal glucose intake.

2. What are the Maternal complications of Gestational Diabetes Mellitus?

In terms of maternal problems, GDM is a substantial risk factor for the development of persistent diabetes later in life (40% in 10 years), as well as GDM in subsequent pregnancies (35%), which increases with the mother's age and weight. It also increases the risk of preeclampsia.

Several recent investigations have established a link between GDM and several long-term problems. Stress urine incontinence and mixed urinary incontinence, a twofold risk of overactive bladder during the premenopausal period, and cardiovascular morbidity are the most serious.

Increased risks of obstetric complications: Pregnancy-induced hypertension, caesarean section, bradytocia related to macrosomia, and inducement of labor all have an increased prevalence. Complications such as shoulder dystocia increase the risk of postpartum hemorrhage and grade 3-4 perineal tears.

3.What are the fetal complications of Pre Gestational Diabetes Mellitus?

Apart from fetal complications seen in neonates born to mother with GDM, new born are at increased risk of congenital malformations (3%) when delivered by mother with Pre GDM. This occurs due to fetal exposure of hyperglycemia in early pregnancy (6-8 weeks).

Most commonly anomalies are seen cardiovascular system followed by musculoskeletal and central nervous system.  As such there is no specific cardiac abnormalities for diabetes, conotruncal cardiac anomalies are more common in new born of diabetic mother. TGA, tricuspid atresia and truncus arteriosus  are 15 times more common in infant of diabetic mother.

Caudal dysgenesis is relatively specific to diabetic pregnancy. Many anomalies are part of VACTRAL syndrome. (Vertebral anomalies, anal atresia, cardiac defect, trachea-esophageal fistula, renal anomalies and limb abnormalities). The absolute risk is congenital anomaly is 3% is when pre-conceptional Hba1c is 6.7% and 10% when HbA1c is 11.3%. Rate of pre term delivery is slightly increase in patients treated with metformin compared to insulin.

4.What are the Maternal complications of Pre Gestational Diabetes Mellitus?

There is increase risk of worsening of diabetic retinopathy, nephropathy and ketoacidosis. DKA is associated with increased risk of fetal loss.

Diabetic Ketoacidosis:

Although type 2 DM can also occur, type 1 DM accounts for the majority of instances. Lower glucose levels are more likely to cause ketoacidosis. Prolonged vomiting and hunger, infections, inadequate glycemic management, the use of corticosteroids for lung maturation, and other factors can all cause it. Fetal discomfort is brought on by DKA, and the fetal mortality rate can reach 10–30%.

Maternal Hypoglycemia              

Pregnant women with type 1 diabetes are especially vulnerable to hypoglycemia, particularly asymptomatic nocturnal hypoglycemia, which raises the risk of severe hypoglycemia and causes hypoglycemia unawareness.  61% of women with type 1 diabetes and 21% of women with type 2 diabetes reported recurrent hypoglycemia, according to CEMACH (Confidential Enquiry into Maternal and Childhood Health).

Diabetic Retinopathy

Pregnancy-related diabetic retinopathy often advances based on two factors: the severity of pre-existing retinopathy and improvements in glycemic management. The risk is low for women who do not have retinopathy.

Growth factors are found in higher concentrations in the blood during pregnancy. PGF (Placental Growth Factor), a VEGF family member, is making the retina more vulnerable.

Retinopathy can occasionally appear de novo, although it never develops into proliferative diabetic retinopathy. The emergence of cotton wool patches is a hallmark of deterioration.

Diabetic Nephropathy

Increased renal failure and pre-eclampsia are maternal risks of diabetic nephropathy; IUGR, pre-maturity, and mortality are fetal sequelae.

GFR often increases by 50% to 100% during pregnancy. When pregnant, women with diabetic nephropathy may see a modest increase in GFR but a sharp rise in protein excretion. In the postpartum phase, the condition typically returns to its pre-pregnancy level, with the exception of stages 3 and 4.

Pre-eclampsia is a serious problem; it can occur in up to 64% of patients with severe proteinuria and is more likely in people with microalbuminuria.

Pre-eclampsia is characterized in women who already have renal illness by worsening hypertension, double proteinuria, and rising plasma creatinine, thrombocytopenia, and transaminase levels.

Early, rigorous treatment lowers the risk of preterm birth and pregnancy-induced hypertension.

5.What are ways to prevent materno-fetal complications apart from Glycemic control?

Breastfeeding has been identified as a significant intervention with long-term metabolic benefits for both mother and child. Lactation was linked to low glucose and insulin concentrations, improved glucose tolerance, and a significant delay in the onset of type 2 diabetes in women with GDM. In contrast, the offspring showed protection against excessive fat accumulation, protection against childhood infections, cardiovascular diseases, and type 2 diabetes.

Materno-fetal problems appear to be less likely when the mother's weight is controlled.

The decrease of maternal-fetal problems is further aided by the prenatal treatment of thyroid issues, hypertension, dyslipidemia, and folic acid supplements.


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