Management Of NIDDM In Pregnancy
NATIONAL JOURNAL OF HOMOEOPATHY 1999 May / Jun VOL VIII NO 3.
Dr Kamini D Nihalani
[Abstracted from Universal News - Aug 1998]

Pregnancy and the Non-Insulin Dependent Diabetic
A Non-Insulin Dependent Diabetic [NIDD] or Type II diabetic, is usually a middle aged, obese, non-ketotic individual with a strong F/H of diabetes. However, the incidence of NIDDM in the young is especially high in India. Should We 'Allow' Diabetics To Conceive?

The incidence of major congenital anomalies in overtly diabetic pregnancies have ranged from 7.5 - 12.9% ie 7-10 times more than in the general population. Hyperglycemia during the critical period of organogenesis is one of the most important causes of embryopathy and its incidence could be reduced if blood sugars could be tightly controlled prior to conception.

Conception should be considered only when the blood sugar and HbAIc (Glycosulated Hb) levels are optimally controlled and other medical conditions appropriately treated.

'NIDDM' - Preconception management? During preconception treatment, an unstated rule would be that all medications used should be acceptable in pregnancy.
Oral hypoglycaemic agents (OHAs) are contraindicated in pregnancy because of their possible tetratogenic effects and prolonged neonatal hypoglycaemia.

Diet is one of the important modalities of management of the diabetic, irrespective of type of diabetes and other modalities of management.

Insulin
It is preferable as of today to treat every pregnant diabetic with insulin. Bovine and porcine insulins have a greater antigenicity than the newer insulins. These induce IgG, which can cross the placenta taking exogenous insulin with them.
In a Type II diabetic the need for insulin therapy is likely to be for the full duration of pregnancy.

Home Glucose Monitoring

1. Urine Tests
   Normal pregnant women have a significant ketonaemia after 12-16 hours fasting. Therefore in a diabetic, there is an increased risk of diabetic ketoacidosis. Since this can cause foetal death or malformation, it is very important to test for ketonuria on a daily basis. If ketonuria is present without hyperglycaemia (BS < 180 Mg/dl), it suggests insufficient intake. Treatment would necessitate the institution or increase in the quantity of a bedtime snack.
2. Blood Sugars
   Home Blood Glucose Monitoring could be read visually or on a meter

Hyperinsulinaemia increases foetal oxygen consumption and reduction in arterial oxygen content. Hyperglycaemia when associated with mild hypoxia could lead to lactic acidosis and foetal death.

Mother's blood sugar can today be maintained under tight control with HBGM and intensified insulin therapy. This control has resulted in reduced frequency of abnormal tests for foetal conditions. Today foetal surveillance programmes may be carried out only in patients with pre-eclampsia, IUGR or reduced foetal activity reported by the mother.

Gestational Diabetes Mellitus [GDM] is defined as 'carbohydrate intolerance of variable severity with onset or first recognition during pregnancy'.
Neonatal hypoglycaemia (blood sugars of < 130 mg/ dl) was another marker for GDM.

The most important test for an infant of a GDM is to identify macrosomia by USG. Antepartum biophysical profile testing should begin at 32 weeks of gestation in an uncomplicated GDM. Pregnancy - induced hypertension, insulin treatment and previous still birth should cause antepartum foetal surveillance to begin earlier at 28 weeks of gestation. A foetus with macrosomia by implication has hyperinsulinaemia. Hence, such a foetus even with a gestational age of 38 weeks would require documentation of pulmonary maturity prior to induction of labour.

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