1. Ultrasound in hyperglycemia in pregnancy
Dr. Chitra Ganesh
Fetal Medicine Consultant
Karthik Ultrasound Scan Centre
Fortis Hospitals
Bangalore
Despite major progress in obstetrics over the last 100 years, the delivery of large fetuses remain a source of anxiety among health care personals because these pregnancies are at increased risk of secveral perinatal complications both to the mother and fetuses and also have long term implications on the offspring

2. Hyperglycemia in Pregnancy

3. Preexisting DM In Pregnancy
increased risk of
1. miscarriage
2.preclampsia
3. congenital abnormalities
4. perinatal mortality ( excluding cong malformations )
2 fold increase
5. Sudden unexplained IUFD
HbA1c level Risk
normal not increased
<8% %
>10% %

4. Ultrasound & maternal diabetes
Viability & Accurate dating
Fetal abnormalities
Macrosomia
Fetal well being

5. Fetal surveillance in Diabetes
Fetal anomalies
Growth & environment
Chromosomal
Structural

6. Chromosomal Anomalies
Fetal Anomalies
Chromosomal Anomalies
Risk is no higher
MoM values will vary
Structural Anomalies
General
Specific

7. Serum markers and FTS Lower by 15% in IDDM Correction required
Influence of maternal IDDM on fetal NT and first-trimester maternal serum biochemical markers of aneuploidy
K. Spencer,N. J. Cowans,  Prenatal Diagnosis , Volume 30, Issue 10, October 2010
PAPP-A
Lower by 15% in IDDM
Risk
Correction required

8. Diabetes & II trimester screening
AFP
Lower
Ue3
Risk
Correction
Beware
AFP low despite high risk for NTDs

10. CARDIAC ANOMALIES
TGA
TOF
FETAL ECHO MANDATORY

11. CNS- NEURAL TUBE DEFECTS

12. SACRAL AGENESIS

13. Caudal Regression

14. OROFACIAL CLEFTING

15. Anomalies specific to Diabetes

16. Diabetes - Pathophysiology
Fetal Hyperglycaemia
Increase the production &
secretion of insulin from fetal pancreas
Hyper insulinemia
Accumulation of glucose in the liver
Increased stimulation of triglycerides synthesis -increase in subcutaneous fat

17. Fetal Growth – MACROSOMIA
MACROSOMIA – “ Big body ”
Established limit
No consensus
Birth weight : > 4000 gm,
> 4200 gm > 4500 gm
ACOG
Birth weight : > 4500 gm
Irrespective of GA
Macrosomia is diagnosed when excessive intra uterine growth occurs and the birth weight exceeds an established limit . There are no nationally or internationally agreed established weight limits for macrosomia . ACOG recommends 4500g because of marked increase in maternal and neonatal complications at this weight
Large for GA
EFW > 90th%tile, or > 2 SD for the period of gestation
8 – 14 % in normal pregnancies
25 – 45 % in Diabetic mothers

18. Macrosomia Diabetic Macrosomia - asymmetric macrosomia
HC/FL less than 90th%tile
AC more than 90th%ile
Non Diabetic Macrosomia -symmetric macrosomia
Constitutional - parents of large stature , recurs in subsequent pregnancies
Genetic Syndromes

19. Diabetic Macrosomia Different body composition
Significant increase in fat mass % & % of fat than fat free mass ( lean body mass )
Increased Fat mass & % body fat is also seen even when there is no macrosomia
Disproportionate growth – more of truncal growth
( abdomen & shoulder ) than head & femur

20. Diabetic Macrosomia Excess growth happens in the III trimester
Selective organomegaly
Accelerated growth of fetal AC

21. Diabetic macrosomia
Accelerated growth despite good glycemic control
Diabetes Spectrum , April 2007
Coexisting risk : obesity, ethnicity, maternal age, wt gain
Once fetal hyperinsulinemia is induced it is difficult to assess whether
maternal glucose level reflects real situation
fetus is using excess maternal glucose and artificially lowering maternal glucose level
Accelerated AC growth before 24 weeks predicted
macrosomia despite good maternal glycemic control

22. USG – Abdominal circumference
AC – single most important & reliable parameter
Two dimensional / elliptical method - equally accurate

23. Macrosomia & AC AC threshold for predicting macrosomia is of
35 – 38 cm
AC > 35 cms - 93% PPPV of > 4000 gm
– fetal diagnosis therapy 2013
Addition of EFW increased DR by 3%

24. Macrosomia – prediction
Predicting macrosomia in Diabetes with poor glycemic control
EFW – overestimates ( margin of error is +/ % )
AC is the most sensitive parameter for fetal overgrowth
AC > 75th %tile weeks increased risk of macrosomia / shoulder dystocia
5th International workshop conference on GDM
Diabetes Spectrum April 2007
AC is the most sensitive parameter for fetal over growth
AC > 75th %tile as a measure of glycemic control

25. Diabetes & Polyhydramnios
Incidence
Dashe et al 2002
All polyhydramnios
5% Gest DM
2% Pregestational DM
Idris et al, 2010
All diabetics
18.8%
Prevalence
8-20%
30 times more than normal Pregnancies

26. Polyhydramnios in DM 314 Pregnancies Pregestational diabetes
singleton pregnancy
> 24 weeks of gestation
1996 to 2006

27. Polyhydramnios in DM The incidence of polyhydramnios - 18.8%.
Increased HbA1c in poly pregnancies Pre and in pregnancy
Increased preterm delivery (54.2% vs. 33.3%, P = 0.004) Majority - iatrogenic preterm deliveries (44.1%).
High El Cesarean section (83.0% vs. 62%; P = 0.006).
No significant differences in perinatal mortality rates.

28. Fetal Growth Restriction & DM
Diabetics with vasculopathy
Preeclampsia
Diabetes with strict glycaemic control
If everything else is normal, and no reason for SGA – look for very tight control

29. Doppler in Diabetes – IUGR
If FGR
Dopplers change as in non IDDM
Cannot prevent /predict DM related SB

30. Conclusions Gestational diabetes is a common problem in India’
Risk stratification and screening is essential in all Indian pregnant women
Good glycemic targets are required for optimal maternal and fetal outcome

31. Conclusions Fetal surveillance starts with dating in first trimester
Detailed Targetted imaging including ECHO mandatory
Serial scans and plotting of graph helps identify growth abnormalities and aids further management

32. THANK YOU