Postpartum care in GDM and Pre-conception counseling Dr Amrita Jaipuriar

Immediate Postpartum Period Late Postpartum Period Maternal risks Immediate Postpartum Period Late Postpartum Period Postpartum hemorrhage Genital tract trauma Infections Hypoglycemia Metabolic syndrome Future obesity Type 2 Diabetes Hypertension Cardiovascular disorder

Neonatal risks Perinatal death Hypoglycemia Respiratory distress Preterm birth Birth trauma& shoulder dystocia Congenital malformation Hypoxic ischemia Macrosomia Polycythemia / Jaundice Hypocalcemia & Hypomagnesemia Newborn of mother with GDM are at greater risk of developing respiratory distress and hypoglycemia Increased risk of morbidity and mortality because of harmful intrauterine metabolic environment, if plasma glucose levels of mother is uncontrolled, or due to the obstetric interventions required to facilitate delivery

Immediate postpartum period is critical for early initiation of preventive health care for both mother and baby

Immediate neonatal Care Essential new born care for every newborn Early breast feeding to avoid hypoglycemia Monitoring for hypoglycemia (cut off < 45 mg/dl) to be started after one hour of delivery every 4 hours (prior to next feed) till four stable glucose values are obtained Evaluate neonate for Respiratory distress syndrome, convulsions, hyperbilirubinemia

Recognition of Neonatal Hypoglycemia Most of the times asymptomatic Stupor, tremors, jitteriness, convulsions Tachypnoea , apneic spells, lethargy, limp, eye rolling Difficulty in feeding, sweating episodes, high pitched or weak cry

Managing a Newborn with hypoglycemia Immediate breast feeding without delay If unable to suck, give expressed milk If no breast milk secretion/production, baby should be given any formula or top feed Dissolve one TSF table sugar in 100 ml of normal cow’s milk Once feed has been given, check blood glucose again after one hour If blood glucose is >45 mg/dl, 2 hourly feeding (breast feeding is the best option but if not available, formula feed can be given) should be ensured

Managing a Newborn with hypoglycemia (contd.) If Neonatal plasma glucose < 20 mg/dl: IV bolus 10% dextrose @ 2 ml/kg Followed by 10% dextrose drip @ 100 ml/kg/d Check blood sugar 30 min after starting infusion If hypoglycemia persists refer to NICU

Danger signs for referral of Neonate Failure to maintain IV line & blood glucose is < 20 mg/dl Two values of plasma glucose < 20 mg/dl in spite of 10% dextrose drip Neonate not able to suck and blood glucose is < 20 mg/dl Seizures

Optimal control in antenatal period reduces the complications !! Minimizes risks of complications in the newborn Reduces malformations, macrosomia, birth trauma, respiratory distress

Breast feeding Early breastfeeding should be encouraged Prevents hypoglycemia in newborn and promotes bonding between mother and baby Protects against infant and maternal complications: - Childhood obesity - Type 2 DM in baby - Helps in postpartum weight loss in mother Treatment with insulin or oral hypoglycemic drugs may be started even in breastfeeding women as secretion of these drugs is negligible in breast milk and does not affect the quality of milk nor the health of newborn

Infections Mothers with GDM are at increased risk of infection especially if delivery was prolonged or required operative intervention Detect early signs of UTI, puerperal sepsis, and surgical site infection (episiotomy and caesarean delivery) Large-sized babes of diabetic mothers do not suckle well. This may lead to milk retention and increased risk of breast engorgement and abscess formation

Contraception Safe, effective and reversible method of postpartum contraception With adequate spacing, her metabolic parameters can return to normal Thus there is reduced risk of GDM, spontaneous abortions or congenital malformations in the next pregnancy

Balance between Risk due to type of contraceptives vs Risk of Unplanned Pregnancy in women with Hyperglycemia

Contraceptive options for women with prior GDM Barrier methods IUCD & PPIUCD COC POP Long acting POC Surgical sterilization

Barrier Methods Well suited due to lack of systemic side effects Does not influence Glucose tolerance Use should be encouraged especially in at risk for STDs & HIV infections

Intrauterine Devices Very effective & reversible No metabolic disturbances Studies reaffirms safety LNG IUD good due to low frequency of bleeding disturbances Cu IUDs shows no increased risks of PID IUCD is ideal contraceptive for women with prior GDM WHO lists no restriction of its use in Type I & II DM

Combined Oral Contraceptives COC – dose of estrogen is responsible for thrombotic risk & hypertension, Progestin effect on Lipid tends to antagonize estrogen effect, lowers triglycerides & HDL & increases LDL Cholesterol Newer COCs has beneficial effect on Lipid profiles – Net effect of COC depends on type/dosage of each hormonal component COC not recommended in diabetic women who smoke, >35 years, have hypertension, obesity & diabetes related vascular complications COC with lowest dose of ethinyl estradiol & lowest potency of progestin can be prescribed Evidence from epidemiological and limited clinical studies in women with DM & Prior GDM

Progestin Only Oral Contraceptives Do not increase thrombosis or BP Shortcoming is irregular bleeding Taken at strict time interval daily No doubling up on missed days Low dose Norethindrone or Levonorgestrel Well suited for Type I Diabetes - do not influence diabetes control, BP & other vascular diseases Good for women with prior GDM who often have several cardio-vascular risk factors Diabetes & prior GDM

POP should not be the first choice for women during lactation There is underlying Insulin resistance & B cell dysfunction in DM & Prior GDM patients POP causes exogenous administration of unopposed progestin In a large cohort study it was found (JAMA 280: 1998) Adjusted 3 fold increase for development of Type II DM during first 2 years compared with low dose COC – Risk is time related, risk increases with duration of POC exposure With use < than 4 month - no increase risk With 4-8 month use 3 fold increase risk of DM With > 8 month use 5 fold increase risk of DM

Long acting POC – DMPA / Implants Not a first line choice in women with prior GDM DMPA should be used with caution in breast feeding women & those with elevated triglycerides Women with prior GDM choosing DMPA had an increased risk of developing DM Diabetes Care 29: 2006

Surgical Sterilization Excellent choice Good for Parous women Especially delivering by LSCS

Post delivery follow up Usual post partum care Maternal glucose levels usually returns to normal after delivery FPG & 2 hr PPPG is performed on 3rd day of delivery 75 g GTT performed after 6 weeks - Cut off for normal blood glucose values are : FPG < 100 mg/dl 75 g OGTT 2 hour PPPG Normal < 140 mg/dl IGT 140-199 mg/dl Diabetes equal or > 200 mg/dl Test normal - Women is counselled about life style modifications, weight monitoring & exercise Test positive women should consult physician

Late postpartum complications Future Obesity Metabolic Syndrome Diabetes Hypertension Cardiovascular Disorders This can best be achieved by linking mother’s follow up to the child’s vaccination and well baby clinic visit A sticker of red dot can alert care giver about GDM offspring and follow up for contraception & discussion about life style changes

GDM women are at higher risk of DM & CVS diseases OGTT to be done 6 wks after delivery with 75 gm of glucose to evaluate glycemic status GDM women are at higher risk of DM & CVS diseases Intensive life style intervention delays & reduces the risk for development of DM & CVS problems

Importance of testing and procedure Result Instructions Normal: <140mg/dL -Lifestyle modifications, weight monitoring, appropriate diet and physical exercise - Blood sugar to be tested every 3 years Impaired Glucose Tolerance: 140- 199mg/dL -Blood sugar to be tested every year -Refer to consult physician to learn about ways to lower risk for developing diabetes later in life Diabetes: >200mg/dL -Refer to consult with physician to start treatment for diabetes

Pre-conception counseling Postpartum care of GDM woman - - Is preconception care for a subsequent pregnancy

Should be a planned pregnancy Counsel for strict follow Malformation screening Diet counselling with well controlled Blood sugar FBS <100 & 2 hr PPBS <140 HbA1C < 6.5 If on oral drugs -change to Insulin ACE inhibitors to be stopped End organ evaluation Peri-conception Folic acid 5 mg/day oral

Thank you