Post Partum

Objectives Discuss the immediate care of the infant Discuss the importance of breast feeding Discuss follow up screening of the mother Discuss risk of IGT or diabetes in future Discuss follow up education for mother

After delivery – the infant Watch for signs of hypoglycemia Check blood glucose – heel prick Within 1st hour after delivery After each of 1st 4 feeds Less than 2.6 mmol/L or 44 mg/dl defined as hypoglycemia Treatment of hypoglycemia Topfeeding/glucose in water/ IV dextrose Seshiah V, Balaji V, et al. Gestational Diabetes Mellitus – Guidelines. J Assoc Physic of India 2006;54:622-28. Seshiah, Balaji, 2006

After delivery – the infant Usual care Vital signs Apgar scores Pre-warmed incubator Start breast feeding within 30 minutes for better latching Watch for jaundice – check bilirubin If macrosomic, check calcium and magnesium on day 2 Seshiah V, Balaji V, et al. Gestational Diabetes Mellitus – Guidelines. J Assoc Physic of India 2006;54:622-28. Seshiah, Balaji, 2006

After delivery - mother Exogenous insulin not required after placenta is delivered Blood glucose usually returns to normal Check fasting within 48 hours to rule out type 1 or type 2 diabetes

Breast feeding Encourage for all Protects infant from over or undernutrition during early childhood May lower risk of Obesity Hypertension Cardiovascular disease Diabetes Gunderson EP. Breastfeeding after gestational diabetes pregnancy. Diabetes Care. 2007;30(supl 20:S161-168. Gunderson, 2007

Post partum period Encourage mother to achieve healthy weight. Healthy eating Adequate intake to sustain breast feeding Regular activity

Future pregnancies Should be planned Education regarding birth control is needed Encourage achieving healthy weight prior to conceiving again Check blood glucose levels well ahead of conception allowing time to normalize if necessary

Contraception Any method of contraception can be safely used in a woman with history of GDM Intrauterine devices are commonly used Progesterone-only oral contraceptives are the best choice within the first 6 weeks post partum They have the lowest risk of thrombosis Preferred during breastfeeding

Glucose tolerance testing Should be done 6-12 weeks post partum Fasting glucose testing is not sufficient to identify all who have IGT or type 2 diabetes Only 34% of women with IGT or type 2 had elevated fasting glucose levels 44% of those with type 2 had fasting less than 5.5 mmol/L (100 mg/dL) OGTT should be done Metzger BE, Buchanan TA, Coustan DR, De Leiva A, Hadden DR, Hod M. Summary and recommendations of the fifth international workshop-conference on gestational diabetes mellitus, Diabetes Care. 2007; 30(suppl 2):S251-260. Metzger, Buchanan, Coustan et al. 2007

CVD risk Women with GDM may have many of characteristics of metabolic syndrome Hypertension, dyslipidemia, obesity, IGT should all be evaluated and treated Metzger BE, Buchanan TA, Coustan DR, De Leiva A, Hadden DR, Hod M. Summary and recommendations of the fifth international workshop-conference on gestational diabetes mellitus, Diabetes Care. 2007; 30(suppl 2):S251-260. Metzger, Buchanan, Coustan et al. 2007

Postpartum education is key OGTT at 6-12 weeks Managing risk factors Obesity Hypertension Dyslipidemia Birth control Preconception screening Annual screening for diabetes – 35-60% risk of type 2 within 10 years Metzger BE, Buchanan TA, Coustan DR, De Leiva A, Hadden DR, Hod M. Summary and recommendations of the fifth international workshop-conference on gestational diabetes mellitus, Diabetes Care. 2007; 30(suppl 2):S251-260. Metzger, Buchanan, Coustan et al. 2007

References Gunderson EP. Breastfeeding after gestational diabetes pregnancy. Diabetes Care. 2007;30(suppl 2):S161-168. Metzger BE, Buchanan TA, Coustan DR, De Leiva A, Hadden DR, Hod M. Summary and recommendations of the fifth international workshop-conference on gestational diabetes mellitus, Diabetes Care. 2007; 30(suppl 2):S251-260. Seshiah V, Balaji V, et al. Gestational Diabetes Mellitus – Guidelines. J Assoc Physic of India 2006;54:622-28.