1. GESTATIONAL DIABETES MELLITUS

2. Definition
GDM is a carbohydrate intolerance of variable severity that develops or first recognised during pregnancy
Develop in the late second trimester or in the third trimester

3. Risk Group Positive family history
Previous birth of an over weight baby 4kg or more
Previous still birth with pancreatic islet hyperplasia revealed on autopsy
Unexplained perinatal loss
Presence of polyhydramnios
Recurrent vaginal candidiasis
Persistent glycosuria
Age over 30
Obesity

4. Screening GCT Between 24 and 28 week Fasting is not necessary
No pretest dietary instruction
Women ingest 50gm of oral glucose solution
1 hour later blood sample is taken
Plasma concentration 140mg% is a cut off for 100 gm GTT

5. GTT
Golden standard for diagnosing GDM
Fast from midnight on the day of the test
Fasting plasma glucose level is determined
The women should ingest 100 gm of oral glucose solution
Plasma glucose level is determined 1hr,2hr and 3hr
Criteria for glucose tolerance test
The maximum blood glucose values during pregnancy:
- fasting mg/ dl,
- one hour mg/dl,
- 2 hours mg/dl,
- 3 hours mg/dl.
If any 2 or more of these values are elevated, the patient is considered to have an impaired glucose tolerance test.

6. Hazzards Perinatal loss Macrosomia Tendency to develop overt diabetes
Polyhydramnios
Birth trauma
Recurrence of GDM in subsequent pregnancies

7. Management Antenatal supervision Restriction of diet
Human insulin if FBS level exceeds 90mg/dl and PPBS greater than 120mg/dl
Abnormal weight gain is to be checked
Diet Kcal for normal weight women and restriction of Kcal for over weight women
Exercise
Early hospitalisation

8. DEFINITION – OVERT DIABETES
A patient with abnormal GTT with or with out symptoms and a raised fasting blood glucose level is called overt diabetic.
Pre – existing or detected for the first time during pregnancy.

9. Classification of diabetes during Pregnancy
Onset
FBS
PPBS
Therapy A1
Gestational
<105mg/dl
<120mg/dl
Diet A2
Gestational -overt
>105mg/dl
>120mg/dl
Insulin
Age of onset (years)
Duration (years)
Vascular disease B
Over 20
<10
None C
10 – 19 D
Before 10
>20
Benign retinopathy F
Any
Nephropathy R
Proliferative retinopathy H
Heart

10. White’s classification of GDM
ONSET
AGE
DURATION A
Gestational B
Overt DM
age 20
10 years C
age 20
10 – 19 years D
Overt DM,benign retinopathy
age 10
20 years E
Calcified pelvic vessels F
Diabetic nephropathy with proteinuria R
Malignant diabetic retinopathy

11. Current classification of pregnant diabetics
Group A
Gestational Diabetes
Group B
Overt diabetes without vasculopathy
Group C
Diabetes with vasculopathy

12. Effects of pregnancy on diabetes
Impaired glucose tolerance
(Altered carbohydrate metabolism)
Insulin antagonism
GESTATIONAL DIABETES MELLITUS

13. Impaired glucose tolerance
Accelerated absorption of glucose from alimentary tract
Delayed utilisation of glucose to form liver glycogen due to anti – insulin activity
DIABETOGENIC EFFECT

14. Insulin Antagonism
Human placental lactogen (human chorionic somatomammotrophin)
Oestrogen
Progesterone
Free cortisol
Degradation of the insulin by the placenta
INSULIN ANTAGONISM

15. Complications - Maternal
PREGNANCY
LABOUR
PUERPERIUM
Abortion
Preterm labour
Infection
Increased incidence of pre eclampsia
Polyhydramnios
Prolonged labour
Shoulder dystocia
Perineal injuries
PPH
Operative interference
Sepsis
Failing lactation

16. Complication - Fetal Fetal macrosomia Maternal hyperglycemia
Elevation of maternal free fatty acid
Congenital malformation
Cardiac abnormalities
Neural tube defect
Birth injuries
Unexplained fetal death
Neonatal complications

17. Management Goals: Preconceptual counselling
To achieve a metabolic control similar to that in normal pregnancy
Careful fetal surveillance to avoid occurrence of sudden IUD and prematurity
To eliminate any maternal complications
Patient education
Optimal time and mode of delivery
Arragement for care of neonate

18. Diet Non caloric sweeteners may be used in moderation
Provision of adequate calories and nutrients (30-35 Kcal/Kg body weight Kcal for fetus)
Non caloric sweeteners may be used in moderation
Four meals and several snacks is used for most patients
Dietary composition should be :
50 to 60 percent carbohydrate
20 percent protein
25 to 30 percent fat
Fiber containing diet

19. Insulin Therapy
When diabetes is first detected during pregnancy and cannot be controlled by diet alone
A PPBS level of more than 140mg% even on diet control is an indication of insulin therapy
Glycemic goal should be around 90mg/dL before meal and 120mg/dL 2hours after meal
As pregnancy advances a double mixed regime may be employed

20. Insulin Therapy
Insulin therapy is recommended when medical nutrition therapy fails to maintain self-monitored glucose at the following levels:
Fasting whole blood glucose <95 mg/dL
Fasting plasma glucose <105 mg/dL or
1-hour postprandial whole blood glucose <140 mg/dL
1-hour postprandial plasma glucose <155 mg/dL
2-hour postprandial whole blood glucose <120 mg/dL
2-hour postprandial plasma glucose <135 mg/dL

21. Contd….
Twice daily ( before breakfast and before dinner) injections of a combination of short and intermediate acting insulins are usually sufficient
The total first dose of insulin is calculated according to the patient’s weight as follow:
In the first trimester weight x 0.7
In the second trimester weight x 0.8
In the third trimester weight x 0.9

23. Fetal Surveillance Kick counts USG Amniotic fluid volume
Biophysical profile
NST
CST
Amniocentesis

24. Maternal surveillance
Blood pressure
Urine protein

25. Admission to hospital
When antepartum testing suggests fetal compromise, delivery must be considered.
Delivery by cesarean section usually is favored when fetal distress has been suggested by antepartum heart rate monitoring.
If a patient reaches 38 weeks' gestation with a mature fetal lung profile and is at significant risk for intrauterine demise because of poor control or a history of a prior stillbirth, an elective delivery is planned.

26. Contd….
During labor, continuous fetal heart rate monitoring is mandatory.
Labor is allowed to progress as long as normal rates of cervical dilatation and descent are documented.
Arrest of dilatation or descent despite adequate labor should alert the physician to the possibility of cephalopelvic disproportion.

27. Indications for induction of labour
GDM with control on insulin therapy and completed 38wks
Women with vascular complications after 37wks

28. Indications for induction of LSCS
Elderly primigravida
Multigravida with bad obstetric history
Diabetes with complications or difficult to control
Obstetrical complications

29. Insulin Management during Labor and Delivery
Usual dose of intermediate-acting insulin is given at bedtime.
Morning dose of insulin and breakfast is withheld.
Intravenous infusion of normal saline is begun.
Once active labor begins or glucose levels fall below 70 mg/dl, the infusion is changed from saline to 5% dextrose
Glucose levels are checked hourly using a portable meter allowing for adjustment in the infusion rate.
Regular (short-acting) insulin in administered by intravenous infusion if glucose levels exceed 140 mg/dl.

30. Neonatal Care Neonatologist should be present
Neonatal intensive care unit for 48 hours
Asphyxia
Congenital malformations identification
Blood glucose checked within 2 hours of birth
1 mg Vitamin K IM
Breast feeding within ½ hour to 1 hour

31. Neonatal Complications
Hypoglycaemia
Respiratory distress syndrome
Hyperbilirubinaemia
Polycythemia
Hypocalcaemia
Hypomagnesemia
Cardiomyopathy

32. Puerperium Antibiotics Insulin dose revert to pre pregnant level
A fresh blood glucose level after 24 hours
Breast feeding
Additional 500 Kcal in daily diet for lactating women
Lactating women insulin dose is lower