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

2. 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

3. 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

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

5. 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

6. 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

7. 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

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

9. 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

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

11. 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

12. 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

13. 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

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

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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

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

23. 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 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

24. 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

25. 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

26. 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: mg/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

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

29. 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

30. Thank you