1. Post Partum

2. 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

3. 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:
Seshiah, Balaji, 2006

4. 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:
Seshiah, Balaji, 2006

5. 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

6. 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:S
Gunderson, 2007

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

8. 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

9. 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

10. 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):S
Metzger, Buchanan, Coustan et al. 2007

11. 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):S
Metzger, Buchanan, Coustan et al. 2007

12. 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):S
Metzger, Buchanan, Coustan et al. 2007

13. References
Gunderson EP. Breastfeeding after gestational diabetes pregnancy. Diabetes Care. 2007;30(suppl 2):S 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):S Seshiah V, Balaji V, et al. Gestational Diabetes Mellitus – Guidelines. J Assoc Physic of India 2006;54: