Diabetes Melitus

Gestasional

Classification
Pregestational diabetes
Type 1 DM
Type 2 DM
Secondary DM
Gestational diabetes

Definition
Gestational diabetes (GDM) is defined as glucose
intolerance of variable degree with onset or first
recognition during the present pregnancy.
Pregestational diabetes precedes the diagnosis
of pregnancy.

Whom to screen ?
Risk stratification based on certain variables

Low risk : no screening

Average risk: at 24-28 weeks

High risk : as soon as possible

Low risk for GDM

To satisfy all these criteria
Age <25 years
Weight normal before pregnancy
Member of an ethnic group with a low prevalence of GDM
No known diabetes in first-degree relatives
No history of abnormal glucose tolerance
No history of poor obstetric outcome

Intermediate
risk

At least one of the criteria in the list

High risk

Marked obesity
Prior GDM
Strong family history

How to screen?
Oral glucose tolerance
test ( OGTT) with 100 gm
glucose

Fasting
1-h

180 mg/dl

2-h

155 mg/dl

3-h

140 mg/dl

Overnight fast of at least 8 hours

At least 3 days of unrestricted diet
and unlimited physical activity
> 2 values must be abnormal

95 mg/dl

Urine monitoring
Urine glucose monitoring is not useful in gestational
diabetes mellitus

Urine ketone monitoring may be useful in detecting

insufficient caloric or carbohydrate intake in women
treated with calorie restriction

Problems of GDM: fetal

Increases the risk of fetal macrosomia

Neonatal hypoglycemia
Jaundice
Polycythemia
Hypocalcemia, hypomagnesemia
Birth trauma
Prematurity

Problems: fetal
Cardiac( including great vessel anomalies) : most common
Central nervous system: 7.2%
Skeletal: cleft lip/palate, caudal regression syndrome
Genitourinary tract: ureteric duplication

Gastrointestinal : anorectal atresia

Poor glycemic control at time of

conception: risk factor

Caudal regression
syndrome

Problems of GDM: maternal

Weight gain

Maternal hypertensive disorders

Miscarriages
Third trimester fetal deaths
Cesarean delivery (due fetal growth disorders)
Long term risk of type 2 diabetes mellitus

Pregnancy in diabetic mother:

risks
Progression of retinopathy: esp. severe proliferative
retinopathy
Progression of nephropathy: especially if renal failure +
Coronary artery disease: Post MI patients: high risk of
maternal death

Management

Preconception counselling
Diabetic mother : glycemic control with insulin/SMBG
Target: HbA1c < 7%
Folic acid supplementation: 5 mg/day
Ensure no transmissible diseases: HBsAg, HIV, rubella
Try and achieve normal body weight: diet/exercise
Stop drugs : oral hypoglycemic drugs, ACE inhibitors,
beta blockers

Clinical parameters: checked at

each visit

medications
pre-pregnancy weight
weight gain
edema
pallor
blood pressure
Fundal height

Patient education
Cornerstone in GDM management

Maternal complication
Fetal complication
Medical Nutrition therapy
Glycemic monitoring: SMBG and targets
Fetal monitoring: ultrasound
Planning on delivery
Long term risks

Glycemic targets
Fasting venous plasma < 95 mg/dl
2 hour postprandial <120 mg/dl
1 hour postprandial <130 mg/dl (140)
Pre-meal and bedtime: 60 to 95 mg/dl
If diet therapy fails to maintain these targets > 2
times/week, start insulin
These are venous plasma targets, not glucometer targets

GDM

Medical nutrition therapy

Failure to maintain glycemic

targets

INSULIN THERAPY

Medical nutrition therapy

Promote nutrition necessary for maternal and fetal health
Adequate energy levels for appropriate gestational weight
gain,
Achievement and maintenance of normoglycemia
Absence of ketones
Regular aerobic exercises

Medical nutrition therapy

Approximately 30 kcal/kg of ideal body weight
> 40-45% should be carbohydrates
6-7 meals daily( 3 meals , 3-4 snacks). Bed time snack to prevent
ketosis
Calories guided by fetal well being/maternal weight gain/blood
sugars/ ketones
Energy requirements during the first 6 months of lactation
require an additional 200 calories above the pregnancy meal
plan.

Fetal monitoring
Baseline ultrasound : fetal size
At 18-22 weeks: major malformations
fetal echocardiogram
26 weeks onwards: growth and liquor volume
III trimester: frequent USG for accelerated growth
( abdominal: head circumference)

Management of labor and delivery

Maternal hyperglycemia in labor: fetal hyperinsulinemia,
worsen fetal acidosis
Maintain sugars: 80-120 mg/dl (capillary: 70-110mg/dl )
Feed patient the routine GDM diet
Maintain basal glucose requirements
Monitor sugars 1-4 hrly intervals during labour
Give insulin only if sugars more than 120 mg/dl

Post partum follow up

Check blood sugars before discharge
Breast feeding: helps in weight loss
Lifestyle modification: exercise, weight reduction
OGTT at 6-12 weeks postpartum: classify patients into
normal/impaired glucose tolerance and diabetes
Preconception counseling for next pregnancy
Increased risk of cardiovascular disease,
future diabetes and dyslipidemia

Management of neonate
Hypoglycemia <40 mg/dl
Encourage early breast feeding
If symptomatic give a bolus of 2- 4 cc/kg, IV, 10% dextrose
Check after 30 minutes, start feeds
IV dextrose : 6-8 mg/kg/min infusion
Check for calcium, if seizure/irritability/RDS
Examine infant for other congenital abnormalities

Long term risk: offspring

Increased risk of obesity and abnormal

glucose tolerance

thank you