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Gestational diabetes mellitus

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Gestational diabetes mellitus Gestational diabetes mellitus Presentation Transcript

  • Gestational Diabetes (GD) Presented by DR . HINA KHUDA-I-DAD Working under supervision of PROF. DR .TASNEEM ASHRAF HEAD OF DEPARTMENT GYNAE UNIT IV
  • INTRODUCTIONGestational diabetes is Any degree ofGlucose intolerance with onset or firstrecognition during pregnancy.It affects 3-5% of all pregnancies.
  • PRENATAL MANAGEMENT 1- Screening and diagnosis 2-PATIENT’S EDUCATION 3-GLYCEMIC TARGETS 4-DIET AND EXERCISE 5-INSULIN AND ORAL HYPO- GLYCEMIC DRUGS 6-MONITORING FETAL GROWTH
  • WHO SHOULD BE SCREENEDAND WHYRisk stratification Low risk: no screening Average risk: at 24-28 weeks High risk: as soon as possible
  • LOW RISK 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 outcomeIn the presence of all these factors no screening is recommended
  • INTERMEDIATE RISK Must exhibit one risk factor of GDM.
  • CautionHigh risk of gestational diabetes Marked obesity BMI >30. Previous history of gestational diabetes mellitus. Strong family history of diabetes . Native Americans, Asians, Hispanics, African AND arabic specially of mid-eastern origin. Previous macrosomic babies, unexplained stillbirths. women with risk factors should be screened as soon as possible
  • Oral glucose tolerance testPrerequisites: Normal diet for 3 days before the test. At least 10 hours fast ,in morning at rest.Give 100 gm of glucose in 250 ml waterCriteria for glucose tolerance test: fasting 5.3 mmol/L 1 hour 10 mmol/L 2 hours 8.6 mmol/L 3 hours 7.8 mmol/L If any 2 or more of these values are elevated, the patient is DIAGNOSED to have GDM.ADA CRITERIA
  • Patient educationcornerstone in GDM management Inform mother about maternal and fetal complications Diet therapy Teach mother about self monitored blood glucose measurement and glycemic targets Fetal monitoring: ultrasound Planning on delivery
  • Potential Risks ofUntreated GDM IN CHILD1,Growth abnormalities -Macrosomia2,Chemical imbalance -Hypoglycemia -Jaundice -HypocalcemiaProne for diabetes in future
  • Potential Risks of UntreatedGDM in mother PIH and Pre-eclampsia: affects 10-25% of all pregnant women with GDM Infections: high incidence of chorioamnionitis and postpartum endometritis Postpartum bleeding: caused by exaggerated uterine distension Ceasarian section due to fetal macrosmia and cephalo- pelvic disproportion Weight gain Third trimester fetal deaths Long term risk of type-2 diabetes mellitus
  • GLYCEMIC TARGET1.Fasting <5.9mmol/L2.1 hr post prandial <7.8 mmol/L
  • Self monitored blood glucose(SBMG)4 times/day minimum, fasting and 1 or 2 hoursafter mealsMaintain log book
  • DIET
  • DietProteins not more than 1g/kgFats < 35% of energy intakeCho <55% of energy intakeSalt <6g/day In 3 meals and 3 snacks
  • Exercise Means regular, moderatephysical activity like1. Walking for 14-30 minutes2. Prenatal Aerobic classes3. Swimming
  • INSULINTHERAPY If persistent hyperglycemia after one week of diet control proceed to insulin
  • INSULIN IN GDM Insulin used if fasting blood glucose >105 mg/dl or 2 hr postprandial blood glucose >120 mg / dl on a diet Use intermittent bolus regime of Short acting insulins to cover each meal. Insulin requirements increase by 50% from 20-24 weeks to 30-32 weeks, after which insulin needs often stabilize.
  • ORAL HYPOGLYCEMICAGENTS Glyburide is a clinically effective alternative to insulin in GDM (Langer et al. 2000) Metformin may be effective in GDM (Ratner et al., 2008; Coustan, 2007
  • HYPOGLYCEMIA During treatment with insulin patient can have low blood sugar <60mg/dl Why does low blood sugar occur?1. Too much exercise2. Skipping meals or snacks3. Delaying meals or snacks4. Not eating enough5. Too much insulin
  • SYMPTOMS OFHYPOGLYCEMIA Very hungry Very tired Shaky or trembling Sweating or clamminess Nervous Confused Like going to pass out or faint Blurred vision
  • HypoglycemiaPrevention Strategies Consistent monitoring
  • Fetal monitoring (1) Ultrasound :NICE guideline is to assessfetal growth on 4 weekly basis from 28-36wks Fetal growth ,Amniotic fluid volume at28,32,36 wks polyhydramnios(2) cardiotocography (C.T.G). after 32 wks(3) Doppler.(4) Biophysical profile B.P.P.
  • TIMING OF DELIVERY In well controlled diabetic mother ,the pregnancy can be continued till 40 wks in the absence of any complications .Indication for induction of labour. Uncomplicated diabetes at 40 wks Developing macrosemia at 38 wks Pre eclampsia
  • MANAGEMENT DURINGLABOUR Vaginal delivery: preferred Cesarian section only for routine obstetric indication GDM alone is not an indication ! > 4.5 Kg fetus: Cesarean delivery may reduce the likelihood of brachial plexus injury in the infant and still birth Maintain euglycemia during labor 4-7mmol/L Monitor sugars 1-4 hrly intervals during labour Give insulin only if blood sugar >120 mg/dl
  • IV INSULIN DURING C-SECTION I.V insulin infusion. 50 ml N/S +50 unit regular insulin Aim at 1-2 unit (1ml)/hr. At the same time 10% of glucose started on other arm. BSL b/w 4.0-7.0 mmol/L
  • POST-PARTUM FOLLOW UP Check blood sugars before discharge Lifestyle modification: exercise, weight reduction Oral glucose tolerance test at 6-12 weeks postpartum Counseling for contra-ception, and pre- conception care for next pregnancy
  • IMMEDIATE MANAGEMENT OFNEONATE Hypoglycemia<40 mg/dl : 50 % of macrosomic infants Encourage early breast feeding If symptomatic give a bolus of 2- 4 ml/kg, IV, 10% dextros Check for calcium, if seizure/irritability/RDS
  • Conclusion Gestational diabetes is a common problem in worldwide Risk stratification and screening is essential in all pregnant women. Tight glycemic targets are required for good maternal and fetal outcome Patient education and Long term follow up is essential
  • 17 POUNDS BABY BORN OF A WOMENWITH GDM