1. Gestational Diabetes (GD) Presented by DR . HINA KHUDA-I-DAD Working under supervision of PROF. DR .TASNEEM ASHRAF HEAD OF DEPARTMENT GYNAE UNIT IV
2. INTRODUCTIONGestational diabetes is Any degree ofGlucose intolerance with onset or firstrecognition during pregnancy.It affects 3-5% of all pregnancies.
3. 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
4. WHO SHOULD BE SCREENEDAND WHYRisk stratification Low risk: no screening Average risk: at 24-28 weeks High risk: as soon as possible
5. 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
6. INTERMEDIATE RISK Must exhibit one risk factor of GDM.
7. 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
8. 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
9. 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
10. Potential Risks ofUntreated GDM IN CHILD1,Growth abnormalities -Macrosomia2,Chemical imbalance -Hypoglycemia -Jaundice -HypocalcemiaProne for diabetes in future
11. 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
12. GLYCEMIC TARGET1.Fasting <5.9mmol/L2.1 hr post prandial <7.8 mmol/L
13. Self monitored blood glucose(SBMG)4 times/day minimum, fasting and 1 or 2 hoursafter mealsMaintain log book
15. DietProteins not more than 1g/kgFats < 35% of energy intakeCho <55% of energy intakeSalt <6g/day In 3 meals and 3 snacks
16. Exercise Means regular, moderatephysical activity like1. Walking for 14-30 minutes2. Prenatal Aerobic classes3. Swimming
17. INSULINTHERAPY If persistent hyperglycemia after one week of diet control proceed to insulin
18. 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.
19. 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
20. 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
21. SYMPTOMS OFHYPOGLYCEMIA Very hungry Very tired Shaky or trembling Sweating or clamminess Nervous Confused Like going to pass out or faint Blurred vision
23. 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.
24. 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
25. 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
26. 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
27. 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
28. 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
29. 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