Gdm 4


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Gdm 4

  2. 2. DEFINITION & MAGNITUDE<br />A carbohydrate intolerance of varying degrees & severity with onset or first recognition during pregnancy with a probable resolution after the end of pregnancy<br />Not the same as Type 1 or Type 2 Diabetes<br />Varies worldwide & among different racial and ethnic groups within a country<br />Prevalence in India: <br />Chennai : 0.56% (Ramachandran A, 2002)<br />Mysore Parthenon Study: 6% ( Fall C,2000)<br />
  3. 3. ETIOLOGY<br />Pregnancy pro-diabetic state<br />Pregnancy  marked insulin resistance  increased insulin requirement  GDM<br />Complicates 4% of all pregnancies<br />60% to 80 % of women with GDM are obese & experience insulin resistance & GDM<br />
  4. 4. Fasting and & postprandial venous plasma sugar during pregnancy<br />
  5. 5. Pregnancy Pathophysiology<br />Glucose is a teratogen at high levels<br />Crosses placenta readily while insulin cannot<br />Insulin resistance occurs because hormonal changes associated with pregnancy partially block the effects of insulin<br />Insulin resistance causes glucose to be shunted from mother to the fetus to facilitate fetal growth and development<br />
  6. 6. Subsequent increase in insulin resistance causes maternal glucose levels to increase 80% of non-pregnant women<br /> Increased insulin resistance<br /> Decreased insulin secretion<br /> Increased maternal glucose<br /> GDM<br />GDM disappears after pregnancy<br />Useful physiologic process out of balance<br />
  7. 7. Problems of GDM: fetal<br />Increases the risk of fetal macrosomia<br />Neonatal hypoglycemia<br />Jaundice<br />Polycythaemia<br />Hypocalcaemia, hypomagnesaemia<br />Birth trauma<br />Prematurity<br />Cardiac( including great vessel anomalies)most common<br />Central nervous system7.2%<br />Skeletal: cleft lip/palate, caudal <br />regression syndrome<br />Genitourinary tract: ureteric duplication<br />Gastrointestinal : anorectalatresia<br />
  8. 8. Problems of GDM: maternal<br />Weight gain<br />Maternal hypertensive disorders<br />Miscarriages<br />Third trimester fetal deaths<br />Cesarean delivery (due fetal growth disorders) <br />Long term risk of type 2 DM <br />Progression of retinopathy: esp. severe proliferative retinopathy<br />Progression of nephropathy: especially if renal failure +<br />Coronary artery disease: Post MI patients  high risk of maternal death <br />
  9. 9. Gestational diabetes diet<br />Water foods are the main concentration. That means plants: vegetables, fruits, grains & legumes<br />Only low-fat and non-fat dairy products<br />Only the leanest cuts of meat with all<br />excess fat trimmed<br />Avoid saturated fats<br />Strongly avoid Trans fats<br />Avoid fast foods, processed foods, microwave foods, high-sugar foods, alcohol & high-sodium foods<br />Drink plenty of fresh water every day<br />Eat 5 or 6 small meals everyday<br />Eat your meals at the same times every day<br />
  10. 10. DIAGNOSIS<br />TWO-STEP STRAREGY<br />50-75g oral glucose challenge<br />Single serum glucose measurement @ 1 hr<br />&lt;7.8 mmol/L(&lt;140mg/dL)  normal<br />&gt;7.8 mmol/L(&gt;140mg/dL)<br />100-g oral glucose challenge<br />Serum glucose measurements in fasting state, I, II & III hrs<br />Normal values<br />Fasting &lt; 5.8 mmol/L (&lt;105mg/dL)<br />I hr  &lt; 10.5 mmol/L (&lt;190mg/dL )<br />II hr  &lt; 9.1 mmol/L (&lt;165mg/dL)<br />III hr  &lt; 8.0 mmol/L (&lt;145mg/dL)<br />
  11. 11. Overnight fast of at least 8 hours<br />At least 3 days of unrestricted diet and unlimited physical activity<br />&gt; 2 values must be abnormal <br />Urine glucose monitoring is not useful in gestational diabetes mellitus<br />Urine ketone monitoring may be useful in detecting insufficient caloric or carbohydrate intake in women treated with calorie restriction<br />
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  13. 13. SCREENING<br />Essentially all Indian women have to be screened<br /> for gestational diabetes mellitus as they belong<br /> to a high risk ethnicity<br />LOW RISK GROUPS:<br />&lt;25 yrs of age <br />BMI &lt;25kg/sq.m<br />No H/O maternal macrosomia<br />No H/O diabetes<br />No H/O D.M in first degree relative<br />Not members of high risk ethnic groups<br />Member of an ethnic group with a low prevalence<br /> of GDM<br />No H/O abnormal glucose tolerance <br />No H/O poor obstetric outcome<br />
  14. 14. Intermediate risk<br />At least one of the criteria in the list<br />High risk<br />Marked obesity<br />Prior GDM<br />Glycosuria<br />Strong family history<br />Must be done between 24 & 28 weeks of pregnancy<br />Most GDM cases revert to normal after delivery<br />
  15. 15. Value of Screening During Current Pregnancy<br />Increased screening, identification and treatment can decrease the morbidity and mortality of GDM<br />Decreased macrosomia, cesarean birth and birth trauma due to a &gt; 4000g infant<br />Decreased neonatal hypoglycemia, hypocalcaemia, hyperbilirubinemia, polycythaemia<br />Identify women at future risk for diabetes and those with insulin resistance<br />
  16. 16. Women are generally screened for GDM with glucose challenge test in the late second trimester<br />If result is abnormal  oral glucose tolerance test<br />Abnormal glucose challenge test but no GDM increased risk of future cardiovascular disease<br />They have a lower risk than women who actually did have gestational diabetes<br />In women with glucose intolerance during pregnancy, type 2 diabetes and vascular disease may develop in parallel, which is consistent with the &quot;common soil&quot; hypothesis for these conditions<br />
  17. 17. Retesting<br />Negative initial test but risk factors present<br />Obesity<br />&gt;33 years of age<br />Positive 1 hour screen followed by a negative OGGT<br />3+/4+ glucosuria<br />Low risk  no screening<br />Average risk  at 24-28 weeks<br />High risk  as soon as possible<br />
  18. 18. treatment<br />The total first dose of insulin is calculated according to the patient’s weight as follow<br />In the first trimester  weight x 0.7<br />In the second trimester  weight x 0.8<br />In the third trimester  weight x 0.9<br />
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  20. 20. Medical nutrition therapy<br />Approximately 30 kcal/kg of ideal body weight<br />&gt;40-45% should be carbohydrates<br />6-7 meals daily( 3meals, 3-4 snacks)<br />Bed time snack to prevent ketosis<br />Calories guided by fetal well being/maternal weight gain/blood sugars/ ketones<br />Energy requirements during the first 6 months of lactation require an additional 200 calories above the pregnancy meal plan<br />
  21. 21. Fetal monitoring<br />Baseline ultrasound : fetal size<br />At 18-22 weeks  major malformations & fetal echocardiogram<br /> 26 weeks onwards  growth and liquor volume<br />III trimester  frequent USG for accelerated growth (abdominal: head circumference) <br />
  22. 22. Insulin Management during Labor & Delivery<br />Usual dose of intermediate-acting insulin is given at bedtime<br />Morning dose of insulin is withheld<br />I.V infusion of normal saline is begun<br />Once active labor begins or glucose levels fall below 70 mg/dl, infusion is changed from saline to 5% dextrose & <br />delivered at a rate of 2.5 mg/kg/min<br />Glucose levels are checked hourly using a portable meter allowing for adjustment in infusion rate<br />Regular (short-acting) insulin is administered by iv infusion if glucose levels exceed 140 mg/dl<br />
  23. 23. Maternal hyperglycemia in labor: fetal hyperinsulinaemia, worsen fetal acidosis<br />Maintain sugars: 80-120 mg/dl (capillary70-110mg/dl )<br />Feed patient the routine GDM diet <br />Maintain basal glucose requirements<br />Monitor sugars 1-4 hrly intervals during labour<br />Give insulin only if sugars more than 120 mg/dl<br />Maternal complication<br />Fetal complication<br />Glycemic monitoring: SMBG and targets<br />Fetal monitoring: ultrasound<br />Planning on delivery<br />Long term risks<br />
  24. 24. THANK YOU<br />