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Gdm 4

Gdm 4






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    Gdm 4 Gdm 4 Presentation Transcript

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