Gestational diabetes among of the complication in pregnancy

1. Session 4.8:Hyperglycaemia in
Pregnancy
Module 4: Management of
Patient with Diabetes
Mellitus

2. Learning Objectives
• At the end of this session participants are
expected to be able to:
 Explain hyperglycaemia in pregnancy and
its pathophysiology
 Identify risk factors for hyperglycaemia in
pregnancy
 Recognize clinical presentation of
hyperglycaemia in pregnancy
 Screen and diagnose hyperglycaemia in
pregnancy

3. Learning Objectives (2)
 Provide appropriate pharmacological and
non-pharmacological treatment
 Identify effects of hyperglycaemia in
pregnancy on the baby
 Provide health education and adherence
counselling for hyperglycaemia in pregnancy
• Conduct regular prenatal, natal and postnatal
follow up of the mother and the baby
• Prevent hyperglycaemia in pregnancy

4. Activity: Brainstorming
• What is hyperglycaemia in pregnancy?
• What is the pathophysiology of
hyperglycaemia in pregnancy?

5. Hyperglycemia in Pregnancy
 Hyperglycaemia in pregnancy or Gestational
Diabetes Mellitus (GDM) is any degree of
glucose intolerance first recognized in
pregnancy
 Diabetes in pregnancy refers to those with pre-
existing diabetes, whether diagnosed or not
 The patients may have previously
undiagnosed diabetes mellitus diagnosed
coincidentally during pregnancy or
 may have developed diabetes during
pregnancy

6. Hyperglycemia in Pregnancy (2)
 Gestational diabetes:
 Affects 3-10% of pregnancies, depending on
the population studied
 Usually shows up in the middle of pregnancy
 Doctors most often test for it between 24 and
28 weeks of pregnancy
 Usually goes away after pregnancy, but it
may persist as type 2 diabetes
 Many women who have had gestational
diabetes will develop type 2 diabetes later

7. Pathophysiology
 The hallmark of GDM is increased insulin
resistance
 It is a normal phenomenon emerging in the
second trimester of pregnancy
 More insulin is needed to overcome this
resistance
 The production of insulin is about 1.5-2.5
times more than in a normal pregnancy
 is thought to secure glucose supply to the
growing foetus

8. Pathophysiology (2)
 Women with GDM have an insulin resistance
which cannot be compensated by increased
insulin production in the β-cells of the
pancreas
 This causes inappropriately elevated blood
sugar levels, hormones and to a lesser
extent increased fat deposits
 To a lesser extent increased fat deposits
seem to mediate the insulin resistance
during pregnancy

9. Pathophysiology (3)
 In untreated gestational diabetes the foetus is
exposed to consistently higher glucose levels
• This leads to increased foetal levels of
insulin
• The growth-stimulating effects of insulin can
lead to excessive growth and a large body
• After birth, the high glucose environment
disappears, leaving the newborn with
ongoing high insulin production and
susceptibility to low blood glucose levels
(hypoglycaemia)

10. Activity:Buzzing
• What are the risk factors for
hyperglycaemia in pregnancy?

11. Risk Factors for Hyperglycaemia in
Pregnancy
• Risk factors for developing gestational
diabetes include:
• A previous diagnosis of gestational
diabetes, impaired glucose tolerance, or
impaired fasting glycaemia
• Maternal age - a woman's risk increases
as she gets older than 35 years of age
• Being overweight, obese or severely
obese increases the risk by a factor 2.1,
3.6 and 8.6, respectively

12. Risk Factors for Hyperglycaemia in
Pregnancy (2)
• A previous pregnancy which resulted in a
child with a birth weight >4kg
• Previous poor obstetric history
• Polycystic ovarian syndrome
• A relative with type 2 diabetes
• Africans and South Asians have a higher
risk
 About 40-60% of women with GDM have no
demonstrable risk factor; for this reason
many advocate to screen all women

13. Activity: Buzzing
• What is the clinical presentation of
hyperglycaemia in pregnancy?

14. Clinical Presentation
• Women with GDM exhibit no symptoms
(another reason for universal screening)
• It is most commonly diagnosed by
screening during pregnancy
• Some women may demonstrate increased
thirst, increased urination, fatigue, nausea
and vomiting, bladder infection, yeast
infections and blurred vision

15. Clinical Presentation
• Typically, women with GDM exhibit no
symptoms (another reason for universal
screening) and it is most commonly
diagnosed by screening during pregnancy.
• Some women may demonstrate increased
thirst, increased urination, fatigue, nausea
and vomiting, bladder infection, yeast
infections and blurred vision

16. Activity: Buzzing
• How do you screen and diagnose
hyperglycaemia in pregnancy?

17. Screening at First Antenatal Visit
• Perform screening in all women at the first
antenatal clinic attendance if they have:
• BMI > 25 kg/m2
• Previous history of GDM
• Previous big baby
• Poor obstetric history
• Family history of DM
• Known impaired glucose
tolerance/impaired fasting glucose
• Grand multipara
• Glycosuria

18. Screening Later in Pregnancy
• Routinely screen for GDM at 24-28 weeks
• All pregnant women over 30 years
• Pregnant women below 30 years if they
present with the above risk factors
• All women with risk factors should have a
75 g OGTT
• A fasting plasma glucose is recommended
in low-risk women

19. Diagnosis
• Normal blood glucose values:
• Fasting < 5.6 mmol/l
• 2-hour postprandial (2hr after a meal) <7.8
mmol/l
• Random glucose test <6.1 mmol/l
• Women in early pregnancy with the following
values which are diagnostic of diabetes should
be treated as having pre-existing diabetes
• HbA1c ≥6.5% or
• Fasting blood glucose ≥7.0 mmol/l or
• Two hour blood glucose ≥11.1 mmol/l

20. Diagnosis (2)
 Women with the following values should be
assessed to determine the need for
immediate home glucose monitoring
HbA1c 6.0–6.4%, or
Fasting glucose 5.1– 6.9 mmol/l, or
Two hour glucose 8.6–11.0 mmol/l
 If the diagnosis remains unclear, assess for
gestational diabetes by 75 g oral glucose
tolerance test (OGTT) at 24–28 weeks

21. Urinary Glucose Testing
• Increased glomerular filtration rates during
pregnancy contribute to some 50% of women
having glucose in their urine on dipstick tests
at some point during their pregnancy
• The sensitivity of glucosuria for GDM in the
first 2 trimesters is only around 10% and the
positive predictive value is around 20%

22. Activity: Brainstorming
• What are the effects of diabetes on the
health of the pregnant woman and the
baby?

23. Effects of Hyperglycaemia on the
Health of Pregnant Woman
• A woman with gestational diabetes whose
blood sugar stays high has an increased
chance of:
• Preeclampsia (high blood pressure, protein
in urine, increased swelling)
• Preterm birth (baby born before 37 weeks)
• Caesarean section

24. Effects of Hyperglycaemia on the
Health of Pregnant Woman (2)
• Blood sugar which remains high in a woman
with pre-existing diabetes can trigger or
worsen certain health problems, including:
• High blood pressure, Preeclampsia
• Kidney, nerve, heart disease, blindness
• Miscarriage, Preterm birth, or Stillbirth
• Deliveries using forceps, ventouse or
caesarean section or problems during
vaginal delivery (such as shoulder
dystocia)

25. Effect of Diabetes on the Child
• Blood sugar that remains high in a pregnant
woman with diabetes can cause the baby to
have health problems:
• Birth defects, especially of the brain, spine,
and heart
• Increased birth weight, if unmanaged (may
affect 12% of normal women compared to
20% of patients with GDM)
• Intrauterine growth retardation, if
managed

26. Effect of Diabetes on the Child (2)
• Nerve damage to the shoulder during delivery
• Low blood sugar after birth (may require
admission to a neonatal care unit)
• Jaundice
• Dysmature babies prone to respiratory
distress syndrome due to incomplete lung
maturation and impaired surfactant synthesis
• Off springs of GDM mothers are prone to
developing childhood overweight/obesity,
and/or type 2 diabetes later in life

27. Activity: Brainstorming
• What are the non-pharmacological and
pharmacological treatment of GDM?

28. Non-Pharmacological Treatments
• All women intending to become pregnant should:
• Be encouraged to achieve excellent glycaemic
control, monitoring both fasting and
postprandial glucose
• Take high-dose (5mg) pre-pregnancy folate
supplementation, up to 12 weeks’ gestation
• Have an eye exam and be informed of the risk
of developing and/or progression of retinopathy
• Have a kidney assessment (random urine
albumin/creatinine ratio and serum creatinine)
and referred if urine protein ≥ 1g

29. Non-Pharmacological Treatments (2)
 A combined healthcare team (obstetrician,
diabetologist or internist, diabetes educator,
paediatrician/neonatologist) is required
 Review SMBG, blood pressure and urine
protein and ketones by dipstick at each visit
 Eye examination in each trimester

30. Non-Pharmacological Treatments (3)
• Self-monitoring can be accomplished using
glucose meters
• Target ranges advised by the Australian
Diabetes in Pregnancy Society are as follows:
• fasting capillary blood glucose 3.5 - 5.5
mmol/L
• 1 hour postprandial capillary blood glucose
<8.0 mmol/L
• 2 hour postprandial blood glucose <6.7
mmol/L

31. Non-Pharmacological Treatments (4)
• Lifestyle management is the preferred means
of managing gestational diabetes.
• Diet is based on the principles of optimal
nutrition and controlled weight gain
• Diet needs to provide sufficient calories for
pregnancy with the exclusion of simple
carbohydrates so as to avoid peaks in blood
sugar levels

32. Non-Pharmacological Treatments (5)
• Spread carbohydrate intake over meals and
snacks throughout the day
• Use slow-release carbohydrate sources
• Ingesting more fiber in foods with whole grains
• Fruit and vegetables can also reduce the risk
of gestational diabetes
• Since insulin resistance is highest in
mornings, breakfast carbohydrates need to be
restricted more

33. Non-Pharmacological Treatments (6)
• Exercise can be helpful in lowering BG levels
• Regular moderately intense physical
exercise is advised
• The most acceptable form of exercise for
most women is walking in their normal
daily routine

34. Pharmacological Treatments
• Glucose-lowering therapy should be
considered in addition to diet where two or
more values per fortnight are:
• Fasting or preprandial ≥5.5 mmol/L, or
• 2 hours postprandial ≥7 mmol/L at ≤35
weeks
• 2 hours postprandial ≥8 mmol/L at >35
weeks
• Postprandial values are >9 mmol/L

35. Pharmacological Treatments (2)
• When pharmacologic treatment is indicated:
• Insulin and oral medications (metformin or
glibenclamide) are equivalent in efficacy,
and either can be an appropriate first-line
therapy
• Metformin (alone or combined with
insulin) 500 mg twice daily, maximum
2000mg in 2–3 doses or
• Glibenclamide 2.5mg once daily to a
maximum of 10mg daily

36. Pharmacological Treatments (3)
• Insulin
• The rapid-acting insulin analogs
• lower postprandial blood glucose
• decrease the risk of nocturnal
hypoglycemia
• Patients on lispro and aspart prior to
conception may continue them during
pregnancy

37. Pharmacological Treatments (4)
• Patients on regular insulin may be switched
to lispro or aspart if
• 1–hour postprandial blood glucose levels
are above target and/or
• the patient is also experiencing pre-meal or
nocturnal hypoglycemia

38. Health Education and Adherence
Counselling
• Plan for the pregnancy
• Follow up with the doctor regularly
• Monitor blood sugar often
• Control and treat low blood sugar quickly
• Continue to exercise and eat a healthy diet
after pregnancy to prevent or delay getting
type 2 diabetes

39. Postnatal Follow Up
• Women with gestational diabetes should be
screened
• At 6–12 weeks postnatal to ensure return to
normal glucose tolerance
• Thereafter, a 1–2 yearly follow up screening
• Metformin and glibenclamide may be used
even if a woman is breastfeeding
• Encourage to breastfeed – it possibly reduces
the risk of diabetes for both mother and child
• If retinopathy, check eyes 1 year postpartum

40. Prognosis
• Gestational diabetes generally resolves once
the baby is born
• The chances of developing GDM in a second
pregnancy are between 30 and 84%,
depending on ethnic background
• Risk of recurrence is high if
• If another pregnancy within 1 year
• In women who needed insulin treatment,
women with more than two previous
pregnancies, and women who were obese

41. Prognosis (2)
• Women requiring insulin to manage
gestational diabetes have a 50% risk of
developing diabetes within the next five years
• Children of women with GDM have
• Increased risk for childhood and adult
obesity
• Increased risk of glucose intolerance and
type 2 diabetes later in life
• This risk relates to increased maternal
glucose values

42. Key Points
 Gestational Diabetes Mellitus is any degree
of glucose intolerance first recognized in
pregnancy
 Diabetes in pregnancy refers to those with
pre-existing diabetes, whether diagnosed or
not
 diagnosed coincidentally during pregnancy
or
 may have developed diabetes during
pregnancy

43. Key Points (2)
 Gestational diabetes affects 3-10% of
pregnancies, depending on the population
 Risk factors include a family history of
diabetes mellitus
 Treatment includes non-pharmacological and
pharmacological
 Health education has to be on taking
medication and monitoring of blood glucose
 Monitoring has to include the baby to prevent
complications

44. Session Evaluation
 What is the clinical presentation of
hyperglycaemia in pregnancy?
 What are the pharmacological and non-
pharmacological treatment?
 What are the effects of hyperglycaemia in
pregnancy on the baby?
 How can you prevent diabetes during
pregnancy?