Gestational diabetes mellitus (GDM) is one of the most common medical complications of pregnancy and is defined as glucose intolerance that first emerges or is first recognized during pregnancy. Gestational diabetes mellitus (GDM) affects between 2% and 5% of pregnant women. Data show that increasing levels of plasma glucose are associated with birth weight above the 90th percentile, cord blood serum C-peptide level above the 90th percentile, and, to a lesser degree, primary cesarean deliveries and neonatal hypoglycemia

1. GESTATIONAL DIABETES
MELLITUS

2. DR. NIRANJAN CHAVAN
MD, FCPS, DGO, MICOG, DICOG, FICOG, DFP,
DIPLOMA IN ENDOSCOPY (USA)
Professor and Unit Chief, L.T.M.M.C & L.T.M.G.H, Sion Hospital
National Co-Ordinator, FOGSI Medical Disorders in Pregnancy Committee (2019-2021)
Vice President MOGS (2020-2021), Scientific Secretary, AFG (2021-2022)
Chairperson, FOGSI Oncology and TT Committee (2012-2014)
Chair & Convener, FOGSI Cell Violence Against Doctors (2015-16)
Dean and Chairman, Academia of Global Obstetricians and Gynecologists
Chief Editor, AFG Times (2015-16)
Course Co-Ordinator of 11 batches of MUHS recognized Certificate Course of B.I.M.I.E at
L.T.M.G.H (2010-16)
Member, Oncology Committee AOFOG (2013-2015)
Member, Managing Committee IAGE (2013-17), (2018-20)
Editorial Board, European Journal of Gynaec. Oncology (Italy)
Course Co-Ordinator of 3 batches of Advanced Minimal Access Gynaec Surgery (AMAS)
at LTMGH (2018-19)

3. • Gestational Diabetes Mellitus (GDM) is defined as Impaired Glucose
Tolerance (IGT) with onset or first recognition during pregnancy.
• Worldwide, one in 10 pregnancies is associated with diabetes, 90% of
which are GDM.
• Moreover, women with GDM and their offsprings are at increased risk of
developing type 2 diabetes later in life.
• In India, one of the most populous country globally, rates of GDM are
estimated to be 10-14.3% which is much higher than the west.

4. CARBOHYDRATE METABOLISM IN PREGNANCY
• Insuilin Resistance
• Production of human placental lactogen, cortisol, estriol and progesterone have anti insulin
effect
• Increased destruction of insulin by kidney and placenta (insulinase)
• Increased Lipolysis
• Mother utilizes fatty acids for her caloric needs sparing glucose for the fetus
• Changes in Gluconeogenesis
• Alanine and other amino acids are the major gluconeogenic source in the mother used by
the fetus

7. PEDERSON HYPOTHESIS

8. • According to IADPSG Guidelines
• Diabetes recognised in Pregnancy can be classified as
Gestational Overt

9. • Criteria for Overt Diagnosis include
Fasting Plasma Glucose >/= 126 mg/dl
HbA1c>/= 6.5%
Random Plasma Glucose > 200 mg/dl

10. WHO SHOULD BE SCREENED EARLY?
• Patient is overweight with BMI of 25 (23 in Asian Americans), and one of
the following:
• Physical inactivity
• Known impaired glucose metabolism
• Previous pregnancy history of:
• GDM
• Macrosomia (≥ 4000 g)
• Stillbirth
• Hypertension (140/90 mm Hg or being treated for hypertension)
• HDL cholesterol ≤ 35 mg/dl (0.90 mmol/L)

11. • Fasting triglyceride ≥ 250 mg/dL (2.82 mmol/L)
• PCOS, acanthosis nigricans, nonalcoholic steatohepatitis, morbid obesity and
other conditions associated with insulin resistance
• Hb A1C ≥ 5.7%, impaired glucose tolerance or impaired fasting glucose
• Cardiovascular disease
• Family history of diabetes – 1st degree relative (parent or sibling)
• Ethnicity of African American, American Indian, Asian American, Hispanic,
Latina, or Pacific Islander

12. GDM –EVOLUTION OF DIAGNOSTIC CRITERIA
Criteria O Sullivan
1964
NDDG
1979
Carpenter
Coustan
1982
ADA
1984
WHO
1999
DIPSI
2006 2010
IADPSG
2010
Challenge 100 gm 100 gm 100 gm 75/100 75 gm 75 gm 75 gm
Methodologi
cal details
Whole blood Plasma Plasma - - Random Fasting
Cut off (0) 90 105 95 95 126 - 92
Cut off (1 hr) 165 190 185 185 - - 180
Cut off (2 hr) 145 165 155 155 140 140 153
Cut off ( 3 125 145 140 140 - - -
No of
abnormal
value
≥ 2 Values ≥ 2 Values ≥ 2 Values - ≥ 1 Values 1 Value ≥ 1 Values

13. HAPO STUDY
• HAPO – Hyperglycemia & Pregnancy outcome
25,000 pregnant – 9 countries
75 gm oral glucose tolerance test between 24- 32 wks

14. NATIONAL GUIDELINE FOR
DIAGNOSIS AND MANAGEMENT OF
GESTATIONAL DIABETES
• Single step test recommended by WHO for diagnosis of GDM using a 75gm
glucose, through Oral Glucose Tolerance Test (OGTT) irrespective of the last
meal with a threshold value of 2-hour BS >140 mg/dL.
• Guidelines advocate for universal screening of all pregnant women at first
antenatal contact.

15. • If the first test is negative, second test should be done at 24-28 weeks of
gestation.
• In the postpartum period, OGTT should be repeated at 6 weeks after
delivery.
• There should be at least 4 weeks gap between the two tests.
• If she presents beyond 28 weeks of pregnancy, only one test is to be done
at the first point of contact.

16. METHODOLOGY:
• Single step testing using 75 gm oral glucose & measuring blood sugar 2
hours after ingestion.
• 75 gm glucose is to be given orally after dissolving in approximately 300 ml
water whether the pregnant women comes in fasting or non-fasting state,
irrespective of the last meal.
• The intake of the solution has to be completed within 5-10 minutes.

17. • If vomiting occurs within 30 minutes of oral glucose intake, the test has to be
repeated the next day, or else refer to a facility.
• If vomiting occurs after 30 minutes, the test continues.
• The threshold blood sugar level of ≥140 mg/dL (more than or equal to 140) is
taken as cut off for diagnosis of GDM.

18. Advantages
Pregnant women need not to be fasting and can be performed at
visit itself
Hardly affects the daily routine of the women
Is both screening as well as diagnostic procedure

20. OTHER SCREENING
• Offer retinal assessment to women with diabetes seeking
preconception care at their first appointment and then annually if no
diabetic retinopathy is found.
• Renal function test  rule out nephropathy, risk of preeclampsia

21. MATERNAL EFFECTS
• Polyhydramnios,
• Pre-eclampsia,
• Prolonged Labour,
• Obstructed Labour,
• Cesarean Section, Uterine Atony,
Postpartum Hemorrhage,
• Infection and progression of
retinopathy which are the leading
global causes of maternal morbidity
and mortality.

22. FETAL EFFECTS
• Spontaneous Abortion,
• Intra-uterine Death,
• Stillbirth,
• Congenital Malformation,
• Shoulder Dystocia,
• Birth Injuries,
• Long term clinical effects of GDM
are important contributors to the
burden of non-communicable
diseases

23. NEONATAL EFFECTS
• Neonatal Hypoglycemia
• Infant Respiratory Distress
Syndrome
• Hypocalcemia
• Hypomagnesemia
• Neonatal Hyperbilirubinemia

24. LONG TERM SEQUELAE
Babies born to diabetic mother have risk of developing
• Obesity
• Type 2 Diabetes
• Cardiovascular disease
• Impaired cognitive and motor function

25. MANAGEMENT
• All Pregnant women who test positive for GDM for the first time should be
started on Medical Nutrition Therapy (MNT) and physical exercise for 2
weeks.
• The woman should walk/exercise for 30 mins a day. After 2 weeks on MNT
and physical exercise, 2 hrs PPBS (post meal) should be done.

26. MEDICAL NUTRITION THERAPY (MNT)
• Healthy eating during pregnancy
• All pregnant women with GDM should get Medical Nutrition Therapy (MNT)
as soon as diagnosis is made.
• MNT for GDM primarily involves a carbohydrate controlled balanced meal
plan which promotes Optimal nutrition for maternal and fetal health
Adequate energy for appropriate gestational weight gain Achievement and
maintenance of normoglycemia.

27. • As per Indian ICMR guidelines, for an average weight gain of 10-12 Kg, an
addition of 350 kcal/ day above the adult requirement is recommended
during second and third trimester.
• Severe caloric restriction is not recommended as it may result in ketonemia
and ketonuria and impair physical and mental development in offspring.
• Equations proposed by ICMR expert group can be used to calculate adult
energy requirement which are as follows:

28. • Energy requirement (kcal/d)= BMR ×PAL *BMR= Basal metabolic rate and
*PAL= Physical activity level
• BMR (kcal/d) for adult females (18-30 yrs)= 14×B.W (Kg) + 471
• BMR (kcal/d) for adult females (30-60 yrs)= 8.3×B.W (Kg) + 788
*B.W= body weight
Pre-pregnancy body weight to be taken into consideration when calculating the
requirement.

29. CARBOHYDRATE FOODS AND DAILY
INTAKES
• Large amounts of carbohydrate foods should be avoided.
• Spreading carbohydrate foods over the day (3 small meals and 2–3 snacks
each day than taking 3 large meals)

30. MEDICAL MANAGEMENT
• Metformin or Insulin therapy is the accepted medical management of
pregnant women with GDM not controlled on MNT.
• Insulin can be started any time during pregnancy for GDM
management
• If 2hr PPBS is >200 mg/dL at diagnosis, starting dose of insulin should
be 8 units pre-mixed insulin.
• The dose to be adjusted on follow-up and at the same time MNT and
physical exercise has to be followed.

31. WHICH INSULIN TO USE???

32. • Total Daily Insulin Requirement – 2/3 in the morning + 1/3 at night
• Morning dose = 2/3 NPH + 1/3 short acting
• Predinner dose = ½ NPH + ½ short acting
• NICE Guidelines suggests daily testing of urine sugars and ketones by
dipstick method

33. SITE OF INSULIN INJECTION
• Front/Lateral aspect of the thigh or over abdomen
• Insulin injection is to be given subcutaneously only

34. DETAILS OF INSULIN DELIVERY
DEVICE
• Insulin syringe – 40 IU syringe is to be used.
• Insulin pen includes an insulin cartridge, dial to measure dose and a
disposable needle.
• Single use-insulin syringe and pen needle should be used.
• Never clean needle with spirit or any other disinfectant
• Tip of needle of syringe or pen should not come in contact with anything
else except cleaned skin.
• Before use, check syringe every time whether needle is straight or not.

36. • Counsel about metformin risks including placental cross over and no long term
studies in offspring available
• May be associated with preterm birth
• Starting dose: 500 mg nightly for 1 week, increase to 500 twice daily
• Check baseline creatinine
• Adverse events include abdominal pain and diarrhea – recommend with meals
• Maximal dose is 2,500-3,000 mg per day, in two or three divided doses

37. • Consider glibenclamide for women with gestational diabetes:
• in whom blood glucose targets are not achieved with metformin but who
decline insulin therapy or
• who cannot tolerate metformin
NICE guidelines
2015

38. HOW TO RECOGNISE & MANAGE
HYPOGLYCEMIA?
•Hypoglycemia is diagnosed when blood sugar level is <
70 mg/dL
•It is Important to recognise symptoms of hypoglycemia & treat
immediately

39. HOW TO RECOGNISE HYPOGLYCEMIA?
Early symptoms
• Tremors of hands,
• sweating,
• palpitations,
• hunger,
• easy fatigability,
• headache,
• mood changes,
• irritability,
• low attentiveness,
• tingling sensation around the
mouth/lips or any other
abnormal feeling w
• Severe - Confusion, abnormal
behaviour or both, visual
disturbances, nervousness or
anxiety. w Uncommon -
Seizures and loss of
consciousness

40. HOW TO MANAGE HYPOGLYCAEMIA?
• Ask pregnant women to take 3 teaspoon of glucose powder (15-20 grams)
dissolved in a glass of water.
• If glucose is not available, take one of the following:
• Sugar - 6 TSF in a glass of water/fruit juice/honey/anything which is sweet/any
food
• Take rest & avoid any physical activity 15 minutes after taking glucose 
eat one chapati with vegetable/rice  If hypoglycemia continues, repeat
same amount of glucose and wait
•

41. ANTENATAL CARE
• In cases diagnosed before 20 weeks of pregnancy, a fetal anatomical
survey by USG should be performed at 18-20 weeks.
• For all pregnancies with GDM, a fetal growth scan should be performed
at 28-30 weeks gestation & repeated at 34-36 weeks gestation.
• There should be at least 3 weeks gap between the two ultrasounds and
it should include fetal biometry & amniotic fluid estimation.

42. • Pregnant women with GDM in whom blood sugar level is well controlled &
there are no complications, should continue with antenatal visits as per high-
risk pregnancy protocol or as recommended by the physician (as least once
monthly).
• Monitor for abnormal fetal growth (macrosomia /growth restriction) and
polyhydramnios at each ANC visit.
• Pregnant women with GDM to be diligently monitored for hypertension in
pregnancy, proteinuria and other obstetric complications.

43. • In pregnant women with GDM between 24-34 weeks of gestation and requiring
early delivery, antenatal steroids should be given as per GOI guidelines
i.e. Inj. Dexamethasone 6 mg IM 12 hourly for 2 days.
• More vigilant monitoring of blood sugar levels should be done for next 72 hours
following injection.
• In case of raised blood sugar levels during this period, adjustment of insulin dose
should be made accordingly.

44. FETAL SURVEILLANCE
• Pregnant women should be explained about Daily Fetal Activity
Assessment.
• One simple method is to ask her to lie down on her side after a meal and
note how long it takes for the foetus to kick 10 times.
• If the foetus does not kick 10 times within 2 hrs, she should immediately
consult

45. LABOUR & DELIVERY
• Timing of delivery: GDM pregnancies are associated with delay in lung
maturity of the fetus;
so routine delivery prior to 39 weeks is not recommended.
• If a pregnant women with GDM with well controlled blood sugar has not
already delivered spontaneously, induction of labour should be scheduled at
or after 39 weeks pregnancy.
• In pregnant women with GDM with poor blood sugar control, those with risk
factors like hypertensive disorder of pregnancy, previous still birth & other
complications should be delivered earlier.
According to NRHM 2018 Guidelines

46. • The timing of delivery should be individualised by the obstetrician accordingly.
• Vaginal delivery should be preferred and LSCS should be done for obstetric
indications only.
• In case of fetal macrosomia (estimated fetal weight >4 kg) consideration should
be given for a primary caesarean section at 39 weeks to avoid shoulder dystocia

47. SPECIAL PRECAUTION DURING LABOUR
• Pregnant women with GDM on medical management (metformin or insulin)
require blood sugar monitoring during labour by a glucometer
continuously.
• The morning dose of insulin/metformin is withheld on the day of
induction/labour and the pregnant women should be started on 2 hourly
monitoring of blood sugar.
• IV infusion with normal saline (NS) to be started & regular insulin to be
added according to blood sugar levels as per the table

49. HYPOGLYCEMIA IN A NEWBORN WITH
GDM MOTHER
• All babies born to mothers with GDM are at risk for development of
hypoglycemia irrespective of treatment whether they are on insulin or not
and should be observed closely.
• All babies of GDM mother should be checked for hypoglycemia at or
within one hour of delivery by glucometer.

50. SIGNS OF HYPOGLYCEMIA
• Stupor or Apathy
• Jitteriness or tremors
• Episodes of cyanosis
• Convulsions
• Weak and high pitched cry,
• limpness and lethargy
• Difficulty in feeding
• Eye rolling
• Episodes of sweating

51. POST-DELIVERY FOLLOW UP OF
PREGNANT WOMEN WITH GDM
• Immediate postpartum care of women with GDM is not different from
women without GDM but these women are at high risk to develop Type 2
Diabetes Mellitus in future.
• Maternal glucose levels usually return to normal after delivery.
• Perform 75 gm OGTT (fasting and 2 hr PP) at 6 weeks postpartum to
evaluate glycemic status of woman.

52. COMPLICATIONS
•Shoulder Dystocia
•Diabetic Ketoacidosis

53. SHOULDER DYSTOCIA
• Incidence: 0.6-1.4%
• 50% occur without risk factors.
• Risk factors:
• 48% in infants<4kg
• Foetal macrosomia 22.6%
• Maternal diabetes mellitus-55% increased risk
• Obesity: BMI>30
• Prev. shoulder dystocia risk 10-15%

54. COMPLICATIONS:
• Birth asphyxia
• Brachial plexus injury in 4-40%,
• C5-C6-Erb’s
• C8-T1-Klumpke’s palsy
• Foetal fractures and bruising-clavicle#
in10%
• Maternal morbidity-lacerations of vulva,
vagina, cervix, episiotomy extensions.
• Intrapartum or postpartum haemorrhage
in 25%

55. MCROBERTS MANEUVER:

56. WOOD’S CORKSCREW MANEUVER

58. • ACOG recommends McRoberts Maneuver as initial approach.
ALARMER
• Ask for help(assistant,anaesthesia,neonatalogy)
• Lift legs (McRoberts Maneuver)
• Anterior shoulder delivery(suprapubic pressure)
• Rotate(Woods Corkscrew Maneuver)
• M removal of posterior arm and shoulder
• Episiotomy
• Repeat steps above.

59. DIABETIC KETOACIDOSIS:
• Diagnosis iof DKA is made when
• Blood glucose >250mg/dl.
• Ketone bodies in blood and urine
• Arterial pH<7.3
• Sr.Bicarbonate <15meq/l

60. TREATMENT
• Periodic monitoring of pulse,blood pressure, input/output, capillary blood
glucose, urine ketones, blood gases and electrolytes.
• Foetal heart monitoring.
• Fluid replacement: Deficit of 6-7 L replaced in 12-24hrs.
• 1 st hr 1 L Normal saline f/b 300-500ml/hr till pulse and blood pressure are
normal.
• Hypokalemia, <4meq/l, 30meq/hr KCl and >4meq/l, 10-15meq/hr.

61. • INSULIN @0.2U/kg IV bolus f/b 0.1U/kg/hr in normal saline.If blood glucose does
not fall by 30% in first 3hrs,drip rate is doubled.
• When glucose is between 200-250mg/dl,normal saline is changed to 5%
dextrose.
• Bicarbonate is given if pH falls less than 6.8,44meq/l in 0.45 normal saline.
• Iv antibiotics.
• Treatment of cause is important.

62. CONTRACEPTIVE ADVICE
• Barrier method is ideal
• Progesterone only pills are also safe
• Combined oral contraceptive pills are best avoided
• Intrauterine devices may predispose to infections
• Can undergo Tubal Ligation with precaution
• Vasectomy for husband is a good option

66. The Federation of Obstetrics and Gynaecological Societies of India (FOGSI) will
develop a special training modality and provide training to healthcare professionals
(HCPs) at three large public hospitals and three private health facilities, one of each
category in three different states of India (Uttar Pradesh, Maharashtra and
Karnataka) .
Project activities will be implemented together with the hospitals and health facilities
and through collaboration with the AVNI Foundation India, and supported by the
health authorities at federal and state level, and by FIGO International.