Treatment of Gestational Diabetes

1. Diabetes in pregnancy
Dr K Jayashree
Dept of Obsetrics and gynaecology
Saveetha Medical College and Hospital

2. Incidence
• 3 to 5 % of pregnant patients show glucose
intolerance
• 90% of these women have gestational
diabetes
• A small group has diabetes before pregnancy
• Genetic and/or metabolic predisposition
• Women with gestational diabetes are those
who are incapable of compensating for the
diabetogenic effects of pregnancy
• 50% of women with GDM will develop type 2
diabetes in later life

3. Diabetes complicating
pregnancy
• A patient with known
diabetes becomes
pregnant
Gestational diabetes
• Disease onset or first
recognition occurs
during the present
pregnancy usually
after 20th week

4. CARBOHYDRATE METABOLISM
DURING PREGNANY
• Normal fasting blood sugar level in
pregnancy is 65 +or -9 mg/dl
• Postprandial elevations normally never
exceed 140mg /dl
• During first trimester and early second
trimester there is an increased insulin
sensitivity
• A progressive increase in insulin
resistance occurs during gestation as
pregnancy progresses

5. Maternal metabolic
adaptations during normal
pregnancy
Pregnancy is a
DIABETOGENIC STRESS

6. 16 28 40
Pregnancy (in weeks)
Conc.
Hormonal changes during normal pregnancy
Insulin
Oestrogens
Progesterone
hPL

7. Non-
pregnant
Courtesy Prof Peter Damm
Insulin
secretion
Insulin
resistance
Gestational
DM
Blood
glucose
Normal
Pregnancy
Insulin
secretion
Insulin
resistance
Insulin
secretion
Insulin
resistance
Glucose intolerance that develop in women with GDM could
be the result of their inability to increase insulin secretion
enough to overcome insulin resistance that occurs even in
non diabetic pregnancy
PATHOPHYSIOLOGY OF GESTATIONAL DM
Kuhl C et al Diabetes 34(suppl 2) 66-70:1980

8. GDM represents detection of
chronic β cell dysfunction, rather
than development of relative insulin
deficiency as insulin resistance
increases during pregnancy
Buchanan TA et al. What is Gestational Diabetes. Fifth International Workshop Conference
on Gestational Diabetes Mellitus. Diabetes Care. Vol 30 (suppl 2), July 2007, S 105 - 111
β cell in GDM
GDM is a stage in the evolution of Type 2 DM
Carpenter MW. Gestational Diabetes, Pregnancy, Hypertension and late vascular disease.
Fifth International Workshop Conference on Gestational Diabetes Mellitus. Diabetes Care,
Vol 30 suppl 2 , July 2007, S 246 – 250.

9. State Health Society
DIAGNOSTIC TEST SCHEDULE
Diagnostic Test
(Trimesters)
Weeks of Pregnancy
I
Ideally 12-16 weeks or at the
time of first visit for AN checkup
II 24-28 weeks
III 32-34 weeks
No screening test, direct diagnostic test with 75g oral
glucose and measure 2h PG
Operational guidelines for Diagnosis of
GDM in the Community

10. Screening /Glucose challenge test
• Universal
• 24 to 28 weeks
• 75 gms of glucose without regard to time of day or last
meal
• Whole blood glucose> or =140mg% is an indication of
GTT

11. TARGET BLOOD GLUCOSE
LEVELS
Oded Langer. Maternal glycemic criteria for insulin therapy in GDM. Diabetes care,
vol 21 (2), August 1998. B91-98.
Fasting PG
80 mg %
90 mg %
PPG
110 mg %
120 mg %
Mean PG
level
95 mg %
105 mg %
V. Seshiah, AK Das, Balaji V, Shashank Joshi, MN Parikh, Sunil Gupta for DIPSI.
GDM- Guidelines. JAPI vol 54, 2006, 622-28
Balaji V, Balaji MS, Seshiah V, Mukundan S, Datta M. Maternal glycemia & neonates
birthweight in Asian Indian women. Diabetes Res Clin Pract. 2006 Aug;73(2):223-4.
Birth weight between 2.5 and 3.5 Kg
Vinod K Paul, Ashok K Deorari, Meharban Singh. Management of Low Birth Weight Babies.
In: IAP Textbook of Pediatrics. 2nd ed. A. Parthasarathy, editor. Jaypee publications,
2002, p60.

12. Risk factors requiring early
screening
• Obesity
• Positive family history/diabetic twins
• History of stillbirth
• History of delivery of a large infant
• Glycosuria
• History of unexplained neonatal death
• History of congenital anomaly
• History of prematurity

13. History of preeclampsia as a multipara
Polyhydramnios
History of traumatic delivery with associated neurological disorder
in the infant
Poor reproductive history(>3 spontaneous abortions in the first or
second trimester)
Chronic hypertension
Recurrent severe monaliasis
Recurrent urinary tract infections
Age > 30 years
History of diabetes in previous pregnancy

14. Effects of diabetes on pregnancy
1. During pregnancy
• Abortion
• Infection
• Pregnancy induced hypertension
• Hydramnios

15. 2. During labour
 Increased incidence of prolonged labour
 Big baby(fetal macrosomia)
 Shoulder dystocia
 Perineal injuries
 PPH
 Operative interference
3. During puerperium
• Puerperial sepsis
• Failing lactation

16. Neonatal complications
• Congenital abnormalities
• Hypoglycaemia
• Hyperviscosity syndrome
• Respiratory distress syndrome
• Hyperbilirubinemia
• Polycythaemia
• Hypocalcaemia
• Traumatic delivery

17. Glucose tolerance test – carpenter and
coustan modification of o’sullivan and
mahan(100 gms )
Time mg/dl m.mol/l
fasting 95 5.3
1 hour 180 10.0
2 hour 155 8.6
3 hour 140 7.8

18. • GDM is diagnosed when any two values are met or
elevated
• GTT returns to normal within 6 weeks of delivery

19. • Clinical diabetes :
• Abnormal response to GTT with the symptoms and
complications
• Asymptomatic (subclinical , chemical): Abnormal GTT
without any symptoms
• Gestational diabetes(latent diabetes): GTT becomes
abnormal in pregnancy

20. Renal glycosuria
• Sugar in urine of pregnant women is common
• 3 to 30%
• Lactose/glucose
• Indicates screening for blood sugar

21. Management
Preconception counseling
Careful and close antenatal supervision
Control of diabetes
Optimum timing for delivery , optimum mode of delivery
Arrangements for the care of newborn
• Exercise
• Aim of Management : Fasting blood sugar level should
be less than 95mg%
• Options
Diet
Exercise
Insulin

22. Preconceptional counseling
Monthly visit from conception till 20th week
biweekly till 30 weeks
Weekly till 34 weeks
Admission at 34 weeks to formulate the obstetrical
management

23. “No single period In
human development
provides a greater
potential
(than pregnancy)
for long – range
‘pay – off’ via a
relatively short –
range Period of
enlightened
metabolic
manipulation”
Freinkel – Excerpta Medica 1979

24. Diet
• 30 to 35 kcal/kg/day
• 2000 to 2500Kcal/day for normal weight
• 1200 to 1800Kcal/day for overweight
• Carbohydrate – 40 to 50 % of calorie intake
• Proteins- 10 to 15 %
Fats – 30 to 40 %Glycaemic index
Carbohydrate counting
SOLUBLE FIBERS- Fruits and vegetable and legumes , reduces
glucose absorption from intestine slowing the rise in postprandial
blood sugar levels and decreasing the requirements of insulin
INSOLUBLE FIBERS-Increases fecal bulk and accelerates GIT transit
time but has little effect on blood glucose
Eg mucopolysacharides

25. Indication of insulin
• FBS > 105mg%
• 2hrs PPBS > 130mg%
even after diet control
Dose is titrated according to blood sugar values in small
steps
Oral hypoglycaemic agents may cross the placenta and
have teratogenic effects

28. Obstetric management
• Good glycemic control and patients not on insulin------
wait for spontaneous onset of labour
• Elective induction or caesarean in patients requiring
insulin or with complications at 37 completed weeks.
• Patient is admitted at 34-36 wks for monitoring the blood
glucose levels
• Induced labour at 37 completed weeks.
Multipara with a good obstetrical history
Primigravida without any associated complications
Previous congenital malformation of the baby

29. Follow - up
• 50% would develop overt diabetes over a follow-up
period of 5-20 years
• Recurrence risk in subsequent pregnancy >50%

30. Risk factors requiring early
screening
• Obesity
• Positive family history/diabetic twins
• History of stillbirth
• History of delivery of a large infant
• Glycosuria
• History of unexplained neonatal death
• History of congenital anomaly
• History of prematurity

31. History of preeclampsia as a multipara
Polyhydramnios
History of traumatic delivery with associated neurological disorder
in the infant
Poor reproductive history(>3 spontaneous abortions in the first or
second trimester)
Chronic hypertension
Recurrent severe monaliasis
Recurrent urinary tract infections
Age > 30 years
History of diabetes in previous pregnancy

32. Glucose tolerance test – carpenter and
coustan modification of o’sullivan and
mahan(100 gms )
time mg/dl m.mol/l
fasting 95 5.3
1 hour 180 10.0
2 hour 155 8.6
3 hour 140 7.8

33. • GDM is diagnosed when any two values are met or
elevated
• GTT returns to normal within 6 weeks of delivery

34. Thank you