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Gestational diabetes

obstetrics & gynecology,

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Gestational diabetes

  1. 1. GestationalGestational diabetesdiabetes BYBY Sohaib AhmedSohaib Ahmed 08-18308-183
  2. 2. DefinitionDefinition:: It is a condition in which women without previously diagnosed  diabetes exhibit high blood glucose levels during  pregnancy (especially during their third trimester(.
  3. 3. Prevalence:Prevalence: Gestational diabetes and impaired glucoseGestational diabetes and impaired glucose tolerance (IGT) in pregnancy affectstolerance (IGT) in pregnancy affects between 2-3% of all pregnanciesbetween 2-3% of all pregnancies and both have been associated withand both have been associated with pregnancy complications.pregnancy complications.
  4. 4. Fasting and 2 hours postprandialFasting and 2 hours postprandial venous plasma sugar duringvenous plasma sugar during pregnancy.pregnancy. Border lineBorder line indicates glucoseindicates glucose tolerance test.tolerance test. 125-200 mg/dl.125-200 mg/dl.100-125 mg/dl100-125 mg/dl DiabeticDiabetic>200 mg/ dl.>200 mg/ dl.>125 mg/ dl>125 mg/ dl Not diabeticNot diabetic< 145mg/ dl.< 145mg/ dl.<100 mg/dl<100 mg/dl ResultResult2h postprandial2h postprandialFastingFasting
  5. 5. Low-risk statusLow-risk status requires no glucose testing, but thisrequires no glucose testing, but this category is limited to those women meetingcategory is limited to those women meeting allall of theof the following characteristics:following characteristics:  Age <25 years.Age <25 years.  Weight normal before pregnancy .Weight normal before pregnancy .  Member of an ethnic group with a low prevalence ofMember of an ethnic group with a low prevalence of gestational diabetes mellitus .gestational diabetes mellitus .  No known diabetes in first-degree relatives .No known diabetes in first-degree relatives .  No history of abnormal glucose tolerance .No history of abnormal glucose tolerance .  No history of poor obstetric outcome .No history of poor obstetric outcome . Risk assessmentRisk assessment
  6. 6. Risk assessmentRisk assessment  marked obesity.marked obesity.  personal history of gestational diabetespersonal history of gestational diabetes mellitus.mellitus.  Glycosuria.Glycosuria.  a strong family history of diabetes .a strong family history of diabetes . A high risk of gestational diabetes mellitus:A high risk of gestational diabetes mellitus:
  7. 7. high risk patients should undergo glucosehigh risk patients should undergo glucose testingtesting A fasting plasma glucoseA fasting plasma glucose levellevel >125mg/dL>125mg/dL or aor a casual plasma glucosecasual plasma glucose >200 mg/dL>200 mg/dL meets themeets the threshold for thethreshold for the diagnosis of diabetesdiagnosis of diabetes In the absence of this degree of hyperglycemia, evaluation for gestational diabetes mellitus in women with average or high-risk characteristics is by glucose tolerance test . Risk assessmentRisk assessment
  8. 8. 5050--g oral glucose challengeg oral glucose challenge The screening test for GDM, a 50-g oral glucoseThe screening test for GDM, a 50-g oral glucose challenge, may be performed in the fasting orchallenge, may be performed in the fasting or fed state. Sensitivity is improved if the test isfed state. Sensitivity is improved if the test is performed in the fasting state .performed in the fasting state . A plasma value aboveA plasma value above one hourone hour afterafter is commonly used as a threshold foris commonly used as a threshold for performing a 3-hour OGTT.performing a 3-hour OGTT. If initial screening is negative, repeat testing isIf initial screening is negative, repeat testing is performed at 24 to 28 weeks.performed at 24 to 28 weeks. 130130--140140mg/dlmg/dl
  9. 9. 33hour Oral glucose tolerance testhour Oral glucose tolerance test Prerequisites: - Normal diet for 3 days before the test. - No diuretics 10 days before. - At least 10 hours fast. - Test is done in the morning at rest. Giving 75 gm (100 gm by other authors) glucose in 250 ml water orally Criteria for glucose tolerance test: The maximum blood glucose values during pregnancy: - fasting 90 mg/ dl, - one hour 165 mg/dl, - 2 hours 145 mg/dl, - 3 hours 125 mg/dl. If any 2 or more of these values are elevated, the patient is considered to have an impaired glucose tolerance test.
  10. 10. MonitoringMonitoring Urine glucose monitoring is not useful inUrine glucose monitoring is not useful in gestational diabetes mellitus. Urinegestational diabetes mellitus. Urine ketone monitoring may be useful inketone monitoring may be useful in detecting insufficient caloric ordetecting insufficient caloric or carbohydrate intake in women treatedcarbohydrate intake in women treated with calorie restriction.with calorie restriction.
  11. 11. DailyDaily self-monitoring of bloodself-monitoring of blood glucose (SMBG) appears to beglucose (SMBG) appears to be superior tosuperior to intermittentintermittent officeoffice monitoring of plasma glucose.monitoring of plasma glucose. MonitoringMonitoring
  12. 12. For women treated with insulin,For women treated with insulin, preprandialpreprandial monitoring ismonitoring is postprandialpostprandial monitoring. However, the success ofmonitoring. However, the success of either approach depends on the glycemiceither approach depends on the glycemic targets that are set and achieved.targets that are set and achieved. MonitoringMonitoring superior tosuperior to
  13. 13. Glycosylated haemoglobin (Hb A1Glycosylated haemoglobin (Hb A1 (( It is normally accounts forIt is normally accounts for 5-6%5-6% of the total haemoglobinof the total haemoglobin mass. A valuemass. A value over 10%over 10% indicates poor diabetesindicates poor diabetes control in the previous 4-8 weeks.control in the previous 4-8 weeks. If this is detected early in pregnancyIf this is detected early in pregnancy, there is a high risk, there is a high risk of congenital anomalies .of congenital anomalies . If this is detected in late pregnancyIf this is detected in late pregnancy it indicates increasedit indicates increased incidence of macrosomia and neonatal morbidity andincidence of macrosomia and neonatal morbidity and mortality.mortality. MonitoringMonitoring
  14. 14. The mean glucose represented by the hemoglobinThe mean glucose represented by the hemoglobin A1c level can be calculated using the "rule ofA1c level can be calculated using the "rule of 8's." A value of 8 percent equals 180 mg/dl, and8's." A value of 8 percent equals 180 mg/dl, and each 1 percent increase or decrease representseach 1 percent increase or decrease represents ± 30 mg/dl.± 30 mg/dl. Glycosylated haemoglobin (Hb A1Glycosylated haemoglobin (Hb A1 (( MonitoringMonitoring
  15. 15. Assessment for asymmetric fetalAssessment for asymmetric fetal growth by ultrasonography,growth by ultrasonography, particularly in early third trimester,particularly in early third trimester, may aid in identifying fetuses that canmay aid in identifying fetuses that can benefit from maternal insulin therapybenefit from maternal insulin therapy MonitoringMonitoring
  16. 16. Maternal surveillance should includeMaternal surveillance should include blood pressure and urine proteinblood pressure and urine protein monitoring to detect hypertensivemonitoring to detect hypertensive disorders.disorders. MonitoringMonitoring
  17. 17. There are insufficient data for any reliableThere are insufficient data for any reliable conclusions about the effects ofconclusions about the effects of treatments for impaired glucose tolerancetreatments for impaired glucose tolerance on perinatal outcome.on perinatal outcome.
  18. 18. Medical nutrition therapy should include theMedical nutrition therapy should include the provision of adequate calories andprovision of adequate calories and nutrients to meet the needs of pregnancynutrients to meet the needs of pregnancy and should be consistent with theand should be consistent with the maternal blood glucose goals that havematernal blood glucose goals that have been established. Noncaloric sweetenersbeen established. Noncaloric sweeteners may be used in moderation.may be used in moderation. 1-medical nutrition therapy
  19. 19. Diet therapy is critical to successful regulation ofDiet therapy is critical to successful regulation of maternal diabetes. A program consisting ofmaternal diabetes. A program consisting of three meals and several snacks is used forthree meals and several snacks is used for most patients. Dietary composition should be :most patients. Dietary composition should be :  50 to 60 percent carbohydrate,50 to 60 percent carbohydrate,  20 percent protein,20 percent protein,  25 to 30 percent fat with less than 10 percent25 to 30 percent fat with less than 10 percent saturated fats, up to 10 percentsaturated fats, up to 10 percent polyunsaturated fatty acids, and the remainderpolyunsaturated fatty acids, and the remainder derived from monosaturated sourcesderived from monosaturated sources
  20. 20. insulin therapy is recommended when medical nutritioninsulin therapy is recommended when medical nutrition therapy fails to maintain self-monitored glucose at thetherapy fails to maintain self-monitored glucose at the following levels:following levels: FastingFasting whole blood glucosewhole blood glucose <<95 mg/dL95 mg/dL Fasting plasma glucoseFasting plasma glucose <<105 mg/dL105 mg/dL oror 1-hour postprandial1-hour postprandial whole blood glucosewhole blood glucose <<140 mg/dL140 mg/dL 1-hour postprandial plasma glucose1-hour postprandial plasma glucose <<155 mg/dL155 mg/dL oror 2-hour postprandial2-hour postprandial whole blood glucosewhole blood glucose <<120 mg/dL120 mg/dL 2-hour postprandial plasma glucose2-hour postprandial plasma glucose <<135 mg/dL135 mg/dL 2-insulin therapy
  21. 21. GOALGOAL Self-blood glucose monitoring combinedSelf-blood glucose monitoring combined with aggressive insulin therapy haswith aggressive insulin therapy has made the maintenance of maternalmade the maintenance of maternal normoglycemianormoglycemia ((fasting and premeal glucose betweenfasting and premeal glucose between 50-80mg/dl and 1 hour postprandial50-80mg/dl and 1 hour postprandial glucose <140mg/dlglucose <140mg/dl)) Insulin therapyInsulin therapy ……..cont..cont..
  22. 22. Insulin therapyInsulin therapy ……..cont..cont.. Twice daily ( before breakfast and beforeTwice daily ( before breakfast and before dinner) injections of a combination of shortdinner) injections of a combination of short and intermediate acting insulins areand intermediate acting insulins are usually sufficient to control most patientsusually sufficient to control most patients otherwise a subcutaneous insulin pump isotherwise a subcutaneous insulin pump is used.used.
  23. 23. The total first dose of insulin is calculatedThe total first dose of insulin is calculated according to the patientaccording to the patient’’s weight as follow:s weight as follow: Insulin therapyInsulin therapy ……..cont..cont.. In the first trimester .......... weight x 0.7In the first trimester .......... weight x 0.7 In the second trimester........ weight x 0.8In the second trimester........ weight x 0.8 In the third trimester........... weight x 0.9In the third trimester........... weight x 0.9
  24. 24. If the total dose of insulin is less than 50If the total dose of insulin is less than 50 units/ dayunits/ day,, it is given in a single morning dose withit is given in a single morning dose with the ratiothe ratio:: Short acting (regular orShort acting (regular or Actrapid)/Intermediate (NPH or Monotard) = 1 : 2Actrapid)/Intermediate (NPH or Monotard) = 1 : 2 In higher dosesIn higher doses ,, As a general rule, the amount ofAs a general rule, the amount of intermediate-acting insulin will exceed the short-intermediate-acting insulin will exceed the short- acting component by a 2:1 ratio. Patients usuallyacting component by a 2:1 ratio. Patients usually receive two thirds their total dose with breakfast andreceive two thirds their total dose with breakfast and the remaining third in the evening as a combinedthe remaining third in the evening as a combined dose with dinnerdose with dinner
  25. 25. Insulin Dose adjustmentInsulin Dose adjustment Home glucose monitoring with a reflectanceHome glucose monitoring with a reflectance meter by measuring fasting and preprandialmeter by measuring fasting and preprandial glucose values 4 times a day (30-40 min)beforglucose values 4 times a day (30-40 min)befor each meal.each meal. preprandial glucose measuring allows addingpreprandial glucose measuring allows adding additional regular insulin to compensate anyadditional regular insulin to compensate any hyperglycemia already present before meals.hyperglycemia already present before meals. All values are recorded in a daily log.All values are recorded in a daily log. NEXT
  26. 26. Each time the fasting or premealEach time the fasting or premeal glucose is measured, the patientglucose is measured, the patient refers to therefers to the supplemental regularsupplemental regular insulin scaleinsulin scale to determine ifto determine if additional regular insulin isadditional regular insulin is neededneeded NEXT Insulin Dose adjustmentInsulin Dose adjustment
  27. 27. PreprandialPreprandial glucose mg/dlglucose mg/dl Additional unitsAdditional units (regular insulin)(regular insulin) <100<100 00 100-140100-140 22 140-160140-160 33 160-180160-180 44 180-200180-200 55 200-250200-250 66 250-300250-300 88 >300>300 1010 supplemental regular insulin scalesupplemental regular insulin scale NEXT
  28. 28. When the pattern for additionalWhen the pattern for additional regular insulin supplementation isregular insulin supplementation is identified over 2-3 days, thatidentified over 2-3 days, that amount of insulin can then beamount of insulin can then be added to the planned daily dose.added to the planned daily dose. Insulin Dose adjustmentInsulin Dose adjustment
  29. 29. In patients who are not well controlled, aIn patients who are not well controlled, a brief period of hospitalization is oftenbrief period of hospitalization is often necessary for the initiation of therapy.necessary for the initiation of therapy. Individual adjustments to the regimensIndividual adjustments to the regimens implemented can then be made.implemented can then be made. 3-Hospitalisation
  30. 30. KETOACIDOSISKETOACIDOSIS
  31. 31. KETOACIDOSISKETOACIDOSIS As pregnancy is a state of relative insulinAs pregnancy is a state of relative insulin resistance marked by enhanced lipolysis andresistance marked by enhanced lipolysis and ketogenesis, diabetic ketoacidosis may developketogenesis, diabetic ketoacidosis may develop in a pregnant woman with glucose levels barelyin a pregnant woman with glucose levels barely exceeding 200 mg/dl .exceeding 200 mg/dl . Thus, DKA may be diagnosed during pregnancyThus, DKA may be diagnosed during pregnancy with minimal hyperglycemia accompanied by awith minimal hyperglycemia accompanied by a fall in plasma bicarbonate and a pH value lessfall in plasma bicarbonate and a pH value less than 7.30. Serum acetone is positive at a 1:2than 7.30. Serum acetone is positive at a 1:2 dilution.dilution.
  32. 32. clinical signs of volume depletion follow theclinical signs of volume depletion follow the symptoms of hyperglycemia, whichsymptoms of hyperglycemia, which includeinclude  polydipsia and polyuria.polydipsia and polyuria.  Malaise.Malaise.  Headache.Headache.  nausea.nausea.  Vomiting.Vomiting. KETOACIDOSISKETOACIDOSIS
  33. 33.  Occasionally, diabetic ketoacidosis may presentOccasionally, diabetic ketoacidosis may present in an undiagnosed diabetic woman receiving β-in an undiagnosed diabetic woman receiving β- mimetic agents to arrest preterm labor.mimetic agents to arrest preterm labor.  Because of the risk of hyperglycemia and diabeticBecause of the risk of hyperglycemia and diabetic ketoacidosis in diabetic women . Terbutaline andketoacidosis in diabetic women . Terbutaline and magnesium sulfate has become the preferredmagnesium sulfate has become the preferred tocolytic for cases of preterm labor in thesetocolytic for cases of preterm labor in these cases.cases.  Sometimes Administration of antenatalSometimes Administration of antenatal corticosteroids to accelerate fetal lung maturationcorticosteroids to accelerate fetal lung maturation can cause significant maternal hyperglycemia andcan cause significant maternal hyperglycemia and precipitate DKA. In diabetic patients.precipitate DKA. In diabetic patients. KETOACIDOSISKETOACIDOSIS
  34. 34. An intravenous insulin infusion will usually beAn intravenous insulin infusion will usually be required and is adjusted on the basis of frequentrequired and is adjusted on the basis of frequent capillary glucose measurements.capillary glucose measurements. Therapy hinges on the meticulous correction ofTherapy hinges on the meticulous correction of metabolic and fluid abnormalities.metabolic and fluid abnormalities. Every effort should therefore be made to correctEvery effort should therefore be made to correct maternal condition before intervening andmaternal condition before intervening and delivering a preterm infant.delivering a preterm infant. KETOACIDOSISKETOACIDOSIS
  35. 35. There isThere is very little evidencevery little evidence to supportto support either elective delivery or expectanteither elective delivery or expectant management at term in pregnant womenmanagement at term in pregnant women with insulin-requiring diabetes. Limitedwith insulin-requiring diabetes. Limited data from a single randomized controlleddata from a single randomized controlled trial suggest that induction of labour intrial suggest that induction of labour in women with gestational diabetes treatedwomen with gestational diabetes treated with insulin reduces the risk of macrosomiwith insulin reduces the risk of macrosomi
  36. 36. When antepartumWhen antepartum testing suggests fetaltesting suggests fetal compromise, deliverycompromise, delivery must be considered.must be considered.
  37. 37. Delivery by cesarean section usually isDelivery by cesarean section usually is favored when fetal distress has beenfavored when fetal distress has been suggested by antepartum heart ratesuggested by antepartum heart rate monitoring.monitoring. If a patient reachesIf a patient reaches 38 weeks'38 weeks' gestationgestation with a mature fetal lung profile and is atwith a mature fetal lung profile and is at significant risk for intrauterine demisesignificant risk for intrauterine demise because of poor control or a history ofbecause of poor control or a history of a prior stillbirth, an elective delivery isa prior stillbirth, an elective delivery is planned.planned.
  38. 38. During labor, continuous fetal heartDuring labor, continuous fetal heart rate monitoring is mandatory. Laborrate monitoring is mandatory. Labor is allowed to progress as long asis allowed to progress as long as normal rates of cervical dilatationnormal rates of cervical dilatation and descent are documented.and descent are documented. arrest of dilatation or descent despitearrest of dilatation or descent despite adequate labor should alert theadequate labor should alert the physician to the possibility ofphysician to the possibility of cephalopelvic disproportion.cephalopelvic disproportion.
  39. 39. •• Usual dose of intermediate-acting insulin is given atUsual dose of intermediate-acting insulin is given at bedtime.bedtime. •• Morning dose of insulin is withheld.Morning dose of insulin is withheld. •• Intravenous infusion of normal saline is begun.Intravenous infusion of normal saline is begun. •• Once active labor begins or glucose levels fall belowOnce active labor begins or glucose levels fall below 70 mg/dl, the infusion is changed from saline to 5%70 mg/dl, the infusion is changed from saline to 5% dextrose and delivered at a rate of 2.5 mg/kg/min.dextrose and delivered at a rate of 2.5 mg/kg/min. •• Glucose levels are checked hourly using a portableGlucose levels are checked hourly using a portable meter allowing for adjustment in the infusion rate.meter allowing for adjustment in the infusion rate. •• Regular (short-acting) insulin in administered byRegular (short-acting) insulin in administered by intravenous infusion if glucose levels exceed 140intravenous infusion if glucose levels exceed 140 mg/dl.mg/dl. Insulin Management during Labor and DeliveryInsulin Management during Labor and Delivery

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