Gestational diabetes mellitus

1. DEPARTMENT OF OBSTETRIC &
GYNECOLOGY
Dr. G/Tsadik E.(GP)
MANAGEMENT SESSION ON
GESTATIONAL DIABETES MELLITUS
.
Wednesday, April 6,
2022
prepared by: G/Tsadik e (GP)
,2022

2. OUTLINE
 Case summary
 Strength & Pitfalls
 GDM
 Physiological changes in Px
 Definition GDM
 Prevalence
 Risk factors
 Screening
 Diagnosis
 Management
 Adverse outcome
 Reference
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3. CASE REPORT
Identification
 Name w/r BG
 sex =female
 age =30 yrs
 Address: x
 MRN--xxx
 Date of admission: ……. to GYN ward.
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2022
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4. ON 26/06/2013
C/C= come to ANC follow up
HPI= This is a 30yrs old G-IV, P-III (all alive)
mother whose LNMP was on 27/09/2012 E.C making her
EDD on 02/07/2013 e.c & GA= 39+2wks by date.
She had ANC follow up at near by HC & took 2 doses of TT
vaccination, iron supplementation. Her Px was uneventful
up to 31+4 weeks of gestation .
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2022
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5. …
 On 25/04/2013(Gb), she presented with flank pain &
admitted to GYN ward with a Dx of 3rd TmPx +MG + ?
acute pyelonephritis
 (PR=132 bpm, T= 38.4◦c )
 Ix with : CBC(Wbc—15.95 n=70) , U/A(Many
wbc) , BG& Rh =O+, serology=NR, obs u/s (SIUPx,
cardiac activity seen, AGA=31+1wks, EFW= 1838GM,
No GCA seen, adequate AF, Ass’t=3rd Tm Px +R-BPP
 Treated with ceftriaxone 1gm iv bid then changed to
po cephalexin 500 mg tid after 5days , tramadol 50
mg iv bid , pcm 1gm po prn
 on 29/04/2013, US =3rd Tm Px +asx Placenta Previa
Partials) plan: re-scan after a wk & stat iron
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2022
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6. …
 On 03/5/2013,Revised order
 dx = late preterm Px +asymptomatic placenta previa
partials +A.Pyelo( Rxed)
 rx: Feso4 325 mg tid, dexa 6mg im bid for 48hrs.
 On 06/05/2013, she discharged @ 10th day , with
improvement after she advice on danger sign px,
nutrition, birth preparedness.
 on 20/05/2013( GP), come for US (SIUPx, cardiac
activity seen, AGA=34+6 wks, EFW= 2700gm,
SDP=4.8cm , No GCA seen, Ass’t=3rd Tm Px +low lying
placenta previa)
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Wednesday, April 6,
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7.  Plan. Continue feso4,appoint after
2wks,Do CBC, U/A,S/E…all are in normal
range. s cr.= 0.8
 On 21/05/2013( senior), US
(Ass’t=3rd Tm Px + R-BPP), her FBS,
1hr & 2hr OGTT after 75gms of
glucose load was found to be
increased, 100mg/dl, 201mg/dl &
190mg/dl respectively.
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2022
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8.  On 18/06/2013, come for ANC follow
up & the plan was update ix:
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9.  On 25/06/2013, admitted to LW, with a Dx = Term Px +GDM, for Cervical
ripening over night & induction to the next day.
 Currently (On 26/05/2013), she come to ANC follow up on 25/06/2013,
& admitted to labor ward for cervical ripening & induction
Other wise:
 she has no vaginal bleeding &No ABM
 She has no fever, cough , chest pain,
 She has no urinary compliant.
 She has no epigastric pain ,blurring of vision &head ache.
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2022
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10. P/E
 GA= well looking
 V/S: BP=140/90 mmHg, PR= 88bpm ,RR=24bpm
T=36.3~c
 HEENT = pink conjunctiva & non-icteric sclera.
 lGS : No significant LAP
 Chest : clear, resonant & good air entry
 CVS: S1 &S2 are well heard no Murmur & no gallop
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11. …
 Abdomen :protuberant , moves with respiration
 Term sized gravid ux
 Longitudinal lie & Cephalic presentation
 FHB +Ve, FHR- 142BPM
 GUS:
 Cervix - admit one finger
 Station- high
 Membrane- intact
 Position -posterior
 Mss: no peripheral edema
 IGS: no palmar pallor
 CNS : COTPP
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12. ….
Ass’t : full term Px + GDM + ? GHTN + MG + Unfavorable
Bishop score
 plan:
 Consult senior (consulted)
 Give misoprostol 25 µgm pv stat
 Evaluate after 4 hr.
 Evaluate her 2hr postprandial RBS
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13. Ix on 26/06/2013
US
SIUP
Cephalic
FHB- +ve
SDP- 3cm
GA-39+4wks
EFW-3614 gm
GBM, BM, FT seen
ASS’T= Term px +R-BPP
1hr postprandial RBS = 203mg/dl
2hr postprandial RBS = 133mg/dl
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14. AFTER 4HR EVATUATION
 Hx & p/e the same
 Cx
 3cm dilate
 Effacement-60%
 Position- Mid
 Consistency- soft
 Ass’t : full term px + GDM+ ?
GHTN+MG+ favorable Bishop score
 Plan- follow with induction follow up chart
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15. Induction chart
Date Time dose drop BP PR RR Tem
perat
ure
FHB UX
co
ntr
act
ion
pv
26/06
/2013
11:1
0
DLT
2.5iu 20 133/8
8
93 20 36.5 144 nill Cx - 3cm
E- 70%
S - -2
P- MID
C- SOFT
11:40 40 132
12:10 60 148
12:40 2.5iu 40 156
1:10
NLT
60 134
1:40 80 158
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16. Induction chart
Da
te
Tim
e
do
se
dro
p
BP PR RR T FHB UX
cont
racti
on
pv RBS
26/0
6/20
13
2:10 2.5
iu
60 136 nill -
2:40 80 12
5/7
7
90 20 36.7 150 nill
3:10
NLT
Maintai-
ned
- - - - 148 1/10
’/20
”
Cx- 3-
4cm
E- 70%
S –2
M- I
4:40 7.5iu 0n
mf
155 nill 109
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17. Induction chart
Date Time dos
e
drop BP PR RR T FHB UX
contra
ction
pv RBS
26/0
6/20
13
5:40 138 nill - 103
6:40 106/
58
96 20 36.5 122 Cx- 3-4cm
E- 70%
S – -2
M- I
7:40 161 nill 108
8:40
NLT
113/
71
76 20 36.5 144 nill
11:40 155 nill 109
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18. 0n 27/6/2013 @9:00AM
 HX- G-IV PIII( all alive) & a known GDM
mother, who is on follow up.
 GA- 39+3 Wks by date from reliable date
 Ripening with balloon catheter & then with
misoprostol 25 µgm pv stat
 On induction for 15 hr & maintained @ phase
3, 80 DPM for 12hr.
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19. P/E
 GA= Confortable
 V/S: BP=120/80 mmHg,PR= 80bpm
,RR=20bpm T=ATT
 HEENT = pink conjunctiva and non-icteric
sclera.
 lGS : No significant LAP
 Chest : clear, resonant & good air entry
 CVS: S1 &S2 are well heard, no Murmur & no
gallop
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2022
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20. …
 Abdomen :
 Protuberant & moves with respiration
 Term sized gravid ux
 Longitudinal lie
 Cephalic presentation
 FHB +Ve, FHR- 144BPM
 Ux contraction- 1/10’/20”
 GUS:
 Cervix - 3cm
 Station -high
 Membrane- intact
 Position- mid
 Consistency- soft
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21. …
 Ass’t : full term px +GDM+ failed
induction
 Plan : prepare for emergency C/D
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22. OPRATION NOTE
 Pre OP DX… full term px +GDM+ failed induction
 Post OP DX.. Same
 Type of procedure… LUST C/S
 IOF
 Well formed lower ux segment
 Healthy looking adnexa, ux ,Ox, bladder
 Done…
 abdomen was entered through pfenistele incision,viscico utrine
serosa reflected down LUST incision done to effect the delivery of
female alive neonate wt= 4100gm with APGAR score of 6 & 8 in
1st & 5th min respectively. Pitocin 10iu im stat was given.
 placenta delivered by CCT
 Ux closed by layer with vicryl # 2
 Abdomen closed with layer
 EBL-400ml
 TOLAC will be possible for the subsequent px
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prepared by: G/Tsadik e (GP)
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23. Post OP order
 P- immediate post OP day after LUST C/S was
done for indication of failed induction
 C- sub critical
 A- Encourage early ambulation
 D- start sips after bowel sound is active
 IX-post op HCT after 8hr
 NC
 V/S Q15’/1hr, q1hr/4hr, then QID
 Keep the catheter for 12hrs
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24. …
 RX-
 MF (1L NS, 1LRL, 1L DNS) each over
8hrs
 Tramadol 50mg iv qid
 Diclofenac 75mg im bid
 Ampicillin 2gm iv qid for 48hr
 Determine RBS with in 4hr
 Do OGTT @6-12 wks of post partum
days
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25. 0N 27/6/13 @ 5:30 DLT
Post op evaluation by MI
 She is a 30 years old –PIV mother on her immediate
post op after LUST c/s was done for an indication of
failed induction to effect the delivery of female alive
neonate wt- 4100gm with APGAR score of 6& 8 in the 1st
& 5th min respectively.
 S- only incisional site pain
 O-
 G/A- ASL
 V/S- BP -120/60mmHg, PR- 64, RR- 18 , T- 36
 Abdomen - 20wks sized contracted Ux
 GUS- no active VX bleeding
Ass’t – immediate post op after LUST c/s was done
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prepared by: G/Tsadik e (GP)
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26. Post op order by MI
 P- immediate post OP day after LUST C/S was
done for indication of failed induction
 C- sub critical
 A- Encourage early ambulation
 D- start sips after bowel sound is active
 IX-post op HCT after 8hr
 NC- V/S Q15’/2hr, q30/2hr, Q1hr/4hr, then
QID
 Keep the catheter for 12hrs
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27. …
 RX-
 MF (1L NS, 1LRL, 1L DNS) each over
8hrs
 Tramadol 50mg iv qid
 Diclofenac 75mg im bid
 Ampicillin 2gm iv qid for 48hr
 Determine RBS with in 4hr
 Do OGTT @6-12 wks of post partum
days
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2022
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prepared by: G/Tsadik e (GP)
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28. Post OP V/S chart
Date Time BP PR RR T
27/06/20
13
5:30 120/57 64 18 36
5:45 111/63 62 18 36
6:00 110/60 - - -
6:35 120/65 84 - -
6:50 130/70 80 - -
7:05 130/70 - - -
7:20 149?79 83 - 36.4
9:00 122/68 80 - -
12:00 138/74 80 20 36
5:00 114/73 72 - -
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29. Progress on 28/06/2013
 she is on her 1st immediate post op day after LUST c/s was done for an
indication of failed induction to effect the delivery of female alive neonate
wt- 4100gm with APGAR score of 6 & 8 in the 1st & 5th min respectively.
 s- comfortable
 objectively
 G/A: well looking
 v/s : BP=110/70, PR= 68, RR=20, T=36.5 oc
 HEENT = pink conjunctiva and non-icteric scelera.
 lGS : No LAP
 Chest : clear , resonant ,good air entry
 CVS: S1 &S2 are well heard, no Murmur & no gallop
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30. Cont…
 Abdomen:
 Moves with respiration
 Not tenderness over the lower abdomen
 GUS: no active vaginal bleeding
 IGS: no palmar pallor
 Asst : Smooth 1st post OP day after LUST c/s was done.
 Plan : Post op hct= 35.9, RBS- 106 Mg/dl
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31. DISCHARGE SUMMARY
On 30/06/2013
 she is on her 3rd post op day after LUST c/s was done for an
indication of failed induction to effect the delivery of female alive
neonate wt- 4100gm with APGAR score of 6 & 8 in the 1st & 5th min
respectively.
 s- comfortable
 Objectively : G/A : well looking , V/s: stable
 ASS,T= smooth 3rd post op day after LUST c/s was done
 Plan: discharged after advised on danger sign, breast feeding & post
partum FP
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32. v/s
Date Time BP PR RR Tempera
ture
28/06/20
13
12:33 125/81 92 22 36.7
29//06/20
13
12:30 111/70 68 20 36.2
9:00 113/80 75 16 36.6
30/06/20
13
12:30 116/64 88 20 36.6
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33. Strength of m’gt team
 Well investigated ( us, OFT, Basic ix)
 Excellent team sprit
 Good documentation
 Put option’s of next px, mode of delivery
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34. pitfalls
 Early GDM screening was not done
 GHTN was dx with one time BP measurement
 To dx failed induction longer time is used
 The status of the new born’s RBS was not determined/ not document
weather send to NICU or not
 On discharge :
 there is no appointment to do OGTT @ 6-12 wks of post partum
period
 not advised on exercise, diet.
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35. GDM
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36. Physiological changes during
Pregnancy
 Pregnancy is a state of physiological insulin
resistance & relative G. intolerance.
 glucose tolerance (GT): decreases
progressively with increasing gestation {anti-
insulin hormones secreted by the placenta; hpl
lactogen, glucagon, cortisol}.
 Increased insulin requirements : Development
of GDM
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37. GESTATIONAL DIABETES
MELLITUS
 DEFINATION: any degree of glucose
intolerance with onset or first recognition
during Px.
 PREVALENCE
 United States in 2010, almost 5% .
 Occurs in 0.6-15% of all pregnancies, depending
on the population studied and the diagnostic
method
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38. Wednesday, April 6,
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39. Risk factors
 risk assessment should be ascertained at the first
prenatal visit.
 Low risk:
Blood glucose testing is not routinely required if all
of the following characteristics are present:
 Member of an ethnic group with a low prevalence
of GDM
 No known DM in first-degree relatives
 Age <25 years
 Weight normal before pregnancy
 No history of abnormal glucose metabolism
 No history of poor obstetric outcome
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40. …
 Average risk: Perform blood glucose
testing at 24 -28 wks by one of the
following methods:
 Two-step procedure: A 50-g GCT followed
by a diagnostic oral GTT in those who meet
the threshold value in the GCT
 One-step procedure: Diagnostic oral GTT
performed on all subjects
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41. …
 High risk: Perform blood glucose
testing as soon as feasible using the
procedures described above if one or
more of these are present:
 Severe obesity
 Strong family history of T2DM
 Previous history of GDM, impaired glucose
metabolism, or glucosuria
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42. SCREENING
 Controversy:
 Advantage and disadvantage of
detecting GDM
 What ?
 When?
 WHO?
 Recommendations
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43.  ADVANTAGE
 GDM is associated with macrosomia and
adverse effects on pregnancy. So
prevention of this adverse effects
 A small proportion are in fact
unrecognized preexisting DM. are at risk
of all complications of DM.
 DISADVANTAGES
 Increase CS rate
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44. What Ideal screening test is?
 Sensitive
 Specific
 Simple
 cheap
 convenient.
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45. When?
 The latter in pregnancy: higher
detection rate {GT deteriorates with
increasing gestation}
 The earlier in pregnancy the GDM is
diagnosed: the greater the potential
to treat hyperglycemia & improve
outcome.
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46. For WHO?... Based on risk
 Universal:
 Screen: all pregnant.
 advantage: will detect all cases.
 Disadvantage: costy
 Selective:
 Screen: high-risk px.
 Advantage: cost effective & convenience.
 Disadvantage: missing up to 50% .
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47. …
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48. DIAGNOSIS
 The 75 g OGTT using recent WHO
criteria is now used almost universally
throughout the world as the gold
standard test for diagnosing GDM
 DIPSI (Diabetes in Pregnancy Societies
of india):
 recommends 1-step procedure with 75 gm
oral glucose without regard to the time of
the last meal.
 A venous plasma glucose value at 2-hour
more than 140 mg/dl is diagnosed GDM.
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51. Medical management
 Patient education
 Medical Nutrition therapy
 Pharmacological therapy
 Glycemic monitoring:
 At least 4x/day (1after fasting, others after
each meal)
 SMBG and targets
 Fetal monitoring: ultrasound
 Planning on deliver
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52. ANTENATAL MANAGEMENT OF
GDM
Identification of risk factors:
 Risk assessment should be done at the first
prenatal visit.
 If one or more of risk factors are present,
perform 75-g 2-hour OGTT as soon as feasible.
 If GDM is not diagnosed, 75 gm 2- hour OGTT
should be repeated:
 24 - 28 wks of gestation Or
 any time a patient has signs and symptoms
of hyperglycemia
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53.  Ultrasound evaluation
 Early U/S
 for dating
 to check for congenital anomaly
 Serial US
 to assess fetal growth every 4 - 6 weeks
 initiate fetal surveillance with BPP starting
from GA of 32 WKs
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54. Diet and Exercise
 Lifestyle change is an essential
component of management of GDM.
 Medications should be added if needed
to achieve glycemic targets.
 Exercise (aerobic, brisk walking)
programs are safe in pregnancy and
may obviate the need of insulin
therapy.
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55. Diet
 2,000–2,500 Kcal/day for normal weight woman
 restriction to 1,200–1,800 Kcal/day for over
weight woman.
 Complex carbohydrates are preferred because
simple carbohydrates produce significant post-
prandial hyperglycemia.
 Maintenance of mean plasma glucose level
between 105 mg/dl and 110 mg/dl is desirable
for good fetal outcome (DIPSI – 2009).
 Nearly 25% women with GDM need insulin
therapy
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56.  MNT goal
 Achieve normal BGL
 Prevent ketosis
 Adequate maternal wt gain
 Adequate fetal growth
 50-60% CHO = excessive wt gain &
postprandial hyperglycemia
 So 33-40% CHO, 20% Protein, 40% fat
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57. When to start Insulin?
Which?
 When blood glucose targets cannot be reached by
MNT or OADs, insulin is required.
 Pair rapid acting with intermediate or long acting
insulin.
 Injection Human Insulin premix 30/70 advised,
40IU/ml by insulin syringe or use prefilled insulin pen.
 Store insulin at 4-8 C, door of refrigerator, use open
vials within a month.
 Insulin requirements increase throughout pregnancy,
0.7units/kg/day in 1stT, 0.8units/kg/day between
18-26 weeks, 0.9units/kg/day from 26-36 weeks and
1.0units/kg/day from 36 weeks to delivery.
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58. …
 If isolated specific abnormal values of
the day
 Eg.
 if only elevate fasting value---- night time
administration of intermediate acting---
NPH
 If Only breakfast postprandial elevation===
short acting insulin B4 breakfast —I.lispro
& aspart both preferable than regular I bz
 Provide rt at time of meal
 avoid pre-prandial administration, hypoglycemia
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59. …
 Insulin
 Insulin is the preferred medication for treating
hyperglycemia in GDM as it does not cross the
placenta to a measurable extent.
 Insulin therapy should be considered for patients
treated with nutrition and exercise therapy when
 1hr postprandial values exceed 130–140 mg/dL or
 2hr postprandial values exceed 120 mg/dL or
 fasting glucose exceeds 92mg/dL
persistently over 2weeks (more than half of the
tests are beyond normal limits).
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61. …
 Metformin
 If a patient cannot take insulin or
declines, metformin can be used.
 Counsel about metformin risks.
 Starting dose: 500 mg at night for 1
week, increase to 500 mg twice daily.
 Check baseline creatinine.
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62. …
 Timing and route of delivery
 Delivery can be planned between 39
and 40wks, but not later than 40wks.
 Induction of labor is recommended at
38wks in patients with poor glycemic
control.
 If early delivery is indicated (before
39wks) lung maturity should be checked
 CS is done only for obstetric indications
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63. OBSTETRIC MANAGEMENT
 Women with good glycemic control
and who do not require insulin may
wait for spontaneous onset of labor.
 However, elective delivery (induction
or cesarean section) is considered in
patients requiring insulin or with
complications (macrosomia) at
around 38 weeks.
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65. INTRAPARTUM MANAGEMENT
 Women with gestational diabetes who have maintained
euglycemia antenatally on diet, lifestyle, and/or medical
therapy rarely develop intrapartum hyperglycemia.
 A blood glucose level is measured on admission.
 During the latent phase, we monitor capillary glucose
levels before and after meals.
 In the absence of significant oral intake, we check
glucose levels no more frequently than every four to six
hours.
 reasonable target range for intrapartum glucose levels is
>70 and <126 mg/dL
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66. …
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67. POSTPARTUM FOLLOW UP
 Determine RBS within 4 hours of delivery
 If FBG exceed 126 mg/dL or RBS exceeds
200mg/dL, insulin in a lower dose (usually one
third to half of the antenatal dose) or
metformin would be required
 If the mother received insulin in the antenatal
period, the dose needs adjustments to pre
pregnant doses in those with T2DM
 Encourage & support breast feeding.
 Reduces the insulin requirement by 25%
 Breast- feed babies have a much lower risk
of developing DM
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69. FAMILY PLANNING
 All reliable method of family planning can be
used as appropriate for the needs of the
individual woman with diabetes.
 Barrier method of contraceptives is ideal for
spacing of births. safe & without metabolic
side effects
 Combined hormonal contraceptives and DMPA
should be avoided in women with
pregestational DM who have vascular
complications
 Permanent methods of contraception are ideal
if family size is complete.
 IUCD may be used once DM is well controlled
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70. ADVERSE OUTCOME
 Maternal risks
 Short term
 Pre-eclampsia 9.8%-18%
 Induced labour
 Operative birth
 C/S 17%--25%
 Preterm labour
 Hydramnious
 PPH
 Infection
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71. ….
 Long term
 Recurrent GDM- 1/3rd- 2/3rd , average-
48%, PG- 40%, MG- 73%
 Increased risk of T2DM- up to70% with in
22-28 years, Average= 50%/5-20yr
 CVD
 Risk of glucose metabolism disorder
 Development of metabolic disorder
 Renal disease
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72. FETAL & BABY RISKS FROM GDM
 Fetal
 ?Malformation
 IUFD
 Macrosomia
 Shoulder dystocia/Erb's palsy
 Neonatal
 Hypoglycemia
 Polycythemia
 Hyperbilirubinaemia
 Hypocalcaemia
 Cardiomyopathy
 Adult
 Obesity
 Increased rate of T2DM,
 hypertension,
 CVD,
 Breast cancer
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73. REFERENCE
1. WILLIAM OBSTETRICS 25th edn
2. GABBE OBSTETRICS 8th edn
3. DC-DUTTA OBSTERICS 8th edn
4. ACOG- 2018
5. MANAGEMENT PROTOCOL ON SELECTED
OBSTETRICS TOPICS FOR HOSPITALS,
FMOH, December 2020
6. UPTODATE 2018
7. MEDSCAPE
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74. THANK YOU!
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