Diabetes in pregnancy 2

1. MANAGEMENT OF GESTATIONAL
DIABETES MELLITUS

2. CONTENTS
 Definition
 Screening
 Diagnosis
 Risk assessment
 Medical Nutrition Therapy
 Insulin Therapy
 Intrapartum management
 Follow up
 Contraception

3.  DEFINITION
Carbohydrate intolerance of
variable severity with onset or first
recognition during pregnancy.
 Pregestational or overt DM
 Gestational DM

4. SCREENING
 Selective screening
ADA
NICE
IADPSG
 Universal screening
DIPSI

5. RISK ASSESSMENT
LOW RISK
Member of an ethnic group with low prevalence
of GDM.
No known diabetes in first degree relative.
Age < 25yrs.
Normal weight before pregnancy.
No h/o abnormal glucose metabolism.
Blood glucose screening not routinely
required

6. AVERAGE RISK
Member of an ethnic group with high
prevelance of GDM.
Diabetes in a first degree relative.
Age > 25yrs.
Overweight before pregnancy.
Blood glucose testing at 24 – 28 weeks

7. HIGH RISK
Marked obesity.
Strong family history of type II DM.
Previous h/o GDM,impaired glucose
metabolism or glycosuria.
Glucose testing as soon as feasible.

8. SCREENING
ONE STEP SCREENING
CRITERIA FBS
mg/dl
1 HR
mg/dl
2 HR
mg/dl
DIPSI
(75 gm)
≥ 140
IADPSG and
ADA
(75gm)
≥ 92 ≥ 180 ≥ 153
WHO
(75 gm)
≥ 125 mg/dl ≥ 140 mg/dl

9. • TWO STEP PROCEDURE
CRITERIA FBS
mg/dl
1 HR
mg/dl
2 HR
mg/dl
3 HR
mg/dl
GLUCOSE
CHALLENGE
TEST(50 gms) .>140mg/dl
CARPENTER
AND COUSTON
(100 gms)
≥95 ≥180 ≥155 ≥140

10. OVERT DM
FBS ≥ 126 mg/dl.
RBS ≥ 200 mg/dl.
HbA1c >6.5

11. Glycemic criteria
Criteria FPG mg/dl 2-hr PG mg/dl
Normal Glucose Tolerance
(NTG)
<100 <140
Impaired Fasting Glucose
(IFG)
100-125 -
Impaired Glucose Tolerance
(IGT)
- 140-199
Diabetes Mellitus (DM) >126 > 200

12. Fasting plasma glucose or
random plasma glucose or
HbA1c
Fasting glucose > 126mg/dl
HbA1c > 6.5%
Random glucose > 200mg/dl
Confirm with Fasting glucose or HbA1c
Fasting plasma glucose
> 92mg/dl but < 126mg/dl
GDM
OVERT DIABETES
2-hour 75g OGTT
Fasting plasma glucose >92mg/dl
1-hour > 180mg/dl
2-hour > 153mg/dl
Fasting glucose > 126mg/dl
One or more values >
thresholds
All 3 values < thresholds
OVERT DIABETES
GDM
Normal
24-28 wks
IADPSG 2
PHASE
STRATEGY

13. FBS <
90mg/dl
PPBS < 120
mg/dl
FBS
>90mg/dl
PPBS >120
mg/dl
Continue on
diabetic diet
To do FBS ,PPBS
Upto 28wks –mthly
once
28-32 wks – once in
2wks
> 32 wks upto
delivery- weekly once.
Start
insulin
Monitor sugar levels
Accordingly to maintain
FBS≤ 95mg/dl
1st hr PPBS ≤ 140mg/dl
2nd hr PPBS ≤ 120
DIABETIC DIET
FOR 2WEEKS
GDM

14. MEDICAL NUTRITION THERAPY
• To achieve normoglycemia ,prevent ketosis,provide
adequate weight gain and contribute to fetal well being.
Major nutritional components,
Caloric allotment
CHO intake
Caloric distribution
• 3 meals with 3 snacks .
• Total caloric requirement calculated based on BMI.

15. CALORIE REQUIREMENT
• Optimal total daily calorie intake will be between 2000- 2500 Kcal/day.
• CALORIE ALLOTMENT : 45% CHO ,20% Protein,
25- 30% Fats, < 10% saturated fat.
• CALORIE INTAKE :Break fast 25%,Lunch 30%,Dinner 30%
• CHO distribution
10 - 15% : Break fast
20- 30% : lunch
30- 40% : dinner
0- 10% : snacks

16. EXERCISE
• Beneficial for the improvement of glucose
control as a result of enhanced insulin
sensitivity due to,
↓ Intra abdominal fat
↑Insulin sensitive glucose transporters
(GLUT 4) in muscle.
↑Blood flow to insulin sensitive tissues
↓ free fatty acid level
• Brisk walking of 2.52 km in 1hr.

17. MONITORING GLYCEMIC CONTROL
• If MNT fails to achieve control ,insulin may
be initiated.
• Till 28 wks - lab monitoring of both FBS and
PPBS once a month.
• After 28 wks - once in 2 wks.
• After 32 wks - once a week
• High risk pregnancies- frequency of
monitoring may be intensified.

18. TARGET PLASMA GLUCOSE LEVELS
• FBS ≤ 95 mg/dl.
• 1 hr PPBS ≤ 140 mg/dl
• 2 hr ≤ 120 mg/ dl
• Consistent elevations more than 4 times
over a two week period – insulin should be
initiated.

19. ORAL HYPOGLYCEMIC AGENTS
GLYBURIDE ( micronised form of glybenclamide)
• 2nd generation Sulphonylurea
• Longer acting
• Category B drug
• Nonteratogenic
• Starting dose is 2.5mg once or twice daily.

20. METFORMIN
• Category B drug
• Biguanides
• Suppress hepatic gluconeogenesis by
activation of an enzyme activated protein
kinase.

21. INSULIN THERAPY
• Cover the basal needs and elevation in blood
sugar that occurs after meals.
• Correction dose supplement to control
sporadic elevations of blood sugar.
• Dose and type of insulin is decided based on
the degree of hyperglycemia and obesity.

22. α α
INSULIN
RECEPTORS
β β
OUTSIDE THE
CELL
INSIDE THE
CELL
Phosphorylation
Altered
enzyme
activity
protein
MECHANISM OF ACTION OF INSULIN
Cell
membrane

23. ANALOGUE
CHANGE IN AMINOACID
SEQUENCE
TYPE
LISPRO 28-29 proline and lysine
are interchanged.
Rapid
ASPART Proline at 28 substituted
by aspartic acid
Rapid
GLARGINE Substitution of glycine for
aspargine at 21 in α chain
and addition of 2 arginine
at 30 in β chain.
Long
DETEMIR β chain 30 threonine
substituted by myristic acid
Long

24. TYPE OF INSULIN ONSET (hr) PEAK (hr) DURATION (hr)
Regular 0.5-1.0 2-3 6-8
Lispro 0.25-0.5 1-2 4-6
Aspart 0.25-0.5 1-2 4-6
NPH 1.0 4-8 10-14
Glargine 1.5 - 30

25. MIXED AND SPLIT DOSE OF INSULIN
 Combination of short and intermediate acting
insulin in the morning and evening.
 2/3rd morning and 1/3rd evening.
 Each combination of 1/3rd dose should be
regular and 2/3rd dose should be intermediate
acting insulin.

26. HOW TO START AN INSULIN?
Every 4th day increase 2 units till 10 units
If FPG remains > 90mg/dl ,6 units
before break fast ; 4 units before dinner
Review with blood sugar test; adjust
dose further.Total insulin dose /day
can be divided as 2/3rd in the
morning and 1/3rd in the evening
Starting dose 4 units before break fast

27. OBSTETRIC MANAGEMENT
ANTEPARTUM .
• Detailed anomaly scan -18 – 20 wks.
• Growth scans at 28, 32 and 36 wks.
• Non stress test and Biophysical profile.
• Doppler – indicated when cases complicated
by preeclampsia and IUGR.

28. TIMING OF DELIVERY
• Depends upon the presence of maternal or fetal
complications or poor glycemic control.
• Good glycemic control with nutritional therapy alone - wait
till 40 wks and plan for IOL.
• High risk patients- plan for IOL at 38 weeks
• Elective caesarean section if estimated fetal weight 4.5kgs .

29. INSULIN MANAGEMENT DURING
LABOUR
Usual dose of intermediate acting insulin is given
at bed time.
Morning dose of insulin is withheld.
Intravenous infusion of normal saline is begun.
Once active labour begins or glucose levels
decrease to <70 mg/dl, infusion is changed from
saline to 5% Dextrose,delivered at a rate of 100-
150ml/hr.
Short acting insulin is administered by IV infusion
at a rate of 1.25U/hr if glucose level exceeds 100
mg/dl.

30. GDM
FPG or 75 gm, 2 hr OGTT at
6-12 wks postpartum
FBS ≥126 mg/dl
2HR ≥ 200 mg/dl
DM
IMPAIRED FASTING GLUCOSE or
IGT or BOTH
FBS 110-125 2HR 140-199
NORMAL
FBS < 110
PPBS< 140
REFER FOR
DIABETES
MANAGEMENT
• Consider referral
Weight loss and physical activity
Counselling as needed
Consider metformin if combined impaired
fasting glucose and IGT.
Medical nutrition therapy.
Yearly assessment of glycemic status.
Assess glycemic
status every 3yrs
Weight loss and
physical activity.
Counselling as
needed.
POSTPARTUM FOLLOW UP

31. CONTRACEPTION
• Barrier methods
• Oral contraceptives
• IUCD

32. THANK YOU